Child & Youth Care Forum (2019) 48:405–425

https://doi.org/10.1007/s10566-019-09487-8

ORIGINAL PAPER

Delivery Mode, Maternal Characteristics, and Developmental

Trajectories of Toddlers’ Emotional and Behavioral Problems

Jurgita Smilte Jasiulione1   · Roma Jusiene1

Published online: 9 January 2019

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Abstract
Background  Little empirical research examines relationships among delivery mode, other
childbirth-related factors, maternal characteristics, and child psychosocial development.
Objective  The aim of this study is to explore the developmental trajectories of toddlers’
emotional and behavioral problems and the predictive role of psycho-social, childbirth, and
maternal characteristics.
Method  Participants were 258 mothers and their children who took part in a longitudi-
nal study from birth till the age of 30  months. Self-report instruments were used for the
assessment of mothers’ infant rearing attitudes, the quality of relationship with the partner,
maternal emotional distress, and maternal self-efficacy. The Child Behavior Checklist (1½–
5) was used for the assessment of children’s behavioral and emotional problems.
Results  Latent class analysis for emotional and behavioral problems ended in 3-class solu-
tions. In regard to emotional problems, 83% of children were classified as having a stable
low, 11% an increasing, and 6% a decreasing level of emotional problems. In regard to
behavioral problems, 86% of children showed a stable low, 5% an increasing, and 9% a
stable high level of behavioral problems. Children’s gender in combination with mater-
nal education and maternal infant rearing attitudes predict children’s membership in the
increasing and decreasing emotional problem classes. Children’s gender and maternal age
in combination with emergency caesarean section, the quality of the relationship with the
partner, and maternal self-efficacy explain children’s membership in the classes of high and
increasing behavioral problems.
Conclusions  A combination of such factors as emergency caesarean section, child’s gen-
der, maternal age and level of education, maternal infant rearing attitudes, maternal self-
efficacy, and inter-parental relationships predict developmental trajectories of emotional
and behavioral problems in toddlers.

Keywords  Emotional and behavioral problems · Developmental trajectories · Delivery

mode · Emergency caesarean section · Maternal self-efficacy · Infant rearing attitudes

* Jurgita Smilte Jasiulione

jurgita.valiukeviciute@gmail.com
1
Institute of Psychology, Faculty of Philosophy, Vilnius University, Universiteto str. 9/1,
01513 Vilnius, Lithuania

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 406 Child & Youth Care Forum (2019) 48:405–425

Introduction

Research on early human development shows that epigenetic, immunological, physiologi-

cal, and psychological adaptations to the environment start from the moment of concep-
tion, which bespeaks the importance of the period from conception to 2–3 years of age for
development throughout the life course (Britto et  al. 2016). There are a number of stud-
ies investigating the links between children’s early psychosocial development and prena-
tal and postnatal maternal and environmental factors. Findings from other studies suggest
that early manifestations of children’s emotional and behavioral problems are associated
with maternal anxiety and symptoms of maternal depression during pregnancy (Leis et al.
2014), maternal perinatal disorders (Stein et  al. 2014), and paternal postnatal depression
(Gutierrez-Galve et al. 2015). Meanwhile, the different circumstances of childbirth, such as
the mode of delivery or administration of oxytocin and other medications during delivery
and their role in children’s later development are overlooked. Predominant in this field is
research on the impact of caesarean section on children’s development. Delivery by cae-
sarean section is a recognized risk factor for a number of health risks, including short-term
lung function impairment (Martelius et al. 2013), reduced breastfeeding initiation (Hobbs
et al. 2016), as well as long-term effects on the development of immune system (Cho and
Norman 2013) and immune-related conditions such as asthma (Magnus et  al. 2011) and
respiratory and food allergies (Almqvist et al. 2012; Metsälä et al. 2008).
Despite the growing interest, much less is known about the potential impact of delivery
mode and other childbirth-related factors on the psychosocial development, emotions, and
behavior of the infant and child. Al Khalaf et al. (2015) investigated the links between the
mode of delivery and early childhood behavior and motor development. The findings of
this research suggest that at age 9 months, elective caesarean section (CS) was associated
with a delay in personal social skills and delay of gross motor function, whereas emer-
gency CS was associated with delayed gross motor function. But at age 3 years there was
no significant increase in the risk of emotional and behavioral problems across all modes
of delivery (Al Khalaf et  al. 2015). Kelmanson (2013) found that at the age of 5  years,
children born by elective caesarean section had more emotional problems, including higher
scores on anxiety/depression and withdrawal problems, and more sleep problems com-
pared with children born by vaginal delivery (Kelmanson 2013). In yet other studies, an
association between caesarean section and the etiology of autism is hypothesized. Chien
et al. (2015) examined the incidence of autism in neonates delivered vaginally, by caesar-
ean section with regional anesthesia, and by caesarean section with general anesthesia to
evaluate the risk of autism associated with caesarean section and obstetric anesthesia. The
results of this study revealed that the incidence of autism was higher in neonates delivered
by caesarean section with general anesthesia than in neonates delivered vaginally (Chien
et  al. 2015). Furthermore, Liang and Chikritzhs (2012) found that vacuum and forceps-
assisted delivery as well as emergency caesarean were associated with an increased risk of
the first ever mental health contact. In this study, an Apgar score of 7–9 at 5 min was asso-
ciated with a significantly higher risk of treatment for a mental disorder when compared to
an Apgar of 10. These results suggest that obstetric conditions at birth may influence the
risk of mental disorders in later life (Liang and Chikritzhs 2012).
The child‘s developmental disadvantages can be associated with a number of physi-
cal childbirth factors such as preterm birth, childbirth complications, and low birth weight
(e.g., Cassiano et  al. 2016). However, it is not clear whether the links between delivery
mode, administration of medication during childbirth, and child’s later development could be

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Child & Youth Care Forum (2019) 48:405–425 407

significant when physical childbirth risk factors are controlled. Therefore it is worthwhile to
explore the development of children born full-term, with normal Apgar scores, from low-risk
pregnancies and deliveries, and without any inborn abnormalities or disabilities.
Findings from other studies indicate that childbirth circumstances also have an impact on
mothers and their emotional wellbeing. For example, it was found that obstetric analgesia may
have some adverse effect on maternal emotional state: namely, epidural fentanyl was nega-
tively related with breastfeeding (Jordan et al. 2005) and nitrous oxide inhalation during natu-
ral delivery was identified as a risk factor for maternal depression 3–4 months after delivery
(Jusiene and Žaliene 2012). The significance of maternal mental health and emotional wellbe-
ing during the postnatal and early childhood periods for the child’s development is reported
in a number of studies (e.g., Giallo et al. 2013; Kingston and Tough 2014). Hence, research
that takes into account childbirth-related factors in addition to other determinants of children’s
development could provide a deeper understanding of the early causes of children’s mental
health problems and lend new insights about their prevention.
According to the World Health Organization, mental health is one of the most important
topics of public health of this century, and mental health of young children should be con-
sidered a priority area. More than 50% of mental health disorders diagnosed in adults begin
in childhood (WHO 2013). It is crucial to identify early risk and protective factors related to
early psychosocial development in order to ensure infants’ and toddlers’ sustainable mental
health. Moreover, it is important to assess the children’s developmental factors from a long-
term perspective. In view of this, we conducted a longitudinal study whose aim was to analyze
the developmental trajectories of emotional and behavioral problems during toddlerhood and
to identify a range of psychosocial, childbirth-related, and maternal factors that have a signifi-
cant impact on the developmental trajectories of emotional and behavioral problems.
This study is part of the prospective birth-cohort study initiated in 2009. It must be noted
that findings from previous studies suggest that difficult infant behavior at the age of 3 and
6 months and children’s emotional and behavioral problems at the age of 18 months are pre-
dicted by complicated maternal and paternal emotional acceptance of pregnancy, a poor state
of the couple’s relationship before pregnancy, and rigid and parent-oriented attitudes toward
infant rearing (Sirvinskiene et al. 2012, 2016). Furthermore, newborns’ suboptimal function-
ing after birth and poor maternal emotional state during pregnancy and in the first months
after childbirth serve as risk factors for children’s emotional and behavioral problems at the
age of 18 months (Sirvinskiene et al. 2016). In the current study we aim to explore develop-
mental changes in children’s emotional and behavioral problems during the next 12 months of
life and identify what psychosocial, childbirth-related, and maternal factors remain important
predictors for these changes. We hypothesize that such childbirth-related factors as delivery by
caesarean section will be significant risk factor for the increasing or high developmental tra-
jectories of children’s emotional and behavioral problems, especially in combination with such
maternal factors as emotional distress after childbirth. We also assume that such maternal fac-
tors as flexible and child-oriented attitudes to infant care as well as high maternal self-efficacy
will serve as protective factors for the stable low developmental trajectories of children’s emo-
tional and behavioral problems.

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 408 Child & Youth Care Forum (2019) 48:405–425

Method

Participants

The sample for this study was drawn from a larger longitudinal birth-cohort study initi-
ated in 2009. The study was performed with the approval of the Regional Biomedical
Research Ethics Committee and informed consent was obtained from all participating
mothers. Criteria for inclusion in the current study were singleton, full-term (during
gestational weeks 37–42) childbirth, absence of any inborn abnormalities or disabilities,
Apgar scores ≥ 7, mother’s age at least 18  years, and mother living with a partner. In
total, 258 mothers and their children took part in the study. 141 (54.6%) of participating
children were male and 117 (45.4%) female, 230 (89.1%) children were born at a hospi-
tal and 28 (10.9%) during homebirth. Of participating mothers, 204 (78.8%) had higher
education, 228 (88%) were married, and 197 (76.3%) were living in an urban area. More
detailed information about the sample is presented in Table 1.
Participants were divided into four groups by the mode of delivery: vaginal delivery
without any medication administered (n = 81); vaginal delivery with administration of
medication such as oxytocin, epidural analgesia, nitrous oxide, systemic medications,
ketoprofen, or pethidine (n = 100); emergency caesarean section (n = 54); elective cae-
sarean section (n = 23).

Procedure

As the study is longitudinal in design, the data were collected over a few stages. Medi-
cal data about delivery were collected by the medical staff of the hospital and from
mothers themselves in the cases of home birth. Psychosocial data in the late stages
were collected by a group of psychologists. Lastly, collection of psychosocial data from
questionnaires filled in by mothers was conducted via mail and e-mail at 3  months,
18 months, and 30 months postpartum.

Table 1  Sample characteristics Mean/N SD/proportion

1. Child characteristics
Boys (n, p) 141 54.6
Firstborn (n, p) 122 47.3
Gestational age: weeks (mean, ± SD) 39.55 1.09
Apgar scores (mean, ± SD) 9.51 .66
Age: months (T1) 19.07 1.34
Age: months (T2) 29.21 1.48
2. Parental characteristics
Maternal age (mean, ± SD) 29.6 5.1
Maternal education: high (n, p) 204 78.8
Father‘s education: high (n, p) 174 67.2
Married (n, p) 228 88
Residence: urban (n, p) 197 76.3

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Child & Youth Care Forum (2019) 48:405–425 409

Measures

Demographic characteristics of the mothers were assessed through questions about mater-
nal age, education, and family structure (married or cohabiting).
Delivery mode information about delivery mode, medication administered during deliv-
ery, and Apgar scores were collected by the staff of the hospital.
Maternal attitudes to infant care were assessed using the Infant-Rearing Attitudes and
Beliefs Scale (Zeifman 2003) 3 months after delivery. The scale consists of 8 statements
and mothers were asked to indicate on an 8 point scale ranging from very strong agreement
to very strong disagreement how much they supported the viewpoint expressed in each
of the statements. The scale allows evaluating the extent to which mothers hold “infant-
oriented” versus “parent-oriented” attitudes regarding infant care. The internal consistency
of this scale is good (Cronbach’s α = .78).
Maternal emotional distress was evaluated by a few questions on how often during the
first 3 months after delivery mothers had experienced emotions such as irritability or bad
mood, feeling sad or low, and feeling nervous or anxious. A higher score on this measure
indicates a lower level of distress.
Quality of the relationship with partner during 3 months after delivery was evaluated
using one question with a Likert type scale ranging from “a very bad relationship” (1 point)
to “a very good relationship” (5 points).
Maternal self-efficacy was measured with the 22-item Parental Efficacy Questionnaire
(Van Ijzendoorn et al. 1999) when children were 18 months old. Items (e.g., “Even when
I am visiting other people, I can prevent my child from arguing over a toy”) were rated on
a five-point scale from − 2 (I really can’t) to 2 (I really can) and summed up to create an
overall score of maternal self-efficacy. A higher score on this scale indicates a higher level
of mother’s self-efficacy. Cronbach’s alpha for internal consistency of the scale was .88.
Children’s emotional and behavioral problems were measured using the Child Behav-
ior Checklist for Ages 1½–5 (CBCL/1½–5; Achenbach and Rescorla 2000) completed by
mothers. This measure was used at two times: at children’s age of 18 (T1) and 30 (T2)
months. The questionnaire consists of 100 items describing various aspects of young chil-
dren’s behavioral, emotional, and social functioning. Two aggregated scales of emotional
(internalizing) and behavioral (externalizing) problems were computed. Emotional prob-
lems include such aspects of emotional functioning as anxiety, depressiveness, somatic
complaints, and withdrawal; behavioral problems include aggressive behavior and attention
problems. The internal consistency (Cronbach’s α) of the Emotional Problems Scale was
.84 and internal consistency of the Behavior Problems Scale was .89.

Analysis Strategy

Latent class growth analysis in Mplus Version 6.0 (Muthén and Muthén 2000, 2006) was
performed to identify subgroups of toddlers with different developmental trajectories of
emotional and behavioral problems. We used the following criteria and reasoning to deter-
mine the number of subgroups in the developmental trajectories of emotional and behavio-
ral problems (see Jung and Wickrama 2008): (1) adding an additional group should result
in an improvement of model fit indicated by a decrease in the sample-size adjusted Bayes-
ian information criterion (SSA BIC) and by a significantly adjusted Lo–Mendell–Rubin
likelihood ratio p test value (p < .05); (2) a high value of entropy (values closer to 1) is an

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indicator of a good classification accuracy; (3) for meaningful interpretation and further
analysis of data, every group has to cover at least 5% of the sample.
Little’s (1988) Missing Completely at Random test was used to estimate missing val-
ues. The test yielded non-significant results [χ2(408) = 449.564, p = .076] indicating that
the data were missing at random. The problem of missing data in Mplus Version 6.0 was
addressed by using the full information maximum likelihood procedure (Muthén and
Muthén 2000). Mplus provides a covariance coverage matrix that gives the proportion of
the available observations for each variable. The minimum coverage necessary for models
to converge is .10 (Muthén and Muthén 2000). In our data, coverage ranged from .59 to
.88, which is adequate for reliable estimation.
Further analysis was carried out by SPSS version 22.0 for Windows. Nonparametric
statistics (Spearman’s correlation and Kruskal–Wallis test) were used in order to compute
correlations between variables and compare different trajectories of emotional and behav-
ioral problems across childbirth, sociodemographic, and maternal variables, and multino-
mial logistic regression was performed in order to identify factors predicting group mem-
bership in the trajectories. The level of two-sided statistical significance was set at p < .05.

Results

Correlations Across Psychosocial, Childbirth, and Maternal Variables

First, correlations across psychosocial, childbirth, and maternal variables were computed
(Table  2). Significant correlations between delivery mode, maternal characteristics, and
children’s emotional and behavioral problems were found: all modes of delivery corre-
lated with maternal age, while elective caesarean section was associated with maternal
education. Vaginal delivery without medication correlated with quality of the relation-
ship with the partner, maternal distress, infant rearing attitudes, and emotional problems at
18 months. Emergency caesarean section correlated with maternal distress, infant rearing
attitudes as well as with all measures of emotional and behavioral problems. All correla-
tion coefficients are reported in Table 2.

Latent Class Growth Analysis of Emotional and Behavioral Problems

Latent class growth analysis fit statistics for emotional and behavioral problems are summa-
rized in Table 3. Models with different numbers of classes were compared with the Bayes-
ian information criterion (BIC), the sample-size adjusted Bayesian information criterion
(SSABIC), the Akaike information criterion (AIC), the Entropy criterion, and Lo–Men-
del–Rubin adjusted likelihood ratio test. Based on the criteria previously described, we
decided upon a three-class solution as best fitting the LCA model for both emotional and
behavioral problems.
In regard to emotional problems, 83% (n = 211) of children were classified as hav-
ing a stable low level, the level of 11% (n = 27) was increasing when children were rated
as exhibiting a relatively low level of emotional problems at the age of 18  months and
reaching a high level at the age of 30 months, and the level of emotional problems of 6%
(n = 16) was classified as decreasing when it started at a relatively high level at the age of
18 months and reached a medium level at the age of 30 months. For behavioral problems,

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 Table 2  Correlations across psychosocial, childbirth, and maternal variables
Apgar Gesta- Child‘s Maternal Maternal Family Relation- Distress Infant Maternal Emo- Behav- Emo- Behavioral
scores tional gender education age status ship with rearing self- tional ioral tional problems
age (boy) partner attitudes efficacy problems problems problems T2
T1 T1 T2

Delivery mode
 Vaginal .116 − .015 .014 .076 .162** − .037 − .200** .190** .360** − .077 − .200** − .093 − .042 − .065
with-
out
medi-
cation
 Vaginal − .059 .027 − .023 − .116 − .162** .022 .113 .067 − .129 .108 .049 − .030 − .128 − .054
Child & Youth Care Forum (2019) 48:405–425

with
medi-
cation
 Emer- − .014 .081 − .016 − .060 − .138* .050 .012 − .255** − .197** − .044 .145* .158* .248** .183*
gency
cesar-
ean
sec-
tion
 Elected − .050 − .139* .040 .164** .213** − .047 .128 − .087 − .121 .007 .032 − .024 .− 063 − .062
cesar-
ean
sec-
tion
Apgar 1.000 – – – – – – – – – – – – –
scores
Gesta- .072 1.000 – – – – – – – – – – – –
tional
age
411

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 Table 2  (continued)
412

Apgar Gesta- Child‘s Maternal Maternal Family Relation- Distress Infant Maternal Emo- Behav- Emo- Behavioral
scores tional gender education age status ship with rearing self- tional ioral tional problems

13
age (boy) partner attitudes efficacy problems problems problems T2
T1 T1 T2

Child‘s − .040 − .096 1.000 – – – – – – – – – – –

gender
(boy)
Maternal − .015 .091 .066 1.000 – – – – – – – – – –
educa-
tion
Maternal − .064 − .128* .079 .300** 1.000 – – – – – – – – –
age
Family − .009 − .007 .066 .208** − .021 1.000 – – – – – – – –
status
Relation- − .033 .065 .002 − .040 − .107 .101 1.000 – – – – – – –
ship
with
partner
Distress − .011 .005 − .139 .047 .026 .057 .021 1.000 – – – – – –
Infant − .047 − .053 .015 .220** .180* .073 − .198* .304** 1.000 – – – – –
rearing
atti-
tudes
Maternal .036 − .033 .014 .023 − .164 .041 .263** .245** .087 1.000 – – – –
self-
efficacy
Emo- − .105 .007 .130 − .200** − .138** .007 − .104 − .354** − .345** − .304** 1.000 – – –
tional
prob-
lems
T1
Child & Youth Care Forum (2019) 48:405–425
 Table 2  (continued)
Apgar Gesta- Child‘s Maternal Maternal Family Relation- Distress Infant Maternal Emo- Behav- Emo- Behavioral
scores tional gender education age status ship with rearing self- tional ioral tional problems
age (boy) partner attitudes efficacy problems problems problems T2
T1 T1 T2

Behav- − .013 .049 .194** − .181** − .253** − .016 − .072 − .242** − .305** − .335** .691** 1.000 – –
ioral
prob-
lems
T1
Emo- .020 − .019 .074 − .104 − .144 − .040 − .059 − .314** − .203* − .243** .654** .529** 1.000 –
tional
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prob-
lems
T2
Behav- .022 .093 .190* − .106 − .197** − .115 − .028 − .209* − .232** –.3** .494** .661** .662** 1.000
ioral
prob-
lems
T2

**p < .001; *p < .05
413

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Table 3  Emotional and behavioral problems class solutions resulting from latent class growth analyses
Solution Parameters Log likelihood BIC SSABIC AIC Entropy Adj. LMR-LRT Trajectory group prevalence (%)
1 2 3 4

Emotional problems
 1 class 5 − 1226.388 2480.463 2464.612 2462.777 – – 100
 2 classes 8 − 1206.979 2458.257 2432.895 2429.958 .880 .005 94 6
 3 classes 11 − 1188.919 2438.749 2403.877 2399.839 .781 .002 83 11 6
 4 classes 14 − 1188.919 2455.361 2410.979 2405.839 .564 .511 83 10 6 1
Behavioral problems
 1 class 5 − 1316.401 2660.548 2644.696 2642.803 – – 100
 2 classes 8 − 1308.363 2661.118 2635.756 2632.726 .616 .001 86 14
 3 classes 11 − 1303.516 2668.073 2633.200 2629.033 .695 .047 86 9 5
 4 classes 14 − 1299.799 2677.284 2632.900 2627.597 .616 .551 55 32 7 6
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Child & Youth Care Forum (2019) 48:405–425 415

Fig. 1  The estimated growth 25

trajectories in the three-group
solution for emotional problems
20

15
1 class
2 class
10
3 class

0
1 2

Fig. 2  The estimated growth 30

trajectories in the three-group
solution for behavioral problems 25

20
1 class
15
2 class

10 3 class

0
1 2

86% (n = 221) of children showed a stable low, 5% (n = 13) an increasing, and 9% (n = 23) a
stable high level of these problems (see Figs. 1 and 2).

Comparison of Study Variables Across Emotional and Behavioral Classes

The next step was to examine differences between latent classes of emotional and behav-
ioral problems. These results are presented in Table  4. Mothers of children in the low
emotional problems class reported more child-oriented infant rearing attitudes (M = 47.8,
SD  = 10.5) than mothers in the increasing (M = 46.21, SD = 12.54) and decreasing
(M = 37.6, SD = 11.02) emotional problems classes. The low emotional problem class
membership is also characterized by lower levels of distress experienced during the first
few months after delivery (M = 11.29, SD = 2.47) and higher maternal self-efficacy scores
(M = 27.03, SD = 8.23).
A comparison of 3 latent classes of behavioral problems shows that the high behavioral
problems class differs by the children’s gestational age (M = 40.18, SD = 1.08) in compari-
son with the low (M = 39.49, SD = 1.08) and increasing (M = 39.55, SD = 0.69) behavioral
problems classes. A few statistically significant trends were observed in the comparison of
behavioral problems classes regarding mothers’ infant rearing attitudes (the low behavioral
problems class had more child-oriented rearing attitudes), maternal self-efficacy (mothers
of the high behavioral problems class obtained lowest self-efficacy scores), and quality of

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Table 4  Differences among the three latent classes of emotional and behavioral problems
Variable Emotional problems classes N (p)/rank χ2 p Behavioral problems classes N (p)/rank χ2 p

13
Low (N = 211) Increasing (N = 27) Decreasing (N = 16) Low (N = 221) High (N = 23) Increasing (N = 13)

Delivery mode
 Vaginal without medi- 69 (32.9) 10 (37) 2 (12.5) 8.717 .190 71 (32.3) 5 (21.7) 4 (30.8) 7.587 .270
cation
 Vaginal with medica- 80 (38.1) 8 (29.6) 7 (43.8) 84 (38.2) 8 (34.8) 7 (53.8)
tion
 Emergency CS 40 (19) 9 (33.3) 5 (31.3) 43 (19.5) 9 (39.1) 2 (15.4)
 Elective CS 21 (10) 0 (0) 2 (12.5) 22 (10) 1 (4.3) 0 (0)
Gestational age 111.63 123.88 97.63 1.796 .407 108,21 148.57 104.32 8.588 .014*
Apgar scores 116.85 130.71 117.44 1.935 .380 117.77 145.59 106.78 3.252 .197
Gender
 Boy 109 (51.7) 18 (66.7) 12 (75) 5.009 .082† 113 (51.1) 20 (87) 6 (46.2) 11.111 .004**
 Girl 102 (48.3) 9 (33.3) 4 (25) 108 (48.9) 3 (13) 7 (53.8)
Maternal age 130.32 96.91 126.59 5.044 .080† 130.15 96.07 119.65 4.686 .096†
Maternal education
 High 172 (81.5) 22 (81.5) 7 (43.8) 12.947 .002** 174 (78.7) 18 (78.3) 11 (84.6) .264 .876
 Low 39 (18.5) 5 (18.5) 9 (56.3) 47 (21.3) 5 (21.7) 2 (15.4)
Family status
 Married 189 (89.6) 23 (85.2) 11 (68.8) 6.211 .045* 195 (88.2) 22 (95.7) 10 (76.9) 2.838 .242
 Unmarried 22 (10.4) 4 (14.8) 5 (31.3) 26 (11.8) 1 (4.3) 3 (23.1)
Maternal distress 98.28 78.00 61.68 7.256 .027* 95.20 83.31 86.75 1.022 .600
Child rearing attitudes 94.79 88.43 52.45 6.707 .035* 94.42 65.41 90.91 4.649 .098†
Maternal self-efficacy 114.32 96.16 70.87 7.683 .021* 112.39 76.50 116.71 5.760 .056†
Quality of relationship 111.23 93.66 97.73 2.145 .342 108.92 127.59 74.88 5.364 .068†
with partner

**p < .001; *p < .05; †p < .10

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Child & Youth Care Forum (2019) 48:405–425 417

the relationship with the partner (mothers of the children’s increasing behavioral problems
group reported lowest rates).
We also analyzed how the categorical variables of delivery mode, child’s gender, mater-
nal education, and family status were related to the child’s class membership. The results
of the Chi square test for homogeneity show significant associations among the behav-
ioral problems class membership and child gender [χ2(6) = 10.972, p = .004]: more boys
than girls fall into the high behavioral problems class in comparison with other classes.
Also, the Chi square test indicates significant levels of variability of maternal education
[χ2(2) = 13.234, p = .001] and family status [χ2(2) = 6.615, p = .037] in the emotional prob-
lems classes. More unmarried mothers and mothers with a lower educational level fall into
the decreasing emotional problems class. No significant associations were found among
membership in the emotional and behavioral problems classes and delivery mode.

Predictors of Developmental Trajectories of Emotional and Behavioral Problems

Multinomial regression was used to explore which psychosocial, childbirth, and mater-
nal variables predict children’s class membership, and to what extent. At the first stage
of regression analysis, all the psychosocial variables (maternal education, family status,
and child’s gender), childbirth variables (delivery mode and gestational age), as well as
maternal variables (age, distress experienced at 3 months after delivery, infant rearing atti-
tudes, maternal self-efficacy, and quality of relationship with partner) were entered into the
regression models for emotional and behavioral problems. We removed statistically insig-
nificant variables from the regression models one by one until we finally obtained 2 models
with all the variables significantly predicting membership in the emotional and behavioral
problems classes.
The regression models for emotional and behavioral problems class membership are
presented in Table  5. The model of the emotional problems class was significant with
χ2(12) = 220.29, p < .001 and correctly classified 84.1% of participants. Nagelkerke’s
pseudo R2 was .78, which indicates that gender, maternal education, delivery mode, and

Table 5  Multinomial regression of class membership for emotional (Nagelkerke’s R Square .78, classifica-
tion accuracy 83.5%) and behavioral problems (Nagelkerke’s R Square .84, classification accuracy 86.6%)
Predictors of emotional problems Increasing class versus low class Decreasing class versus low class
B SE Wald p OR B SE Wald p OR

Gender (1-boy, 2-girl) − 1.15 .55 4.42 .036 .32 − 1.41 .76 3.49 .062† .25
Maternal education (1-high, 2-low) − .53 .79 .456 .587 .56 1.79 .69 6.60 .010* 5.99
Infant rearing attitudes − .02 .02 .768 .381 .98 − .08 .03 6.41 .011* .92
Predictors of behavioral problems Increasing class versus low class High class versus low class
B SE Wald p OR B SE Wald p OR

Gender (1-boy, 2-girl) .46 .62 .56 .456 1.58 − 1.79 .69 6.57 .010* .17
Delivery mode: emergency CS .28 .81 .12 .727 1.33 1.17 .57 4.19 .040* .31
Maternal age − .04 .06 .49 .484 .96 − .014 .07 4.12 .043* .87
Maternal self-efficacy .03 .04 .43 .514 1.03 − .82 .04 5.08 .024* .92
Quality of relationship with partner − .46 .23 3.82 .051† .63 .39 .26 2.36 .124 1.49

**p < .001; *p < .05; †p < .10

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maternal infant rearing attitudes explain approximately 78% of the variance in class mem-
bership. As shown in Table  5, male gender significantly increases the probability to fall
into the increasing but not the low emotional problems class when mothers have a higher
level of education and more parent-oriented infant rearing attitudes. Membership in the
decreasing emotional problems class in comparison with the low emotional problems class
is significantly predicted by a lower level of maternal education and more parent-oriented
infant rearing attitudes.
Parameters of the regression model for behavioral problems class membership are as
follows: χ2(12) = 229.79, p < .001, with 86.6% of participants correctly classified. Nagel-
kerke’s pseudo R2 was .84, which indicates that gender, maternal age, delivery mode,
maternal self-efficacy, and quality of the relationship with the partner explain approxi-
mately 84% of the variance in class membership. Male gender, being born by emergency
caesarean section, younger maternal age, and lower maternal self-efficacy scores have sig-
nificant effects on class membership in the high as opposed to low behavioral problems
class. Membership in the increasing behavioral problems class has no significant predictors
but we can see a statistical tendency (p = .051) that a lower quality of the relationship with
the partner in combination with the female gender, emergency caesarean section, lower
maternal age, and higher maternal self-efficacy have an impact on the membership in the
increasing class compared with the low class.

Discussion

In this longitudinal study we examined children’s developmental trajectories of emotional

and behavioural problems throughout second and third year of life and the association of
these trajectories with child-birth related factors and maternal characteristics. Results of
the previous stages of this study showed that a child’s emotional and behavioral problems
at the age of 18 months were predicted by childbirth-related factors such as caesarean sec-
tion and suboptimal newborn physiological functioning, maternal factors of distress and
depressiveness during the first 3 months after delivery, and inflexible and parent-oriented
infant rearing attitudes (Sirvinskiene et  al. 2016). Our follow-up of children’s develop-
ment gave us an opportunity to explore individual differences in emotional and behavioral
problems as well as to track and analyze children’s developmental pathways from infancy
through toddlerhood.
Results of the present study show that the majority of children born full-term and with
low biopsychosocial risks maintain a stable low level of emotional (83%) and behavioral
(86%) problems during the first 30 months of life. Only a small portion of toddlers in our
study had increasing levels of emotional and behavioral problems, a high level of behav-
ioral problems and decreasing levels of emotional problems. Therefore, these trajectories
were objects of our particular interest and we looked at the trajectories and predictive fac-
tors of increasing emotional problems as well as increasing and high behavioral problems
as opposed to the trajectories of low emotional and behavioral problems.
We hypothesized that caesarean section delivery in combination with maternal emo-
tional distress after childbirth would be significant risk factors for elevated levels of
emotional and behavioral problems, while flexible and child-oriented maternal infant
rearing attitudes and a high level of maternal self-efficacy would serve as protective
factors for emotional and behavioral problems. Our findings revealed that emergency
caesarean section in combination with certain maternal and psychosocial factors

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Child & Youth Care Forum (2019) 48:405–425 419

significantly predicted membership in the behavioral but not in the emotional problems
classes, while membership in the emotional problems classes was predicted by a com-
bination of maternal and psychosocial factors. Maternal emotional state after delivery,
which was measured as emotional distress experienced during the first 3  months after
delivery in our study, had no significant impact on the developmental trajectories of
children’s emotional and behavioral problems.
Results of our study also show that male gender is a risk factor for a child to have an
increasing level of emotional problems when mothers have a higher level of education and
more parent-oriented infant rearing attitudes. Surprisingly, a decreasing level of emotional
problems, which means that the incidence of child’s symptoms of emotional problems
becomes lower from the age of 18 months till the age of 30 months, was predicted by more
parent-oriented infant rearing attitudes in combination with a lower level of maternal edu-
cation. In regard to behavioral problems, we found that a higher probability to have stable
high levels of behavioral problems was found for boys born by emergency caesarean sec-
tion when their mothers are younger and have lower self-efficacy scores. A lower quality of
the relationship with the partner has a tendency to predict children’s, especially that of girls
born by caesarean section, membership in the increasing behavioral problems class when
mothers are younger and score higher on self-efficacy.
In addition, the findings of the current study suggest that during the first 30 months of
the child’s life, maternal infant rearing attitudes significantly affect the child’s emotional
problems because child-oriented rearing attitudes are linked with lower rates of emotional
problems at the age of 18 months, as it was found by one previous study (Sirvinskiene et al.
2016), and with the developmental trajectory of stable and low emotional problems during
the first 30  months of life. This confirms our assumption about the protective impact of
flexible and child-oriented rearing attitudes on the level of emotional problems. Zeifman,
author of the Infant-Rearing Attitudes Scale used in our study, contends that parental child-
oriented rearing attitudes are associated with parents’ more sensitive behavior, especially
when the infant is experiencing distress (Zeifman 2003). Other prior research has shown
that sensitive maternal behaviors observed during emotionally arousing tasks in infancy
are related to infants’ adaptive emotion regulation and the absence of behavioral problems
(Leerkes et al. 2009). These results are in line with our study and suggest that child-ori-
ented maternal rearing attitudes in infancy could be a protective factor for emotional prob-
lems in later developmental stages.
It is not clear how parent-oriented infant rearing attitudes are related with a decrease
in emotional problems from high to medium levels during toddlerhood, which looks ben-
eficial for the child’s development. Perhaps this association between low maternal educa-
tion, parent-oriented infant rearing attitudes, and a decrease in emotional problems could
be explained by parental childrearing practices applied during the child’s second and third
years of life. Hence, further research that would include a broader range of factors possibly
related with links between developmental trajectories of toddlers’ emotional problems and
parental rearing attitudes is needed.
Another finding from our study is that an emergency caesarean section poses a risk for
a high level of behavioral problems during toddlerhood as an emergency caesarean section
is a significant predictor of a stable high level of children’s behavioral problems during the
first 30 months of life. These results differ from previous findings indicating that children
born by caesarean section—both elective and emergency—had higher rates of emotional
but not behavioral problems at the age of 18 months (Sirvinskiene et al. 2016). This incon-
sistency in findings can be related with methodological issues. In the current study we had
two groups of children born via caesarean section (those born by elective caesarean section

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and by emergency caesarean section), while in the aforementioned study there was only
one group.
Before looking more deeply into this finding, it is important to mention that caesarean
section is a surgical procedure with numerous potential complications for both the mother
and the child, such as infections, organ injuries, etc. (Mylonas and Friese 2015). In our
study, all children, including those born by emergency caesarean sections, were born full-
term, had good Apgar scores (≥ 7), and no significant differences in Apgar scores were
found between different delivery groups. We consider this as evidence of no post-opera-
tional caesarean section complications for newborns.
The association of childbirth conditions and later emotional and behavioral problems
in children has been reported in a few previous studies. Kelmanson (2013) found an asso-
ciation between elective caesarean section and emotional but not behavioral problems
in preschool-age children. Other research suggests that although there is no direct link
between childbirth complications and behavioral problems, externalizing problem behav-
ior is thought to be especially likely to develop when such birth complications as induced
labor, caesarean section, forceps or vacuum extraction, etc. are combined with psychoso-
cial risk factors, e.g., a disadvantaged family environment and poor parenting (Arsenault
et al. 2002; Beck and Shaw 2005).
On the other hand, emergency caesarean section is a risk factor for maternal postnatal
mental health as women after caesarean section have a higher risk for posttraumatic stress
disorder (Andersen et al. 2012), anxiety disorders (Ross and McLean 2006), and postnatal
depression (Xu et al. 2017) compared with women after vaginal delivery. Postnatal mater-
nal mental health problems pose a risk for children to develop emotional and behavioral
problems. For example, research by Rijlaarsdam et  al. (2013) indicates that externaliz-
ing problems are directly predicted by economic disadvantage and indirectly by maternal
depressive symptoms, parenting stress, and harsh discipline. In our study, mothers after
emergency caesarean section reported higher levels of distress during the first few months
after delivery, which allows us to hypothesize that maternal emotional well-being could
have a mediating effect on the relationships between modes of delivery and children’s
behavioral problems.
The male gender was another significant predictor of children’s membership in the
classes of high behavioral problems and increasing emotional problems. This finding is in
line with other research showing that mothers tend to see boys as having more behavioral
problems than girls (Jusiene and Raižiene 2006; Fuchs et  al. 2013; Caughy et  al. 2016).
Regarding emotional problems, there is a consensus in the literature that at preschool age,
the levels of emotional problems are evenly distributed across gender (Fuchs et al. 2013;
Caughy et al. 2016), however not much is known about the changes in emotional problems
over time, hence this association remains unclear.
Lower maternal age and lower maternal self-efficacy also predicted a stable high level
of children’s behavioral problems. This supports our assumption about the protective role
of maternal self-efficacy in child’s behavioral problems. These results are also supported
by findings from other studies showing that a high level of maternal self-efficacy is related
with a lower level of children’s behavioral problems and other positive developmental out-
comes (Coleman and Karraker 2000, 2003; Weaver et al. 2008). Older maternal age could
be associated with negative outcomes for the child’s health from the medical perspective
but recent research shows that older maternal age is also seen as a protective factor against
children’s behavioral problems (Tearne et  al. 2015; Goisis 2015). Researchers argue that
in high-income countries, older parental age is associated with a higher level of educa-
tion, higher socio-economic position, a more stable family environment, higher income and

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better living conditions, as well as better parenting practices (Schmidt et  al. 2012; Myr-
skylä et al. 2017).
Finally, we want to discuss the role of parents’ relationship in their children’s behav-
ioral problems. Our previous research shows that low maternal ratings of the quality of
the relationship with her partner during pregnancy are associated with more children’s
emotional and behavioral problems at the age of 18 months (Sirvinskiene et al. 2016). In
this study, a lower quality of parents’ relationship has an impact on the child’s increas-
ing behavioral problems trajectory, which means that the incidence of child’s symptoms of
behavioral problems such as aggressiveness, attention problems becomes higher and more
problematic from the age of 18 months till the age of 30 months. Although this association
has a value that approaches statistical significance, it is worth to mention that poor inter-
parental relationship is one of the risk factors for the child’s maladjustment and behavioral
problems (Grych et  al. 2000). Research also shows that this association is bidirectional
as children’s behavioral problems serve as a predictor of parents’ relationship quality, and
children’s improved problem behavior enhances parents’ relationship quality (Zemp et al.
2016).
Furthermore, it is important to mention some methodological limitations of our
research. First, our study sample was relatively small and homogenous in terms of fam-
ily status, maternal level of education, and area of residence. The majority of participant
mothers were highly educated and married as well as living in urban areas, therefore our
findings about children’s emotional and behavioral problems cannot be applied to a broader
context. Second, some problem classes were found to be very small in our research—only
13 children were classified as exhibiting increasing behavioral problems trajectories and
16 children were classified as showing trajectories of decreasing emotional problems.
Although we decided to include these classes into our statistical analysis because we
believe that nonparametric statistical methods applied for the analysis allow us to discuss
certain trends, still it is important to look at the interpretation of our findings with reserva-
tion and caution. Third, information about children’s emotional and behavioral problems
and psychosocial factors is based solely on mothers’ reports, other informants were not
included. Fourth, a great variety of factors may influence children’s development and their
emotional and behavioral problems, yet not all of them were included in our research, e.g.,
parental mental health problems, the quality of mother–child relationship, or early parent-
ing practices.
For future research it would be important to use a more representative sample with
mothers from different social and educational backgrounds. The use of maternal reports in
conjunction with reports of other informants, like fathers and staff from educational institu-
tions, as well as other methods of gathering data (e.g., direct observations) could provide a
more accurate and complete picture of children’s emotional and behavioral problems, their
developmental trajectories, and links with childbirth, maternal, and family factors. Finally,
it is important to find out in further studies the likely pathways of associations between
early child development and pregnancy, childbirth-related, maternal, and family factors.
Examination of the mediating and moderating effects of such factors as maternal personal-
ity, the quality of early mother–child interactions, maternal sensitivity and emotional avail-
ability, early parenting practices, and fathers’ involvement in infant rearing activities would
be beneficial for a deeper understanding of these questions, too.
Despite the mentioned limitations, our findings suggest some implications for practice.
First, it is imperative to provide emotional support for mothers and families after the emer-
gency caesarean section. Some mothers can experience the emergency caesarean section
as a traumatic event, which may have a serious impact on maternal postnatal well-being.

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Emotional support for women after the emergency caesarean could prevent maternal men-
tal health problems and would be beneficial for early mother–infant interactions and early
child development. Second, our results show that child-oriented and flexible infant rearing
attitudes serve as a protective factor for the child’s emotional problems rated by mothers.
Child-centered rearing attitudes entail certain maternal beliefs about caring for an infant:
feeding when the baby wants, holding and carrying the baby when he/she is distressed
without the fear of spoiling him or her, and reacting promptly and caringly to the baby’s
needs. Thus, it is important for health practitioners to educate mothers during pregnancy
or soon after birth about infants’ needs and sensitive baby care. Third, maternal self-effi-
cacy is an important factor for the level of child’s behavioral problems. Mothers, especially
first-time and younger in age, face different questions and challenges related with mater-
nity. Various educational activities like lectures or discussions would provide mothers with
answers to important questions about child care and education, as well as help them to
strengthen maternal self-confidence.

Conclusions

The findings of the current study show that inter-individual differences in the development
of emotional and behavioral problems in toddlers based on maternal ratings occur during
the first 2.5 years of life and these differences are associated with a number of childbirth-
related, psychosocial, and maternal factors. The majority of children born full-term and
with high Apgar scores and reared in families without social or economic disadvantages
maintain a stable low level of emotional and behavioral problems, with only a small por-
tion classified to have increasing and decreasing levels of emotional problems and increas-
ing and stable high levels of behavioral problems. Such factors as emergency caesarean
section, the child’s male gender, younger maternal age and lower educational level, more
rigid infant rearing attitudes, lower maternal self-efficacy, and less satisfactory inter-paren-
tal relationships are significant predictors of early manifestations and stability or increase
of emotional and behavioral problems in toddlerhood.

Acknowledgements  This research is a part of the prospective birth-cohort study initiated in 2009. We thank
a whole group of scientists from Vilnius University and Lithuanian university of Health sciences who has
worked on this study, as well as the mothers who participated in it.

Funding  This research is part of the project funded by the following Grants: T-09157/2009 from the Lithu-
anian State Science and Studies Foundation, MIP-147/2010 from the Research Council of Lithuania, and
MIP-014/2012 from the Research Council of Lithuania.

Compliance with Ethical Standards 

Conflict of interest  Jurgita Smilte Jasiulione declares that she has no conflict of interest. Roma Jusiene has
received research Grants from Lithuanian State Science and Studies Foundation and the Research Council
of Lithuania; however the funders have not intervened and/or influenced the research and the content of the
manuscript.

Ethical Standards  All procedures performed were in accordance with the ethical standards of the national
research committee and with 1964 Helsinki declaration and its later amendments. The study was approved by
Regional Biomedical Research Ethics Committee (No. P1‐143/2007).

Informed Consent  It was obtained from all participating mothers.

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