title: Breastfeeding after cesarean delivery: a systematic review and meta-analysis of world literature.
abstract: BACKGROUND
  The rate of exclusive breastfeeding remains low in many countries. Furthermore, cesarean delivery (CD) is increasing and may affect breastfeeding success.
  
  
  OBJECTIVE
  The objective was to conduct a systematic review and meta-analysis of observational studies to determine whether CD (prelabor or in-labor) is associated with a lower rate of breastfeeding compared with vaginal delivery (VD).
  
  
  METHODS
  Studies published before January 2011 that reported breastfeeding up to 6 mo postpartum and compared outcomes after CD or VD, including foreign language publications, were identified through PubMed and bibliographic review. Prespecified data were extracted independently by multiple observers. The types of CD [prelabor (elective/scheduled) or in-labor (emergency)] were compared by subgroup analyses. Potential sources of study-level bias were analyzed by using meta-regression and sensitivity analyses.
  
  
  RESULTS
  The systematic review included 53 studies (554,568 subjects, 33 countries); 25 authors contributed additional data (245,455 subjects), and 48 studies (553,306 subjects, 31 countries) were included in the meta-analysis. Rates of early breastfeeding (any initiation or at hospital discharge) were lower after CD compared with after VD (pooled OR: 0.57; 95% CI: 0.50, 0.64; P < 0.00001) and lower after prelabor but not after in-labor CD (prelabor OR: 0.83; 95% CI: 0.80, 0.86; P < 0.00001; in-labor OR: 1.00; 95% CI: 0.97, 1.04; P = 0.86). In mothers who initiated breastfeeding, CD had no significant effect on any breastfeeding at 6 mo (OR: 0.95; 95% CI: 0.89, 1.01; P = 0.08).
  
  
  CONCLUSIONS
  There was a negative association between prelabor CD and early breastfeeding. If breastfeeding is initiated, mode of delivery has no apparent effect on the number of mothers still breastfeeding at 6 mo. Women and health care workers should be aware of the negative associations between CD and early breastfeeding and consequent implications for infants' well-being.
authors.affiliation: Section of Neonatal Medicine, Department of Medicine, Imperial College London, London, United Kingdom.
authors.forename: Emily
authors.initials: E
authors.lastname: Prior
authors.forename: Shalini
authors.initials: S
authors.lastname: Santhakumaran
authors.forename: Chris
authors.initials: C
authors.lastname: Gale
authors.forename: Lara H
authors.initials: LH
authors.lastname: Philipps
authors.forename: Neena
authors.initials: N
authors.lastname: Modi
authors.forename: Matthew J
authors.initials: MJ
authors.lastname: Hyde
mesh_terms: D001942:Breast Feeding; D002585:Cesarean Section; D005260:Female; D006801:Humans; D007743:Labor, Obstetric; D011247:Pregnancy; D047929:Term Birth