Elsevier

The Lancet

Volume 392, Issue 10155, 13–19 October 2018, Pages 1349-1357
The Lancet

Series
Short-term and long-term effects of caesarean section on the health of women and children

https://doi.org/10.1016/S0140-6736(18)31930-5Get rights and content

Summary

A caesarean section (CS) can be a life-saving intervention when medically indicated, but this procedure can also lead to short-term and long-term health effects for women and children. Given the increasing use of CS, particularly without medical indication, an increased understanding of its health effects on women and children has become crucial, which we discuss in this Series paper. The prevalence of maternal mortality and maternal morbidity is higher after CS than after vaginal birth. CS is associated with an increased risk of uterine rupture, abnormal placentation, ectopic pregnancy, stillbirth, and preterm birth, and these risks increase in a dose–response manner. There is emerging evidence that babies born by CS have different hormonal, physical, bacterial, and medical exposures, and that these exposures can subtly alter neonatal physiology. Short-term risks of CS include altered immune development, an increased likelihood of allergy, atopy, and asthma, and reduced intestinal gut microbiome diversity. The persistence of these risks into later life is less well investigated, although an association between CS use and greater incidence of late childhood obesity and asthma are frequently reported. There are few studies that focus on the effects of CS on cognitive and educational outcomes. Understanding potential mechanisms that link CS with childhood outcomes, such as the role of the developing neonatal microbiome, has potential to inform novel strategies and research for optimising CS use and promote optimal physiological processes and development.

Introduction

Although caesarean section (CS) can be a life-saving intervention for mothers and children, it can also lead to short-term and long-term health consequences. Greater understanding of how the mode of birth can affect longer term health outcomes for women and children is crucial to inform decision making by clinicians, women, and policy makers, considering the very different circumstances and varied risks between low-resource and high-resource settings.

The Right Care Series1, 2, 3 created a framework for understanding overuse and underuse of medical interventions and drivers of poor care around the world. Right care was defined as “care that weighs up benefits and harms, is patient-centred (taking individual circumstances, values, and wishes into account), and is informed by evidence, including cost-effectiveness”.4 CS is an example of a medical intervention that is underused in some low-resource settings and overused in many parts of the world.5 The first paper6 in this Series on Optimising Caesarean Section Use6, 7 showed that, globally, CS use is high and increasing: in 2015, an estimated 29·7 million (21·1%) births occurred by CS, which was almost double the proportion in 2000 (12·1%). WHO has estimated that 6·2 million excess—ie, not medically indicated—CSs are being performed each year, 50% of which are in Brazil and China alone.8 However, there is ongoing debate around the optimal frequency of CS use.9

Previous reviews10, 11, 12, 13 have examined the specific effects of CS for non-medical reasons and for women with previous CS, preterm birth, and term breech. However, to our knowledge, there is no published overview that has collated and summarised the evidence to include an analysis of the short-term and long-term health effects of CS on women and children. There are benefits of CS for maternal and infant health, but our focus here is instead on the effects of increasing CS use, not on the benefits of CS in regions where it is underused. We have selected important, large, and recent systematic reviews and cohort studies to summarise the effects of CS on short-term and long-term outcomes for both women and children.

Key messages

  • Caesarean section (CS) is a life-saving intervention for specific complications during pregnancy and childbirth that should be available to all women in need. CS also confers an increased risk of maternal mortality and severe acute morbidity and a higher risk for adverse outcomes in subsequent pregnancy compared with vaginal birth. Multiple CSs are associated with a higher risk of maternal morbidity and mortality.

  • Some benefits of CS, such as less frequent incontinence and urogenital prolapse have been described.

  • Infants born by CS have different hormonal, physical, bacterial, and medical exposures (such as intrapartum antibiotics and uterotonins) and are exposed to more short-term risks, which range from altered immune development, allergy, atopy, asthma, and reduced diversity of the intestinal gut microbiome, compared with those born vaginally.

  • Emerging research has shown biological mechanisms that underlie the acute and chronic effects of CS on child health and the long-term effects of CS on children, including how these effects might be mitigated.

Section snippets

Limitations to CS studies

Understanding of the short-term and long-term outcomes of CS for women has been restricted by limitations in study design, inadequate power of studies, failure to control for confounders, and inappropriate selection of comparison groups. Additionally, there has been a failure to differentiate between elective and emergency procedures, or to account for obstetric and medical conditions that have prompted the need for CS that could be the underlying cause of increased morbidity and mortality. A

Intrauterine effects on infant health

CSs can save infants' lives and prevent perinatal mortality and severe morbidity, such as intrapartum asphyxia; however, is should be recognised that severe neurological morbidities can originate during the antenatal period, not only in the intrapartum period.9 Additionally, many clinicians perform planned CSs before 39 weeks of gestation. Such planned early birth could increase the risk of respiratory problems and hypoglycaemia.56, 57

Intrauterine exposures have far-reaching effects on the

Implications in low-resource settings

The balance of risk and benefit must also be considered in relation to whether settings are high-resource or low-resource. In 2013, a WHO analysis93, 94 considered maternal near-miss or maternal death by mode of birth and showed that, in 29 African, Asian, Latin American, and Middle Eastern countries, 62·5% of women had a severe maternal outcome after CS, compared with 37·5% for vaginal birth. By contrast, a Finnish register-based retrospective cohort study of 110 000 births—ie, a high-resource

Conclusions

Almost every woman who has a CS increases her risk of certain morbidities in her subsequent pregnancies. The axiom once a caesarean, always a caesarean is not evidence-based, but once a caesarean, always a scar reinforces the maxim that women with a previous CS should be considered to be at increased risk of obstetric complications and poorer outcomes for mother and baby. The discussed evidence shows the complexity in achieving an initially favourable result from an operative intervention and,

Search strategy and selection criteria

To assess the effects of caesarean section on the health of women, we searched the Cochrane Library, PubMed, and Scopus databases with the search terms “cesarean OR caesarean section AND vaginal delivery”, “benefit OR risk OR complication”, and “long term OR short term”. The first two of these searches were combined, followed by combining all three search terms. We further narrowed the results by searching in the results for the terms “trial of labour”, “planned vaginal birth”, “vaginal birth

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