This is troubling because for many women a planned cesarean is their only in-hospital birthing “option.” More on that in a moment. First, to the research:
The first study, a large meta analysis of research on breastfeeding and cesarean births, included 48 studies reflecting the experience of over 550,000 subjects. It found that “rates of early breastfeeding (any initiation or at hospital discharge) were were lower after cesarean delivery compared with after vaginal delivery and lower after prelabor but not after in-labor cesarean delivery.”
A second study looked at the weight loss of 200 exclusively breastfed babies delivered by cesarean section in a U.S. Baby Friendly hospital, almost half of which did not undergo labor prior to delivery. It found that “absence of labor prior to delivery was significantly associated with a greater percentage of weight loss,” and concluded “for exclusively breastfed infants delivered by cesarean birth in a Baby-Friendly hospital, absence of labor prior to cesarean birth may be a previously unreported risk factor for greater than expected weight loss.” Excessive weight loss isn’t a breastfeeding outcome per se, but higher weight loss in the first few days after birth often leads to supplementation, which in turn is associated with shortened duration and less exclusivity of breastfeeding.
Why would cesarean birth without labor pose these risks? As I’ve written before, cesarean births in general are associated with a number of breastfeeding issues. With respect to cesarean births without labor, the authors of this second study point to a number of possible explanations: “the complex and incompletely understood endocrine and neuroendocrine mechanisms that regular labor,” greater fluid retention in the infants’ lungs, and lower gestational age at birth.
Let’s zoom in on this last factor – gestational age – for a moment, because I think that the implications are quite staggering.
We know that the vast majority of repeat cesareans are planned and do not involve labor. We also know that many planned cesareans are performed electively (for no medical reason) before 39 weeks of gestation. One study found that, of 13,000 elective repeat cesareans, 36% were done prior to 39 weeks gestation (in the study referenced above the mean gestational age was 39 weeks, so a good number were likely born before). This in itself is a risk factor for a number of problems, including breastfeeding problems and problems that have a direct effect on breastfeeding (respiratory issues, hypoglycemia, admission to NICU), as we’ve discussed before. Babies born in this range are known among breastfeeding support people as “impostor babies” because their size often masks their immaturity when it comes to feeding.
I find the conclusions of these studies particularly troubling because for many women, a planned cesarean without labor is the only in-hospital birth available to them.
Of course, there are a number of reasons why mothers might not be able to experience labor before a cesarean, such as maternal or fetal complications, and multiples or breech presentation where vaginal delivery is not practiced.
But since 50% of hospitals have an outright or de facto ban on vaginal birth after cesarean (VBAC), for many women the only in-hospital birth is a planned cesarean, whether they want one or not. Considering that one in three births is by cesarean and that the VBAC rate is just 8.4%, this absence of choice affects the breastfeeding experience of a significant percentage of women.
So, to connect the dots: Cesarean birth without labor appears to be a risk factor for breastfeeding difficulty. Babies born by planned cesarean are frequently delivered early for no medical reason – a risk factor for breastfeeding. Most women having second and subsequent babies after a c-section have no in-hospital choice besides a cesarean birth without labor.
What are the implications of these findings for mothers and providers?
- For providers, it may be that this and future research will establish that cesarean birth without labor is a risk factor for breastfeeding problems, and appropriate support will be provided.
- For both mothers and providers, it’s critical to understand the risks of elective birth of any kind (cesarean or vaginal) prior to 39 completed weeks of gestation, on breastfeeding and a whole range of infant outcomes.
- And finally, we suggest as always that all mothers 1) explore their birthing options carefully, and 2) have good support in place for both birth and breastfeeding.
Did you have a cesarean without labor? Did it have any effect on your breastfeeding experience?