Abstract
Childbirth is a life-transforming event often followed by a time of heightened psychological vulnerability in the mother. There is a growing recognition of the importance of obstetrics aspects in maternal well-being with the way of labor potentially influencing psychological adjustment following parturition or failure thereof. Empirical scrutiny on the association between mode of delivery and postpartum well-being remains limited. We studied 685 women who were on average 3 months following childbirth and collected information concerning mode of delivery and pre- and postpartum mental health. Analysis of variance revealed that women who had cesarean section or vaginal instrumental delivery had higher somatization, obsessive compulsive, depression, and anxiety symptom levels than those who had natural or vaginal delivery as well as overall general distress, controlling for premorbid mental health, maternal age, education, primiparity, and medical complication in newborn. Women who underwent unplanned cesarean also had higher levels of childbirth-related PTSD symptoms excluding those with vaginal instrumental. The risk for endorsing psychiatric symptoms reflecting clinically relevant cases increased by twofold following unplanned cesarean and was threefold for probable childbirth-related PTSD. Maternal well-being following childbirth is associated with the experienced mode of delivery. Increasing awareness in routine care of the implications of operative delivery and obstetric interventions in delivery on a woman’s mental health is needed. Screening at-risk women could improve the quality of care and prevent enduring symptoms. Research is warranted on the psychological and biological factors implicated in the mode of delivery and their role in postpartum adjustment.
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Abdi H (2007) Bonferroni and Šidák corrections for multiple comparisons. In: Salkind NJ (ed) Encyclopedia of measurement and statistics. Sage, Thousand Oaks, pp 284–290
American College of Obstetricians and Gynecologists (2017) Committee opinion no. 687: approaches to limit intervention during labor and birth. Obstet Gynecol 129(2):e20–e28. https://doi.org/10.1097/AOG.0000000000001905
American Psychiatric Association (2013) Diagnostic and statistical manual of mental disorders (DSM-5). American Psychiatric Association, Arlington
Andersen LB, Melvaer LB, Videbech P, Lamont RF, Joergensen JS (2012) Risk factors for developing post-traumatic stress disorder following childbirth: a systematic review. Acta Obstet Gynecol Scand 91(11):1261–1272. https://doi.org/10.1111/j.1600-0412.2012.01476.x
Ayers S, Ford E (2016) Post-traumatic stress during pregnancy and the postpartum period. In: Wenzel A (ed) Oxford handbook of perinatal psychology. Oxford University Press, Oxford, pp 182–200
Ayers S, Bond R, Bertullies S, Wijma K (2016) The aetiology of post-traumatic stress following childbirth: a meta-analysis and theoretical framework. Psychol Med 46(6):1121–1134. https://doi.org/10.1017/S0033291715002706
Betrán AP, Torloni MR, Zhang JJ et al (2016) WHO statement on caesarean section rates. BJOG 123(5):667–670. https://doi.org/10.1111/1471-0528.13526
Biggs MA, Upadhyay UD, McCulloch CE, Foster DG (2017) Women’s mental health and well-being 5 years after receiving or being denied an abortion: a prospective, longitudinal cohort study. JAMA Psychiatry 74(2):169–178. https://doi.org/10.1001/jamapsychiatry.2016.3478
Blevins CA, Weathers FW, Davis MT, Witte TK, Domino JL (2015) The posttraumatic stress disorder checklist for DSM-5 (PCL-5): development and initial psychometric evaluation. J Trauma Stress 28(6):489–498. https://doi.org/10.1002/jts.22059
Brockington I (2004) Postpartum psychiatric disorders. Lancet 363(9405):303–310. https://doi.org/10.1016/S0140-6736(03)15390-1
Campbell SB, Cohn JF, Flanagan C, Popper S, Meyers T (1992) Course and correlates of postpartum depression during the transition to parenthood. Dev Psychopathol 4(1):29–47. https://doi.org/10.1017/S095457940000554X
Carter FA, Frampton CM, Mulder RT (2006) Cesarean section and postpartum depression: a review of the evidence examining the link. Psychosom Med 68(2):321–330. https://doi.org/10.1097/01.psy.0000204787.83768.0c
Castillo-Ruiz A, Mosley M, Jacobs AJ, Hoffiz YC, Forger NG (2018) Birth delivery mode alters perinatal cell death in the mouse brain. Proc Natl Acad Sci U S A 115(46):11826–11831. https://doi.org/10.1073/pnas.1811962115
Chaaya M, Campbell OMR, El Kak F, Shaar D, Harb H, Kaddour A (2002) Postpartum depression: prevalence and determinants in Lebanon. Arch Womens Ment Health 5(2):65–72. https://doi.org/10.1007/s00737-002-0140-8
Chang SR, Chen KH, Ho HN, Lai YH, Lin MI, Lee CN, Lin WA (2015) Depressive symptoms, pain, and sexual dysfunction over the first year following vaginal or cesarean delivery: a prospective longitudinal study. Int J Nurs Stud 52(9):1433–1444. https://doi.org/10.1016/j.ijnurstu.2015.04.019
Chen HH, Lai JCY, Hwang SJ, Huang N, Chou YJ, Chien LY (2017) Understanding the relationship between cesarean birth and stress, anxiety, and depression after childbirth: a nationwide cohort study. Birth 44(4):369–376. https://doi.org/10.1111/birt.12295
Cicchetti D, Rogosch FA, Toth SL (1998) Maternal depressive disorder and contextual risk: contributions to the development of attachment insecurity and behavior problems in toddlerhood. Dev Psychopathol 10(2):283–300. https://doi.org/10.1017/S0954579498001618
Davies J, Slade P, Wright I, Stewart P (2008) Posttraumatic stress symptoms following childbirth and mothers’ perceptions of their infants. Infant Ment Health J 29(6):537–554. https://doi.org/10.1002/imhj.20197
Dekel S, Stuebe C, Dishy G (2017) Childbirth induced posttraumatic stress syndrome: a systematic review of prevalence and risk factors. Front Psychol 8:560. https://doi.org/10.3389/fpsyg.2017.00560
Dekel S, Thiel F, Dishy G, Ashenfarb AL (2018) Is childbirth-induced PTSD associated with low maternal attachment? Arch Womens Ment Health 22:1–4. https://doi.org/10.1007/s00737-018-0853-y
Dekel S, Ein-Dor T, Ruohomäki A, et al (2019) The dynamic course of peripartum depression across pregnancy and childbirth. J Psychiatr Res, 113: 72–78. https://doi.org/10.1016/j.jpsychires.2019.03.016
Derogatis LR (1993) BSI brief symptom inventory: administration, scoring, and procedure manual, 4th edn. National Computer Systems, Minneapolis
Eckerdal P, Georgakis MK, Kollia N, Wikström AK, Högberg U, Skalkidou A (2018) Delineating the association between mode of delivery and postpartum depression symptoms: a longitudinal study. Acta Obstet Gynecol Scand 97(3):301–311. https://doi.org/10.1111/aogs.13275
Feldman R, Weller A, Zagoory-Sharon O, Levine A (2007) Evidence for a neuroendocrinological foundation of human affiliation: plasma oxytocin levels across pregnancy and the postpartum period predict mother-infant bonding. Psychol Sci 18:965–997. https://doi.org/10.1111/j.1467-9280.2007.02010.x
Guintivano J, Sullivan PF, Stuebe AM, Penders T, Thorp J, Rubinow DR, Meltzer-Brody S (2018) Adverse life events, psychiatric history, and biological predictors of postpartum depression in an ethnically diverse sample of postpartum women. Psychol Med 48(7):1190–1200. https://doi.org/10.1017/S0033291717002641
Jobst A, Krause D, Maiwald C, Härtl K, Myint AM, Kästner R, Obermeier M, Padberg F, Brücklmeier B, Weidinger E, Kieper S, Schwarz M, Zill P, Müller N (2016) Oxytocin course over pregnancy and postpartum period and the association with postpartum depressive symptoms. Arch Womens Ment Health 19:571–579. https://doi.org/10.1007/s00737-016-0644-2
Lobel M, DeLuca RS (2007) Psychosocial sequelae of cesarean delivery: review and analysis of their causes and implications. Soc Sci Med 64(11):2272–2284. https://doi.org/10.1016/j.socscimed.2007.02.028
Marshall RD, Olfson M, Hellman F, Blanco C, Guardino M, Struening EL (2001) Comorbidity, impairment, and suicidality in subthreshold PTSD. Am J Psychiatry 158(9):1467–1473. https://doi.org/10.1176/appi.ajp.158.9.1467
Mathisen SE, Glavin K, Lien L, Lagerløv P (2013) Prevalence and risk factors for postpartum depressive symptoms in Argentina: a cross-sectional study. Int J Women's Health 5:787–793. https://doi.org/10.2147/IJWH.S51436
McKeever VM, Huff ME (2003) A diathesis-stress model of posttraumatic stress disorder: ecological, biological, and residual stress pathways. Rev Gen Psychol 7(3):237–250. https://doi.org/10.1037/1089-2680.7.3.237
Moehler E, Brunner R, Wiebel A, Reck C, Resch F (2006) Maternal depressive symptoms in the postnatal period are associated with long-term impairment of mother–child bonding. Arch Womens Ment Health 9(5):273–278. https://doi.org/10.1007/s00737-006-0149-5
Murray L, Cartwright W (1993) The role of obstetric factors in postpartum depression. J Reprod Infant Psychol 11(4):215–219. https://doi.org/10.1080/02646839308403221
Netsi E, Pearson RM, Murray L, Cooper P, Craske MG, Stein A (2018) Association of persistent and severe postnatal depression with child outcomes. JAMA Psychiatry 75(3):247–253. https://doi.org/10.1001/jamapsychiatry.2017.4363
O'Hara MW, Zekoski EM, Philipps LH, Wright EJ (1990) Controlled prospective study of postpartum mood disorders: comparison of childbearing and nonchildbearing women. J Abnorm Psychol 99(1):3–15. https://doi.org/10.1037/0021-843X.99.1.3
O'Hara MW, Schlechte JA, Lewis DA, Wright EJ (1991) Prospective study of postpartum blues: biologic and psychosocial factors. Arch Gen Psychiatry 48(9):801–806. https://doi.org/10.1001/archpsyc.1991.01810330025004
Olieman RM, Siemonsma F, Bartens MA, Garthus-Niegel S, Scheele F, Honig A (2017) The effect of an elective cesarean section on maternal request on peripartum anxiety and depression in women with childbirth fear: a systematic review. BMC Pregnancy Childbirth 17(1):195. https://doi.org/10.1186/s12884-017-1371-z
Örün E, Yalçın SS, Mutlu B (2013) Relations of maternal psychopathologies, social-obstetrical factors and mother-infant bonding at 2-month postpartum: a sample of Turkish mothers. World J Pediatr 9(4):350–355. https://doi.org/10.1007/s12519-013-0432-2
Petterson SM, Albers AB (2001) Effects of poverty and maternal depression on early child development. Child Dev 72(6):1794–1813. https://doi.org/10.1111/1467-8624.00379
Rauh C, Beetz A, Burger P, Engel A, Häberle L, Fasching PA, Kornhuber J, Beckmann MW, Goecke TW, Faschingbauer F (2012) Delivery mode and the course of pre- and postpartum depression. Arch Gynecol Obstet 286:1407–1412. https://doi.org/10.1007/s00404-012-2470-8
Reck C, Stehle E, Reinig K, Mundt C (2009) Maternity blues as a predictor of DSM-IV depression and anxiety disorders in the first three months postpartum. J Affect Disord 113(1–2):77–87. https://doi.org/10.1016/j.jad.2008.05.003
Ross LE, Evans SG, Sellers EM, Romach MK (2003) Measurement issues in postpartum depression part 1: anxiety as a feature of postpartum depression. Arch Womens Ment Health 6(1):51–57. https://doi.org/10.1007/s00737-002-0155-1
Rowe-Murray HJ, Fisher JR (2001) Operative intervention in delivery is associated with compromised early mother-infant interaction. BJOG 108(10):1068–1075. https://doi.org/10.1111/j.1471-0528.2001.00242.x
Rowlands IJ, Redshaw M (2012) Mode of birth and women’s psychological and physical wellbeing in the postnatal period. BMC Pregnancy Childbirth 12(1):138. https://doi.org/10.1186/1471-2393-12-138
Rubin DB (2009) Multiple imputation for nonresponse in surveys, vol 307. John Wiley & Sons, Hoboken
Ryding EL, Wijma K, Wijma B (1998) Psychological impact of emergency cesarean section in comparison with elective cesarean section, instrumental and normal vaginal delivery. J Psychosom Obstet Gynecol 19(3):135–144. https://doi.org/10.3109/01674829809025691
Sadat Z, Kafaei Atrian M, Masoudi Alavi N, Abbaszadeh F, Karimian Z, Taherian A (2014) Effect of mode of delivery on postpartum depression in Iranian women. J Obstet Gynaecol Res 40(1):172–177. https://doi.org/10.1111/jog.12150
Scheepstra KWF, van Steijn ME, Dijksman LM, van Pampus MG (2017) Post-traumatic stress disorder in women and their partners, following severe post-partum hemorrhage: a study protocol for a prospective cohort study. Cogent Med 4(1):1278840. https://doi.org/10.1080/2331205X.2017.1278840
Šidák Z (1967) Rectangular confidence regions for the means of multivariate normal distributions. J Am Stat Assoc 62(318):626–633. https://doi.org/10.1080/01621459.1967.10482935
Söderquist J, Wijma B, Thorbert G, Wijma K (2009) Risk factors in pregnancy for post-traumatic stress and depression after childbirth. BJOG 116(5):672–680. https://doi.org/10.1111/j.1471-0528.2008.02083.x
Stjernholm YV, Nyberg A, Cardell M, Höybye C (2016) Circulating maternal cortisol levels during vaginal delivery and elective cesarean section. Arch Gynecol Obstet 294(2):267–271. https://doi.org/10.1007/s00404-015-3981-x
Stramrood C, Slade P (2017) A woman afraid of becoming pregnant again: posttraumatic stress disorder following childbirth. In: Paarlberg K, van de Wiel H (eds) Bio-psycho-social obstetrics and gynecology. Springer, Cham, pp 33–49
Swain JE, Tasgin E, Mayes LC, Feldman R, Todd Constable R, Leckman JF (2008) Maternal brain response to own baby-cry is affected by cesarean section delivery. J Child Psychol Psychiatry 49:1042–1052. https://doi.org/10.1111/j.1469-7610.2008.01963.x
Sword W, Kurtz Landy C, Thabane L, Watt S, Krueger P, Farine D, Foster G (2011) Is mode of delivery associated with postpartum depression at 6 weeks: a prospective cohort study. BJOG 118(8):966–977. https://doi.org/10.1111/j.1471-0528.2011.02950.x
Van Heumen MA, Hollander MH, van Pampus MG, van Dillen J, Stramrood CA (2018) Psychosocial predictors of postpartum posttraumatic stress disorder in women with a traumatic childbirth experience. Front Psychiatry 9:348. https://doi.org/10.3389/fpsyt.2018.00348
Villar J, Carroli G, Zavaleta N, Donner A, Wojdyla D, Faundes A, Velazco A, Bataglia V, Langer A, Narváez A, Valladares E, Shah A, Campodónico L, Romero M, Reynoso S, de Pádua KS, Giordano D, Kublickas M, Acosta A, World Health Organization 2005 Global Survey on Maternal and Perinatal Health Research Group (2007) Maternal and neonatal individual risks and benefits associated with caesarean delivery: multicentre prospective study. BMJ 335(7628):1025. https://doi.org/10.1136/bmj.39363.706956.55
Weathers FW, Litz BT, Keane TM, Palmieri PA, Marx BP, Schnurr PP (2013) The PTSD checklist for DSM-5 (PCL-5). Scale available from the National Center for PTSD at www.ptsd.va.gov
Wyler AR, Masuda M, Holmes TH (1971) Magnitude of life events and seriousness of illness. Psychosom Med 33(2):115–122. https://doi.org/10.1097/00006842-197103000-00003
Yehuda R, Bell A, Bierer LM, Schmeidler J (2008) Maternal, not paternal, PTSD is related to increased risk for PTSD in offspring of holocaust survivors. J Psychiatr Res 42(13):1104–1111. https://doi.org/10.1016/j.jpsychires.2008.01.002
Zanardo V, Svegliado G, Cavallin F, Giustardi A, Cosmi E, Litta P, Trevisanuto D (2010) Elective cesarean delivery: does it have an effect on breastfeeding? Birth 37(4):275–279. https://doi.org/10.1111/j.1523-536X.2010.00421.x
Acknowledgments
The authors would like to thank Ms. Shannon Hennig for her generous support in initiating this research project. We also would like to thank Gabriella Dishy for developing the online survey and Philip Mayopoulos for assisting with manuscript editing.
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Dr. Dekel was supported by a grant from the National Institute of Child Health and Human Development (R21 HD090396) and an award from the MGH Center for Faculty Development. Dr. Dekel also recieved the Susan A. Hickman Memorial Research Award from Postpartum Support International.
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Dekel, S., Ein-Dor, T., Berman, Z. et al. Delivery mode is associated with maternal mental health following childbirth. Arch Womens Ment Health 22, 817–824 (2019). https://doi.org/10.1007/s00737-019-00968-2
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DOI: https://doi.org/10.1007/s00737-019-00968-2