{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,11,12]],"date-time":"2026-11-12T07:41:17Z","timestamp":1794469277618,"version":"4.9.1"},"reference-count":76,"publisher":"MDPI AG","issue":"17","license":[{"start":{"date-parts":[[2026,9,4]],"date-time":"2026-09-04T00:00:00Z","timestamp":1788480000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"Danone Specialized Nutrition Indonesia"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Nutrients"],"abstract":"<jats:p>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\u2013infant 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.<\/jats:p>","DOI":"10.3390\/nu18172911","type":"journal-article","created":{"date-parts":[[2026,9,4]],"date-time":"2026-09-04T16:07:32Z","timestamp":1788538052000},"page":"2911","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":1,"title":["Mechanistic Pathways Underlying Breastfeeding Challenges Following Cesarean Delivery: A Systematic Review"],"prefix":"10.3390","volume":"18","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-9507-527X","authenticated-orcid":false,"given":"Ray Wagiu","family":"Basrowi","sequence":"first","affiliation":[{"name":"Occupational Medicine Division, Department of Community Medicine, Faculty of Medicine, Universitas Indonesia, Jakarta 10320, Indonesia"},{"name":"Danone Specialized Nutrition Indonesia, Jakarta 12940, Indonesia"},{"name":"Health Collaborative Center, Jakarta 12430, Indonesia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0006-0296-4593","authenticated-orcid":false,"given":"Febriansyah","family":"Darus","sequence":"additional","affiliation":[{"name":"Department of Obstetric Gynecology, Gatot Subroto Army Hospital (RSPAD), Jakarta 10410, Indonesia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"I Gusti Ayu Nyoman","family":"Partiwi","sequence":"additional","affiliation":[{"name":"Bunda Mother and Child Hospital (RSIA Bunda), Jakarta 10350, Indonesia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0006-0530-980X","authenticated-orcid":false,"given":"Hilna Khairunisa","family":"Shalihat","sequence":"additional","affiliation":[{"name":"Faculty of Medicine, Universitas Sumatera Utara, Medan 20155, Indonesia"},{"name":"Adam Malik Hospital, Medan 20136, Indonesia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3404-707X","authenticated-orcid":false,"given":"Refani Alycia","family":"Kusuma","sequence":"additional","affiliation":[{"name":"Department of Nutrition, Faculty of Medicine, Universitas Negeri Semarang, Semarang 50229, Indonesia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Dessy","family":"Pratiwi","sequence":"additional","affiliation":[{"name":"Danone Specialized Nutrition Indonesia, Jakarta 12940, Indonesia"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,9,4]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","unstructured":"Purkiewicz, A., Regin, K.J., Mumtaz, W., and Pietrzak-Fie\u0107ko, R. 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