The association between caesarean section delivery and later life obesity in 21-24 year olds in an Urban South African birth cohort

Autoři: Eniola Sogunle aff001;  Gwinyai Masukume aff001;  Gill Nelson aff001
Působiště autorů: School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa aff001
Vyšlo v časopise: PLoS ONE 14(11)
Kategorie: Research Article
doi: 10.1371/journal.pone.0221379



Obesity is an important public health problem and rates have reached epidemic proportions in many countries. Studies have explored the association between infants delivered by caesarean section and their later life risk of obesity, in many countries outside Africa. As a result of the increasing caesarean section and obesity rates in South Africa, we investigated the association in this country.


This was a retrospective analysis of data that were collected from a prospective South African birth cohort (Birth to Twenty Plus), established in 1990. A total of 889 young adults aged 21–24 years were included in the analysis. Poisson regression models were fitted to assess the association between mode of delivery and early adulthood obesity.


Of the 889 young adults, 106 (11.9%) were obese while 72 (8.1%) were delivered by caesarean section; of which 14 (19.4%) were obese. Caesarean section delivery was significantly associated with obesity in young adults after adjusting for potential confounders like young adults’ sex and birth weight, mothers’ parity, and education (incidence rate ratio 1.64, 95% CI 1.01–2.68, p = 0.045).


The association of caesarean section with early adulthood obesity should be interpreted with caution because data on certain key confounding factors such as mothers’ pre-pregnancy body mass index and gestational diabetes were not available. Further research from Africa, with larger sample sizes and databases with useful linking of maternal and infant data, should be conducted.

Klíčová slova:

Birth weight – Body Mass Index – Cohort studies – Infants – Labor and delivery – Obesity – Young adults


1. Van der Merwe M. Obesity in childhood and adolescence. South African Medical Journal. 2012 May;102(5): 289-.

2. World Health Organization. Obesity and overweight. 2014. [Accessed 2019 Mar 15]. Available from:

3. South Africa Demographic and Health Survey 2016. 2019. [Accessed 2019 Mar 15]. Available from:

4. De Mutsert R, Sun Q, Willett WC, Hu FB, van Dam RM. Overweight in Early Adulthood, Adult Weight Change, and Risk of Type 2 Diabetes, Cardiovascular Diseases, and Certain Cancers in Men: a Cohort Study. American Journal of Epidemiology. 2014 Apr 30;179(11):1353–65. [Accessed 2019 Mar 22]. Available from: doi: 10.1093/aje/kwu052

5. Fuemmeler BF, Pendzich MK, Tercyak KP. Weight, dietary behavior, and physical activity in childhood and adolescence: implications for adult cancer risk. Obesity Facts. 2009 Jul 1;2(3):179–86. [Accessed 2019 Mar 22]. Available from: doi: 10.1159/000220605 20054223

6. Neovius K, Neovius M, Rasmussen F. The combined effects of overweight and smoking in late adolescence on subsequent disability pension: a nationwide cohort study. International Journal of Obesity. 2010 Jan 1;34(1):75–82. [Accessed Mar 23]. Available from: doi: 10.1038/ijo.2009.178 19752877

7. Stevens J, Truesdale KP, Wang C-H, Cai J, Erber E. Body mass index at age 25 and all-cause mortality in whites and African Americans: the Atherosclerosis Risk in Communities study. Journal of Adolescent Health. 2012 Mar 1;50(3):221–7. doi: 10.1016/j.jadohealth.2011.06.006 22325126

8. Van Dam RM, Willett WC, Manson JE, Hu FB. The Relationship between Overweight in Adolescence and Premature Death in Women. Annals of Internal Medicine. 2006 Jul 18;145(2):91–7. doi: 10.7326/0003-4819-145-2-200607180-00006 16847291

9. Wengreen HJ, Moncur C. Change in diet, physical activity, and body weight among young-adults during the transition from high school to college. Nutrition Journal. 2009 Dec 1;8(1):1–7. [Accessed 2019 Mar 23]. Available from: PMCID:PMC2720988

10. Niemeier HM, Raynor HA, Lloyd-Richardson EE, Rogers ML, Wing RR. Fast Food Consumption and Breakfast Skipping: Predictors of Weight Gain from Adolescence to Adulthood in a Nationally Representative Sample. Journal of Adolescent Health. 2006 Dec 1;39(6):842–9. doi: 10.1016/j.jadohealth.2006.07.001 17116514

11. Timlin MT, Pereira MA. Breakfast Frequency and Quality in the Etiology of Adult Obesity and Chronic Diseases. Nutrition Reviews. 2007 Jun 1;65(6):268–81.

12. allAfrica. Namibia: Private Hospitals Over-Perform C-Sections. 2015. [Accessed 2019 Feb 21]. Available from:

13. Filipovic J. Inside a war on natural birth: c-sections as status symbol and “choice” as a myth. 2014. [Accessed 2019 Mar 15]. Available from:

14. Sifferlin A. C-Sections Should Only Be Done When Medically Necessary—World Health Organzation. 2015. [Accessed 2019 Mar 15]. Available from:

15. Redden M. A third of people get major surgery to be born’: why are C-sections routine in the US? In: The Guardian. 2017. [Accessed 2019 Mar 15]. Available from:

16. Dayi C, Gray A. South African Health Review: Health and Related Indicators. Health System Trust. 2016. [Accessed 2019 Mar 22]. Available from:

17. Zhou X, Brown CJ, Abdo Z, Davis CC, Hansmann MA, Joyce P, et al. Differences in the composition of vaginal microbial communities found in healthy Caucasian and black women. ISME Journal: Multidisciplinary Journal of Microbial Ecology. 2007 Jun 1;1(2):121–33. [Accessed 2019 Mar 23]. Available from:

18. Penders J, Thijs C, Vink C, Stelma FF, Snijders B, Kummeling I, et al. Factors influencing the composition of the intestinal microbiota in early infancy. Pediatrics. 2006 Aug 1;118(2):511–21. doi: 10.1542/peds.2005-2824 16882802

19. Yuan C, Gaskins AJ, Blaine AI, Zhang C, Gillman MW, Missmer SA, et al. Cesarean birth and risk of offspring obesity in childhood, adolescence and early adulthood. JAMA pediatrics. 2016 Nov 1;170(11):e162385. [Accessed 2019 Mar 23]. Available from: doi: 10.1001/jamapediatrics.2016.2385 27599167

20. 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. Public Library of Science ONE. 2014 Feb 26;9(2):e87896–. [Accessed 2019 Mar 23]. Available from: PMCID:PMC3935836 doi: 10.1371/journal.pone.0087896 24586295

21. Li H-T, Zhou Y-B, Liu J-M. The Impact of Cesarean Section on Offspring Overweight and Obesity: A Systematic Review and Meta-Analysis. Obstetrical & Gynecological Survey. 2014 Jul 1;37(7):893–900. [Accessed 2019 Mar 23]. Available from:

22. Sutharsan R, Mannan M, Doi SA, Mamun AA. Caesarean delivery and the risk of offspring overweight and obesity over the life course: a systematic review and bias-adjusted meta-analysis. Clinical Obesity. 2015 Nov 23;5(6):293–301. doi: 10.1111/cob.12114 26286021

23. Mesquita DN, Barbieri MA, Goldani HA, Cardoso VC, Goldani MZ, Kac G, et al. Cesarean Section Is Associated with Increased Peripheral and Central Adiposity in Young Adulthood: Cohort Study. 2013 Jun 27;8(6):e66827 doi: 10.1371/journal.pone.0066827 23826150

24. Bernardi JR, Goldani HAS, Pinheiro TV, Goldani MZ, Mueller NT, Bettiol H, et al. Cesarean delivery and metabolic risk factors in young adults: a Brazilian birth cohort study. The American Journal of Clinical Nutrition. 2015 Jun 17;102(2):295–301. [Accessed 2019 Mar 23]. Available from: doi: 10.3945/ajcn.114.105205 26085513

25. Hansen S, Halldorsson TI, Olsen SF, Rytter D, Bech BH, Granström C, et al. Birth by cesarean section in relation to adult offspring overweight and biomarkers of cardiometabolic risk. International Journal Of Obesity. 2018 Jan 1;42(1):15–9. [Accessed 2019 Mar 23]. Available from: doi: 10.1038/ijo.2017.175 28757643

26. Barros AJD, Santos LP, Wehrmeister F, Motta JV dos S, Matijasevich A, Santos IS, et al. Caesarean section and adiposity at 6, 18 and 30 years of age: results from three Pelotas (Brazil) birth cohorts. BMC Public Health. 2017 Mar 14;17(1):256. [Accessed 2019 Mar 23]. Available from: doi: 10.1186/s12889-017-4165-3 28292278 PMCID:PMC5351260

27. Mamun AA, Sutharsan R, O’Callaghan M, Williams G, Najman J, McIntyre HD, et al. Cesarean Delivery and the Long-Term Risk of Offspring Obesity. Obstetrics & Gynecology. 2013 Dec 1;122(6):1176–83. [Accessed 2019 Mar 23]. Available from:

28. Barros FC, Matijasevich A, Hallal PC, Horta BL, Barros AJ, Menezes AB, et al. Cesarean section and risk of obesity in childhood, adolescence, and early adulthood: Evidence from 3 Brazilian birth cohorts. American Journal of Clinical Nutrition. 2012 Jan 11;95(2):465–70. doi: 10.3945/ajcn.111.026401 22237058

29. Huh SY, Rifas-Shiman SL, Zera CA, Edwards JWR, Oken E, Weiss ST, et al. Delivery by caesarean section and risk of obesity in preschool age children: a prospective cohort study. Archives of Disease in Childhood. 2012 Jul 1;97(7):610–6. doi: 10.1136/archdischild-2011-301141 22623615

30. Goldani H, Bettiol H, Barbieri M, Silva A, Agranonik M, Morais M, et al. Cesarean delivery is associated with an increased risk of obesity in adulthood in a Brazilian birth cohort study. American Journal of Clinical Nutrition. 2011;93(6):1344–7. [Accessed 2019 Mar 23]. Available from: doi: 10.3945/ajcn.110.010033 21508088

31. Goldani MZ, Barbieri MA, da Silva AAM, Gutierrez MRP, Bettiol H, Goldani HAS. Cesarean section and increased body mass index in school children: two cohort studies from distinct socioeconomic background areas in Brazil. Nutrition Journal. 2013 July 25;12(1):104.

32. Horta BL, Gigante DP, Lima RC, Barros FC, Victora CG. Birth by caesarean section and prevalence of risk factors for non-communicable diseases in young adults: a birth cohort study. PloS one. 2013;8: e74301–e74301. doi: 10.1371/journal.pone.0074301 24040224

33. Rooney B, Mathiason M, Schauberger C. Predictors of Obesity in Childhood, Adolescence, and Adulthood in a Birth Cohort. Maternal & Child Health Journal. 2011;15.

34. Flemming K, Woolcott CG, Allen AC, Veugelers PJ, Kuhle S. The association between caesarean section and childhood obesity revisited: a cohort study. Archives of disease in childhood. 2013;98: 526–532. doi: 10.1136/archdischild-2012-303459 23680850

35. Masukume G, McCarthy FP, Baker PN, Kenny LC, Morton SM, Murray DM, et al. Association between caesarean section delivery and obesity in childhood: a longitudinal cohort study in Ireland. BMJ open. 2019;9: e025051. doi: 10.1136/bmjopen-2018-025051 30878984

36. Richter L, Norris S, Pettifor J, Yach D, Cameron N. Cohort Profile: Mandela’s children: the 1990 Birth to Twenty study in South Africa. International journal of epidemiology. 2007;36: 504–511. doi: 10.1093/ije/dym016 17355979

37. Richter L, Yach D, Cameron N, Griesel R, De Wet T. Enrolment into Birth to Ten (BTT): population and sample characteristics. Paediatric and perinatal epidemiology. 1995;9: 109–120. doi: 10.1111/j.1365-3016.1995.tb00124.x 7724410

38. World Health Organization. Obesity: preventing and managing the global epidemic. 2000. [Accessed 2019 Mar 23]. Available from:

39. Lee AC, Kozuki N, Cousens S, Stevens GA, Blencowe H, Silveira MF, et al. Estimates of burden and consequences of infants born small for gestational age in low and middle income countries with INTERGROWTH-21 (st) standard: analysis of CHERG datasets. British Medical Journal (BMJ). 2017;358: j3677.

40. Mueller NT, Mao G, Bennet WL, Hourigan SK, Dominguez-Bello MG, Appel LJ, et al. Does vaginal delivery mitigate or strengthen the intergenerational association of overweight and obesity? Findings from the Boston Birth Cohort. International journal of obesity (2005). 2017;41: 497–501. doi: 10.1038/ijo.2016.219 27899809

41. Schafer J. Multiple imputation: a primer. Statistical Methods in Medical Research. 1999;8: 3. doi: 10.1177/096228029900800102 10347857

42. Choi K-H, Hoff C, Gregorich SE, Grinstead O, Gomez C, Hussey W. The Efficacy of Female Condom Skills Training in HIV Risk Reduction Among Women: A Randomized Controlled Trial. Am J Public Health. 2008;98: 1841–1848. doi: 10.2105/AJPH.2007.113050 18703460

43. Seitzman RL, for the Study of Osteoporotic Fractures Research Group, Mahajan VB, for the Study of Osteoporotic Fractures Research Group, Mangione C, for the Study of Osteoporotic Fractures Research Group, et al. Estrogen Receptor Alpha and Matrix Metalloproteinase 2 Polymorphisms and Age-related Maculopathy in Older Women. American Journal of Epidemiology. 2008;167: 1217–1225. doi: 10.1093/aje/kwn024 18359774

44. Rubin DB. Multiple imputation for nonresponse in surveys. John Wiley & Sons; 2004.

45. Cois A, Day C. Obesity trends and risk factors in the South African adult population. BMC Obes. 2015;2: 42–42. doi: 10.1186/s40608-015-0072-2 26617987

46. Micklesfield LK, Lambert EV, Hume DJ, Chantler S, Pienaar PR, Dickie K, et al. Socio-cultural, environmental and behavioural determinants of obesity in black South African women. Cardiovasc J Afr. 2013;24: 369–375. doi: 10.5830/CVJA-2013-069 24051701

47. Dominguez-Bello MG, Costello EK, Contreras M, Magris M, Hidalgo G, Fierer N, et al. Delivery mode shapes the acquisition and structure of the initial microbiota across multiple body habitats in newborns. Proceedings of the National Academy of Sciences. 2010; 201002601.

48. Tun HM, Bridgman SL, Chari R, Field CJ, Guttman DS, Becker AB, et al. Roles of Birth Mode and Infant Gut Microbiota in Intergenerational Transmission of Overweight and Obesity From Mother to OffspringIntergenerational Maternal Transmission of Overweight and ObesityIntergenerational Maternal Transmission of Overweight and Obesity. JAMA Pediatrics. 2018;172: 368–377. doi: 10.1001/jamapediatrics.2017.5535 29459942

49. Wampach L, Heintz-Buschart A, Fritz JV, Ramiro-Garcia J, Habier J, Herold M, et al. Birth mode is associated with earliest strain-conferred gut microbiome functions and immunostimulatory potential. Nature Communications. 2018;9: 5091. doi: 10.1038/s41467-018-07631-x 30504906

50. Rodríguez JM, Murphy K, Stanton C, Ross RP, Kober OI, Juge N, et al. The composition of the gut microbiota throughout life, with an emphasis on early life. Microbial Ecology in Health and Disease. 2015;26.

51. Kalliomäki M, Collado MC, Salminen S, Isolauri E. early differences in fecal microbiota composition in children may predict overweight1-3. The American Journal of Clinical Nutrition. 2008;87: 534–538. doi: 10.1093/ajcn/87.3.534

52. Huurre A, Kalliomäki M, Rautava S, Rinne M, Salminen S, Isolauri E. Mode of Delivery–Effects on Gut Microbiota and Humoral Immunity. Neonatology. 2008;93: 236–240. doi: 10.1159/000111102 18025796

53. Benenati B, Biasucci G, Morelli L, Bessi E, Boehm G. Cesarean Delivery May Affect the Early Biodiversity of Intestinal Bacteria. The Journal of Nutrition. 2008;138: 1796S–1800S. doi: 10.1093/jn/138.9.1796S 18716189

54. Chu SY, Kim SY, Schmid CH, Dietz PM, Callaghan WM, Lau J, et al. Maternal obesity and risk of cesarean delivery: a meta-analysis. Obesity Reviews. 2007;8: 385–394. doi: 10.1111/j.1467-789X.2007.00397.x 17716296

55. Yu Z, Han S, Zhu J, Sun X, Ji C, Guo X. Pre-pregnancy body mass index in relation to infant birth weight and offspring overweight/obesity: a systematic review and meta-analysis. PloS one. 2013;8: e61627–e61627. doi: 10.1371/journal.pone.0061627 23613888

56. Canavan TP, Simhan HN, Caritis S. An evidence-based approach to the evaluation and treatment of premature rupture of membranes: Part II. Obstet Gynecol Surv. 2004;59: 678–89. [Accessed 2019 Mar 23]. Available from: doi: 10.1097/01.ogx.0000137611.26772.2d 15329561

57. Plough AC, Galvin G, Li Z, Lipsitz SR, Alidina S, Henrich NJ, et al. Relationship between labor and delivery unit management practices and maternal outcomes. Obstetrics & Gynecology. 2017;130: 358–365.

58. Mears K, McAuliffe F, Grimes H, Morrison J. Fetal cortisol in relation to labour, intrapartum events and mode of delivery. Journal of Obstetrics and Gynaecology. 2004;24: 129–132. doi: 10.1080/01443610410001645389 14766445

59. Aiken CE, Aiken AR, Brockelsby JC, Scott JG. Factors influencing the likelihood of instrumental delivery success. Obstet Gynecol. 2014;123: 796–803. doi: 10.1097/AOG.0000000000000188 24785607

Článek vyšel v časopise


2019 Číslo 11