Cesarean Section and Postpartum Depression: A Review of the Evidence Examining the Link
Carter, Frances A. PhD; Frampton, Chris M. A. PhD; Mulder, Roger T. MBChB, FRANZCP, PhD
From the Department of Psychological Medicine, Christchurch School of Medicine and Health Sciences, University of Otago, Christchurch, New Zealand.
Address correspondence and reprint requests to Frances A. Carter, Department of Psychological Medicine, Christchurch School of Medicine, PO Box 4345, Christchurch, New Zealand. E-mail: email@example.com
Received for publication May 5, 2005; revision received September 23, 2005.
Objective: The objective of this study was to examine the evidence for an association between cesarean section and postpartum depression.
Methods: Medline and PsychInfo databases were searched. All studies on cesarean section that evaluated maternal mood between 10 days and 1 year after delivery were reviewed. Nine methodologically superior studies, including the only randomized, controlled trial (RCT), were analyzed separately. The nine studies that provided adequate summary statistics were combined in a meta-analysis.
Results: Of the 24 studies that have examined the association between cesarean section and postpartum depression, five found a significant adverse association, 15 found no significant association, and four found mixed results. With only one exception, methodologically superior studies found either no significant association or mixed evidence for an association between cesarean section and postpartum depression. Meta-analyses of suitable studies failed to find evidence for a significant association between cesarean section and postpartum depression. Possible reasons why different studies have obtained different results are critically evaluated.
Conclusion: A link between cesarean section and postpartum depression has not been established.
CS = cesarean section; EPDS = Edinburgh Postnatal Depression Scale; PPD = postpartum depression; RCT = randomized, controlled trial.
Delivery by cesarean section (CS) is now a relatively common event for women giving birth in the developed world. More than 20% of deliveries were performed by CS in the United States and the United Kingdom over recent years (1). Since the 1970s, concern has been raised that delivery by CS may be associated with adverse psychological consequences for women, including postpartum depression (PPD) (2,3). Postpartum depression affects approximately 10% of women after delivery (4–6) and has an adverse impact on parenting behavior, child well-being, and child progress (7–15).
Reviews examining the psychological impact of CS have either failed to separate studies examining PPD from studies examining other psychological outcomes (16) or have reached disparate conclusions (16–18). Fisher (18) reported that the literature examining the link between CS and PPD was equivocal. Clement (17) stated that although mode of delivery may play a small role in the etiology of PPD, other nonbirth-related factors are more clearly implicated. None of these previous reviews (16–18) have conducted a meta-analysis. Since the most recent review was written (17), 11 studies have been published that were not included in that review (19–29). Many of these studies are large and well-conducted. Finally, recent reports suggest that rates of CS are continuing to rise in the developed world (1). For these reasons, a systematic review and meta-analysis of the potential link between CS and PPD is necessary.
Computerized Medline and PsychInfo searches were performed covering the periods from 1966 onward and 1974 onward, respectively. Various terms were entered to capture references relating to CS (“cesarean section,” “cesarean section,” and “caesarian section”) and PPD (“postpartum depression,” “postnatal depression,” and “depression”), and citations combining these groups of terms were identified. All published citations were crossreferenced for other relevant studies. Articles were required to be in English and in a peer-reviewed journal or book.
The present review addresses the specific issue of whether CS is associated with an increased risk of PPD. To examine this question, it is essential to specify both the risk variable (CS) and the outcome variable (PPD) under consideration.
First, only studies that have analyzed the specific impact of CS are reviewed in the results. Studies that have examined “delivery complications,” “assisted delivery,” “obstetric interventions,” “nonspontaneous delivery,” “peripartum stressful events,” “emergency delivery,” or have lumped CS together with delivery by forceps and/or vacuum extraction are not examined (30–41).
Second, only studies that have analyzed the specific impact on PPD are reviewed in the results. For this review, PPD is defined broadly to avoid discarding studies of potential value. All studies that have evaluated maternal mood between 10 days and 1 year after delivery are examined. This is a broader time frame than the 4 weeks postpartum required by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (42). If that requirement had been adhered to, only four studies could have been included (21,43–45). Studies are also included that have analyzed depressive symptoms as a continuous measure rather than categorizing participants into depressed and nondepressed. For convenience, the term PPD is applied across all of these studies.
Studies are not included that examined the impact of CS on
* “The blues” rather than PPD, i.e., significant tearfulness and low mood, lasting for at least part of 1 day during the first 10 days postpartum (46–48);
* Diagnostically heterogeneous variables such as “psychiatric admissions” and “psychiatric contacts” (49,50); and
* Psychological variables other than mood such as “fear of childbirth,” “mother-infant interaction,” and “mental distress” (51–53).
Methodological difficulties with studies examining the link between CS and PPD include small sample sizes, possible selection biases, lack of prospective assessment, inadequate and diverse assessment measures, and lack of appropriate controls (16–18). In addition, it is important to control for potential confounding variables. Ideally, factors that may place a woman at increased risk for having a CS, and developing PPD, need to be controlled for. For example, it may be that being older when you have your first child is independently associated with both CS and PPD (30,54). Also, depressive symptoms during pregnancy have repeatedly been found to be associated with PPD (see  for a review), and may be associated with mode of delivery, although the evidence is mixed (56–58). Studies have attempted to control for potential confounding factors either through the use of statistical techniques or through their design. Few studies have adequately controlled for all confounding factors.
Quantitative Data Synthesis
Methodologically Superior Studies
The following criteria were developed to identify methodologically superior studies:
* Large sample size. This was arbitrarily set to include studies with one hundred subjects or more;
* PPD assessed prospectively;
* PPD assessed using a standardized, non substantially modified, generally accepted measure of depressive disorder; and
* Able to control for some confounding factors. Studies were included if they were a randomized, controlled trial (RCT) or if they assessed mood during pregnancy.
Studies that provided sufficient summary statistics for PPD were combined in meta-analyses to produce a quantitative assessment of the impact of CS on PPD. Two separate meta-analyses were conducted. First, a meta-analysis was conducted involving studies with comparable assessments of PPD (Edinburgh Postnatal Depression Scale >12, >12.5, or ≥13) that were conducted at similar times postpartum (6–20 weeks postpartum).
The EPDS was selected because it has been extensively evaluated (see [59,60] for reviews) and was by far the most commonly used measure of depression in the studies identified in this review. Although depression occurs on a continuum, a categorical measure of depression was used because most studies using the EPDS reported results in this way and did not report sufficient data for a continuous measure to be used. Some studies that did not use the EPDS used measures of depression of uncertain validity (43,44,61–64). Studies that did use alternative, accepted measures of depression (e.g., Beck Depression Inventory) were not included in the meta-analysis because it is not clear which cut points should be applied to these measures to ensure that the data are directly comparable with those obtained using EPDS cutoffs. Although this reduced the number of studies that were able to be included in the analysis, it improved the comparability of those studies being combined.
Second, another meta-analysis was conducted involving studies that met criteria for inclusion in the first meta-analysis plus had been classified as being “methodologically superior” (see the previous section). Overall measures of the effect of CS on PPD were calculated using the Mantel-Haenszel odds ratio estimate. Measure of the homogeneity of the association of CS and PPD across studies was calculated using the Breslow-Day χ-squared test.
Description of Study Findings: All Studies
Table 1 shows studies examining the relation between CS and PPD. The table provides the following information for each study: sample size, study design, a description of the participants and the recruitment strategy used, where the study was conducted, whether mood was assessed during pregnancy, when PPD was assessed, how PPD was assessed, and the method for collecting obstetric data. The following study designs were identified: RCT, case-control studies (participants selected according to whether the outcome variable was present or absent, i.e., PPD versus no PPD), cohort studies (participants selected on the basis of exposure to the risk factor, i.e., CS versus no CS), and case-series (women selected who were either pregnant or had recently given birth, not on the basis of either exposure to the risk factor or the presence of the outcome variable).
Overall, 24 studies are included in Table 1. Studies are organized according to their findings, as follows:
* Studies showing a significant adverse association between CS and PPD (n = 5 studies);
* Studies showing no significant association between CS and PPD (n = 15 studies); and
* Studies showing mixed evidence for an association between CS and PPD (n = 4 studies).
The latter category includes studies that found different results depending on which variables were analyzed. Three of these four studies found a mixture of adverse and neutral effects for CS on PPD, depending on which measure of PPD was analyzed (65) and when PPD was assessed (45,61). The remaining study showed a mixture of advantageous and neutral effects for CS on PPD, depending on whether women came from an urban or rural area, respectively (19).
Methodologically Superior Studies
The 24 studies were examined to see if they met criteria for being classified as being methodologically superior. The following studies (indicated in brackets) were not classified as being methodologically superior for the following reasons:
* Not a large sample size (i.e., <100) (43,63,66);
* PPD not assessed prospectively (64,65);
* PPD not assessed using an accepted measure (43,44,61–64); and
* Not able to control for confounding factors (i.e., no assessment of mood during pregnancy and not an RCT) (19,20,24,25,27,28,43,61,64–68).
These studies were excluded, leaving eight methodologically superior studies (21–23,26,29,45,69,70). These eight studies found the following results:
* Studies showing a significant adverse association between CS and PPD (n = 1 study, 70);
* Studies showing no significant association between CS and PPD (n = 6 studies [21–23,26,29], n = 6 studies ); and
* Studies showing mixed evidence for an association between CS and PPD (n = 1 study ). This study found a mixture of adverse and neutral effects depending on when the postpartum assessment was conducted (45).
Of the methodologically superior studies examined here, one study stands out above the rest. Hannah and colleagues conducted the only RCT evaluating the effect of CS on PPD (23). The RCT is the ideal study design for controlling for potential confounding factors. Participants were pregnant women with a breech presentation at full term who were randomized to either planned CS or planned vaginal delivery (n = 1596). The authors only present analyses examining the impact of planned CS versus planned vaginal delivery (i.e., treatment as assigned at randomization; no significant difference). However, data are presented for all groups (i.e., planned and unplanned CS and vaginal deliveries). Our analysis of these data showed that there were no significant differences between women who had a CS or a vaginal delivery regardless of whether they were planned or unplanned (χ-squared tests: unplanned CS versus planned vaginal p = .46; all CS versus all vaginal p = .71). Recent findings from Patel and colleagues are consistent with this finding (29).
Meta-Analyses of Selected Studies
Table 2 shows a summary of the reasons studies were, or were not, included in the two meta-analyses and the results of these analyses. For the first meta-analysis, eight studies were identified that provided sufficient data for inclusion in a meta-analysis and had a common assessment of PPD (EPDS >12 or >12.5) within a reasonable range of postpartum times (6–20 weeks) (19,22,23,27,29,45,67,68). When these studies were combined, the common odds ratio for the effect of CS on PPD was 1.083 (95% confidence interval [CI]: 0.95–1.24). The test of the homogeneity of effect across studies was not significant (χ2 = 24.9, df = 7, p = .001).
For the second meta-analysis, studies were required to meet the criteria for the first meta-analysis plus be classified as being methodologically superior. Only four such studies were identified (22,23,29,45). When these studies were combined, the common odds ratio for the effect of CS on PPD was 1.15 (95% CI: 0.97–1.36). The test of the homogeneity of effect across studies was significant (χ2 = 17.3, df = 3, p = .001).
Delivery by CS and PPD are not rare experiences for women giving birth over recent years in the Western world. Concern has been expressed since the 1970s that these experiences may be linked. This article examined the evidence for an association between CS and PPD. Overall, the evidence for a link is unconvincing. Of the 24 studies that were able to address this issue, most found either no significant association (n = 15) or mixed evidence for an association (n = 4). Methodologically superior studies also largely failed to find a significant adverse association. Meta-analyses of suitable studies failed to find evidence for a significant association between CS and PPD.
Although the vast majority of studies found no significant association between CS and PPD, a broad range of findings have been reported; the statistical significance of the measure of the heterogeneity in both meta-analyses provides good evidence of this. For example, CS has been found to be both a significant risk factor for PPD (43,62,67,70,71) and to be protective against PPD in certain settings (19). A number of possible explanations exist for these diverse findings.
First, some studies may be methodologically weak. Studies with substantial methodological problems would be expected to produce less valid results. It is possible that the wide range of results obtained are a consequence of including methodologically weak studies. When only methodological superior studies were examined, greater consensus was found. Thus, methodological problems may account for some of the diversity of results found among existing studies.
Second, it is possible that CS is a risk factor for PPD but that it is not a powerful risk factor. If this were the case, then it would be expected that studies with greater power would find a significant adverse association, but studies with less power would not. However, the results do not appear to follow this pattern. For example, the studies with the largest sample sizes found no significant association between CS and PPD (22,23,27,68). Cohort studies have more power to evaluate the impact of a risk factor than other designs, because they have equal proportions of participants who have been exposed, or not exposed, to the risk factor. However, only one of the four cohort studies found a significant association between CS and PPD (43). Together, these studies suggest that CS is not a weak risk factor for PPD that only some studies can detect. In contrast, these same studies were able to detect an association between a variety of other risk factors and PPD.
Third, it may be that CS operates as a risk factor for PPD only if women are vulnerable to PPD for some other reason. Gottlieb (43) found that lack of experience with children was a moderating variable between CS and PPD. Two studies are of indirect relevance to this issue. Green (62) found that low antenatal mood and “negative experiences of labor” had independent and cumulative effects on PPD. However, women who had had a CS were excluded from these analyses, and therefore is not in the results section of this article. Murray (33) found that mode of delivery was only associated with PPD if women had a history of depressive disorder. However, this study grouped together women with forceps and CS deliveries and is, therefore, not included in the results section of this article.
It has also been suggested that the impact of CS on maternal mood may depend on the context in which the CS occurs, including the cultural norms, preparedness, and the social support available to women. Chen and Wang (20) found no adverse impact of CS on PPD and suggested that women who deliver by CS in Taiwan may receive greater social support. Chaaya and colleagues (19) found that CS was protective against PPD for women from an urban setting. Thus, it appears that the potential adverse impact of CS can be mitigated, nullified, or even reversed in certain contexts.
Fourth, perhaps diverse results have been obtained by studies because CS is a risk factor that is manifested in a range of ways. Clearly, CS is more than a surgical obstetric intervention. A variety of factors may or may not be part of a woman's experience of CS. For example, CSs may differ according to whether they are planned or unplanned, if they are an emergency or not, if a general anesthetic or epidural anesthetic is administered, if unwanted people are present or not, how adequate the information provided has been, and how much control the woman feels that she has over what is happening to her. In isolation, variables such as whether the CS is planned or unplanned do not appear to significantly increase the risk of PPD (23,29). However, CS is a package of variables that may vary somewhat from person to person. Although it may be useful to try to identify the most harmful components of this package, these factors remain an integral part of how the risk factor may be manifested. The diversity with which the risk factor may be experienced may have contributed to the wide range of findings that have been found.
In summary, concern has been expressed since the 1970s that CS and PPD may be linked. A broad range of findings have been reported, probably in part as a result of methodological factors. Most commonly, however, studies have failed to find an association between CS and PPD. Methodologically superior studies were more likely to find no significant association. A meta-analysis of suitable studies found no significant association between CS and PPD.
A link between CS and PPD has not established.
We thank Professor Pippa Kyle (Department of Obstetrics and Gynaecology, Christchurch School of Medicine & Health Sciences) for her helpful comments on this article.
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cesarean section; postpartum depression; review
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