Early Initiation of Breastfeeding up to Six Months and Breastfeeding Experience of Mothers who had Cesarean Section: A Scoping Review


 Background: Breastfeeding is a gold nutritional feeding for the infant for optimal growth and development. Early initiation of breastfeeding is an important initial step for successful continuing breastfeeding. Cesarean section (C-section) has been reported to have negative effects on early initiation of breastfeeding. However, no current literature summarized the breastfeeding rate after C-section and vaginal delivery globally. Therefore, this scoping review aimed to systematically collect, assess, and map the existing literature regarding the rate and experience of breastfeeding of mothers after C-section.Design: We conducted a scoping review in accordance with the PRISMA extension for scoping reviews (PRISMA-ScR) statement.Methods: We performed an electronic database search on Cumulative Index of Nursing and Allied Health Literature, PubMed, Embase, Cochrane Library, and PsychINFO on March 16, 2021. The inclusion criteria were (a) research, experiential, and case reports; (b) reports on the rate of breastfeeding after C-section and vaginal delivery; (c) qualitative studies on the experience of breastfeeding after C-section.Results: The search identified 4635 potentially relevant articles. After screening, 27 articles (24 quantitative and three qualitative studies) were included in the scoping review from 1990 to 2020. Most studies reported a higher breastfeeding rate in mothers who had vaginal delivery than in mothers who had C-Section at breastfeeding initiation, hospital discharge, one month, three months, and six months postoperatively. A large difference in breastfeeding rate was found at early breastfeeding initiation between the vaginal delivery and C-section groups. Most studies showed a breastfeeding rate of more than 30% at late breastfeeding initiation, one month, and three months after C-section. A mother’s physical discomfort, low self-efficacy, and lack of knowledge, and the insufficient support from healthcare providers were identified as breastfeeding barriers after C-section.Conclusions: The rate of breastfeeding after C-section has remained low to date. Lack of breastfeeding knowledge and insufficient healthcare provider support after C-section are the common underlying issues. Approaches to enhance breastfeeding must be developed and consistently implemented.

Health Literature, PubMed, Embase, Cochrane Library, and PsychINFO. The search terms were related to postpartum, breastfeeding, and C-section. The full search strategy is shown in Appendix 1. Date limitation was not set.

Selection of studies
The search results were downloaded into RefWorks to identify and remove duplicates. The results were then transferred to Rayyan application to ease screening [14]. Titles and abstracts that met the inclusion criteria were independently screened by the lead researcher. Then, eligible full text articles were assessed independently for inclusion in the study.
Although quality appraisal is not required in scoping reviews, three researchers critically appraised the included studies using the JBI framework for crosssectional and cohort studies and the critical appraisal skill programme for qualitative studies to rigorously screen the studies included and remove poorquality studies. The quality score of the studies were divided into three categories: high quality (total score > 70%), moderate quality (total score 40%-70%), and poor quality (total score < 40%). The three researchers scored the articles independently, and the scores were then compared and discussed. An old article published in 1990 was included in this study because of its valuable old study.

Data charting
Data were extracted by the lead researcher and con rmed by the other researchers. The extracted studies were characterized as follows: (1) author(s), (2) year of publication, (3) country, (4) study design, (5) objectives, (6) population, (7) Other factors associated with breast feeding initiation and exclusive breastfeeding, (8) summary of results, and (9) quality appraisal.

Selection of sources
The database search identi ed 4635 potentially relevant articles. Of these, 1238 duplicate articles were removed. A total of 3397 articles were screened and 3332 records were excluded based on their titles and abstracts. The remaining 65 articles were assessed for eligibility. After full text screening, 38 articles that did not meet the eligibility criteria were removed. Finally, 27 articles were included in the scoping review ( Figure 1).
Twenty-seven published articles from 1990-2020 were identi ed and included in this scoping review. Twenty-four were quantitative studies and three were qualitative studies. As for the quantitative studies, nine articles were cross-sectional studies and 15 articles were cohort studies.
The present study investigated the breastfeeding rate of mothers after C-section and VD. We included the time of breastfeeding. There were 13 studies on the early initiation of breastfeeding (within one hour after delivery), seven studies on the late initiation of breastfeeding (after one hour of delivery), six studies on breastfeeding at hospital discharge (hospitalization: two to ve days), eight studies on exclusive breastfeeding one month after delivery, six studies on exclusive breastfeeding three months after delivery, and eight studies on exclusive breastfeeding six months after delivery.

Synthesis of results
The characteristics of included studies is summarized in Table 2. The results showed that most of mothers who had VD can initiate breastfeeding compared with mothers who had C-section. Most of the studies showed that a successful early initiation of breastfeeding will continue to exclusive breastfeeding at one and three months. However, we cannot de nitively conclude an association of early initiation of breastfeeding with exclusive breastfeeding at six months. High quality Figure 2 shows that the percentages of early initiation of breastfeeding (≤ 1 hr) were higher in the mothers who had VD than in the mothers who had C-Section. Most of the studies showed that more than 50% the mothers who had VD had early initiation of breastfeeding and only two studies reported an initiation below 50%.
As for the mothers who had C-Section, nine studies reported that the rate of early initiation of breastfeeding were below 50%. In addition, Figure 2 shows a large difference in the percentages of early initiation of breastfeeding between VD and C-section, and only 1 article showed a small difference in the rate of early initiation of breastfeeding between these two groups [16].
Most of the studies reported that the rate of exclusive breastfeeding at hospital discharge were more than 50% in the mothers who had VD and more than 30% in the mothers who had C-Section (Figure 4). Only two studies from Vietnam and Taiwan showed that the rate of exclusive breastfeeding at hospital discharge were below 25% in both the mothers who had VD and the mothers who had C-section [34,37]. Two studies showed a large difference in the rate of early initiation of breastfeeding between the mothers who had VD and the mothers who had C-section [7,12]. Figure 8 shows that the percentages of any breastfeeding 6 months after delivery in most studies were more than 50% for both the VD and C-section groups. There were almost same percentage between vaginal delivery and C-section of any breastfeeding 6 months after delivery [5,30,37].
As for the qualitative study, we synthesized the ndings from three articles on barriers to breastfeeding experience after C-section. The categories were mother's physical discomfort, low self-e cacy, lack of breastfeeding knowledge, and inadequate support from a healthcare provider. The subcategory of these three articles is shown in Table 2. Positioning di culties "Very traumatised after labour, baby did not latch properly and I found it painful" [24] Pain of scare "Too painful to lift and carry baby post CS" [24,27] "I sort of moved to get up on the bed or to sort of move down a bit to go to sleep then I got the pain" [27] Low self-e cacy Feelings of failure "I don't want to try anymore…feel stressed and the baby has mucus. I'm disappointed that I couldn't [breast feed]." [25] Lack of breastfeeding knowledge False belief "Not having enough breast milk -baby was still hungry no matter how long I fed her" [24] Misperception of insu cient milk "'I was unsure that I was giving enough milk as she was not gaining substantial weight, also when breastfeeding I could hear the wind in her stomach" [24] Inadequate support from healthcare provider Separation of mother and baby ''they just showed me the baby in theatre when he rst came out. I don't think I got to touch him.. . I thought I would have been allowed to touch him'' [27] Unnecessary formula supplementation "after 24-48 hours I just couldn't get her to latch so I started expressing but then I wasn't expressing much at all... so we had to go and get the formula" [27] Lack of professional skills on breast latching "I received much con icting advice from ward staff with each shift change and feel this prevented me from adequately latching my baby and therefore being able to breastfeed her" [24] CS, Cesarean section 5. Discussion

Low percentage of breastfeeding after C-Section
This scoping review synthesized data of breastfeeding after C-Section from 1990 to 2020. Surprisingly, the results showed that the percentage of breastfeeding after C-section did not improve compared with the results of a previous study by Prior et  The present results showed a large difference in the percentage of early initiation of breastfeeding between the VD and C-section groups (Figure 2). Several factors have been reported to cause the delayed breastfeeding initiation after C-Section. These include the mother's physical discomfort after delivery, low self-e cacy, and lack of breastfeeding knowledge, as well as the inadequate support from healthcare providers [24,25,27]. Limited mobility and di cult mother-baby attachment owing to the pain after C-section impair the mother's ability to breastfeed her baby. Moreover, the absence of a rooming-in policy in a hospital/clinic after C-section and instead keeping the baby in a nursery room further delays the early initiation of breastfeeding [24,26,29,37]. Chaplin et al. also observed that most infants born by C-section were given formula milk in a nursery room before they were given to their mothers [27]. However, rooming-in is still raising a debate. Rooming-in can boost breastfeeding and self-e cacy [38,39]. On the other hand, rooming-in has been reported to disturb well-rested mothers after delivery [40]. In their systematic review, Jaafar, Lee & Ho showed that rooming-in was associated with successful breastfeeding initiation [41].
In Figure 4, two studies from Vietnam and Taiwan showed that the rate of exclusive breastfeeding at hospital discharge were below 25% in both the VD and C-Section groups [34,37]. This phenomenon in Taiwan is rooted in the traditional cultural belief of Chinese that pregnancy and delivery are considered as a tiring process which weakens the physical condition of women. Therefore, it is believed that women should take su cient rest in bed after delivery.
Moreover, mothers believe that there was insu cient milk for infants before breast engorgement [34]. In Vietnam, the low percentage of breastfeeding was due to the high rate of prelacteal feeding (particularly formula milk) and usage of antibiotics after C-Section. Mothers will delay breastfeeding to avoid passing on the antibiotics to their infants [37].
As for exclusive breastfeeding at six months after delivery, the results showed that the rate of exclusive breastfeeding were under 80%. The reasons for the low percentages were returning to work, less milk production, and the introduction of solid food [21,24]. Healthcare providers should point out that the rst period of hospitalization is very important to the successful continuance of breastfeeding.

Forms of support to increase breastfeeding after C-section
Barriers to breastfeeding after C-section can be overcome with appropriate assistance and breastfeeding education. For assistance, professional healthcare providers can provide physical and mental support to mothers in performing breastfeeding after C-section, particularly in the early postpartum period.
Skin-to-skin contact (SSC) is a form of support to increase successful breastfeeding after C-Section [42]. Healthcare providers can help administer SSC after C-Section to increase the mother's con dence and intimacy with her baby. Moran-Peter et al. explained that SSC contact after delivery can enhance exclusive breastfeeding practices [43].
As for the limited mobility and pain caused by surgery, the use of pain control (analgesia) has been recommended [44]. Healthcare providers can introduce different kinds of painkiller such suppository, oral medicine, and epidural anaesthesia. Tiredness was also reported to delay breastfeeding. Therefore, physical support from nurses or families is needed to help in the mother-baby attachment for breastfeeding and to build the con dence of mothers in breastfeeding their baby.

Provision of evidence through breastfeeding education
Providing counselling, motivation, and education to mothers about breastfeeding is an important task by healthcare providers. This is especially crucial in terms of providing adequate information about the breastmilk process, myths, and mother mobilization. Evidence suggests that breastfeeding education is effective in increasing both the rate of breastfeeding initiation and breastfeeding duration [45]. Lumbiganon  Breastfeeding education is not only for mothers and their families, but also for healthcare providers. As science and research are constantly evolving, healthcare providers should receive continuing education, particularly on lactation knowledge and professional assistance on breastfeeding after Csection. A regular update on the knowledge of healthcare providers can be considered as part of a successful breastfeeding program.
Recently, healthcare providers have also introduced a decision-making aid on breastfeeding to help mothers decide whether to breastfeed their babies after delivery. In 2020, the Ottawa Hospital Research Institute launched a breastfeeding decision aid that can be used by healthcare providers. Breastfeeding education regarding the proper position and baby attachment has been given following the postnatal period. Home visits by peer counsellors have also been shown to signi cantly increase exclusive breastfeeding 12 and 24 weeks postpartum [47].

Adopting a baby friendly hospital initiative program
In 1991, the WHO and United Nations International Children's Emergency Fund promoted the early initiation of breastfeeding through the Baby Friendly Hospital Initiative (BFHI) programme. This programme introduced breastfeeding domains such as no infant formula, promotion and support (prenatal breastfeeding education), and mother-baby rooming-in throughout the hospital [48].
The policy of the BFHI programme can be adopted by maternity clinics and hospitals to improve the breastfeeding practices of mothers who gave birth by VD or C-section. Thus, it is crucial to support mothers to breastfeed just after delivery and avoid formula milk. Rooming-in is considered as one of the approaches to creating a bond between the mother and the baby, making it easier for mothers to breastfeed their baby on demand. However, there is still no de nitive evidence regarding the corelation of rooming-in with breastfeeding duration [41]. Optimal breastfeeding care for mothers who had C-section may increase their rate of early initiation of breastfeeding.

Strengths and Limitations
This study has several limitations. It was limited to peer-reviewed studies published in English. Speci cally, it included only studies reporting on the percentages of breastfeeding after C-section and VD. Moreover, only three qualitative studies were included. Despite these limitations, the strengths of this study were its rigorous methodological frameworks for conducting and reporting this scoping review and the meticulous review of studies for critical appraisal by three independent reviewers.

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This scoping review found a low percentage of breastfeeding among mothers who had C-section. The underlying reasons for the large differences in the percentages of breastfeeding after C-section and VD were the physical discomfort, low self-e cacy, and lack of breastfeeding knowledge of mothers, as well as the inadequate support from healthcare providers. Pain control, SSC, breastfeeding education in antenatal care, development of a breastfeeding decision aid, and implementing a baby friendly hospital policy are some important approaches to improving breastfeeding after C-section.  Percentages of exclusive breastfeeding at hospital discharge Percentages of exclusive breastfeeding one month after delivery Figure 6 Percentages of exclusive breastfeeding three months after delivery Percentages of exclusive breastfeeding six months after delivery