Introduction
Methods
Study population
Sampling frame
Exposure
Outcome
Strengths and Difficulties Questionnaire (SDQ)
Confounding variables
Statistical analysis
Results
Characteristic | Spontaneous VD | Assisted VD | Induced VD | Emergency CS | Planned CS | CS after induction |
---|---|---|---|---|---|---|
Total population, N (%) | 8866 (48.68) | 1735 (9.53) | 3739 (20.52) | 1253 (6.88) | 1440 (7.91) | 1180 (6.48) |
Maternal age, years, mean (SD) | 27.92 (5.89) | 28.06 (5.81) | 27.69 (6.07) | 29.30 (5.88) | 30.75 (5.34) | 29.14 (5.95) |
Maternal education completed, n (%) | ||||||
Less than O level | 1853 (20.90) | 198 (11.41) | 841 (22.49) | 208 (16.60) | 247 (17.15) | 191 (16.19) |
O level | 3887 (43.84) | 751 (43.29) | 1718 (45.95) | 524 (41.82) | 636 (44.17) | 513 (43.47) |
A level | 811 (9.15) | 187 (10.78) | 344 (9.20) | 126 (10.06) | 114 (7.92) | 111 (9.41) |
Diploma or above | 2008 (22.65) | 559 (32.22) | 721 (19.28) | 358 (28.57) | 406 (28.19) | 326 (27.63) |
Other/unknown | 307 (3.46) | 40 (2.31) | 115 (3.08) | 37 (2.95) | 37 (2.57) | 39 (3.31) |
Maternal smoking status, n (%) | ||||||
Non-smoker | 5691 (64.21) | 1137 (65.61) | 2266 (60.64) | 827 (66.00) | 984 (68.33) | 785 (66.53) |
Quit during pregnancy | 1055 (11.90) | 277 (15.98) | 479 (12.82) | 158 (12.61) | 176 (12.22) | 170 (14.41) |
Smoked during pregnancy | 2117 (23.89) | 319 (18.41) | 992 (26.55) | 268 (21.39) | 280 (19.44) | 225 (19.07) |
Maternal alcohol consumption during pregnancy, n (%) | ||||||
Yes | 2612 (29.47) | 513 (29.57) | 1026 (27.46) | 333 (26.58) | 432 (30.00) | 321 (27.20) |
Maternal pre-pregnancy BMI, n (%) | ||||||
Underweight | 529 (5.97) | 84 (4.84) | 231 (6.18) | 73 (5.83) | 47 (3.26) | 42 (3.56) |
Normal weight | 5497 (62.00) | 1135 (65.42) | 2127 (56.89) | 677 (54.03) | 746 (51.81) | 621 (52.63) |
Overweight | 1483 (16.73) | 310 (17.87) | 715 (19.12) | 257 (20.51) | 315 (21.88) | 261 (22.12) |
Obese | 539 (6.08) | 103 (5.94) | 336 (8.99) | 129 (10.30) | 178 (12.36) | 153 (12.97) |
Unknown | 818 (9.23) | 103 (5.94) | 330 (8.83) | 117 (9.34) | 154 (10.69) | 103 (8.73) |
Household income, n (%) | ||||||
Lowest quintile | 2391 (27.05) | 311 (17.95) | 1084 (29.16) | 262 (21.04) | 281 (19.54) | 228 (19.34) |
Second quintile | 2118 (23.96) | 283 (16.33) | 901 (24.23) | 251 (20.16) | 287 (19.96) | 242 (20.53) |
Third quintile | 1627 (18.41) | 344 (19.85) | 712 (19.15) | 238 (19.12) | 296 (20.58) | 226 (19.17) |
Fourth quintile | 1466 (16.59) | 377 (21.75) | 553 (14.87) | 240 (19.28) | 289 (20.10) | 239 (20.27) |
Highest quintile | 1236 (13.99) | 418 (24.12) | 468 (12.59) | 254 (20.40) | 285 (19.82) | 244 (20.70) |
Small for gestational age, n (%) | 790 (8.91) | 136 (7.84) | 410 (10.97) | 170 (13.57) | 93 (6.46) | 139 (11.78) |
Infant sex, n (%) | ||||||
Male | 4480 (50.53) | 956 (55.10) | 1870 (50.01) | 721 (57.54) | 705 (48.96) | 636 (53.90) |
Parity (first born child), n (%) | 3047 (34.37) | 1356 (78.16) | 1423 (38.06) | 693 (55.31) | 350 (24.31) | 781 (66.19) |
Hypertensive disorders of pregnancy, n (%) | 326 (3.68) | 160 (9.22) | 346 (9.25) | 150 (11.97) | 123 (8.54) | 192 (16.27) |
Maternal depression/serious anxiety, n (%) | 2061 (23.25) | 400 (23.05) | 1013 (27.09) | 302 (24.10) | 398 (27.64) | 299 (25.34) |
Total SDQ, mean (SD) | ||||||
Age 3 years (N = 13,600) | 9.63 (5.30) | 9.35 (4.84) | 9.86 (5.51) | 9.33 (5.14) | 9.12 (5.17) | 9.55 (5.36) |
Age 5 years (N = 13,831) | 7.37 (4.98) | 7.14 (4.83) | 7.45 (5.09) | 7.53 (5.13) | 6.88 (4.72) | 7.13 (5.12) |
Age 7 years (N = 12,687) | 7.44 (5.43) | 7.20 (5.13) | 7.73 (5.64) | 7.54 (5.43) | 7.14 (5.12) | 7.41 (5.54) |
Age 11 years (N = 11,055) | 7.37 (5.72) | 7.15 (5.26) | 7.76 (5.74) | 7.81 (5.93) | 7.14 (5.43) | 7.69 (5.85) |
Age 14 years (N = 10,745) | 8.17 (6.01) | 7.56 (5.62) | 8.52 (6.04) | 8.13 (5.88) | 7.74 (5.85) | 8.11 (5.81) |
Age 17 years (N = 8839) | 7.90 (6.19) | 7.73 (6.12) | 8.23 (6.37) | 7.82 (6.14) | 7.55 (6.17) | 7.68 (5.91) |
Mode of delivery and SDQ (ages 3, 5, 7, 11, 14 and 17 years)
No. in each exposure group with SDQ ≥ 17 | Total SDQ (cut-off ≥ 17) OR (95% CI)a | Emotional OR (95% CI)a | Conduct OR (95% CI)a | Hyperactivity OR (95% CI)a | Peer problems OR (95% CI)a | Prosocial behaviour OR (95% CI)a | |
---|---|---|---|---|---|---|---|
Age 3 years | |||||||
Spontaneous VD (N = 6571) | 710 | Ref | Ref | Ref | Ref | Ref | Ref |
Assisted VD (N = 1348) | 107 | 0.91 (0.68, 1.20) | 1.13 (0.82, 1.55) | 1.01 (0.85, 1.18) | 0.93 (0.75, 1.15) | 0.98 (0.78, 1.23) | 0.98 (0.72, 1.34) |
Induced VD (N = 2741) | 350 | 1.02 (0.86, 1.21) | 1.04 (0.84, 1.29) | 0.99 (0.88, 1.10) | 0.93 (0.80, 1.08) | 0.92 (0.79, 1.09) | 0.88 (0.70, 1.10) |
Emergency CS (N = 942) | 83 | 0.80 (0.58, 1.09) | 1.21 (0.87, 1.70) | 0.85 (0.70, 1.03) | 0.94 (0.73, 1.20) | 0.95 (0.74, 1.23) | 1.19 (0.85, 1.66) |
Planned CS (N = 1112) | 102 | 0.89 (0.67, 1.17) | 0.99 (0.70, 1.39) | 0.94 (0.79, 1.11) | 1.01 (0.81, 1.27) | 0.85 (0.66, 1.09) | 0.67 (0.48, 0.94)* |
CS after induction (N = 886) | 99 | 1.29 (0.95, 1.74) | 1.25 (0.88, 1.77) | 0.97 (0.80, 1.18) | 1.00 (0.78, 1.29) | 0.71 (0.54, 0.93) | 0.69 (0.47, 1.03) |
Age 5 years | |||||||
Spontaneous VD (N = 6714) | 372 | Ref | Ref | Ref | Ref | Ref | Ref |
Assisted VD (N = 1370) | 66 | 1.08 (0.77, 1.52) | 1.25 (0.92, 1.71) | 0.84 (0.64, 1.10) | 0.98 (0.77, 1.26) | 1.03 (0.77, 1.38) | 0.74 (0.41, 1.34) |
Induced VD (N = 2810) | 187 | 1.11 (0.89, 1.38) | 0.92 (0.72, 1.17) | 0.88 (0.74, 1.04) | 0.95 (0.80, 1.13) | 1.09 (0.89, 1.34) | 1.08 (0.75, 1.55) |
Emergency CS (N = 937) | 66 | 1.49 (1.04, 2.11)* | 1.08 (0.74, 1.55) | 0.86 (0.63, 1.17) | 1.30 (0.99, 1.70) | 1.39 (1.03, 1.87)* | 1.41 (0.81, 2.47) |
Planned CS (N = 1102) | 44 | 0.73 (0.48, 1.11) | 0.93 (0.64, 1.35) | 0.63 (0.46, 0.85)* | 0.91 (0.69, 1.21) | 0.93 (0.68, 1.28) | 0.87 (0.51, 1.47) |
CS after induction (N = 898) | 51 | 1.10 (0.75, 1.63) | 1.12 (0.77, 1.62) | 0.86 (0.63, 1.17) | 0.80 (0.59, 1.08) | 1.15 (0.83, 1.59) | 1.00 (0.54, 1.87) |
Age 7 years | |||||||
Spontaneous VD (N = 6161) | 450 | Ref | Ref | Ref | Ref | Ref | Ref |
Assisted VD (N = 1249) | 82 | 0.81 (0.58, 1.12) | 1.04 (0.77, 1.40) | 0.95 (0.72, 1.26) | 0.84 (0.66, 1.07) | 1.20 (0.92, 1.57) | 0.60 (0.33, 1.09) |
Induced VD (N = 2572) | 226 | 1.13 (0.92, 1.39) | 1.00 (0.81, 1.23) | 1.10 (0.92, 1.32) | 1.02 (0.86, 1.20) | 1.18 (0.98, 1.43) | 0.76 (0.50, 1.15) |
Emergency CS (N = 877) | 65 | 0.88 (0.61, 1.27) | 1.01 (0.71, 1.42) | 0.79 (0.57, 1.10) | 1.22 (0.94, 1.59) | 1.09 (0.79, 1.50) | 0.74 (0.38, 1.44) |
Planned CS (N = 1016) | 66 | 1.01 (0.72, 1.42) | 0.99 (0.71, 1.38) | 1.02 (0.77, 1.35) | 0.94 (0.72, 1.21) | 0.87 (0.64, 1.18) | 0.56 (0.28, 1.12) |
CS after induction (N = 812) | 55 | 0.88 (0.61, 1.28) | 0.97 (0.69, 1.37) | 0.91 (0.66, 1.25) | 0.87 (0.65, 1.17) | 0.99 (0.72, 1.37) | 0.99 (0.53, 1.87) |
Age 11 years | |||||||
Spontaneous VD (N = 5391) | 431 | Ref | Ref | Ref | Ref | Ref | Ref |
Assisted VD (N = 1099) | 76 | 0.94 (0.68, 1.29) | 1.09 (0.84, 1.42) | 0.67 (0.48, 0.94)* | 0.99 (0.74, 1.30) | 1.07 (0.82, 1.39) | 0.78 (0.43, 1.43) |
Induced VD (N = 2193) | 191 | 0.98 (0.79, 1.22) | 1.00 (0.83, 1.21) | 0.97 (0.79, 1.18) | 1.13 (0.94, 1.37) | 1.03 (0.85, 1.24) | 1.20 (0.79, 1.83) |
Emergency CS (N = 754) | 73 | 1.20 (0.86, 1.67) | 1.13 (0.85, 1.49) | 1.12 (0.81, 1.53) | 1.39 (1.05, 1.84)* | 1.32 (1.01, 1.75)* | 0.66 (0.29, 1.46) |
Planned CS (N = 892) | 55 | 0.77 (0.54, 1.11) | 1.16 (0.89, 1.52) | 0.86 (0.63, 1.18) | 0.93 (0.69, 1.25) | 0.90 (0.66, 1.21) | 0.79 (0.36, 1.75) |
CS after induction (N = 726) | 60 | 1.10 (0.76, 1.59) | 1.57 (1.19, 2.07)* | 0.85 (0.60, 1.21) | 0.90 (0.64, 1.26) | 1.44 (1.08, 1.90)* | 0.93 (0.47, 1.85) |
Age 14 years | |||||||
Spontaneous VD (N = 5310) | 526 | Ref | Ref | Ref | Ref | Ref | Ref |
Assisted VD (N = 1036) | 90 | 0.93 (0.69, 1.25) | 0.91 (0.70, 1.18) | 1.02 (0.76, 1.37) | 0.81 (0.59, 1.11) | 1.00 (0.79, 1.27) | 0.89 (0.61, 1.29) |
Induced VD (N = 2114) | 229 | 1.07 (0.87, 1.31) | 1.02 (0.85, 1.22) | 0.99 (0.81, 1.21) | 1.00 (0.81, 1.23) | 1.02 (0.86, 1.20) | 0.72 (0.52, 0.98) |
Emergency CS (N = 747) | 68 | 0.98 (0.70, 1.38) | 1.18 (0.89, 1.56) | 0.79 (0.56, 1.11) | 1.10 (0.78, 1.53) | 1.09 (0.85, 1.42) | 1.03 (0.67, 1.58) |
Planned CS (N = 851) | 75 | 1.03 (0.75, 1.42) | 0.92 (0.69, 1.21) | 1.09 (0.80, 1.48) | 0.93 (0.67, 1.29) | 0.85 (0.66, 1.11) | 0.85 (0.52, 1.36) |
CS after induction (N = 687) | 67 | 1.03 (0.73, 1.43) | 1.37 (1.04, 1.80)* | 0.87 (0.62, 1.22) | 1.13 (0.80, 1.58) | 1.04 (0.79, 1.35) | 1.04 (0.66, 1.64) |
Age 17 years | |||||||
Spontaneous VD (N = 4367) | 442 | Ref | Ref | Ref | Ref | Ref | Ref |
Assisted VD (N = 894) | 81 | 1.06 (0.78, 1.45) | 1.14 (0.88, 1.47) | 0.96 (0.70, 1.31) | 1.42 (1.01, 1.99)* | 0.87 (0.68, 1.11) | 1.23 (0.81, 1.86) |
Induced VD (N = 1671) | 196 | 1.19 (0.96, 1.48) | 0.93 (0.77, 1.13) | 1.17 (0.93, 1.47) | 1.09 (0.83, 1.43) | 0.90 (0.75, 1.08) | 1.06 (0.73, 1.52) |
Emergency CS (N = 638) | 58 | 1.08 (0.75, 1.56) | 1.15 (0.87, 1.53) | 0.78 (0.53, 1.16) | 0.95 (0.61, 1.47) | 1.10 (0.84, 1.43) | 0.51 (0.26, 1.00) |
Planned CS (N = 692) | 60 | 1.26 (0.89, 1.78) | 1.27 (0.97, 1.66) | 1.22 (0.86, 1.73) | 1.00 (0.65, 1.53) | 1.04 (0.80, 1.36) | 0.84 (0.46, 1.53) |
CS after induction (N = 577) | 49 | 1.04 (0.71, 1.50) | 1.20 (0.90, 1.62) | 0.81 (0.54, 1.21) | 0.94 (0.58, 1.52) | 0.80 (0.60, 1.08) | 1.04 (0.60, 1.80) |
Mean trajectory (95% CI) spontaneous VD | Mean trajectory (95% CI) assisted VD | Mean trajectory (95% CI) induced VD | Mean trajectory (95% CI) emergency CS | Mean trajectory (95% CI) planned CS | Mean trajectory (95% CI) CS after induction | |
---|---|---|---|---|---|---|
Model 1a | ||||||
Age 3 SDQ | 9.78 (9.67, 9.90) | 9.42 (9.17, 9.68) | 10.00 (9.82, 10.18) | 9.48 (9.18, 9.79) | 9.18 (8.90, 9.46) | 9.63 (9.32, 9.95) |
Change SDQ age 5 | −2.28 (−2.17, −2.39) | −2.21 (−1.96, −2.45) | −2.38 (−2.21, 2.55) | −1.82 (−1.53, −2.12) | −2.15 (−1.88, −2.42) | −2.37 (−2.07, −2.67) |
Change SDQ age 7 | 0.09 (−0.01, 0.20) | 0.12 (−0.11, 0.36) | 0.31 (0.15, 0.48) | 0.14 (−0.14, 0.43) | 0.16 (−0.09, 0.43) | 0.34 (0.04, 0.63) |
Change SDQ age 11 | 0.15 (0.03, 0.27) | 0.13 (−0.13, 0.40) | 0.15 (−0.03, 0.35) | 0.48 (0.15, 0.80) | 0.18 (−0.11, 0.48) | 0.40 (0.06, 0.74) |
Change SDQ age 14 | 0.59 (0.46, 0.72) | 0.25 (−0.03, 0.53) | 0.62 (0.42, 0.82) | 0.22 (−0.11, 0.55) | 0.53 (0.22, 0.84) | 0.37 (0.03, 0.72) |
Change SDQ age 17 | −0.09 (−0.24, 0.05) | 0.14 (−0.18, 0.46) | −0.01 (−0.24, 0.22) | −0.16 (−0.54, 0.22) | −0.03 (−0.40, 0.33) | −0.24 (−0.65, 0.15) |
Age 17 SDQ | 8.24 (8.07, 8.44) | 7.85 (7.46, 8.27) | 8.69 (8.42, 9.00) | 8.34 (7.86, 8.83) | 7.87 (7.42, 8.33) | 8.13 (7.63, 8.64) |
Model 2b | ||||||
Age 3 SDQ | 12.45 (10.35, 14.56) | 12.46 (10.35, 14.57) | 12.38 (10.27, 14.48) | 12.29 (10.18, 14.40) | 12.30 (10.19, 14.42) | 12.49 (10.38, 14.60) |
Change SDQ Age 5 | −1.11 (−3.41, 1.76) | −1.07 (−3.37, 1.22) | −1.18 (−3.47, 1.11) | −0.71 (−3.01, 1.58) | −1.09 (−3.39, 1.21) | −1.27 (−3.57, 1.03) |
Change SDQ Age 7 | −0.21 (−2.42, 1.98) | −0.29 (−2.50, 1.90) | −0.01 (−2.21, 2.19) | −0.25 (−2.45, 1.95) | −0.10 (−2.32, 2.10) | −0.04 (−2.25, 2.16) |
Change SDQ Age 11 | 0.43 (−2.16, 3.03) | 0.48 (−2.12, 3.08) | 0.39 (−2.20, 2.99) | 0.74 (−1.86, 3.35) | 0.35 (−2.25, 2.96) | 0.64 (−1.96, 3.24) |
Change SDQ Age 14 | 0.51 (−2.15, 3.18) | 0.29 (−2.38, 2.97) | 0.52 (−2.14, 3.19) | 0.24 (−2.43, 2.92) | 0.46 (−2.21, 3.14) | 0.38 (−2.29, 3.06) |
Change SDQ Age 17 | −1.77 (−4.65, 1.11) | −1.41 (−4.30, 1.47) | −1.67 (−4.55, 1.20) | −1.75 (−4.65, 1.13) | −1.74 (−4.64, 1.14) | −1.83 (−4.73, 1.06) |
Age 17 SDQ | 10.30 (6.85, 13.73) | 10.46 (7.00, 13.89) | 10.43 (7.00, 13.87) | 10.56 (7.11, 14.00) | 10.18 (6.71, 13.62) | 10.37 (6.91, 13.81) |