Gestational Age at Delivery and Special Educational

Need: Retrospective Cohort Study of 407,503

Schoolchildren
Daniel F. MacKay1, Gordon C. S. Smith2, Richard Dobbie3, Jill P. Pell4*
1 Section of Public Health, University of Glasgow, Glasgow, United Kingdom, 2 Department of Obstetrics and Gynaecology, Cambridge University, The Rosie Hospital
Cambridge, United Kingdom, 3 Information Services Division, NHS Scotland, Edinburgh, United Kingdom, 4 Section of Public Health, University of Glasgow, Glasgow,
United Kingdom

Abstract
Background: Previous studies have demonstrated an association between preterm delivery and increased risk of special
educational need (SEN). The aim of our study was to examine the risk of SEN across the full range of gestation.
Methods and Findings: We conducted a population-based, retrospective study by linking school census data on the
407,503 eligible school-aged children resident in 19 Scottish Local Authority areas (total population 3.8 million) to their
routine birth data. SEN was recorded in 17,784 (4.9%) children; 1,565 (8.4%) of those born preterm and 16,219 (4.7%) of
those born at term. The risk of SEN increased across the whole range of gestation from 40 to 24 wk: 3739 wk adjusted
odds ratio (OR) 1.16, 95% confidence interval (CI) 1.121.20; 3336 wk adjusted OR 1.53, 95% CI 1.431.63; 2832 wk
adjusted OR 2.66, 95% CI 2.382.97; 2427 wk adjusted OR 6.92, 95% CI 5.588.58. There was no interaction between
elective versus spontaneous delivery. Overall, gestation at delivery accounted for 10% of the adjusted population
attributable fraction of SEN. Because of their high frequency, early term deliveries (3739 wk) accounted for 5.5% of cases of
SEN compared with preterm deliveries (,37 wk), which accounted for only 3.6% of cases.
Conclusions: Gestation at delivery had a strong, dose-dependent relationship with SEN that was apparent across the whole
range of gestation. Because early term delivery is more common than preterm delivery, the former accounts for a higher
percentage of SEN cases. Our findings have important implications for clinical practice in relation to the timing of elective
delivery.
Please see later in the article for the Editors Summary.
Citation: MacKay DF, Smith GCS, Dobbie R, Pell JP (2010) Gestational Age at Delivery and Special Educational Need: Retrospective Cohort Study of 407,503
Schoolchildren. PLoS Med 7(6): e1000289. doi:10.1371/journal.pmed.1000289
Academic Editor: Tze Kin Lau, Chinese University of Hong Kong, Hong Kong
Received February 15, 2010; Accepted April 29, 2010; Published June 8, 2010
Copyright: 2010 MacKay et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Funding: The study was funded by a project grant from NHS Health Scotland. The funders had no role in the study design, data collection and analysis, decision
to publish, or preparation of the manuscript.
Competing Interests: The authors have declared that no competing interests exist.
Abbreviations: CI, confidence interval; OR, odds ratio; SEN, special educational need; SMR2, Scottish Morbidity Record
* E-mail: [email protected]

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Gestation and Special Educational Need

(4.4%), estimated gestation (5.6%), and induction of labour (6.4%)

(Jim Chalmers, Information Services Division, National Health
Service, Edinburgh, Scotland, written communication, April
2001). In the SMR2, gestational age at birth is defined as
completed weeks of gestation on the basis of the estimated date of
delivery recorded in each womans clinical record. Gestational age
has been confirmed by ultrasound in the first half of pregnancy in
more than 95% of women in the United Kingdom since the early
1990s [5]. Previous miscarriage was defined as previous delivery of
a conceptus, showing no signs of life before 24 wk gestation,
excluding therapeutic abortions. Previous therapeutic abortion
was defined as previous therapeutic termination of pregnancy, by
any means, prior to 24 wk gestation.
The school census data were linked, via birth certificate data,
to the relevant SMR2 record to provide individual-level
obstetric data. We excluded individuals who were aged ,4 y
or .19 y at the time of the school census, and births where the
maternal height was recorded as less than 100 cm or greater
than 200 cm, the birth weight was recorded as less than 400 g
or greater than 5,000 g, or the gestation at delivery was
recorded as less than 24 wk or greater than 43 wk. We also
excluded multiple births because the SMR2 record does not
record infant name. Therefore, in the case of multiple births, we
could not ensure that the school census record was linked to the
correct infant. Permission to access, link, and analyse these data
was granted by both the South-East of Scotland Multi-Centre
Research Ethics Committee and the Scottish Privacy Advisory
Committee.

Introduction
Infants delivered preterm are at increased risk of neurodevelopmental problems including impaired intelligence and school
performance [1,2]. Amongst preterm infants there is no evidence
of a threshold effect, with the risk declining steadily with advancing
gestational age up to 36 wk. However, there is a lack of
information on whether the increased risk continues across the
early term period (3739 wk of gestation). This question is of
considerable clinical relevance because early term births account
for an increasing proportion of deliveries [3], and many of these
are elective deliveries.
The aim of our study was to investigate the risk of special
educational need (SEN) across the whole spectrum of gestational
age at delivery, and to use these results to determine the
population attributable risks associated with delivery at different
gestational ages.

Methods
Data Sources
Under the Special Educational Needs and Disability Act of
2001, both schools and local education authorities in the United
Kingdom have a statutory duty to identify, assess, and make
provision for children with SEN. The Department of Education
defines SEN as a learning difficulty that requires special
educational provision. In turn, a learning difficulty is defined as
either greater difficulty in learning than a majority of children of
the same age, or a disability that prevents or hinders a child from
making use of educational facilities of the kind that are generally
provided for children of the same age (http://www.teachernet.
gov.uk/_doc/3724/SENCodeOfPractice.pdf).
SEN includes both children with learning disabilities (including
dyslexia, dyspraxia, autism, Aspergers syndrome, and attention
deficit hyperactivity disorder), as well as children with physical
disabilities that impact on learning (including some children with
hearing, motor, and visual impairments). We used data from the
2005 school census. The school census is undertaken annually in
September and the data are provided by head-teachers at each
school and collated by their local education authority. The school
census covers all schools in Scotland irrespective of their funding
source and includes local authority, grant-aided, independent,
and self-governing schools. The response rate is 99.8%. It
includes all primary and secondary school children. It excludes
adults (.19 y of age) who are attending courses held in schools. It
covers mainstream schools, special schools, and special classes
and units within mainstream schools. Children on long-term
illness absence are included. The information is collected at
the level of individual pupils and includes a record of need for
all children with an SEN. Of the 32 Scottish local education
authorities, 19 agreed to participate and provide data from the
school census. The participating authorities covered a total
population of 3.8 million, equivalent to 74% of the Scottish
population (http://www.statistics.gov.uk/STATBASE/Expodata/
Spreadsheets/D5966.xls).
The Scottish Morbidity Record (SMR2) collects information on
all women discharged from Scottish maternity hospitals, including
maternal and infant characteristics, clinical management, and
obstetric complications. The SMR2 is subjected to regular quality
assurance checks and has been more than 99% complete since the
late 1970s [4]. A quality assurance exercise performed in 1997
compared a 5% sample of SMR2 returns (n = 1,414) to case
records and demonstrated that all of the fields used in our study
had less than 2% errors, with the exception of maternal height
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Statistical Analysis
Continuous variables were summarised by the median and
interquartile range (IQR). Univariate comparisons between groups
were performed using the Kruskal-Wallis test, Chi square test, and
Cuzicks test for trend [6] for continuous, categorical, and ordinal
data, respectively. The p-values for all hypothesis tests were twosided and statistical significance was assumed at p,0.05. The
associations between obstetric factors and the risk of SEN were
analysed using univariate and multivariable logistic regression and
presented as odds ratios. The covariates included in the
multivariable analysis were infant sex, maternal age and height,
marital status, parity, birth-weight centile, induction of labour,
mode of delivery, year of delivery, previous spontaneous and
therapeutic deliveries, and 5-min Apgar score.
Missing values for maternal height, deprivation, and maternal
age were created using multiple imputation by chained equations
through the use of the ICE module available in STATA [7].
Variables included in the imputation included all covariates in the
final model and the outcome variable. Five imputed datasets were
created and a sensitivity analysis of complete cases with the
imputed datasets was conducted. Gestation- and sex-specific birthweight centiles were calculated. Year of delivery of the child was
included as a covariate. Years 1980 to 1987 and years 2000 to
2003 were aggregated because of the small numbers of children
born in these years.
Goodness of fit was assessed using a plot of observed versus
expected values as well as residual and influence plots. These
tests showed that the model was an adequate fit to the data. The
area under the ROC curve was equal to 67.6%. Adjusted
population attributable fractions [8] were estimated using
individuals with complete data to determine what proportion
of SEN cases were potentially explained by gestation at delivery.
All statistical analyses were undertaken using STATA V10.1
(Stata Corporation).
2

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Gestation and Special Educational Need

Table 1. Pregnancy characteristics of schoolchildren according to whether they have special educational needs.

Pregnancy Characteristics

No Special Educational Need, n = 387,682

Special Educational Need, n = 19,821

Gestation at delivery (wk)

n (%)

n (%)

2427

335 (0.09)

140 (0.7)

2832

3,006 (0.8)

443 (2.2)

3336

16,754 (4.3)

1,281 (6.5)

37

18,617 (4.8)

1,217 (6.1)

38

48,810 (12.6)

2,759 (13.9)

39

77,217 (19.9)

3,848 (19.4)

40

125,067 (32.3)

5,731 (28.9)

41

81,607 (21.1)

3,530 (17.8)

42

15,936 (4.1)

850 (4.3)

43

333 (0.08)

22 (0.11)

Missing

Female

194,648 (50.2)

5,934 (29.9)

Male

193,034 (49.8)

13,887 (70.1)

Missing

Nulliparous

172,935 (44.6)

7,473 (37.7)

Multiparous

214,747 (55.7)

12,348 (62.3)

Missing

No

296,449 (76.5)

15,307 (77.2)

Yes

91,233 (23.5)

4,514 (22.8)

Missing

316,005 (81.5)

15,762 (79.5)

56,360 (14.5)

3,093 (15.6)

$2

15,317 (4.0)

966 (4.9)

Missing

349,982 (90.3)

17,602 (88.8)

33,215 (8.6)

1,918 (9.7)

p-Valuea

,0.001

Sex
,0.001

Parity
,0.001

Induced
0.014

Previous spontaneous abortions

0

,0.001

Previous therapeutic abortions

$2

4,485 (1.1)

301 (1.5)

Missing

1 (affluent)

63,073 (16.3)

2,731 (13.8)

65,094 (16.9)

3,063 (15.5)

78,692 (20.4)

4,029 (20.4)

80,406 (20.8)

4,317 (21.9)

5 (deprived)

98,837 (25.6)

5,611 (28.4)

Missing

1,580

70

Married

262,980 (67.8)

11,911 (60.1)

Not married

124,702 (32.2)

7,910 (39.9)

Missing

,0.001

Deprivation quintiles
,0.001

Marital status
,0.001

Birth-weight centiles
13

11,447 (3.0)

1,084 (5.5)

410

27,037 (7.0)

1,865 (9.4)

1120

39,238 (10.1)

2,334 (11.8)

2180

233,002 (60.1)

11,110 (56.1)

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,0.001

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Gestation and Special Educational Need

Table 1. Cont.

No Special Educational Need, n = 387,682

Special Educational Need, n = 19,821

8190

38,496 (9.9)

1,687 (8.5)

9197

27,094 (7.0)

1,230 (6.2)

98100

11,368 (2.9)

511 (2.6)

Missing

No

373,782 (96.4)

19,023 (96.0)

Yes

13,900 (3.6)

798 (4.0)

Missing

03

2,647 (0.7)

303 (1.5)

47

8,144 (2.1)

782 (4.0)

Pregnancy Characteristics

p-Valuea

Pre-eclampsia
0.001

5-min Apgar score

,0.001

810

376,891 (97.2)

18,736 (94.5)

Missing

Mode of delivery
Vaginal, cephalic delivery

269,294 (69.5)

13,658 (68.9)

Assisted vaginal delivery

54,346 (14.0)

2,358 (11.9)

Breech delivery

1,601 (0.4)

145 (0.70)

Cesarean section (elective)

23,846 (6.2)

1,343 (6.8)

Cesarean section (emergency, prelabour)

10,043 (2.6)

782 (4.0)

Cesarean section (emergency, postlabour) 28,534 (7.4)

1,535 (7.7)

Missing

27 (2331)

28 (2431)

Median maternal age (y) (IQR)

Missing
Median maternal height (cm) (IQR)
Missing

,0.001

,0.001

161 (157165)

162 (157166)

41,328

1,967

,0.001

a
Kruskal-Wallis test for continuous data; Cuzicks nonparametric test for trend for ordinal data; x2 test for categorical data.
doi:10.1371/journal.pmed.1000289.t001

Low birth weight (,2,500 g) was associated with an increased

risk of subsequent SEN (unadjusted odds ratio [OR] 2.22, 95%
confidence interval [CI] 2.102.33, p,0.001). This result was
explained by associations with both preterm delivery and low birthweight centile (Table 2). The relationship between SEN and
gestation at delivery was reverse J-shaped (Figure 1). The reverse Jshaped relationship was tested using a multivariable restricted cubic
spline, which confirmed that the effect of gestational age was robust
to the inclusion of the covariates. There was a very strong
association with extreme preterm delivery (2427 wk: adjusted
OR 6.92, 95% CI 5.588.58, p,0.001) (Table 2). The risk steadily
declined with increasing gestational age up to 4041 wk, but then
increased among those who delivered post-dates (42 wk; adjusted
OR 1.16, 95% CI 1.081.25, p,0.001). Compared with infants
born at 40 wk, those delivered early term (3739 wk) were at
increased risk of SEN (adjusted OR 1.16, 95% CI 1.121.20,
p,0.001). The risk decreased across the early term range, from 39
to 37 wk, but nonetheless was significantly increased among
children born at 39 wk of gestation (adjusted OR 1.09, 95% CI
1.041.14, p,0.001). There was no statistically significant interaction between gestational age and elective versus spontaneous
delivery. The results were very similar when we re-ran the logistic
regression models without imputation of missing values. Maternal
smoking status was only recorded on SMR2 from 1992 onwards.
When we re-ran the models for this subgroup of children including
maternal smoking data, the J-shaped relationship remained and the

Results
Of the 514,118 children included in the school census, 93,340
(18.2%) could not be linked to their obstetric data and 4,998
(5.3%) of these had a record of SEN. Of the 420,778 (81.8%) who
were successfully linked to their obstetric data, 13,275 were
ineligible for inclusion because they fulfilled one or more exclusion
criteria. Of the remaining 407,503 children, 362,688 (89.0%)
children had complete data on all variables and, of these, 17,784
(4.9%) had a record of SEN. The children had a median age of
12 y, with no significant difference according to the presence or
absence of SEN.
Overall, 184,260 (50.8%) infants were male, 18,527 (5.0%) were
born preterm (,37 wk gestation), 58,611 (16.2%) were delivered
by cesarean section, and 10,404 (2.8%) had a 5-min Apgar score
less than eight. The median birth weight was 3,400 g (IQR 3,060
3,740). The mothers had a median age of 28 y (IQR 2431) at
delivery and a median height of 162 cm (IQR 157166). Among
the mothers, 203,114 (56.0%) were multiparous, 115,356 (31.8%)
were unmarried at the time of delivery, and 12,579 (3.5%) suffered
pre-eclampsia. 67,181 (18.5%) had a history of spontaneous
abortion and 35,483 (9.8%) had a history of therapeutic abortion.
Table 1 presents a breakdown of maternal and pregnancy
characteristics according to whether or not the child had an
SEN (Table 1).
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Gestation and Special Educational Need

Table 2. Univariate and multivariable logistic regression analysis of the association between pregnancy characteristics and risk of
special educational needs in schoolchildren.

Pregnancy Characteristics

Multivariablea

Univariate
OR (95% CI)

p-Value

OR (95% CI)

p-Value

2427

9.14 (7.5311.18)

,0.001

6.92 (5.588.58)

0.001

2832

3.21 (2.903.57)

,0.001

2.66 (2.382.97)

,0.001

3336

1.67 (1.571.78)

,0.001

1.53 (1.431.63)

,0.001

37

1.43 (1.341.52)

,0.001

1.36 (1.271.45)

,0.001

38

1.24 (1.181.29)

,0.001

1.19 (1.141.25)

,0.001

39

1.09 (1.051.14)

,0.001

1.09 (1.041.14)

,0.001

40

1.00

41

0.95 (0.900.98)

0.010

0.97 (0.931.01)

42

1.17 (1.091.26)

,0.001

1.16 (1.081.25)

,0.001

43

1.46 (0.952.25)

0.085

1.35 (0.872.09)

0.180

Gestation at delivery (wk)

1.00

p for trend

,0.001

0.188

,0.001

Sex
Female

1.00

1.00

Male

2.36 (2.292.43)

,0.001

2.36 (2.282.43)

,0.001

Maternal age (y)

1.37 (1.301.45)

,0.001

1.42 (1.341.51)

,0.001

2024

1.26 (1.211.31)

,0.001

1.21 (1.161.26)

,0.001

2529

1.00

3034

0.92 (0.890.96)

,0.001

0.91 (0.880.95)

3539

0.98 (0.931.04)

0.490

0.93 (0.880.98)

0.012

.39

1.31 (1.171.48)

,0.001

1.19 (1.051.34)

0.005

,20

1.00

p for trend

,0.001

,0.001

,0.001

Maternal height (cm)

,150

1.55 (1.421.69)

,0.001

1.25 (1.141.37)

,0.001

150154

1.22 (1.161.28)

,0.001

1.08 (1.031.14)

0.003

155159

1.05 (1.011.09)

0.017

0.99 (0.951.03)

0.609

160164

1.00

165169

0.95 (0.910.99)

0.010

1.01 (0.971.06)

0.566

170174

0.94 (0.891.00)

0.035

1.07 (1.001.13)

0.038

.174

0.92 (0.831.01)

0.071

1.09 (0.971.19)

0.154

1.00

p for trend

0.186

,0.001

Marital status
Married

1.00

Not married

1.40 (1.361.44)

1.00
,0.001

1.36 (1.311.40)

,0.001

Deprivation
1 (affluent)

0.84 (0.800.89)

,0.001

0.95 (0.911.00)

0.100

0.92 (0.880.97)

0.001

0.97 (0.931.02)

0.378

1.00

1.05 (1.011.10)

0.027

0.98 (0.941.03)

0.462

5 (deprived)

1.11 (1.071.16)

,0.001

0.94 (0.900.98)

0.002

1.00

p for trend

0.343

,0.001

Parity
Nulliparous

1.00

Multiparous

1.33 (1.291.37)

1.00
,0.001

1.61 (1.551.66)

,0.001

1.09 (1.051.14)

,0.001

Previous spontaneous abortion

0

1.00

1.10 (1.061.15)

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1.00

,0.001

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Gestation and Special Educational Need

Table 2. Cont.

Pregnancy Characteristics

$2

Multivariablea

Univariate
OR (95% CI)

p-Value

OR (95% CI)

p-Value

1.27 (1.181.35)

,0.001

1.21 (1.131.30)

,0.001

p for trend

,0.001

,0.001

Previous therapeutic abortion

0

1.00

1.15 (1.091.20)

,0.001

1.10 (1.041.15)

1.00
,0.001

$2

1.34 (1.191.50)

,0.001

1.26 (1.121.42)

0.001

p for trend

,0.001

,0.001

Birth-weight centiles
13

1.99 (1.862.12)

,0.001

1.95 (1.822.08)

,0.001

410

1.45 (1.381.52)

,0.001

1.43 (1.351.50)

,0.001

1120

1.25 (1.171.31)

,0.001

1.24 (1.181.30)

,0.001

2180

1.00

8190

0.92 (0.880.97)

0.003

0.93 (0.880.98)

0.005

9197

0.95 (0.901.01)

0.103

0.95 (0.891.01)

0.077

98100

0.95 (0.871.04)

0.248

0.93 (0.851.02)

1.00

p for trend

,0.001

0.130
,0.001

Pre-eclampsia
None

1.00

Yes

1.14 (1.061.22)

1.00
0.001

0.99 (0.921.07)

0.016

1.03 (0.991.07)

0.829

Induced
No

1.0

Yes

0.96 (0.930.99)

1.00
0.126

Mode of delivery
Vaginal, cephalic delivery

1.00

Assisted vaginal delivery

0.86 (0.820.89)

1.00
,0.001

1.04 (0.991.09)

0.132

Breech delivery

1.77 (1.492.10)

,0.001

1.22 (1.021.47)

0.031

Cesarean section (elective)

1.10 (1.041.17)

0.001

1.06 (0.991.13)

0.075

Cesarean section (emergency, prelabour)

1.54 (1.431.66)

,0.001

1.19 (1.101.29)

,0.001

Cesarean section (emergency, postlabour)

1.06 (1.001.12)

0.034

1.13 (1.071.20)

,0.001

p for trend

,0.001

,0.001

5-min APGAR score

03

2.30 (2.042.59)

,0.001

1.66 (1.461.88)

,0.001

47

1.94 (1.802.09)

,0.001

1.55 (1.431.67)

,0.001

810

1.00

1.00

p for trend

,0.001

,0.001

Also adjusted for year of delivery.

doi:10.1371/journal.pmed.1000289.t002

the present analysis is that this trend continued across gestational

ages classified as term. Although the risk of SEN was highest
among infants who were delivered preterm (,37 wk gestation),
these accounted for only 5.1% of deliveries. Therefore, only a
relatively small proportion of SEN (3.5%) could be attributed to
preterm delivery. By contrast, 39.6% of infants were delivered
between 37 and 39 wk gestation. Therefore, whilst these early
term infants had only a moderately increased risk, 5.3% of SEN
cases could be attributed to early term delivery.
The association between gestational age and risk of SEN was
strong, consistent, and demonstrated a dose response. Historically,
preterm delivery has been the main focus of research and clinical
efforts because of the high risk to the individual infant. The

strength of association between gestational age at delivery and risk

of SEN was barely altered (3739 wk: adjusted OR 1.12, 95% CI
1.071.18, p,0.001). The population attributable fraction of SEN
accounted for by gestation as a whole was 10.0% (Table 3). Preterm
delivery had a population attributable fraction of 3.6% compared
with 5.5% for early term deliveries (Table 3). Text S1 contains a
sensitivity analysis showing that the findings could not be explained
by bias due to missing data.

Discussion
Our study demonstrated a strong trend of decreasing risk of
SEN with advancing gestational age at birth. The key finding of
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Gestation and Special Educational Need

Figure 1. Prevalence of special educational need by gestation at delivery.

doi:10.1371/journal.pmed.1000289.g001

neurodevelopmental sequelae of early term deliveries may be too

subtle to be observed prior to commencing school. Nonetheless,
our study suggests that, at a population level, they are a
contributor to SEN. In the United States, there has been an

absolute increase of 8.9% in deliveries of early term infants over

the past decade, with all of this increase occurring among elective
deliveries, largely due to an increase in cesarean section upon
request [3]. In Scotland, between 1980 and 2005, there has been a
2.0% absolute increase in the proportion of live-born infants
delivered preterm (from 5.4% to 7.4% of all deliveries) compared
with a 6.2% absolute increase in the proportion of live-born
infants delivered at early term (from 33.2% to 39.4%) (unpublished SMR2 data). Therefore, the population impact of SEN in
this subgroup of infants is likely to increase.
Previous studies have shown that preterm delivery is associated
with neurodevelopmental problems including developmental
delay, learning and language difficulties, impaired cognitive
function, and behavioural problems [914]. Studies suggest that
whereas all preterm infants are at increased risk, the risk increases
across the preterm spectrum from late preterm delivery (34
36 wk), through very preterm delivery (2834 wk), to extreme
preterm delivery (,28 wk) [15,16]. The percentage of infants born
early term (3739 wk) has risen dramatically over the past decade
[3]. In spite of this increase, there is a relative paucity of research
into the risk of SEN in this group of children. Our study did not
demonstrate any evidence of a threshold effect at 37 wk.
Therefore, the tendency of most previous studies to treat gestation
as a binary factor (preterm versus term) has masked a dose-effect
across the whole range of gestation.

Table 3. Population attributable fractions for special

educational needs due to gestational age at delivery (wk).

Gestation at Delivery (wk)

Attributable Fractiona

95% CI

2427

0.005

(0.0040.006)

2832

0.011

(0.0100.013)

3336

0.020

(0.0170.024)

37

0.016

(0.0120.020)

38

0.020

(0.0160.028)

39

0.019

(0.0120.027)

42

0.007

(0.0030.010)

43

0.000

(0.0000.000)

Total

0.100

(0.0070.129)

Adjusted for infant sex, maternal age and height, marital status, parity, birthweight centile, induction of labour, mode of delivery, year of delivery, previous
spontaneous and therapeutic deliveries, and 5-min Apgar score.
doi:10.1371/journal.pmed.1000289.t003

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Gestation and Special Educational Need

A small number of studies have examined the relationship

between gestational age, rather than preterm delivery, and either
school performance or intelligence scores. In a study of 317,761
male, Norwegian conscripts, mean intelligence score increased
from 28 to 4041 wk gestation [15]. However, individuals with
significant intellectual impairment were exempt from conscription
and were, therefore, excluded from the study. More recently, a
study of 13,824 children in Belarus confirmed an increase in
intelligence score from 37 to 40 wk gestation [16]. Small
reductions in cognitive tests and IQ do not necessarily equate to
detectable differences in school performance or childrens ability
to function in society. In a study of 873 Swedish children,
Lagerstrom et al. found no significant association between
gestational age and either school performance or intelligence
scores at 13 y of age [17]. In a study of 5,319 Danish children,
parents reported their childs performance at school at 10 y of age
[18]. Compared with children delivered at 3940 wk gestation,
those delivered at 3738 wk had a higher risk of reading and
spelling difficulties. No association was found with arithmetic
difficulties. The study excluded children born at less than 33 wk
gestation and was underpowered to examine the effect of delivery
prior to 37 wk. Therefore, the investigators were unable to
determine whether there was a significant trend across the
spectrum of gestational age. In the Bavarian Longitudinal Study,
IQ decreased by around 2.5 points for each week of gestation from
32 to 27 wk [19].
Our study demonstrated that the risk of SEN was lowest at 40
41 wk gestation and rose beyond this. The effect of delivery postdates has been ignored in most previous studies. Among
Norwegian conscripts, intelligence scores fell from 41 to 44 wk
gestation [15] and, in a study of 86,630 children born in 1950
1954, verbal reasoning scores in the 11 plus examination were
lower among those delivered beyond 40 wk gestation [20].
Similarly, among children in Belarus, intelligence score fell from
40 to 43 wk of gestation [16]. In contrast, a longitudinal study of
575 normal birth-weight infants demonstrated significantly higher
IQ scores at 810 y among those delivered at .40 wk compared
those delivered at 3840 wk [21].
Our study has a number of strengths. It is the largest study of its
kind and the first unselected, population-based study to examine
risk over the whole gestational spectrum. Being based on a
national population register, it is not subject to selection bias. The
obstetric and SEN data were obtained from routine data sources

obviating possible recall, response, or ascertainment bias. Our

ascertainment of SEN included all school-age children irrespective
of type of school and was, therefore, representative of the
population as a whole. Because Scotland has a stable population
and high quality routine data sources, a very high percentage of
pupils could be linked to their birth records. The obstetric register
is detailed and accurate enabling adjustment for a wide range of
possible confounding factors. A number of previous studies have
examined birth weight, rather than gestation. Although mean
birth weight is lower among preterm infants, individual low birth
weight is a poor proxy of gestation since it is also a marker of intrauterine growth restriction. Furthermore, there is an interaction
between absolute birth weight and gestational age, such that low
birth weight is a risk factor for intellectual impairment among term
infants but not preterm infants [14,15,17]. Therefore, a specific
strength of our study is that we measured gestation and adjusted
for sex- and gestation-specific birth-weight centile, rather than
using absolute birth weight. Wiener et al. restricted their analysis
to infants of normal birth weight and demonstrated lower IQ
scores at 810 y of age among those born preterm compared with
those born at term [21].
Early term deliveries have increased over time. The normal
timing of elective delivery has changed over time from 37 towards
39 wk. 75% of deliveries at 39 wk are elective (unpublished SMR2
data). However, our data suggest that even at 39 wk infants are at
increased risk of SEN and account for 1.7% of all SEN cases.
These findings have implications for clinical practice in relation to
both the decision to undertake elective delivery and the timing of
elective deliveries.

Supporting Information
Text S1 Sensitivity analysis.
Found at: doi:10.1371/journal.pmed.1000289.s001 (0.04 MB
DOC)

Author Contributions
ICMJE criteria for authorship read and met: DFM GCS RD JPP. Agree
with the manuscripts results and conclusions: DFM GCS RD JPP.
Designed the experiments/the study: GCS RD JPP. Analyzed the data:
DFM RD. Collected data/did experiments for the study: RD JPP. Wrote
the first draft of the paper: JPP. Contributed to the writing of the paper:
DFM GCS RD JPP.

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Gestation and Special Educational Need

Editors Summary
increased across the gestation range from 40 to 24 weeks.
Thus, compared to children born at 40 weeks, children born
at 3739 weeks of gestation were 1.16 times as likely to have
an SENan odds ratio of 1.16. Children born at 3336, 28
32, and 2427 weeks were 1.53, 2.66, and 6.92 times as likely
to have an SEN, respectively, as children born at 40 weeks.
Although the risk of SEN was much higher in preterm than in
early term babies, because many more children were born
between 37 and 39 weeks (about a third of babies) than
before 37 weeks (one in 20 babies), early term births
accounted for 5.5% of cases of SEN, whereas preterm
deliveries accounted for only 3.6% of cases.

Background. Most pregnancies last around 40 weeks, but

the number of babies who are born early is increasing. In the
US, for example, more than half a million babies a year are
now born before 37 weeks of gestation (gestation is the
period during which a baby develops in its mother). Sadly,
babies born this early (premature babies) are more likely to
die than babies delivered between 37 and 42 weeks of
gestation (term babies) and many have short- and/or longterm health problems. They are also more likely to have a
special educational need (SEN) as children, a learning
difficulty (for example, dyslexia or autism), or a physical
difficulty such as deafness or poor vision that requires special
educational help, than term babies. The severity of all the
problems associated with being born early depends on the
degree of prematurity. Thus, the risk of SEN associated with
prematurity declines steadily with advancing gestational age
up to 36 weeks. That is, a baby born at 24 weeks of gestation
is more likely to have an SEN later in life than one born at 36
weeks of gestation.

What Do These Findings Mean? These findings show

that gestational age at delivery strongly affects a childs
subsequent risk of having an SEN in a dose-dependent
manner across the whole range of gestational age.
Furthermore, because early term delivery is much more
common than preterm delivery, these findings show that
early term delivery is responsible for more cases of SEN than
preterm delivery. These findings, which are likely to be
accurate because of the large size of the study and its design,
have important implications for the timing of elective
delivery. They suggest that deliveries should ideally wait
until 40 weeks of gestation because even a baby born at 39
weeksthe normal timing for elective deliveries these
dayshas an increased risk of SEN compared with a baby
born a week later.

Why Was This Study Done? Early term births (between 37

and 39 weeks of gestation) are also becoming more
common, because more mothers are electing to be
delivered early for nonmedical reasons (so-called birth
scheduling). Unfortunately, it is not known whether early
term babies have an increased risk of SEN compared with
babies born at 40 weeks, because few studies have looked at
SEN in children born between 37 and 39 weeks of gestation.
In this retrospective cohort study, the researchers investigate
the risk of SEN across the whole spectrum of gestational age
at delivery and use their results to calculate the fraction of
SEN associated with delivery at different gestational ages
the population attributable risk. In a retrospective cohort
study, researchers examine the medical records of groups of
people who differ in a specific characteristic (in this case,
having an SEN) for a particular outcome (in this case,
gestational age at birth).

Additional Information. Please access these Web sites via

the online version of this summary at http://dx.doi.org/10.
1371/journal.pmed.1000289.

N
N

What Did the Researchers Do and Find? The researchers

linked 2005 School Census data (which includes a record of
all children with an SEN) for more than 400,000 school-aged
children in 19 Scottish Local Authority areas (covering threequarters of the Scottish population) with routine birth data
held in the Scottish Morbidity Record. SEN was recorded for
nearly 18,000 children (4.9% of the children). 8.4% of the
children who were born preterm and 4.7% of those born at
term were recorded as having an SEN. The risk of SEN

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N
N

10

The March of Dimes, a nonprofit organization for

pregnancy and baby health, provides information on
preterm birth and an article on why the last weeks of
pregnancy count (in English and Spanish)
The US National Institute of Child Health and Human
Development has information on preterm labor and birth
and on learning disabilities
The UK Government provides information for parents on
special educational needs
Medline Plus has links to further information on both
premature birth and learning disabilities (in English and
Spanish)

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