European Journal of Pediatrics

, Volume 177, Issue 11, pp 1653–1659 | Cite as

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

  • Yael BaumfeldEmail author
  • Asnat Walfisch
  • Tamar Wainstock
  • Idit Segal
  • Ruslan Sergienko
  • Daniella Landau
  • Eyal Sheiner
Original Article


Maternal morbidity is associated with cesarean deliveries. However, new evidence suggests that short- and long-term neonatal morbidity is also associated. This includes respiratory morbidity with conflicting results. To determine whether mode of delivery has an impact on the long-term risk for respiratory morbidity in the offspring, a population-based cohort analysis was conducted including all singleton term deliveries occurring between 1991 and 2014 at a single tertiary medical center. A comparison was performed between children delivered via elective cesarean delivery (CD) and those delivered vaginally. Multiple gestations and fetuses with congenital malformations were excluded from the analysis as were all cases of urgent CDs. Pediatric hospitalizations involving respiratory morbidity of offspring up to the age of 18 years were evaluated. A Kaplan-Meier survival curve was used to compare cumulative respiratory morbidity incidence and a Cox regression model to control for confounders. During the study period, 132,054 term deliveries met the inclusion criteria; 8.9% were via elective CDs (n = 11,746) and 91.1% (n = 120,308) were vaginal deliveries. Hospitalizations of the offspring involving respiratory morbidity were significantly more common in offspring delivered by CDs (5.2 vs. 4.3% in vaginal deliveries, p < 0.001). The Kaplan-Meier survival curve demonstrated a significantly higher cumulative incidence of respiratory morbidity in the elective CD group (log rank p < 0.001). In a Cox proportional hazards model, while controlling for maternal age, gestational age, and birthweight, CD exhibited a significant and independent association with long-term respiratory morbidity of the offspring (adjusted hazard ratio = 1.22 (CI, 1.12–1.33), p < 0.001).

Conclusion: Elective cesarean delivery at term is a significant risk factor for long-term pediatric respiratory morbidity of the offspring.

What is Known:

• Cesarean delivery is a major surgery with known possible complications.

• Cesarean delivery has possible immediate complications for the newborn including respiratory complications.

What is New:

• Our study shows more long term respiratory morbidity in the CD group including asthma and obstructive sleep apnea.

• Different possible explanations have been proposed including exposure to maternal flora during vaginal delivery and the stress hormones secreted during contractions and delivery.


Asthma Mode of delivery Obstructive sleep apnea (OSA) Respiratory morbidity 


Authors’ contributions

All authors contributed to the study, including study design (Walfisch, Sheiner, Landau Baumfeld), data acquisition (Sheiner, Segal, Baumfeld, Wainstock), data analysis (Wainstock, Sergienko), data interpretation (Baumfeld, Walfisch, Landau, Sheiner) and writing the paper (Baumfeld, Walfisch, Sheiner).


The authors state that they do not have a financial relationship and that this research was not funded.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Supplementary material

431_2018_3225_MOESM1_ESM.xlsx (11 kb)
ESM 1 (XLSX 10 kb)


  1. 1.
    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):1369–1376CrossRefGoogle Scholar
  2. 2.
    Bäckhed F, Roswall J, Peng Y et al (2015) Dynamics and stabilization of the human gut microbiome during the first year of life. Cell Host Microbe 17(5):690–703CrossRefGoogle Scholar
  3. 3.
    Bager P, Wohlfahrt J, Westergaard T (2008) Caesarean delivery and risk of atopy and allergic disease: meta-analyses. Clin Exp Allergy 38(4):634–642CrossRefGoogle Scholar
  4. 4.
    Blustein J, Liu J (2015) Time to consider the risks of caesarean delivery for long term child health. BMJ 350:h2410CrossRefGoogle Scholar
  5. 5.
    Breim MC, Segre CA, Lippi UG (2010) Morbidity in neonates according to the mode of delivery: a comparative study. Einstein (São Paulo) 8(3):308–314CrossRefGoogle Scholar
  6. 6.
    Debley JS, Smith JM, Redding GJ, Critchlow CW (2005) Childhood asthma hospitalization risk after cesarean delivery in former term and premature infants. Ann Allergy Asthma Immunol 94(2):228–233CrossRefGoogle Scholar
  7. 7.
    Håkansson S, Källén K (2003) Caesarean section increases the risk of hospital care in childhood for asthma and gastroenteritis. Clin Exp Allergy 33(6):757–764CrossRefGoogle Scholar
  8. 8.
    Hansen AK, Wisborg K, Uldbjerg N, Henriksen TB (2008) Risk of respiratory morbidity in term infants delivered by elective caesarean section: cohort study. BMJ 336(7635):85–87CrossRefGoogle Scholar
  9. 9.
    Heritage CK, Cunningham MD (1985) Association of elective repeat cesarean delivery and persistent pulmonary hypertension of the newborn. Am J Obstet Gynecol 152(6 Pt 1):627–629CrossRefGoogle Scholar
  10. 10.
    Leung JY, Li AM, Leung GM, Schooling CM (2015) Mode of delivery and childhood hospitalizations for asthma and other wheezing disorders. Clin Exp Allergy 45(6):1109–1117CrossRefGoogle Scholar
  11. 11.
    Lynch SV, Pedersen O (2016) The human intestinal microbiome in health and disease. N Engl J Med 375(24):2369–2379CrossRefGoogle Scholar
  12. 12.
    Maitra A, Sherriff A, Strachan D, Henderson J, ALSPAC Study Team (2004) Mode of delivery is not associated with asthma or atopy in childhood. Clin Exp Allergy 34(9):1349–1355CrossRefGoogle Scholar
  13. 13.
    Menezes AMB, Hallal PC, Matijasevich AM et al (2011) Caesarean sections and risk of wheezing in childhood and adolescence: data from two birth cohort studies in Brazil. Clin Exp Allergy 41(2):218–223CrossRefGoogle Scholar
  14. 14.
    Miller JM Jr (1988) Maternal and neonatal morbidity and mortality in cesarean section. Obstet Gynecol Clin N Am 15(4):629–638Google Scholar
  15. 15.
    Molina G, Weiser TG, Lipsitz SR, Esquivel MM, Uribe-Leitz T, Azad T, Shah N, Semrau K, Berry WR, Gawande AA, Haynes AB (2015) Relationship between cesarean delivery rate and maternal and neonatal mortality. JAMA 314(21):2263–2270CrossRefGoogle Scholar
  16. 16.
    Pistiner M, Gold DR, Abdulkerim H, Hoffman E, Celedón JC (2008) Birth by cesarean section, allergic rhinitis, and allergic sensitization among children with parental history of atopy. J Allergy Clin Immunol 122(2):274–279CrossRefGoogle Scholar
  17. 17.
    Renz-Polster H, David MR, Buist AS, Vollmer WM, O’Connor EA, Frazier EA, Wall MA (2005) Caesarean section delivery and the risk of allergic disorders in childhood. Clin Exp Allergy 35(11):1466–1472CrossRefGoogle Scholar
  18. 18.
    Roduit C, Scholtens S, de Jongste JC, Wijga AH, Gerritsen J, Postma DS, Brunekreef B, Hoekstra MO, Aalberse R, Smit HA (2009) Asthma at 8 years of age in children born by caesarean section. Thorax 64(2):107–113CrossRefGoogle Scholar
  19. 19.
    Saccone G, Berghella V (2016) Antenatal corticosteroids for maturity of term or near term fetuses: systematic review and meta-analysis of randomized controlled trials. BMJ 355:i5044CrossRefGoogle Scholar
  20. 20.
    Sonnenschein-van der Voort AM, Arends LR, de Jongste JC et al (2014) Preterm birth, infant weight gain, and childhood asthma risk: a meta-analysis of 147,000 European children. J Allergy Clin Immunol 133(5):1317–1329. CrossRefPubMedPubMedCentralGoogle Scholar
  21. 21.
    Stutchfield P, Whitaker R, Russell I, Antenatal Steroids for Term Elective Cesarean section (ASTECS) Research team (2005) Antenatal betamethasone and incidence of neonatal respiratory distress after elective caesarean section: pragmatic randomized trial. BMJ 331(7518):662CrossRefGoogle Scholar
  22. 22.
    Tamay Z, Akcay A, Kilic G, Suleyman A, Ones U, Guler N (2006) Are physicians aware of obstructive sleep apnea in children? Sleep Med 7(7):580–584CrossRefGoogle Scholar
  23. 23.
    Thavagnanam S, Fleming J, Bromley A, Shields MD, Cardwell CR (2008) A meta-analysis of the association between Caesarean section and childhood asthma. Clin Exp Allergy 38(4):629–633CrossRefGoogle Scholar
  24. 24.
    Tollånes MC, Moster D, Daltveit AK, Irgens LM (2008) Cesarean section and risk of severe childhood asthma: a population-based cohort study. J Pediatr 153(1):112–116CrossRefGoogle Scholar
  25. 25.
    Tun HM, Bridgman SL, Chari R, Field CJ, Guttman DS, Becker AB, Mandhane PJ, Turvey SE, Subbarao P, Sears MR, Scott JA, Kozyrskyj AL, for the Canadian Healthy Infant Longitudinal Development (CHILD) Study Investigators (2018) Roles of birth mode and infant gut microbiota in intergenerational transmission of overweight and obesity from mother to offspring. JAMA Pediatr 172:368–377. CrossRefPubMedGoogle Scholar
  26. 26.
    Walfisch A, Beharier O, Wainstock T, Sergienko R, Landau D, Sheiner E (2017) Early-term deliveries as an independent risk factor for long-term respiratory morbidity of the offspring. Pediatr Pulmonol 52(2):198–204. CrossRefPubMedGoogle Scholar
  27. 27.
    Werner A, Ramlau-Hansen CH, Jeppesen SK, Thulstrup AM, Olsen J (2007) Caesarean delivery and risk of developing asthma in the offspring. Acta Paediatr 96(4):595–596CrossRefGoogle Scholar
  28. 28.
    Yu M, Han K, Kim DH, Nam GE (2015) Atopic dermatitis is associated with Caesarean sections in Korean adolescents, but asthma is not. Acta Paediatr 104(12):1253–1258CrossRefGoogle Scholar
  29. 29.
    Zainal N, Rahardja A, Faris Irfan CY, Nasir A, Wan Pauzi WI, Mohamad Ikram I, Van Rostenberghe H (2016) Prevalence of asthma-like symptoms and assessment of lung function in schoolchildren born with low birth weight. Singap Med J 57(12):690–693. CrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of Obstetrics and Gynecology, Soroka University Medical CenterBen-Gurion University of the NegevBeer ShevaIsrael
  2. 2.The Clinical Research Center, Soroka University Medical CenterBen-Gurion University of the NegevBeer-ShevaIsrael
  3. 3.Department of Public Health, Faculty of Health SciencesBen-Gurion University of the NegevBeer-ShevaIsrael
  4. 4.Ministry of HealthJerusalemIsrael
  5. 5.Department of Neonatology, Soroka University Medical CenterBen-Gurion University of the NegevBeer-ShevaIsrael

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