Abstract
BackgroundGlobal cesarean section (CS) rates range from 1% to 52%, with a previous CS being the commonest indication. Labour following a previous CS carries risk of scar rupture, with potential for offspring hypoxic brain injury, leading to high rates of repeat elective CS. However, the effect of delivery by CS on long-term outcomes in children is unclear. Increasing evidence suggests that in avoiding exposure to maternal bowel flora during labour or vaginal birth, offspring delivered by CS may be adversely affected in terms of energy uptake from the gut and immune development, increasing obesity and asthma risks, respectively. This study aimed to address the evidence gap on long-term childhood outcomes following repeat CS by comparing adverse childhood health outcomes after (1) planned repeat CS and (2) unscheduled repeat CS with those that follow vaginal birth after CS (VBAC).Methods and FindingsA data-linkage cohort study was performed. All second-born, term, singleton offspring delivered between 1 January 1993 and 31 December 2007 in Scotland, UK, to women with a history of CS (n = 40,145) were followed up until 31 January 2015. Outcomes assessed included obesity at age 5 y, hospitalisation with asthma, learning disability, cerebral palsy, and death. Cox regression and binary logistic regression were used as appropriate to compare outcomes following planned repeat CS (n = 17,919) and unscheduled repeat CS (n = 8,847) with those following VBAC (n = 13,379).Risk of hospitalisation with asthma was greater following both unscheduled repeat CS (3.7% versus 3.3%, adjusted hazard ratio [HR] 1.18, 95% CI 1.05–1.33) and planned repeat CS (3.6% versus 3.3%, adjusted HR 1.24, 95% CI 1.09–1.42) compared with VBAC. Learning disability and death were more common following unscheduled repeat CS compared with VBAC (3.7% versus 2.3%, adjusted odds ratio 1.64, 95% CI 1.17–2.29, and 0.5% versus 0.4%, adjusted HR 1.50, 95% CI 1.00–2.25, respectively). Risk of obesity at age 5 y and risk of cerebral palsy were similar between planned repeat CS or unscheduled repeat CS and VBAC. Study limitations include the risk that women undergoing an unscheduled CS had intended to have a planned CS, and lack of data on indication for CS, which may confound the findings.ConclusionsBirth by repeat CS, whether planned or unscheduled, was associated with an increased risk of hospitalisation with asthma but no difference in risk of obesity at age 5 y. Greater risk of death and learning disability following unscheduled repeat CS compared to VBAC may reflect complications during labour. Further research, including meta-analyses of studies of rarer outcomes (e.g., cerebral palsy), are needed to confirm whether such risks are similar between delivery groups.
Highlights
Cesarean section (CS) accounts for a quarter of UK births, and between 1% and 52% of births in countries across the globe, with a previous cesarean section (CS) being the leading indication [1,2]
Greater risk of death and learning disability following unscheduled repeat CS compared to vaginal birth after CS (VBAC) may reflect complications during labour
We aimed to use a national birth cohort to compare the risk of adverse childhood health outcomes following planned CS and unscheduled CS with that following vaginal birth in women who had a previous CS, and to compare outcomes following planned repeat CS with those of unscheduled repeat CS to explore the role of exposure to labour
Summary
Cesarean section (CS) accounts for a quarter of UK births, and between 1% and 52% of births in countries across the globe, with a previous CS being the leading indication [1,2]. Increasing evidence suggests that in avoiding exposure to maternal bowel flora during labour or vaginal birth, offspring delivered by CS may be adversely affected in terms of energy uptake from the gut and immune development, increasing obesity and asthma risks, respectively. Women who have had a previous cesarean section (CS) face a slightly elevated risk of negative outcomes during a subsequent vaginal birth This is because, in rare cases, the abdominal CS scar ruptures during labor, which may cause complications and serious problems, such as oxygen deprivation to the brain of a child. The researchers focused on singleton births (as opposed to twins, triplets, etc.) to mothers who have had a previous CS In this group, where the decision about a preferred delivery mode is likely made before labor starts, they examined how childhood health outcomes compared between repeat CS and VBAC
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