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R E S E A R C H Open Access
Prelacteal feeding practices in Pakistan: a
mixed-methods study
Muhammad Asim
1,2,3
, Zarak Husain Ahmed
1
, Mark D. Hayward
4
and Elizabeth M. Widen
5*
Abstract
Background: Prelacteal feeding, the feeding a newborn substances or liquids before breastfeeding, is a common
cultural practice in Pakistan, but is associated with neonatal morbidity and mortality because it delays early
initiation of breastfeeding. In this study, we sought to examine the social and cultural factors associated with
prelacteal feeding in Pakistan.
Methods: This mixed-method study used data from the Pakistan Demographic and Health Survey (PDHS) 2012–13.
Findings from the survey were complemented by qualitative interviews with mothers and healthcare providers. In a
subset of PDHS dyads (n= 1361) with children (0–23 months), descriptive statistics and bivariate and multivariable
logistic regression analysis examined factors associated with prelacteal feeding. The qualitative study included in-depth
interviews with six mothers and six health care providers, which were analyzed using NVivo software version 10.
Results: In PDHS, a majority of children (64.7%) received prelacteal feeding. The most common prelacteal food was
milk other than breast milk (24.5%), while over a fifth (21.8%) of mothers reported giving honey and sugar water. Factors
associated with prelacteal feeding included: birth at public health facilities (AOR 0.46, 95% CI 0.02, 0.95), maternal
primary education (AOR 2.28, 95% CI 1.35, 3.85), and delayed breastfeeding initiation (AOR 0.03, 95% CI 0.01, 0.61). In
our qualitative study, the major themes found associated with prelacteal feedings included: easy access to prelacteal
substances at health facilities, deliveries in private health facilities, prelacteals as a family tradition for socialization,
insufficient breast milk, Sunna of Holy Prophet, and myths about colostrum.
Conclusions: These data indicate that prelacteal feeding is a well-established practice and social norm in Pakistan.
Policies and interventions aimed at promoting breastfeeding need to take these customs into consideration to achieve
the desired behavioral changes.
Keywords: Prelacteal, Delayed breastfeeding, Insufficient breast milk, Home and hospital deliveries, Pakistan
Background
Nutrition and care in the neonatal period are critical for
infant survival, growth, and development. The World
Health Organization (WHO) recommends initiation of
breastfeeding within the first hour of birth and exclusive
breastfeeding for the first 6 months of life, meaning no
other foods or liquids should be introduced to the infant
during that time [1]. However, the practice of feeding
substances or liquids other than breast milk to newborns
is a common cultural practice in many low-income
countries [2]. Providing different substances to infants
before the initiation of breastfeeding, or in the first 3
days after delivery, is known as prelacteal feeding [3–5],
and the substances are known as prelacteals [6]. The
type of prelacteal fed varies according to cultural prefer-
ences and include a diverse array of substances such as
honey, goat milk, and rose or sap water [7,8].
Prelacteal feeding is a major cause of delayed breast-
feeding, non-exclusive breastfeeding, and lactation
failure [9–11]. Prelacteal feeding deprives neonates of
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data made available in this article, unless otherwise stated in a credit line to the data.
* Correspondence: elizabeth.widen@austin.utexas.edu
5
Department of Nutritional Sciences & Population Research Center, University
of Texas at Austin, Austin, Texas, USA
Full list of author information is available at the end of the article
Asim et al. International Breastfeeding Journal (2020) 15:53
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the potential benefits of colostrum, which may be a
major contributor to high morbidity and mortality in the
neonatal period [12–16]. This practice may lead to the
development of a weak immune system and infection in
children. To avoid these negative health outcomes, some
believe that shifting prelacteal feeding practices could
potentially save the lives of around 830,000 children an-
nually [17].
According to data from low and middle-income coun-
tries (LMICs), the prevalence of prelacteal feeding in
Ethiopia [18], India [19], Bangladesh [20], Afghanistan
[21], and Nigeria [22] is 19, 21, 27, 43, and 59%, respect-
ively. When compared to these countries, the situation is
markedly worse in Pakistan, where the practice of giving
prelacteal feeds to neonates increased from 68% of all
births in 2007 to 76% in 2018 [23]. Consequently,
Pakistan has the lowest prevalence of early initiation of
breastfeeding and highest rate of non-exclusive breast-
feeding in South Asia [24]. This can be attributed to
culture-specific prelacteal practices, where early initi-
ation of breastfeeding is deliberately delayed to adhere
to cultural and social norms [25]. Thus, breastfeeding is,
unfortunately, not an immediate priority for nursing
mothers in Pakistan, many of whom believe that the first
feed of neonates should be honey, rosewater, or goat
milk [26,27]. Such high prevalence of prelacteal feeding,
may therefore place Pakistani neonates at a greater risk
for morbidities and mortality associated with prelacteals
and delayed breastfeeding than other LMICs.
To advance the understanding of prelacteal feeding prac-
tices in Pakistan, we applied a mixed-methods approach to
explore the major determinants for prelacteal feeding in
Pakistan. This study includes quantitative analysis with
Pakistan Demographic and Health Survey (PDHS) data, as
well as a qualitative assessment of healthcare providers and
mothers. This approach allowed us to comprehensively
examine prelacteal feeding practices in Pakistan.
Methods
We applied a sequential exploratory mixed-methods de-
sign, which consisted of two phases: qualitative investiga-
tion, followed by quantitative data analysis and data
triangulation [28]. During the first phase, we conducted
in-depth interviews with mothers and healthcare pro-
viders. Subsequently, we analyzed the PDHS 2012–2013
data regarding neonatal feeding practices. Following this,
we triangulated the findings of both data sets to generate
a holistic picture of the sociocultural factors that influence
prelacteal feeding in the Pakistani population.
Qualitative assessment of prelacteal feeding
For in-depth understanding of sociocultural context of
prelacteal feeding, semi-structured in-depth interviews
were conducted with mothers and healthcare providers.
Study participants and sampling
To help narrow down our sampling pool for the qualita-
tive assessment, we looked to the PDHS 2012–2013 data
set. According to PDHS, a majority of caretakers (87%)
in the Punjab province of Pakistan administered prelac-
teals, and the prevalence of prelacteal feeding was much
higher in Punjab compared to other provinces. There-
fore, we conducted our qualitative interviews in select
districts of the Punjab Pakistan’s most populous prov-
ince. Three districts (Okara, Sahiwal and Pakpatan)
were randomly selected out of the thirty-six districts
that comprise Punjab. These three districts have a
predominantly rural populations and are situated in
east-central Pakistan. Informants and key-informants
were selected via non-probability sampling in each
district. Mothers (i.e., informants) were selected pur-
posively based on their educational status and parity.
First, we selected mothers with varying education
levels (i.e., illiterate, primary, middle, and secondary).
To acquire detailed information about prelacteal feed-
ing practices, we selected mothers who had at least
two children, with the youngest child aged 0–23
months. Selection criteria for healthcare providers
(i.e., key-informants) included working in public or
private health facility, and having more than 5 years
of work experience within the community. Key-
informants included health workers, midwives, nurses,
and physicians. We conducted a total of twelve semi-
structured in-depth interviews with informants (n=6)
and key informants (n=6).
Data collection
For informants, an interview guide with several prob-
ing options was designed to explore sociocultural
preferences and reasons for prelacteal feeding. Simi-
larly, a separate interview guide was used for key-
informants to explore their perceptions on prelacteal
feeds. Each interview was conducted at a house or
health facility, and the duration of interviews ranged
from 20 to 25 min. Interviews were recorded using a
digital recorder and hand-written field notes were col-
lected in the local language by a native speaker (MA).
The research team collected data between March
2017 and May 2017. The first author (MA) collected
data with the help of two research assistants trained
in qualitative methods and with educational back-
grounds in the social sciences. After reaching theme
saturation during the interviews, data collection was
concluded.
Ethical consideration
Study protocols were approved by the ethical review com-
mittee of The University of Sargodha, Pakistan [UOS/
Acad/399]. Additionally, the research team obtained
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official permission to conduct interviews with informants
and key-informants from the District Health Authority in
each district. All participants received a structured letter
outlining study aims and procedures, and informed partic-
ipants of their right to withdraw from the study at any
moment and stated a promise of anonymity. Study objec-
tives were thoroughly discussed with each participant, and
written informed consent was obtained before starting the
interview.
Data analysis
Interviews were conducted in the local language
(Punjabi), then transcribed verbatim and translated into
English by the first author. Later, the English transcrip-
tions were counter-checked by another co-author (ZHA)
using the hand-written field notes to ensure the quality of
the data. Then, the English transcriptions were uploaded
into NVivo software (version 10) for data management
and analysis. The inductive method was used to formulate
major themes and categories from the transcripts [29]. In
this approach, an exhaustive list of codes was organized
through transcripts rather than utilizing a predetermined
codebook. Codes were subsequently grouped under cat-
egories and themes, and a thematic matrix was developed
to display coded text data. Coding discrepancies were dis-
cussed and resolved to reduce bias. To ensure the authen-
ticity of the findings, data were triangulated by the data
sources (i.e., informants, key-informants, and field obser-
vation) and reported in this study. Finally, overarching
themes were discussed by the co-authors and repeated
codes were reconciled during interpretation.
Quantitative assessment of prelacteal feeding
We analyzed the PDHS data for years 2012–2013, which
was the third national survey funded by the US Agency
for International Development [26]. The PDHS is a na-
tionally representative dataset on sociodemographic and
mother-child health related indicators collected with rep-
resentative proportions across four provinces (i.e., Punjab,
Sindh, Khyber Pakhtunkhawa, and Baluchistan), along
with Gilgit-Baltistan and Islamabad. We also selected the
PDHS dataset because it collected information on the
types of liquids or substances provided to the neonate.
While PDHS survey data are available for children ages
0–59 months, we analyzed a subset of data of mothers
with children ages 0–23 months (n= 1361) to ensure that
mothers could more accurately recall their prelacteal
practices. The prelacteal feeding variable (categorical
dependent, yes/no) was determined by pooling results
from a battery of questions that recalled history of giving
anything to the infant by mouth in the first 3 days after
delivery. Relevant predictors of prelacteal feeding in PDHS
were selected by conducting a review of the literature
[30–34], and included sociodemographic characteristics
such as: wealth quintile, region, mothers’educational level,
sex of the head of household, and type of residence. Other
characteristics included: maternal age, place of delivery
(categorical), type of delivery (categorical), initiation of
breastfeeding (categorical), and sex of the child (categor-
ical). Some variables were re-coded for analyses, including
mother’s age (categorical), antenatal health utilization, and
initiation of first breastfeed (after birth in hours and days).
Data were coded and analyzed using SPSS (version
21). Descriptive analysis, including frequency distribu-
tions and percentages, were used to examine the
dependent and independent variables. Binary logistic re-
gression analysis examined associations between socio-
demographic characteristics and other independent
variables with the likelihood of prelacteal feeding. Fur-
thermore, multivariable logistic regression analysis with
backward stepwise selection was performed using vari-
ables that predicted prelacteal feeding (p< 0.20) in bin-
ary analysis. Multicollinearity was assessed between
highly correlated variables before developing the multi-
variate model. All independent variables had a variance
inflation factor of less than 1.5.
Results
Qualitative results
Through in-depth semi-structured interviews, infor-
mants and key-informants were asked to identify the fac-
tors associated with prelacteal feeding. Informants were
mothers and key-informants were health workers, mid-
wives, nurses, and physicians (See Table 1). A number of
sociocultural and administrative motivations were identi-
fied for feeding prelacteals to neonates. These included:
delivery in a private health facility, inadequate antenatal
counseling, myths about colostrum, Sunna of the Holy
Prophet, family rituals, and perceptions of insufficient
breast milk.
Deliveries in private hospitals and prelacteal feedings
While deliveries in private health facilities are considered
to be relatively safer than government facilities or home
deliveries, our research indicated that prelacteals are
more common in private health facilities. According to
the interviews, the support staff of these facilities (such
as traditional birth attendants, nurses, and paramedical
staff) were seen to be supportive towards prelacteal feed-
ing. This was best illustrated by a mother who shared
her experience describing the unsolicited administration
of a prelacteal by the Aaya (child attendant):
“When my child was born at a private health facil-
ity, the Aaya gave the prelacteal to my child in the
labor room without our consent and demanded
money for her good gesture. She did not hand over
the baby [to me] until she was paid.”(Informant, 3).
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Apart from the administration of prelacteals by hos-
pital staff, parents also brought prelacteals into hospitals,
or purchased them from medical stores located near the
private health centers. Highlighting this, one physician
in a private hospital made the following comment:
“When women are admitted to the hospital for delivery,
they also bring a bottle containing honey and rose water
with their luggage to give prelacteal to the newborn after
delivery. If someone forgets to bring the prelacteals, then
they [caretakers] purchase the prelacteals from medical
stores in the hospitals.”(Key-informant, 6).
It is worth mentioning here that anyone can buy medi-
cine and supplies from any medical store or hospital with-
out a prescription in Pakistan, and several prelacteal
brands (e.g., Anmol Ghutti, Hamdard Ghutti, Asli Ghutti,
and Janam Ghutti) are available at medical stores. More-
over, there are no governmental or health facility policies
that currently discourage the use or sale of prelacteals.
Inadequate antenatal counseling
Antenatal visits represent key opportunities to counsel
mothers on prelacteals and exclusive breastfeeding.
However, such services are rarely accessible for mothers
living in rural areas. Furthermore, mothers who are for-
tunate enough to receive antenatal care may not follow
through with the advice given, choosing to instead fol-
low traditional practices of prelacteal feeding. This was
evident in the account of a physician who reported:
“We tell the women to feed the colostrum imme-
diately after birth instead of any prelacteal. But
mothers do not follow our advice.”(Key-inform-
ant, 6).
A mother corroborated this statement, stating:
“Now the doctors condemn the prelacteal feeding,
but prelacteal is our family tradition that must be
carried out.”(Informant, 3).
As these excerpts illustrate, prelacteal feedings are a
well-established social norm. Therefore, future interven-
tions will likely require comprehensive antenatal coun-
seling about the potential adverse health complications
of prelacteal feedings. Such counselling would not only
be needed for expecting mothers, but also to other fam-
ily members (specifically, mothers-in-laws).
Myths about colostrum
Colostrum is the first form of milk produced by the
mammary glands. It contains numerous antibodies that
protect the newborn against disease. While most infor-
mants reported feeding colostrum to their newborn,
some mothers from rural areas reported not giving col-
ostrum to their neonates. They attributed this to various
taboos that revolve around the belief that the colostrum
is stale and harmful for the neonate’s health. Some rural
mothers reported testing the colostrum before initiation
of breastfeeding at home. One rural mother with four
children explained the process she follows:
“First, an ant is put into the colostrum to check the
milk. If the ant dies, then we do not feed colostrum
to baby and throw it away. If the insect does not die,
then we feed it to the baby. If the insect dies, it
means that the milk is poisonous. We also get it
checked by local practitioners (Quacks); if they say
the milk is not harmful then we feed it to the ba-
bies.”(Informant, 6).
Table 1 Background characteristics of the informants (n= 6) and key-informants recruited for qualitative interviews (n=6)
Codes Informants/
key-informant
Education/ Type of employment Age in years Professional experience Urbanicity of Position/Locale
1 Informant 5th grade 26 –Rural, Sahiwal
2 Informant Illiterate 40 –Rural, Sahiwal
3 Informant 8th grade 30 –Urban, Okara
4 Informant 10th grade 22 –Rural, Okara
5 Informant 12th grade 37 –Urban, Pakpatan
6 Informant Illiterate 25 –Rural, Pakpatan
1 GP Private hospital 33 6 years Urban, Sahiwal
2 HW Public sector 31 10 years Rural, Sahiwal
3 Nurse Public sector 45 13 years Rural, Okara
4 HW Public sector 36 12 years Rural, Okara
5 Midwife Private sector 37 6 years Urban, Pakpatan
6 GP Public hospital 34 10 years Rural, Pakpatan
GP = General Prac titioner; HW = Health Worker
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This excerpt signifies that some mothers in rural areas
think the colostrum might be poisonous. The reasoning
behind this belief stems from the idea that the colostrum
remains in the mother’s breasts for several months, mak-
ing it stale and dangerous to feed to children. Such be-
liefs drive some women to deprive their children of the
colostrum until their transitional milk comes.
Prelacteal as a family ritual
Our interviews also uncovered that families prefer the
first prelacteal feed be given by a senior family member,
or a virtuous individual. Families believe this practice
will transfer the qualities and habits of the feeder into
the child. A surprising finding from our study indicated
that some families may even feed the saliva of the per-
ceived virtuous individual as a prelacteal. This is illus-
trated in the account of a key informant presented
below:
“Parents prefer a virtuous person from the family to
pour honey or saliva into the mouth of the neonate,
so that child may acquire the personality traits and
habits of that person in his/her future life. After feed-
ing the prelacteal, mothers may start breastfeeding
the child.”(Key-informant, 2).
Sunna of holy prophet
The Islamic ceremony of Tahnik consists of touching
the lips of a newborn baby with a sweet substance, such
as honey. During the lifetime of the Prophet, it is said
that Muslims would bring their newborns to him so that
he may perform Taḥnīkupon them. Consequently, the
use of honey as a prelacteal has taken on a special mean-
ing and is considered a sacred tradition of the prophet
(Sunna). Owing to this sacred origin, the use of honey is
imbued with cleansing properties, and many individuals
now consider it to be a beneficial laxative that cleanses
the baby’s stomach. This notion is illustrated in the ex-
cerpt below:
“To feed the honey as prelacteal is the Sunna of our
beloved Prophet. The Holy Prophet used to feed
honey and dates to neonates immediately after birth.
After delivery, I could have breastfed my child but
my mother-in-law gave [the child] honey to clean his
stomach and help to pass the meconium.”(Inform-
ant, 5).
Therefore, the use of certain prelacteals have strong
roots in religion and home medication. Honey is consid-
ered a sacred prelacteal, and parents prefer honey as the
first feed for newborns to accomplish Sunna and to pass
the meconium.
Insufficient breast milk
Our qualitative interviews also revealed that mothers are
rarely aware of the importance of early initiation of
breastfeeding. Moreover, many mothers hold a strong
belief that breast milk comes after the third day of deliv-
ery. Consequently, prelacteals are perceived to be the
best option to satiate the child. Apart from mothers, this
view is also propagated by community health workers,
who suggest that mothers give prelacteals to supplement
perceived insufficient breast milk:
“Mother’s milk comes after three days even in case of
normal delivery. A mother’s body does not produce
milk after a couple of days of delivery; that is why
mothers should give prelacteals to newborns”(Key-
Informant, 5).
Breast milk supply is tightly regulated by infant de-
mand, and immediate breastfeeding is recommended to
foster breast milk production. However, most of the
mothers interviewed were not well aware of the best
practices for successful breastfeeding. In certain cases,
mothers often waited up to 3 days after delivery to start
breastfeeding their newborns.
Quantitative results
In the PDHS 2012–2013 survey, about half of the index
infants were male, and the prevalence of prelacteal feed-
ing did not differ by infant sex (see Table 2). The mean
age of mothers was 26.94 (SD = 5.54) years, and more
than half were illiterate (52%) and living in rural areas
(54.6%). The mean age of children was 13.42 months
(SD = 2.37). For prenatal care, a large proportion of
mothers (60.6%) had less than four antenatal care visits,
and nearly half (45.3%) of infants were born at home.
After delivery, nearly half of mothers (49.4%) reported
delayed initiation of breastfeeding during the first day of
life (2–24 h.), while a quarter of mothers (27.6%) re-
ported that they initiated breastfeeding more than 24 h
after delivery (Table 2). Almost two-thirds (64.7%) of re-
spondents reported giving prelacteals to their children
aged 0–23 months. The most common prelacteal was
milk other than breast milk (24.5%), while over a fifth
(21.8%) of mothers reported giving honey or sugar water
(see Table 3).
Binary logistic regression showed that maternal educa-
tion, wealth index, region, antenatal care visits, place of
delivery, cesarean delivery, timing of breastfeeding rela-
tive to delivery, and birth order were associated with
prelacteal feeding (Table 4). Adjusted multiple logistic
regression model (Table 4) with backward stepwise se-
lection showed that maternal education, region, place of
birth (hospital type or home birth), and timing of initi-
ation of breastfeeding are associated with prelacteal
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feeding. Compared to highly educated mothers, mothers
with primary education were two-times more likely to give
prelacteals. When compared to Gilgit-Baltistan, living in
the provinces of Punjab and Khyber Pakhtunkhwa was as-
sociated with substantially higher odds of prelacteal feed-
ings. Additionally, it was found that children who were
born at government hospitals were less likely to receive
prelacteal feeds, compared to children born at private hos-
pitals and home. Children who were breastfed immedi-
ately after birth were also much less likely to receive
prelacteals, compared to children who breastfed after 24 h.
Triangulation of findings
As a result of the mixed-methods design, we were able
to triangulate findings from our qualitative analysis with
the quantitative assessment (see Fig. 1). The figure sum-
marizes the nexus between qualitative and quantitative
Table 2 Characteristic of dyads including in analysis of
prelacteal feeding in Pakistan, PDHS 2012–13 (n= 1361)
Variables All
(n= 1361)
%(n)
Prelacteal feeding P-
value
Yes
%(n)
No
%(n)
Total Sample –64.7 (881) 35.3 (480)
Maternal education
No education 52.5 (715) 63.3 (453) 36.7 (262) < 0.001
Primary 15.4 (210) 75.1 (158) 24.9 (52)
Middle 8.2 (112) 68.8 (77) 31.2 (35)
Secondary 11.4 (155) 65.8 (102) 34.2 (53)
Higher 12.6 (171) 53.2 (91) 46.8 (80)
Maternal age
15–24 33.1 (450) 66.5 (299) 33.5 (151) 0.27
25–34 52.8 (719) 64.9 (467) 35.1 (252)
34 and above 14.1 (192) 59.9 (115) 40.1 (77)
Wealth index
Poorest 20.1 (274) 56.8 (156) 43.2 (118) < 0.001
Poorer 20.4 (278) 61.2 (170) 38.8 (108)
Middle 19.8 (269) 69.6 (187) 30.4 (82)
Rich 19.6 (267) 74.5 (199) 25.5 (68)
Richest 20.1 (274) 61.9 (170) 38.1 (104)
Sex of household head
Male 93.2 (1268) 64.0 (812) 36.0 (456) 0.030
Female 6.8 (93) 74.0 (69) 26.0 (24)
Place of residence
Urban 43.6 (593) 62.3 (370) 37.7 (223) 0.055
Rural 56.4 (768) 66.6 (511) 33.4 (257)
Region
Punjab 28.0 (381) 86.6 (330) 13.4 (51) < 0.001
Sindh 22.1 (301) 56.5 (170) 43.5 (131)
Khyber Pakhtunkhwa 20.2 (275) 73.1 (201) 26.9 (74)
Baluchistan 15.0 (204) 62.3 (127) 37.7 (77)
Islamabad 5.1 (69) 56.5 (39) 43.5 (30)
Gilgit-Baltistan 9.6 (131) 10.7 (14) 89.3 (117)
Antenatal care
No 23.0 (313) 59.7 (187) 40.3 (126) 0.04
1–3 visits 37.6 (512) 68.4 (350) 31.6 (162)
≥4 visits 39.4 (536) 64.1 (344) 35.9 (192)
Place of delivery
At home 45.3 (617) 67.2 (415) 32.8 (202) < 0.001
Public health facility 19.5 (265) 51.9 (137) 48.1 (128)
Private 35.2 (479) 68.7 (329) 31.3 (150)
Birth by cesarean section
No 86.2 (1173) 63.4 (743) 36.6 (430) 0.004
Yes 13.8 (188) 73.7 (138) 26.3 (50)
Table 2 Characteristic of dyads including in analysis of
prelacteal feeding in Pakistan, PDHS 2012–13 (n= 1361)
(Continued)
Variables All
(n= 1361)
%(n)
Prelacteal feeding P-
value
Yes
%(n)
No
%(n)
When child put to breast after delivery
Within one hour 23.0 (313) 38.7 (121) 61.3 (192) < 0.001
2–24 h 49.4 (672) 59.2 (398) 40.8 (274)
After one day 27.6 (376) 96.3 (362) 3.7 (14)
Sex of child
Male 50.7 (690) 63.6 (439) 36.4 (251) 0.21
Female 49.3 (671) 65.9 (442) 34.1 (229)
Birth order
First born child 23.7 (323) 70.5 (228) 29.5 (95) 0.008
Subsequent child 76.3 (1038) 62.9 (653) 37.1 (385)
Table 3 Analysis of preferred prelacteal feeding during the first
three days of birth (n
a
= 881; 64.7%)
Types of prelacteals Frequency Percentage
Milk other than breast milk 216 24.5
Honey/ Sugar water 192 21.8
Infant formula 119 13.5
Marketed Ghutti 132 15.0
Plain water 48 5.4
Fruit juice 44 5.0
Rosewater 41 4.6
Green tea 41 4.6
Ghee/ Butter or tea 28 3.2
Gripe water 20 2.3
a
Only 881 dyads are included who gave a prelacteal feed during the first 3
days of birth
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Table 4 Adjusted and unadjusted odd ratios (95% confidence interval [CI]) for factors associated with prelacteal feeding in Pakistan,
(PDHS, 2012–2013)
Likelihood of prelacteal feeding
Variables OR
a
P- value 95% CI AOR P- value 95% CI
Education of mother
No education 1.53 0.013 1.09, 2.15 1.28 0.369 0.78, 1.91
Primary 2.65 < 0.001 1.71, 4.09 2.28 0.002 1.35, 3.85
Middle 1.93 0.010 1.93, 1.17 1.88 0.041 1.02, 3.47
Secondary 1.69 0.021 1.08, 2.64 1.80 0.034 1.04, 3.09
Higher 1 1
Wealth index
Poorest 0.80 0.223 0.57, 1.13
Poorer 0.97 0.856 0.68, 1.36
Middle 1.41 0.058 0.98, 2.01
Rich 1.80 0.002 1.24, 2.60
Richest 1
Sex of household
Male 0.62 0.50 0.38, 0.99
Female 1
Region
Punjab 54.07 < 0.001 28.8, 101.3 24.92 < 0.001 12.6, 49.1
Sindh 10.84 < 0.001 5.95, 19.74 7.03 < 0.001 3.65, 13.5
Khyber Pakhtunkhwa 22.70 < 0.001 12.31, 42.0 16.21 < 0.001 8.30, 31.6
Baluchistan 13.78 < 0.001 7.39, 25.68 12.20 < 0.001 6.14, 24.3
Islamabad 10.86 < 0.001 5.23, 52.55 9.60 < 0.001 4.31, 21.4
Gilgit-Baltistan 1 1
Antenatal care
None 0.83 0.040 0.62, 1.10
1–3 visits 1.20 0.250 0.93, 1.56
≥4 visits 1
Place of delivery
At home 0.93 0.604 0.72, 1.20 0.997 0.89 0.69, 1.37
Public health facility 0.49 < 0.001 0.36, 0.66 0.462 0.02 0.43, 0.95
Private health facility 1
Birth by Cesarean section
No 0.62 0.007 0.43, 0.87
Yes 1
When child put to breast
Within one hour 0.02 < 0.001 0.14, 0.44 0.03 < 0.001 0.01, 0.61
2–24 h 0.05 < 0.001 0.32, 0.98 0.07 < 0.001 0.43, 0.95
After one day 1 1
Birth order
First born child 1.40 0.013 1.07, 1.84
Subsequent child 1
a
Binary logistic regression
Education of mothers, region, place of delivery, and when child put to breast
Asim et al. International Breastfeeding Journal (2020) 15:53 Page 7 of 11
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
findings, and provides a holistic perspective to our
findings.
Discussion
Prelacteal feeding is mostly practiced in LMICs, owing
to cultural traditions and its perceived health benefits.
This is the first mixed-methods study seeking to under-
stand the sociodemographic and cultural factors influen-
cing prelacteal feeding in Pakistan. Our quantitative
analyses, using PDHS (2012–13) data, revealed that a
majority of children (64.7%) under 2 years of age re-
ceived prelacteal feeds in Pakistan. This finding is critical
given that prelacteal feeding has been shown to delay
the early initiation of breastfeeding, a practice that is
detrimental to neonatal health. Additionally, our findings
suggest mothers, irrespective of age and place of resi-
dence, gave prelacteals to both male and female neo-
nates. Moreover, there was also no difference in
prelacteal feeding between highly educated and illiterate
mothers. However, mothers who had pre-college educa-
tion (i.e., 5th to 12th grade) were more likely to give pre-
lacteals compared to both illiterate mothers and mothers
with higher education. This finding has also been
depicted in studies from Nigeria [35] and Ethiopia [34,
36–38]. A similar pattern was also observed in relation
to household income. Our analyses indicated that house-
holds of both low and high income were slightly less
likely to give the prelacteals, compared to middle or
upper-middle income households. This finding was sur-
prising, particularly since several studies from LMICs
found no association between household income and
prelacteal feeding, specifically in Nepal [39,40], Nigeria
[35], and Egypt [4].
This indicates that prelacteals have a distinct import-
ance in different socio-economic classes in LMICs, and
caretakers use prelacteals according to their sociocul-
tural preferences. Within the context of Pakistan, it is
plausible that the most disadvantaged households may
be too poor or burdened to purchase prelacteals, while
more affluent households may be more influenced by
Western medical discourse at the expense of traditional
practices. However, middle-income households are
viewed as more value-oriented and inclined to preserve
cultural traditions. Our interviews revealed several such
traditions. For example, value-oriented families preferred
that a virtuous individual or family member administer
prelacteals to transfer the positive characteristics of the
feeder to the newborn. As another example, owing to its
importance as a practice of the prophet (Sunna), middle-
income families also preferred the use of honey as a
Fig. 1 Triangulation of the findings
Asim et al. International Breastfeeding Journal (2020) 15:53 Page 8 of 11
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
prelacteal. This is consistent with studies from Muslim
countries that found the use of prelacteals is related to
the preservation of religious beliefs [41–45].
Antenatal care visits provide health care professionals
opportunities to counsel pregnant mothers on optimal
breastfeeding practices and newborn care. Therefore, we
were surprised when our quantitative analyses revealed
that mothers who did not receive any antenatal care
were less likely to give prelacteal feeds. It is likely that
these results can be explained by taking into consider-
ation that low income households are unable to visit
antenatal clinics due to accessibility and financial con-
straints. Consequently, a larger pool of antenatal visitors
may consist of women from middle income households,
a segment of the population most likely to implement
prelacteals. Results from the national survey corroborate
this account, as they indicate that the poorest house-
holds in Pakistan immediately start breastfeeding and
are less likely to implement prelacteal feeds [46].
Despite the survey results, our qualitative interviews
revealed that several participants reported not receiving
effective breastfeeding counseling during antenatal
visits. Further, several studies from Ethiopia have docu-
mented lack of infant feeding counseling during ante-
natal care as a major determinant of prelacteal feeding
[33,34,47,48]. Effective counseling on infant feeding
practices can serve as an avenue to address two findings
identified as potential predictors of prelacteal feeding by
our study: 1) parity, and 2) myths about colostrum.
Primiparous women were more likely to administer pre-
lacteals. This practice may reflect upon a general ten-
dency for mothers to be more sensitive about neonatal
care practices when expectingtheirfirstchild,andthat
primiparous women are more likely to rely on support
from others when establishing breastfeeding.
Concerning parity, and given that our study revealed
that some prelacteals are believed to be imbued with
strong religious meanings and are associated with health
benefits, it is likely that these first-time mothers are
more open to administering them due to these beliefs.
Incorporating breastfeeding education into antenatal
care can inform mothers on the importance of the early
initiation of breastfeeding, a fact that is neglected when
mothers opt to administer prelacteals. Secondly, our in-
terviews revealed that some mothers held the view that
colostrum may be harmful to neonates and should be
discarded. The practice of discarding colostrum has been
observed in other settings due to a perceived fear of
child’s abdominal pain [49], beliefs that colostrum is old
or stale [48–50], and beliefs that colostrum is associated
with mortality [50]. We also learned that some mothers
and healthcare providers believed that the breast milk
transition from colostrum to milk takes 3 days after de-
livery. In light of this, different prelacteals are given to
satiate the child during this perceived transitioning phase.
In many cases, mothers may deliberately delay breastfeed-
ing until the implementation of the prelacteal feed. This
insight is noteworthy given the strong association between
prelacteal feeding and the delayed initiation of breastfeed-
ing. It is essential that such misconceptions be addressed
through antenatal care.
Finally, we explored the role of healthcare facility type,
including private health facilities, in facilitating prelacteal
feeding. It is interesting to see that there was no differ-
ence in prelacteal administration to newborns who were
delivered at home and in private health facilities. How-
ever, children born at public health facilities were less
likely to receive prelacteals. Our interviews revealed that
in some cases, attendants in private health facilities ad-
minister prelacteals to neonates without soliciting con-
sent from the parents. Taken together, the prevalence of
prelacteal feeding in Pakistan may be highest due to this
practice by caretakers and hospital staff. However, previ-
ous reports have highlighted that home deliveries were
associated with prelacteal feeding, but other studies from
Nepal [39], Ethiopia [47] and Pakistan [51] did not ob-
serve an association between prelacteal feeding and place
of delivery. The difference in our findings may be ex-
plained by taking into consideration that impoverished
mothers in Pakistan may be unable to afford both a pri-
vate hospital delivery and prelacteal feeds. This may
make them more likely to deliver their babies at home
or in public facilities, and breastfeed immediately.
Strength and limitations
This mixed-methods research is a pioneering approach
to understand sociodemographic factors associated with
prelacteal feeding in Pakistan. This approach represents
a strength of this research, as the findings reported have
been triangulated from different sources. Our qualitative
study provided further insight into the quantitative find-
ings to better understand the widely accepted practice of
prelacteal feedings. However, our quantitative findings
are from a cross-sectional survey, and limit our ability to
infer causality. Additionally, the qualitative interviews
were conducted in only three districts from Punjab and
our findings may not be generalizable to other areas or
regions of Pakistan.
Conclusions
Pakistan has the highest global rate of neonatal mortality
and child malnutrition due to substandard infant feeding
practices and non-exclusive breastfeeding. Prelacteal feed-
ing is customarily practiced and is a socially normative be-
havior in Pakistan. Many studies have reported associations
between prelacteal feeding and child morbidity and mortal-
ity across the world. In our mixed-methods study, we found
that mothers with pre-college education, primiparous
Asim et al. International Breastfeeding Journal (2020) 15:53 Page 9 of 11
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
women, mothers delivering at private health facilities, and
mothers delaying the early initiation of breastfeeding were
more likely to administer prelacteals to their infants. Apart
from the socio-economic and demographic factors, we also
identified several cultural practices that propagated the
practice of prelacteal feeding.
This study provides necessary insight for policies, pro-
grams, and individuals promoting early initiation of
breastfeeding and exclusive breastfeeding. Given the im-
portance of early initiation of breastfeeding, along with the
role of prelacteals in delaying this practice, it is essential
that policies and educational programs be designed in
ways that incorporate these findings to achieve the desired
behavior change (i.e., early initiation of breastfeeding) and
improve neonatal health outcomes. Without addressing
these identified sociocultural influences and psychosocial
barriers that impact breastfeeding initiation and avoidance
of prelacteal feeding, interventions may not be successful
in their efforts and families will continue to administer
prelacteals to their children, leading to increased neonatal
morbidity and mortality.
Abbreviations
AOR: Adjusted Odds Ratio; PDHS: Pakistan Demographic and Health Survey;
SD: Standard Deviation; LMIC: Low and Middle Income Countries;
WHO: World Health Organization
Acknowledgements
We would like to thank, Sara Dube, Graica Dala, and Diane Coffey at The
University of Texas at Austin for their feedback on our mixed-method study.
Authors’contributions
MA collected and analyzed the data. ZHA assisted in qualitative data
collection, and discussion. MDH conceptualized, designed, and supervised
this study. EMW contributed to the design and interpretation of quantitative
analysis, interpretation and contextualization of the qualitative and
quantitative results, drafting the manuscript, and supervision and mentoring
of MA on manuscript drafting, writing, presentation of results and the
manuscript preparation process. The authors read and approved the final
manuscript.
Authors’information
Muhammad Asim, PhD, Department of Community Health Sciences, Aga
Khan University, Karachi, Pakistan; Department of Sociology University of
Sargodha; Pakistan. Population Research Center, University of Texas at Austin,
USA.
Zarak Husain Ahmed, MS, Department of Community Health Sciences, Aga
Khan University, Karachi, Pakistan.
Mark D. Hayward, PhD, Population Research Center & Department of
Sociology, University of Texas at Austin, USA.
Elizabeth M. Widen, PhD, RD, Department of Nutritional Sciences &
Population Research Center, University of Texas at Austin, USA.
Funding
This research was supported by grant, P2CHD042849, Population Research
Center, awarded to the Population Research Center at The University of
Texas at Austin by the Eunice Kennedy Shriver National Institute of Child
Health and Human Development. Dr. Widen was supported by the grant,
R00HD086304, by the Eunice Kennedy Shriver National Institute of Child
Health and Human Development. The content is solely the responsibility of
the authors and does not necessarily represent the official views of the
National Institutes of Health.
Availability of data and materials
The DHS dataset is publicly available in the DHS repository, https://www.
dhsprogram.com/data/available-datasets.cfm. The qualitative data generated
during the current study are not publicly available, but a restricted use
dataset is available from the corresponding author on reasonable request.
Ethics approval and consent to participate
Study protocols were approved by the ethical review committee of The
University of Sargodha, Pakistan [UOS/17/Acad/399]. We obtained official
permission to conduct interviews from the District Health Authorities in each
district. All participants received a structured letter outlining study aim,
procedure, the right to withdraw, and a promise of anonymity. Study
objectives were thoroughly discussed with each participant, and written
informed consent was obtained before starting interviews.
Consent for publication
Not applicable.
Competing interests
The authors declare that they have no competing interests.
Author details
1
Department of Community Health Sciences, Aga Khan University, Karachi,
Pakistan.
2
Department of Sociology, University of Sargodha, Sargodha,
Pakistan.
3
Population Research Center, University of Texas at Austin, Austin,
USA.
4
Department of Sociology & Population Research Center, University of
Texas at Austin, Austin, USA.
5
Department of Nutritional Sciences &
Population Research Center, University of Texas at Austin, Austin, Texas, USA.
Received: 16 December 2019 Accepted: 25 May 2020
References
1. World Health Organization. Infant and young child feeding: model chapter
for textbooks for medical students and allied health professionals; 2009.
2. Goswami A. Analytical study of prevalent and traditional Prelacteal feeding
practices and their relevance. Indian J Prev Soc Med. 2009;40:218–24.
3. Boccolini CS, Pérez-Escamilla R, Giugliani ERJ, de MM BP. Inequities in milk-
based prelacteal feedings in Latin America and the Caribbean: the role of
cesarean section delivery. J Hum Lact. 2015;31:89–98.
4. El-Gilany A-H, Abdel-Hady DM. Newborn first feed and prelacteal feeds in
Mansoura, Egypt. Biomed Res Int. 2014. https://doi.org/10.1155/2014/258470.
5. Roy MP, Mohan U, Singh SK, Singh VK, Srivastava AK. Determinants of
prelacteal feeding in rural northern India. Int J Prev Med. 2014;5:658.
6. Sadagopal M. Her healing heritage: study conducted in 7 states of India
through LPSS & CHETNAAhmedabad; 1986.
7. Asim M, Mahmood B, Sohail MM. Infant health care practices in Pakistan: a
systematic review. Professional Med J. 2015;22:978–88.
8. Kanagasabapathy S, Sadhasivam M. Pre lacteal feeding practice among rural
mothers in Tamil Nadu-a questionnaire based study. Int J Biomed Adv Res.
2015;6:484–7.
9. Lakati A, Makokha O, Binns C, Kombe Y. The effect of pre-lacteal feeding on
full breastfeeding in Nairobi, Kenya. East Afr J Public Health. 2011;7:258–62.
10. Punia S, Chhikara S, Sangawan S. Infant feeding and weaning practices in
selected cultural zones of Haryana. Indian J Nutr Dietetics. 1997;34:102–5.
11. Qiu L, Zhao Y, Binns CW, Lee AH, Xie X. A cohort study of infant feeding
practices in city, suburban and rural areas in Zhejiang Province, PR China.
Int Breastfeed J. 2008;3:4.
12. Bekele Y, Mengistie B, Mesfine F. Prelacteal feeding practice and associated
factors among mothers attending immunization clinic in Harari region
public health facilities, eastern Ethiopia. Open J Prev Med. 2014;4:529.
13. Nguyen PH, Keithly SC, Nguyen NT, Nguyen TT, Tran LM, Hajeebhoy N.
Prelacteal feeding practices in Vietnam: challenges and associated factors.
BMC Public Health. 2013;13:932.
14. Dalal S, Bansal M, Pande K. Study of infants deaths and pre lacteal feeding
practices using verbal autopsy as a tool in Deharadun. Natl J Commun Med.
2016;7:216–8.
15. Edmond KM, Kirkwood BR, Amenga-Etego S, Owusu-Agyei S, Hurt LS. Effect
of early infant feeding practices on infection-specific neonatal mortality: an
investigation of the causal links with observational data from rural Ghana.
Am J Clin Nutr. 2007;86:1126–31.
Asim et al. International Breastfeeding Journal (2020) 15:53 Page 10 of 11
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
16. Smith ER, Hurt L, Chowdhury R, Sinha B, Fawzi W, Edmond KM, et al.
Delayed breastfeeding initiation and infant survival: a systematic review and
meta-analysis. PLoS One. 2017;12:e0180722.
17. Victora CG, Bahl R, Barros AJ, França GV, Horton S, Krasevec J, et al.
Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong
effect. Lancet. 2016;387:475–90.
18. Demographic health survey. Health survey-2005. Central statistical agency
Addis Ababa. Maryland: Ethiopia ICF International Calverton; 2006.
19. International Institute for Population Sciences (IIPS) and ICF. National family
health survey (NFHS-4), 2015–16: India. Mumbai: International Institute for
Population Sciences; 2017.
20. National Institute of Population Research and Training (NIPORT), Mitra and
associates, and ICF international. 2016. Bangladesh demographic and health
survey 2014. Dhaka, and Rockville: NIPORT, Mitra and Associates, and ICF
International; 2014.
21. Central Statistics Organization (CSO), Ministry of Public Health (MoPH), and
ICF. Afghanistan demographic and health survey 2015. Kabul: Central
Statistics Organization; 2017.
22. Ogbo FA, Page A, Idoko J, Claudio F, Agho KE. Trends in complementary
feeding indicators in Nigeria, 2003–2013. BMJ Open. 2015;5:e008467.
23. National Institute of Population Studies (NIPS) [Pakistan] and ICF. Pakistan
demographic and health survey 2017–18. Islamabad and Rockville: NIPS and
ICF; 2019.
24. Patel A, Bucher S, Pusdekar Y, Esamai F, Krebs NF, Goudar SS, et al. Rates
and determinants of early initiation of breastfeeding and exclusive breast
feeding at 42 days postnatal in six low and middle-income countries: a
prospective cohort study. Reprod Health. 2015;12:S10.
25. Greiner T. Breastfeeding in Bangladesh: a review of the literature.
Bangladesh J Nutr. 1997;10:37–50.
26. National Institute of Population Sciences (NIPS) [Pakistan] and ICF
International. Pakistan demographic and health survey 2012–13. Islamabad
and Rockville: NIPS and ICF; 2013.
27. Zakar R, Zakar MZ, Zaheer L, Fischer F. Exploring parental perceptions and
knowledge regarding breastfeeding practices in Rajanpur, Punjab province,
Pakistan. Int Breastfeed J. 2018;13:24.
28. Cresswell JW, Clark VLP, Gutmann ML, Hanson WE. (2003) Research design:
qualitative, quantitative, and mixed methods approaches. In: Handbook of
mixed methods in Social & Behavioral Research; 2009. p. 209–40.
29. Thomas DR. A general inductive approach for analyzing qualitative
evaluation data. Am J Eval. 2006;27:237–46.
30. Himani BK, Kumar P. Effect of initiation of breastfeeding within one hour of the
delivery on maternal-infant bonding. Nurs Midwifery Res J. 2011;7:99–109.
31. Agho K, Ogeleka P, Ogbo F, Ezeh O, Eastwood J, Page A. Trends and predictors of
prelacteal feeding practices in Nigeria (2003–2013). Nutrients. 2016;8:462.
32. Belachew AB, Kahsay AB, Abebe YG. Individual and community-level factors
associated with introduction of prelacteal feeding in Ethiopia. Arch Public
Health. 2016;74:6.
33. Bililign N, Kumsa H, Mulugeta M, Sisay Y. Factors associated with prelacteal
feeding in north eastern Ethiopia: a community based cross-sectional study.
Int Breastfeed J. 2016;11:13.
34. Legesse M, Demena M, Mesfin F, Haile D. Prelacteal feeding practices and
associated factors among mothers of children aged less than 24 months in
Raya kobo district, north eastern Ethiopia: a cross-sectional study. Int
Breastfeed J. 2014;9:189.
35. Jimoh AO, Adaji SE, Adelaiye HA, Olorukooba AA, Garba C, Mfuh AL, et al.
Factors associated with prelacteal feeding practices in a rural northern
Nigerian setting. South African J Clin Nutr. 2018;31:37–42.
36. Argaw MD, Asfaw MM, Ayalew MB, Desta BF, Mavundla TR, Gidebo KD, et al.
Factors associated with prelacteal feeding practices in Debre Berhan district,
north Shoa, Central Ethiopia: a cross-sectional, community-based study.
BMC Nutrition. 2019;5:14.
37. Tariku A, Biks GA, Wassie MM, Gebeyehu A, Getie AA. Factors associated
with prelacteal feeding in the rural population of Northwest Ethiopia: a
community cross-sectional study. Int Breastfeed J. 2016;11:14.
38. Tekaly G, Kassa M, Belete T, Tasew H, Mariye T, Teshale T. Pre-lacteal feeding
practice and associated factors among mothers having children less than
two years of age in Aksum town, Tigray, Ethiopia, 2017: a cross-sectional
study. BMC Pediatr. 2018;18:310.
39. Khanal V, Adhikari M, Sauer K, Zhao Y. Factors associated with the
introduction of prelacteal feeds in Nepal: findings from the Nepal
demographic and health survey 2011. Int Breastfeed J. 2013;8:9.
40. Karkee R, Lee AH, Khanal V, Binns CW. Initiation of breastfeeding and factors
associated with prelacteal feeds in Central Nepal. J Hum Lact. 2014;30:353–7.
41. Raheem RA, Binns CW, Chih HJ, Sauer K. Determinants of the introduction
of prelacteal feeds in the Maldives. Breastfeed Med. 2014;9:473–8.
42. Asim M, Malik N, Tabassum A, Haider M, Anwar HN. Perception and
practices of mothers about feeding practices of newborn babies in
Faisalabad. Pakistan Mediterranean J Soc Sci. 2014;5:662.
43. Khamis AG, Omar AM, Suleiman SA, Ali FS. Prevalence of exclusive
breastfeeding and its predictors among mothers in Micheweni, Chake-
Chake and north ‘A’districts, Zanzibar. Clin Mother Child Health. 2017;14:2.
44. McKenna KM, Shankar RT. The practice of prelacteal feeding to newborns
among Hindu and Muslim families. J Midwifery Womens Health. 2009;54:
78–81.
45. Shaikh U, Ahmed O. Islam and infant feeding. Breastfeed Med. 2006;1:164–7.
46. Mahmood A, Sultan M. NIPS. National Institute of population studies (NIPS)
[Pakistan] and ICF. 2019. Pakistan demographic and health survey 2017-18
Islamabad, Pakistan, and Rockville, Maryland, USA: NIPS and ICF, vol. 7; 2018.
p. 123–45.
47. Chea N, Asefa A. Prelacteal feeding and associated factors among newborns
in rural Sidama, South Ethiopia: a community based cross-sectional survey.
Int Breastfeed J. 2018;13:7.
48. Yenit MK, Genetu H, Tariku A. Infant feeding counseling and knowledge are
the key determinants of prelacteal feeding among HIV exposed infants
attending public hospitals in Ethiopia. Arch Public Health. 2017;75:23.
49. Rogers NL, Abdi J, Moore D, Nd’iangui S, Smith LJ, Carlson AJ, et al.
Colostrum avoidance, prelacteal feeding and late breast-feeding initiation in
rural northern Ethiopia. Public Health Nutr. 2011;14:2029–36.
50. Khadduri R, Marsh DR, Rasmussen B, Bari A, Nazir R, Darmstadt GL.
Household knowledge and practices of newborn and maternal health in
Haripur district, Pakistan. J Perinatol. 2008;28:182.
51. Ayaz A, Saleem S. Neonatal mortality and prevalence of practices for
newborn care in a squatter settlement of Karachi, , Pakistan: a cross-
sectional study. PLoS One. 2010;5:e13783.
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