BACKGROUND

The prevalence and risk factors of postpartum depression after cesarean delivery remain unclear.

OBJECTIVE

To assess the prevalence of postpartum depression and its risk factors 2 months after cesarean delivery.

STUDY DESIGN

Prospective ancillary cohort study of the Tranexamic Acid for Preventing Postpartum Hemorrhage after Cesarean Delivery trial, conducted in 27 French hospitals in 2018 to 2020 and enrolling women undergoing cesarean delivery before or during labor at 34 or more weeks of gestation. After randomization, characteristics of the cesarean delivery, postpartum blood loss, and immediate postpartum period, including memories of delivery and postoperative pain, were prospectively collected. Women's characteristics, particularly any psychiatric history, were collected from medical records. Two months after childbirth, a postpartum depression provisional diagnosis was defined as a score of 13 or higher on the Edinburgh Postnatal Depression Scale, a validated self-administered questionnaire. The corrected prevalence of postpartum depression was calculated with the inverse probability weighting method to take nonrespondents into account. Multivariate logistic regression analyzed associations between potential risk factors and postpartum depression. A sensitivity analysis used an Edinburgh Postnatal Depression Scale cutoff value of 11 or higher.

RESULTS

The questionnaire was returned by 2793/4431 women (63.0% response rate). The corrected prevalence of postpartum depression provisional diagnosis was 16.4% (95% confidence interval, 14.9%-18.0%) with an Edinburgh Postnatal Depression Scale score of 13 or higher and 23.1% (95% confidence interval, 21.4%-24.9%) with a cutoff value of 11 or higher. Characteristics associated with a higher risk of postpartum depression were prepregnancy characteristics such as young age (adjusted odds ratio 0.83, 95% confidence interval 0.74-0.93 for each 5-year increase in maternal age) and non-European country of birth (adjusted odds ratio 2.58, 95% confidence interval 1.85-3.59 for North Africa; adjusted odds ratio 1.57, 95% confidence interval 1.09-2.26 for Sub-Saharan Africa and adjusted odds ratio 1.99, 95% confidence interval 1.28-3.10 for other country of birth; reference: Europe) and some aspects of the cesarean delivery, notably its timing and context, emergency before labor (adjusted odds ratio 1.70, 95% confidence interval 1.15-2.50; reference: before labor without emergency) and during labor after induction of labor (adjusted odds ratio 1.36, 95% confidence interval 1.03-1.84; reference: before labor without emergency). Also at higher risk were women reporting high intensity pain during the postpartum stay (adjusted odds ratio 1.73, 95% confidence interval 1.32-2.26) and bad memories of delivery on day 2 postpartum (adjusted odds ratio 1.67, 95% confidence interval 1.14-2.45). Conversely, women who had social support in the operating room had a lower risk of postpartum depression (adjusted odds ratio 0.73, 95% confidence interval 0.53-0.97).

CONCLUSION

Around one woman in 6 had postpartum depression symptoms 2 months after cesarean delivery. Some cesarean-related obstetric factors may increase this risk: cesareans before labor for emergency situations or during labor after medically indicated induction of labor, severe postoperative pain, and bad memories of delivery before discharge. Specific subgroups of at-risk women could benefit from early screening or intervention to reduce the onset of postpartum depression. Perinatal professionals should pay particular attention to postoperative pain management.