Long-Term Neurodevelopmental Outcomes Differ According to Mode of Delivery, Finds JAMA Study
Canada: A large retrospective cohort study of over half a million Canadian births found that children born via operative vaginal delivery and second-stage cesarean delivery (SSCD) generally had similar long-term neurodevelopmental outcomes.
Two small exceptions were noted: vacuum-assisted deliveries were associated with a slightly higher rate of intellectual disability, and sequential instrument deliveries (failed vacuum followed by forceps) showed a slightly increased risk of ADHD compared with second-stage cesarean delivery. Researchers emphasized that these differences were small and should be interpreted with caution.
The findings were reported in JAMA Network Open by Maya Rajasingham, Department of Obstetrics and Gynecology, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada, and colleagues. The study sought to determine whether different modes of delivery during the second stage of labor were associated with long-term risks of attention-deficit/hyperactivity disorder (ADHD), autism spectrum disorder (ASD), or intellectual disability (ID) in children.
The population-based retrospective cohort study analyzed health administrative data from British Columbia, Canada, covering births between April 2000 and December 2019. A total of 504,380 singleton, full-term infants without congenital anomalies were included.
The following were the key findings:
- All children included in the analysis survived beyond their first year of life and were followed for neurodevelopmental outcomes for up to 22 years, with follow-up extending through March 2022.
- The majority of births occurred via spontaneous vaginal delivery (80.9%), followed by vacuum-assisted delivery (9.2%), forceps delivery (4.6%), sequential instrument delivery (0.6%), and second-stage cesarean delivery (4.7%).
- Attention-deficit/hyperactivity disorder was the most commonly diagnosed neurodevelopmental outcome during follow-up, followed by autism spectrum disorder and intellectual disability.
- The overall incidence rates were 6.6 per 1,000 person-years for ADHD, 1.8 per 1,000 person-years for ASD, and 0.3 per 1,000 person-years for intellectual disability.
- After adjustment for maternal, obstetric, and clinical factors, sequential instrument delivery was associated with a 13% higher rate of ADHD compared with second-stage cesarean delivery.
- Vacuum-assisted delivery was linked to a 53% higher rate of intellectual disability compared with second-stage cesarean delivery.
- No significant differences were observed in autism spectrum disorder rates across the different modes of delivery.
- Forceps delivery alone was not associated with an increased risk of ADHD, ASD, or intellectual disability.
The authors noted that the absolute risk differences were small and likely reflected underlying clinical indications rather than a direct effect of delivery method. Unlike earlier studies that compared non-equivalent groups, this analysis used clinically comparable second-stage delivery scenarios.
Key limitations included possible underdiagnosis of ASD in administrative data, lack of socioeconomic and demographic information, and potential residual confounding or survival bias. However, sensitivity analyses showed consistent findings, and mortality rates were similar across delivery groups.
Overall, the results support comparable long-term neurodevelopmental safety between operative vaginal delivery and second-stage cesarean delivery. The authors highlighted the need for future studies using clinically relevant comparisons to clarify whether delivery mode is a modifiable risk factor for childhood neurodevelopmental disorders.
Reference:
Rajasingham M, Lisonkova S, Razaz N, Muraca GM. Long-Term Neurodevelopmental Outcomes After Forceps, Vacuum, and Second-Stage Cesarean Delivery. JAMA Netw Open. 2026;9(1):e2556637. doi:10.1001/jamanetworkopen.2025.56637
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