BMJ  2005;330:879 (16 April), doi:10.1136/bmj.38376.603426.D3 (published 25 February 2005)

Paper

Operative delivery and postnatal depression: a cohort study

¹ Level D, Division of Obstetrics and Gynaecology, University of Bristol, St Michael's Hospital, Bristol BS2 8EG, ² Division of Maternal and Child Health Sciences, University of Dundee, Ninewells Hospital and Medical School, Dundee DD1 9SY, ³ Academic Unit of Primary Health Care, Department of Community Based Medicine, University of Bristol, Bristol BS8 1AU

Abstract

Objectives To assess the association between elective caesarean section and postnatal depression compared with planned vaginal delivery and whether emergency caesarean section or assisted vaginal delivery is associated with postnatal depression compared with spontaneous vaginal delivery.

Design Prospective population based cohort study.

Setting ALSPAC (the Avon longitudinal study of parents and children).

Participants 14 663 women recruited antenatally with a due date between 1 April 1991 and 31 December 1992.

Main outcome measure Edinburgh postnatal depression scale score 13 at eight weeks postnatal on self completed questionnaire.

Results Albeit with wide confidence intervals, there was no evidence that elective caesarean section altered the odds of postnatal depression compared with planned vaginal delivery (adjusted odds ratio 1.06, 95% confidence interval 0.66 to 1.70, P = 0.80). Among planned vaginal deliveries there was similarly little evidence of a difference between women who have emergency caesarean section or assisted vaginal delivery and those who have spontaneous vaginal delivery (1.17, 0.77 to 1.79, P = 0.46, and 0.89, 0.68 to 1.18, P = 0.42, respectively).

Conclusions There is no reason for women at risk of postnatal depression to be managed differently with regard to mode of delivery. Elective caesarean section does not protect against postnatal depression. Women who plan vaginal delivery and require emergency caesarean section or assisted vaginal delivery can be reassured that there is no reason to believe that they are at increased risk of postnatal depression.

Introduction

The prevalence of depression in the postnatal period is similar to background population rates of depression and affects about 8-15% of women.¹ Postnatal depression is similar to depression occurring at other times in life and only distinguishable by the timing of onset. Depression at any time is associated with negative sequelae. What makes postnatal depression of particular concern is its possible detrimental long term effects on subsequent child development. Infants of depressed mothers have been found to perform less well on object concept tasks and be more insecurely attached to their mothers.² Other studies have found higher rates of intellectual deficits at 4 years of age,^{3 4} behavioural disturbances up to 5 years,^{4 5} and increased rates of special educational needs at 11 years.⁶ If labour is complicated and the delivery unexpectedly performed as an emergency procedure it could potentially be stressful to the mother. In such scenarios there may be an association between emergency operative delivery and postnatal depression. Several studies have investigated this association, though the current evidence is conflicting. There may be an association between elective caesarean section and a reduced risk of postnatal depression.

We compared the rates of postnatal depression in women who had an elective caesarean section and those who had a planned vaginal delivery (this included emergency caesarean section and assisted or spontaneous vaginal delivery).

Methods

The Avon longitudinal study of parents and children (ALSPAC) is a cohort study of over 14 000 women recruited antenatally in 1990-2.^{7 8} We have included all women with singleton, liveborn infants and term pregnancies (37 to 44 weeks) who completed the eight week postnatal questionnaire.

Results

Of the 12 944 women who met the study criteria, 10 934 (84.5%) completed the depression scale at eight weeks postnatally. Of these women, 8731 (79.9%) had a spontaneous vaginal delivery and 1242 (11.4%) had an assisted vaginal delivery. Of the 961 responders who had a caesarean section, 572 had an emergency operation (5.2%) and 389 (3.6%) had an elective procedure.

Elective caesarean section v planned vaginal delivery—A higher proportion of the women who had an elective caesarean section had a depression score 13 compared with women who planned a vaginal delivery (table 1), although the mean scores were similar. The unadjusted odds ratio of score 13 in women who had elective caesarean section compared with women who planned vaginal delivery was 1.31 (95% confidence interval 0.96 to 1.78). Adjustment for the prenatal factors identified as being associated with elective caesarean section (table 1) and housing status caused a fall in the odds ratio (1.06, 0.66 to 1.70). Neither a history of depression nor antenatal depression at 18 and 32 weeks was associated with elective caesarean section in this dataset.

View this table: [in this window] [in a new window]   Table 1 Association between elective caesarean section and Edinburgh postnatal depression score* compared with planned vaginal delivery

 

Emergency caesarean section v spontaneous vaginal delivery—About 10% of women in both delivery groups had an depression score 13 (table 2). The unadjusted odds ratio of the association between emergency caesarean section and depression score 13 was 0.99 (0.74 to 1.32). Adjustment for the nine prenatal variables found to be associated with emergency caesarean section from the previous analyses of this dataset (table 2) and housing status increased the odds ratio to 1.17 (0.77 to 1.79), but still with no strong evidence of an association.

View this table: [in this window] [in a new window]   Table 2 Association between emergency caesarean section and Edinburgh postnatal depression score* compared with spontaneous vaginal delivery

 

Assisted vaginal delivery v spontaneous vaginal delivery—A lower proportion of women who had an assisted vaginal delivery had depression scores 13 compared with women who delivered spontaneously. Their mean scores, however, were the same (table 3). The unadjusted odds ratio between assisted vaginal delivery and depression score 13 was 0.85 (0.69 to 1.05). Adjustment for the factors identified as being associated with assisted vaginal delivery in this dataset (see table 3) had minimal effect on the results and suggested little evidence of an association.

View this table: [in this window] [in a new window]   Table 3 Association between assisted vaginal delivery and Edinburgh depression score* compared with spontaneous vaginal delivery

 

Discussion

Though our results had wide confidence intervals, we could find no association between postnatal depression at eight weeks and elective caesarean section compared with planned vaginal delivery. Exploration of planned vaginal delivery similarly found little evidence of an association between emergency caesarean section or assisted vaginal delivery and postnatal depression compared with spontaneous vaginal delivery.

Strengths of study
Our research had several advantages over other studies in this specialty. We used prospectively collected data to evaluate the association between postnatal depression and operative delivery in a British cohort, which is important to clinical practice given the high prevalence of both mental illness and operative delivery in the UK population. Our cohort was also much larger than in most other similar studies. The Edinburgh postnatal depression scale was developed and validated in the United Kingdom and as such is an appropriate screening tool for postnatal depression in this population. Research has shown, however, that self reported screening tools for postnatal depression yield a higher rate of positive cases than clinical interview methods.⁹ Antenatal depression is known to be associated with postpartum depression^{1 10} and must therefore be considered in any exploration of risk factors of postnatal depression. Many of the published studies are limited by the absence of data on antenatal depression, which were available in our research. Data were also available on all types of operative delivery, which allowed us to examine more specific comparisons. Finally, we minimised confounding by incorporating factors previously identified to be associated with each delivery method studied.

Comparison with other studies
Our results support the current review of evidence by the National Institute for Clinical Excellence that postnatal depression is not a sequela of caesarean section.¹¹ Several other studies have also not found evidence of an association between planned mode of delivery and postnatal depression. One prospective cohort found a weak association between some complications in pregnancy and postnatal depression but none with mode of delivery.¹² Saisto et al adjusted for antenatal depression and found that mode of delivery did not predict postnatal depression at 8 to 12 weeks.¹⁰ Each of these studies comprised fewer than 500 women. Two larger prospective studies found no association between delivery complications and depression scores 13, though this was assessed at four months post partum.^{13 14} One study found some evidence of higher rates of raised depression scores at three months post partum in women who had an emergency caesarean section compared with those who had a spontaneous vaginal delivery.¹⁵ This study, however, involved only 21 women who had an emergency caesarean section. An Australian study found that both elective and emergency caesarean delivery were associated with a small but not significant increased risk of postnatal depression at eight weeks post partum.¹⁶

Conclusions
Our work adds an important component to the counselling of women who are planning mode of delivery. It is especially relevant for women considering elective caesarean section and in keeping with NICE guidelines helps "women to make informed decisions about childbirth."¹¹

There is no reason for women with a history of depression or those at high risk of depression to be managed differently with regard to mode of delivery. Furthermore, even if emergency caesarean section or assisted vaginal delivery is required, women can be reassured that there is no reason to believe that they are more likely to experience postnatal depression.

What is already known on this topic Postnatal depression affects 8-15% of women and may have long term effects on child development Rates of caesarean section are increasing worldwide and it is important to identify any long term risks associated with the procedure The conflicting evidence regarding operative delivery and postnatal depression is based on small observational studies What this study adds Elective caesarean section does not protect women from postnatal depression Neither emergency caesarean section nor assisted vaginal delivery is associated with an increased risk of postnatal depression Understanding the association between postnatal depression and caesarean section helps women to make informed choices about mode of delivery

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This is the abridged version of an article that was posted on bmj.com on 25 February 2005: http://bmj.com/cgi/doi/10.1136/bmj.38376.603426.D3

We are extremely grateful to all the mothers who took part and to the midwives for their cooperation and help in recruitment. The ALSPAC study team comprises interviewers, computer technicians, laboratory technicians, clerical workers, research scientists, volunteers, and managers who continue to make the study possible. We are grateful to Jean Golding for discussions about this research and to Jon Heron for data preparation.

Contributors: See bmj.com

Funding: Wellcome Trust, Medical Research Council, University of Bristol, Department of Health, and Department of Environment. The ALSPAC study is part of the WHO initiated European longitudinal study of pregnancy and childhood. RP received a clinical academic training fellowship from NHS South West research and development.

Competing interests: None declared.

Ethical approval: The research programme is governed by the four local research ethics committees. The ALSPAC ethics committee approved this project.

References

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2. Wrate RM, Rooney AC, Thomas PF, Cox JL. Postnatal depression and child development. A three-year follow-up study. Br J Psychiatry 1985;146: 622-7.[Abstract/Free Full Text]
3. Cogill S, Caplan H, Alexandra H, Robson K, Kumar R. Impact of postnatal depression on cognitive development of young children. BMJ 1986;292: 1165-7.
4. Sharp D, Hay DF, Pawlby S, Schmucker G, Allen H, Kumar R. The impact of postnatal depression on boys' intellectual development. J Child Psychol Psychiatry 1995;36: 1315-36.[Web of Science][Medline]
5. O'Connor TG, Heron J, Glover V, Alspac Study Team. Antenatal anxiety predicts child behavioral/emotional problems independently of postnatal depression. J Am Acad Child Adolesc Psychiatry 2002;41: 1470-7.[CrossRef][Web of Science][Medline]
6. Hay DF, Pawlby S, Sharp D, Asten P, Mills A, Kumar R. Intellectual problems shown by 11-year-old children whose mothers had postnatal depression. J Child Psychol Psychiatry 2001;42: 871-89.[CrossRef][Web of Science][Medline]
7. Avon longitudinal study of parent and children, 2003. www.alspac.bris.ac.uk/ (accessed 9 Feb 2005).
8. Golding J, Pembrey M, Jones R, ALSPAC study team. ALSPAC—the Avon longitudinal study of parents and children. I. Study methodology. Paediatric Perinat Epidemiol 2001;15: 74-87.
9. O'Hara M, Swain A. Rates and risks of postpartum depression: a meta-analysis. Int Rev Psychiatry 1996;8: 37-54.
10. Saisto T, Salmela-Aro K, Nurmi JE, Halmesmaki E. Psychosocial predictors of disappointment with delivery and puerperal depression. A longitudinal study. Acta Obstet Gynecol Scand 2001;80: 39-45.[CrossRef][Medline]
11. National Collaborating Centre for Women's and Children's Health. Caesarean section. Clinical guideline. London: Royal College of Obstetricians and Gynaecologists, 2004.
12. Verdoux H, Sutter AL, Glatigny-Dallay E, Minisini A. Obstetrical complications and the development of postpartum depressive symptoms: a prospective survey of the MATQUID cohort. Acta Psychiatr Scand 2002;106: 212-9.[CrossRef][Medline]
13. Nielsen FD, Videbech P, Hedegaard M, Dalby Salvig J, Secher NJ. Postpartum depression: identification of women at risk. Br J Obstet Gynaecol 2000;107: 1210-7.[Web of Science]
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15. Boyce PM, Todd AL. Increased risk of postnatal depression after emergency caesarean section. Med J Aust 1992;157: 172-4.[Web of Science][Medline]
16. Johnstone SJ, Boyce PM, Hickey AR, Morris-Yatees AD, Harris MG. Obstetric risk factors for postnatal depression in urban and rural community samples. Austral N Z J Psychiatry 2001;35: 69-74.[CrossRef][Web of Science][Medline]

(Accepted 17 January 2005)

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