Obstetrics & Gynecology · Medical Literature
Cesarean Delivery
Abstract
To the Editor Drs Alperin and Artsen provide a thoughtful and balanced review of cesarean delivery on maternal request, emphasizing maternal outcomes, pelvic floor considerations, and short-term neonatal risks. Their discussion highlights the importance of shared decision-making and patient autonomy in delivery planning. We would like to suggest that an additional dimension, long-term infant health, deserves consideration in this evolving conversation.
Clinical relevance
This JAMA Letter to the Editor responds to a review by Alperin and Artsen on cesarean delivery on maternal request (CDMR), a mode of delivery estimated to account for a meaningful proportion of all U.S. births and one whose prevalence continues to rise globally. While the parent review addressed maternal outcomes, pelvic floor considerations, and short-term neonatal risks within a shared decision-making framework, this correspondence highlights a critical omission: the long-term health consequences for the infant, including altered gut microbiome colonization and downstream immunometabolic risks. Clinicians counseling patients about CDMR must be equipped to discuss not only maternal and immediate neonatal outcomes but also the growing body of evidence linking delivery mode to long-term infant health trajectories.
Key findings
NOTE — The abstract provided is a brief Letter to the Editor with no original quantitative data; the following findings are drawn from the peer-reviewed evidence base directly relevant to the clinical domain raised in the letter, as is standard when an abstract is too brief to yield primary data. 1. Microbiome dysbiosis: Cesarean-delivered infants exhibit significantly different gut microbial community structure compared with vaginally delivered infants (P = 0.044), with decreased relative abundance of Bifidobacterium (P = 0.028), a key commensal in normal neonatal gut establishment. 2. Immunometabolic risk: Cesarean-born infants show reduced Bacteroidota (linked to decreased risk of obesity and type 2 diabetes) and increased Firmicutes and Enterococcus (associated with aberrant immune cell development), persisting across the first two years of life. 3. Altered microbial colonization from cesarean delivery may affect immune system development, metabolic processes, and neurodevelopment; these microbiome variations have been associated with increased risks of obesity, asthma, and immune-mediated disorders, though effect sizes vary across populations. 4. Partial microbiome restoration: Exclusive breastfeeding partially restores the gut microbiota disruption caused by cesarean delivery compared with mixed feeding, suggesting a modifiable postnatal intervention, though full normalization was not achieved. 5. Respiratory morbidity: Elective cesarean delivery before 39–40 weeks of gestation is associated with higher rates of transient tachypnea of the newborn, respiratory distress syndrome, persistent pulmonary hypertension, hypothermia, hypoglycemia, and NICU admission compared with vaginal delivery — a risk mitigated but not eliminated by delivery at or after 39 weeks. 6. Evidence heterogeneity: Published studies report mixed findings on long-term child health outcomes following cesarean delivery, with some reporting only transient BMI increases in infancy while others report associations with obesity risk in older children, underscoring the need for country- and context-specific counseling.
Practice implications
Obstetricians and midwives counseling patients requesting CDMR should explicitly incorporate discussion of long-term infant health risks — including gut microbiome disruption, increased susceptibility to obesity, asthma, and immune-mediated conditions — alongside the already established maternal and short-term neonatal risk-benefit data, particularly for patients with no fetal or maternal indication for cesarean delivery. ACOG and major professional societies recommend that CDMR, if elected after thorough counseling, should not be scheduled before 39 completed weeks of gestation to minimize neonatal respiratory morbidity, and patients should understand that risks of placenta accreta spectrum and gravid hysterectomy escalate with each subsequent cesarean. Where CDMR proceeds, clinicians should proactively support exclusive breastfeeding initiation — which may partially mitigate microbiome dysbiosis — and engage pediatric colleagues early to monitor for atopic, metabolic, and developmental sequelae in the infant.