Exposure to anesthesia during delivery and risk of autism spectrum disorder: A retrospective cohort study

In this retrospective cohort study, cesarean delivery under general anesthesia, but not under neuraxial anesthesia, was associated with a higher risk of a later diagnosis of autism spectrum disorder compared to natural delivery.

Aviv Ben Kish, Yair Binyamin, Analya Michaelovski, Gal Meiri, Idan Menashe

First published: 11 February 2026

 https://doi.org/10.1111/aogs.70150

https://obgyn.onlinelibrary.wiley.com/toc/16000412/0/0

Transcript

SPEAKER_01 0:00

So for years now, if you go on any parenting forum, you've probably seen the threads. People are just terrified that getting an epidural during childbirth might, you know, increase the risk of autism.

SPEAKER_00 0:11

Oh yeah. The warnings, the whispered anxieties, it's everywhere online.

SPEAKER_01 0:15

Right. And when you're in that hospital room and you are exhausted, just navigating one of the most overwhelming experiences of your life, the last thing you need is this creeping fear that managing your pain is going to somehow harm your baby's future.

SPEAKER_00 0:30

Exactly. It's a high-stakes environment. And you want to make the best possible choice for you and your child.

SPEAKER_01 0:34

Aaron Powell Well, today we're looking at a massive 100,000-person study that finally proves the epidural is completely innocent. But and this is the big piece. But in the process of clearing the epidural, they uncovered a different, very real neurodevelopmental risk hiding right there in the delivery room.

SPEAKER_00 0:52

Yeah, we are looking at a scenario where the raw data seemed to point a finger at one thing, but uh when the statistical smoke actually cleared, the reality was entirely different.

SPEAKER_01 1:01

And that's why we do this, right? To help you separate those internet rumors from the hard, peer-reviewed evidence. Okay, let's unpack this. We are diving into a 2026 retrospective cohort study from the Acta Obstet Ginecole scan.

SPEAKER_00 1:16

Yes, and the scale of this deep dive is just incredible.

SPEAKER_01 1:19

It really is. The scope here is what caught my eye immediately. I mean, we're talking about tracking 98,630 single live births. This all happened at Soroka University Medical Center in Israel.

SPEAKER_00 1:30

Right, looking at deliveries between 2011 and 2019, and then following those children's development all the way up to January 2023.

SPEAKER_01 1:38

Aaron Powell Following nearly 100,000 kids over a decade, that gives you a level of statistical power that a small clinical trial just, you know, simply cannot achieve.

SPEAKER_00 1:47

No, it really can't. Especially when you have an endpoint like autism spectrum disorder or ASD. Because ASD often isn't reliably diagnosed until a child is, you know, three, four, or five years old.

SPEAKER_01 1:58

Aaron Powell Right. You need that long runway.

SPEAKER_00 1:59

Exactly. You need to be able to look back at the precise medical conditions of the birth years later.

SPEAKER_01 2:04

Aaron Powell So before we get to the final verdict on what is and isn't a risk, we need to understand the blueprint of this study. The researchers categorized all these mothers based on the mode of delivery and uh the type of pain management they received.

SPEAKER_00 2:18

Which is a crucial distinction to make right up front.

SPEAKER_01 2:20

Aaron Powell Yeah, let's clarify the terminology really quickly because reading through the source material, the words analgesia and anesthesia get thrown around a lot. And well, they aren't the same thing.

SPEAKER_00 2:30

Aaron Powell They get conflated all the time. But anagesia refers to pain relief, where you generally retain sensation and movement, you're just dulling the pain. Trevor Burrus, Jr.

SPEAKER_01 2:38

Like taking the edge off.

SPEAKER_00 2:39

Exactly. Anesthesia, on the other hand, that involves a complete loss of physical sensation and often a total loss of consciousness.

SPEAKER_01 2:47

Aaron Powell Okay, that distinction makes the four groups in this study make a lot of sense. So group one was the reference group, basically vaginal delivery without any analgesia, no medical pain relief.

SPEAKER_00 2:58

Aaron Powell Right, the baseline. And that was the majority, making up 64% of the births.

SPEAKER_01 3:02

Then group two was vaginal delivery with an epidural, which accounted for 21%. Moving from vaginal to surgical deliveries, group three was cesarean delivery with neuraxial anesthesia.

SPEAKER_00 3:13

So think spinal blocks or epidurals, where the mother is awake but completely numb from the chest down.

SPEAKER_01 3:18

Aaron Powell Right. And that was about 4% of the total births. And finally, group four was cesarean delivery with general anesthesia, where the mother is completely put to sleep. That made up 11% of the covort.

SPEAKER_00 3:29

Aaron Powell Setting up those four distinct lanes is well, it's how epidemiologists begin to isolate variables. You have to know the baseline before you can see if an intervention actually changes the outcome.

SPEAKER_01 3:40

Yeah, and I pulled the baseline numbers from the study. Across all 98,630 kids, regardless of how they were born, the overall diagnosis rate of ASD by 2023 was 0.54%.

SPEAKER_00 3:50

Aaron Powell Which comes out to 535 children.

SPEAKER_01 3:53

Right. So 0.54% is the baseline. But I have to admit, when I first looked at the unpolished raw numbers for the different anesthesia groups, my stomach just completely dropped.

SPEAKER_00 4:02

Oh, I bet. The initial unadjusted data can be quite alarming to read.

SPEAKER_01 4:06

Alarming is an understatement. The natural delivery group hovered right at that baseline, an ASD incid rate of 0.55%. But in the vaginal epidural group, it jumped to 1.25%.

SPEAKER_00 4:18

Yeah, that's a big jump.

SPEAKER_01 4:20

And for cesareans with a spinal block, it was 1.56%. And for cesareans with general anesthesia, 1.50%. When you just look at those raw numbers, it looks like getting any form of medical pain relief nearly doubles the risk of autism.

SPEAKER_00 4:35

It does look that way, yes.

SPEAKER_01 4:37

Like, wait, so does this mean any pain relief doubles the risk of autism? This feels like looking at a distorted shadow on the wall, you know. The shape is terrifying, but is it actually a monster or just a trick of the light? If someone just skimmed the abstract or saw a screenshot of that data table on social media, it would completely panic.

SPEAKER_00 4:53

Oh, absolutely. Which is precisely why raw data in epidemiology is essentially useless until it's been properly contextualized. Right. What's fascinating here is how scientists fix that trick of the light. In science, we're always hunting for confounding variables. A confounder is basically a hidden third factor that causes a false association between two things.

SPEAKER_01 5:12

It reminds me of that classic ice cream and shark attacks trap. Have you heard that one?

SPEAKER_00 5:16

Oh yeah, the correlation trap.

SPEAKER_01 5:18

Exactly. If you plot the data, ice cream sales and shark attacks both spike at the exact same time every year. The raw data shows a perfect correlation. You could look at a chart and conclude that eating a soft serve cone attracts sharks.

SPEAKER_00 5:35

Which is obviously absurd.

SPEAKER_01 5:37

Right. Because the confounding variable, the the hidden third factor, is the summer heat. Hot weather causes people to buy ice cream, and hot weather causes people to swim in the ocean where the sharks are. The ice cream didn't cause the shark attack, they were just, you know, happening in the same environment.

SPEAKER_00 5:52

That is the perfect way to look at this. The researchers had to figure out if the epidural was the ice cream.

SPEAKER_01 5:57

Exactly.

SPEAKER_00 5:58

And to do that, they built incredibly complex statistical models to adjust the math. They were systematically removing the summer heat from the delivery room. They looked at prenatal factors, perinatal factors during birth, and infant characteristics.

SPEAKER_01 6:11

Right. I noticed they adjusted for maternal age, which makes total sense. The data showed that mothers having cesarean deliveries were, on average, two to four years older than those having vaginal deliveries.

SPEAKER_00 6:21

Yes, and broader medical research confirms that advanced maternal age is independently associated with a slightly higher risk of ASD.

SPEAKER_01 6:29

Right, right. They also factored in gestational diabetes and uh whether the pregnancy involved assisted reproductive technology like IVF, both of which were higher in the medical intervention groups.

SPEAKER_00 6:41

The adjustments for the mother's health were rigorous. But the true summer heat in this scenario, the major confounding variable, was found when they analyzed the infant's immediate health at the time of delivery.

SPEAKER_01 6:52

Oh, right. When they filtered the data based on infant birth weight and apgar scores.

SPEAKER_00 6:57

Exactly.

SPEAKER_01 6:57

Let's define the apgar score for anyone who isn't familiar. Is that rapid-fire test they give to a newborn at one minute and five minutes after birth? They check the baby's heart rate, muscle tone, breathing, reflexes, and skin color.

SPEAKER_00 7:09

Aaron Powell Right. A high score means the baby is thriving outside the womb. A low score means the baby is in distress and needs immediate medical intervention. Aaron Powell Right.

SPEAKER_01 7:18

So what did the researchers find when they looked at that?

SPEAKER_00 7:20

Aaron Ross Powell They focused specifically on a one-minute abnormal apgar score and babies who were classified as small for gestational age. Those two factors indicate a difficult, potentially distressed environment in the womb or during the labor process itself.

SPEAKER_01 7:35

Aaron Ross Powell Okay. So the summer heat is fetal distress.

SPEAKER_00 7:38

Aaron Ross Powell Yes. And when the statisticians adjusted their models to account for those specific infant distress factors, the association between epidurals and ASD completely vanished. The math cleared the epidural entirely for both vaginal births and cesarean births.

SPEAKER_01 7:53

Oh wow. So the epidural was just in the room. The actual risk was linked to the underlying distress of the baby, which makes perfect sense.

SPEAKER_00 8:00

It really does.

SPEAKER_01 8:01

If a labor is difficult or prolonged or complicated, the baby is more likely to be in distress, resulting in a low apgar score. And that same difficult, painful labor is exactly the scenario where a mother is most likely to request an epidural.

SPEAKER_00 8:15

Exactly. The difficult labor was the summer heat causing both outcomes. The medication didn't cause the ASD risk, the complex nature of those specific births did.

SPEAKER_01 8:25

That is huge.

SPEAKER_00 8:26

It is a monumental finding for maternal care. Millions of people rely on epidurals to endure labor. The rigorous statistical filtering confirms that this common, highly effective form of analgesia does not carry a neurodevelopmental risk for the child.

SPEAKER_01 8:42

Hearing that is just a massive sigh of relief. Like if you are listening to this and building a birth plan, you can take that fear completely off your plate. But then this is where it gets tough. The relief only goes so far in this deep dive.

SPEAKER_00 8:56

Because of the fourth group.

SPEAKER_01 8:57

Yeah. Because as I kept reading, I realized that while the epidural got cleared, not every medical intervention survived that statistical gauntlet. We have to talk about the cesareans with general anesthesia.

SPEAKER_00 9:08

Right. Having eliminated epidurals and spinal blocks as risk factors, the conversation zeroes in on the single variable that the math could not clear. It did. Even after adjusting for maternal age, diabetes, IVF, birth weight, and those critical apgar scores, the general anesthesia group still showed a significant link to ASD.

SPEAKER_01 9:28

The resources calculated an adjusted hazard ratio of 1.571 for the general anesthesia cesarean group. If my math holds up, that means we are looking at roughly a 57% increased risk of an ASD diagnosis later in childhood compared to a natural delivery.

SPEAKER_00 9:46

Your math is spot on.

SPEAKER_01 9:47

And again, that is after they neutralize all those other confounding health and situational factors.

SPEAKER_00 9:52

Right. That 57% increase is the residual risk that remains when all other measurable factors are equalized. It points a compelling finger at the pharmacological agents used to induce complete unconsciousness.

SPEAKER_01 10:04

Okay, here's where it gets really interesting, though, because I want to play devil's advocate for a second. I struggled with this exact point when I was reviewing the data.

SPEAKER_00 10:11

Let's hear it.

SPEAKER_01 10:12

If you are being put under general anesthesia for a C-section, meaning you are completely knocked out, a breathing tube is inserted, isn't it almost always because something has gone terrifyingly wrong?

SPEAKER_00 10:21

Usually, yes. It's often an emergency.

SPEAKER_01 10:23

Right. We're talking about a massive split-second emergency where there is literally no time to place a spinal block. Couldn't the sheer trauma of that emergency, like the lack of oxygen to the baby or the extreme physiological panic, couldn't that be the thing causing the increased ASD risk and not the anesthesia drug itself?

SPEAKER_00 10:42

It is a vital critique of the findings. And honestly, the researchers anticipated the emergency trauma theory as their primary counterargument.

SPEAKER_01 10:50

Oh, they did? How do you even test for that?

SPEAKER_00 10:52

To test it, they took that entire general anesthesia group, the 11% of the total cohort, and they split it down the middle based on the urgency of the surgery.

SPEAKER_01 11:00

Aaron Powell Wait, really? What actually constitutes a non-urgent general anesthesia for childbirth? Uh-huh. I was under the impression you only got put to sleep if it was a life or death rushed down the hallway scenario with zero time to spare. Why would anyone have a calm, non-urgent C-section under general anesthesia?

SPEAKER_00 11:16

Aaron Powell There are actually several clinical reasons. Sometimes a patient has severe anatomical issues in their spine, like severe scoliosis or previous spinal fusion surgeries that make placing a spinal block physically impossible.

SPEAKER_01 11:28

Aaron Powell Oh, I hadn't thought of that.

SPEAKER_00 11:30

Yeah, or in other cases, a mother might have a bleeding disorder where a needle in the spine carries too high a risk of a spinal hematoma. Or there are cases of extreme maternal anxiety or psychiatric conditions where being awake during major abdominal surgery is strongly contraindicated.

SPEAKER_01 11:46

Aaron Powell Okay, that makes sense. So in those situations, the surgery is planned, calm, and non-urgent, but it still requires general anesthesia.

SPEAKER_00 11:55

Aaron Powell Exactly. So they essentially created two test groups, the forensic emergency trauma group and the calm planned surgery group. Both groups got the exact same general anesthesia drugs.

SPEAKER_01 12:06

Aaron Powell Okay, so what happened to the hazard ratio when they compared them?

SPEAKER_00 12:10

There was no significant difference. The hazard ratios between the urgent and non-urgent subgroups were effectively identical.

SPEAKER_01 12:16

Wait, really?

SPEAKER_00 12:17

Yes. The risk stayed elevated across the board.

SPEAKER_01 12:20

Wow. So the risk was consistent regardless of the panic level in the room. If the trauma of an urgent delivery was the culprit, you'd expect the ASD risk to spike in the urgent group and like plummet in the planned group.

SPEAKER_00 12:32

Exactly. The fact that it stayed high points directly at the chemical intervention itself, it strongly implies that the association is tied to the anesthesia drugs, not the surgical emergency.

SPEAKER_01 12:42

Which means we have to look at the pharmacology of what is actually happening when those specific medications are administered, which naturally leads us to the biology of it all. How could an anesthesia drug given to the mother cross over and affect the long-term brain development of the child?

SPEAKER_00 12:58

Well, if we connect this to the broader scientific landscape, this finding aligns with existing concerns. The FDA has previously issued warnings regarding potential neurotoxic changes in brain development linked to the use of general anesthesia in young children and pregnant women. Yes. Animal studies have increasingly suggested that early life exposure to volatile anesthetics might interfere with crucial stages of fetal brain development.

SPEAKER_01 13:24

Okay. What specifically are the drugs interfering with in the fetal brain?

SPEAKER_00 13:28

Aaron Ross Powell The primary concerns center around potential impacts on synaptogenesis and myelination.

SPEAKER_01 13:33

Aaron Powell Let me make sure I'm visualizing this correctly. So synaptogenesis is essentially the brain laying down the electrical wires, forming the connections between neurons.

SPEAKER_00 13:43

Aaron Powell That's a great way to put it, yes.

SPEAKER_01 13:45

Aaron Powell And myelination is the process of wrapping those newly formed electrical wires in a protective rubber insulation, the myelin sheath, so the electrical impulses can travel quickly without short circuiting.

SPEAKER_00 13:57

Aaron Powell That is a highly accurate way to visualize it. The fetal brain is undergoing an incredibly rapid, sensitive period of wiring and insulating right before birth. Right. If volatile anesthetic agents cross the placenta and disrupt those specific cellular processes during that critical window of vulnerability, it stands to reason that it could alter the neurodevelopmental trajectory of the child, potentially manifesting as ASD years later.

SPEAKER_01 14:23

The biological mechanism makes total sense. But as I was reading this, there was a glaring demographic detail in the study that I just couldn't wrap my head around.

SPEAKER_00 14:31

You mean the 11% figure?

SPEAKER_01 14:33

Yes. You mentioned earlier that 11% of the total births in this cohort use general anesthesia for a C-section. From everything I understand about modern obstetrics, doctors do everything in their power to avoid general anesthesia during birth. An 11% rate seems unusually, almost impossibly high for a minor medical center. Why was this specific intervention so common at this specific hospital?

SPEAKER_00 14:57

It's a great question. To understand that 11% figure, we have to look beyond biology and statistics. We have to examine the cultural context unique to the Negev region of southern Israel, where Saroka Medical Center is actually located.

SPEAKER_01 15:10

Aaron Powell Okay, what's unique about the region?

SPEAKER_00 15:12

Aaron Powell The patient population there is highly diverse, and a significant portion, over 25% of the regional population, is Bedouin Arab. In fact, the Bedouin population accounts for more than 50% of the births at this specific hospital.

SPEAKER_01 15:23

Aaron Powell I saw the demographic breakdown in the paper, but um, how does ethnicity dictate the type of anesthesia used in a delivery room?

SPEAKER_00 15:30

Aaron Powell It comes down to deeply rooted cultural beliefs and perceptions regarding spinal interventions. Within this specific community, there is a strong, culturally prevalent hesitation and often outright refusal to accept epidurals or noraxial anesthesia.

SPEAKER_01 15:47

Oh wow. Really? Why is that?

SPEAKER_00 15:49

It stems from various community beliefs. Sometimes it's fear of long-term back pain, fear of paralysis, or simply a deeply held cultural norm about experiencing the natural process of labor without intervention.

SPEAKER_01 16:01

Right, I see.

SPEAKER_00 16:02

Because of these cultural norms, many Bedouin women strongly prefer to decline epidurals, even for pain management during intense vaginal labor.

SPEAKER_01 16:10

Aaron Powell Uh I see where the domino effect starts. If a mother declines an epidural during a standard labor, and then suddenly the labor stalls or you know a complication arises where an emergency cesarean becomes medically necessary.

SPEAKER_00 16:23

She doesn't have a spinal block already in place.

SPEAKER_01 16:25

Exactly.

SPEAKER_00 16:25

Placing a new spinal block takes time and requires the patient to sit perfectly still, which is incredibly difficult during an emergency complication. Furthermore, even when a C-section is recommended, many women in this demographic will continue to decline the spinal block for the surgery itself due to those same cultural fears.

SPEAKER_01 16:44

So the doctors are backed into a corner.

SPEAKER_00 16:46

Precisely. The medical staff, faced with an urgent need to perform major surgery safely and painlessly, has no choice but to default to general anesthesia.

SPEAKER_01 16:56

It's a total cascade of choices. The cultural preference to avoid the spinal needle inadvertently pushes the medical team into using the more aggressive chemical intervention when surgery becomes unavoidable.

SPEAKER_00 17:07

Right. Additionally, many women in this specific demographic tend to have larger families, leading to a higher rate of multiple repeated C-sections.

SPEAKER_01 17:15

Oh, and repeated C-sections are complicated, right?

SPEAKER_00 17:19

A second, third, or fourth C-section carries significantly higher complication risks due to scar tissue. In those complex surgical scenarios, an optetrician might actually prefer general anesthesia because it provides more profound muscle relaxation and better overall surgical conditions.

SPEAKER_01 17:35

Wow. Okay, that cultural and medical context perfectly explains why the exposure rate was an astonishing 11%. But wait, this introduces a massive potential confounder.

SPEAKER_00 17:47

Yes, it does.

SPEAKER_01 17:48

If this one specific ethnic group is receiving the vast majority of the general anesthesia, couldn't their genetics or their environment or their socioeconomic status be the hidden summer heat? Could the autism risk actually be tied to the demographic reality of the Bedouin population rather than the anesthesia drug?

SPEAKER_00 18:04

That is the exact question you should be asking. And the researchers recognized that exact vulnerability in their data. To ensure the demographic wasn't the confounder, they ran a rigorous sensitivity analysis.

SPEAKER_01 18:14

How did they do that?

SPEAKER_00 18:15

They stratified the data by ethnicity, basically separating the cohort to see if the ASD risk associated with general anesthesia differed between the Bedouin children and the Jewish children in the study.

SPEAKER_01 18:27

And what did the stratified data show?

SPEAKER_00 18:29

The result was definitive. The increased risk associated with general anesthesia remained consistent across both groups. The 57% increased risk held true regardless of ethnicity.

SPEAKER_01 18:40

So it wasn't a confounder at all. No.

SPEAKER_00 18:42

The cultural difference did not confound the actual finding. It merely explained why the sample size for general anesthesia was so unusually robust. It gave the researchers enough statistical power to finally detect the link.

SPEAKER_01 18:54

It's just incredible how all these disparate pieces lock together. You have deeply held cultural beliefs driving individual medical choices. Those choices inadvertently create a massive, unique data set. And then that data set allows scientists to spot a neurodevelopmental risk that might have been entirely invisible in a typical hospital where general anesthesia is only used like 1% of the time.

SPEAKER_00 19:16

It is a remarkable chain of causality. And what is truly encouraging is how the hospital responded to their own data. They didn't just publish the paper in a journal and walk away.

SPEAKER_01 19:26

Wait, they actually changed their practices.

SPEAKER_00 19:28

Yes. If we connect this to the bigger picture, armed with this very information, the medical staff at Soroka Medical Center initiated a massive intervention starting in 2020.

SPEAKER_01 19:39

But how do you intervene against a deeply held cultural belief? I mean, you can't just force someone to take a spinal block.

SPEAKER_00 19:46

You intervene with education. They made a concerted, extensive effort to communicate these exact statistical risks regarding general anesthesia directly to the women coming in for deliveries.

SPEAKER_01 19:57

Oh wow. Just giving them the data directly.

SPEAKER_00 19:59

Exactly. They respected the cultural hesitation regarding spinal taps, but they clearly laid out the newly discovered risks to the infant's neurodevelopment. By providing the hard data, they empowered these mothers to make a more informed choice, weighing the cultural fear of the spinal block against the statistical risk of the general anesthesia.

SPEAKER_01 20:17

Did it work?

SPEAKER_00 20:18

It did. As a result, the hospital achieved a significant measurable shift towards spinal anesthesia for C-sections within that population.

SPEAKER_01 20:26

That is amazing. So what does this all mean for you, the listener? Let's distill this entire deep dive down to the actionable takeaways. If you or a partner or a loved one are pregnant and navigating the stressful terrain of childbirth, this massive data set offers a really clear, calming signal through the noise.

SPEAKER_00 20:44

A very calming signal.

SPEAKER_01 20:46

First, the data strongly statistically supports the safety of epidurals and anoraxial anesthesia when it comes to ASD risk. The rigorous math completely clears them. The relief that an epidural provides during labor does not come at the cost of an increased risk of autism for your child.

SPEAKER_00 21:02

That is the primary reassurance here. The epidural is not the hidden danger in the room.

SPEAKER_01 21:07

Right. But second, and perhaps more importantly, this study provides a crucial evidence-based data point for your birth plan. It is a powerful reason to actively advocate for avoiding general anesthesia during a C-section unless it is absolutely strictly medically necessary. Absolutely. If you have the option for a spinal block for your surgical delivery, the science firmly points to it being the safer choice for your baby's long-term neurodevelopment, protecting those vital processes of wiring and insulating the brain.

SPEAKER_00 21:36

I couldn't agree more. And as we wrap up, I'd like to leave you with a thought that stretches a bit beyond the walls of the delivery room.

SPEAKER_01 21:44

Please do.

SPEAKER_00 21:45

This study from southern Israel proves that a medical database isn't just a cold record of biology, it is a living, breathing mirror of human culture.

SPEAKER_01 21:53

Aaron Powell That's a beautiful way to put it.

SPEAKER_00 21:55

In the Negev, deeply held community beliefs directly dictated the Type of chemical anesthesia these mothers received. And that invisible cultural choice, in turn, subtly altered the long-term neurodevelopmental statistics of an entire generation. It makes you realize how deeply intertwined our social values are with our biological outcomes. It makes you wonder, you know, what deep-seated cultural preferences in your own community are invisibly shaping your local health data right now.

SPEAKER_01 22:23

What a question to end on. Because the data isn't just driven by the medical instruments, right? It's driven by the beliefs, the fears, and the humanity of the people in the bed. Thank you so much for joining us on this deep dive and for taking the time to get truly well informed. We will catch you on the next one.