# _Early initiation of breastfeeding_

The early initiation of breastfeeding safeguards infants from death in the first month of life, when they are most susceptible to this risk. South Asia has made more progress since 2000 in improving the early initiation rate than any other region of the world. Between 2000 and 2016, the early initiation rate more than doubled, from 16 to 40 percent (UNICEF 2016; UNICEF 2018a). However, more than 20 million infants are still not being breastfed within the first hour of birth (UNICEF 2016). Progress is extremely uneven across the region. The two countries with the lowest rates, Pakistan at 18 percent and Afghanistan at 41 percent, have both experienced recent declines in the early initiation rate; they also rank among the top three countries globally for neonatal mortality (UNICEF 2018b). In contrast, nine out of 10 newborn children benefit from early initiation in Sri Lanka (figure 1a).

Caesarean delivery is a consistent determinant of delayed breastfeeding initiation in South Asia, as post-delivery practices often fail to support early initiation (Dibley et al. 2010; Sharma and Byrne 2016; Kavle et al. 2017; Benedict et al. 2018a). Other barriers to early initiation include maternal or infant, sociocultural, and health system factors (Dibley et al. 2010; Sharma and Byrne 2016; Kavle et al. 2017; Benedict et al. 2018). Delayed initiation is often more likely among women with no formal education, with low access to media, and with low decision-making autonomy (Dibley 2010; Sharma and Byrne 2016; Benedict et al. 2018a). In Pakistan, early initiation is less likely among overweight women (Benedict et al. 2018a)–a pattern that deserves greater attention given the rising prevalence of overnutrition among women in both Pakistan and across the region. Infants who are small at birth are less likely to breastfeed early, potentially reflecting suckling difficulties in premature or smallfor-gestational age newborn children (Benedict et al. 2018a). Infants in wealthy households are less likely to be exclusively breastfed than other infants, presumably because these households can more easily afford breastmilk substitutes (Benedict et al. 2018a). Harmful traditional customs, including prelacteal feeding, interfere with early initiation (Sharma and Byrne 2016). Both Bangladesh and Nepal have made good progress in reducing the rate of prelacteal feeding since 2000, but the practice has become more common in recent years and is notably high in Pakistan, at 75 percent, and in Afghanistan, at 44 percent, mirroring the poor progress on early initiation of breastfeeding in these countries (Benedict et al. 2018a). Health system barriers include inadequate availability or utilization of skilled antenatal or delivery care (no or few antenatal care checkups, and lack of skilled support to initiate breastfeeding) (Dibley 2010; Sharma and Byrne 2016; Benedict et al. 2018a).

# _Exclusive breastfeeding_

Exclusive breastfeeding–that is, feeding infants only breastmilk for the first six months of life–is the safest and surest option for healthy growth in early life. The exclusive breastfeeding rate in South Asia increased by only five percentage points between 2000 and 2016, from 47 percent to 52 percent (UNICEF 2016; UNICEF 2018a). As with early initiation rates, countries in the region differ widely in terms of their exclusive breastfeeding rates, with the lowest rates in Pakistan (38 percent) and Afghanistan (43 percent), and the highest rate in Sri Lanka (82 percent) (figure 1b).

Barriers to exclusive breastfeeding are often identical to those for early initiation (Dibley et al. 2010; Kavle et al. 2017; Benedict et al. 2018a). They include harmful sociocultural customs (prelacteal feeding), infant factors (small birth size), and health system factors (low uptake of antenatal care, caesarean delivery, and home delivery). The Tajik and other smaller 3