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 .