Mechanistic Pathways Underlying Breastfeeding Challenges Following Cesarean Delivery: A Systematic Review

Background/Objectives: Cesarean delivery has been linked with breastfeeding difficulties. However, the mechanistic pathways underlying these challenges remain incompletely understood. This systematic review aimed to synthesize evidence regarding the physiological, clinical, psychological, and health system-related mechanisms contributing to breastfeeding challenges following cesarean delivery. Methods: A systematic search was conducted in PubMed/MEDLINE and Scopus for studies published between 2020 and 2026. Studies with observational, interventional, and qualitative designs that examined breastfeeding challenges following cesarean delivery were eligible. A theory-informed narrative synthesis was applied, categorizing challenges into physiological, clinical, psychological, and health system domains and integrating them into a pathway-based conceptual framework. Results: Twenty-six studies were included. Across heterogeneous study designs, commonly reported breastfeeding challenges included delayed lactogenesis, postoperative pain and functional limitations, difficulties with early mother-infant interaction, concerns regarding human milk sufficiency, reduced breastfeeding self-efficacy, and variability in postpartum breastfeeding support. These findings were organized into physiological, clinical, psychological, and health-system domains. Cross-study synthesis suggested potential interactions among these domains, particularly involving delayed breastfeeding initiation, breastfeeding difficulties, lactation-related concerns, maternal perceptions, and subsequent feeding decisions. However, the proposed relationships were not uniformly tested within individual studies. Intervention studies suggested that strategies including skin-to-skin contact, breastfeeding counseling, and enhanced lactation support may improve selected breastfeeding outcomes. Conclusions: The findings suggest that breastfeeding challenges following cesarean delivery may involve interconnected biological, behavioral, clinical, and health-system factors. Understanding these mechanisms is essential for developing supportive and context-sensitive interventions that optimize breastfeeding establishment while maintaining adequate infant nutrition.