Cesarean delivery on maternal request and common child health outcomes: A prospective cohort study in China

Background Cesarean delivery vs vaginal delivery was reported to increase the risks of childhood obesity, pneumonia, anemia, and neurobehavioral disorders, but few studies were able to deal with the confounding biases associated with medical conditions indicating cesareans. This prospective cohort study aims to investigate the associations of non-medically indicated cesarean delivery on maternal request (CDMR) with these child health outcomes. Methods Among 17 748 liveborn infants whose mothers (primiparas) participated in a randomized controlled trial on micronutrient supplementation and pregnancy outcomes during 2006-2009 in 5 rural counties in Hebei Province, China, 6972 singletons born by full-term spontaneous vaginal delivery (SVD) and 3626 by CDMR were extracted for the assessments of obesity (weight-for-height z-score >3) and pneumonia (self-reported) at 1.5-5 years in 2011. Some children were further randomly selected from these two groups for the assessments of anemia (hemoglobin <110 g/L, 2341 SVD and 2417 CDMR) and neurobehavioral disorders (raw score of Child Behavior Checklist larger than the 90th percentile of the normative sample, 1257 SVD and 1060 CDMR). Results Compared with SVD, CDMR was associated with increased risks of obesity (adjusted odds ratio (aOR) = 1.41, 95% confidence interval (CI) = 1.14-1.75, P = 0.002) and anemia (aOR = 1.65, 95% CI = 1.28-2.12, P < 0.001), but not with the risk of pneumonia (aOR = 1.16, 95% CI = 0.94-1.45, P = 0.17) or neurobehavioral disorders (aORs varied from 0.82 to 0.91, P > 0.05) in childhood. Conclusions Cesarean delivery, independent of cesarean indications, is likely associated with childhood obesity and anemia, indicating a need to keep pregnant women informed, especially those seeking CDMR, a need to explore possible improvement on obstetric service, and even a need for main stakeholders to reach a compromise in making a cesarean decision. Trial registration ClinicalTrials.gov: NCT00133744 and NCT01404416


Online Supplementary Document
Text S1 Sampling strategy Text S2 Brief introduction of the Child Behavior Checklist Table S1 Comparisons of maternal and offspring characteristics between the included and the excluded Table S2 Maternal and offspring characteristics by mode of delivery (for outcomes other than obesity)

Table S3
Crude and adjusted odds ratios for multiple child health outcomes by mode of delivery (complete case analysis)

Table S4
Crude and adjusted odds ratios for multiple child health outcomes by mode of delivery (intention-to-treat analysis)

Table S5
Crude and adjusted odds ratios for childhood obesity and anemia by mode of delivery (restricted to women who had normal BMI in the 1 st trimester and normal gestational weight gain rate in the 2 nd /3 rd trimester)

Figure S2
Probability of anemia in different delivery modes by child's age

Text S2 Brief introduction of the Child Behavior Checklist
CBCL is a scale used to assess the emotional and behavioral problems in children aged 18-60 months.
Caregivers are asked to rate 99 specific problem items and 1 open-ended problem item as 0 for not true of the children, 1 for somewhat or sometimes true, and 2 for very true or often true based on the children's behaviors in the last 2 months. These items are scored on 8 empirically based syndromes (emotionally reactive, anxious/depressed, somatic complaints, withdrawn, attention problems, aggressive behavior, sleep problems, and other problems). The first 4 syndromes are merged into an internalizing problem scale, the 5 th and 6 th as an externalizing problem scale, and all of the syndromes as a total problem scale.
The total score in each scale is the raw score. Each raw score corresponds to a percentile of the normative sample. The clinical range of internalizing/externalizing/total problems is above the 90 th percentile, the borderline clinical range is between the 83 rd and 90 th percentile, and the rest is in normal range.   CBCL -Child Behavior Checklist, BMIbody mass index, GWGgestational weight gain, IQRinterquartile range, SDstandard deviation *Percentages may not add up to 100% due to rounding.
6     <18.5, 18.5-22.9, 23.0-27.4, or ≥27.5 kg/m 2 ), gestational weight gain rate in the 2 nd /3 rd trimester (kg/week, in quintiles), and micronutrient supplementation (folic acid, iron-folic acid, or multiple micronutrients); child's gender (male or female), birth weight (g, continuous), age at the follow-up visit (month, continuous), and feeding pattern before 6 months old (exclusive breastfeeding, mixed feeding, or formula feeding). †Additionally adjusted for level of delivery hospital (provincial/city, county/district, or township/village level) and medical insurance status (yes or no). ‡Additionally adjusted for maternal anemia in mid-pregnancy (yes or no). VDvaginal delivery, CDMRcesarean delivery on maternal request, ORodds ratio, CIconfidence interval *Adjusted for maternal age at delivery (year, continuous), education (≤primary, secondary, or ≥high school), occupation (farmer or not), gestational age (week, continuous), body mass index in the 1 st trimester (<18.5, 18.5-22.9, 23.0-27.4, or ≥27.5 kg/m 2 ), gestational weight gain rate in the 2 nd /3 rd trimester (kg/week, in quintiles), and micronutrient supplementation (folic acid, iron-folic acid, or multiple micronutrients); child's gender (male or female), birth weight (g, continuous), age at the follow-up visit (month, continuous), and feeding pattern before 6 months old (exclusive breastfeeding, mixed feeding, or formula feeding). †Additionally adjusted for level of delivery hospital (provincial/city, county/district, or township/village level) and medical insurance status (yes or no). index in the 1 st trimester (kg/m 2 , continuous), gestational weight gain rate in the 2 nd /3 rd trimester (kg/week, continuous), and micronutrient supplementation (folic acid, iron-folic acid, or multiple micronutrients); child's gender (male or female), birth weight (g, continuous), age at the follow-up visit (month, continuous), and feeding pattern before 6 months old (exclusive breastfeeding, mixed feeding, or formula feeding). †Additionally adjusted for level of delivery hospital (provincial/city, county/district, or township/village level) and medical insurance status (yes or no). ‡Additionally adjusted for maternal anemia in mid-pregnancy (yes or no).

Figure S1
Flowchart of inclusion and exclusion in the intention-to-treat analysis.
Live singletons in the original trial (n=17 748) Unknown delivery mode (n=104)