Although preterm birth and formula feeding increase the risk of necrotizing enterocolitis (NEC), the influences of cesarean section (CS) and vaginal delivery (VD) are unknown. Therefore, gut characteristics and NEC incidence and severity were evaluated in preterm pigs (92% gestation) delivered by CS or VD. An initial study showed that newborn CS pigs (n=6) had decreased gastric acid secretion, absorption of intact proteins, activity of brush border enzymes and pancreatic hydrolases, plasma cortisol, rectal temperature, and changes in blood chemistry indicating impaired respiratory function, compared with VD littermates (n=6). In a second experiment, preterm CS (n=16) and VD (n=16) pigs were given total parenteral nutrition (36h) then fed porcine colostrum (VD-COL, n=6; CS-COL, n=6) or infant milk formula (VD-FORM, n=10; CS-FORM, n=10) for 2d. Across delivery, FORM pigs showed significantly higher NEC incidence, tissue proinflammatory cytokines (INF- and IL-6), Clostridium colonization and impaired intestinal function, compared with COL pigs. NEC incidence was equal for CS (6/16) and VD (6/16) pigs, CS pigs had decreased bacterial diversity and density, higher villus heights, and increased brush border enzyme activities (lactase, aminopeptidases) compared with VD pigs. In particular, VD-FORM pigs showed reduced mucosal proportions, reduced lactase and aminopeptidases, and increased proinflammatory cytokine IL-6 compared with CS-FORM (P0.06). Despite the initial improvement of intestinal and metabolic functions following VD, gut function and inflammation were similar, or more negatively affected in VD neonates than CS neonates. Both delivery modes exhibited positive and negative influences on the preterm gut, which may explain the similar NEC incidence.