**4.1 Prenatal preparation**

Decisions about infant feeding are determined by a range of complex factors including the woman's socio-demographic background, age, ethnicity, and peer support network [71]. To date, the most important factor for the success of breastfeeding is the mother's motivation. As it has been commented earlier, mothers planning to have a cesarean birth report lower level of willingness to breastfeed their offspring [42, 43]. It has been reported in the literature that all health professionals need to look closely into this fact and identify the reasons that drive women to this decision. Antenatal programs addressing the importance of breastfeeding both for mothers and babies, with emphasis to the key effects on CS newborns' health need to be implemented. There is a false impression that women after a CS are not able to breastfeed adequately their offspring and this involves the women themselves, their families and exists even among health professionals. As mentioned above, women after a CS may face more difficulties than women following a vaginal birth but with adequate help and consultation from health professionals and their family, they are able to provide the best nourishment to their newborns. The women themselves express lack of knowledge and skills about breastfeeding after the CS birth [54]. During the antenatal courses, midwives have the opportunity and ability to provide this knowledge in a secure relaxed environment and demonstrate coping strategies that women can easily rehearse and learn prior to their birth. This way their confidence will increase, and they will feel more confident and ready to breastfeed their newborns after their CS.

#### **4.2 The importance of adequate bonding time**

We know from the neuroendocrine mechanisms involved in the initiation and maintenance of lactogenesis that the mother-to-newborn contact is the most effective and powerful stimulus to milk production. Health professionals need to ensure undisturbed immediate or early skin-to-skin contact for mothers and their newborns after a cesarean birth. Skin-to-skin contact is a practice that requires

minimal organizational effort or costs for the hospitals that offer it [67]. Numerous studies show that skin-to-skin contact is an easy to apply, low-cost and safe intervention that can have important health benefits both for the mother and newborn, as described in the previous sections. There are studies that prove the feasibility of applying this method to women undergoing an uncomplicated CS, and even on an emergent basis, while skin-to-skin contact can safely begin during surgery and continue uninterrupted for an extended time duration [66]. As an alternative, when the mother is not capable or willing to provide skin-to-skin contact, then the partner can assist and hold the newborn [67]. Furthermore, the health professionals need to ensure that the mother and newborn will have undisturbed time to bond by minimizing the separation time spams. This can be achieved with performing the clinical examination while the newborn is on the mother's arms, delaying the first newborn bath for after the first 24 hours, and by delaying the transfer of the mother while she is breastfeeding [50]. Rooming-in should be offered to all mothers as well as reassurance that the health professionals will be present to provide their assistance if needed, as the Family-Centered Care and the Baby-Friendly Hospital Initiative (BFHI) recommends [72]. Mothers following a cesarean birth will require more help handling their newborn, so the hospital policies should allow for a family member to be present or additional helping staff to be allocated. On the other hand, undisturbed bonding time with the newborn means that there should be a minimum number of visitors and in specified time frames during the hospital stay. Moreover, while breastfeeding there should be an indication on the door to keep people away from entering so as to preserve privacy and comfort.
