In This article

• Cesarean delivery is associated with a small increase in risk of new postpartum psychiatric conditions.
• Both planned and unplanned cesareans show elevated risk compared to vaginal delivery.
• Absolute risk differences are modest despite statistical significance.
• Prior psychiatric history likely remains the most important predictor of postpartum illness.

After childbirth, about one in five individuals will experience symptoms of depression, anxiety, posttraumatic stress, or other serious mental health conditions. Previous studies have identified risk factors for postpartum mood and anxiety disorders; the strongest predictors of risk include a personal history of mood or anxiety disorder and, more robustly, depressive symptoms or anxiety during pregnancy. While it makes sense that complications occurring at delivery could increase risk for postpartum psychiatric illness, data supporting this link have been somewhat inconsistent.

A new study examines the association between mode of delivery and the incidence of new postpartum psychiatric conditions in a national obstetric cohort.

Study Design

In this observational cohort study, individuals with singleton live births in the United States (2008–2022) were identified in the Merative™ MarketScan® Commercial Database using International Classification of Diseases (ICD) codes. 

This study focused only on new psychiatric diagnoses; therefore, individuals with a psychiatric diagnosis preceding delivery were excluded. In addition, those who experienced a preterm birth (before 37 weeks of gestation) were also excluded.

Mode of delivery was categorized as:

• spontaneous vaginal delivery
• successful operative vaginal delivery (OVD)
• planned cesarean
• unplanned cesarean without OVD attempt
• unplanned cesarean after failed OVD attempt

The researchers identified individuals with a new diagnosis of depression, anxiety, posttraumatic stress, or other serious psychiatric condition, or a new antidepressant prescription within 6 months postpartum.

Results

Of 934,524 births included in this study, 66% were spontaneous vaginal deliveries, 4% were successful OVD, 14% were planned cesareans, 15% were unplanned cesareans without OVD attempt, and 1% were unplanned cesareans after failed OVD attempt.

Compared with spontaneous vaginal births, postpartum psychiatric conditions were more likely after:

• Planned cesarean births (11.4% vs 9.2%, adjusted risk ratio [RR] 1.19, 95% CI, 1.17–1.21)
• Unplanned cesarean births without OVD (10.8% vs 9.2%, adjusted RR 1.16, 95% CI, 1.14–1.18)
• Unplanned cesarean births with failed OVD (10.9% vs 9.2%, adjusted RR 1.26, 95% CI, 1.18–1.35)

Postpartum psychiatric condition risks were similar between individuals with spontaneous vaginal births and those with successful OVDs (9.2% vs 9.2%, adjusted RR 1.00, 95% CI, 0.97–1.03).

The Bottom Line

This study, focusing on the new onset of psychiatric illness after delivery, suggests a small but statistically significant increase in the risk of postpartum psychiatric conditions after cesarean deliveries—both planned and unplanned—but not after successful OVDs. While statistically significant, the increase in risk is relatively small.

In this analysis, it would have been helpful to include women with a history of psychiatric illness, particularly those with a history of PTSD. We know that individuals with a psychiatric history are more vulnerable to recurrent illness when exposed to a stressful life event (for example, complications at delivery). It is likely that, in this population, we would see a more meaningful increase in risk of postpartum psychiatric illness.

In their conclusions, the authors note that the results “suggest that cesarean delivery may be associated with an increased risk of psychiatric conditions and warrants closer surveillance postpartum.” This recommendation is evidence-based but may miss the larger clinical context. While some women may be vulnerable to postpartum psychiatric illness following cesarean delivery, there are many more robust risk factors, more specifically a personal history of psychiatric illness.

—Ruta Nonacs, MD PhD