Although breastfeeding is a key child survival strategy, breastfeeding practices in South African health institutions can generally be categorised as being poor. This cross-sectional study aimed to document practices around breastfeeding support and compliance with the Baby-Friendly Hospital Initiative’s “10 steps to successful breastfeeding”. Suboptimal practices were identified in both baby-friendly accredited and non-accredited facilities, but more so in the latter. None of the facilities passed all 10 steps. Steps that required advice and support from nursing staff - namely step 5 (showing mothers how to breastfeed), step 8 (encouraging breastfeeding on demand), and step 10 (breastfeeding support after discharge from the facility) were particularly poorly done in the majority of facilities. Baby-friendly certified institutions were significantly better than non-accredited facilities for steps 2 (training), 4 (initiating breastfeeding within 1 hour), and 7 (rooming-in). Baby-Friendly Hospitals could not maintain their accredited status on this assessment. However, some good practices appeared to be more sustainable over time.