Breastfeeding by Mothers with Cesarean Section Delivery

Abstract

Cesarean section (C-section) is an alternative to childbirth if a normal delivery cannot be achieved. However, in recent decades, the C-section rate has increased in many countries to become more common than vaginal birth. C-section deliveries are associated with lower rates of early initiation breastfeeding. Delay in early initiation of breastfeeding at C-section delivery is related to separation of mother and baby, reduced ability to breastfeed the baby, decreased acceptance of the baby, and lack of milk supply, which can result in shorter duration of breastfeeding. The results of previous studies showed that there was a negative correlation between delivery by C-section and the implementation of early initiation of breastfeeding. This fact indicates that C-section is one of the obstacles in early breastfeeding. Therefore, health workers need to educate the mothers to encourage them to have a spontaneous delivery if there is no medical indication. Suppose indeed the mother needs a C-section for medical reasons. In that case, healthcare professionals (obstetricians, midwives and nurses) also need to optimize the implementation of early breastfeeding initiation for mothers with C-section so that mothers and babies can still gain the experiences and benefits of early breastfeeding initiation and early bonding to the baby.

1. Introduction

Cesarean section (C-section) is an intervention to overcome complications in labour by delivering the foetus to the uterine wall through the front abdominal wall. Currently, SC is much more performed because of the very development of the procedure [1]. A C-section must still be understood as an alternative to childbirth if a normal delivery cannot be done. Ninety per cent of the delivery processes are normal, while the rest might have complications. Prioritizing the safety of the mother and baby is essential to address the difficulty during labour process [2]. C-section is also associated with maternal and newborn survival, as it can be a life-saving intervention if appropriately indicated [3]. However, in recent decades, the rate of CS has increased in many countries to become more common than vaginal birth [3, 4]. C-section rates worldwide increased from 6.7% in 1990 to 19.1% in 2014 [5]. The increase in CS in various countries can be seen in the following graph (Figure 1).

Figure 1.

Global and regional trends in CS, 1990–2014 [5].

A recent WHO report showed that C-section deliveries continue to rise worldwide, accounting for more than one-fifth (21%) of all deliveries. This figure is expected to rise further in the future decades, with almost one-third (29%) of all newborns predicted to be delivered via C-section by 2030 [4]. The trends (1990–2018) and projections (2030) in global, regional and subregional estimates of C-section rates.

By 2030, the C-section rate will be similar in more and less developed countries 36.6% (95% CI 31.7% to 41.4%) and 36.5% (95% CI 32.7% to 40.3%), respectively (Figure 2). The C-section rate in the least developed countries will be 11.8% (95% CI 9.7% to 13.8%). In Africa, the Northern sub-region will increase to 48.1% (95% CI 37.4% to 58.8%) CS rate in 2030, while the Sub-Saharan sub-region will remain at 7.1% (95% CI 6.4% to 7.9%). Eastern and Western Asia will reach the 50% mark by 2030, with C-section rates of 63.4% (95% CI 52.9% to 74.0%) and 50.2% (95% CI 47.4% to 52.9%) respectively. Central Asia, on the other hand, has the lowest prediction in this region with a C-section rate of 13.3% (95% CI 2.0% to 24.6%). According to projections for the Americas, 54.3% (95% CI 48.3% to 60.2%) of women in Latin America and the Caribbean will give birth by C-section in 2030, while Northern America will use C-section at a lower rate of 33.8% (95% CI 22.8% to 44.8%). According to projections for Europe, the highest C-section rates are expected in Southern Europe, at 47% (95% CI 38.8% to 53.3%), while C-section will be used in 27.6% (95% CI 16.2% to 39.1%) of births in Northern Europe, with little change over the next decade. In Australia and New Zealand, the use of C-section will rise to 45% (95% CI 38.1% to 52.0%) by 2030 [6]. In current conditions, C-section delivery is not only used as an emergency delivery but as a choice for mothers to give birth even without labour complications.

Figure 2.

Trends (1990–2018) and projections (2030) in global, regional and subregional estimates of C-section rates. The solid lines represent trend estimations, while the dotted lines represent predictions. (A) World; (B) Africa; (C) Asia; (D) Americas; (E) Europe; and (F) Oceania. Rates and projections for Melanesia, Micronesia, and Polynesia were not estimated due to the low coverage of data in this Oceania subregion [6].

The trend of selecting C-section as the birth method chosen by mothers is influenced by several reasons, namely women’s intense fear of pain and injuries to the mother and child during labour, unpredictability in vaginal delivery, and favorable attitudes or perceived advantages of C-section [7]. In line with the research of Suwanrath et al., [8] which states the results of a qualitative study of mother’s reasons for C-section preference, such as fear of the birthing process, concerns about safety related to perceived risks that could disrupt health conditions, unpleasant experiences in previous births, positive views towards C-section, access to biased information and belief in auspicious date. Most women choose to give birth by C-section for more than one reason [8]. This increase in C-section delivery occurred globally in both developed and developing countries. This shows that C-section delivery is a global issue that needs special attention and follow-up to reduce it. In addition, this situation must be mindful of because it could have an impact on the health outcomes of mothers and babies.

Recent studies have related C-section delivery with an increased risk of several outcomes later in life, such as type 1 diabetes, asthma and obesity. Another study also stated that mothers who gave birth by C-section were less likely to breastfeed or to delay early initiation of breastfeeding [9]. In fact, early initiation of breastfeeding is one of the keys to the success of exclusive breastfeeding. In addition, early initiation of breastfeeding is important because it has many benefits, namely, it allows the release of colostrum as the baby’s first immunity, contains many vitamins and other protective factors, can increase the bond between mother and baby and reduce the risk of postpartum hemorrhage [10]. Delay in early initiation of breastfeeding at C-section is associated with separation of mother and baby, reduced ability to breastfeed the baby, decreased acceptance of the baby, and lack of milk supply, which can result in shorter duration of breastfeeding [9]. The results of previous studies showed that there was a negative correlation between delivery by C-section and the implementation of early initiation of breastfeeding [11]. This shows that C-section is one of the obstacles in early breastfeeding [12]. Therefore, health workers need to provide education to mothers and families if they can give birth spontaneously and do not have medical indications, then delivery can be done spontaneously. If indeed the mother needs a C-section delivery for medical reasons, healthcare professionals (obstetricians, midwives and nurses) also need to optimize the implementation of early initiation of breastfeeding for mothers with C-section delivery so that mothers and babies can still gain the experience of early initiation of breastfeeding and early bonding to the baby [9, 11]. According to the research, a variety of variables, including breastfeeding constraints brought on by the mother’s physical discomfort and surgical incision pain, may impair breastfeeding following a C-section. Another study revealed that women who received C-sections experienced breastfeeding challenges. It was discovered through semi-structured interviews that the majority of the mothers had post-C-section nausea, vomiting, and exhaustion. In addition, these women’s early postpartum limb numbness from the local anesthetic used during surgery limited their ability to move around and made it more difficult for them to interact with their infants. The majority of women frequently express breastfeeding issues, which are significantly influenced by incision discomfort. Most mothers who undergo a C-section in a South African exploratory study stated that the soreness following the procedure was excruciating [13].

2. The importance of early breastfeeding initiation and breastfeeding practice

Breastfeeding has been recognized as the most effective means of ensuring the health and survival of children. Breastfeeding for the first 6 months is crucial, so the World Health Organization (WHO) recommends related to breastfeeding, such as:

1. Initiate early breastfeeding in the first hour

2. Babies must be exclusively breastfed for 6 months to achieve optimal growth

3. Fulfillment of nutrition for children by providing appropriate and safe complementary foods for babies after 6 months while continuing to be breastfed.

4. Breastfeeding should continue for up to 2 years or beyond [10].

Early Breastfeeding Initiation is the process of giving breast milk to the mother to the baby within the first hour of birth. This is also a step towards ensuring the newborn receives colostrum [14, 15]. Early breastfeeding initiation benefits infants by providing newborn protection from infection and reducing newborn mortality [16]. This process also facilitates the emotional bond between mother and baby which has a positive impact on the duration of exclusive breastfeeding [17]. A mother who starts breastfeeding within an hour of giving birth will stimulate milk production. The milk produced in the first few days is yellow, called colostrum, a vital source of nutrition and immune protection for newborns [10].

In addition to providing protective benefits for the baby, early initiation of breastfeeding also provides an opportunity for skin-to-skin contact (SSC) between mother and baby. Skin-to-skin contact is defined as the practice of laying the baby on the mother’s bare chest after the baby is dried and covered with a warm blanket and left for 1 hour after birth [18]. This contact stimulates the release of oxytocin in both mother and baby so it is associated with calm, bonding and reduction of stress, anxiety, and psychological distress [19, 20]. Full-body contact and the sound of a mother’s heartbeat are thought to simulate the sensations a baby experiences before birth, further reducing stress. SSC has many benefits for postnatal neuro-physical adjustment [21]. Previous studies have shown that newborns who experience SSC with their mothers have better and more stable physiological functions than newborns who do not have SSC. This is related to newborns’ temperature regulation, heart rate, respiration, and gastrointestinal adaption. Babies who experience SSC sleep better, cry less and have fewer painful reactions to routine hospital procedures [21, 22]. This is an important reason for early initiation of breastfeeding after delivery.

The implementation of early breastfeeding initiation is associated with success in continuing exclusive breastfeeding and beyond. Breastfeeding provides health benefits for children and mothers. The benefits of breastfeeding for mothers include helping to accelerate the postpartum involution process thereby reducing the risk of bleeding, reducing stress and accelerating the return of pre-pregnancy weight. Long-term benefits that can be obtained by breastfeeding mothers include reducing the risk of cardiovascular disease, type 2 diabetes, the risk of breast, ovarian and endometrial cancer [23, 24]. In addition to the benefits that mothers get, breastfeeding babies also provides benefits for optimal baby growth and development [25]. Breastfeeding also reduces the risk of infectious diseases in infancy but also reduces the risk of childhood obesity and later metabolic diseases [17, 26].

Exclusive breastfeeding is giving only breast milk for 6 months without any additional food and drinks [27]. However, globally the coverage of exclusive breastfeeding in infants still reaches 44% [28]. UNICEF global databases showed that South Asia achieved the highest exclusive breastfeeding coverage of 61%. Exclusive breastfeeding coverage Eastern and Southern Africa 55%, Latin America and the Caribbean 43%. Eastern Europe, Central Asia, East Asia and the Pacific are at 42% exclusive breastfeeding coverage. Meanwhile, in the West and Central Africa region it was at 38%, then the lowest was in the Middle East and North Africa at 32% [29]. Evidence from research results showed that breastfeeding practice is affected by a variety of sociodemographic (i.e., mother’s age, marital status, level of education, employment status, income) and perinatal factors (i.e., parity, method of childbirth, early SSC practice, early initiation of breastfeeding, prenatal class, rooming-in practice) [17]. These factors can be optimized to become reinforcing factors to enable mothers to breastfeed from the first hour after birth.

The evidence about the risks of not breastfeeding for mothers and infants showed that non-breastfed newborns have a higher risk of infectious morbidities, such as an increased risk of childhood obesity, type 1 and type 2 diabetes, leukemia and sudden infant death syndrome (SIDS). Premature infants who are not breastfed are related to a higher risk of necrotizing enterocolitis (NEC). For mothers, failure to breastfeed has been linked with an increased prevalence of premenopausal breast cancer, ovarian cancer, persistent pregnancy weight gain, type 2 diabetes, and metabolic syndrome [30]. Psychologically, mothers who do not breastfeed their babies are reported to experience frustration and feel guilty due to not being able to breastfeed. They think they are not capable of breastfeeding, especially when the baby is crying [31]. This evidence shows that breastfeeding is important in the first hour after birth and continues for 6 months exclusively.

3. The early initiation of breastfeeding and breastfeeding practice by mothers with C-section delivery

Several studies have shown the low practice of early initiation of breastfeeding and breastfeeding in mothers who give birth with C-section delivery [9, 11, 32, 33, 34, 35, 36]. In comparison to women who gave birth vaginally, mothers who underwent a C-section had reduced odds of timely initiation of breastfeeding (TIBF), according to the findings of a systematic review. This situation also occurs in studies conducted in Ethiopia, Nigeria, Turkey, Saudi Arabia, Lebanon, Brazil, and India [31]. Another study using data from the Ethiopian Demographic and Health Survey revealed that among mothers who had given birth to their last living child, the prevalence of delayed breastfeeding was 25.03% (95%CI, 20.5–32.2). C-section delivery was one of the important variables linked with delayed breastfeeding initiation [AOR = 4.06 (95%CI, 2.66–6.2)]. The likelihood of delayed initiation of breastfeeding is four times higher among women who had C-section deliveries as compared to women who delivered vaginally [11].

According to a study conducted in Alberta, Canada, more mothers who had planned C-sections had no intention of breastfeeding or did not initiate breastfeeding (7.4% and 4.3%, respectively) than mothers who had a vaginal delivery (3.4% and 1.8%, respectively) or emergency C-sections (2.7% and 2.5%, respectively) [9]. It is also supported by another study that women with vaginal birth are 4.57 (3.16, 6.61) compared to planned C-section deliveries 1.64 (1.09, 2.46) four times more likely to initiate early breastfeeding [37]. According to a meta-analysis of 17 research, the pooled estimate of timely breastfeeding initiation among C-section women in Ethiopia was 40.1% (95% CI 33.29, 46.92). When compared to vaginal birth, C-section was related to a 79% reduced chances of timely breastfeeding initiation (OR 0.21; 95% CI 0.16, 0.28) [38].

According to numerous research, C-section births are related to delays in breastfeeding initiation or perhaps no breastfeeding initiation at all. The duration of breastfeeding in the months that follow may be impacted by this condition. According to the study, women who underwent C-section deliveries had lower rates of both exclusive and general breastfeeding than women who gave birth vaginally. Additionally, consuming formula in the hospital and a delayed start to breastfeeding were associated with C-section birth. The duration of breastfeeding was also reduced after C-section birth (hazard ratio = 1.40, 95% confidence range [1.06, 1.84]) [32]. Another study also showed that Women who had a planned C-section were more likely (OR = 1.61; 95% CI: 1.14, 2.26; p = 0.014) to cease breastfeeding before 12 weeks [9]. Several of these studies show that the practice of early initiation of breastfeeding and breastfeeding by mothers with C-section delivery is still low. The strategy is needed to be able to improve the implementation of early breastfeeding initiation and breastfeeding practices in mothers who deliver by C-section.

4. The barriers in breastfeeding by mothers with C-section Delivery

4.1 Mother’s condition after C-section

Based on the literature, several barriers are evident for mothers to make initial contact with the baby, namely the physical condition of the mother including labour pain and limited movement [39, 40]. It was found that most of the mothers experienced nausea, vomiting, and fatigue C-section. Moreover, mothers in the early post-C-section experience numbness of the limbs due to local anesthesia during surgery, experience limitations in physical activity, and have difficulty interacting with newborns. Most mothers stated that pain at the incision was a significant factor for mothers having difficulty breastfeeding [39, 41]. Another study found that the mothers who gave birth by C-section frequently have obstetric-related health issues such as general anesthesia effect, pain, and exhaustion, which delay mother-baby contact [31]. In an exploratory study in South Africa, most mothers stated unbearable pain after C-section. However, some said the pain after a C-section was tolerable and worthwhile [40].

In addition to physical problems, after C-section mothers also experience barriers in psychological conditions. Some literature shows that mothers feel unable to breastfeed because of the baby’s condition, the mother’s perception that breast milk is insufficient, decreased mother’s confidence to breastfeed and uncomfortable position to breastfeed [39, 40, 41, 42]. This is in line with a study conducted by Hobbs et al., [9] which found that 62% (n = 1832) of mothers stated that they had more than one difficulty breastfeeding. Studies showed a significant difference between mode of delivery and breastfeeding difficulties with the baby (e.g., latching or sleepy baby), discomfort during breastfeeding (e.g., sore nipples, swollen breasts), and other difficulties (e.g., low milk supply or problems with flat or inverted nipples) [9].

In line with the study conducted on women who underwent a C-Section between July to September 2019 in a Women and Children’s Hospital in China showed the results that only six participants (31.58%) chose to exclusively breastfeed, half of all participants used a mix of breast and formula feeding, and three (15.79%) selected formula feeding only. The participants stated that they made the decision to either cease breastfeeding or not to breastfeed because they thought there wasn’t enough breast milk to suit their infants’ demands. The participants believed that women after C-section have insufficient milk, and therefore, could not start to breastfeed right away [42]. As shown in the literature, mothers often experience frustration and failure due to not being able to breastfeed. They think they are not capable of breastfeeding, especially when the baby is crying. For instance, the mother’s belief that her breast milk is insufficient is a significant factor hindering exclusive breastfeeding in China. In addition, mothers said that their infants were sleepy, had trouble sucking on milk, and occasionally even threw up, which frequently caused them to feel frightened and anxious. Thus, mothers’ perceptions of infant health affect their breastfeeding practice. For example, it was reported by another study that a mother’s perception of baby size might cause delayed breastfeeding in Nicaragua [13].

4.2 Lack of support

The literature showed that mothers with C-sections report a lack of support from health workers in the breastfeeding process. In previous studies, it has been stated repeatedly about the lack of support and patience of family members. In the UK it was reported that mothers felt tired and were not motivated to continue breastfeeding because the family did not support the breastfeeding program. Likewise, women in Hong Kong who do not receive support from their families tend to use formula milk [13]. Supported by another study, the results showed that all mothers had good knowledge about breastfeeding, 26.4% of whom had prior experience in giving breast milk, but only 6.9% and a total of 29.2% started breastfeeding on the first and second day after C-section. Support from health workers in terms of assisting the process of breastfeeding is reported to be low. The correlation test found that the support of health care professionals and the conditions of rooming-in were factors related to the breastfeeding practice (p-value 0.39; p = 0.001; phi value = 0.47; p = 0.001). The low breastfeeding for mothers after C-section correlates with the low support of health care professionals and delays in rooming-in [33].

5. The facilitators to optimize breastfeeding by mothers with C-section Delivery

5.1 Optimizing promotion of breastfeeding during antenatal care

Health services for pregnant women are continuous with delivery, postpartum and newborn health services. Through antenatal care (ANC), promotion and education related to breastfeeding can be conveyed to mothers and their families. Education that needs to be conveyed includes the importance of breastfeeding, the implementation of early initiation breastfeeding and early contact, the right technique to breastfeed, to maintaining breastfeeding until the child is 2 years old can be given to mothers. This aims to prepare pregnant women so they have good knowledge regarding breastfeeding, readiness to breastfeed and self-efficacy for being able to breastfeed after birth [43]. Previous studies suggest that women who learn breastfeeding techniques and have high breastfeeding self-efficacy are more likely to be successful in breastfeeding their babies [44]. Enhancing and investing in healthcare facility ability to facilitate breastfeeding with continuity from prenatal care, early initiation breastfeeding advice, follow-up until hospital discharge, and postpartum care visits might improve exclusive breastfeeding [35].

5.2 Education on normal childbirth for mothers without complications

One of the main goals of every medical team dealing with childbirth is to have a safe delivery [3]. In accordance with the competence of midwives in facilitating clean, safe deliveries and providing a positive experience of the delivery process [45]. C-section was initially introduced to save the condition of the mother and fetus who were in an emergency. However, currently, there is a paradigm shift that C-section is considered an escape from labour pain. In addition, women also have the wrong assumption that C-section is considered painless, safer and healthier than vaginal delivery. In fact, more than half of women voluntarily choose C-section as the preferred mode of delivery [3]. Health education about normal delivery is important and crucial for health workers to restore the perception in women that normal delivery is a physiological process and has less risk than C-section delivery. Women need to be educated that C-sections are only performed in emergency situations in an effort to save the mother and baby. A cross-sectional study among 150 women in India showed that the most common reason for a voluntary C-section was a previous one, which happened 29 times (33%). Besides these, fetal distress (17%), mal-presentations (13%), and maternal request (9%), there were other signs. Most emergency C-sections were done because the baby was in fetal distress (39, or 62%), or because the woman had C-section history in previous labour (12, or 19%) [46]. Another study said that the indication of C-section could come from maternal side, uterine/anatomic side and from fetal side [1].

According to a Norwegian study, primiparous women, those who have had several pregnancies, CS in the past, are older, have a higher gestational age, and have health issues related to pregnancy are less likely to deliver vaginally (gestational diabetes, low-lying placenta, high blood pressure). A model of care with a more natural birth philosophy, not restricting the woman’s freedom of movement and position throughout labour and delivery, and continuity of care providers during labour are a few factors that can increase the likelihood of having a normal birth [47]. Raising knowledge of this link and including mothers in decision-making are crucial steps in achieving normal birth [13]. Promotion of normal delivery is achieved with a personalized strategy, encouraging the mother about her capacity, strength and confidence that the mother has to face the normal delivery process. It is important for the mother to feel empowered in the face of labour so that she can achieve a normal delivery and a positive birth experience [48]. Awareness of the mother’s ability in the delivery process is expected to increase the mother’s self-confidence to undergo a normal delivery process and not choose C-section delivery.

5.3 Policy for implementing C-section delivery procedures according to indications

Taking into account the trend of cases of C-section deliveries that continue to increase, the current policy of C-section deliveries at health care providers needs to be reviewed. The factors that influence the increase in C-section deliveries need to be re-examined to reduce unnecessary C-sections. Health care professionals really need to make strict policies on the implementation of C-section deliveries. This procedure is done if it is to save the mother and baby. It is only recommended when the life of the mother or fetus is threatened [3]. If the mothers do not experience any complications at the end of the pregnancy, C-sections should not be implemented for them [5]. It should be made apparent that a C-section will actually cause complications for the mother and baby.

5.4 Facilitating the mothers with C-sections for early initiation of breastfeeding

Likewise, mothers who give birth vaginally, mothers with C-section delivery also need early contact and early initiation of breastfeeding. A study of women planning an elective C-section birth at a public hospital in New South Wales, Australia found that mothers who had skin-to-skin contact (SSC) during a C-section had positive experiences with better bonding. Mothers also reported lower anxiety and depression than prior C-sections. Chi-square analysis in the intervention group also showed that there was a significant relationship between having SSC and exclusive breastfeeding, p < 0.005. According to the odds ratio, newborns (n = 51) were twice (OR: 2.24; 95% CI 1.79–2.82) more likely to breastfeed exclusively if they were in the intervention group. A recent study provides evidence of the benefits of skin-to-skin contact during C-section [49].

Studies have shown that skin-to-skin contact after birth enhances innate behavior and the release of maternal oxytocin and can benefit breastfeeding outcomes and early attachment of the mother’s baby. Although obstacles were found associated with skin-to-skin contact during C-section. This can be overcome by educating operating room staff about the benefits of SSC so that it can facilitate mothers and babies to do SSC and early initiation of breastfeeding. That study confirms previous findings that new mothers need skilled support and accompaniment after birth [39].

According to the findings of a different study, mothers who underwent an emergency C-section were more likely to have tried breastfeeding their child unsuccessfully before, be unable to do so for the first 24 hours after giving birth, and be unable to do so after leaving the hospital. This is consistent with recent research that found that mothers who gave birth through emergency C-section had a higher likelihood of being unable to breastfeed their child at either the time of delivery or upon discharge. It has been established that early postpartum breastfeeding difficulties and early discontinuation may be related to the mother and fetal stress response associated with delivery issues, particularly those related to C-section. Abdominal surgery’s insult in both intended and emergency C-section may equally affect the lacto genesis process, although the notion of an emergency may invoke a greater or prolonged maternal stress response [9]. In these emergency conditions, facilitation for contact as early as possible between mother and baby still needs to be pursued while still paying attention to the condition of the mother and baby.

Research by Zavala-Soto et al. by observing mothers giving birth with C-section who had SSC showed satisfaction felt by the mother, exclusive breastfeeding and continued breastfeeding. The majority of participants in this study group were considered high risk due to previous C-section (39%), abnormal presentation, twins or premature babies, exacerbated diseases such as hypertension and diabetes, or complications during labour (42%). Nevertheless, since the mother’s and infant’s condition were stable, a pro-breastfeeding C-section was conducted, which included emotional and physical support, a warm environment, woman-centred care and skin-to-skin contact, particularly without interruption with supervised initial feeding at the breast. It was observed that the majority of these women exclusively breastfed for 6 months, including twins and six of eight premature babies (75%) [50]. This shows that optimal facilitation by health care professionals in women giving birth with C-sections can help implement SSC and increase the achievement of exclusive breastfeeding and the continuation of breastfeeding.

5.5 Support of health care professionals, husband and family and community

When mothers are supported at the institution, in the community, or in their families, breastfeeding practices have been found to improve [12, 14, 15].

Offering breastfeeding assistance to women was linked to a 12% lower risk of discontinuing exclusive breastfeeding before the age of 6 months, according to a Cochrane analysis (RR 0.88, 95% CI 0.85–0.92, 46 studies) [14]. Another study discovered that the most successful intervention to increase breastfeeding rates was hospital support that was Baby Friendly Hospital Initiative (BFI), which was linked to a 49% increase in exclusive breastfeeding (RR 1.49, 95% CI 1.33–1.68) and a 20% increase in early breastfeeding initiation (RR 1.20, 95% CI 1.11–1.28) [35]. In line with other study showed that several participants stated that they received positive support from the midwife, especially regarding their breastfeeding problems. The participants felt empowered and developed better relationships with their babies because of the support they received [40].

Difficulties encountered in the early stages of breastfeeding could lead to misperceptions about inadequate milk secretion [13]. This perception can affect the success of breastfeeding postpartum mothers in the future. The comfort of breastfeeding is one of the important factors in stimulating milk secretion, which is a reflex elicited by the baby’s sucking. This type of suction can stimulate the secretion of prolactin which is secreted from the anterior lobe of the pituitary gland. However, the pain from a C-section and anxiety suppresses both prolactin and milk secretion because pain stimulates the release of catecholamine neurotransmitters. The results of previous studies show that 2–5 days after delivery, the secretion of breast milk in women with C-sections is less than in women with vaginal birth. Furthermore, psychological adjustment after C-section interferes with the mother’s learning about maternal and infant care skills and makes her feel incompetent in breastfeeding [13]. Therefore, C-section is a significant obstacle to early initiation of breastfeeding [51]. This condition indicates that mothers with C-sections really need support to be able to breastfeed their babies. There is evidence to suggest that professional support or the support of trained and experienced health workers supports the continuation of breastfeeding [35]. Women undergoing C-section need more specialized resources that can provide mental and physical support for breastfeeding, especially in the early postpartum period. It is also critical to promote optimal postpartum nursing positions, such as “biological nurturing.” Breast milk volume and maternal self-efficacy could be improved by maintaining a comfortable breastfeeding position and hastening postoperative recovery [42].

5.6 Implementing breastfeeding support

WHO has provided guidance on ‘Counseling women to improve breastfeeding practice’, which was compiled based on a systematic literature review and developed by a group of international experts. The policy expands on prior recommendations from the ‘Global Strategy for Infant and Young Child Feeding’ and increases the strength of the recommendation for breastfeeding counseling. It provides evidence-based breastfeeding counseling suggestions: (1) Every pregnant woman and mother with newborns or young children should get breastfeeding counseling. (2) Breastfeeding counseling should be provided during both the antenatal and postnatal periods, for a duration of up to 24 months or longer. (3) Breastfeeding counseling should be offered at least six times and as required. (4) Face-to-face breastfeeding counseling should be provided. Breastfeeding counseling may also be delivered over the phone or through other remote ways of counseling. (5) Breastfeeding counseling should be offered as part of a continuum of care by suitably qualified healthcare professionals as well as community-based lay and peer breastfeeding counselors. and (6) Breastfeeding counseling should anticipate and overcome major breastfeeding issues and situations, as well as help the mothers to develop skills, competencies and confidence. By implementing breastfeeding counseling optimally for mothers and families, it is hoped that it can increase the understanding of mothers and families and increase the self-efficacy of mothers to breastfeed their babies [52].

6. Conclusion

Cesarean Section (C-section) delivery is a global issue in maternal and child health care. Mothers who gave birth by C-section could have an impact on delays in SSC and early initiation of breastfeeding. This in turn can lead to a shorter duration of breastfeeding and hinder the attainment of exclusive breastfeeding. C-section deliveries without indications should not be performed on the mother. This method is only performed on mothers or babies with emergency conditions. Mothers who give birth by C-sections still need to be facilitated for initial contact and early initiation of breastfeeding for their babies so that bonding can be established between mother and baby. Assistance in overcoming breastfeeding difficulties is carried out with the help and support of health workers, families and the community. Healthcare professionals are really expected to be able to provide education and facilitate mothers with C-sections to maintain early skin-to-skin contact in the context of early initiation of breastfeeding and as an effort to increase the duration of breastfeeding in mothers with C-sections delivery. It is also important to provide breastfeeding promotion and education to mothers and their families so that they have an adequate understanding of breastfeeding, even for mothers with C-sections.

Conflict of interest

The authors declare no conflict of interest.