{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,1,31]],"date-time":"2026-01-31T06:50:55Z","timestamp":1769842255308,"version":"3.49.0"},"reference-count":35,"publisher":"American Medical Association (AMA)","issue":"1","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JAMA Netw Open"],"abstract":"\n Importance<\/jats:title>\n Prior studies have compared neurodevelopmental outcomes across delivery modes that are not interchangeable (eg, operative vs spontaneous vaginal delivery [SVD]), limiting the clinical utility of their conclusions.<\/jats:p>\n <\/jats:sec>\n \n Objective<\/jats:title>\n To examine the association between mode of operative delivery in the second stage of labor and attention-deficit\/hyperactivity disorder (ADHD), autism spectrum disorder (ASD), and intellectual disability (ID) in children.<\/jats:p>\n <\/jats:sec>\n \n Design, Setting, and Participants<\/jats:title>\n This population-based, retrospective cohort study used data from health administrative databases from British Columbia, Canada, from April 1, 2000, to December 31, 2019. The population included 504\u202f380 nonanomalous, singleton, full-term infants who survived and did not emigrate during their first year of life. Neurodevelopmental outcomes were collected through March 31, 2022, and analyses were performed from June 2024 to August 2025.<\/jats:p>\n <\/jats:sec>\n \n Exposure<\/jats:title>\n Delivery mode during the second stage of labor, categorized as SVD, forceps, vacuum, sequential instrument, or second-stage cesarean delivery (SSCD).<\/jats:p>\n <\/jats:sec>\n \n Main Outcomes and Measures<\/jats:title>\n The main outcome was ADHD, ASD, and ID from 1 year to a maximum of 22 years of age. Cox proportional hazards regression models were used to assess the association between mode of operative delivery (SVDs excluded) and each neurodevelopmental outcome, adjusting for maternal and clinical characteristics.<\/jats:p>\n <\/jats:sec>\n \n Results<\/jats:title>\n Among 504\u202f380 children (253\u202f256 males [50.2%] and 44\u202f202 [8.8%] with a maternal history of neurodevelopmental or psychiatric disorders), 407\u202f792 (80.9%) were delivered by SVD, 46\u202f493 (9.2%) by vacuum, 23\u202f140 (4.6%) by forceps, 3009 (0.6%) by sequential instrument, and 23\u202f946 (4.7%) by SSCD. The overall rate of ADHD was 6.6 (95% CI, 6.5-6.7) per 1000 person-years; ASD, 1.8 (95% CI, 1.7-1.8) per 1000 person-years; and ID, 0.3 (95% CI, 0.2-0.3) per 1000 person-years. Compared with SSCD, children who underwent sequential instrument delivery had a 13% higher ADHD rate (7.9 [95% CI, 7.1-8.8] vs 6.6 [95% CI, 6.3-6.9] per 1000 person-years; adjusted hazard ratio [AHR], 1.13 [95% CI, 1.00-1.28]) and those who underwent vacuum delivery had a 53% higher ID rate (0.3 [95% CI, 0.3-0.4] vs 0.2 [95% CI, 0.1-0.3] per 1000 person-years; AHR, 1.53 [95% CI, 1.12-2.10]). There was no significant association with ASD and mode of delivery.<\/jats:p>\n <\/jats:sec>\n \n Conclusions and Relevance<\/jats:title>\n The findings of this cohort study suggest that children who underwent operative vaginal delivery and SSCD had comparable neurodevelopmental outcomes, except among those who underwent sequential instrument delivery and vacuum delivery, which were associated with ADHD and ID, respectively. Further research is warranted to develop a better understanding of delivery mode as a potentially modifiable risk factor for neurodevelopmental disorders in childhood.<\/jats:p>\n <\/jats:sec>","DOI":"10.1001\/jamanetworkopen.2025.56637","type":"journal-article","created":{"date-parts":[[2026,1,30]],"date-time":"2026-01-30T16:30:21Z","timestamp":1769790621000},"page":"e2556637","source":"Crossref","is-referenced-by-count":0,"title":["Long-Term Neurodevelopmental Outcomes After Forceps, Vacuum, and Second-Stage Cesarean Delivery"],"prefix":"10.1001","volume":"9","author":[{"given":"Maya","family":"Rajasingham","sequence":"first","affiliation":[{"name":"Department of Obstetrics and Gynecology, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada"},{"name":"Department of Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Sarka","family":"Lisonkova","sequence":"additional","affiliation":[{"name":"Department of Obstetrics and Gynecology, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Neda","family":"Razaz","sequence":"additional","affiliation":[{"name":"Clinical Epidemiology Unit, Department of Medicine, Solna, Karolinska Institutet, Eugeniahemmet, Stockholm, Sweden"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Giulia M.","family":"Muraca","sequence":"additional","affiliation":[{"name":"Department of Obstetrics and Gynecology, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada"},{"name":"Department of Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada"},{"name":"Clinical Epidemiology Unit, Department of Medicine, Solna, Karolinska Institutet, Eugeniahemmet, Stockholm, Sweden"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"10","published-online":{"date-parts":[[2026,1,30]]},"reference":[{"issue":"5","key":"zoi251502r1","doi-asserted-by":"publisher","first-page":"326","DOI":"10.1177\/07067437231213553","article-title":"Prevalence and incidence trends of attention deficit\/hyperactivity disorder in children and youth aged 1-24 years in Ontario, Canada: a validation study of health administrative data algorithms: tendances de la pr\u00e9valence et de l\u2019incidence du trouble de d\u00e9ficit de l\u2019attention\/hyperactivit\u00e9 chez les enfants et les jeunes \u00e2g\u00e9s de 1 \u00e0 24 ans, en Ontario, Canada: une \u00e9tude de validation des algorithmes de donn\u00e9es administratives de sant\u00e9.","volume":"69","author":"Butt","year":"2024","journal-title":"Can J Psychiatry"},{"issue":"5","key":"zoi251502r2","doi-asserted-by":"publisher","first-page":"308","DOI":"10.1007\/s12519-022-00524-6","article-title":"Prenatal risk factors and genetic causes of ADHD in children.","volume":"18","author":"Kian","year":"2022","journal-title":"World J Pediatr"},{"key":"zoi251502r4","doi-asserted-by":"publisher","first-page":"155","DOI":"10.1016\/j.reprotox.2015.05.007","article-title":"Prenatal factors associated with autism spectrum disorder (ASD).","volume":"56","author":"Ornoy","year":"2015","journal-title":"Reprod Toxicol"},{"issue":"1","key":"zoi251502r5","doi-asserted-by":"publisher","DOI":"10.1093\/ije\/dyad184","article-title":"Association of pre-existing maternal cardiovascular diseases with neurodevelopmental disorders in offspring: a cohort study in Sweden and British Columbia, Canada.","volume":"53","author":"Hossin","year":"2024","journal-title":"Int J Epidemiol"},{"issue":"4","key":"zoi251502r6","doi-asserted-by":"publisher","first-page":"421","DOI":"10.1515\/jpm-2015-0059","article-title":"Preventing intellectual disability during pregnancy: what are the potentially high yield targets?","volume":"44","author":"Wang","year":"2016","journal-title":"J Perinat Med"},{"issue":"10064","key":"zoi251502r7","doi-asserted-by":"publisher","first-page":"14","DOI":"10.1016\/S0140-6736(16)31702-0","article-title":"Expanding the evidence base to drive more productive early childhood investment.","volume":"389","author":"Shonkoff","year":"2017","journal-title":"Lancet"},{"issue":"2","key":"zoi251502r9","doi-asserted-by":"publisher","first-page":"147.e1","DOI":"10.1016\/j.ajog.2007.03.034","article-title":"Neurodevelopmental outcome at 5 years after operative delivery in the second stage of labor: a cohort study.","volume":"197","author":"Bahl","year":"2007","journal-title":"Am J Obstet Gynecol"},{"issue":"8","key":"zoi251502r10","doi-asserted-by":"publisher","first-page":"1697","DOI":"10.1007\/s00127-022-02233-x","article-title":"Obstetrical mode of delivery and behavioural outcomes in childhood and adolescence: findings from the Millennium Cohort Study.","volume":"57","author":"Maher","year":"2022","journal-title":"Soc Psychiatry Psychiatr Epidemiol"},{"key":"zoi251502r11","doi-asserted-by":"publisher","DOI":"10.1016\/j.ajp.2022.103334","article-title":"Risks of attention-deficit\/hyperactivity disorder, autism spectrum disorder, and intellectual disability in children delivered by caesarean section: a population-based cohort study.","volume":"80","author":"Lin","year":"2023","journal-title":"Asian J Psychiatr"},{"issue":"3","key":"zoi251502r12","doi-asserted-by":"publisher","DOI":"10.1001\/jamanetworkopen.2021.0837","article-title":"Assessment of cesarean delivery and neurodevelopmental and psychiatric disorders in the children of a population-based Swedish birth cohort.","volume":"4","author":"Zhang","year":"2021","journal-title":"JAMA Netw Open"},{"issue":"9","key":"zoi251502r13","doi-asserted-by":"publisher","first-page":"935","DOI":"10.1001\/jamapsychiatry.2015.0846","article-title":"Association between obstetric mode of delivery and autism spectrum disorder: a population-based sibling design study.","volume":"72","author":"Curran","year":"2015","journal-title":"JAMA Psychiatry"},{"issue":"1","key":"zoi251502r14","doi-asserted-by":"publisher","first-page":"627","DOI":"10.1186\/s12884-025-07687-w","article-title":"Obstetric mode of delivery and risk of attention deficit hyperactivity disorder in children: insights from the Quebec Pregnancy Cohort.","volume":"25","author":"Sheehy","year":"2025","journal-title":"BMC Pregnancy Childbirth"},{"issue":"1","key":"zoi251502r15","doi-asserted-by":"publisher","DOI":"10.1136\/bmjpo-2023-002048","article-title":"Long-term neurodevelopmental outcome in children born after vacuum-assisted delivery compared with second-stage caesarean delivery and spontaneous vaginal delivery: a cohort study.","volume":"7","author":"Romero","year":"2023","journal-title":"BMJ Paediatr Open"},{"issue":"2","key":"zoi251502r16","doi-asserted-by":"publisher","first-page":"532","DOI":"10.1093\/ije\/dyw001","article-title":"Obstetric mode of delivery and attention-deficit\/hyperactivity disorder: a sibling-matched study.","volume":"45","author":"Curran","year":"2016","journal-title":"Int J Epidemiol"},{"issue":"8","key":"zoi251502r17","doi-asserted-by":"publisher","DOI":"10.1001\/jamanetworkopen.2019.10236","article-title":"Association of cesarean delivery with risk of neurodevelopmental and psychiatric disorders in the offspring: a systematic review and meta-analysis.","volume":"2","author":"Zhang","year":"2019","journal-title":"JAMA Netw Open"},{"issue":"3","key":"zoi251502r19","doi-asserted-by":"publisher","DOI":"10.1097\/og9.0000000000000084","article-title":"Temporal trends in second-stage cesarean birth in Ontario, Canada, 2012-2021.","volume":"2","author":"H\u00e9bert","year":"2025","journal-title":"O G Open"},{"issue":"9596","key":"zoi251502r22","doi-asserted-by":"publisher","first-page":"1453","DOI":"10.1016\/S0140-6736(07)61602-X","article-title":"The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies.","volume":"370","author":"von Elm","year":"2007","journal-title":"Lancet"},{"issue":"1","key":"zoi251502r23","doi-asserted-by":"publisher","first-page":"123","DOI":"10.1186\/s12884-015-0563-7","article-title":"Validating the British Columbia Perinatal Data Registry: a chart re-abstraction study.","volume":"15","author":"Frosst","year":"2015","journal-title":"BMC Pregnancy Childbirth"},{"issue":"3","key":"zoi251502r24","doi-asserted-by":"publisher","first-page":"456","DOI":"10.1002\/aur.2252","article-title":"Identification of pediatric autism spectrum disorder cases using health administrative data.","volume":"13","author":"Bickford","year":"2020","journal-title":"Autism Res"},{"issue":"2","key":"zoi251502r25","doi-asserted-by":"publisher","first-page":"603","DOI":"10.1007\/s10803-015-2616-1","article-title":"Obstetrical mode of delivery and childhood behavior and psychological development in a British cohort.","volume":"46","author":"Curran","year":"2016","journal-title":"J Autism Dev Disord"},{"issue":"4","key":"zoi251502r26","doi-asserted-by":"publisher","first-page":"356","DOI":"10.1111\/ppe.13162","article-title":"Timing of delivery of low-risk persons and the risk of attention-deficit hyperactivity disorder in offspring: Sweden and British Columbia, Canada.","volume":"39","author":"Nguyen","year":"2025","journal-title":"Paediatr Perinat Epidemiol"},{"issue":"1","key":"zoi251502r27","doi-asserted-by":"publisher","first-page":"e14","DOI":"10.1542\/peds.2013-1434","article-title":"Environmental risk factors by gender associated with attention-deficit\/hyperactivity disorder.","volume":"133","author":"Silva","year":"2014","journal-title":"Pediatrics"},{"issue":"6","key":"zoi251502r28","doi-asserted-by":"publisher","first-page":"727","DOI":"10.1038\/mp.2014.90","article-title":"Prenatal antidepressant exposure is associated with risk for attention-deficit hyperactivity disorder but not autism spectrum disorder in a large health system.","volume":"20","author":"Clements","year":"2015","journal-title":"Mol Psychiatry"},{"issue":"S2","key":"zoi251502r29","doi-asserted-by":"publisher","first-page":"203","DOI":"10.1007\/s11121-022-01359-3","article-title":"A systematic review and meta-analysis of prenatal, birth, and postnatal factors associated with attention-deficit\/hyperactivity disorder in children.","volume":"25","author":"Bitsko","year":"2024","journal-title":"Prev Sci"},{"issue":"2","key":"zoi251502r30","first-page":"429","article-title":"Caesarean section and risk of autism across gestational age: a multi-national cohort study of 5 million births.","volume":"46","author":"Yip","year":"2017","journal-title":"Int J Epidemiol"},{"issue":"4","key":"zoi251502r31","doi-asserted-by":"publisher","first-page":"361.e1","DOI":"10.1016\/j.ajog.2013.11.015","article-title":"Birth by vacuum extraction delivery and school performance at 16 years of age.","volume":"210","author":"Ahlberg","year":"2014","journal-title":"Am J Obstet Gynecol"},{"issue":"6","key":"zoi251502r32","doi-asserted-by":"publisher","first-page":"432","DOI":"10.1016\/S2352-4642(22)00067-0","article-title":"Mental health problems in children with intellectual disability.","volume":"6","author":"Totsika","year":"2022","journal-title":"Lancet Child Adolesc Health"},{"issue":"1","key":"zoi251502r33","doi-asserted-by":"publisher","DOI":"10.1371\/journal.pone.0050963","article-title":"Maternal conditions and perinatal characteristics associated with autism spectrum disorder and intellectual disability.","volume":"8","author":"Langridge","year":"2013","journal-title":"PLoS One"},{"issue":"4","key":"zoi251502r34","doi-asserted-by":"publisher","first-page":"1448","DOI":"10.1017\/S0954579420000620","article-title":"Early environmental risk factors for neurodevelopmental disorders\u2014a systematic review of twin and sibling studies.","volume":"33","author":"Carlsson","year":"2021","journal-title":"Dev Psychopathol"},{"issue":"10","key":"zoi251502r35","doi-asserted-by":"publisher","first-page":"819","DOI":"10.1016\/S2215-0366(19)30289-5","article-title":"Prevalence of co-occurring mental health diagnoses in the autism population: a systematic review and meta-analysis.","volume":"6","author":"Lai","year":"2019","journal-title":"Lancet Psychiatry"},{"key":"zoi251502r18","volume-title":"Williams Obstetrics","author":"Cunningham","year":"2018","edition":"25th ed"},{"key":"zoi251502r3","unstructured":"Autism spectrum disorder: highlights from the 2019 Canadian Health Survey on Children and Youth. 2022. Public Health Agency of Canada. Accessed February 7, 2025. https:\/\/www.canada.ca\/en\/public-health\/services\/publications\/diseases-conditions\/autism-spectrum-disorder-canadian-health-survey-children-youth-2019.html"},{"key":"zoi251502r8","unstructured":"Lee K, Cascella M, Marwaha R. Intellectual disability. In: StatPearls. StatPearls Publishing; 2025. Accessed February 7, 2025. https:\/\/www.ncbi.nlm.nih.gov\/books\/NBK547654\/"},{"key":"zoi251502r20","unstructured":"British Columbia Perinatal Data Registry. Perinatal Services British Columbia. Accessed February 5, 2025. https:\/\/www.perinatalservicesbc.ca\/health-professionals\/data-surveillance\/perinatal-data-registry"},{"key":"zoi251502r21","unstructured":"Population Data BC. University of British Columbia. Accessed February 5, 2025. https:\/\/www.popdata.bc.ca\/"}],"container-title":["JAMA Network Open"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/jamanetwork.com\/journals\/jamanetworkopen\/articlepdf\/2844567\/rajasingham_2026_oi_251502_1769180913.57345.pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,1,30]],"date-time":"2026-01-30T16:30:24Z","timestamp":1769790624000},"score":1,"resource":{"primary":{"URL":"https:\/\/jamanetwork.com\/journals\/jamanetworkopen\/fullarticle\/2844567"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,1,30]]},"references-count":35,"journal-issue":{"issue":"1","published-print":{"date-parts":[[2026,1,2]]}},"URL":"https:\/\/doi.org\/10.1001\/jamanetworkopen.2025.56637","relation":{},"ISSN":["2574-3805"],"issn-type":[{"value":"2574-3805","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,1,30]]}}}