Cesarean section and body mass index in children: is there a causal effect?

Cavalcante, Lilian Fernanda Pereira; Carvalho, Carolina Abreu de; Padilha, Luana Lopes; Viola, Poliana Cristina de Almeida Fonseca; Silva, Antônio Augusto Moura da; Simões, Vanda Maria Ferreira

doi:10.1590/0102-311X00344020

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ARTICLE • Cad. Saúde Pública 38 (4) • 2022 • https://doi.org/10.1590/0102-311X00344020 copy

Cesarean section and body mass index in children: is there a causal effect?

Parto cesáreo e índice de massa corporal em crianças: existe um efeito causal?

Operación de cesárea e índice de masa corporal en niños: ¿existe un efecto causal?

Authorship SCIMAGO INSTITUTIONS RANKINGS

Obesity is considered a global public health problem. Cesarean section has been associated with high body mass index (BMI) and increased obesity throughout life. However, this association has been challenged by some studies. This study aims to assess the causal effect of cesarean section on the BMI of children aged 1-3 years. This is a cohort study of 2,181 children aged 1-3 years, born in 2010, obtained from the BRISA Birth Cohort, in São Luís, state of Maranhão, Brazil. Sociodemographic variables, maternal characteristics, type of childbirth, morbidity, anthropometric measurements, and BMI were assessed. Marginal structural models with a counterfactual approach were used to check the causal effect of the type of childbirth on obesity, weighted by the inverse probability of selection and exposure. Out of the 2,181 children assessed (52% female), 50.6% were born by cesarean section, 5.9% of the newborn infants were large for gestational age, and 10.7% of them had excess weight. No causal effect of cesarean section on BMI was observed (coefficient = -0.004; 95%CI: -0.136; 0.127; p = 0.948). Cesarean section did not have a causal effect on the BMI of children aged 1-3 years.

Keywords:
Cesarean Section; Child Obesity; Body Mass Index

Variables	Total		C-section		Vaginal birth		p-value
Variables	n	%	n	%	n	%
Sector							< 0.001
Public	1,788	82.0	1,069	59.8	719	40.2
Private	393	18.0	385	98.0	8	2.0
Socioeconomic classification *							< 0.001
A/B	462	21.1	356	77.1	106	22.9
C	1,251	57.4	579	46.3	672	53.7
D/E	468	21.5	169	36.1	299	63.9
Schooling (years)							< 0.001
0-4	39	1.8	15	38.5	24	61.5
5-8	328	15.0	112	34.1	216	65.9
9-11	1,414	64.9	667	47.2	747	52.8
> 12	400	18.3	310	77.5	90	22.5
Skin color/Race							< 0.001
White	406	18.7	260	64.0	146	36.0
Black	291	13.3	144	49.5	147	50.5
Mixed-race	1,454	66.7	683	47.0	771	53.0
Yellow/Asian	26	1.2	17	65.4	9	34.6
Indigenous	2	0.1	0	0.0	2	100.0
Gestational hypertension							< 0.001
No	1,804	82.7	850	47.1	954	52.9
Yes	376	17.3	254	67.6	122	32.5
Prenatal care							0.457
Adequate	2,173	99.6	1,101	50.7	1,072	49.3
Inadequate	8	0.4	3	37.5	5	62.5
Number of children							< 0.001
1	1,128	51.7	612	54.3	516	45.7
2-4	1,001	45.9	478	47.8	523	52.3
≥ 5	52	2.4	14	26.9	38	73.1
Pregestational BMI *							< 0.001
Underweight	511	23.4	190	37.2	321	62.8
Normal weight	1,289	59.1	678	52.6	611	47.4
Excess weight	381	17.5	236	61.9	145	38.1

Variables	n	%
Sex
Male	1,048	48.0
Female	1,133	52.0
Weight for gestational age - birth weight
Small for gestational age	49	2.2
Appropriate for gestational age	2,004	91.9
Large for gestational age	128	5.9
Children’s BMI
Underweight	47	2.2
Normal weight	1,900	87.1
Overweight	234	10.7

Variables	Differences in standardized means
Variables	Raw	Weighted	Raw	Weighted
Maternal BMI
Underweight	Reference
Normal weight	0.113	-0.002	0.953	1.001
Excess weight	0.241	0.000	1.616	1.001
Weight for gestational age
Small for gestational age	Reference
Appropriate for gestational age	-0.026	-0.009	1.084	1.032
Large for gestational age	0.055	0.007	1.230	1.029
Maternal socioeconomic classification *
A/B	Reference
C	-0.210	0.007	1.065	0.997
D/E	0.582	-0.009	2.460	0.986
Maternal age (years)
< 20	Reference
20-34	0.071	-0.017	0.918	1.022
> 35	0.333	0.036	2.840	1.114
Maternal schooling (years)
0-4	Reference
5-8	-0.268	-0.002	0.558	0.994
9-11	-0.235	0.018	1.161	0.988
> 12	0.556	-0.021	2.655	0.967
Number of children
1	-0.015	-0.006	0.986	1.006
2-4	-0.116	0.006	0.788	1.012
≥ 5	-0.130	-0.016	0.410	1.109
Weight gain during pregnancy	0.238	-0.005	1.069	0.975
Prenatal care adequacy	-0.001	0.011	0.959	1.271

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[1] Correspondence
L. F. P. Cavalcante Universidade Federal do Maranhão. Av. dos Portugueses s/n, São Luís, MA 65085-580, Brasil. liliancavalcante03@gmail.com