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Elective cesarean delivery at term and the long-term risk for endocrine and metabolic morbidity of the offspring

  • R. Moshkovsky (a1), T. Wainstock (a2), E. Sheiner (a3), D. Landau (a4) and A. Walfisch (a3)...


Other than obesity, no definitive insights have been gained regarding the apparent association between mode of delivery and long-term endocrine and metabolic outcomes in the offspring. We aimed to determine whether elective cesarean delivery (CD) impacts on long-term endocrine and metabolic morbidity of the offspring. A population-based cohort analysis was performed including all singleton-term deliveries occurring between 1991 and 2014 at a single tertiary medical center. A comparison was performed between children delivered via a non-emergent CD and those delivered vaginally (VD). Hospitalizations of the offspring up to the age of 18 years involving endocrine morbidity were evaluated. A Kaplan–Meier survival curve was used to compare cumulative morbidity incidence. Cox and a Weibull regression models were used to control for confounders. During the study period 131,880 term deliveries met the inclusion criteria; 8.9% were elective non-urgent CDs (n=11,768) and 91.1% (n=120,112) were VDs. The survival curve demonstrated a significantly higher cumulative incidence of endo-metabolic morbidity in offspring born via CD (P=0.010). In the regression models, adjusted for maternal obesity, CD was not noted as an independent risk factor for long-term pediatric endocrine and metabolic morbidity of the offspring while maternal obesity emerged as a strong predictor. We therefore conclude that CD per-se does not appear to increase the risk for long-term pediatric endo-metabolic morbidity of the offspring.


Corresponding author

Address for correspondence: Ran Moshkovsky, The Joyce and Irving Goldman Medical School, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva 8410501, Israel. E-mail:


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Presented in part at the 38th annual SMFM meeting, Dallas, Texas, USA, January 2017.



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1.Yuan, C, Gaskins, AJ, Blaine, AI, et al. Association between cesarean birth and risk of obesity in offspring in childhood, adolescence, and early adulthood. JAMA Pediatr. 2016; e162385e162385.
2.Martin, JA, Hamilton, BE, Osterman, MJ. Births in the United States, 2013. NCHS Data Brief. 2014; 175, 18.
3.Indicators, O. Health at a glance 2011. OECD Indicators; 2015. OECD Publishing: Paris. Retrieved 15 February 2016 from
4.Liu, S, Liston, RM, Joseph, KS, et al. Maternal mortality and severe morbidity associated with low-risk planned cesarean delivery versus planned vaginal delivery at term. CMAJ. 2007; 176, 455460.
5.Hansen, AK, Wisborg, K, Uldbjerg, N, Henriksen, TB. Risk of respiratory morbidity in term infants delivered by elective caesarean section: Cohort study. BMJ. 2008; 336, 8587.
6.Li, H, Zhou, Y, Liu, J. The impact of cesarean section on offspring overweight and obesity: a systematic review and meta-analysis. Int J Obes. 2013; 37, 893899.
7.Darmasseelane, K, Hyde, MJ, Santhakumaran, S, Gale, C, Modi, N. Mode of delivery and offspring body mass index, overweight and obesity in adult life: a systematic review and meta-analysis. PLoS One. 2014; 9, e87896.
8.Hansen, S, Halldorsson, T, Olsen, S, et al. Birth by cesarean section in relation to adult offspring overweight and biomarkers of cardiometabolic risk. Int J Obes. 2018; 42, 1519.
9.Cani, PD. Crosstalk between the gut microbiota and the endocannabinoid system: impact on the gut barrier function and the adipose tissue. Clin Microbiol Infect. 2012; 18, 5053.
10.Azad, M, Konya, T, Persaud, R, et al. Impact of maternal intrapartum antibiotics, method of birth and breastfeeding on gut microbiota during the first year of life: a prospective cohort study. BJOG. 2016; 123, 983993.
11.Adlerberth, I, Lindberg, E, Åberg, N, et al. Reduced enterobacterial and increased staphylococcal colonization of the infantile bowel: an effect of hygienic lifestyle? Pediatr Res. 2006; 59, 96101.
12.Dominguez-Bello, MG, Costello, EK, Contreras, M, et al. Delivery mode shapes the acquisition and structure of the initial microbiota across multiple body habitats in newborns. Proc Natl Acad Sci U S A. 2010; 107, 1197111975.
13.Musso, G, Gambino, R, Cassader, M. Obesity, diabetes, and gut microbiota: the hygiene hypothesis expanded? Diabetes Care. 2010; 33, 22772284.
14.Sevelsted, A, Stokholm, J, Bonnelykke, K, Bisgaard, H. Cesarean section and chronic immune disorders. Pediatrics. 2015; 135, e92e98.
15.Kulas, T, Bursac, D, Zegarac, Z, Planinic-Rados, G, Hrgovic, Z. New views on cesarean section, its possible complications and long-term consequences for children’s health. Med Arch. 2013; 67, 460463.
16.WHO multicentre growth reference study group. WHO child growth standards: length/height-for-age, weight-for-age, weight-for-length, weight-for-height and body mass index-for-age: methods and development. 2006. pp. 312. World Health Organization: Geneva.
17.Achoki, R, Opiyo, N, English, M. Mini-review: management of hypoglycaemia in children aged 0–59 months. J Trop Pediatr. 2009; 56, 227234.
18.Gavin, JR III, Alberti, K, Davidson, MB, DeFronzo, RA. Report of the expert committee on the diagnosis and classification of diabetes mellitus. Diabetes Care. 1997; 20, 11831197.
19.American Academy of Pediatrics, Rose SR, Section on Endocrinology and Committee on Genetics, American Thyroid Association, et al . Update of newborn screening and therapy for congenital hypothyroidism. Pediatrics. 2006; 117, 22902303.
20.Lem, AJ, de Rijke, YB, van Toor, H, et al. Serum thyroid hormone levels in healthy children from birth to adulthood and in short children born small for gestational age. J Clin Endocrinol Metabol. 2012; 97, 31703178.
21.Tun, HM, Bridgman, SL, Chari, R, et al. Roles of birth mode and infant gut microbiota in intergenerational transmission of overweight and obesity from mother to offspring. JAMA Pediatri. 2018; 172, 368377.
22.Li, HT, Zhou, YB, Liu, JM. Cesarean section might moderately increase offspring obesity risk. Am J Clin Nutr. 2012; 96, 215216, author reply 216.
23.Lynch, SV, Pedersen, O. The human intestinal microbiome in health and disease. N Engl J Med. 2016; 375, 23692379.
24.Musso, G, Gambino, R, Cassader, M. Statements obesity, diabetes, and gut microbiota the hygiene hypothesis expanded? Diabetes Care. 2010; 33, 22772284.
25.Neu, J, Rushing, J. Cesarean versus vaginal delivery: long-term infant outcomes and the hygiene hypothesis. Clin Perinatol. 2011; 38, 321331.
26.Kumari, M, Kozyrskyj, A. Gut microbial metabolism defines host metabolism: an emerging perspective in obesity and allergic inflammation. Obes Rev. 2017; 18, 1831.
27.Cho, I, Yamanishi, S, Cox, L, et al. Antibiotics in early life alter the murine colonic microbiome and adiposity. Nature. 2012; 488, 621626.
28.Poroyko, VA, Carreras, A, Khalyfa, A, et al. Chronic sleep disruption alters gut microbiota, induces systemic and adipose tissue inflammation and insulin resistance in mice. Sci Rep. 2016; 6, 35405.
29.Gitau, R, Menson, E, Pickles, V, et al. Umbilical cortisol levels as an indicator of the fetal stress response to assisted vaginal delivery. Eur J Obstet Gynecol Reprod Biol. 2001; 98, 1417.
30.Nikischin, W, Peter, M, Oldigs, HD. The influence of mode of delivery on hematologic values in the umbilical vein. Gynecol Obstet Invest. 1997; 43, 104107.
31.Dahlquist, G, Källén, B. Maternal-child blood group incompatibility and other perinatal events increase the risk for early-onset type 1 (insulin-dependent) diabetes mellitus. Diabetologia. 1992; 35, 671675.
32.GBD. 2015 obesity collaborators. Health effects of overweight and obesity in 195 countries over 25 years. N Engl J Med. 2017; 377, 1327.
33.Best, D, Bhattacharya, S. Obesity and fertility. Horm Mol Biol Clin Investig. 2015; 24, 510.
34.Zain, MM, Norman, RJ. Impact of obesity on female fertility and fertility treatment. Women’s Health. 2008; 4, 183194.
35.Pantasri, T, Norman, RJ. The effects of being overweight and obese on female reproduction: a review. Gynecol Endocrinol. 2014; 30, 9094.
36.Bellver, J, Melo, MA, Bosch, E, et al. Obesity and poor reproductive outcome: the potential role of the endometrium. Fertil Steril. 2007; 88, 446451.
37.Lubchenco, LO, Bard, H. Incidence of hypoglycemia in newborn infants classified by birth weight and gestational age. Pediatrics. 1971; 47, 831838.
38.Stanley, CA, Baker, L. The causes of neonatal hypoglycemia. N Engl J Med. 1999; 340, 12001201.
39.Chu, DM, Ma, J, Prince, AL, et al. Maturation of the infant microbiome community structure and function across multiple body sites and in relation to mode of delivery. Nat Med. 2017; 23, 314326.
40.Azad, MB, Konya, T, Maughan, H, et al. Gut microbiota of healthy Canadian infants: profiles by mode of delivery and infant diet at 4 months. CMAJ. 2013; 185, 385394.
41.Guise, J, Denman, MA, Emeis, C, et al. Vaginal birth after cesarean: new insights on maternal and neonatal outcomes. Obstet Gynecol. 2010; 115, 12671278.
42.Koenig, JE, Spor, A, Scalfone, N, et al. Succession of microbial consortia in the developing infant gut microbiome. Proc Natl Acad Sci U S A. 2011; 108(Suppl. 1), 45784585.
43.David, LA, Maurice, CF, Carmody, RN, et al. Diet rapidly and reproducibly alters the human gut microbiome. Nature. 2014; 505, 559563.
44.Jukes, TH. Antibiotics in animal feeds and animal production. Bioscience. 1972; 22, 526534.
45.Lin, J. Effect of antibiotic growth promoters on intestinal microbiota in food animals: a novel model for studying the relationship between gut microbiota and human obesity? Front Microbiol. 2011; 2, 53.
46.Jost, T, Lacroix, C, Braegger, CP, Rochat, F, Chassard, C. Vertical mother–neonate transfer of maternal gut bacteria via breastfeeding. Environ Microbiol. 2014; 16, 28912904.


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