Association of Birth by Cesarean Delivery With Obesity and Type 2 Diabetes Among Adult Women

Jorge E Chavarro,Qi Sun,Karin B Michels,Changzheng Yuan,Nerea Martín-Calvo,Janet W Rich-Edwards,Mariel Arvizu

doi:10.1001/jamanetworkopen.2020.2605

Abstract

Cesarean delivery is associated with an increased risk of childhood obesity in offspring. However, whether this increased risk also includes obesity-associated conditions remains unclear. To evaluate the association of birth by cesarean delivery with offspring's risks of obesity and type 2 diabetes in adulthood. This prospective cohort study compared the incidence of obesity and type 2 diabetes between birth by cesarean delivery and vaginal delivery among 33 226 women participating in the Nurses' Health Study II who were born between 1946 and 1964, with follow-up through the end of the 2013-2015 follow-up cycle. Participants' mothers provided information on mode of delivery and pregnancy characteristics. Participants provided information every 2 years on weight and diagnosis of type 2 diabetes. Relative risks of obesity and type 2 diabetes were estimated using log-binomial and proportional hazards regression accounting for maternal body mass index and other confounding factors. Statistical analysis was performed from June 2017 to December 2019. Birth by cesarean delivery compared with birth by vaginal delivery. Risk of obesity and incidence of type 2 diabetes. At baseline, the participants' mean (SD) age was 33.8 (4.6) years (range, 24.0-44.0 years). A total of 1089 of the 33 226 participants (3.3%) were born by cesarean delivery. After 1 913 978 person-years of follow-up, 12 156 (36.6%) women were obese and 2014 (6.1%) had received a diagnosis of type 2 diabetes. Women born by cesarean delivery were more likely to be classified as obese and to have received a diagnosis of type 2 diabetes during follow-up. The multivariable-adjusted relative risk of obesity among women born by cesarean vs vaginal delivery was 1.11 (95% CI, 1.03-1.19). The multivariable-adjusted hazard ratio for type 2 diabetes among women born by cesarean vs vaginal delivery was 1.46 (95% CI, 1.18-1.81); this association remained significant after additional adjustment for participant's own body mass index (relative risk, 1.34 [95% CI, 1.08-1.67]). These associations persisted when analyses were restricted to women at low risk of cesarean delivery based on maternal characteristics. This study suggests that women born by cesarean delivery may have a higher risk than women born by vaginal delivery of being obese and developing type 2 diabetes during adult life.

Highlights

More than 1.2 million cesarean deliveries are performed yearly in the United States, making it the most common inpatient surgical procedure and accounting for nearly one-third of births nationwide.[1,2] Starting at approximately 2.6% of all births in the 1930s and remaining stable around 5% between the 1950s3 and 1970s,4 the cesarean delivery rate in the United States rose to 24% in 1986,4 reaching a peak of 33% in 2009 and stabilizing around 30% thereafter,[1] with primary cesarean delivery accounting for 50% of the increasing rate.[5]
The multivariable-adjusted hazard ratio for type 2 diabetes among women born by cesarean vs vaginal delivery was 1.46; this association remained significant after additional adjustment for participant’s own body mass index
The cumulative risk of obesity through the end of follow-up was 36.5% (11 722 of 32 137) among women born by vaginal delivery and 39.9% (434 of 1089) among women born by cesarean delivery

Summary

Introduction

More than 1.2 million cesarean deliveries are performed yearly in the United States, making it the most common inpatient surgical procedure and accounting for nearly one-third of births nationwide.[1,2] Starting at approximately 2.6% of all births in the 1930s (prior to the widespread availability of penicillin) and remaining stable around 5% between the 1950s3 and 1970s,4 the cesarean delivery rate in the United States rose to 24% in 1986,4 reaching a peak of 33% in 2009 and stabilizing around 30% thereafter,[1] with primary cesarean delivery accounting for 50% of the increasing rate.[5]. Women without medical or obstetric risk factors for obstetric complications undergoing a planned cesarean delivery at term experience a 3-fold greater risk of major morbidity—including greater risks of cardiac arrest, hysterectomy, puerperal infection, and thromboembolism—relative to comparable women undergoing vaginal deliveries.[9] For newborns, the most common immediate risk with cesarean delivery is a higher frequency of respiratory complications.[10,11] many cesarean deliveries performed in the United States do not have a clear indication,[12,13] raising concerns that the excess maternal and newborn morbidity and mortality may be largely preventable With these concerns in mind, leading professional organizations have advocated for the prevention of primary cesarean delivery as a strategy to reduce their overall frequency.[13,14]

Methods

Results

Discussion

Conclusion