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 breastfeed-ing compared with vaginal delivery (VD). Design: Studies published before January 2011 that reported breast-feeding 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 com-pared 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 sub-jects, 33 countries); 25 authors contributed additional data (245,455 subjects), and 48 studies (553,306 subjects, 31 countries) were in-cluded in the meta-analysis. Rates of early breastfeeding (any ini-tiation or at hospital discharge) were lower after CD compared with