Breastfeeding is recognized as the optimal form of infant nutrition. The World Health Organization recommends initiation of breastfeeding within the first hour after birth and exclusive breastfeeding (EBF) for the first six months. However, facility-based breastfeeding practices, especially for small and sick newborns (SSN), face numerous challenges. The Saving Little Lives (SLL) program in Ethiopia seeks to improve SSN survival by promoting comprehensive neonatal healthcare practices, including appropriate feeding. Despite these efforts, limited data exist on clinicians’ experiences and perspectives regarding SSN feeding support in healthcare facilities. This qualitative study explored the neonatal feeding experiences of clinicians in selected SLL facilities in the Amhara region, Ethiopia. Semi-structured interviews revealed multilevel barriers influencing facility-based SSN feeding practices. These barriers were categorized as: (1) facility factors—including insufficient clinician training, staff shortages, and inadequate feeding tools; (2) neonatal/maternal factors—such as health complications in newborns and mothers and maternal concerns about insufficient milk production; and (3) sociocultural factors— including traditional practices like uvulectomy and prelacteal feeding. A key facilitator identified was the role of predominantly female clinicians with personal breastfeeding experience, which positively influenced feeding support efforts. The findings suggest that many barriers are modifiable through targeted interventions, including enhanced clinician training, integration of infant feeding counseling into prenatal and postnatal care, and improved access to feeding tools in healthcare facilities. These insights offer critical guidance for developing evidence-based strategies to strengthen facility-based SSN feeding support, contributing to improved neonatal health outcomes in low-resource settings.

What is already known on this topic Breastfeeding is crucial for infant nutrition, with early initiation and exclusive breastfeeding (EBF) for six months recommended by the World Health Organization. However, challenges persist in supporting small and sick newborns (SSN), particularly in low-resource healthcare settings.

What this study adds This study highlights multilevel barriers to facility-based SSN feeding in Ethiopia. The barriers include clinician training gaps, inadequate feeding tools, insufficient facility-based neonatal feeding support to struggling mothers and neonates, and sociocultural practices like uvulectomy and prelacteal feeding. A key facilitator was having predominantly female clinicians with personal breastfeeding experience.

How this study might affect research, practice and policy The findings inform targeted interventions, such as clinician training, integration of newborn feeding counseling into maternal care, and improved access to feeding tools, shaping research, policy, and practice to enhance neonatal feeding outcomes in low-resource settings.

The authors have declared no competing interest.

This study was nested within the Saving Little Lives (SLL) project (Reference Number: NoH/R/T/T/D/5/9, Date:12/13/2021), funded by the Global Financing Facility through UNICEF. Additional support was provided by the Emory Global Health Institute (EGHI).

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The details of the IRB/oversight body that provided approval or exemption for the research described are given below:

The Research Ethics Committee (REC) of the Amhara Public Health Institute (APHI) approved the study (Reference Number: NoH/R/T/T/D/5/9, Date:12/13/2021). The Institutional Review Board of Emory University granted an exemption for this research study as it falls under the category of non-human subject research.

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