**4. The barriers in breastfeeding by mothers with C-section Delivery**

### **4.1 Mother's condition after C-section**

Based on the literature, several barriers are evident for mothers to make initial contact with the baby, namely the physical condition of the mother including labour pain and limited movement [39, 40]. It was found that most of the mothers experienced nausea, vomiting, and fatigue C-section. Moreover, mothers in the early post-C-section experience numbness of the limbs due to local anesthesia during surgery, experience limitations in physical activity, and have difficulty interacting with newborns. Most mothers stated that pain at the incision was a significant factor for mothers having difficulty breastfeeding [39, 41]. Another study found that the mothers who gave birth by C-section frequently have obstetric-related health issues such as general anesthesia effect, pain, and exhaustion, which delay mother-baby contact [31]. In an exploratory study in South Africa, most mothers stated unbearable pain after C-section. However, some said the pain after a C-section was tolerable and worthwhile [40].

In addition to physical problems, after C-section mothers also experience barriers in psychological conditions. Some literature shows that mothers feel unable to breastfeed because of the baby's condition, the mother's perception that breast milk is insufficient, decreased mother's confidence to breastfeed and uncomfortable position to breastfeed [39–42]. This is in line with a study conducted by Hobbs et al., [9] which found that 62% (n = 1832) of mothers stated that they had more than one difficulty breastfeeding. Studies showed a significant difference between mode of delivery and breastfeeding difficulties with the baby (e.g., latching or sleepy baby), discomfort during breastfeeding (e.g., sore nipples, swollen breasts), and other difficulties (e.g., low milk supply or problems with flat or inverted nipples) [9].

In line with the study conducted on women who underwent a C-Section between July to September 2019 in a Women and Children's Hospital in China showed the results that only six participants (31.58%) chose to exclusively breastfeed, half of all participants used a mix of breast and formula feeding, and three (15.79%) selected formula feeding only. The participants stated that they made the decision to either cease breastfeeding or not to breastfeed because they thought there wasn't enough breast milk to suit their infants' demands. The participants believed that women after C-section have insufficient milk, and therefore, could not start to breastfeed right away [42]. As shown in the literature, mothers often experience frustration and failure due to not being able to breastfeed. They think they are not capable of breastfeeding, especially when the baby is crying. For instance, the mother's belief that her breast milk is insufficient is a significant factor hindering exclusive breastfeeding in China. In addition, mothers said that their infants were sleepy, had trouble sucking on milk, and occasionally even threw up, which frequently caused them to feel frightened and anxious. Thus, mothers' perceptions of infant health affect their breastfeeding practice. For example, it was reported by another study that a mother's perception of baby size might cause delayed breastfeeding in Nicaragua [13].
