Social Psychiatry and Psychiatric Epidemiology

, Volume 50, Issue 10, pp 1557–1567 | Cite as

The impact of obstetric mode of delivery on childhood behavior

  • Sukainah Y. Al Khalaf
  • Sinéad M. O’Neill
  • Linda M. O’Keeffe
  • Tine B. Henriksen
  • Louise C. Kenny
  • John F. Cryan
  • Ali S. Khashan
Original Paper



We investigated the hypothesis that mode of delivery affects childhood behavior and motor development and examined whether there are sex-specific associations, i.e., whether males and females have different risk estimates.


Families with infants born between December 2007 and May 2008 (N = 11,134) were randomly selected and recruited to the Growing Up in Ireland study. Mode of delivery was classified into spontaneous vaginal delivery; instrumental vaginal delivery; emergency Cesarean section (CS); and elective CS. The ‘Ages and Stages Questionnaire’ was completed at age 9-months and the ‘Strengths and Difficulties Questionnaire’ at 3 years. Data were weighted to represent the national sample (N = 73,662) and multivariate logistic regression was used for the statistical analyses.


At age 9 months, elective CS was associated with a delay in personal social skills [adjusted odds ratio, aOR 1.24; (95 % confidence interval, CI 1.04, 1.48)] and gross motor function [aOR 1.62, (95 % CI 1.34, 1.96)], whereas emergency CS was associated with delayed gross motor function [aOR 1.30, (95 % CI 1.06, 1.59)]. At age 3 years there was no significantly increased risk of an abnormal total SDQ score across all modes of delivery.


Children born by elective CS may face a delay in cognitive and motor development at age 9 months. No increase in total SDQ score was found across all modes of delivery. Further investigation is needed to replicate these findings in other populations and explore the potential biological mechanisms.


Cesarean section Obstetric mode of delivery Childhood behavioral problems Behavioral development Cognitive skills 

Supplementary material

127_2015_1055_MOESM1_ESM.docx (23 kb)
Supplementary material 1 (DOCX 22 kb)


  1. 1.
    Karlström A, Lindgren H, Hildingsson I (2013) Maternal and infant outcome after caesarean section without recorded medical indication: findings from a Swedish case–control study. BJOG Int J Obstet GynaecolGoogle Scholar
  2. 2.
    Waldenstrom U, Hildingsson I, Ryding EL (2006) Antenatal fear of childbirth and its association with subsequent caesarean section and experience of childbirth. BJOG Int J Obstet Gynaecol 113(6):638–646CrossRefGoogle Scholar
  3. 3.
    Barber EL, Lundsberg LS, Belanger K, Pettker CM, Funai EF, Illuzzi JL (2011) Indications contributing to the increasing cesarean delivery rate. Obstet Gynecol 118(1):29–38PubMedCentralCrossRefPubMedGoogle Scholar
  4. 4.
    Räisänen S, Gissler M, Kramer MR, Heinonen S (2014) Influence of delivery characteristics and socioeconomic status on giving birth by caesarean section-a cross sectional study during 2000-2010 in Finland. BMC Pregnancy Childbirth 14(1):120PubMedCentralCrossRefPubMedGoogle Scholar
  5. 5.
    Lavender T, Hofmeyr GJ, Neilson James P, Kingdon C, Gyte Gillian ML (2012) Caesarean section for non-medical reasons at term. Cochrane database of systematic reviews 3:CD004660.
  6. 6.
    Roberts CL, Algert CS, Ford JB, Todd AL, Morris JM (2012) Pathways to a rising caesarean section rate: a population-based cohort study. BMJ open 2(5)Google Scholar
  7. 7.
    Ventura SJ, Martin JA, Curtin SC, Mathews T (1999) Births: final data for 1997. Natl Vital Stat Rep 47(18):1–96Google Scholar
  8. 8.
    Hamilton BE, Hoyert DL, Martin JA, Strobino DM, Guyer B (2013) Annual summary of vital statistics: 2010–2011. Pediatrics 131(3):548–558CrossRefPubMedGoogle Scholar
  9. 9.
    Lavender T, Hofmeyr GJ, Neilson JP, Kingdon C, Gyte GM (2012) Caesarean section for non-medical reasons at term. Cochrane Database Syst Rev 3(3)Google Scholar
  10. 10.
    Rutter M, Bishop D, Pine D et al (2011) Rutter’s child and adolescent psychiatry. Wiley, New yorkGoogle Scholar
  11. 11.
    Goodman R, Ford T, Simmons H, Gatward R, Meltzer H (2003) Using the Strengths and Difficulties Questionnaire (SDQ) to screen for child psychiatric disorders in a community sample. Int Rev Psychiatry 15(1–2):166–172CrossRefPubMedGoogle Scholar
  12. 12.
    Knapp M, Romeo R, Beecham J (2009) Economic cost of autism in the UK. Autism 13(3):317–336CrossRefPubMedGoogle Scholar
  13. 13.
    Van Loo K, Martens G (2007) Genetic and environmental factors in complex neurodevelopmental disorders. Curr Genomics 8(7):429PubMedCentralCrossRefPubMedGoogle Scholar
  14. 14.
    Desbonnet L, Clarke G, Shanahan F, Dinan T, Cryan J (2013) Microbiota is essential for social development in the mouse. Mol Psychiatry 19:146–148PubMedCentralCrossRefPubMedGoogle Scholar
  15. 15.
    Sudo N, Chida Y, Aiba Y et al (2004) Postnatal microbial colonization programs the hypothalamic–pituitary–adrenal system for stress response in mice. J Physiol 558(1):263–275PubMedCentralCrossRefPubMedGoogle Scholar
  16. 16.
    Dominguez-Bello MG, Costello EK, Contreras M et al (2010) Delivery mode shapes the acquisition and structure of the initial microbiota across multiple body habitats in newborns. Proc Natl Acad Sci 107(26):11971–11975PubMedCentralCrossRefPubMedGoogle Scholar
  17. 17.
    Mulle JG, Sharp WG, Cubells JF (2013) The Gut Microbiome: a New Frontier in Autism Research. Curr Psychiatry Rep 15(2):1–9CrossRefGoogle Scholar
  18. 18.
    Kelmanson IA (2013) Emotional and behavioural features of preschool children born by Caesarean deliveries at maternal request. Eur J Dev Psychol 1–15 (ahead-of-print)Google Scholar
  19. 19.
    Li HT, Ye R, Achenbach T et al (2011) Caesarean delivery on maternal request and childhood psychopathology: a retrospective cohort study in China. BJOG Int J Obstet Gynaecol 118(1):42–48CrossRefGoogle Scholar
  20. 20.
    MacKay DF, Smith G, Dobbie R, Pell JP (2010) Gestational age at delivery and special educational need: retrospective cohort study of 407,503 school children. PLoS Med 7(6):e1000289PubMedCentralCrossRefPubMedGoogle Scholar
  21. 21.
    Azad MB, Konya T, Maughan H et al (2013) Gut microbiota of healthy Canadian infants: profiles by mode of delivery and infant diet at 4 months. Can Med Assoc J 185(5):385–394CrossRefGoogle Scholar
  22. 22.
    Gardener H, Spiegelman D, Buka SL (2011) Perinatal and neonatal risk factors for autism: a comprehensive meta-analysis. Pediatrics 128(2):344–355PubMedCentralCrossRefPubMedGoogle Scholar
  23. 23.
    Glasson EJ, Bower C, Petterson B, de Klerk N, Chaney G, Hallmayer JF (2004) Perinatal factors and the development of autism—a population study. Arch Gen Psychiatry 61(6):618–627CrossRefPubMedGoogle Scholar
  24. 24.
    McCrory C, Murray A (2013) The effect of breastfeeding on neuro-development in infancy. Matern Child Health J 17(9):1680–1688CrossRefPubMedGoogle Scholar
  25. 25.
    Kelly D, O’Dowd T, Reulbach U (2012) Use of folic acid supplements and risk of cleft lip and palate in infants: a population-based cohort study. Br J Gen Pract 62(600):e466–e472PubMedCentralCrossRefPubMedGoogle Scholar
  26. 26.
    Castro PD, Kearney J, Layte R (2014) A study of early complementary feeding determinants in the Republic of Ireland based on a cross-sectional analysis of the Growing Up in Ireland infant cohort. Public health nutrition 1–11Google Scholar
  27. 27.
    Williams J, Greene S, McNally S, Murray A, Quail A (2010) Growing up in Ireland national longitudinal study of children. The infants and their families. The Stationery OfficeGoogle Scholar
  28. 28.
    Murray A, McNally S, Williams J, Mc Crory C (2013) Growing Up In Ireland: development from birth to three yearsGoogle Scholar
  29. 29.
    Theunissen MHC, Vogels AGC, de Wolff MS, Reijneveld SA (2013) Characteristics of the Strengths and Difficulties Questionnaire in preschool children. Pediatrics 131(2):e446–e454CrossRefPubMedGoogle Scholar
  30. 30.
    Squires J, Potter L, Bricker D (1995) The ASQ user’s guide for the Ages & Stages Questionnaires: A parent-completed, child-monitoring system. Paul H Brookes Publishing, TowsonGoogle Scholar
  31. 31.
    Squires J, Bricker D, Potter L (1997) Revision of a parent-completed developmental screening tool: ages and Stages Questionnaires. J Pediatr Psychol 22(3):313–328CrossRefPubMedGoogle Scholar
  32. 32.
    Albers CA, Grieve AJ (2007) Review of Bayley scales of infant and toddler developmentGoogle Scholar
  33. 33.
    American Academy of Pediatrics COCWD (2001) Developmental surveillance and screening of infants and young children. Pediatrics 118(1):192–196Google Scholar
  34. 34.
    Goodman R (2001) Psychometric properties of the strengths and difficulties questionnaire. J Am Acad Child Adolesc Psychiatry 40(11):1337–1345CrossRefPubMedGoogle Scholar
  35. 35.
    Vostanis P (2006) Strengths and Difficulties Questionnaire: research and clinical applications. Curr Opin Psychiatry 19(4):367–372CrossRefPubMedGoogle Scholar
  36. 36.
    Goodman R (1997) The Strengths and Difficulties Questionnaire: a research note. J Child Psychol Psychiatry 38(5):581–586CrossRefPubMedGoogle Scholar
  37. 37.
    Goodman R (1999) The extended version of the Strengths and Difficulties Questionnaire as a guide to child psychiatric caseness and consequent burden. J Child Psychol Psychiatry 40(5):791–799CrossRefPubMedGoogle Scholar
  38. 38.
    Goodman R, Ford T, Simmons H, Gatward R, Meltzer H (2000) Using the Strengths and Difficulties Questionnaire (SDQ) to screen for child psychiatric disorders in a community sample. The British Journal of Psychiatry. 177(6):534–539CrossRefPubMedGoogle Scholar
  39. 39.
    Goodman R, Ford T, Corbin T, Meltzer H (2004) Using the Strengths and Difficulties Questionnaire (SDQ) multi-informant algorithm to screen looked-after children for psychiatric disorders. Eur Child Adolesc Psychiatry 13(2):ii25–ii31PubMedGoogle Scholar
  40. 40.
    Mullick MSI, Goodman R (2001) Questionnaire screening for mental health problems in Bangladeshi children: a preliminary study. Soc Psychiatry Psychiatr Epidemiol 36(2):94–99CrossRefPubMedGoogle Scholar
  41. 41.
    Glazebrook C, Hollis C, Heussler H, Goodman R, Coates L (2003) Detecting emotional and behavioural problems in paediatric clinics. Child Care Health Dev 29(2):141–149CrossRefPubMedGoogle Scholar
  42. 42.
    Heikkilä K, Sacker A, Kelly Y, Renfrew MJ, Quigley MA (2011) Breast feeding and child behaviour in the Millennium Cohort Study. Arch Dis Child 96(7):635–642CrossRefPubMedGoogle Scholar
  43. 43.
    Kelly Y, Sacker A, Gray R, Kelly J, Wolke D, Quigley MA (2009) Light drinking in pregnancy, a risk for behavioural problems and cognitive deficits at 3 years of age? Int J Epidemiol 38(1):129–140CrossRefPubMedGoogle Scholar
  44. 44.
    Berry JO, Jones WH (1995) The parental stress scale: initial psychometric evidence. J Soc Pers Relat 12(3):463–472CrossRefGoogle Scholar
  45. 45.
    Condon JT, Corkindale CJ (1998) The assessment of parent-to-infant attachment: development of a self-report questionnaire instrument. J Reprod Infant Psychol 16(1):57–76CrossRefGoogle Scholar
  46. 46.
    Maldonado G, Greenland S (1993) Simulation study of confounder-selection strategies. Am J Epidemiol 138(11):923–936PubMedGoogle Scholar
  47. 47.
    Zanardo V, Svegliado G, Cavallin F et al (2010) Elective cesarean delivery: does it have a negative effect on breastfeeding? Birth 37(4):275–279CrossRefPubMedGoogle Scholar
  48. 48.
    Whyte H, Hannah ME, Saigal S et al (2004) Outcomes of children at 2 years after planned cesarean birth versus planned vaginal birth for breech presentation at term: the International Randomized Term Breech Trial. Am J Obstet Gynecol 191(3):864–871CrossRefPubMedGoogle Scholar
  49. 49.
    Molkenboer J, Roumen F, Smits L, Nijhuis J (2006) Birth weight and neurodevelopmental outcome of children at 2 years of age after planned vaginal delivery for breech presentation at term. Am J Obstet Gynecol 194(3):624–629CrossRefPubMedGoogle Scholar
  50. 50.
    Kulie T, Slattengren A, Redmer J, Counts H, Eglash A, Schrager S (2011) Obesity and women’s health: an evidence-based review. J Am Board Fam Med 24(1):75–85CrossRefPubMedGoogle Scholar
  51. 51.
    Goodman R, Scott S (1999) Comparing the Strengths and Difficulties Questionnaire and the Child Behavior Checklist: is small beautiful? J Abnorm Child Psychol 27(1):17–24CrossRefPubMedGoogle Scholar
  52. 52.
    Klasen H, Woerner W, Wolke D et al (2000) Comparing the German versions of the strengths and difficulties questionnaire (SDQ-Deu) and the child behavior checklist. Eur Child Adolesc Psychiatry 9(4):271–276CrossRefPubMedGoogle Scholar
  53. 53.
    Quigley M, Hockley C, Davidson L (2007) Agreement between hospital records and maternal recall of mode of delivery: evidence from 12 391 deliveries in the UK Millennium Cohort Study. BJOG Int J Obstet Gynaecol 114(2):195–200CrossRefGoogle Scholar
  54. 54.
    Ryding EL, Wijma K, Wijma B (1998) Psychological impact of emergency cesarean section in comparison with elective cesarean section, instrumental and normal vaginal delivery. J Psychosom Obstet Gynaecol 19(3):135–144CrossRefPubMedGoogle Scholar
  55. 55.
    Jolly J, Walker J, Bhabra K (1999) Subsequent obstetric performance related to primary mode of delivery. BJOG Int J Obstet Gynaecol 106(3):227–232CrossRefGoogle Scholar
  56. 56.
    English J (1994) Being born Caesarean: physical and psychosocial aspects. Int J Prenat Perinatal Psychol Med 6(3):381–394Google Scholar
  57. 57.
    Verdult R (2009) Caesarean Birth: Psychological Aspects in Adults. Int J Prenat Perinatal Psychol Med 21(1/2):17–36Google Scholar
  58. 58.
    Almqvist C, Cnattingius S, Lichtenstein P, Lundholm C (2012) The impact of birth mode of delivery on childhood asthma and allergic diseases—a sibling study. Clin Exp Allergy 42(9):1369–1376PubMedCentralCrossRefPubMedGoogle Scholar
  59. 59.
    Kenny LC, Lavender T, McNamee R, O’Neill SM, Mills T, Khashan AS (2013) Advanced maternal age and adverse pregnancy outcome: evidence from a large contemporary cohort. PLoS One 8(2):e56583PubMedCentralCrossRefPubMedGoogle Scholar
  60. 60.
    Dahlen HG, Tracy S, Tracy M, Bisits A, Brown C, Thornton C (2014) Rates of obstetric intervention and associated perinatal mortality and morbidity among low-risk women giving birth in private and public hospitals in NSW (2000–2008): a linked data population-based cohort study. BMJ open 4(5):e004551PubMedCentralCrossRefPubMedGoogle Scholar
  61. 61.
    O’Neill SM, Khashan AS, Henriksen TB et al (2014) Does a Caesarean section increase the time to a second live birth? A register-based cohort study. Hum Reprod 29:2560–2568CrossRefPubMedGoogle Scholar
  62. 62.
    Nilsson C, Lundgren I, Karlström A, Hildingsson I (2012) Self reported fear of childbirth and its association with women’s birth experience and mode of delivery: a longitudinal population-based study. Women Birth 25(3):114–121CrossRefPubMedGoogle Scholar
  63. 63.
    Psaty BM, Koepsell TD, Lin D et al (1999) Assessment and control for confounding by indication in observational studies. J Am Geriatr Soc 47:749–754CrossRefPubMedGoogle Scholar
  64. 64.
    Freemantle N, Marston L, Walters K, Wood J, Reynolds MR, Petersen I (2013) Making inferences on treatment effects from real world data: propensity scores, confounding by indication, and other perils for the unwary in observational research. BMJ 347:f6409CrossRefPubMedGoogle Scholar
  65. 65.
    Khashan A, Everard C, McCowan L et al (2014) Second-trimester maternal distress increases the risk of small for gestational age. Psychol Med 1–12Google Scholar
  66. 66.
    Li J, Olsen J, Vestergaard M, Obel C (2010) Attention-deficit/hyperactivity disorder in the offspring following prenatal maternal bereavement: a nationwide follow-up study in Denmark. Eur Child Adolesc Psychiatry 19(10):747–753CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2015

Authors and Affiliations

  • Sukainah Y. Al Khalaf
    • 1
  • Sinéad M. O’Neill
    • 2
    • 3
  • Linda M. O’Keeffe
    • 1
    • 2
  • Tine B. Henriksen
    • 4
  • Louise C. Kenny
    • 3
  • John F. Cryan
    • 5
  • Ali S. Khashan
    • 1
    • 3
  1. 1.Department of Epidemiology and Public HealthUniversity College CorkCorkIreland
  2. 2.Department of Obstetrics and Gynaecology, National Perinatal Epidemiology Centre (NPEC)Cork University Maternity HospitalCorkIreland
  3. 3.Department of Obstetrics and Gynaecology, The Irish Centre for Fetal and Neonatal Translational Research (INFANT)University College CorkCorkIreland
  4. 4.Perinatal Epidemiology Research Unit, Department of PediatricsAarhus University HospitalSkejbyDenmark
  5. 5.Department of Anatomy and Neuroscience, Alimentary Pharmabiotic CentreUniversity College CorkCorkIreland

Personalised recommendations