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Yu HZ, Wang XW, Guo ZY, Lin Z, Zhou YB, Li HT, Liu JM. Association of caesarean delivery with offspring health outcomes in full-cohort versus sibling-comparison studies: a comparative meta-analysis and simulation study. BMC Med 2023; 21:348. [PMID: 37679672 PMCID: PMC10486071 DOI: 10.1186/s12916-023-03030-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 08/14/2023] [Indexed: 09/09/2023] Open
Abstract
BACKGROUND Full-cohort and sibling-comparison designs have yielded inconsistent results about the impacts of caesarean delivery on offspring health outcomes, with the effect estimates from the latter being more likely directed towards the null value. We hypothesized that the seemingly conservative results obtained from the sibling-comparison design might be attributed to inadequate adjustment for non-shared confounders between siblings, particularly maternal age at delivery. METHODS A systematic review and meta-analysis was first conducted. PubMed, Embase, and the Web of Science were searched from database inception to April 6, 2022. Included studies (1) examined the association of caesarean delivery, whether elective or emergency, with offspring health outcomes; (2) simultaneously conducted full-cohort and sibling-comparison analyses; and (3) reported adjusted effect estimates with 95% confidence intervals (95% CIs). No language restrictions were applied. Data were extracted by 2 reviewers independently. Three-level meta-analytic models were used to calculate the pooled odds ratios (ORs) and 95% CIs for caesarean versus vaginal delivery on multiple offspring health outcomes separately for full-cohort and sibling-comparison designs. Subgroup analyses were performed based on the method of adjustment for maternal age at delivery. A simulation study was then conducted. The simulated datasets were generated with some key parameters derived from the meta-analysis. RESULTS Eighteen studies involving 21,854,828 individuals were included. The outcomes assessed included mental and behavioral disorders; endocrine, nutritional and metabolic diseases; asthma; cardiorespiratory fitness; and multiple sclerosis. The overall pooled OR for estimates from the full-cohort design was 1.14 (95% CI: 1.11 to 1.17), higher than that for estimates from the sibling-comparison design (OR = 1.08; 95% CI: 1.02 to 1.14). Stratified analyses showed that estimates from the sibling-comparison design varied considerably across studies using different methods to adjust for maternal age at delivery in multivariate analyses, while those from the full-cohort design were rather stable: in studies that did not adjust maternal age at delivery, the pooled OR of full-cohort vs. sibling-comparison design was 1.10 (95% CI: 0.99 to 1.22) vs. 1.06 (95% CI: 0.85 to 1.31), in studies adjusting it as a categorical variable, 1.15 (95% CI: 1.11 to 1.19) vs. 1.07 (95% CI: 1.00 to 1.15), and in studies adjusting it as a continuous variable, 1.12 (95% CI: 1.05 to 1.19) vs. 1.12 (95% CI: 0.98 to 1.29). The severe underestimation bias related to the inadequate adjustment of maternal age at delivery in sibling-comparison analyses was fully replicated in the simulation study. CONCLUSIONS Sibling-comparison analyses may underestimate the association of caesarean delivery with multiple offspring health outcomes due to inadequate adjustment of non-shared confounders, such as maternal age at delivery. Thus, we should be cautious when interpreting the seemingly conservative results of sibling-comparison analyses in delivery-related studies.
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Affiliation(s)
- Hong-Zhao Yu
- Institute of Reproductive and Child Health, National Health Commission Key Laboratory of Reproductive Health, Peking University Health Science Center, Beijing, China
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University Health Science Center, Beijing, China
| | - Xiao-Wei Wang
- Institute of Reproductive and Child Health, National Health Commission Key Laboratory of Reproductive Health, Peking University Health Science Center, Beijing, China
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University Health Science Center, Beijing, China
| | - Zhen-Yu Guo
- Institute of Reproductive and Child Health, National Health Commission Key Laboratory of Reproductive Health, Peking University Health Science Center, Beijing, China
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University Health Science Center, Beijing, China
| | - Zhi Lin
- Institute of Reproductive and Child Health, National Health Commission Key Laboratory of Reproductive Health, Peking University Health Science Center, Beijing, China
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University Health Science Center, Beijing, China
| | - Yu-Bo Zhou
- Institute of Reproductive and Child Health, National Health Commission Key Laboratory of Reproductive Health, Peking University Health Science Center, Beijing, China.
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University Health Science Center, Beijing, China.
| | - Hong-Tian Li
- Institute of Reproductive and Child Health, National Health Commission Key Laboratory of Reproductive Health, Peking University Health Science Center, Beijing, China.
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University Health Science Center, Beijing, China.
- Center for Intelligent Public Health, Institute for Artificial Intelligence, Peking University, Beijing, China.
| | - Jian-Meng Liu
- Institute of Reproductive and Child Health, National Health Commission Key Laboratory of Reproductive Health, Peking University Health Science Center, Beijing, China
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University Health Science Center, Beijing, China
- Center for Intelligent Public Health, Institute for Artificial Intelligence, Peking University, Beijing, China
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Chiavarini M, De Socio B, Giacchetta I, Fabiani R. Overweight and Obesity in Adult Birth by Cesarean Section: A Systematic Review With Meta-analysis. JOURNAL OF PUBLIC HEALTH MANAGEMENT AND PRACTICE 2023; 29:128-141. [PMID: 36715592 DOI: 10.1097/phh.0000000000001687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
CONTEXT Overweight/obesity is one of the most important health problems. Birth by cesarean section has been shown to influence long-term health outcomes including obesity. OBJECTIVE The aim of this systematic review-meta-analysis is to update acknowledgment of the increased risk of cesarean section on offspring's overweight/obesity. METHODS This study follows the PRISMA guidelines. A systematic literature search was conducted on Scopus, PubMed, and Web of Science; we have selected all the articles published until January 2, 2022. For inclusion, studies must have reported either (i) both birth by cesarean section and adult (≥18 years) offspring's body mass index; (ii) cohort or case-control study design; and (iii) a risk estimate. Heterogeneity testing was performed using Cochran's Q and I2 statistics. Publication bias was assessed by the Egger test and the Begg test. Meta-analysis was performed through a random-effects model. RESULTS Twelve studies with a combined population of 180 065 subjects were included in the meta-analysis. The overall analysis (N = 19) yielded a combined risk estimate for overweight/obesity of 1.19 (95% CI, 1.08-1.30) and the test of heterogeneity resulted into Q = 57.44 ( I2 = 68.67%, P ≤ .001). The risk of offspring obesity is 1.23 (95% CI, 1.09-1.39) and the test of heterogeneity resulted into Q = 39.55 ( I2 = 69.66%, P ≤ .001). Children born by cesarean section have an increased risk of obesity in adulthood.
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Affiliation(s)
- Manuela Chiavarini
- Department of Medicine and Surgery, Section of Public Heath (Dr Chiavarini), Nursing and Midwifery Science (Ms De Socio), Department of Chemistry, Biology and Biotechnology (Dr Fabiani), and Department of Medicine and Surgery, Section of Public Heath, School of Hygiene and Preventive Medicine (Dr Giacchetta), University of Perugia, Perugia, Italy
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Baran J, Weres A, Baran R, Czenczek-Lewandowska E, Leszczak J, Wyszyńska J. Preterm Birth and the Type of Birth and Their Impact on the Incidence of Overweight and Obesity in Children. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph191912042. [PMID: 36231343 PMCID: PMC9566099 DOI: 10.3390/ijerph191912042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 09/19/2022] [Accepted: 09/21/2022] [Indexed: 05/02/2023]
Abstract
The purpose of the study was to evaluate the influence of the type of birth and preterm birth on the risk of overweight and obesity in the children studied. The study involved 749 children of pre-school and school age, between 4 and 15 years of age. Information about the type of delivery and the potential preterm birth came from the child's health book and the mother's pregnancy card. The authors assessed the body height and body weight of each child. The analysis showed that on average every six children were born before due date (before the end of 37 weeks of gestation) and slightly more than 40% of the children were born by cesarean section (CS). A statistical analysis was performed, including descriptive statistics and Spearman's correlation, and to evaluate the differences in the analyzed groups, nonparametric tests and chi-square independence tests were used: the Mann-Whitney test, and the Kruskal-Wallis test due to the lack of a normalized distribution. The incidence of overweight and obesity was higher in 7-11-year-old boys born with CS vs. vaginal birth (VD) (p = 0.026). There were no statistically significant differences between BMI centile value and preterm birth. Cesarean section birth significantly increases the percentage of boys with overweight and obesity in early school age and may be associated with higher percentile values of children with BMI in this age group.
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Affiliation(s)
- Joanna Baran
- Institute of Health Sciences, Medical College, University of Rzeszów, 35-310 Rzeszów, Poland
- Natural and Medical Center for Innovative Research, 35-310 Rzeszów, Poland
- Correspondence:
| | - Aneta Weres
- Institute of Health Sciences, Medical College, University of Rzeszów, 35-310 Rzeszów, Poland
| | - Rafał Baran
- Institute of Health Sciences, Medical College, University of Rzeszów, 35-310 Rzeszów, Poland
- SOLUTION-Statistical Analysis, 35-120 Rzeszów, Poland
| | - Ewelina Czenczek-Lewandowska
- Institute of Health Sciences, Medical College, University of Rzeszów, 35-310 Rzeszów, Poland
- Natural and Medical Center for Innovative Research, 35-310 Rzeszów, Poland
| | - Justyna Leszczak
- Institute of Health Sciences, Medical College, University of Rzeszów, 35-310 Rzeszów, Poland
- Natural and Medical Center for Innovative Research, 35-310 Rzeszów, Poland
| | - Justyna Wyszyńska
- Institute of Health Sciences, Medical College, University of Rzeszów, 35-310 Rzeszów, Poland
- Natural and Medical Center for Innovative Research, 35-310 Rzeszów, Poland
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Quecke B, Graf Y, Epure AM, Santschi V, Chiolero A, Carmeli C, Cullati S. Caesarean section and obesity in young adult offspring: Update of a systematic review with meta-analysis. Obes Rev 2022; 23:e13368. [PMID: 34585502 PMCID: PMC9286585 DOI: 10.1111/obr.13368] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 09/03/2021] [Accepted: 09/03/2021] [Indexed: 12/13/2022]
Abstract
As compared with vaginal delivery (VD), caesarean section (CS) birth could be associated with increased risk of obesity in young adult offspring. We aimed to evaluate this association by updating data from a systematic review with meta-analysis of observational studies. From 3774 records identified in PubMed and Embase, we retained six studies and added five studies from the last systematic review, for a total of 11 studies. Crude estimates of the association were retrieved from nine cohort studies (n = 143,869), and maximally adjusted estimates were retrieved from eight cohort studies. Young adults born by CS had higher risk of obesity (body mass index [BMI] ≥ 30 kg/m2 ) than young adults born by VD, corresponding to a crude pooled risk ratio (RR) of 1.30 [95% confidence interval (CI) 1.13 to 1.50] and a maximally adjusted pooled RR of 1.22 [95% CI 1.02 to 1.46]. In a sensitivity analysis pooling, five studies that included maternal prepregnancy BMI, a major potential confounding factor, in the set of controlled covariates, the RR was 1.08 [95% CI 0.92 to 1.27]. We concluded that the association between CS and obesity in young adulthood was mostly explained by confounding from maternal prepregnancy BMI.
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Affiliation(s)
- Berenike Quecke
- Population Health Laboratory (#PopHealthLab), University of Fribourg, Fribourg, Switzerland
| | - Yannick Graf
- Population Health Laboratory (#PopHealthLab), University of Fribourg, Fribourg, Switzerland
| | - Adina-Mihaela Epure
- Population Health Laboratory (#PopHealthLab), University of Fribourg, Fribourg, Switzerland
| | - Valérie Santschi
- La Source, School of Nursing Sciences, HES-SO University of Applied Sciences and Arts Western Switzerland, Lausanne, Switzerland
| | - Arnaud Chiolero
- Population Health Laboratory (#PopHealthLab), University of Fribourg, Fribourg, Switzerland.,Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland.,School of Population and Global Health, McGill University, Montreal, Canada
| | - Cristian Carmeli
- Population Health Laboratory (#PopHealthLab), University of Fribourg, Fribourg, Switzerland
| | - Stéphane Cullati
- Population Health Laboratory (#PopHealthLab), University of Fribourg, Fribourg, Switzerland.,Department of Readaptation and Geriatrics, University of Geneva, Geneva, Switzerland
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Begum T, Fatima Y, Perales F, Anuradha S, Mamun A. Associations of caesarean section with body mass and waist circumference trajectories from age 2 to 13 years: A nationally representative birth cohort study in Australia. Pediatr Obes 2021; 16:e12769. [PMID: 33403832 DOI: 10.1111/ijpo.12769] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 11/22/2020] [Accepted: 12/17/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Measuring obesity at a single time point does not explain the independent association between C-section birth and obesity in a child's life course. OBJECTIVES This study aimed to explore the longitudinal link between C-section with obesity trajectories during childhood. METHODS We analysed data from a nationally representative birth cohort study named "Longitudinal Study of Australian Children (LSAC)", commenced in 2004. General obesity was measured through the Body Mass Index (BMI) and abdominal obesity by the Waist Circumference (WC) using the biennially collected data from age 2 to 13 years (2006-2016). Group-based trajectory modelling was applied to identify the distinct pattern of BMI & WC trajectories. Multivariable multinomial logistic regression models were used to assess the association between C-section and obesity trajectories after adjusting for perinatal factors. RESULTS Of the 3524 study children, 30% were born by C-section. Three distinct BMI trajectory groups emerged: stable normal (60%), moderately rising (33%) and accelerated (7%). The WC trajectories were, stable normal (58%), moderate (34%) and accelerated (8%). Compared with the stable normal group, children born through C-section had a higher risk to follow accelerated trajectories for both BMI (OR:1.72; 95% CI: 1.28-2.32) and WC (OR: 1.51; 95% CI: 1.15-1.98) with P-value <0.01. Adjustment of potential confounders did not alter these associations substantially. CONCLUSIONS C-section birth significantly increases the risk of having an accelerated obesity trajectory in children. Limiting the C-section for absolute clinical causes and early institution of preventive approach can reduce the obesity burden among children delivered through C-section.
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Affiliation(s)
- Tahmina Begum
- Institute for Social Science Research, The University of Queensland (UQ), St Lucia, QLD, Australia.,ARC Centre of Excellence for Children and Families Over the Life Course Centre, UQ, St Lucia, QLD, Australia.,Health Systems and Population Studies Division, icddr,b, Dhaka, Bangladesh
| | - Yaqoot Fatima
- Institute for Social Science Research, The University of Queensland (UQ), St Lucia, QLD, Australia.,Centre for Rural and Remote Health, James Cook University, Mount Isa, QLD, Australia
| | - Francisco Perales
- ARC Centre of Excellence for Children and Families Over the Life Course Centre, UQ, St Lucia, QLD, Australia.,School of Social Science, The University of Queensland, St Lucia, QLD, Australia
| | | | - Abdullah Mamun
- Institute for Social Science Research, The University of Queensland (UQ), St Lucia, QLD, Australia.,ARC Centre of Excellence for Children and Families Over the Life Course Centre, UQ, St Lucia, QLD, Australia
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Abreu JDMFD, Abreu SLLD, Bragança MLBM, Cavalcante LFP, França AKTDC, Ribeiro CCC, Lamy Filho F. Birth by cesarean delivery and central adiposity in adolescents from a birth cohort. CAD SAUDE PUBLICA 2021; 37:e00033320. [PMID: 33503161 DOI: 10.1590/0102-311x00033320] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Accepted: 06/16/2020] [Indexed: 12/26/2022] Open
Abstract
The aim of this study was to analyze the association between birth by cesarean section and central adiposity in adolescents in São Luís, Maranhão State, Brazil. This was a cohort study that included 601 participants evaluated at birth and at 18-19 years. At birth we assessed type of delivery, maternal education, family income, maternal marital status, maternal body mass index before pregnancy, prenatal care, maternal smoking habit, gestational age at delivery and intrauterine growth restriction. In the adolescents, we evaluated central adiposity using the dual X-ray energy absorptiometry method. The indicators of central fat used were the trunk-to-total fat mass ratio (T/T), the android-to-gynoid fat mass ratio (A/G), the trunk-to-limb fat mass ratio (T/Lb), and the trunk-to-leg fat mass ratio (T/Lg). A theoretical model for the study of associations was developed using directed acyclic graphs, which allowed selecting the variables that required minimum adjustment for inclusion in the predictive model of exposure to cesarean delivery. The data were analyzed with marginal structural models weighted by the inverse of the probability of selection. A total of 38.6% of the adolescents studied were delivered by cesarean section. There was no significant difference in the central adiposity of adolescents delivered by cesarean section according to the indicators used: T/T ( coefficient = -0.003; 95%CI: -0.013; 0.007), A/G (coefficient = 0.001; 95%CI: -0.015; 0.018); T/Lb (coefficient = -0.016; 95%CI: -0.048; 0.016); T/Lg (coefficient = 0.014; 95%CI: -0.060; 0.030). In conclusion, there was no association between cesarean section delivery and greater central adiposity in the studied adolescents.
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Martín-Calvo N, Martínez-González MÁ, Segura G, Chavarro JE, Carlos S, Gea A. Caesarean delivery is associated with higher risk of overweight in the offspring: within-family analysis in the SUN cohort. J Epidemiol Community Health 2020; 74:586-591. [PMID: 32332117 DOI: 10.1136/jech-2019-213724] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Revised: 02/29/2020] [Accepted: 03/21/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Most studies assessing the association between caesarean delivery (CD) and childhood overweight/obesity have failed to account for important confounders, such as maternal prepregnancy body mass index (BMI) or the indication of the CD. Furthermore, within-family analyses have reported contradictory results. We aimed at evaluating the association between CD and offspring's risk of overweight/obesity while adjusting for important confounders and accounting for correlations between siblings. METHODS Women in the 'Seguimiento Universidad de Navarra' cohort provided structured information regarding their pregnancy history and their children's health through online cross-sectional questionnaires. We calculated adjusted differences in BMI z-score and risk ratios (RR) for offspring's overweight/obesity associated with CD, with hierarchical models to account for correlations between siblings. We also performed a within-family analysis in 341 siblings who were discordant in delivery mode, using conditional multivariable logistic regression. RESULTS Among the 2791 children analysed, those born by CD had higher average BMI z-scores (difference: 0.17; 95% CI 0.07 to 0.27) and higher risk of overweight/obesity (RR: 1.32, 95% CI 1.05 to 1.65) than children born vaginally. The association did not differ by maternal characteristics or offspring's age strata, and the results were consistent in sensitivity analyses. Furthermore, within-family analysis showed that children born by CD had 2.67-fold higher risk of overweight/obesity (95% CI 1.10 to 5.12) than their peers born vaginally. CONCLUSION Children born by CD have higher average BMI z-scores and higher risk of overweight/obesity than children born vaginally. The consistency of these findings across multiple approaches to address potential residual confounding likely suggests a true biological effect.
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Affiliation(s)
- Nerea Martín-Calvo
- Department of Preventive Medicine and Public Health, University of Navarra. School of Medicine, Pamplona, Spain
- Navarra Institute for Health Research, Pamplona, Spain
- Centro de Investigación Biomédica en Red, Fisiopatología de la Obesidad y Nutrición Instituto de Salud Carlos III., Madrid, Spain
| | - Miguel Ángel Martínez-González
- Department of Preventive Medicine and Public Health, University of Navarra. School of Medicine, Pamplona, Spain
- Navarra Institute for Health Research, Pamplona, Spain
- Centro de Investigación Biomédica en Red, Fisiopatología de la Obesidad y Nutrición Instituto de Salud Carlos III., Madrid, Spain
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston Massachusetts, USA
| | - Gloria Segura
- University of Navarra. School of Medicine, Pamplona, Spain
| | - Jorge E Chavarro
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston Massachusetts, USA
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston Massachusetts, USA
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston Massachusetts, USA
| | - Silvia Carlos
- Department of Preventive Medicine and Public Health, University of Navarra. School of Medicine, Pamplona, Spain
- Navarra Institute for Health Research, Pamplona, Spain
- Centro de Investigación Biomédica en Red, Fisiopatología de la Obesidad y Nutrición Instituto de Salud Carlos III., Madrid, Spain
| | - Alfredo Gea
- Department of Preventive Medicine and Public Health, University of Navarra. School of Medicine, Pamplona, Spain
- Navarra Institute for Health Research, Pamplona, Spain
- Centro de Investigación Biomédica en Red, Fisiopatología de la Obesidad y Nutrición Instituto de Salud Carlos III., Madrid, Spain
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Sogunle E, Masukume G, Nelson G. The association between caesarean section delivery and later life obesity in 21-24 year olds in an Urban South African birth cohort. PLoS One 2019; 14:e0221379. [PMID: 31725725 PMCID: PMC6855451 DOI: 10.1371/journal.pone.0221379] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 10/30/2019] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Obesity is an important public health problem and rates have reached epidemic proportions in many countries. Studies have explored the association between infants delivered by caesarean section and their later life risk of obesity, in many countries outside Africa. As a result of the increasing caesarean section and obesity rates in South Africa, we investigated the association in this country. METHODS This was a retrospective analysis of data that were collected from a prospective South African birth cohort (Birth to Twenty Plus), established in 1990. A total of 889 young adults aged 21-24 years were included in the analysis. Poisson regression models were fitted to assess the association between mode of delivery and early adulthood obesity. RESULTS Of the 889 young adults, 106 (11.9%) were obese while 72 (8.1%) were delivered by caesarean section; of which 14 (19.4%) were obese. Caesarean section delivery was significantly associated with obesity in young adults after adjusting for potential confounders like young adults' sex and birth weight, mothers' parity, and education (incidence rate ratio 1.64, 95% CI 1.01-2.68, p = 0.045). CONCLUSION The association of caesarean section with early adulthood obesity should be interpreted with caution because data on certain key confounding factors such as mothers' pre-pregnancy body mass index and gestational diabetes were not available. Further research from Africa, with larger sample sizes and databases with useful linking of maternal and infant data, should be conducted.
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Affiliation(s)
- Eniola Sogunle
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Gwinyai Masukume
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Gill Nelson
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Ferraro AA, Barbieri MA, da Silva AAM, Goldani MZ, Fernandes MTB, Cardoso VC, Stein AD, Bettiol H. Cesarean Delivery and Hypertension in Early Adulthood. Am J Epidemiol 2019; 188:1296-1303. [PMID: 31111861 DOI: 10.1093/aje/kwz096] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Revised: 04/03/2019] [Accepted: 04/04/2019] [Indexed: 12/17/2022] Open
Abstract
The rate of cesarean delivery (CD) is high in many parts of the world. Birth via CD has been associated with adverse later health outcomes, such as obesity, asthma, and type 1 diabetes mellitus. Few studies have focused on hypertension. We investigated the associations of CD with hypertension, systolic blood pressure (BP), and diastolic BP and tested whether body mass index (BMI; weight (kg)/height (m)2) was a mediator of these associations in a birth cohort (n = 2,020) assembled in 1978-1979 and followed up in 2002-2004 in Ribeirão Preto, Brazil. The CD rate was 32.0%. Hypertension was present in 11.7% of persons born via CD and 7.7% of those born vaginally. Being born by CD increased the odds of hypertension by 51% (odds ratio = 1.51, 95% confidence interval (CI): 1.10, 2.07). After adjustment for confounders, this estimate changed little (odds ratio = 1.49, 95% CI: 1.07, 2.06). In a mediation analysis, odds ratios for the indirect and direct effects were 1.18 (95% CI: 1.11, 1.25) and 1.31 (95% CI: 0.97, 1.65), respectively. CD also had indirect effects on both systolic and diastolic BP via BMI. Our findings suggest that CD is associated with young-adult hypertension and that this association is at least partially mediated by BMI. This has implications for countries struggling with the burden of noncommunicable diseases and where CD rates are high.
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Affiliation(s)
| | - Marco Antônio Barbieri
- Department of Pediatrics, Faculty of Medicine of Ribeirão Preto, University of São Paulo, Ribeirão Preto, Brazil
| | | | - Marcelo Zubaran Goldani
- Department of Pediatrics, Faculty of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | | | - Viviane Cunha Cardoso
- Department of Pediatrics, Faculty of Medicine of Ribeirão Preto, University of São Paulo, Ribeirão Preto, Brazil
| | - Aryeh David Stein
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Heloisa Bettiol
- Department of Pediatrics, Faculty of Medicine of Ribeirão Preto, University of São Paulo, Ribeirão Preto, Brazil
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Diejomaoh MFE, Al-Jassar W, Bello Z, Karunakaran K, Mohammed A. The Relevance of the Second Cesarean Delivery in the Reduction of Institutional Cesarean Delivery Rates. Med Princ Pract 2018; 27:555-561. [PMID: 30165369 PMCID: PMC6422118 DOI: 10.1159/000493362] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2017] [Revised: 08/30/2018] [Accepted: 08/30/2018] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE The cesarean delivery rate has increased worldwide. The aim of our study was to assess the events associated with the second cesarean deliveries in our institution. SUBJECTS AND METHODS All cesarean deliveries at the Maternity Hospital, Kuwait, from January 1 to December 31, 2013, were identified. A comparative study was undertaken on patients having their first and second cesarean deliveries. The social and clinical characteristics of these patients were extracted from our records and the antenatal, intrapartum, and postpartum course of the pregnancies and their outcomes documented. RESULTS During the study period, 10,586 deliveries were recorded, including 3,676 cesarean deliveries, i.e., a cesarean delivery rate of 34.7%. 840 of these patients were undergoing their first cesarean delivery (group A) and 607 patients were undergoing their second (group B); 484 patients from group A and 341 patients from group B with complete records were analyzed. Mean age (30.89 ± 4.93 vs. 29.94 ± 5.56 years, p = 0.008), parity (1.49 ± 1.22 vs. 0.98 ± 1.60, p < 0.0001), gestational age at delivery (38.12 ± 2.61 vs. 37.66 ± 3.11 weeks, p = 0.02), and fetal birth weight (3,211.60 ± 691.51 vs. 2,829.73 ± 863.26 g, p < 0.001) were significantly higher in group B than in group A. 53.2% of the patients in group B requested repeat cesarean delivery, their second cesarean. The rate of maternal morbidity was low. CONCLUSIONS The incidence of repeat cesarean delivery in group B is high, and its reduction should contribute to a lowering of the overall cesarean delivery rate.
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Affiliation(s)
- Michael F E Diejomaoh
- Department of Obstetrics and Gynecology, Faculty of Medicine, Kuwait University, Safat,
- Department of Obstetrics and Gynecology, Maternity Hospital, Safat,
| | - Waleed Al-Jassar
- Department of Obstetrics and Gynecology, Faculty of Medicine, Kuwait University, Safat, Kuwait
- Department of Obstetrics and Gynecology, Maternity Hospital, Safat, Kuwait
| | - Zainab Bello
- Department of Obstetrics and Gynecology, Maternity Hospital, Safat, Kuwait
| | | | - Asiya Mohammed
- Department of Obstetrics and Gynecology, Faculty of Medicine, Kuwait University, Safat, Kuwait
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11
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Keag OE, Norman JE, Stock SJ. Long-term risks and benefits associated with cesarean delivery for mother, baby, and subsequent pregnancies: Systematic review and meta-analysis. PLoS Med 2018; 15:e1002494. [PMID: 29360829 PMCID: PMC5779640 DOI: 10.1371/journal.pmed.1002494] [Citation(s) in RCA: 426] [Impact Index Per Article: 71.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Accepted: 12/18/2017] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Cesarean birth rates continue to rise worldwide with recent (2016) reported rates of 24.5% in Western Europe, 32% in North America, and 41% in South America. The objective of this systematic review is to describe the long-term risks and benefits of cesarean delivery for mother, baby, and subsequent pregnancies. The primary maternal outcome was pelvic floor dysfunction, the primary baby outcome was asthma, and the primary subsequent pregnancy outcome was perinatal death. METHODS AND FINDINGS Medline, Embase, Cochrane, and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases were systematically searched for published studies in human subjects (last search 25 May 2017), supplemented by manual searches. Included studies were randomized controlled trials (RCTs) and large (more than 1,000 participants) prospective cohort studies with greater than or equal to one-year follow-up comparing outcomes of women delivering by cesarean delivery and by vaginal delivery. Two assessors screened 30,327 abstracts. Studies were graded for risk of bias by two assessors using the Scottish Intercollegiate Guideline Network (SIGN) Methodology Checklist and the Risk of Bias Assessment tool for Non-Randomized Studies. Results were pooled in fixed effects meta-analyses or in random effects models when significant heterogeneity was present (I2 ≥ 40%). One RCT and 79 cohort studies (all from high income countries) were included, involving 29,928,274 participants. Compared to vaginal delivery, cesarean delivery was associated with decreased risk of urinary incontinence, odds ratio (OR) 0.56 (95% CI 0.47 to 0.66; n = 58,900; 8 studies) and pelvic organ prolapse (OR 0.29, 0.17 to 0.51; n = 39,208; 2 studies). Children delivered by cesarean delivery had increased risk of asthma up to the age of 12 years (OR 1.21, 1.11 to 1.32; n = 887,960; 13 studies) and obesity up to the age of 5 years (OR 1.59, 1.33 to 1.90; n = 64,113; 6 studies). Pregnancy after cesarean delivery was associated with increased risk of miscarriage (OR 1.17, 1.03 to 1.32; n = 151,412; 4 studies) and stillbirth (OR 1.27, 1.15 to 1.40; n = 703,562; 8 studies), but not perinatal mortality (OR 1.11, 0.89 to 1.39; n = 91,429; 2 studies). Pregnancy following cesarean delivery was associated with increased risk of placenta previa (OR 1.74, 1.62 to 1.87; n = 7,101,692; 10 studies), placenta accreta (OR 2.95, 1.32 to 6.60; n = 705,108; 3 studies), and placental abruption (OR 1.38, 1.27 to 1.49; n = 5,667,160; 6 studies). This is a comprehensive review adhering to a registered protocol, and guidelines for the Meta-analysis of Observational Studies in Epidemiology were followed, but it is based on predominantly observational data, and in some meta-analyses, between-study heterogeneity is high; therefore, causation cannot be inferred and the results should be interpreted with caution. CONCLUSIONS When compared with vaginal delivery, cesarean delivery is associated with a reduced rate of urinary incontinence and pelvic organ prolapse, but this should be weighed against the association with increased risks for fertility, future pregnancy, and long-term childhood outcomes. This information could be valuable in counselling women on mode of delivery.
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Affiliation(s)
- Oonagh E. Keag
- NHS Lothian Department of Obstetrics and Gynaecology, Simpson’s Centre for Reproductive Health, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - Jane E. Norman
- Tommy’s Centre for Maternal and Fetal Health, MRC Centre for Reproductive Health, University of Edinburgh Queen’s Medical Research Institute, Edinburgh, United Kingdom
| | - Sarah J. Stock
- Tommy’s Centre for Maternal and Fetal Health, MRC Centre for Reproductive Health, University of Edinburgh Queen’s Medical Research Institute, Edinburgh, United Kingdom
- School of Women’s and Infants’ Health, University of Western Australia, Crawley, Australia
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12
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Black M, Bhattacharya S, Philip S, Norman JE, McLernon DJ. Planned Repeat Cesarean Section at Term and Adverse Childhood Health Outcomes: A Record-Linkage Study. PLoS Med 2016; 13:e1001973. [PMID: 26978456 PMCID: PMC4792387 DOI: 10.1371/journal.pmed.1001973] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Accepted: 01/29/2016] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Global 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 FINDINGS A 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. CONCLUSIONS Birth 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.
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Affiliation(s)
- Mairead Black
- Division of Applied Health Sciences, University of Aberdeen, Aberdeen, United Kingdom
| | | | - Sam Philip
- Diabetes Research Unit, NHS Grampian, Aberdeen, United Kingdom
| | - Jane E Norman
- Tommy's Centre for Maternal and Fetal Health, University of Edinburgh, Edinburgh, United Kingdom
| | - David J McLernon
- Medical Statistics Team, Division of Applied Health Sciences, University of Aberdeen, Aberdeen, United Kingdom
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Sutharsan R, Mannan M, Doi SA, Mamun AA. Caesarean delivery and the risk of offspring overweight and obesity over the life course: a systematic review and bias-adjusted meta-analysis. Clin Obes 2015; 5:293-301. [PMID: 26286021 DOI: 10.1111/cob.12114] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2015] [Revised: 07/07/2015] [Accepted: 07/16/2015] [Indexed: 12/15/2022]
Abstract
A causal role of Caesarean delivery (CD) on developing overweight and obesity in the life course of offspring has been postulated. However, the true strength of this association is not clear and the potential for confounding has not been adequately addressed. A systematic review and meta-analysis were conducted to evaluate the strength of this association, this time using a bias-adjusted model in addition to conventional methods. Our search yielded 32 estimates from 14 publications (n = 261,000) for meta-analysis. The pooled analysis of seven estimates (n = 194,463) demonstrated a trend only towards a risk increase (RR = 1.15; 95% CI:0.94, 1.40) in overweight and obesity combined (ow+ob) due to CD in early childhood (0-5 years) and a similar trend was observed for mid-childhood and adolescence (5-18 years). In adulthood, a moderate increase in risk for ow+ob due to CD was observed (n = 30,200) (RR = 1.28; 95% CI 1.02, 1.34). Results for obesity and overweight separately were stronger for obesity and demonstrated a decreasing effect across the three life stages. Conventional methods of analysis suggested less uncertainty than we report and publication bias assessment was strongly suggestive of a bias in favour of positive studies. The current analysis therefore suggests that the small effects seen with CD in this and previous meta-analyses are probably a cumulative consequence of several biases we have outlined, including confounding effect and publication bias.
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Affiliation(s)
- R Sutharsan
- School of Public Health, The University of Queensland, Brisbane, QLD, Australia
- Eskitis Institute, Griffith University, Brisbane, QLD, Australia
| | - M Mannan
- School of Pharmacy, The University of Queensland, Brisbane, QLD, Australia
| | - S A Doi
- Research School of Population Health, Australian National University, Canberra, ACT, Australia
| | - A A Mamun
- School of Public Health, The University of Queensland, Brisbane, QLD, Australia
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Abstract
The DOHaD research field has successfully associated adult non-communicable diseases with inadequate nutrition in early periods of life. More recently, different types of exposure have been linked with impaired developmental outcomes and later health consequences, such as cesarean section at delivery, air pollution and domestic violence during pregnancy. The aim of this work is to bring up this issue looking at the published evidence on these three highly prevalent hazards in Latin American countries.
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Kuhle S, Tong OS, Woolcott CG. Association between caesarean section and childhood obesity: a systematic review and meta-analysis. Obes Rev 2015; 16:295-303. [PMID: 25752886 DOI: 10.1111/obr.12267] [Citation(s) in RCA: 153] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2014] [Revised: 01/07/2015] [Accepted: 01/14/2015] [Indexed: 12/15/2022]
Abstract
Birth by caesarean section has been recently implicated in the aetiology of childhood obesity, but studies examining the association have varied with regard to their settings, designs, and adjustment for potential confounders. We conducted a systematic review and meta-analysis to summarize the available evidence and to explore study characteristics as sources of heterogeneity. A search of Medline, EMBASE, and Web of Science identified 28 studies. Random effects meta-analysis was used to calculate pooled risk ratios (RR) with 95% confidence intervals (CI). Caesarean section had a RR of 1.34 (CI 1.18-1.51) for obesity in the child compared with vaginal birth. The RR was lower for studies that adjusted for maternal pre-pregnancy weight than for studies that did not (1.29, CI 1.16-1.44 vs. 1.55, CI 1.11-2.17). Studies that examined multiple early life factors reported lower RRs than studies that specifically examined caesarean section (1.39, CI 1.23-1.57 vs. 1.23, CI 0.97-1.56). Effect estimates did not vary by child's age at obesity assessment, study design or country income. Children born by caesarean section are at higher risk of developing obesity in childhood. Findings are limited by a moderate heterogeneity among studies and the potential for residual confounding and publication bias.
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Affiliation(s)
- S Kuhle
- Perinatal Epidemiology Research Unit, Departments of Obstetrics and Gynaecology and Pediatrics, Dalhousie University, Halifax, NS, Canada
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