Elective Cesarean Delivery: Does It Have a Negative Effect on Breastfeeding?

Abstract

Cesarean delivery has negative effects on breastfeeding. The objective of this study was to evaluate breastfeeding rates, defined in accordance with World Health Organization guidelines, from delivery to 6 months postpartum in infants born by elective and emergency cesarean section and in infants born vaginally.
Delivery modalities were assessed in relation to breastfeeding patterns in 2,137 term infants delivered at a tertiary center, the Padua University School of Medicine in northeastern Italy, from January to December 2007. The study population included 677 (31.1%) newborns delivered by cesarean section, 398 (18.3%) by elective cesarean, 279 (12.8%) by emergency cesarean section, and 1,496 (68.8%) delivered vaginally.
Breastfeeding prevalence in the delivery room was significantly higher after vaginal delivery compared with that after cesarean delivery (71.5% vs 3.5%, p < 0.001), and a longer interval occurred between birth and first breastfeeding in the newborns delivered by cesarean section (mean ± SD, hours, 3.1 ± 5 vs 10.4 ± 9, p < 0.05). No difference was found in breastfeeding rates between the elective and emergency cesarean groups. Compared with elective cesarean delivery, vaginal delivery was associated with a higher breastfeeding rate at discharge and at the subsequent follow-up steps (7 days, 3 mo, and 6 mo of life). Conclusions:  Emergency and elective cesarean deliveries are similarly associated with a decreased rate of exclusive breastfeeding compared with vaginal delivery. The inability of women who have undergone a cesarean section to breastfeed comfortably in the delivery room and in the immediate postpartum period seems to be the most likely explanation for this association.

Full text

Elective Cesarean Delivery: Does It Have
a Negative Effect on Breastfeeding?
Vincenzo Zanardo, MD, Giorgia Svegliado, MD, Francesco Cavallin, MS, Arturo
Giustardi, MD, Erich Cosmi, MD, Pietro Litta, MD, and Daniele Trevisanuto, MD
ABSTRACT: Background: Cesarean delivery has negative effects on breastfeeding. The
objective of this study was to evaluate breastfeeding rates, defined in accordance with World
Health Organization guidelines, from delivery to 6 months postpartum in infants born by elec-
tive and emergency cesarean section and in infants born vaginally. Methods: Delivery modal-
ities were assessed in relation to breastfeeding patterns in 2,137 term infants delivered at a
tertiary center, the Padua University School of Medicine in northeastern Italy, from January to
December 2007. The study population included 677 (31.1%) newborns delivered by cesarean
section, 398 (18.3%) by elective cesarean, 279 (12.8%) by emergency cesarean section, and
1,496 (68.8%) delivered vaginally. Results: Breastfeeding prevalence in the delivery room
was significantly higher after vaginal delivery compared with that after cesarean delivery
(71.5% vs 3.5%, p< 0.001), and a longer interval occurred between birth and first breastfeed-
ing in the newborns delivered by cesarean section (mean ± SD, hours, 3.1 ± 5 vs 10.4 ± 9,
p< 0.05). No difference was found in breastfeeding rates between the elective and emergency
cesarean groups. Compared with elective cesarean delivery, vaginal delivery was associated
with a higher breastfeeding rate at discharge and at the subsequent follow-up steps (7 days,
3 mo, and 6 mo of life). Conclusions: Emergency and elective cesarean deliveries are
similarly associated with a decreased rate of exclusive breastfeeding compared with vaginal
delivery. The inability of women who have undergone a cesarean section to breastfeed comfort-
ably in the delivery room and in the immediate postpartum period seems to be the most likely
explanation for this association. (BIRTH 37:4 December 2010)
Key words: breastfeeding, cesarean section, elective cesarean delivery
Anecdotal evidence suggests that lactogenesis and
breastfeeding outcomes are dependent on the mode of
the infant’s delivery (1). Several studies have reported
that emergency cesarean deliveries have a negative
effect on breastfeeding, particularly during the early
postpartum period (2,3). Nevertheless, these studies
were biased in that they did not distinguish infants born
after an emergency from those born after elective cesar-
ean section, and lactation performance patterns in
infants born after an elective cesarean section are not
entirely clear (4–6). This issue is relevant, considering
the increase in rates of cesarean deliveries over the past
30 years in the Western hemisphere (7). In particular,
the incidence of elective cesarean deliveries has
increased, largely because of the use of repeat proce-
dures (8–11).
Lactogenesis is a function of a finely tuned feedback
mechanism, which is potentially susceptible to pharma-
cological, physical, and psychological manipulations on
the part of the mother, her infant, or both (2,12–18).
Vincenzo Zanardo is a Neonatologist and Aggregated Professor of
Pediatrics; Giorgia Svegliado is a Fellow in Pediatrics; Francesco
Cavallin is a Statistician; Arturo Giustardi is a Pediatrician; Erich
Cosmi is an Obstetrician and Aggregated Professor of Obstetrics and
Gynecology; Pietro Litta is an Obstetrician and Associate Professor of
Obstetrics and Gynecology; and Daniele Trevisanuto is a Neonato-
logist in the Department of Pediatrics at Padua University, Padua,
Italy.
Address correspondence to Vincenzo Zanardo, MD, Department
of Pediatrics, Padua University School of Medicine, Via Giustiniani,
3 35128 Padua, Italy.
Accepted April 23, 2010
2010, Copyright the Authors
Journal compilation 2010, Wiley Periodicals, Inc.
BIRTH 37:4 December 2010 275

Many important factors can influence a mother’s deci-
sion to begin and continue breastfeeding, and problems
encountered at the beginning may have a long-term
effect on supplemental feedings or the decision to give
up breastfeeding altogether (12,13).
The objective of this study was to evaluate breastfeed-
ing rates, defined in accordance with World Health
Organization (WHO) guidelines, from delivery to
6 months postpartum in infants born by elective or
emergency cesarean delivery and in infants born vagi-
nally, in an industrialized area of northern Italy where
high cesarean delivery rates are prevalent.
Methods
Mothers and all term newborns admitted to the regular
nursery of the Department of Pediatrics in the University
of Padua School of Medicine in Italy, a Level III hospi-
tal with full resources for obstetric and complete neona-
tal intensive care, from January 1 through December 31,
2007, were eligible for inclusion in this study (Table 1).
The study was approved by the Institutional Review
Board of the hospital.
Outcome variables, methods of analysis, and inclu-
sion and exclusion criteria were determined prospec-
tively. Data on the mode of delivery, gestational age,
birthweight, Apgar scores, and breastfeeding initiation
and duration rates were recorded for all the newborns
and subsequently entered into a computer database by
trained personnel. Of these newborns, 513 (19.0%) were
initially excluded (36 because they were admitted to the
neonatal intensive care unit, 467 because their mothers
were unable to speak and read Italian, and 10 refusals).
Breastfeeding outcomes for these newborns were veri-
fied by a telephone follow-up interview concerning
breastfeeding prevalence at three time points in the post-
partum period: at 7 days and at 3 and 6 months. Only
information related to the breastfeeding patterns of the
mothers who participated in the interviews (1,567,
72.1%) were considered for analysis. Thus, 597 un-
tracked mothers (31 had a changed telephone number
and 566 were inaccessible), 8 refusals, and 1 maternal
death, were excluded.
Deliveries were classified as vaginal, elective cesar-
ean section, and emergency cesarean section. We classi-
fied term cesarean sections before the onset of
spontaneous or induced labor as elective cesarean sec-
tions and after labor began as emergency cesarean sec-
tions. Labor was defined as regular uterine contractions
with progression of cervical dilatation. Complications
that occurred during or after delivery were not taken into
consideration when women were being evaluated for
eligibility for inclusion because only factors that could
be identified prenatally were considered to reflect the
information available to the obstetrician when planning
a delivery. Resuscitation in the delivery room was
carried out according to the international guidelines for
neonatal resuscitation (19).
Mothers and infants spent at least 72 hours postpar-
tum after a vaginal delivery and 96 hours postpartum
after a planned or an emergency cesarean delivery in the
study hospital. Standard practices to optimize immediate
skin-to-skin contact, breastfeeding initiation in the deliv-
ery room, and breastfeeding at request in a rooming-in
regimen, although not easy after cesarean section, were
routinely ensured for mothers who gave birth vaginally
and for those who underwent a cesarean section. After
delivery the infant was triaged to the regular nursery,
while the mother, who was transferred to a postnatal
ward, received information and practical instruction on
how to breastfeed, the purpose of rooming-in, and the
advantages of breastfeeding.
For initial analysis, the obstetric study population
comprised those women whose pregnancy terminated
between the 37 0 ⁄7 and 41 6⁄7 weeks of gestation (esti-
mated on the basis of the last menstrual period or, if
uncertain, by a sonogram). Subsequently, they were
classified into two groups: women with vaginal delivery
and women with caesarean delivery. The cesarean
Table 1. Anthropometrical and Clinical Parameters of the Study Population by Mode of Delivery
Characteristics
Vaginal Delivery
(n= 1,496)
Emergency Cesarean
Delivery (n= 279)
Elective Cesarean
Delivery (n= 398)
Maternal age (yr), mean ± SD 33.0 ± 4.4 33.2 ± 4.1 35.0 ± 4.3
Gestational age (wk), mean ± SD 39.4 ± 1.1 39.3 ± 1.3 38.4 ± 0.9
Birthweight (g), mean ± SD 3,387 ± 397 3,398 ± 411 3,286 ± 421
Apgar score £5, No. (%)
1 min 4 ⁄1,496 (0.3) 1 ⁄398 (0.3) 0
5 min 0 0 0
Weight at discharge (g), mean ± SD 3,220 ± 387 3,239 ± 398 3,106 ± 396
Breastfeeding
In the delivery room, No. (%) 1,071 (71.5) 4 (1.4) 14 (3.5)
Initiation (hr), mean ± SD 3.1 ± 6.0 13.4 ± 13.1 10.4 ± 9.0
276 BIRTH 37:4 December 2010

section group was further subdivided into those who
underwent elective cesarean section and those who
underwent emergency cesarean section.
Indications for elective cesarean section were repeat
cesarean section (197, 49.4%), and other causes of uter-
ine scarring (i.e., antecedent myomectomy 33, 8.2%);
severe medical conditions such as myopia (39, 9.7%);
and medical contraindications to vaginal delivery (8,
2.0%) such as multiple gestation (13, 3.2%), malpresen-
tation (74, 18.5%), macrosomia (17, 4.2%), patient
choice (8, 2.0%), and ‘‘old’’ primiparas (9, 2.2%). The
main indications for emergency cesarean section were
fetal distress (70, 25.0%), dystocia (54,19.3%), pre-
eclampsia (15, 5.3%), long labor (57, 20.4%), clinical
chorioamnionitis (14, 5.0%), and other (69, 24.7%).
Feeding modalities, defined according to WHO guide-
lines (20), were as follows: exclusive breastfeeding
(breastmilk only), predominant breastfeeding (additional
water-based liquids), mixed feeding (breastmilk and for-
mula), and formula feeding (exclusive formula only).
The type of feeding ‘‘at discharge’’ was the type of feed-
ing the infant had received during the last 24 hours of
hospital stay. Exclusive and predominant breastfeeding
were categorized together as exclusive breastfeeding.
Differences between groups were tested using the chi-
square or Fisher exact test for categorical variables and
the Student ttest for normally distributed variables. The
relative risk with 95% confidence interval was used to
analyze the effects of explanatory variables on depen-
dent variables, exclusive breastfeeding, and mixed feed-
ing or formula feeding at regular nursery discharge, at
day 7 and months 3 and 6 postpartum. Statistical analy-
sis was carried out with SPSS statistical software pack-
age (21). A pvalue of < 0.05 was considered significant.
Results
From January 1 through December 31, 2007, 2,686 term
newborns were admitted to the nursery of the Depart-
ment of Pediatrics of the University of Padua School of
Medicine. Anthropometrical and clinical data for the eli-
gible maternal and neonatal study population (2,173,
80%) are outlined in Table 1. In particular, 677 (31.1%)
newborns were delivered by cesarean section, 398 elec-
tive (18.3%) and 279 emergency (12.8%), and 1,496
were delivered vaginally (68.8%). Elective cesarean sec-
tion was performed for 224 newborns (56.2%) before
the 39 0 ⁄7 weeks of gestation.
Elective cesarean delivery was performed at a signifi-
cantly earlier gestational age (p< 0.001) compared with
that of the vaginal and emergency cesarean deliveries,
respectively. The birthweight of electively delivered
infants was likewise significantly lower (p< 0.001).
Furthermore, mothers who delivered electively were
older (p< 0.001) compared with those who delivered
vaginally or after an emergency cesarean section. In
addition, breastfeeding prevalence in the delivery room
was significantly lower (p< 0.001) after elective cesar-
ean delivery compared with that after vaginal delivery,
and the interval was longer (p< 0.05) between birth
and first breastfeeding in the elective cesarean section
mothers.
Breastfeeding rates at the time of hospital discharge
and during the follow-up in relation to the mode of deliv-
ery are presented in Table 2. Mothers of 1,567 (72.1%)
newborns agreed to respond to telephone interviews.
The sample was comparable to an original cohort for
delivery modalities (69.7% vaginal delivery, 12.1%
emergency cesarean section, and 18% elective cesarean
delivery). No difference was found in breastfeeding rates
between elective and emergency cesarean deliveries.
Compared with elective cesarean delivery, vaginal deliv-
ery was associated with a higher breastfeeding rate at
discharge from the regular nursery and at the subsequent
follow-up steps (at 7 days and at 3 and 6 mo of life).
Discussion
This study, carried out in an industrialized area of north-
eastern Italy where cesarean delivery rates are high (11),
demonstrated that elective and emergency cesarean
delivery is negatively associated with breastfeeding.
Published data indicate that particularly emergency
cesarean sections can have a marked effect on breast-
feeding during the early postpartum period (4,22–24).
Emergency cesarean section, which often follows a long,
difficult labor, does not seem to facilitate breastfeeding,
particularly during the early postpartum period and char-
acterized by confinement to bed, fasting, analgesia
and ⁄or anesthesia for pain, oxytocin augmentation, and
anxiety and stress (4,22–24). These difficulties are also
faced and shared by mothers who electively decide to
have a cesarean section.
After a surgical delivery, unassisted mothers are
almost certainly unable to hold their newborns in the
delivery room or for the frequent breastfeeding periods
that follow (25), and bottle-feeding has become a com-
mon clinical practice in these cases (4,6). In addition,
feeding milk-based formulas will reduce the newborn’s
sucking capacity and consequently the mother’s lacta-
tion stimulus. If the newborn becomes accustomed to
bottle (formula) feedings, he or she may have difficulty
adjusting to breastfeeding, which may cause the mother
to become discouraged and to consider giving up breast-
feeding (16).
The most striking aspect of this study is the finding,
the implications of which are probably not fully compre-
hended, that elective cesarean delivery is a significant
BIRTH 37:4 December 2010 277

risk factor for not initiating breastfeeding in the delivery
room or during hospital stay and for not continuing to
breastfeed in the 6-month postpartum period. Women in
our study had a high rate (about 30%) of cesarean deliv-
ery, significantly higher than the 15 percent rate consid-
ered the highest acceptable by WHO (26). This finding
suggests that many women underwent cesarean delivery
for nonmedical reasons and that their health status was
probably less likely to interfere with breastfeeding initia-
tion during their hospital stay. In addition, the low over-
all rate of initiation of breastfeeding in the delivery
room and the longer interval between birth and first
breastfeeding indicate that planned measures to optimize
postoperative breastfeeding care for women who have
undergone a cesarean section, but who nevertheless need
to breastfeed their infants to stimulate their natural oral
searching reflex (3), have been unsuccessful.
Some evidence has been reported on an association
between cesarean delivery and long-term breastfeeding,
and many of our findings seem relevant to this debate.
Identifying elective cesarean section as a significant risk
factor for breastfeeding failure extends the conclusions
of previous biased studies that did not distinguish
between newborns delivered by unscheduled and sched-
uled cesarean sections. Studies by Samuels et al and
Procianoy et al reported that cesarean section mothers
were more likely to stop breastfeeding within the first
2 weeks and at 2 months postpartum (27,28). Vester-
mark et al reported that breastfeeding mothers in the
cesarean section group had a later onset of full lactation
during the first 4 days postpartum, but unlike the find-
ings in our study, no statistical difference was found at 3
and 6 months in those mothers in this group who were
breastfeeding at discharge (29). A prospective study by
Janke likewise found no difference in breastfeeding out-
comes by delivery method (30). This finding is impor-
tant, because support and encouragement have been
recognized as key indicators of breastfeeding success
even after surgical births.
Some limitations in our study should be noted. We
did not determine the role of fatigue, stress, pain, and
health complications in scheduled cesarean deliveries.
Lacking assistance, the mother may be unable to breast-
feed initially, which can affect lactation and cause
breastfeeding to fail. Another limitation relates to the
external validity of our findings because our participants
did not include mothers with limited socioeconomic
means and foreign mothers. Similar and more advanced
studies carried out in different regions and with different
samples of mother groups are warranted.
Table 2. Breastfeeding Follow-up in Term Infants by Mode of Delivery
Characteristics
Vaginal Delivery
No. (%)
Emergency Cesarean
Delivery
No. (%)
Elective Cesarean
Delivery
No. (%) RR (95% CI)
At discharge 1,496 (68.8) 279 (12.8) 398 (18.3)
Exclusive 1,312 (87.8) 204 (73.4) 296 (74.4) A vs B: 1.19 (1.14–1.29)
A vs C: 1.17 (1.10–1.25)
Mixed feeding 170 (11.3) 70 (25.3) 94 (23.6) A vs C: 0.45 (0.35–0.67)
A vs B: 0.48 (0.38–0.60)
Formula 14 (0.9) 5 (1.7) 8 (3.2) —
Follow-up 1,093 (69.7) 191 (12.1) 283 (18.0)
Day 7
Exclusive 939 (85.9) 150 (78.5) 211 (74.5) A vs B: 1.09 (1.01–1.18)
A vs C: 1.19 (1.06–1.30)
Mixed feeding 55 (5.0) 14 (7.3) 28 (9.8) —
Formula 99 (9.0) 27 (14.2) 44 (15.7) A vs B: 0.64 (0.43–0.95)
A vs C: 0.58 (0.41–0.81)
3mo
Exclusive 765 ⁄1,093 (69.9) 106 ⁄191 (55.4) 156 ⁄283 (55.1) A vs B: 1.26 (1.10–1.44)
A vs C: 1.26 (1.13–1.42)
Mixed feeding 108 (9.8) 25 (13.0) 40 (14.1) —
Formula 220 (20.1) 55 (28.7) 86 (30.3) A vs B: 0.69 (0.54–0.89)
A vs C: 0.66 (0.53–0.81)
6mo
Exclusive 645 (59.0) 82 (42.9) 132 (46.6) A vs B: 1.37 (1.15–1.63)
A vs C: 1.26 (1.10–1.44)
Mixed feeding 86 (7.8) 21 (10.9) 25 (8.8) —
Formula 362 (33.1) 88 (46.0) 126 (44.5) A vs B: 0.74 (0.63–0.86)
A vs C: 0,71 (0.60–0.85)
278 BIRTH 37:4 December 2010

Conclusions
Our data indicate that elective and emergency cesarean
delivery is associated with a decreased rate of exclusive
breastfeeding at various time points after birth when
compared with vaginal delivery. The difficulty that
women who have undergone a surgical delivery have
when they attempt to breastfeed in the delivery room
and immediately thereafter, and the lack of preparation
on the part of hospital staff to sustain these new mothers
would appear to be the most likely explanation for this
association.
References
1. Kroeger M, Smith LJ. Impact of Birthing Practices on Breastfeed-
ing. Sudbury, MA: Jones and Bartlett, 2004.
2. Evans KC, Evans RG, Royal R, et al. Effect of cesarean section
on breast milk transfer to the normal term newborn over the first
week of life. Arch Dis Child Fetal Neonatal Ed 2003;88:F380–
F388.
3. Rowe-Murray HJ, Fisher JRW. Baby friendly hospital practices:
Cesarean section is a persistent barrier to early initiation of breast-
feeding. Birth 2002;29:124–131.
4. Perez-Escamilla R, Maulen-Radovan I, Dewey KG. The associa-
tion between cesarean delivery and breast-feeding outcomes
among Mexican women. Am J Public Health 1996;86:832–836.
5. Cakmak H, Kuguoglu S. Comparison of the breastfeeding patterns
of mothers who delivered their babies per vagina and via cesarean
section. An observational study using the LATCH breastfeeding
charting system. Int J Nurs Stud 2007;44:1128–1137.
6. Chapman DJ, Perez-Escamilla R. Identification of risk factors for
delayed onset of lactation. J Am Diet Assoc 1999;99:450–454.
7. Menacker F, Declercq E, Macdorman E. Cesarean delivery:
Background, trends, and epidemiology. Semin Perinatol 2006;30:
235–241.
8. Madar J, Richmond S, Hey E. Surfactant-deficient respiratory
distress after elective delivery at term. Acta Paediatr 1999;98:
1244–1248.
9. Morrison J, Rennie JM, Milton PJ. Neonatal respiratory morbidity
and mode of delivery at term: Influence of timing of elective
caesarean section. Br J Obstet Gynaecol 1995;102:101–106.
10. Halliday HL. Elective delivery at term: Implications for the
neonate. Acta Paediatr 1999;88:1180–1183.
11. Zanardo V, Padovani E, Pittini C, et al. The influence of timing
of elective cesarean section on risk of neonatal pneumothorax.
J Pediatr 2007;150:252–255.
12. Dewey KG. Maternal and fetal stress are associated with impaired
lactogenesis in humans. J Nutr 2001;131:3012–3015.
13. Dewey KG, Nommsen-Rivers LA, Heinig MJ, Cohen RJ. Risk
factors for suboptimal infant breastfeeding behavior, delayed
onset of lactation, and excess neonatal weight loss. Pediatrics
2003;112:607–819.
14. Chen DC, Nommsen-Rivers L, Dewey K, Lonnerdal B. Stress
during labor and delivery and early lactation performance. Am J
Clin Nutr 1998;68:335–344.
15. Nissen E, Lillja G, Mathiesen AS, et al. Effects of maternal pethi-
dine on infants’ developing breastfeeding behavior. Acta Paediatr
1995;84:140–145.
16. Welan A, Lupton P. Promoting successful breast feeding among
women with a low income. Midwifery 1998;14:94–100.
17. Sepkoski CM, Lester RM, Osheimer GW, Brazelton TB. The
effects of maternal epidural anaesthesia on neonatal behavior
during the first month. Dev Med Child Neurol 1992;34:
1072–1080.
18. Lagerckrantz H, Slotkin TA. The stress of being born. Sci Am
1986;254:91–102.
19. American Heart Association (AHA). 2005 American Heart Asso-
ciation guidelines for cardiopulmonary resuscitation (CPR) and
emergency cardiovascular care (ECC) of pediatric and neonatal
patients: Neonatal resuscitation guidelines. Pediatrics 2006;117:
e1029–e1038.
20. World Health Organisation. Indicators for Assessing Breast-
feeding Practices. Geneva, Switzerland: Publication WHO ⁄
CDD ⁄SER ⁄91.14, 1991.
21. SPSS. Statistical Package for the Social Sciences (SPSS) for
Windows, Version 15.0. Chicago: Author, 2006.
22. Patel RR, Liebling RE, Murphy DJ. Effect of operative delivery in
the second stage of labor on breastfeeding success. Birth 2003;
30:255–260.
23. World Health Organisation. Protecting, Promoting and Support-
ing Breastfeeding: The special Role of Maternity Services. A joint
WHO ⁄UNICEF Statement. Geneva, Switzerland: World Health
Organisation, 1989.
24. Kraner MS, Chalmers B, Hodnett ED, et al. Promotion of breast-
feeding intervention trial. A randomized trial in the Republic of
Belarus. JAMA 2001;285:413–420.
25. Mohrbacher N, Stock J. The Breastfeeding Answer Book. Scham-
burg, IL: La Leche League International, 2003.
26. World Health Organization. Appropriate technology for birth.
Lancet 1985;2:436–437.
27. Samuels SE, Margen S, Schoen E. Incidence and duration of
breast-feeding in a health maintenance organization population.
Am J Clin Nutr 1985;42:504–510.
28. Procianoy RS, Fernandes-Filho PH, Lazaro L, Sartori NC. Factors
affecting breastfeeding: The influence of caesarean section. J Trop
Pediatr 1984;30:39–42.
29. Vestermark V, Høgdall CK, Birch M, et al. Influence of the mode
of delivery on initiation of breast-feeding. Eur J Obstet Gynecol
Reprod Biol 1991;38:33–38.
30. Janke JR. Breastfeeding duration following cesarean and vaginal
births. J Nurse Midwifery 1988;33:159–164.
BIRTH 37:4 December 2010 279