Barriers and facilitators to facility-based feeding support for small and sick newborns in Ethiopia: a qualitative study of clinicians' perspectives.

Abstract

Breastfeeding is widely recognised as the optimal form of infant nutrition, with the WHO recommending initiation within the first hour after birth and exclusive breastfeeding for the first 6 months. However, small and sick newborns (SSNs) often face challenges in achieving recommended feeding practices, including in facility-based settings. This study explored clinicians' experiences and perspectives on SSN feeding support within selected facilities implementing the Saving Little Lives (SLL) programme in Ethiopia. A qualitative study employing semistructured indepth interviews and participant observation, analysed thematically. Government hospitals participating in the SLL programme in the Amhara region of Ethiopia. Clinicians involved in neonatal care and feeding support for SSN, including nurses, midwives and paediatric care providers. Clinicians identified multilevel barriers affecting facility-based SSN feeding practices. These were categorised into: (1) facility-level factors, including inadequate clinician training, staff shortages and lack of appropriate feeding tools; (2) neonatal and maternal factors, such as newborn and maternal health complications and concerns about insufficient breast milk production and (3) sociocultural factors, including traditional practices like uvulectomy and prelacteal feeding. A notable facilitator was the involvement of predominantly female clinicians with personal breastfeeding experience, which enhanced support for SSN feeding. Despite the challenges, many barriers were found to be modifiable. This study highlights critical gaps and opportunities in facility-based SSN feeding support in low-resource settings. The findings suggest that targeted interventions, including improved clinician training, integration of feeding counselling into maternal care, and enhanced access to feeding tools, can strengthen neonatal feeding support and contribute to improved health outcomes for SSN.