Association of Elective and Emergency Cesarean Delivery With Early Childhood Overweight at 12 Months of Age | Obesity | JAMA Network Open | JAMA Network
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    Original Investigation
    November 21, 2018

    Association of Elective and Emergency Cesarean Delivery With Early Childhood Overweight at 12 Months of Age

    Author Affiliations
    • 1Duke-NUS Medical School, Singapore, Singapore
    • 2Department of Reproductive Medicine, KK Women’s and Children’s Hospital, Singapore, Singapore
    • 3Department of Maternal Fetal Medicine, KK Women’s and Children’s Hospital, Singapore, Singapore
    • 4Medical Research Council Lifecourse Epidemiology Unit, University of Southampton, Southampton, United Kingdom
    • 5National Institute for Health Research Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton National Health Service Foundation Trust, Southampton, United Kingdom
    • 6Liggins Institute, University of Auckland, Auckland, New Zealand
    • 7Brenner Centre for Molecular Medicine, Singapore Institute for Clinical Sciences, Agency for Science, Technology and Research, Singapore, Singapore
    • 8Department of Obstetrics & Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
    • 9Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
    • 10Khoo Teck Puat-National University Children’s Medical Institute, National University Hospital, National University Health System, Singapore, Singapore
    • 11Center for Quantitative Medicine, Duke-NUS Medical School, Singapore, Singapore
    • 12Tampere Center for Child Health Research, University of Tampere and Tampere University Hospital, Tampere, Finland
    • 13Department of Paediatrics, KK Women’s and Children’s Hospital, Singapore, Singapore
    • 14Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
    • 15Yong Loo Lin School of Medicine, National University of Singapore, Singapore
    • 16Family Medicine Service, KK Women’s and Children’s Hospital, Singapore, Singapore
    JAMA Netw Open. 2018;1(7):e185025. doi:10.1001/jamanetworkopen.2018.5025
    Key Points español 中文 (chinese)

    Question  Are elective and emergency cesarean delivery both associated with risk of childhood overweight at age 12 months?

    Findings  In this cohort study that analyzed 727 mother-child pairs, elective cesarean delivery was significantly associated with high body mass index–for–age z score at 12 months. Emergency cesarean delivery was not significantly associated with high body mass index–for–age z score at 12 months.

    Meaning  Choice of delivery mode may influence risk of early childhood overweight, which is a concern clinicians may discuss with patients who intend to have children.


    Importance  Global cesarean delivery (CD) rates have more than doubled over the past 2 decades, with an increasing contribution from elective CDs. Cesarean delivery has been linked to early childhood overweight and obesity, but limited studies have examined elective and emergency CDs separately.

    Objective  To investigate whether elective or emergency CD was associated with risk of early childhood overweight.

    Design, Setting, and Participants  Data were drawn from the Growing Up in Singapore Toward Healthy Outcomes (GUSTO) study, an ongoing prospective mother-child birth cohort study. Participants were pregnant women aged 18 years or older with homogeneous parental ethnic background in their first trimester recruited between June 2009 and September 2010 (n = 1237) at 2 major public hospitals in Singapore. Those with type 1 diabetes or undergoing chemotherapy or psychotropic drug treatment were excluded. Data analysis commenced in October 2017.

    Exposures  Delivery mode obtained from clinical records. Elective and emergency CD examined separately against vaginal delivery as reference.

    Main Outcomes and Measures  Body mass index–for–age z scores at age 12 months calculated based on 2006 World Health Organization Child Growth Standards from infant weight and recumbent crown-heel length measurements taken between December 2010 and April 2012. High body mass index status at risk of overweight was defined as a z score of more than 1 SD and less than or equal to 2 SDs. Overweight was defined as a z score of more than 2 SDs.

    Results  Among 727 infants analyzed (51.2% [372] male), 30.5% (222) were born via CD, of which 33.3% (74) were elective. Prevalence of at risk of overweight and overweight at age 12 months was 12.2% (89) and 2.3% (17), respectively. Elective CD was significantly associated with at risk of overweight or overweight at age 12 months after adjusting for maternal ethnicity, age, education, parity, body mass index, antenatal smoking, hypertensive disorders of pregnancy, gestational diabetes, and sex-adjusted birth weight–for–gestational age (odds ratio, 2.05; 95% CI, 1.08-3.90; P = .03). The association persisted after further adjustment for intrapartum antibiotics and first 6 months infant feeding, 2 potential mediators of early childhood overweight and obesity (odds ratio, 2.02; 95% CI, 1.05-3.89; P = .04). No significant associations were found for emergency CD. Analysis with multiple imputation for missing covariates yielded similar results.

    Conclusions and Relevance  Choice of delivery mode may influence risk of early childhood overweight. Clinicians are encouraged to discuss potential long-term implications of elective CD on child metabolic outcomes with patients who intend to have children.