ABSTRACT

OBJECTIVES: to evaluate the influence of type of childbirth, on skin-to-skin contact and breastfeeding in the first hour of life in public maternity hospitals in Manaus, Amazonas, Brazil.
METHODS: cross-sectional study with 443 puerperal women from eight public maternity hospitals in Manaus (August 2023 to January 2024). Data were collected via a validated questionnaire and analyzed by logistic regression in Stata^® 18.0, adjusted for sociodemographic, prenatal, and perinatal variables. Crude and adjusted odds ratios, 95% confidence intervals, and p-values were estimated.
RESULTS: vaginal delivery was associated with a higher probability of breastfeeding in the first hour of life (adjusted odds ratio = 2.05; 95%CI= 1.19-3.54; p=0.010) and skin-to-skin contact (adjusted odds ratio = 1.96; 95%CI= 1.15-3.34; p=0.013). Each additional week of gestational age increased the chance of breastfeeding in the first hour of life by 40%. Neonatal complications and the use of analgesia significantly reduced the chances of both outcomes.
CONCLUSIONS: vaginal delivery favors skin-to-skin contact and breastfeeding in the first hour of life, reinforcing the need for policies that standardize humanized practices, especially after cesarean section, for equity in neonatal care.

Keywords: Childbirth, Breast feeding, Cesarean section, Vaginal delivery

RESUMO

OBJETIVOS: avaliar a influência do tipo de parto no contato pele a pele e na amamentação na primeira hora de vida em maternidades públicas de Manaus, Amazonas, Brasil.
MÉTODOS: estudo transversal com 443 puérperas de oito maternidades públicas de Manaus (agosto/2023 a janeiro/2024). Dados coletados via questionário validado e analisados por regressão logística no Stata^® 18.0, com ajuste para variáveis sociodemográficas, pré-natais e perinatais. Foram estimadas razões de odds brutas e ajustadas, intervalos de confiança de 95% e valores de p.
RESULTADOS: o parto vaginal associou-se a maior probabilidade de amamentação na primeira hora de vida (razão de chances ajustada= 2,05; IC95%= 1,19–3,54; p=0,010) e de contato pele a pele (razão de chances ajustada=1,96; IC95%= 1,15–3,34; p=0,013). Cada semana adicional de idade gestacional aumentou em 40% a chance de amamentação na primeira hora de vida. Intercorrências neonatais e uso de analgesia reduziram significativamente as chances de ambos os desfechos.
CONCLUSÕES: o parto vaginal favorece o contato pele a pele e a amamentação na primeira hora de vida, reforçando a necessidade de políticas que padronizam práticas humanizadas, especialmente após cesárea, para equidade no cuidado neonatal.

Palavras-chave: Parto, Aleitamento materno, Cesárea, Parto vaginal

Introduction

Breastfeeding within the first hour of life and immediate skin-to-skin contact are fundamental strategies for promoting maternal and child health, as recommended by the World Health Organization (WHO).¹ These practices reduce neonatal morbidity and mortality while strengthening the mother–infant bond.² However, their implementation is influenced by sociodemographic factors, obstetric conditions, and particularly, the type of childbirth.^3,4

Vaginal delivery in low-risk pregnancies favors early initiation of breastfeeding and skin-to-skin contact, as it facilitates maternal recovery and rooming-in.⁵ Conversely, cesarean section is associated with barriers such as postoperative pain, mother–infant separation, and delays in breastfeeding initiation.⁶ Studies have shown that, in hospitals lack humanized protocols, these difficulties are even more evident.^7,8

In Brazil, prevalence rates vary: the Nascer no Brasil (2011–2012) (Born in Brazil) survey reported that only 28.2% of the newborns experienced immediate skin-to-skin contact⁹; in private hospitals, the rate of breastfeeding within the first hour reached 58%¹⁰; and in Hospital Amigo da Criança (Child-Friendly Hospital), it reached 65%,¹¹ highlighting the impact of institutional policies. Regional inequalities also interfere. In the North of Brazil, where Manaus is located, presents geographic, socioeconomic, and cultural vulnerabilities that hinder access to prenatal care, safe childbirth, and breastfeeding support.^12,13 A recent study emphasized that this region concentrates the territories with the greatest vulnerability for achieving the health goals of the 2030 Agenda.¹⁴

In this context, the present study aims to evaluate the influence of the type of childbirth, skin-to-skin contact and breastfeeding within the first hour of life in public maternity hospitals in Manaus, Amazonas.

Methods

This is a cross-sectional study designed to assess the association between the type of childbirth (main exposure) and the outcomes "breastfeeding within the first hour of life" and "immediate skin-to-skin contact." The hypothesis was that vaginal deliveries would be associated with higher odds of these outcomes compared to cesarean sections.

The target population comprised postpartum women who delivered at the eight public maternity hospitals in Manaus, Amazonas, between August 2023 and January 2024. Inclusion criteria included women in the immediate postpartum period (at least six hours after delivery) who had at least one live newborn, regardless of birth weight or gestational age; or stillbirths weighing ≥500 g and/or gestational age ≥22 weeks.

Sample size calculation was based on the finite population of childbirths recorded at each maternity hospital in 2022, the expected prevalence of outcomes, and a margin of error of 1 to 5 percentage points, resulting in 443 puerperal women, proportionally stratified across hospitals.

The main independent variable was type of childbirth (cesarean or vaginal). Adjustment variables included:Sociodemographic: maternal age (years), schooling (none, elementary, high school, higher education), and self-reported race/skin color (white, mixed, black, Asian, Indigenous);Prenatal: number of prenatal visits (none; 1–3; 4–5; ≥6); Perinatal: gestational age (weeks), neonatal complications (yes/no), and analgesia use (yes/no).

Primary outcomes were breastfeeding within the first hour of life and skin-to-skin contact, both categorized as "yes" or "no."

The information were obtained using the hospital–puerperal women questionnaire developed by the Escola Nacional de Saúde Pública (ENSP/Fiocruz) (National School of Public Health) as part of the Nascer no Brasil (Born in Brazil) project.⁹ Data collection was conducted by trained researchers through electronic recording in REDCap^®, ensuring standardization and security. Interviews were conducted by bedside, at least six hours after the childbirth.

Analyses were performed using Stata^® version 18.0 (StataCorp LLC, USA), adopting a 5% significance level. Sample characteristics were described using absolute and relative frequencies (categorical variables) and mean with standard deviation (maternal age). Crude and adjusted associations were estimated using logistic regression, reporting odds ratios, 95% confidence intervals (95%CI), and p-values. Confounder selection followed a hierarchical model in three blocks: sociodemographic, prenatal, and perinatal, with stepwise inclusion (p<0.20). Sensitivity analyses excluded high-risk pregnancies.

The study was approved by the Research Ethics Committee of the Escola de Enfermagem de Ribeirão Preto da Universidade de São Paulo (CEP-EERP-USP) (School of Nursing, University of São Paulo) (CAAE: 55040522.2.0000.5393).

Results

A total of 443 puerperal women were included, with a mean age of 25.9 years (SD = 7.1). The majority had completed high school (69.5%), self-identified as mixed-race (82.2%), and had vaginal delivery (55.3%). Almost 81% of the sample breastfed within the first hour of life, and about two-thirds (64.8%) engaged in skin-to-skin contact (Table 1).
 



The crude association between type of childbirth and the outcomes of interest was assessed and presented in Table 2. Vaginal delivery was associated with higher odds of breastfeeding within the first hour of life (OR = 2.33; 95%CI = 1.42–3.80; p= 0.001) and of skin-to-skin contact (OR = 13.6; 95%CI =8.32–22.16; p<0.001), compared to cesarean section. Each additional week of gestational age increased the likelihood of breastfeeding by 40% (95%CI = 1.27–1.54; p < 0.001) and of skin-to-skin contact by 17% (95%CI = 1.09–1.26; p < 0.001).
 



After adjustment for number of prenatal visits, neonatal complications, and gestational age, vaginal delivery remained significantly associated with higher odds of breastfeeding within the first hour of life (_aOR = 2.05; 95%CI = 1.19–3.54; p= 0.010) and skin-to-skin contact (_aOR = 1.96; 95%CI= 1.15–3.34; p=0.013). Neonatal complications reduced the likelihood of both outcomes by approximately 50%, whereas gestational age maintained a positive effect (Table 3).
 



Discussion

The results demonstrated that vaginal delivery was associated with higher odds of skin-to-skin contact and breastfeeding within the first hour of life, even after adjustment for sociodemographic and perinatal variables. Gestational age was also a determining factor, increasing the probability of breastfeeding by 40% with each additional week.

Regional vulnerabilities must also be considered. The North of Brazil presents structural inequalities that hinder the implementation of good obstetric and neonatal practices, including limited access to health services, lower prenatal care coverage, and a higher prevalence of elective cesarean sections.¹⁹ These inequalities help explain the challenges observed in Manaus. Internationally, similar results have been reported: in Sub-Saharan Africa, cesarean section reduced the odds of breastfeeding within the first hour by 46%²⁰; in Vietnam, this probability was 75% lower among women undergoing cesarean section.²¹ These findings confirm that the type of childbirth directly impacts the implementation of essential neonatal practices.

The positive association between gestational age and immediate breastfeeding observed in Manaus reinforces the role of neonatal maturity. Late preterm infants have a reduced capacity for effective sucking, which explains the lower rates of breastfeeding within the first hour compared to full-term infants.²²

Mother–infant separation, which is common in cesarean sections, reduces opportunities to stimulate breastfeeding, as observed in Bangladesh, where 71% of newborns delivered via cesarean did not experience skin-to-skin contact.²³ Moreover, the lack of protocols enabling skin-to-skin contact in surgical settings, combined with the prioritization of hospital routines over practices recommended by WHO, perpetuates inequalities in neonatal care.^7,8,24

This study has limitations that must be acknowledged. The cross-sectional design prevents causal inferences, as it is not possible to determine whether the type of childbirth directly preceded the outcomes or whether unmeasured factors, such as prior breastfeeding intentions, influenced both variables. Data collection in the immediate postpartum period may introduce recall bias, as the puerperal women may not accurately remember events during the baby's first hour of life. The restriction of the sample to public maternity hospitals limits generalizability to private settings or regions with lower cesarean prevalence. The possibility of residual confounding bias remains, given that variables such as family support and previous breastfeeding experiences were not adjusted for, which may affect the magnitude of associations. Selection bias from the exclusion of high-risk pregnancies (8.1% of the initial sample) may have produced an overly homogeneous population, reducing data variability and limiting applicability to vulnerable groups. Finally, it is noteworthy that national reference data on childbirth and newborn care practices still derive from the Nascer no Brasil (2011–2012).⁹ (Born in Brazil) survey. The second edition (Nascer no Brasil II) completed data collection in March 2025 and has released preliminary results, but full publication is still pending, limiting more up-to-date comparisons.

Vaginal delivery was associated with higher odds of skin-to-skin contact and breastfeeding within the first hour of life, regardless of sociodemographic and perinatal factors. Gestational age proved to be a determinant, with a 40% increase in the probability of breastfeeding for each additional week, while neonatal complications significantly reduced these outcomes.

These findings reinforce the importance of policies ensuring skin-to-skin contact and early breastfeeding also in cesarean sections, in line with the Hospital Amigo da Criança (Child Friendly) Initiative, in addition to continuous training of multiprofessional teams to integrate humanization practices in surgical settings. Future longitudinal and qualitative studies are recommended to further explore perceived barriers, providing evidence for more effective interventions.


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Authors' contribution
Silva ALC, Faisal Cury A, Gomes-Sponholz FA: data analysis, manuscript drafting, and critical revision.
Parreira BDM, Barbosa NG, Gozzo TO, Nascimento ES: manuscript drafting and critical revision.
All authors approved the final version of the manuscript and declare no conflicts of interest.

Data Availability
The full dataset supporting the results of this study is contained within the article.

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Received on July 8, 2025
Final version presented on October 1, 2025
Approved on October 2, 2025

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Associated Editor: Daniele Gattas