First 72-hours after birth: Newborn feeding practices and neonatal mortality in India

Piyasa Mal; Usha Ram

doi:10.1371/journal.pone.0292353

. 2023 Oct 5;18(10):e0292353. doi: 10.1371/journal.pone.0292353

First 72-hours after birth: Newborn feeding practices and neonatal mortality in India

Piyasa Mal ¹, Usha Ram ^2,^*

Editor: Chandan Kumar³

PMCID: PMC10553319 PMID: 37796893

Abstract

Background

The reductions in mortality levels among children under five years are observed in most populations, including populations that were lagging the progress in the past. However, the reduction is not uniform across ages during childhood. The mortality declines within the first month have shown relatively slow progress. Early initiation of breastfeeding and discarding pre-lacteal feed protects the newborn from acquiring infection and, thereby, reduces mortality. This paper assesses the change in the prevalence of early initiation of breastfeeding and pre-lacteal feed along with their associated factors, and their association with neonatal mortality in India.

Methods

We used data from the three rounds of National Family Health Surveys conducted during 2005–06, 2015–16 and 2019–21 in India. We used bivariate and multivariate analyses to examine prevalence rates, risk factors, and relationships between breastfeeding practices, including early initiation of breastfeeding and pre-lacteal feed, and neonatal mortality.

Results

Early initiation of breastfeeding within one hour after birth increased rapidly from 25% in 2005–06 to 42% in 2019–21, and the pre-lacteal feeding practice declined from 57% in 2005–06 to 15% in 2019–21. Pre-lacteal feed is lower in states/districts where early breastfeeding initiation is predominant and vice versa. The role of health professionals during pregnancy and the first two days after delivery significantly improved breastfeeding practice. Further, the findings suggest that an early breastfeeding initiation is associated with lower neonatal mortality, whereas pre-lacteal feed is not harmful compared to late breastfeeding initiation.

Conclusion

Prevalence of pre-lacteal feed reduced, and initiation of early breastfeeding increased considerably after the launch of the National Rural Health Mission in India. However, after 2015–16, early breastfeeding initiation has stagnated, and the decline in pre-lacteal feed has slowed down. The future program needs special attention to emphasize the availability and accessibility of breastfeeding advisers and observers in health facilities to help mitigate adverse neonatal outcomes.

Introduction

The past few decades have witnessed rapid improvements in the global health scenario as a result of childhood mortality reduction in most populations. Several countries, including India, for example, have made remarkable progress in mortality reductions among children below five years of age (under-five mortality rate, U5MR), especially during the past decade. The global child mortality rate has dropped by 60% between 1990 and 2020, from 93 to 37 per 1,000 live births [1]. However, the available evidence suggests that the reduction is slower in mortality within the first month of life. The United Nations Inter-agency Group for Child Mortality Estimation (UNIGME, 2021) estimates indicate that globally the neonatal mortality rate (NMR) has dropped from 37 per 1,000 live births in 1990 to 17 per 1,000 live births in 2020, yet contributed 47% of all under-five deaths [2].

In 2020, India accounted for the highest number of global neonatal deaths (490 thousand; 20% of global neonatal deaths) [3]. In India, neonatal deaths comprised almost half of all under-5 deaths in 2000, which rose 62% in 2020 [4]. Globally as well as in India, prematurity and low birth weight, neonatal infections (neonatal pneumonia, neonatal sepsis, and central nervous system infections), and birth asphyxia and birth trauma account for more than three-quarters of all neonatal deaths [5].

Early initiation of breastfeeding protects the newborn from acquiring infections and reduces mortality [6–8]. It further strengthens the emotional bonding between the newborn and mother and positively impacts the duration of exclusive breastfeeding [9, 10]. The yellow or golden first milk produced in the first few days (also called colostrum) is an essential source of nutrition and immune protection for the newborn. Colostrum is a complex biological nutrient-rich fluid produced by female mammals immediately after giving birth that provides immune, growth, and tissue repair capabilities [11, 12]. Early breastfeeding initiation can significantly contribute to the achievement of the child survival [13].

Breastfeeding among Indian mothers is nearly universal; however, myths and superstitions such as discarding colostrum, delayed initiation of breastfeeding, pre-lacteal feeding, and early initiation of complementary feeding persist [14, 15]. Several social, cultural, and economic factors, including maternal education and employment, maternal age, attitude and confidence, prenatal intention, ethnicity, residence, type of family, emulating western lifestyles, the influence of healthcare professionals, and availability of infant formula, influence breastfeeding practices [14, 16]. Further, breastfeeding attitudes and practices differ in different segments of society depending on traditional cultural practices and taboos prevalent in them [13]. Timely initiation of breastfeeding remains low in India, and the pre-lacteal feeding is still prevalent [17]. As also reflected from the global estimate (WHO 2021), 3 in 5 newborn babies in India are not breastfed within the first hour of life [18].

India is committed to achieving the targeted reduction in child mortality under the third Sustainable Development Goal (SDG) and is making multi-pronged efforts in achieving them. This study assesses breastfeeding practices regarding early initiation and pre-lacteal feeding in India and their association with neonatal mortality. The study specifically appraises i) the prevalence of early initiation of breastfeeding and pre-lacteal feeding practices by socio-demographic characteristics of mother and child, and household; ii) predictors of early initiation of breastfeeding and pre-lacteal feeding practices; and iii) how the level of neonatal mortality differs across the status of pre-lacteal feeding and delayed breastfeeding initiation.

Methods

Data

We have used data from the last three rounds of the National Family Health Survey (NFHS-3 conducted during 2005–06, NFHS-4 conducted during 2015–16, and NFHS-5 conducted during 2019–21) to analyse trends in the early initiation of breastfeeding and pre-lacteal feed. The details of the survey are available at (https://dhsprogram.com/data/available-datasets.cfm). The NFHS-3 (2005–06) surveyed 109,041 households and 124,385 women of reproductive age. From NFHS-4 (2015–16), the survey was implemented at the district levels and interviewed 572,000 households and 699,686 women of reproductive age. The NFHS-5 (2019–21) surveyed 636,699 households and 724,115 women of reproductive age. Data were collected following all the ethical guidelines. Ethical approval was granted from the Institutional Review Board (IRB) of the International Institute for Population Sciences (IIPS) and ICF Institutional Review Board. During the field survey, verbal and written consent were taken from the respondents.

Study sample

A total of 56,381 children born during the past five years preceding the survey were enumerated in 2005–06. Of these, 39,620 were the last-born surviving children and the information on pre-lacteal feed and timing of breastfeeding initiation was available for 38,527 children. In NFHS-4 (2015–16), 249,967 children born during the past five years preceding the survey were enumerated, and of them, 184,641 were the youngest surviving children. The information on pre-lacteal feed and timing of breastfeeding were available for 174,468 children. The NFHS-5 (2019–21) enumerated 230,870 children who were born during the past five years preceding the survey and out of these, 174,947 were the youngest surviving children. However, pre-lacteal feed and timing of breastfeeding initiation information were available for 165,131 children.

Outcome variables

The study has two primary outcome variables: early initiation of breastfeeding and pre-lacteal feed. The NFHS asked women who had a livebirth during the past five years preceding the survey–‘How long after birth did you start breastfeeding (your youngest surviving child)?’ We considered the ‘early initiation of breastfeeding’ practice if mothers breastfed the child within one hour after birth. Similarly, the survey also asked mothers–‘In the first three days after delivery, was the baby given anything to drink other than breast milk?’ If mothers reported that they gave child anything other than breast milk, we considered it as ‘pre-lacteal feed’. In addition, the neonatal mortality rate was estimated stratified by the status of breastfeeding initiation and pre-lacteal feeding. As mentioned previously, the study sample constitutes the last-born children of the women of reproductive age during the last five years preceding the respective surveys.

Predictor variables

These predictor variables include: place of residence (rural, urban); sex of the child (male, female); maternal age at birth (≤19, 20–34, ≥35); birth order (1, 2, 3 or more), maternal education (no education, primary, secondary or higher); household wealth tertile (poor, middle, rich); maternal caste/tribe (Scheduled Castes (SCs), Scheduled Tribes (STs), Other Backward Class (OBC), others); mother’s ANC visits during pregnancy (No visit, 1–3, 4 or more); place of delivery (not in a health facility, public health facility, private health facility); types of delivery (vaginal deliveries, C-section in a public facility, C-section in a private facility); mother received breastfeeding advice during pregnancy (no, yes), and healthcare provider observed breastfeeding during first two days after birth (no, yes).

Statistical analysis

By applying appropriate sampling weights, we conducted bivariate analyses to assess the levels of early initiation of breastfeeding and pre-lacteal feeding practice by socioeconomic and demographic characteristics of the mother, child, and household. We used Chi-squared tests to assess statistical significance of bivariate associations of outcome variables with the socioeconomic and demographic characteristics.

The study has two dichotomous outcome variables: early initiation of breastfeeding and pre-lacteal feed. The surveys collected information on these outcome variables only for the youngest surviving children. The information for older living children were not collected, and therefore, we applied logistic regression models to examine the odds of early initiation of breastfeeding and pre-lacteal feeding practice concerning exposure variables using the pooled datasets of the last three rounds of the NFHS covering the past two decades. We tested all exposure variables for possible multi-collinearity before inclusion into the regression models.

Two studies, viz. Edmond et al. [19] and Phukan et al. [20] have examined impact of breastfeeding practices on child mortality. While Edmond et al. [19] found that pre-lacteal feeding increased infant mortality in rural Ghana. Phukan et al. [20] observed that neonatal mortality was higher among neonates with delayed initiation of breastfeeding in India. Given the paucity of studies, the present study conducted a bivariate analysis to examine the association between levels of neonatal mortality by timing of initiation of breastfeeding and pre-lacteal feeding practices in Indian population using the data for the period 2019–21. Additionally, we used scatter plots to explore the ecological (at state level) association between the level of NMR and the breastfeeding and pre-lacteal feeding practices.

We conducted the analyses using STATA version 16 [21]. Maps were created using ArcMap 10 [22]. The shape files of the maps were accessed from the official website of the Demographic Health Survey (https://dhsprogram.com/data/available-datasets.cfm).

Results

Levels and trends in early initiation of breastfeeding and pre-lacteal feeding: National, sub-national and by population subgroups

Early initiation of breastfeeding within one hour after birth increased rapidly from just about one-quarter in 2005–06 to nearly 42% in 2019–21 and the percentage of newborn babies given a pre-lacteal feed declined from more than 57% in 2005–06 to 15% in 2019–21 (Fig 1).

In sixteen of the 30 Indian states in 2005–06, fewer than 35% of newborn babies were fed breastmilk immediately after birth. However, in 11 states (Maharashtra, Kerala, Tamil Nādu, Orissa, and the north-eastern states), more than 50% of the newborn babies were breastfed immediately after birth (data not shown). The early initiation of breastfeeding improved dramatically over time (Fig 2). By 2019–21, more than half of the newborn babies were breastfed within one hour of birth in 37% of districts, and in another 28% of districts 35–50% of newborn babies received breastfeeding within one hour of birth. Nonetheless, fewer than 35% of newborn babies were breastfed early in about 35% of districts, mostly in Uttar Pradesh, Bihar, Jharkhand, Rajasthan, and Gujarat.

Fig 2 — A: Prevalence of early initiation of breastfeeding, B: Prevalence of pre-lacteal feed. Note: NFHS 3 (2005–06) provides statewise data only.

Pre-lacteal feed showed a downward trend in all the states/districts of India. In 2005–06, while more than 25% of newborn babies were given a pre-lacteal feed in 23 states, including Uttar Pradesh, Bihar, Punjab, Rajasthan, Madhya Pradesh, West Bengal etc, fewer than 12.5% of newborn babies were given a pre-lacteal feed in Kerala and Sikkim (data not shown). By 2019–21, the proportions reduced tremendously. For example, more than 25% of newborn babies received a pre-lacteal feed in about 11% of the Indian districts (mostly concentrated in Uttar Pradesh). In nearly 46% of the districts in 2019–21, fewer than 12.5% of newborn babies received a pre-lacteal feed.

Compared to the children born to mothers in rural areas, children in urban areas had an advantage, as higher proportion of children born to urban mothers were initiated early breastfeeding and fewer were given a pre-lacteal feed(Table 1). For example, in 2019–21, 44% of newborn babies in urban areas were breastfed within one hour compared to 41% newborn babies in rural areas. Similarly, 15% of newborn babies in urban areas were given a pre-lacteal feed compared 17% of newborn babies in rural areas. The feeding practice did not differ by newborn’ gender. While early initiation of breastfeeding was higher and, pre-lacteal feed was lower among children born to younger mothers and children of lower birth order (1 or 2). Similarly, children born to mothers with secondary or higher education, belonging to rich wealth tertile had huge advantage over those born to mothers with no education or mothers in poor wealth tertile as more received early breastmilk and fewer were given a pre-lacteal feed. For example, in 2019–21, 37% of children born to mothers who did not receive any education and 43% children born to mothers who had completed secondary or higher education received early breastmilk. The corresponding numbers for children receiving a pre-lacteal feeding are 15% and 16%, respectively. A higher proportion of children born to scheduled tribe mothers received breastmilk early while fewer received a pre-lacteal feed compared to the children born to mothers of other caste groups.

Table 1. Percentage of children^* who were breastfed within one hour after birth and who received a pre-lacteal feeding by selected socio-demographic characteristics, India, 2005–06 to 2019–21.

	Early initiation of breastfeeding			Pre-lacteal feeding
	2005–06	2015–16	2019–21	2005–06	2015–16	2019–21
Overall	24.5	41.4	41.7	57.2	20.8	15.3
Place of residence
Rural	22.4	40.9	40.7	57.6	20.6	17.1
Urban	30.3	42.6	44.2	48.0	21.2	14.6
Sex of child
Male	24.7	41.0	41.7	55.2	21.0	15.6
Female	24.3	41.9	41.7	54.9	20.5	14.9
Maternal age at birth (in years)
≤19	22.3	42.6	45.7	56.9	18.7	14.0
20–34	25.3	41.6	41.6	53.9	20.7	15.3
≥35+	18.3	36.6	38.3	66.5	25.6	16.0
Birth order
1	26.5	41.2	41.1	52.0	22.0	18.0
2	30.0	43.9	43.8	47.2	18.0	14.0
3 or higher	19.8	39.0	39.9	61.9	22.5	13.7
Maternal education
No education	16.7	35.9	36.8	65.0	23.8	14.7
Primary	26.1	40.6	41.9	51.7	20.4	13.5
Secondary or higher	33.4	44.2	43.1	44.1	19.5	15.8
Household wealth tertile
Poor	18.5	38.9	39.3	63.4	21.4	12.4
Middle	23.9	42.9	42.1	55.9	18.9	14.6
Rich	30.4	42.3	43.4	46.8	22.0	18.4
Maternal caste/tribe
Scheduled castes	23.2	41.2	41.9	56.7	19.7	14.2
Scheduled tribe	28.6	45.4	46.1	42.0	12.4	10.2
Other backward class	22.0	40.1	38.8	60.4	23.4	16.1
Other castes	26.8	41.2	43.6	51.7	22.2	18.8
Mother received ANC visits during pregnancy
No visit	11.3	34.0	32.4	75.3	23.8	15.4
1 to 3 visits	21.1	37.2	34.9	58.1	23.3	16.5
4 or more visits	35.8	46.4	46.5	40.0	18.4	14.7
Place of delivery
Not in a health facility	17.8	34.3	34.2	64.9	29.0	20.9
Public health facility	37.3	45.8	44.6	34.8	14.4	10.5
Private health facility	31.1	38.1	38.1	46.6	27.2	24.4
Type of delivery
Vaginal deliveries	24.8	43.4	43.8	55.3	18.8	12.1
C-section public facility	25.9	37.7	39.5	43.3	19.4	17.2
C-section private facility	20.1	30.9	32.1	56.5	34.7	31.2
Mother received breastfeeding advice during pregnancy
No	19.0	34.4	37.8	61.2	28.4	19.4
Yes	36.1	47.0	44.4	40.4	16.6	13.8
Healthcare providers observed breastfeeding during first 2 days after birth
No	NA	NA	36.3	NA	NA	18.4
Yes	NA	NA	43.4	NA	NA	14.6
N	38528	184641	174947	38528	174,468	165,131

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Notes:

The results of χ2 suggest that all variables are significant at less than 1% for both early initiations of breastfeeding and pre-lacteal feeding for all three time periods included in the analysis.

Sex of the child is significant at <10% for early initiations of breastfeeding in 2019–21 and is insignificant for the years 2005–06 for both early initiations of breastfeeding and pre-lacteal feeding

NA = Not available

*youngest surviving child among children born during the past five years preceding the survey

In 2019–21, early initiation of breastfeeding was higher among children whose mothers received 4 or more ANC visits (47%) than those with fewer ANC visits (35%) or no ANC visit (32%). Conversely, fewer children (15%) were given a pre-lacteal feed if the mothers received 4 or more ANC visits during pregnancy compared to those who received fewer (17%) or no ANC visit (15%). Relatively higher proportions of newborn babies were initiated early breastfeeding and fewer were given a pre-lacteal feed if the delivery occurred in a public health facility. In contrast, only fewer children were breastfed early and more received a pre-lacteal feed if the delivery did not occur in a health facility. Similarly, higher proportions of children were breastfed early (44%) and fewer received a pre-lacteal feed (12%) if the delivery was vaginal.

The percentage of children who were breastfed early was higher among mothers who were advised about early initiation of breastfeeding during the pregnancy. At the same time, fewer children whose mothers received this advice were given a pre-lacteal feed. Similarly, feeding practices were better when a healthcare provider observed breastfeeding during the first 2 days after birth.

Not only have the feeding practices improved in all population subgroups during the analysis period, but also the gap across population subgroups too have narrowed. For example, the relative disadvantage in rural children has reduced from 8% points in 2005–06 to 3% points in 2019–21. Similarly, the relative disadvantage of pre-lacteal feed reduced from about 10% points to 3% points during the same period.

Pre-lacteal feed by delivery type

Regardless of the time period, other milk (not breastmilk) followed by plain water, honey and Sugar, glucose or salt water solution was the most common pre-lacteal feed (Table 2). About 59% of newborn babies in 2005–06 were fed with other milk (not breastmilk), which increased to 72% in 2019–21. About 11% and 9% of newborn babies in 2019–21 were fed plain water and honey, respectively. Another nearly 8% of newborn babies in 2019–21 were given sugar, glucose or saltwater solution before initiating breastfeeding. A minority of newborn babies were also given janam ghutti, tea/infusions, infant formula or gripe water. The choice of pre-lacteal feed varied by delivery type. For example, in 2019–21 higher percentages of newborn babies born by a C-section delivery (77%) were given other milk than vaginal delivery (69%). Likewise, a higher proportion of newborn babies delivered by a C-section reportedly were given plain water or honey before breastmilk.

Table 2. Distribution of children by types of pre-lacteal feed and delivery type, India, 2005–06 to 2019–21.

Pre-lacteal type	2005–06			2015–16			2019–21
Pre-lacteal type	Vaginal	C-section	Overall	Vaginal	C-section	Overall	Vaginal	C-section	Overall
Other milk (not breastmilk)	59.1	54.4	58.7	61.7	69.6	63.8	68.6	77.1	71.9
Plain water	15.8	15.8	15.8	12.6	11.9	12.4	12.7	8.7	11.2
Honey	25.5	16.8	24.7	15.2	9.0	13.6	10.5	6.4	8.9
Sugar/glucose/salt water or solution	26.1	30.3	23.2	11.8	12.9	12.1	8.5	7.2	8.0
Janam ghutti	8.9	3.9	8.4	8.4	4.6	7.4	7.0	3.2	5.5
Tea/infusions	5.6	2.6	5.3	7.2	2.1	5.8	7.4	2.3	5.4
Infant formula	0.6	7.1	1.2	2.0	6.6	3.2	2.6	7.6	4.6
Fruit juice	0.2	0.2	0.2	0.8	0.7	0.8	1.9	1.2	1.6
Gripe water	0.5	1.1	0.6	1.4	1.9	1.5	1.5	1.6	1.5
Others	3.8	1.8	3.6	4.0	2.6	3.6	3.2	3.3	3.3

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Determinants of early initiation of breastfeeding

After adjusting for other socioeconomic, demographic, and programmatic variables, results from logistic regression analysis (Table 3) reveal that compared to children born to rural mothers, children born to a mother in urban areas had higher odds of receiving breastmilk within one hour of birth (odds ratio (OR): 1.10 (95% CI: 1.06,1.13)). The odd of receiving early breastmilk were lower for children born to mothers aged 20–34 years and older than those whose mothers were older than 35 years had lower odds (OR: 0.90 (0.86,0.95) and 0.88 (0.82,0.95), respectively) than those born to younger mothers. Compared to first born, children of subsequent birth orders had higher odds to be breastfed within one hour after birth. Mother’s educational attainment had a statistically significant positive association with early initiation of breastfeeding. For example, compared to newborn babies of uneducated mothers, newborn babies whose mothers had primary or secondary or higher education had higher odds (OR: 1.18 (1.13,1.23) and 1.30 (1.26,1.35), respectively) to have received early breastmilk. Compared to the scheduled tribes, the odds of receiving early breastmilk were lower for newborn born to mothers in other backward class (OR: 0.78 (0.75,0.81)) or to those in scheduled castes or other castes categories (OR: 0.84 (0.81,0.88)).

Table 3. Adjusted odds ratios (and 95% confidence intervals) from logistic regression analyses examining children’s likelihood of receiving early initiation of breastfeeding and pre-lacteal feed by selected characteristics, India [Based on Pooled NFHS Data, 2005–06, 2015–16, 2019–21].

Characteristics	Odds Ratio (95% confidence interval)
Characteristics	Early initiation of breastfeeding	Pre-lacteal feed
Place of residence
Rural ®
Urban	1.10^***[1.06,1.13]	0.93^***[0.89,0.97]
Sex of child
Female ®
Male	0.99[0.97,1.01]	1.04^*[1.01,1.07]
Maternal age at birth (in years)
≤19 ®
20–34	0.90^***[0.86,0.95]	1.06[1.00,1.13]
≥35	0.88^***[0.82,0.95]	1.17^**[1.07,1.29]
Birth order
1 ®
2	1.20^***[1.16,1.23]	0.73^***[0.70,0.76]
3 or higher	1.11^***[1.08,1.15]	0.82^***[0.79,0.86]
Maternal education
No education ®
Primary	1.18^***[1.13,1.23]	0.86^***[0.81,0.90]
Secondary or higher	1.30^***[1.26,1.35]	0.76^***[0.72,0.79]
Household wealth tertile
Poor ®
Middle	1.01[0.97,1.04]	1.10^***[1.05,1.15]
Rich	1.00[0.96,1.04]	1.24^***[1.18,1.31]
Maternal caste/tribe
Scheduled Tribe ®
Scheduled Castes	0.84^***[0.81,0.88]	1.64^***[1.54,1.75]
Other backward class	0.78^***[0.75,0.81]	1.80^***[1.70,1.91]
Other castes	0.84^***[0.81,0.88]	1.84^***[1.72,1.97]
Mother received ANC visits during pregnancy
No visit ®
1 to 3 visits	0.98[0.93,1.03]	1.18^***[1.11,1.26]
4 or more visits	1.53^***[1.45,1.62]	0.84^***[0.78,0.89]
Place of delivery
Not in a health facility ®	.
Public health facility	1.45^***[1.40,1.51]	0.46^***[0.44,0.48]
Private health facility	1.19^***[1.14,1.25]	0.82^***[0.77,0.87]
Type of delivery
Vaginal deliveries ®
C- section in a public facility	0.64^***[0.61,0.67]	1.81^***[1.71,1.92]
C- section in a private facility	0.56^***[0.53,0.59]	2.12^***[2.00,2.25]
Mother received breastfeeding advice during pregnancy
No ®
Yes	1.44^***[1.40,1.49]	0.56^***[0.54,0.59]
Survey period
2005–06 ®
2015–16	1.61^***[1.52,1.70]	0.34^***[0.32,0.36]
2019–21	1.43^***[1.35,1.51]	0.27^***[0.25,0.29]

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® = Reference category

* p<0.05

** p<0.01

*** p<0.001

Newborn babies of mothers who had 4 or more ANC visits had substantially higher odds (OR: 1.53 (1.45,1.62)) of receiving early breastmilk than those born to mothers who had no ANC visit. Similarly, newborn babies delivered in a public health facility had higher odds (OR: 1.45 (1.40,1.51)) of receiving early breastmilk than those delivered in a non-health facility. Similarly, the odds were also higher for children born in a private health facility (OR: 1.19 (1.14,1.25)). Children delivered by a C-section in either a public or a private health facility had lower odds (OR: 0.64 (0.61,0.67) and 0.56 (0.53,0.59), respectively) of early initiation of breastfeeding than a vaginal delivery. Children born to mothers who received breastfeeding advice during pregnancy had much higher odds (OR: 1.44 (1.40,1.49)) of early breastfeeding than those born to mothers who were not advised. Similarly, odds of early initiation of breastfeeding were higher among children surveyed in 2015–16 (OR: 1.61 (1.52,1.70)) and 2019–21 (OR: 1.43 (1.35,1.51)) compared to those surveyed earlier (in 2005–06).

Determinants of pre-lacteal feed

Results adjusted for other socioeconomic, demographic, and programmatic variables suggest that the odds of newborn babies getting a pre-lacteal feed were lower for those born to mothers in urban areas (OR: 0.93 (95% CI: 0.89,0.97)) than those born in rural areas. Newborn boys had higher odds to receive a pre-lacteal feed than the newborn girls (OR: 1.04 (1.01,1.07)). Newborn babies of older mothers had substantially higher odds (OR: 1.17 (1.07,1.29)) to get a pre-lacteal feed than those born to younger mothers. Compared to first born, children of subsequent birth order had lower odds of getting a pre-lacteal feed (OR: 0.73 (0.70,0.76) for second order births and 0.82 (0.79,0.86) for three or higher order births). Compared to newborn babies of uneducated mothers, newborn babies whose mothers had primary (OR: 0.76 (0.72,0.79)) or secondary or higher education (OR: 0.86 (0.81,0.90)) had much lower odds of receiving a pre-lacteal feed. Newborn babies of mothers belonging to middle and rich wealth tertile had significantly higher odds (OR: 1.10 (1.05,1.15) for middle wealth tertile and 1.24 (1.18,1.31) for rich wealth tertile) of receiving a pre-lacteal feed compared to those born to mothers in poor wealth tertile. Compared to the Scheduled tribes, newborn babies from other castes had substantially higher odds (OR: 1.64 (1.54,1.75) to 1.84 (1.70,1.91)) of receiving a pre-lacteal feed.

While newborn babies of mothers who had 4 or more ANC visits had lower odds (OR: 0.84 (95% CI: 0.78,0.89)) of receiving a pre-lacteal feed, those born to mothers who had 1–3 ANC visits had higher odds (OR: 1.18 (1.11,1.26)) of receiving a pre-lacteal feed than those born to mothers who had no ANC visit. Further, newborn delivered in a public health facility or in a private health facility had significantly lower odds (OR: 0.46 (0.44,0.48) and 0.82 (0.77,0.87), respectively) of receiving a pre-lacteal feed than those delivered outside a health facility. Children born to mothers who had a C-section delivery in a public or private health facility had much higher odds (OR: 1.81 (1.71,1.92) and 2.12 (2.00,2.25), respectively) of receiving a pre-lacteal feed than vaginal delivery. Newborn babies whose mothers received breastfeeding advice during pregnancy had much lower odds (OR: 0.56 (0.54,0.59)) of receiving a pre-lacteal feed than those whose mothers were not advised. Compared to children surveyed in 2005–06, odds of receiving a pre-lacteal feed was lower among children surveyed in 2015–16 (OR: 0.34 (0.32,0.36)) or in 2019–21 (OR: 0.27 (0.25,0.29)).

Neonatal mortality and feeding practices

The overall estimated neonatal mortality rate (NMR) was 24.8 per 1000 livebirths in India in 2019–21 (Table 4). The NMR among children who were ever breastfed was 6.9 per 1000 livebirths as against of 198 per 1000 livebirths among those who were never breastfed. The NMR was 28.4 per 1000 livebirths among children born to mothers who did not answer on breastfeeding status. The NMR was 6.6 and 6.8 per thousand livebirths among children who were breastfed within one hour after birth or between one hour to one day after birth, respectively. In contrast, the NMR was 8.1 per 1000 livebirths among children who received delayed breastfeeding one day after birth. The NMR was 5.1 per thousand livebirths among newborn who received pre-lacteal feed and 7.1 per 1000 live births among those who did not receive a pre-lacteal feed.

Table 4. Neonatal mortality rate per thousand live births by the breastfeeding and pre-lacteal feeding status, India (2019–21).

Practices	Neonatal mortality rate (NMR)	Number of live births
Ever breastfed
Yes	6.9 [6.5,7.3]	1,67,606
No	197.7 [191.3, 206.8]	16,377
Did not answer	28.4 [26.9, 29.9]	46,887
Timing of breastfeeding initiation
Within one hour	6.6 [6.0, 7.2]	72,960
One hour to one day	6.8 [6.3,7.4]	77,001
More than one day	8.1 [6.7,9.6]	15171
Pre-lacteal feeding (for last birth)
Yes	5.1 [4.3,6.1]	25,212
No	7.1 [6.7,7.6]	1,39,919
Did not answer	178.9 [171.4, 186.6]	9,816
Overall	24.8 [24.17, 25.44]	2,30,870

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We also explored the ecological (at state level) association between the level of NMR and the breastfeeding practices, which is illustrated in Fig 3. The correlation between NMR and early initiation of breastmilk was -0.59 and that with pre-lacteal feed was 0.12 (data not shown). The results suggest that the NMR was lower in states where higher proportions of newborn babies received early breastmilk. However, the association between NMR and pre-lacteal feed appears relatively weak. These ecological associations are consistent with the pattern shown in Table 4.

Fig 3 — Association of neonatal mortality with early initiation of breastfeeding (A) and pre-lacteal feeding (B), based on state-level estimates, India, 2019–21.

Discussion

The study documents a spatial pattern in initiation of early breastfeeding and pre-lacteal feed in India. The pre-lacteal feeding practice is less common in regions where early initiation of breastfeeding is predominant and vice versa. The study observed that early breastfeeding initiation is more commonly prevalent in southern India where pre-lacteal is less prevalent, conversely, initiation of early breastfeeding is lower and pre-lacteal is higher in the northern India. Mothers who gave a pre-lacteal feed, initiated breastfeeding later than the recommended guidelines [17, 23, 24]. The early breastfeeding initiation may actually help reduce pre-lacteal feeding. The breastfeeding practices in India have shown considerable improvement, especially after the launch of the National Rural Health Mission in 2005. However, the recent data shows a stagnation in the levels of early breastfeeding initiation. At the same time, the pace of decline in the pre-lacteal feeding too has slowed down.

The study found that the children delivered in the public health facilities have a higher chance of getting breastfeeding within one hour after birth. In contrast, the practice is less common for children born in private health facilities and is lowest for children not delivered in a health facility. Earlier studies have also found significant association between place of birth with timely initiation of breastfeeding [25, 26]. Further, pre-lacteal feeding is less common among children born in public health facilities and is relatively at higher levels for children born in private health facilities. This suggests that the service providers in public health facilities follow the breastfeeding guidelines more strictly than those in private health facilities. The levels of timely initiation of breastfeeding were found to be undesirably low, and the practice of giving pre-lacteal feeding existed even in tertiary-care hospitals [17].

The factors associated with timely initiation were higher maternal education, antenatal counselling, absence of obstetric problems, and vaginal delivery. In contrast, those associated with pre-lacteal feeding were lower maternal education and caesarean delivery [17, 27–29]. A study found that breastfeeding initiation was delayed after birth because the mothers perceived colostrum to be harmful for child’s health and that the mother’s milk is ‘not ready’ until two to three days postpartum [30].

The prevalence of pre-lacteal is significantly high, and early initiation is low in C-section deliveries. Use of general or spinal anaesthesia for caesarean delivery and the trauma during surgery delay mothers’ recovery, which delays the early initiation of breastfeeding. Meanwhile, it is compensated by milk other than breastmilk [17, 31, 32]. Results show that the distribution of those items for which mothers’ breastmilk in critical conditions can compensate is more predominant, such as milk other than breastmilk and infant formula in C-section delivery. But in vaginal deliveries, other factors related to cultures such as honey and janam ghutti were more dominant. The study also notes a change in the distribution of the types of pre-lacteal feed over the study period. Earlier there was a predominance of items related to cultural and traditional practices. With time, the distribution has shifted in favour of honey, janam ghutti, sugar/glucose water is reduced, and milk other than breastmilk and infant formula.

The role of health professionals during pregnancy and the first two days after delivery is visible in improving breastfeeding practices. The study found that mothers who received breastfeeding advice during pregnancy have elevated levels of early initiation of breastfeeding and lower levels of pre-lacteal feeding practice. The study revealed that higher percentages of children were breasted within one hour of birth and lower percentages were given a pre-lacteal feed when healthcare providers observed breastfeeding during the first two days after birth. There is a significant association between two important interventions of receiving prenatal counselling on breastfeeding and postnatal support to mothers, with early initiation of breastfeeding [25, 33].

The study results show that early initiation of breastfeeding lowers neonatal mortality and thus provides compelling evidence supporting the critical role the timing of breastfeeding initiation, particularly within the first one hour can significantly reduce the risk of severe illnesses during the first month of life. Earlier studies also showed an increased risk of neonatal death by 33% when the breastfeeding initiation is delayed between 2 and 23 hours and doubles when the initiation is delayed beyond 24 hours [8, 34, 35]. This could be linked to the immune system which is still growing during infancy, making them highly vulnerable to diseases [36]. Breastmilk contains vital nutrients, antibodies, and other bioactive substances that work as a natural defence against illnesses and boost the immunological response during infancy [37]. Further, using the most recent available data of 2019–21, this study found that pre-lacteal feed does not influence child survival much. This could be due to the fact that the study found that the items given as pre-lacteal feed predominantly used in India are typically not harmful and can be compensated by mothers’ breastmilk.

We also acknowledge a few limitations of this study. First, this study considered any food given to the newborn within the first three days after birth other than breastmilk as pre-lacteal feed. This is mainly due to the fact that the survey collects information by asking ‘In the first three days after delivery, was the baby given anything to drink other than breast milk?’ Further, the survey does not provide information on timing. Second, the pre-lacteal and initiation of breastfeeding information is available only for the last birth in the NFHS data. Due to this, the estimated NMR is restricted only to the last birth. Third, the NFHS 3 provides only state level data and hence unable to provide district level analysis.

Conclusions

The present study found that promoting early initiation of breastfeeding reduces the pre-lacteal feeding practices suggesting that a stringent focus on enhancing levels of early initiation of breastfeeding may yield reductions in levels of pre-lacteal feeding among the newborn babies. The study findings further indicate that the breastfeeding advice during pregnancy and breastfeeding observation by the health service provider after the birth significantly improve breastfeeding and pre-lacteal feeding practices. This supports that increased focus on these practices by the grass root level heath workers at the time of visits can help accelerate reductions in neonatal mortality. However, there is a gap in the program implementation as it lacks universal adherence, more specifically in the private health facilities. Thus, it is of utmost importance that the future programs make concerted efforts and pay greater attention to ensure that the expectant mothers are duly advised on early initiation of breastfeeding and that the service providers observe the early initiation to ensure adherence. For example, it may be helpful to create the awareness and greater commitments among the service provides about the importance of early initiation and its adherence and how this can bring about positive changes in the health outcomes among newborn babies including reduced mortality. Additionally, supporting new mothers with proper guidance and resources may facilitate establishing successful breastfeeding routines.

The study also documents evidence on association between neonatal mortality and breastfeeding and pre-lacteal feeding practices in India. The neonatal mortality rate is found to be lower among newborn who were given breastmilk within one hour after birth. The study further noted, that the pre-lacteal feed did not influence neonatal survival, but early initiation of breastfeeding does. Although, pre-lacteal feeding practices may continue given cultural context of the practices, it may be essential to create awareness on the choice of pre-lacteal feeds that are harmless. It is suggested that there is a need to strengthen the intervention of early breastfeeding initiation through breastfeeding adviser and cohesive observance of the early initiation to reduce neonatal mortality.

Acknowledgments

We acknowledge and are grateful to anonymous reviewers and the academic editor for their elaborate, critical and constructive suggestions in improving the paper.

Data Availability

Data is publicly available and accessible upon request from the DHS program at https://dhsprogram.com/data/available-datasets.cfm

Funding Statement

The authors received no specific funding for this work.

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PLoS One. doi: 10.1371/journal.pone.0292353.r001

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PONE-D-22-34236First 72-hours after birth: Newborn feeding practices and neonatal mortality in IndiaPLOS ONE

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Reviewer #1: The present paper is a timely contribution to the existing literature on neonatal mortality and determinants like initiation of breast feeding and the substance fed. However, while the paper highlights an important finding that ‘the pre-lacteal feed did not influence neonatal survival’; it may be important to consider (a) a couple of lines explanting the phenomenon; and (b) giving viable suggestions for strengthening early breastfeeding. This will add value to the paper. Similarly for lines 339-340 too, concrete suggestions will be useful for policy makers.

Reviewer #2: REPORT TEMPLATE

Paper title: First 72-hours after birth: Newborn feeding practices and neonatal mortality in India

Manuscript no: PONE-D-22-34236

Reviewer's report

The manuscript addressed trends, spatial variation, and determinants of early initiation of breastfeeding and pre-lacteal feeding in India. On very short, the manuscript also analyzed the effect of these breastfeeding practices on neonatal mortality. The study used the three latest rounds of the National Family Health Survey (NFHS) data conducted during 2005-06, 2015-16, and 2019-21. The study applied bivariate and multivariate (the Tobit regression analysis) analysis to examine the level, trends, and determinants of breastfeeding practices.

While reviewing this manuscript, I found that there is a mismatch between the title and the analysis presented in the manuscript. While the title indicates that this manuscript focused on what is the effect of breastfeeding practices on neonatal mortality. However, most of the result section focused on the level, trends, and determinants of the early initiation of breastfeeding and pre-lacteal feeding, and very less is talked about the effect of these on neonatal mortality. This is completely different than what the method section of the abstract claims. Therefore, my suggestion is please remove the neonatal mortality part and only focus on the level, trends, and determinants of the feeding practices. That itself will be a good enough material for a paper. Below is my specific observation on the paper.

Abstract:

1. In the method section, please mention the timing of the survey period. Some readers may wonder which three rounds, the first three or the last three out of the five rounds of the National Family Health Survey (NFHS). Though I noticed that it was mentioned in the results section, however, it’s always good to mention the survey date in the method section.

2. Please mention and define the outcome variable in the method section.

3. Please provide some numeric values in the result section.

4. Some parts of the result section can be moved into the discussion or in the conclusion. Such as “While the prevalence of pre-lacteal feed reduced and initiation of early breastfeeding increased considerably after the launch of National Rural Health Mission in India….”.

5. It would be good to present the results and conclusion separately.

Introduction:

6. Is the first sentence complete?? “The past few decades have witnessed rapid improvements in the global health scenario as a result of mortality reduction in most populations, including lagers”. Please check. Further, the very first sentence of the introduction section is talking about the reduction in overall mortality. Isn’t it?? If so, then my suggestion is please start talking about childhood mortality or neonatal mortality.

7. Please abbreviate ‘UNIGME’ as many readers may not be aware of it.

8. The “)” at the last of the first paragraph seems unnecessary, please check and remove it.

Data and method:

9. In the very first sentence, please write ‘2005-6’ as “2005-06”. Also please provide the survey period of each of the last three rounds of the NFHS.

10. Nothing was mentioned about neonatal mortality. Is neonatal mortality, not your dependent variable? You may consider ‘Early initiation’ as well as ‘Pre-lacteal feed’ as predictors, and independent variables as confounders or independent. Moreover, please provide some reference that why you are considering these independent variables in the analysis.

Results:

11. From line number 160-185, nowhere the results (numeric value) are reported. Please report the results in those paragraphs and shorten those.

12. In Table 3, for the reference categories, you have mentioned ‘@’ as well as ‘R’. Please keep only one.

Discussion:

13. Too much focus is on the early initiation of breastfeeding and pre-lacteal feeding, and almost nothing is talked about neonatal mortality.

Conclusions:

14. The conclusion section is focusing on neonatal mortality only.

**********

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Reviewer #1: Yes: Sanghmitra Acharya

Reviewer #2: No

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PLoS One. 2023 Oct 5;18(10):e0292353. doi: 10.1371/journal.pone.0292353.r002

Author response to Decision Letter 0

21 Aug 2023

Reviewer 1

Review of the Paper Titled: First 72-hours after birth: Newborn feeding practices and neonatal mortality in India

The present paper is of relevance in context of the child health in early years of life. While much of the literature concentrate on analysing the infant and child by the socio-cultural background of the mother. Initiation of breastfeeding as well as the substance to be fed is highly determined by it. The present paper mortality, the present paper engages with the crucial first 72 hours of life. This also the period which is influenced has used robust methodology to examine the feeding practices and neonatal mortality in India evident from the NFHS data of three selected rounds. The analysis bring out the nuances of the early neonatal stage and related mortality.

Response 1: We are very grateful to the reviewers for reviewing the manuscript and appreciating the work. We thank reviewer for constructive suggestions and comments. We have incorporated all these valuable suggestions in revised manuscript.

The following points may be considered for value addition-

Comment 1:

In lines 28-29 as given below�

28 The mortality within the first month of life (during the neonatal period) has shown relatively

29 slow progress

Observation/Suggestion� ‘Progress in mortality’ is certainly not what the authors intend. Therefore, this line needs to be re-stated as- The mortality decline within the first month…slow progress.

Response 2: Thanks for pointing this out. We have replaced ‘Progress in mortality’ with ‘mortality decline’. [please see line no. 27].

Comment 2:

In line 34 as given below�

34 We used data from three rounds of National Family Health Surveys in India.

Observation/Suggestion� May be a good idea to mention the three rounds of NFHS used in the paper.

Response 3: Thanks for the suggestion. We have mentioned the last three rounds of NFHS. [please see line nos. 33-34]

Comment 3:

In line 332-334 as given below�

332……… The study further noted, that the pre-lacteal feed did

333 not influence neonatal survival. It is suggested that there is a need to strengthen the intervention of early

334 breastfeeding initiation.

Observation/Suggestion� It is an important finding that ‘the pre-lacteal feed did not influence neonatal survival’. Therefore, (a) a couple of lines explanting the phenomenon; and (b) giving viable suggestions for strengthening early breastfeeding will add value to the paper. Similarly for lines 339-340 too, concrete suggestions will be useful for policy makers.

Response 4: Thanks for the suggestion. We have added a line in the revised manuscript and have explained the phenomenon [please see line nos. 398-400] and provided viable suggestions for strengthening early breastfeeding component for the future programme [please see line nos. 383-385, 400-402].

We have also provided suggestions that may be useful for policy makers [please see line nos. 389-393].

SANGHMITRA S ACHARYA -ORCID ID

https://orcid.org/0000-0001-6488-4181

Reviewer 2

Paper title: First 72-hours after birth: Newborn feeding practices and neonatal mortality in India

Manuscript no: PONE-D-22-34236

Reviewer's report

Response 5: Thank you for your suggestion and comment. In the revised manuscript we have made necessary changes/modifications. However, the referred table and text, demonstrate that there is a strong association between neonatal mortality and breastfeeding practices as well as pre-lacteal feeding practice. Therefore, we have not removed neonatal mortality part.

Abstract:

Comment 4:

In the method section, please mention the timing of the survey period. Some readers may wonder which three rounds, the first three or the last three out of the five rounds of the National Family Health Survey (NFHS). Though I noticed that it was mentioned in the results section, however, it’s always good to mention the survey date in the method section.

Response 6: Thank you for your suggestion. We have mentioned the survey date in the method section of the abstract. [please see line nos. 33-34]

Comment 5:

Please mention and define the outcome variable in the method section.

Response 7: Thank you for your suggestion. We have mentioned the outcome variable in the method section of abstract [please see line nos. 35-36]. Detailed definitions of the outcome variables are already mentioned in the method section of the complete manuscript [please see line nos. 106-112].

Comment 6:

Please provide some numeric values in the result section.

Response 8: Thank you for your suggestion. We have included numeric values as necessary in the result section of the abstract. [please see line nos. 38-39]

Comment 7:

Some parts of the result section can be moved into the discussion or in the conclusion. Such as “While the prevalence of pre-lacteal feed reduced and initiation of early breastfeeding increased considerably after the launch of National Rural Health Mission in India….”.

Response 9: Thank you for your suggestion. We have moved this section into the conclusion. [please see line nos. 46-48]

Comment 8:

It would be good to present the results and conclusion separately.

Response 10: Thank you for your suggestion. We have moved this part under a new head ‘conclusion’. [please see line no. 45]

Introduction:

Comment 9:

Is the first sentence complete?? “The past few decades have witnessed rapid improvements in the global health scenario as a result of mortality reduction in most populations, including lagers”. Please check. Further, the very first sentence of the introduction section is talking about the reduction in overall mortality. Isn’t it?? If so, then my suggestion is please start talking about childhood mortality or neonatal mortality.

Response 11: Thanks for pointing out. We have modified the sentence [please see line nos. 53-55]. We have replaced ‘mortality’ by ‘childhood mortality’ as suggested. [please see line no. 54]

Comment 10:

Please abbreviate ‘UNIGME’ as many readers may not be aware of it.

Response 12: Thank you for your suggestion. We have mentioned the full form of ‘UNIGME’. [please see line no. 60]

Comment 11:

The “)” at the last of the first paragraph seems unnecessary, please check and remove it.

Response 13: Thanks for pointing out the typo. We have removed “)”. [please see line no. 62]

Data and method:

Comment 12:

In the very first sentence, please write ‘2005-6’ as “2005-06”. Also please provide the survey period of each of the last three rounds of the NFHS.

Response 14: Thank you for your suggestion. We have ensured consistency throughout the manuscript and corrected the year as ‘2005-06’. [please see line nos. 94 and 216]. We have provided survey periods. [please see line nos. 93-94 and response 6]

Comment 13:

Nothing was mentioned about neonatal mortality. Is neonatal mortality, not your dependent variable? You may consider ‘Early initiation’ as well as ‘Pre-lacteal feed’ as predictors, and independent variables as confounders or independent. Moreover, please provide some reference that why you are considering these independent variables in the analysis.

Response 15: Thank you for your suggestion. We have added a few lines about neonatal mortality in the method section [please see line nos. 137-145] and also included two references by Edmond et al (2008) and Phukan et al (2018). [please see line nos. 137-140]

Results:

Comment 14:

From line number 160-185, nowhere the results (numeric value) are reported. Please report the results in those paragraphs and shorten those.

Response 16: Thank you for your suggestion. We have included numeric values. [please see line nos. 186-188, 193-195, 200, 202-203, 206-207]

Comment 15:

In Table 3, for the reference categories, you have mentioned ‘@’ as well as ‘R’. Please keep only one.

Response 17: Thank you for your suggestion. We have now used ® to indicate reference category in the Table 3.

Discussion:

Comment 16:

Too much focus is on the early initiation of breastfeeding and pre-lacteal feeding, and almost nothing is talked about neonatal mortality.

Response 18: Thank you for your suggestion. We have added a paragraph about neonatal mortality. [please see line nos. 365-368, 370-376]

Conclusions:

Comment 17:

The conclusion section is focusing on neonatal mortality only.

Response 19: Thank you for your suggestion. We have now modified conclusion and included breastfeeding practices as well as pre-lacteal feed. [please see line nos. 386-393, 398-400].

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PLoS One. doi: 10.1371/journal.pone.0292353.r003

Decision Letter 1

Chandan Kumar

11 Sep 2023

PONE-D-22-34236R1First 72-hours after birth: Newborn feeding practices and neonatal mortality in IndiaPLOS ONE

Dear Dr. Ram,

Please submit your revised manuscript by Oct 26 2023 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

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We look forward to receiving your revised manuscript.

Kind regards,

Chandan Kumar, Ph.D.

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

Additional Editor Comments:

Thank you for considering the reviewers' comments and suggestions and submitting your revised manuscript to PLOS ONE. However, after careful consideration, we found that the manuscript still needs to address a few minor concerns in order to fully meet PLOS ONE’s publication criteria. The comments are provided in the attached edited copy of the submitted manuscript along with suggested editing in the text using track-change mode. We, therefore, invite you to submit a revised version of the manuscript that addresses the points raised in the attached copy of the manuscript.

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PLoS One. 2023 Oct 5;18(10):e0292353. doi: 10.1371/journal.pone.0292353.r004

Author response to Decision Letter 1

16 Sep 2023

Thank you to the academic editor for your valuable comments and suggestions. We have responded to each query and have modify the manuscript accordingly.

Note: The line numbers mentioned against every response is based on the clean version of the revised manuscript.

Editor comment 1: It would be better if the authors briefly provide information on the study sample added in the analyses from all the rounds of the NFHS, before discussing the statistical analysis. This becomes more important to add, as there is no section in this paper discussing the sample characteristics, usually mentioned in the Results section.

Response 1: Thank you for the suggestion. We have included a brief on the same in the method section under a sub head ‘Study sample’ in the revised manuscript [Please see line nos. 106-115].

Editor comment 2: Before it please add a few sentences to describe the nature of the outcome variable, for which the Tobit Regression model has been opted as an appropriate method of analysis. As both the outcome variables seem to be typical dichotomous variables, not censored continuous variables. If it is not so, please briefly describe the rationale for selecting the Tobit regression model.

Response 2: Thank you for your suggestion. We have explained the same in the revised manuscript. We have now used logistic regression analysis to identify predictors of the early breastfeeding initiation and pre-lacteal feed and modified the text accordingly. [Please see line nos. 147-148 and Table 3]

Editor comment 3: Comparison of or change in the prevalence must be discussed in the same unit for a better understanding of the trend. The authors can show the change while comparing the district prevalence in 2015-16 with the district prevalence in 2019-21. Comparing state prevalence with district prevalence is not useful, although they can be mentioned in the text.

Please refer to this comment for the interpretation in the paragraph below too.

Response 3: Thank you for the suggestion. We have now modified figure 2 keeping NFHS4 and 5 results. [Please see figure 2]

Editor comment 4: Results must be interpreted in terms of the unit of the study sample. In this study, last-born children/newborns are the study sample unit, so these proportions should refer to the children, not their mothers, despite their numbers being the same.

Response 4: Thank you for pointing out. We have written the proportion referring the children/newborn babies throughout the text at all appropriate places in the revised manuscript [Please also see line nos. 197, 198, 213, 246, 250, 252-253].

Editor comment 5: Please refer to the earlier comments. Results must be written considering the study unit - proportion here refers to children, not the mothers. This must be followed throughout the manuscript.

Response 5: Thanks. The same has been addressed. [Please also see response 4].

Editor comment 6: Received more or less?

Response 6: Thank you for pointing out the missing word error. We have written “received breastmilk early” in the revised manuscript. [Please see line no 208]

Editor comment 7: This doesn't seem to be a correct interpretation of the regression coefficient; these are not the odds ratios.

Please refer to this comment for the following texts wherever it is applicable in the manuscript.

Response 7: Thank you for pointing out the mistake. We have corrected the interpretation of regression coefficient in the revised manuscript at all places. [Please see line nos. 291-304, 306-317]

Editor comment 8: The study sample, i.e., children, constitutes all those born during the five years preceding the respective NFHS. They are not those who were born during the survey period.

Response 8: Thank you for pointing out. We have modified the line. [Please see line nos. 285-287, 315-317]

Editor comment 9: Additionally, authors may also try showing the association between NMR and the coverage of early breastfeeding/pre-lacteal feeding using scatterplots and respective linear regression equations. State-level NMR on y-axis and state-level percentage of early breastfeeding/pre-lacteal feeding on x-axis can be illustrated using scatterplots.

Response 9: Thank you for your suggestion. We have now added Figure 3 that gives scatterplots showing the association between NMR and the coverage of early breastfeeding/pre-lacteal feeding. State-level NMR are on y-axis and state-level percentage of early breastfeeding/pre-lacteal feeding on x-axis. [Please see Figure 3]

Editor comment 10: This would be good to provide 95% CIs for the NMRs shown in Table 4.

Response 10: Thank you for your suggestion. We have provided 95% CIs for the NMRs shown in Table 4. [Please see Table 4]

Editor comment 11: Authors may thank two anonymous reviewers for their suggestions.

Response 11: Thank you for your suggestion. We have acknowledged two anonymous reviewers and academic editor for their suggestions. [Please see line nos. 449-450]

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PLoS One. doi: 10.1371/journal.pone.0292353.r005

Decision Letter 2

Chandan Kumar

20 Sep 2023

First 72-hours after birth: Newborn feeding practices and neonatal mortality in India

PONE-D-22-34236R2

Dear Dr. Ram,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Kind regards,

Chandan Kumar, Ph.D.

Academic Editor

PLOS ONE

PLoS One. doi: 10.1371/journal.pone.0292353.r006

Acceptance letter

Chandan Kumar

25 Sep 2023

PONE-D-22-34236R2

First 72-hours after birth: Newborn feeding practices and neonatal mortality in India

Dear Dr. Ram:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

If we can help with anything else, please email us at plosone@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. Chandan Kumar

Academic Editor

PLOS ONE

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

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Data Availability Statement

Data is publicly available and accessible upon request from the DHS program at https://dhsprogram.com/data/available-datasets.cfm

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PERMALINK

First 72-hours after birth: Newborn feeding practices and neonatal mortality in India

Piyasa Mal

Usha Ram

Roles

Abstract

Background

Methods

Results

Conclusion

Introduction

Methods

Data

Study sample

Outcome variables

Predictor variables

Statistical analysis

Results

Levels and trends in early initiation of breastfeeding and pre-lacteal feeding: National, sub-national and by population subgroups

Fig 1. Early initiation of breastfeeding and pre-lacteal feed in India, 2005–06 to 2019–21.

Fig 2. Early initiation of breastfeeding (within one hour after birth) and pre-lacteal feed after birth across districts in India, 2015–16 to 2019–21.

Table 1. Percentage of children* who were breastfed within one hour after birth and who received a pre-lacteal feeding by selected socio-demographic characteristics, India, 2005–06 to 2019–21.

Pre-lacteal feed by delivery type

Table 2. Distribution of children by types of pre-lacteal feed and delivery type, India, 2005–06 to 2019–21.

Determinants of early initiation of breastfeeding

Table 3. Adjusted odds ratios (and 95% confidence intervals) from logistic regression analyses examining children’s likelihood of receiving early initiation of breastfeeding and pre-lacteal feed by selected characteristics, India [Based on Pooled NFHS Data, 2005–06, 2015–16, 2019–21].

Determinants of pre-lacteal feed

Neonatal mortality and feeding practices

Table 4. Neonatal mortality rate per thousand live births by the breastfeeding and pre-lacteal feeding status, India (2019–21).

Fig 3.

Discussion

Conclusions

Acknowledgments

Data Availability

Funding Statement

References

Decision Letter 0

Chandan Kumar

Roles

Author response to Decision Letter 0

Decision Letter 1

Chandan Kumar

Roles

Author response to Decision Letter 1

Decision Letter 2

Chandan Kumar

Roles

Acceptance letter

Chandan Kumar

Roles

Associated Data

Supplementary Materials

Data Availability Statement

ACTIONS

PERMALINK

RESOURCES

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Links to NCBI Databases

Table 1. Percentage of children^* who were breastfed within one hour after birth and who received a pre-lacteal feeding by selected socio-demographic characteristics, India, 2005–06 to 2019–21.