ORIGINAL ARTICLE Impact of mother-baby friendly initiative plus approach on improving human milk feeding for neonates in hospital: a quality improvement before-and-after uncontrolled study Jayashree Mondkar 1 & Deepak Chawla 2 & Ruchika Chugh Sachdeva 3 & Swati Manerkar 1 & Sunita Shanbhag 4 & Aisha Khan 4 & Minu Manuhar 5 & Maya Ganesh Wankhede 5 & Vidya Thakur 5 & Kiersten Israel-Ballard 6 Received: 1 April 2021 /Revised: 27 May 2021 /Accepted: 31 May 2021 # The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature 2021 Abstract Breastfeeding, use of pasteurised donor human milk when mother’s own milk is unavailable and kangaroo mother care have independently proven benefits in improving survival of vulnerable sick babies. A triangulated approach called the Mother Baby Friendly Initiative Plus (MBFI+) model, bringing together the combined benefits of these proven interventions, was used to improve exclusive human milk feeding at health facilities through quality improvement and system strengthening approach. This quality improvement before-and-after uncontrolled study enrolled 5343 term and 278 very low birth weight (VLBW) mother- infant dyads. Pre- and post-intervention data were compared to evaluate effect on feeding-related healthcare processes and outcomes. Primary outcome which was incidence of exclusive human milk feeding during hospital stay, improved from 44 to 64.8% (RR 1.47, 95% CI: 1.40–1.55) among term and from 60.5 to 80.7% (RR: 1.33; 95% CI: 1.12–1.59) among VLBW neonates. Neonates receiving extended KMC improved from 43 to 71.1% (RR: 1.65; 95% CI: 1.30–2.10). Conclusion: MBFI+ approach improved exclusive human milk feeding among term and preterm VLBW neonates. Keywords Human milk banking . Breastfeeding support . Kangaroo mother care . MBFI plus . Pasteurised donor human milk . Quality improvement Introduction Breastfeeding has significant health benefits for both term and preterm neonates and has the potential to prevent 0.16 million under-five deaths annually in India [1]. Kangaroo mother care (KMC) is another intervention shown to improve exclusive breastfeeding and prevent up to half of all deaths in infants weighing < 2000 g [2]. Many babies lack access to mothers’ What is Known: • Breastfeeding has immense health benefits to sick preterm neonates admitted in NICU. What is New: • Quality improvement approach can lead to system strengthening and can help overcome hindrances to achieve increased breastfeeding rates. Communicated by Daniele De Luca * Swati Manerkar drswatimanerkar@gmail.com 1 Department of Neonatology, Lokmanya Tilak Municipal Medical College and Lokmanya Tilak Municipal General Hospital, Sion, Mumbai 400022, India 2 Department of Neonatology, Government Medical College and Hospital, Chandigarh 160 030, India 3 Nutrition Lead, India Country office, Bill and Melinda Gates Foundation, Seattle, USA 4 Lokmanya Tilak Municipal Medical College and Lokmanya Tilak Municipal General Hospital, Sion, Mumbai 400022, India 5 Seth V C Gandhi and M.A. Vora Municipal General Hospital, Rajawadi, Ghatkopar East, Mumbai 400077, India 6 Maternal, Newborn and Child Health and Nutrition Program, PATH, Seattle, WA 98121, USA European Journal of Pediatrics https://doi.org/10.1007/s00431-021-04141-9