Abstract
This is the first detailed study of the relation between cesarean birth and child cognitive development. We measure differences in child cognitive performance at 4 to 9 years of age between cesarean-born and vaginally-born children (n = 3,666) participating in the Longitudinal Study of Australian Children (LSAC). LSAC is a nationally representative birth cohort surveyed biennially. Using multivariate regression, we control for a large range of confounders related to perinatal risk factors and the socio-economic advantage associated with cesarean-born children. Across several measures, we find that cesarean-born children perform significantly below vaginally-born children, by up to a tenth of a standard deviation in national numeracy test scores at age 8–9. Estimates from a low-risk sub-sample and lower-bound analysis suggest that the relation is not spuriously related to unobserved confounding. Lower rates of breastfeeding and adverse child and maternal health outcomes that are associated with cesarean birth are found to explain less than a third of the cognitive gap, which points to the importance of other mechanisms such as disturbed gut microbiota. The findings underline the need for a precautionary approach in responding to requests for a planned cesarean when there are no apparent elevated risks from vaginal birth.
Highlights
Cesarean sections can save lives, but rates well above the World Health Organization’s recommended 15% ceiling in most developed countries suggest that many procedures are unnecessary[1]
Causal impacts on child development are yet to be proven, altered signaling from disturbed gut microbiota is thought to be a possible driver of higher rates of cognitive disorders, especially autism spectrum disorder (ASD) and attention deficit hyperactivity disorder (ADHD), among cesarean-born children
We build on the work of Bentley et al.[31] by using mediation analysis to test to what extent any relation is associated with lower rates of breastfeeding and adverse child and maternal health outcomes
Summary
Cesarean sections can save lives, but rates well above the World Health Organization’s recommended 15% ceiling in most developed countries suggest that many procedures are unnecessary[1]. We build on the work of Bentley et al.[31] by using mediation analysis to test to what extent any relation is associated with lower rates of breastfeeding and adverse child and maternal health outcomes This is important because it helps to identify the importance of direct effects, such as those related to disturbed gut microbiota and helps identify how widespread any effects may be within the population. We more rigorously test the sensitivity of any relation to bias from confounding variables not observed in the data or ‘selection on unobserved covariates’ We do this using two methods — re-estimating on a sub-sample where selection on unobserved covariates is likely to be less of an issue (privately insured births without any observed perinatal risk factors) and by estimating lower-bound estimates under conservative assumptions about the magnitude of selection on unobserved covariates using the Oster[32] technique. This helps to provide some guidance on whether estimated relation is plausibly causal
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