Abstract
The number of births by caesarean section (CS) is increasing worldwide. In line with this trend, there is growing interest in the neurodevelopmental outcome of children born by CS. This study examined the relationship between the mode of delivery and suspected neurodevelopmental delay in young children. A total of 53,716 mother–child pairs participating in the Japan Environment and Children’s Study, a representative Japanese cohort study of children, were included in the analysis of the association between CS and suspected developmental delay, as assessed by the Ages and Stages Questionnaires, Third Edition, in 3-year-old children. Multivariate logistic regression analysis was performed to calculate adjusted odds ratios (aORs) with 95% confidence intervals (CIs). No significant overall relationship was found between mode of delivery and suspected developmental delay. In an analysis by sex, CS was associated with increased risk of suspected gross motor developmental delay (aOR 1.27, 95% CI 1.07–1.49) in boys and increased risk of suspected fine motor developmental delay (aOR 1.34, 95% CI 1.11–1.63) in girls. These results suggest that there may be a relationship between CS and suspected motor developmental delay at the age of 3 years.
Data availability
Data are unsuitable for public deposition due to ethical restrictions and the legal framework of Japan. It is prohibited by the Act on the Protection of Personal Information (Act No. 57 of 30 May 2003, amended 9 September 2015) to publicly deposit data containing personal information. Ethical Guidelines for Medical and Health Research Involving Human Subjects enforced by the Japan Ministry of Education, Culture, Sports, Science and Technology and the Ministry of Health, Labour and Welfare also restrict the open sharing of epidemiologic data. All inquiries about access to data should be sent to jecs-en@nies.go.jp. The person responsible for handling enquiries sent to this e-mail address is Dr Shoji F. Nakayama, JECS Programme Office, National Institute for Environmental Studies.
References
Betran, A. P., Ye, J., Moller, A.-B., Souza, J. P. & Zhang, J. Trends and projections of caesarean section rates: global and regional estimates. BMJ Glob. Health 6, e005671 (2021).
Angolile, C. M., Max, B. L., Mushemba, J. & Mashauri, H. L. Global increased cesarean section rates and public health implications: a call to action. Health Sci. Rep. 6, e1274 (2023).
Betran, A. P. et al. The increasing trend in caesarean section rates: Global, regional and national estimates: 1990-2014. PLoS ONE 11, e0148343 (2016).
World Health Organization. Caesarean section rates continue to rise, amid growing inequalities in access. https://www.who.int/news/item/16-06-2021-caesarean-section-rates-continue-to-rise-amid-growing-inequalities-in-access (2021).
World Health Organization. WHO statement on caesarean section rates. https://www.who.int/publications/i/item/WHO-RHR-15.02 (2015).
Caesarean Birth. NICE guideline. NG192. https://www.nice.org.uk/guidance/ng192 (2025).
Jenabi, E., Khazaei, S., Bashirian, S., Aghababaei, S. & Matinnia, N. Reasons for elective cesarean section on maternal request: A systematic review. J. Matern. Fetal Neonatal Med. 33, 3867–3872 (2020).
Kristensen, K. & Henriksen, L. Cesarean section and disease associated with immune function. J. Allergy Clin. Immunol. 137, 587–590 (2016).
Decker, E. et al. Cesarean delivery is associated with celiac disease but not inflammatory bowel disease in children. Pediatrics 125, e1433–e1440 (2010).
Cardwell, C. R. et al. Caesarean section is associated with an increased risk of childhood-onset type 1 diabetes mellitus: a meta-analysis of observational studies. Diabetologia 51, 726–735 (2008).
Słabuszewska-Jóźwiak, A., Szymański, J. K., Ciebiera, M., Sarecka-Hujar, B. & Jakie, G. Pediatrics consequences of caesarean section—A systematic review and meta-analysis. Int. J. Environ. Res. Public Health 17, 8031 (2020).
Keag, O. E., Norman, J. E. & Stock, S. J. Long-term risks and benefits associated with cesarean delivery for mother, baby, and subsequent pregnancies: Systematic review and meta-analysis. PLoS Med. 15, e1002494 (2018).
Zhang, T. et al. Association of cesarean delivery with risk of neurodevelopmental and psychiatric disorders in the offspring. JAMA Netw. Open 2, e1910236 (2019).
Bellman, M., Byrne, O. & Sege, R. Developmental assessment of children. BMJ 346, e8687 (2013).
Lissauer T & Clayden G. Illustrated Textbook of Paediatrics. 4th Edition. (Mosby, 2012)
Choo, Y. Y., Agarwal, P., How, C. H. & Yeleswarapu, S. P. Developmental delay: Identification and management at primary care level. Singapore Med. J. 60, 119–123 (2019).
Al Khalaf, S. Y. et al. The impact of obstetric mode of delivery on childhood behavior. Soc. Psychiatry Psychiatr. Epidemiol. 50, 1557–1567 (2015).
Polidano, C., Zhu, A. & Bornstein, J. C. The relation between cesarean birth and child cognitive development. Sci. Rep. 7, 11483 (2017).
Yoshida, T., Matsumura, K., Hatakeyama, T., Inadera, H., The Japan Environment, Children’s Study Group. Association between Cesarean section and neurodevelopmental disorders in a Japanese birth cohort: the Japan Environment and Children’s Study. BMC Pediatr. 23, 306 (2023).
Sansavini, A. et al. Developmental language disorder: early predictors, age for the diagnostic tools. A scoping review. Brain Sci. 11, 654 (2021).
Holzinger, D., Weber, C., Barbaresi, W., Beitel, C. & Fellinger, J. Language screening in 3-year-olds: Development and validation of a feasible and effective instrument for pediatric primary care. Front. Pediatr. 9, 752141 (2021).
Matsuo, T., Matsuo, C., Matsuoka, H. & Kio, K. Detection of strabismus and amblyopia in 1.5- and 3-year-old children by a preschool vision-screening program in Japan. Acta Med. Okayama 61, 9–16 (2007).
Kawamoto, T. et al. Rationale and study design of the Japan Environment and Children’s Study (JECS). BMC Public Health 14, 25 (2014).
Michikawa, T. et al. Baseline profile of participants in the Japan Environment and Children’s Study (JECS). J. Epidemiol. 28, 99–104 (2018).
Mezawa, H. et al. Prevalence of congenital anomalies in the Japan Environment and Children’s Study. J. Epidemiol. 29, 247–256 (2019).
Squires, J., Bricker, D., Elizabeth, T., Jantina, C. & Robert, N. Ages & Stages Questionnaires: Third Edition (ASQ-3) (Brookes Publishing, 2009).
Mezawa, H. et al. Psychometric profile of the Ages and Stages Questionnaires, Japanese translation. Pediatr. Int. 61, 1086–1095 (2019).
Minatoya, M. et al. Cat and dog ownership in early life and infant development: a prospective birth cohort study of Japan Environment and Children’s Study. Int. J. Environ. Res. Public Health 17, 205 (2020).
Matsumura, K. et al. Prospective association of air purifier use during pregnancy with the neurodevelopment of toddlers in the Japan Environment and Children’s Study. Sci. Rep. 11, 19454 (2021).
Levy, S. E., Mandell, D. S. & Schultz, R. T. Autism. Lancet 374, 1627–1638 (2009).
Hampton, S. Autistic Mothers and the Perinatal Period: Maternal Experiences and Infant Development. (University of Cambridge Repository, 2020).
Grace, T., Bulsara, M., Robinson, M. & Hands, B. Early life events and motor development in childhood and adolescence: a longitudinal study. Acta Paediatr. 105, e219–e227 (2016).
Yokoyama, Y. et al. Validity of short and long self-administered food frequency questionnaires in ranking dietary intake in middle-aged and elderly Japanese in the Japan Public Health Center-Based Prospective Study for the Next Generation (JPHC-NEXT) protocol area. J. Epidemiol. 26, 420–432 (2016).
Matsumura, K. et al. Cesarean section and parenting stress: results from the Japan Environment and Children’s Study. Eur. Psychiatry 66, e18 (2023).
Arendt, R. E. et al. The influence of rotary vestibular stimulation upon motor development of nonhandicapped and Down syndrome infants. Res. Dev. Disabil. 12, 333–348 (1991).
Urbančič, N. B., Battelino, S. & Vozel, D. Appropriate vestibular stimulation in children and adolescents—a prerequisite for normal cognitive, motor development and bodily homeostasis—a review. Children 11, 2 (2024).
Clark, D. L., Kreutzberg, J. R. & Chee, F. K. Vestibular stimulation influence on motor development in infants. Science 196, 1228–1229 (1977).
Wachs, T. D., Georgieff, M., Cusick, S. & McEwen, B. S. Issues in the timing of integrated early interventions: Contributions from nutrition, neuroscience, and psychological research. Ann. N. Y. Acad. Sci. 1308, 89–106 (2014).
Cryan, J. F. & Dinan, T. G. Mind-altering microorganisms: The impact of the gut microbiota on brain and behaviour. Nat. Rev. Neurosci. 13, 701–712 (2012).
Westfall, S. et al. Microbiome, probiotics and neurodegenerative diseases: deciphering the gut brain axis. Cell. Mol. Life Sci. 74, 3769–3787 (2017).
Dominguez-Bello, M. G. et al. Delivery mode shapes the acquisition and structure of the initial microbiota across multiple body habitats in newborns. Proc. Natl. Acad. Sci. U. S. A. 107, 11971–11975 (2010).
Rodrigues, S. M. L. & Silva, P. M. M. Vaginal delivery versus elective cesarean section and the impact on children’s skill development. Rev. Enf. Ref. 4, 107–116 (2018).
Zaigham, M., Hellström-Westas, L., Domellöf, M. & Andersson, O. Prelabour caesarean section and neurodevelopmental outcome at 4 and 12 months of age: an observational study. BMC. Pregnancy Childbirth 20, 564 (2020).
Yazıcı, M. & Livanelioglu, A. Investigation of the effects of cesarean section on general movements of the newborn. J. Curr. Pediatr. 17, 374–386 (2019).
Massa, A. et al. Mode of delivery and behavioral and neuropsychological outcomes in children at 10 years of age. J. Perinat. Med. 52, 1010–1019 (2024).
Adams, R. C., Tapia, C., Council on Children With Disabilities. Early intervention, IDEA Part C services, and the medical home: collaboration for best practice and best outcomes. Pediatrics 132, e1073–e1088 (2013).
Barger, B., Rice, C., Wolf, R. & Roach, A. Better together: Developmental screening and monitoring best identify children who need early intervention. Disabil. Health J. 11, 420–426 (2018).
Lipkin, P. H., Okamoto, J., Council on Children with Disabilities, Council on School Health. The Individuals With Disabilities Education Act (IDEA) for children with special educational needs. Pediatrics 136, e1650–e1662 (2015).
Acknowledgements
We thank all the study participants and researchers who have contributed to the JECS. We are also grateful to the members of the JECS Group as of 2025: Michihiro Kamijima (Principal Investigator, Nagoya City University, Nagoya, Japan), Shin Yamazaki (National Institute for Environmental Studies, Tsukuba, Japan), Maki Fukami (National Center for Child Health and Development, Tokyo, Japan), Reiko Kishi (Hokkaido University, Sapporo, Japan), Chiharu Ota (Tohoku University, Sendai, Japan), Koichi Hashimoto (Fukushima Medical University, Fukushima, Japan), Kenichi Sakurai (Chiba University, Chiba, Japan), Shuichi Ito (Yokohama City University, Yokohama, Japan), Ryoji Shinohara (University of Yamanashi, Chuo, Japan), Hidekuni Inadera (University of Toyama, Toyama, Japan), Takeo Nakayama (Kyoto University, Kyoto, Japan), Ryo Kawasaki (Osaka University, Suita, Japan), Yasuhiro Takeshima (Hyogo Medical University, Nishinomiya, Japan), Hideki Nagashima (Tottori University, Yonago, Japan), Narufumi Suganuma (Kochi University, Nankoku, Japan), Mayumi Tsuji (University of Occupational and Environmental Health, Fukuoka, Japan), and Kimitoshi Nakamura (Kumamoto University, Kumamoto, Japan).
Funding
This study was funded by the Ministry of the Environment, Japan. The findings and conclusions of this article are solely the responsibility of the authors and do not represent the official views of the above government. The funding source played no role in the study’s design, collection, analysis, or interpretation of data; in the writing of the report; or in the decision to submit this paper for publication.
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I.S., K.M. and H.I. drafted the paper. K.M. and H.I. analysed the data. I.S., K.M., and H.I. conceived and designed the study. I.S., K.M., A.T., J.S., H.I., K.S., H.I., and the JECS Group critically reviewed the draft and checked the analyses. The JECS Group collected the data and obtained funding. All authors approved the submission of the manuscript in its current form.
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Sanzen, I., Matsumura, K., Inano, H. et al. Caesarean section may be associated with suspected motor developmental delay at 3 years of age in the Japan Environment and Children’s Study. Sci Rep (2026). https://doi.org/10.1038/s41598-026-46955-3
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DOI: https://doi.org/10.1038/s41598-026-46955-3
