Birthing Choices and ADHD Risk in Children

Data from over 500,000 births suggest delivery context may correlate with modest neurodevelopment differences

A large Canadian cohort study suggests certain operative vaginal delivery techniques may be associated with small increases in ADHD and intellectual disability risk, though absolute differences remain low and immediate birth safety remains the priority.

In more than 500,000 full-term births followed up to 22 years, sequential instrument delivery and vacuum-assisted birth were associated with slightly higher rates of ADHD and intellectual disability compared with second-stage cesarean delivery. However, the absolute risk differences were small, and experts emphasize that immediate maternal and neonatal safety outweighs long-term statistical associations.

Study Details

The study, published in JAMA Network Open, examined birth records from British Columbia, Canada, between 2000 and 2019. Researchers analyzed over 500,000 full-term births and followed children for up to 22 years to evaluate long-term neurodevelopmental outcomes.

Delivery modes included:

• Spontaneous vaginal delivery: 80.9%

• Vacuum-assisted delivery: 9.2%

• Forceps delivery: 4.6%

• Second-stage cesarean delivery: 4.7%

• Sequential instruments (vacuum followed by forceps): 0.6%

The study aimed to answer a common clinical question: Do late-stage delivery decisions meaningfully alter long-term risk of neurodevelopmental disorders such as attention-deficit/hyperactivity disorder (ADHD) or intellectual disability?

Methodology

Researchers conducted a population-based cohort study using linked administrative health databases.

They adjusted for multiple maternal, obstetric, and infant variables, including:

• Maternal age and health conditions

• Pregnancy complications

• Birth weight and gestational age

• Socioeconomic and demographic factors

The reference comparison group was second-stage cesarean delivery, meaning cesarean performed after full cervical dilation during labor.

Outcomes evaluated included:

• ADHD

• Intellectual disability

• Autism spectrum disorder

Hazard ratios were calculated to assess relative risk while accounting for confounders.

Key Findings

• Sequential instrument delivery was associated with a modestly higher ADHD risk compared with second-stage cesarean (adjusted hazard ratio 1.13).

• Vacuum-assisted delivery was associated with a 53% higher relative risk of intellectual disability compared with second-stage cesarean (aHR 1.53).

• Forceps delivery alone was not significantly associated with increased ADHD or intellectual disability.

• Autism spectrum disorder rates did not differ significantly by delivery mode.

• Absolute differences were small:

  • ADHD: 7.9 vs 6.6 cases per 1000 person-years (sequential instruments vs second-stage cesarean).

  • Intellectual disability: 0.3 vs 0.2 per 1000 person-years (vacuum vs second-stage cesarean).

Clinical Context

Independent expert commentary emphasized that delivery room decisions are driven primarily by immediate safety.

Operative vaginal delivery can sometimes be faster than transitioning to cesarean, particularly in cases of fetal distress. In many cases, the underlying indication for intervention, such as fetal distress or prolonged labor, may contribute more to long-term outcomes than the instrument itself.

Professional guidance from the American College of Obstetricians and Gynecologists has historically cautioned against sequential operative deliveries and highlighted rare but serious risks such as intracranial hemorrhage.

Importantly:

• Operative vaginal delivery is relatively uncommon in the United States.

• Sequential instrument use is generally avoided.

• Most long-term neurodevelopmental risk likely relates to complications during birth rather than the delivery method alone.

Implications for Practice

For expectant parents, these findings may sound concerning at first glance, but the overall message is reassuring. The absolute differences in risk were small. Most children delivered via vacuum or forceps do not develop ADHD or intellectual disability.

For clinicians, the study supports continued emphasis on individualized decision-making. Immediate maternal and neonatal outcomes should remain the primary priority. Statistical associations observed years later should not override urgent intrapartum safety considerations.