Association Between Delivery Mode and Postpartum Psychiatric Conditions

OBJECTIVE: To evaluate the association between mode of delivery and incidence of new postpartum maternal psychiatric conditions in a national obstetric cohort. METHODS: This was an observational cohort study of individuals with singleton live births in the United States (2008-2022) identified from the Merative™ MarketScan® Commercial Database using International Classification of Diseases, Ninth or Tenth Revision, Clinical Modification codes. Individuals with a psychiatric diagnosis preceding delivery and those with preterm births before 37 weeks of gestation were excluded. The exposure was mode of delivery, categorized as 1) spontaneous vaginal, 2) successful operative vaginal delivery (OVD), 3) planned cesarean, 4) unplanned cesarean without OVD attempt, 5) and unplanned cesarean after failed OVD attempt. The primary outcome was a new diagnosis of depression, anxiety, posttraumatic stress, or other serious psychiatric condition or a new antidepressant prescription within 6 months postpartum. Multivariable Poisson regression models with robust SEs estimated associations between mode of delivery and postpartum psychiatric conditions, first for any psychiatric condition and then separately by each condition. RESULTS: Of 934,524 included births, 66% were spontaneous vaginal, 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 higher 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), and 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). CONCLUSION: Postpartum psychiatric conditions were increased after cesarean deliveries, planned or unplanned, but not after successful OVDs. Results suggest that cesarean delivery may be associated with an increased risk of psychiatric conditions and warrants closer surveillance postpartum.