feeding practices in the first few days of life play an important role in 
 neonatal health : studies in nepal , india , and ghana 
  have reported that 
 newborns who were first breastfed within 24 hours of birth had a lower risk of 
 neonatal mortality relative to newborns for whom breastfeeding was initiated after 
 the first day .
several studies in south asia have drawn attention to harmful 
 practices such as delayed breastfeeding , giving prelacteals , and discarding 
 colostrum . 

colostrum is an important source of antibodies and lymphocytes and provides 
 nutrition appropriate to the immature digestive system of the newborn .
however , with 
 the exception of demographic and health surveys ( dhs ) , little is known about feeding 
 practices for neonates in sub - saharan africa , and particularly in francophone 
 africa .
globally , there is also limited understanding of the demographic , economic , 
 and cultural factors influencing newborn feeding practices .
burkina faso is a predominantly rural landlocked country in west africa that 
 has high levels of under - five and maternal mortality and has an estimated neonatal 
 mortality rate of 29 per 1000 live births .
feeding practices are generally poor : in the 2010 dhs , less 
 than 25% of infants
05 months were exclusively breastfed and 
 36% received something other than breastmilk in the first three days of life 
 .
the prevalence of 
 malnutrition is correspondingly high : 6% of children under 5 years and 
 11% of those less than 6 months were severely wasted in 2010 ( weight for 
 height z - score <
a prospective study of exclusive breastfeeding promotion and mortality is 
 underway in southwest burkina faso , but little is known about feeding practices in newborns or 
 factors influencing those practices . given the poor coverage of positive feeding 
 practices as well as the high levels of malnutrition and stagnant neonatal mortality 
 rate in burkina faso , there is an urgent need to better understand those practices 
 as well as factors influencing them in order to design effective interventions .
a 
 cross - sectional household survey to measure coverage of maternal , neonatal , and 
 child health ( mnch ) interventions was conducted in 20102011 in the context 
 of a program evaluation and included a set of questions addressing newborn care 
 practices .
we report on the coverage of newborn feeding practices measured in this 
 survey as well as an analysis of the determinants of those practices .
the survey was conducted in 16 health districts across seven regions of 
 burkina faso with a population of 4 424 354 in 2010 , representing 28% of 
 the country s population .
nine of the survey districts were implementing a mnch 
 program and were purposively selected by the ministry of health because of their 
 high under five mortality rates and weak presence of health partners , relative 
 to other regions of the country .
the remaining seven districts , which serve as a 
 comparison arm in the evaluation , were selected using an adapted approach to 
 restricted randomization , 
 in which the comparison and intervention districts were balanced on education , 
 health systems , and socio - economic variables .
the survey sample size was 18 000 households . based on previous household 
 surveys , 0.42 women with a live birth in the previous year per household were 
 expected , for a sample size of 7560 live births in the two years preceding the 
 survey . this sample size would allow measurement of newborn feeding indicators 
 with an absolute precision of 3 percentage points or less , assuming a design 
 effect of 2 and alpha of 0.05 .
all households in the survey districts were eligible to participate , 
 with the exception of those residing in urban census enumeration areas ( eas ) , 
 which were excluded from the sampling frame .
households were selected using 
 two - stage cluster sampling stratified by district . in each district , 34 rural 
 census eas ( 68 per district in each of two districts implementing community case 
 management of pneumonia ) were selected with probability proportional to 
 population size , and 30 households were selected in each ea using systematic 
 sampling .
a household questionnaire , including a household listing , was 
 administered to the head of household or other adult household member and used 
 to identify eligible women of reproductive age ( 1549 years ) residing in 
 the household .
no other inclusion or exclusion criteria were used beyond 
 willingness to participate in the survey . after being read an oral consent script and providing consent to 
 participate , all women were asked to provide summary birth histories and basic 
 socio - demographic data .
women reporting one or more live births in the 24 months 
 preceding the interview date were asked a series of questions about the most 
 recent birth , including antenatal and delivery care , newborn characteristics , 
 and postnatal care .
we used standard dhs questions regarding prelacteals and the 
 time to initiation of breastfeeding .
the questions concerning which prelacteals 
 were given and whether colostrum was given were adapted from a previous study in 
 bangladesh .   a 14-day training workshop that included training in local languages , 
 role plays , and a field exercise was conducted with 113 potential interviewers , 
 of whom 72 were selected as interviewers and 18 as team leaders based on 
 performance measures .
language experts from the institut national 
 dalphabetisation ( ina ) translated the questionnaires into the five 
 principal local languages in the survey area ( moor , fulfuld , 
 gourmatchma , kassna , and nuni ) and trained the interviewers to 
 administer the questionnaires in these languages . although there was no formal 
 written back - translation , the local language training was conducted as a 
 discussion between study staff , language experts , and interviewers in order to 
 determine the most appropriate terminology and formulation for each question . 

interviewers had been selected for the training based on their language 
 capacity . because local languages are primarily oral and can not be read by most 
 people in burkina , interviewers were given french questionnaires with key terms 
 noted in parentheses in the local language .
interviewers practiced administering 
 the questionnaires in the local language during the training to ensure that 
 translation was standard across interviewers .
team leaders and supervisors 
 regularly observed interviews in the field to ensure that questions were being 
 translated correctly .
data were collected between august 26 and october 31 , 2010 , 
 corresponding to the end of the rainy season in burkina .
supplementary data collection was 
 conducted from december 3 , 2010 to january 18 , 2011 in 31 clusters that had been 
 inaccessible during the rainy season , as well as 55 clusters where data 
 collection was not completed during the study period .
in addition , 24 clusters 
 covered during the main data collection period were re - surveyed ( households 
 initially surveyed were re - interviewed by different teams ) , primarily because of 
 low woman / household ratios , which raised questions of omission of eligible 
 women .
supervision was provided by 
 the team leaders , who had received additional training in supervision methods , 
 and by the study investigators .
questionnaires returned to the central office were re - checked for 
 inconsistencies , and open answers were coded .
four feeding practices were measured : breastfeeding initiation within 1 
 hour of birth , breastfeeding initiation within 24 hours of birth , giving the 
 colostrum , and giving prelacteals . to estimate coverage levels , the proportion 
 of newborns receiving each feeding practice was calculated . for this analysis , 
 missing and 
do nt know  responses were included and 
 analyzed as separate categories , as they provided some indication of data 
 quality .
when calculating coverage rates , newborns who did not have an 
 opportunity to receive the care practice were excluded .
for example , babies who 
 died within 72 hours of birth , or who were less than 72 hours old at the time of 
 the interview , were excluded from the numerator and denominator when calculating 
 the proportion of newborns who received a prelacteal .
time to breastfeeding initiation was measured as a continuous variable 
 and categorized for analysis as < 1 hour , 111 hours , 1223 
 hours , 2447 hours , and 48 hours or more .
two coverage indicators were 
 calculated from these categories : newborns breastfed < 1 hours of birth , and 
 newborns breastfed < 24 hours of birth .
a newborn was considered to have 
 received a prelacteal if the mother reported giving anything other than 
 breastmilk in the first 3 days of life ( definition is consistent with 
 dhs ) .
mothers were 
 asked whether they had given the newborn any colostrum , and their response was 
 coded as a binary ( yes / no ) variable .
maternal , newborn , and household - level characteristics were included in 
 the model as explanatory variables . for newborns , we included sex , perceived 
 size at birth , place of delivery ( home or facility ) , delivery complications , and 
 anc attendance ( number of visits ) during the pregnancy .
maternal characteristics 
 included age categorized in 5 year intervals , education ( none , primary , or 
 secondary ) , parity , previous death of a child , religion , and ethnicity .
we also 
 included household wealth quintile , which was determined by applying principal 
 components analysis to a set of household asset variables including household 
 goods , land ownership , and livestock ownership .
complicated delivery was defined as an unplanned facility delivery , a 
 delivery by cesarean section , or a delivery where women reported staying at the 
 facility for at least 3 days post - birth . with the exception of delivery by 
 cesarean section , which in rural burkina faso would be done exclusively in cases 
 of obstructed labor or other complications ,
these measures are proxies for 
 complicated deliveries ; by definition they include only facility deliveries .
data on birthweight were not collected in this study because in a 
 previous survey , most babies 
 born in rural areas were not weighed at birth . instead , mothers were asked 
 whether the baby was very large , larger than average , average , smaller than 
 average , or very small at birth .
data on birthweight and perceived size at birth 
 were both collected in the national 2010 burkina faso dhs , in which 66% of live births had 
 a measured birthweight . in the 2010 dhs , perceived size at birth had good 
 specificity ( 94% ) but poor sensitivity ( 45% ) in detecting low 
 birthweight ( < 2500 g ) . 
 therefore , perceived size at birth in this analysis was used not as a proxy for 
 low birthweight but rather as an indicator of the mother s perception of 
 the newborn s size .
bivariate and multivariate poisson regression models were used to 
 estimate relative risk ratios comparing the risk of feeding behaviors ( early 
 initiation of breastfeeding , giving colostrum , giving prelacteals ) by 
 maternal / newborn characteristic .
all variables hypothesized to be determinants , confounders , or effect 
 modifiers were retained in the final analysis , whether statistically significant 
 or not , as causal determinants might not show statistically significant 
 associations with these feeding practices for reasons related to sample size , 
 measurement , or model .
variance inflation factors ( vif ) were calculated for 
 variables hypothesized to be collinear . with the exception of maternal age and 
 parity , which had a vif of 1.74 , the other variables had vifs near 1.00 . 

standard errors and confidence intervals were adjusted using the taylor 
 linearization method to account for the effect of stratification and clustering . 

survey weights were used to account for unequal probability of selection and for 
 non - response .
all analyses were weighted , and weights were standardized by 
 dividing the weight for each live birth by the mean weight .
the study was reviewed and approved by the burkina faso national ethics 
 committee for health research ( n 2009 - 67 ) , by the burkina faso national 
 statistics council , and by the johns hopkins school of public health 
 institutional review board ( irb2590 ) .
the survey was conducted in 16 health districts across seven regions of 
 burkina faso with a population of 4 424 354 in 2010 , representing 28% of 
 the country s population .
nine of the survey districts were implementing a mnch 
 program and were purposively selected by the ministry of health because of their 
 high under five mortality rates and weak presence of health partners , relative 
 to other regions of the country .
the remaining seven districts , which serve as a 
 comparison arm in the evaluation , were selected using an adapted approach to 
 restricted randomization , 
 in which the comparison and intervention districts were balanced on education , 
 health systems , and socio - economic variables .
the survey sample size was 18 000 households . based on previous household 
 surveys , 0.42 women with a live birth in the previous year per household were 
 expected , for a sample size of 7560 live births in the two years preceding the 
 survey .
this sample size would allow measurement of newborn feeding indicators 
 with an absolute precision of 3 percentage points or less , assuming a design 
 effect of 2 and alpha of 0.05 .
all households in the survey districts were eligible to participate , 
 with the exception of those residing in urban census enumeration areas ( eas ) , 
 which were excluded from the sampling frame .
households were selected using 
 two - stage cluster sampling stratified by district . in each district , 34 rural 
 census eas ( 68 per district in each of two districts implementing community case 
 management of pneumonia ) were selected with probability proportional to 
 population size , and 30 households were selected in each ea using systematic 
 sampling . a household questionnaire , including a household listing , was 
 administered to the head of household or other adult household member and used 
 to identify eligible women of reproductive age ( 1549 years ) residing in 
 the household .
no other inclusion or exclusion criteria were used beyond 
 willingness to participate in the survey .
after being read an oral consent script and providing consent to 
 participate , all women were asked to provide summary birth histories and basic 
 socio - demographic data .
women reporting one or more live births in the 24 months 
 preceding the interview date were asked a series of questions about the most 
 recent birth , including antenatal and delivery care , newborn characteristics , 
 and postnatal care .
we used standard dhs questions regarding prelacteals and the 
 time to initiation of breastfeeding .
the questions concerning which prelacteals 
 were given and whether colostrum was given were adapted from a previous study in 
 bangladesh .
a 14-day training workshop that included training in local languages , 
 role plays , and a field exercise was conducted with 113 potential interviewers , 
 of whom 72 were selected as interviewers and 18 as team leaders based on 
 performance measures .
language experts from the institut national 
 dalphabetisation ( ina ) translated the questionnaires into the five 
 principal local languages in the survey area ( moor , fulfuld , 
 gourmatchma , kassna , and nuni ) and trained the interviewers to 
 administer the questionnaires in these languages .
although there was no formal 
 written back - translation , the local language training was conducted as a 
 discussion between study staff , language experts , and interviewers in order to 
 determine the most appropriate terminology and formulation for each question . 

interviewers had been selected for the training based on their language 
 capacity . because local languages are primarily oral and can not be read by most 
 people in burkina , interviewers were given french questionnaires with key terms 
 noted in parentheses in the local language .
interviewers practiced administering 
 the questionnaires in the local language during the training to ensure that 
 translation was standard across interviewers .
team leaders and supervisors 
 regularly observed interviews in the field to ensure that questions were being 
 translated correctly .
data were collected between august 26 and october 31 , 2010 , 
 corresponding to the end of the rainy season in burkina .
supplementary data collection was 
 conducted from december 3 , 2010 to january 18 , 2011 in 31 clusters that had been 
 inaccessible during the rainy season , as well as 55 clusters where data 
 collection was not completed during the study period .
in addition , 24 clusters 
 covered during the main data collection period were re - surveyed ( households 
 initially surveyed were re - interviewed by different teams ) , primarily because of 
 low woman / household ratios , which raised questions of omission of eligible 
 women .
supervision was provided by 
 the team leaders , who had received additional training in supervision methods , 
 and by the study investigators .
questionnaires returned to the central office were re - checked for 
 inconsistencies , and open answers were coded .
four feeding practices were measured : breastfeeding initiation within 1 
 hour of birth , breastfeeding initiation within 24 hours of birth , giving the 
 colostrum , and giving prelacteals . to estimate coverage levels ,
the proportion 
 of newborns receiving each feeding practice was calculated . for this analysis , 
 missing and 
do nt know  responses were included and 
 analyzed as separate categories , as they provided some indication of data 
 quality . when calculating coverage rates , newborns who did not have an 
 opportunity to receive the care practice were excluded .
for example , babies who 
 died within 72 hours of birth , or who were less than 72 hours old at the time of 
 the interview , were excluded from the numerator and denominator when calculating 
 the proportion of newborns who received a prelacteal .
time to breastfeeding initiation was measured as a continuous variable 
 and categorized for analysis as < 1 hour , 111 hours , 1223 
 hours , 2447 hours , and 48 hours or more .
two coverage indicators were 
 calculated from these categories : newborns breastfed < 1 hours of birth , and 
 newborns breastfed < 24 hours of birth . a newborn was considered to have 
 received a prelacteal if the mother reported giving anything other than 
 breastmilk in the first 3 days of life ( definition is consistent with 
 dhs ) .
mothers were 
 asked whether they had given the newborn any colostrum , and their response was 
 coded as a binary ( yes / no ) variable .
maternal , newborn , and household - level characteristics were included in 
 the model as explanatory variables . for newborns , we included sex , perceived 
 size at birth , place of delivery ( home or facility ) , delivery complications , and 
 anc attendance ( number of visits ) during the pregnancy .
maternal characteristics 
 included age categorized in 5 year intervals , education ( none , primary , or 
 secondary ) , parity , previous death of a child , religion , and ethnicity .
we also 
 included household wealth quintile , which was determined by applying principal 
 components analysis to a set of household asset variables including household 
 goods , land ownership , and livestock ownership .
complicated delivery was defined as an unplanned facility delivery , a 
 delivery by cesarean section , or a delivery where women reported staying at the 
 facility for at least 3 days post - birth . with the exception of delivery by 
 cesarean section , which in rural burkina faso would be done exclusively in cases 
 of obstructed labor or other complications ,
these measures are proxies for 
 complicated deliveries ; by definition they include only facility deliveries .
data on birthweight were not collected in this study because in a 
 previous survey , most babies 
 born in rural areas were not weighed at birth . instead , mothers were asked 
 whether the baby was very large , larger than average , average , smaller than 
 average , or very small at birth .
data on birthweight and perceived size at birth 
 were both collected in the national 2010 burkina faso dhs , in which 66% of live births had 
 a measured birthweight . in the 2010 dhs , perceived size at birth had good 
 specificity ( 94% ) but poor sensitivity ( 45% ) in detecting low 
 birthweight ( < 2500 g ) . 
 therefore , perceived size at birth in this analysis was used not as a proxy for 
 low birthweight but rather as an indicator of the mother s perception of 
 the newborn s size .
bivariate and multivariate poisson regression models were used to 
 estimate relative risk ratios comparing the risk of feeding behaviors ( early 
 initiation of breastfeeding , giving colostrum , giving prelacteals ) by 
 maternal / newborn characteristic .
all variables hypothesized to be determinants , confounders , or effect 
 modifiers were retained in the final analysis , whether statistically significant 
 or not , as causal determinants might not show statistically significant 
 associations with these feeding practices for reasons related to sample size , 
 measurement , or model .
variance inflation factors ( vif ) were calculated for 
 variables hypothesized to be collinear . with the exception of maternal age and 
 parity , which had a vif of 1.74 , the other variables had vifs near 1.00 . 

standard errors and confidence intervals were adjusted using the taylor 
 linearization method to account for the effect of stratification and clustering . 

survey weights were used to account for unequal probability of selection and for 
 non - response .
all analyses were weighted , and weights were standardized by 
 dividing the weight for each live birth by the mean weight .
the study was reviewed and approved by the burkina faso national ethics 
 committee for health research ( n 2009 - 67 ) , by the burkina faso national 
 statistics council , and by the johns hopkins school of public health 
 institutional review board ( irb2590 ) .
from august 26 , 2010 to january 18 , 2011 , 18 360 households across 16 
 health districts in burkina faso were visited by study interviewers . 

interviewers completed 17 139 ( 93% ) household interviews identifying 23 
 134 women of reproductive age , of whom 21 953 ( 95% ) completed the 
 interview .
the main reason for household and woman non - response was the absence 
 of the household or of the woman .
data collection was largely completed during 
 the rainy season and harvest period , when individuals and households frequently 
 move away from their compounds to be closer to their fields . among
the women interviewed , 7 878 reported a live birth in the 
 preceding two years .
these women were young ( median age 27 years , range 
 1549 years ) , but of high parity ( median 4 live births , range 
 115 ) , indicative of the high fertility in this population .
the vast 
 majority of the women ( 94% ) had no formal education . despite declining 
 under - five mortality rates in burkina faso ,
mortality was high : after excluding 
 primiparas , approximately 45% of all women with a live birth in the two 
 years before the survey reported a death of a prior live born child .
respondents 
 reported frequent health service contacts , with 45% reporting 4 or more 
 antenatal care ( anc ) visits during the pregnancy and over 70% delivering 
 in a health facility .
breastfeeding was very common in this 
 population : 0.5% ( n=36 ) of live births were reported as never 
 breastfed , and 64% ( 23 of 36 ) of these non - breastfed babies died in the 
 first seven days after birth .
one - quarter 
 of newborns were put to the breast within one hour of birth , and three - quarters 
 were breastfed in the first 24 hours .
most mothers reported initiating 
 breastfeeding either in the first few hours of life , or after 24 hours ; only 
 2% reported initiating breastfeeding 1223 hours after 
 birth .
colostrum was given to 84% of newborns , and 21% of those 
 surviving to 3 days were given something other than breastmilk in the first 3 
 days of life ( table 1 ) .
water , 
 sugar - water , and teas were the most common prelacteals ( table 2 ) .
receipt of colostrum was more frequent among those breastfed in the 
 first 24 hours : 88% of those breastfed within 24 hours received the 
 colostrum , as compared to 75% among those who began breastfeeding at 1 
 day or later ( arr=1.16 ) .
receipt of prelacteals was more frequent among 
 babies first breastfed after 24 hours relative to those breastfed in the first 
 day ( 42% vs. 15% , arr=2.67 ) .
birth in a 
 health facility was associated with receipt of positive feeding practices : 
 facility - born babies were slightly more likely to be breastfed within 24 hours 
 ( arr=1.06 95% ci : 1.021.10 ) and to receive colostrum 
 ( arr=1.07 , 95% ci : 1.041.11 ) , relative to those born at 
 home .
facility - born babies were also 34% less likely to be given 
 prelacteals ( arr=0.66 , 95% ci : 0.570.75 ) .
however , 
 there was a slight negative association between facility birth and breastfeeding 
 within one hour of birth ( arr=0.81 , 95% ci : 0.710.94 ) . 

more frequent anc attendance was associated with an increased probability of 
 giving colostrum ( arr=1.12 , 95% ci : 1.011.24 for 4 or 
 more anc visits as compared to no anc ) , and decreased risk of giving prelacteals 
 ( arr=0.57 , 95% ci : 0.450.73 for 4 or more anc 
 visits ) .
newborn sex and maternal education , age , parity , and death of a child 
 were not consistently associated with breastfeeding practices , except that women 
 with a secondary education , relative to no education , were more likely to give 
 colostrum to the newborn ( arr=1.13 , 95% ci : 1.081.19 ) . 

maternal ethnicity and religion , however , were strongly associated with all 
 feeding practices , although the direction of these associations varied .
bissa 
 ethnicity was associated with protective breastfeeding practices , relative to 
 the majority mossi ethnic group ( arr=2.47 95% ci : 
 2.042.98 for breastfeeding within one hour , arr=1.12 , 
 95% ci : 1.061.17 for colostrum , arr=0.32 , 95% 
 ci : 0.150.66for prelacteals ) .
women of the gourmatch ethnic 
 group were slightly more likely than the mossi to initiate breastfeeding within 
 24 hours ( arr=1.16 , 95% ci : 1.111.21 ) and to give 
 colostrum to the newborn ( arr=1.11 , 95% ci : 1.051.16 ) , 
 but less likely to give prelacteals ( arr=0.67 , 95% ci : 
 0.490.91 )
. traditional or animist religion was negatively associated 
 with initiation of breastfeeding within one hour of birth ( arr=0.74 , 
 95% ci : 0.590.94 ) , and with giving the colostrum 
 ( arr=0.94 , 95% ci : 0.881.00 ) , and positively associated 
 with giving prelacteals ( arr=1.57 , 95% ci : 1.301.90 ) 
 relative to muslim religion .
from august 26 , 2010 to january 18 , 2011 , 18 360 households across 16 
 health districts in burkina faso were visited by study interviewers . 

interviewers completed 17 139 ( 93% ) household interviews identifying 23 
 134 women of reproductive age , of whom 21 953 ( 95% ) completed the 
 interview .
the main reason for household and woman non - response was the absence 
 of the household or of the woman .
data collection was largely completed during 
 the rainy season and harvest period , when individuals and households frequently 
 move away from their compounds to be closer to their fields . among
the women interviewed , 7 878 reported a live birth in the 
 preceding two years .
these women were young ( median age 27 years , range 
 1549 years ) , but of high parity ( median 4 live births , range 
 115 ) , indicative of the high fertility in this population .
the vast 
 majority of the women ( 94% ) had no formal education . despite declining 
 under - five mortality rates in burkina faso ,
mortality was high : after excluding 
 primiparas , approximately 45% of all women with a live birth in the two 
 years before the survey reported a death of a prior live born child .
respondents 
 reported frequent health service contacts , with 45% reporting 4 or more 
 antenatal care ( anc ) visits during the pregnancy and over 70% delivering 
 in a health facility .
breastfeeding was very common in this 
 population : 0.5% ( n=36 ) of live births were reported as never 
 breastfed , and 64% ( 23 of 36 ) of these non - breastfed babies died in the 
 first seven days after birth .
one - quarter 
 of newborns were put to the breast within one hour of birth , and three - quarters 
 were breastfed in the first 24 hours .
most mothers reported initiating 
 breastfeeding either in the first few hours of life , or after 24 hours ; only 
 2% reported initiating breastfeeding 1223 hours after 
 birth .
colostrum was given to 84% of newborns , and 21% of those 
 surviving to 3 days were given something other than breastmilk in the first 3 
 days of life ( table 1 ) .
water , 
 sugar - water , and teas were the most common prelacteals ( table 2 ) .
receipt of colostrum was more frequent among those breastfed in the 
 first 24 hours : 88% of those breastfed within 24 hours received the 
 colostrum , as compared to 75% among those who began breastfeeding at 1 
 day or later ( arr=1.16 ) .
receipt of prelacteals was more frequent among 
 babies first breastfed after 24 hours relative to those breastfed in the first 
 day ( 42% vs. 15% , arr=2.67 ) .
birth in a 
 health facility was associated with receipt of positive feeding practices : 
 facility - born babies were slightly more likely to be breastfed within 24 hours 
 ( arr=1.06 95% ci : 1.021.10 ) and to receive colostrum 
 ( arr=1.07 , 95% ci : 1.041.11 ) , relative to those born at 
 home .
facility - born babies were also 34% less likely to be given 
 prelacteals ( arr=0.66 , 95% ci : 0.570.75 ) .
however , 
 there was a slight negative association between facility birth and breastfeeding 
 within one hour of birth ( arr=0.81 , 95% ci : 0.710.94 ) . 

more frequent anc attendance was associated with an increased probability of 
 giving colostrum ( arr=1.12 , 95% ci : 1.011.24 for 4 or 
 more anc visits as compared to no anc ) , and decreased risk of giving prelacteals 
 ( arr=0.57 , 95% ci : 0.450.73 for 4 or more anc 
 visits ) .
newborn sex and maternal education , age , parity , and death of a child 
 were not consistently associated with breastfeeding practices , except that women 
 with a secondary education , relative to no education , were more likely to give 
 colostrum to the newborn ( arr=1.13 , 95% ci : 1.081.19 ) . 

maternal ethnicity and religion , however , were strongly associated with all 
 feeding practices , although the direction of these associations varied .
bissa 
 ethnicity was associated with protective breastfeeding practices , relative to 
 the majority mossi ethnic group ( arr=2.47 95% ci : 
 2.042.98 for breastfeeding within one hour , arr=1.12 , 
 95% ci : 1.061.17 for colostrum , arr=0.32 , 95% 
 ci : 0.150.66for prelacteals ) .
women of the gourmatch ethnic 
 group were slightly more likely than the mossi to initiate breastfeeding within 
 24 hours ( arr=1.16 , 95% ci : 1.111.21 ) and to give 
 colostrum to the newborn ( arr=1.11 , 95% ci : 1.051.16 ) , 
 but less likely to give prelacteals ( arr=0.67 , 95% ci : 
 0.490.91 ) . traditional or animist religion was negatively associated 
 with initiation of breastfeeding within one hour of birth ( arr=0.74 , 
 95% ci : 0.590.94 ) , and with giving the colostrum 
 ( arr=0.94 , 95% ci : 0.881.00 ) , and positively associated 
 with giving prelacteals ( arr=1.57 , 95% ci : 1.301.90 ) 
 relative to muslim religion .
this paper describes current feeding practices in the early neonatal period 
 in rural burkina faso , and identifies factors associated with positive feeding 
 practices .
breastfeeding was almost universal , and initiation of breastfeeding 
 occurred in the first 24 hours for 76% of newborns , which is similar to 
 breastfeeding initiation patterns reported in northern ghana ( 71% within 24 
 hours ) .
studies of breastfeeding 
 initiation in south asia have reported a wide range of coverage rates for 
 breastfeeding initiation within 24 hours ( 15%  90% ) 
 .
consistent with the high coverage for 
 breastfeeding initiation in the first day , most women in our survey also reported 
 giving colostrum to their newborns .
although colostrum has traditionally been 
 perceived as dirty or old milk and was often discarded in many settings 4 , 5 , 
 19 , recent studies in india and 
 the gambia have also documented increased acceptance of the practice of giving 
 colostrum .
harmful practices such as giving prelacteals were reported for only 
 21% of newborns . in this study , after accounting for confounders , early 
 initiation of breastfeeding was associated with a reduced risk of receiving 
 prelacteals , perhaps because early initiation of breastfeeding reduced the perceived 
 need for prelacteals , or because mothers had received counseling on both practices . 

this finding contradicts previous qualitative studies in india and the gambia that 
 have reported that prelacteals are given to newborns even when breastfeeding is 
 initiated soon after birth , but is consistent with a study in 
 rural nepal that found an eight - fold increase in the odds of being exclusively 
 breastfed among newborns breastfed within 24 hours of birth relative to those for 
 whom breastfeeding was initiated after 24 hours . the practice of giving water as a prelacteal echoes the findings from 
 studies in other african settings , where water was perceived to be necessary for 
 breastfed infants in order to prevent dehydration . in mozambique and the gambia , for 
 example ,
caregivers interviewed were resistant to exclusive breastfeeding , believing that children needed to be given water even in 
 the newborn period .
addressing this belief through mass media campaigns and/or 
 counseling during antenatal and postnatal visits could reduce the use of prelacteals 
 and increase the prevalence of exclusive breastfeeding . in an analysis of dhs data in bangladesh ,
secondary education was positively 
 associated with early initiation of breastfeeding . 
 in this study , however , secondary education was positively associated with giving 
 colostrum but not with any other practice , possibly because the proportion of women 
 with any secondary education was very small ( 1.5% in burkina faso vs. 
 34% in bangladesh ) .
surprisingly , maternal characteristics other than 
 ethnicity , religion , and education showed no association with feeding practices 
 after adjusting for confounders .
the association with ethnicity suggests that 
 feeding behavior may be largely determined by established practices within the 
 mother s ethnic group . to date ,
educational and behavior change campaigns 
 related to newborn feeding practices in this setting have been limited and not 
 explicitly designed to meet the varying needs of specific ethnic groups , which may 
 also explain our failure to find associations between feeding practices and maternal 
 age or education .
newborns perceived to have been smaller than average or very small at birth 
 were less likely to have been breastfed within 24 hours of birth , relative to 
 newborns perceived to have been of average or larger than average size .
studies in 
 brazil and sri lanka have also reported that breastfeeding initiation was delayed 
 among low birthweight newborns relative to normal birthweight newborns . it should be noted that our analysis used maternal 
 perception of size at birth , which may not be a good proxy for birthweight . of 
 concern , however , is that even when mothers perceived a newborn to be smaller than 
 average , he or she was no more likely to receive positive feeding practices than 
 larger newborns . further exploring breastfeeding practices among vulnerable babies 
 ( low birth weight , preterm ) is critically important given the suspected high 
 prevalence of low birthweight in this population ( 19% , based on adjusted dhs 
 data ) and the vulnerability of 
 these babies . an important limitation to this study is that the indicators are based 
 on maternal recall of events soon after birth , with the recall period extending 
 up to 2 years after the birth .
standard survey questions were used where 
 possible , both to increase comparability with other surveys and because the 
 questions had already been tested in various settings . as is true of most mnch 
 survey questions ,
in addition , 
 there were limitations to some of our explanatory variables , such as complicated 
 delivery , which was based on imperfect proxies .
some misclassification is 
 therefore likely to have occurred for both feeding practices and explanatory 
 variables . to the extent that the misclassification was non - differential ,
. however , 
 differential misclassification by explanatory variables ( such as place of 
 delivery ) is possible and would have resulted in biased relative risk estimates , 
 though the direction of the bias is difficult to predict .
the effectiveness of early initiation of breastfeeding may be dependent 
 on its timing in relation to birth 1 , 
 2 , 3 .
recall of the interval between birth and initiation of 
 breastfeeding is likely to be difficult for women in many settings ; in this 
 study population an additional complication was that most of the women in the 
 sample had no formal education and had difficulty providing a numeric response 
 when asked to recall time intervals .
if women were not accurately able to gauge 
 or recall these time intervals , misclassification is likely to have occurred . if 
 the ability to recall or gauge time was differential ( e.g. , women with some 
 education were able to recall or estimate time more accurately ) , it may have 
 biased observed associations between maternal characteristics and feeding 
 practices .
we considered asking about the timing of breastfeeding initiation in 
 relation to an event such as the delivery of the placenta ; however , the use of 
 this as an anchoring time point is not recommended , given the substantial natural 
 variability in time to placental delivery .
in addition to misclassification , 
 social desirability bias may have led women to over - report practices like early 
 initiation of breastfeeding , if they perceived those practices to be positive . 
 however , this risk may be minimal in this study given the lack of educational 
 activities or campaigns about newborn feeding practices .
positive early feeding practices may positively influence breastfeeding 
 duration and exclusivity later in infancy : delayed breastfeeding initiation and 
 use of prelacteals have been associated with shorter duration of breastfeeding , 
 relative to newborns breastfed within 12 hours of birth and who received 
 breastmilk as their first feed .
the prevalence of positive feeding practices in the 
 newborn period is therefore of critical importance , particularly in settings 
 with a high prevalence of malnutrition , such as burkina faso .
the results of 
 this study indicate that positive feeding practices , including breastfeeding 
 initiation within 24 hours , giving colostrum , and not giving prelacteals , are 
 relatively common in the study population , although more progress is needed , 
 particularly with respect to breastfeeding initiation .
the data also suggest 
 that early initiation of breastfeeding led to reduced use of prelacteals and a 
 higher likelihood of receiving the colostrum .
the finding that facility - born neonates are more likely to receive 
 positive feeding practices is encouraging , especially given the increasing 
 coverage of facility birth in rural burkina . however , initiation of 
 breastfeeding appeared to be somewhat delayed in facility births .
this delay may 
 have been due to other activities surrounding the birth ( weighing of the 
 newborn , monitoring of the third stage of labor ) and suggests the need for 
 additional promotion of immediate breastfeeding among auxiliary midwives and 
 nurses who are in the delivery room .
these results suggest several avenues for 
 improving feeding practices for newborns in burkina faso , such as through 
 counselling during postnatal health checks after home births , and increased 
 efforts to improve facility practices around breastfeeding initiation .
the 
 findings also highlight the need for a qualitative assessment of factors 
 influencing feeding practices in the neonatal period .
if water is given after 
 birth in an effort to prevent dehydration , for example , then addressing this 
 understanding will be essential to reducing the use of prelacteals .
it could 
 also increase early initiation of breastfeeding , if breastfeeding was promoted 
 as a means of preventing dehydration .
research is also needed to understand the 
 role ethnicity plays in determining feeding practices in burkina in the neonatal 
 period and beyond , and to assess what interventions might be effective in 
 changing these practices .
an important limitation to this study is that the indicators are based 
 on maternal recall of events soon after birth , with the recall period extending 
 up to 2 years after the birth .
standard survey questions were used where 
 possible , both to increase comparability with other surveys and because the 
 questions had already been tested in various settings . as is true of most mnch 
 survey questions ,
in addition , 
 there were limitations to some of our explanatory variables , such as complicated 
 delivery , which was based on imperfect proxies .
some misclassification is 
 therefore likely to have occurred for both feeding practices and explanatory 
 variables .
to the extent that the misclassification was non - differential , it 
 would have biased relative risk estimates towards the null . however , 
 differential misclassification by explanatory variables ( such as place of 
 delivery ) is possible and would have resulted in biased relative risk estimates , 
 though the direction of the bias is difficult to predict .
the effectiveness of early initiation of breastfeeding may be dependent 
 on its timing in relation to birth 1 , 
 2 , 3 .
recall of the interval between birth and initiation of 
 breastfeeding is likely to be difficult for women in many settings ; in this 
 study population an additional complication was that most of the women in the 
 sample had no formal education and had difficulty providing a numeric response 
 when asked to recall time intervals .
if women were not accurately able to gauge 
 or recall these time intervals , misclassification is likely to have occurred . if 
 the ability to recall or gauge time was differential ( e.g. , women with some 
 education were able to recall or estimate time more accurately ) , it may have 
 biased observed associations between maternal characteristics and feeding 
 practices .
we considered asking about the timing of breastfeeding initiation in 
 relation to an event such as the delivery of the placenta ; however , the use of 
 this as an anchoring time point is not recommended , given the substantial natural 
 variability in time to placental delivery .
in addition to misclassification , 
 social desirability bias may have led women to over - report practices like early 
 initiation of breastfeeding , if they perceived those practices to be positive
. 
 however , this risk may be minimal in this study given the lack of educational 
 activities or campaigns about newborn feeding practices .
positive early feeding practices may positively influence breastfeeding 
 duration and exclusivity later in infancy : delayed breastfeeding initiation and 
 use of prelacteals have been associated with shorter duration of breastfeeding , 
 relative to newborns breastfed within 12 hours of birth and who received 
 breastmilk as their first feed .
the prevalence of positive feeding practices in the 
 newborn period is therefore of critical importance , particularly in settings 
 with a high prevalence of malnutrition , such as burkina faso .
the results of 
 this study indicate that positive feeding practices , including breastfeeding 
 initiation within 24 hours , giving colostrum , and not giving prelacteals , are 
 relatively common in the study population , although more progress is needed , 
 particularly with respect to breastfeeding initiation .
the data also suggest 
 that early initiation of breastfeeding led to reduced use of prelacteals and a 
 higher likelihood of receiving the colostrum .
the finding that facility - born neonates are more likely to receive 
 positive feeding practices is encouraging , especially given the increasing 
 coverage of facility birth in rural burkina .
this delay may 
 have been due to other activities surrounding the birth ( weighing of the 
 newborn , monitoring of the third stage of labor ) and suggests the need for 
 additional promotion of immediate breastfeeding among auxiliary midwives and 
 nurses who are in the delivery room .
these results suggest several avenues for 
 improving feeding practices for newborns in burkina faso , such as through 
 counselling during postnatal health checks after home births , and increased 
 efforts to improve facility practices around breastfeeding initiation .
the 
 findings also highlight the need for a qualitative assessment of factors 
 influencing feeding practices in the neonatal period .
if water is given after 
 birth in an effort to prevent dehydration , for example , then addressing this 
 understanding will be essential to reducing the use of prelacteals
. it could 
 also increase early initiation of breastfeeding , if breastfeeding was promoted 
 as a means of preventing dehydration .
research is also needed to understand the 
 role ethnicity plays in determining feeding practices in burkina in the neonatal 
 period and beyond , and to assess what interventions might be effective in 
 changing these practices .
 objectivesnewborn feeding practices are important to neonatal health and 
 survival , but understudied in sub - saharan africa . 
 we assessed the prevalence 
 and determinants of newborn feeding practices in burkina faso.study designan 18 000 household survey was conducted in rural burkina faso in 
 20102011 . 
 women of reproductive age were asked about antenatal , 
 delivery , and newborn care practices for their most recent live birth . 
 
 coverage of newborn feeding practices was estimated and multivariate 
 regression was used to assess determinants of these practices.resultsseventy-six percent of live births were breastfed within 24 hours of 
 birth , 84% were given colostrum , and 21% received 
 prelacteals . facility delivery and antenatal care attendance were associated 
 with positive feeding practices.conclusionspositive newborn feeding practices were common in rural burkina faso , 
 relative to other low - income settings . 
 interventions are needed to improve 
 feeding practices among home - born babies , and to encourage earlier 
 initiation of breastfeeding among facility - born newborns . 
Background
Methods
Setting
Sample size
Selection of households, women, and births
Data collection
Data management and analysis
Ethical and administrative clearance
Results
Study population
Coverage of newborn care practices
Determinants of breastfeeding practices
Discussion
Limitations
Conclusions
Supplementary Material