Background The association between caesarean section and breastfeeding is poorly understood in sub-Saharan Africa. We aimed to examine the impact of caesarean section on breastfeeding indicators—early initiation of breastfeeding, exclusive breastfeeding, and ever breastfeeding—in sub-Saharan Africa.

Methods We used the most recent data from 32 Demographic and Health Surveys (DHS) completed in sub-Saharan Africa. We analysed the data to examine the impact of caesarean section on breastfeeding indicators using log-Poisson regression models for each country adjusted for potential confounders. For each breastfeeding indicator, the within-country adjusted prevalence ratios were pooled in random effects meta-analysis.

Results The within-country adjusted analyses showed, compared with vaginal birth, caesarean section was associated with adjusted prevalence ratios (aPR) for early initiation of breastfeeding that ranged from 0·23 (95%CI, 0·16, 0·31) in Tanzania to 0·81 (95%CI, 0·64, 1·02) in Cameroon. Similarly, the aPR for exclusive breastfeeding ranged from 0·57 (95%CI; 0·33, 0·99) in Senegal to 1·60 (95%CI; 1·07, 2·39) in Mali, while the aPR for ever breastfeeding ranged from 0·90 (95%CI, 0·82, 0·99) in Liberia to 1·02 (95%CI, 0·98, 1·06) in Guinea. Meta-analysis combining the adjusted effects from 32 countries showed that caesarean section was associated with a 47% lower prevalence of early initiation of breastfeeding (pooled PR, 0·53 (95%CI, 0·48, 0·58)), but not with exclusive breastfeeding (pooled PR, 0·93 (95%CI; 0·86, 0·99)) nor ever breastfeeding (pooled PR, 0·98 (95%CI; 0·98, 0·99)).

Conclusion Caesarean section had a negative influence on early initiation of breastfeeding, but showed little difference in exclusive- and ever-breastfeeding between infants born by caesarean versus vaginal birth in sub-Saharan Africa.