Background: Documented barriers to the implementation of Step 4 of the Baby Friendly Hospital Initiative, which relates to early initiation of breastfeeding, have not considered the impact of operative intervention in delivery on achievement of the goal. This study was designed to test the hypothesis that hospital practices in the immediate postpartum period that are associated with operative intervention in delivery can affect first mother-infant contact and initiation of breastfeeding. Methods: In a prospective, longitudinal study, a sociodemographically representative sample of 203 primiparous women was recruited. Participants were interviewed at 2 days postpartum in metropolitan hospitals in Melbourne, Australia, and medical records were inspected. At 8 months postpartum 81 percent of participants completed a postal questionnaire. Three mode-of-delivery groups (spontaneous vaginal delivery, instrumentally assisted vaginal delivery and cesarean section) and 4 hospital-of-delivery groups (including one accredited Baby Friendly Hospital) were compared. Results: Two way ANOVA revealed that women who had a cesarean section experienced a significant delay in initiating breastfeeding compared with women giving birth vaginally, with or without instrumental assistance (p < 0.001). Significant differences in this aspect of care were also observed among hospitals, with the Baby-Friendly hospital performing significantly better than the other three hospitals (p < 0.001). An effect due to mode of delivery alone was demonstrated that could not be abolished by differences in hospital practices (p = 0.231). Nevertheless, shorter elapsed time between birth and initiation of breastfeeding was not significantly associated with continuation of breastfeeding at 8 months postpartum (p = 0.642). Conclusions: The findings confirmed that cesarean section was a significant barrier to the implementation of Baby Friendly Hospital Initiative Step 4 and that hospital practices were amenable to changes that enabled its implementation regardless of the mode of delivery.