The Baby Friendly Hospital Initiative and Ten Steps to Successful Breastfeeding programs: applying the Non-adoption, Abandonment, Spread, Scale up, Sustainability (NASSS) health technology adoption framework to analyze challenges to hospital implementation in Australia and Indonesia.

Background: Global uptake of the Baby Friendly Hospital Initiative (BFHI) and Ten Steps to Successful Breastfeeding (Ten Steps) is low, and sustainability is a challenge. Although both programs are backed by strong evidence and international endorsement, their integration into national health systems has been inconsistent and often lacks institutional prioritization. This study aimed to analyze challenges to implementation of the BFHI and Ten Steps programs in Australia and Indonesia.

Methods: We used the Non-adoption, Scale-up, Spread and Sustainability (NASSS) framework and categorized the relative complexity of implementing the program into each setting.

Results: Most BFHI/Ten Steps implementation domains were categorized as complicated or complex, and the policy level, organizational and community settings for the intervention overlapped for most domains. Despite the cultural and health systems differences between Australia and Indonesia, both environments present challenges and also unique opportunities for the uptake and scale up of BFHI/Ten Steps with the right support and adaptation. Importantly, the complexity was not only technical but also institutional, with implementation often relying on individual champions rather than systemic support.

Conclusions: Systems that require and motivate compliance to the WHO Code (Step 1) and optimize healthcare professionals' (HCP) lactation support capacity (Step 2) are crucial, and need to be regulated and coordinated from the national level. To achieve optimal support for initiating and establishing breastfeeding, governments, facilities, and relevant HCPs must support birth models that ensure women receive continuity of care and adequate time with skilled midwives, who in turn are educated in ways that are free from commercial influence (Step 1). These policy and clinical level steps can reduce the misalignment of costs and benefits of BFHI and Ten Steps implementation. Strengthening institutional commitment and embedding BFHI into national quality frameworks may further enhance sustainability and scale-up. A coordinated, system-wide approach is essential to ensure these evidence-based practices become standard in maternal and newborn care.