Mode of delivery and postpartum depression: the role of patient preferences

Published:September 10, 2014DOI:


      The purpose of this study was to explore the relationship between strength of preference for vaginal delivery, delivery mode undergone, and postpartum depression.

      Study Design

      We conducted a secondary analysis of data from a longitudinal study of delivery-mode preferences. During an interview between 24-36 weeks of gestation, participants were asked whether they preferred vaginal or cesarean delivery; the strength of this preference was measured by the standard gamble metric. Depression was assessed antepartum and at 8-10 weeks and 6-8 months after delivery by using the Patient Health Questionnaire (PHQ-9). The primary outcome was PHQ-9 score at 8-10 weeks after delivery. We used multivariable regression analysis to assess the effect of strength of preference for vaginal delivery and delivery mode undergone on postpartum depression.


      Of 160 participants, 33.1% were nulliparous, and 30.6% had a previous cesarean delivery. Most of the participants (92.4%) preferred vaginal delivery, but the strength of preference varied substantially. The mean strength-of-preference score (0-1 scale; higher scores denote stronger vaginal delivery preference) was 0.658 (SD, ±0.352). A significant interaction emerged between the effects of delivery mode and vaginal delivery preference score on postpartum PHQ-9 score (P = .047). Specifically, a stronger preference for vaginal delivery was associated with higher PHQ-9 scores among women who underwent cesarean delivery (P = .027) but not among women who underwent vaginal delivery (P = .761). The interaction between delivery mode and vaginal delivery preference score was no longer significant at 6-8 months after delivery.


      Women who have a strong antepartum preference for vaginal delivery and deliver by cesarean may be at increased risk for depression in the early postpartum period.

      Key words

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        • Gaynes B.N.
        • Gavin N.
        • Meltzer-Brody S.
        • et al.
        Perinatal depression: prevalence, screening accuracy, and screening outcomes.
        Evid Rep Technol Assess. 2005; 119: 1-8
        • American College of Obstetricians and Gynecologists
        Screening for depression during and after pregnancy: Committee Opinion no. 453.
        Obstet Gynecol. 2010; 115: 394-395
        • Earls M.F.
        • Committee on Psychosocial Aspects of Child and Family Health American Academy of Pediatrics
        Incorporating recognition and management of perinatal and postpartum depression into pediatric practice.
        Pediatrics. 2010; 126: 1032-1039
        • Pearlstein T.
        • Howard M.
        • Salisbury A.
        • Zlotnik C.
        Postpartum depression.
        Am J Obstet Gynecol. 2009; 200: 357-364
        • Seehusen D.A.
        • Baldwin L.M.
        • Runkle G.P.
        • Clark G.
        Are family physicians appropriately screening for postpartum depression?.
        J Am Board Fam Med. 2005; 18: 104-112
        • Evans J.
        • Heron J.
        • Francomb H.
        • Oke S.
        • Golding J.
        Cohort study of depressed mood during pregnancy and after childbirth.
        BMJ. 2001; 323: 257-260
        • Lancaster C.A.
        • Gold K.J.
        • Flynn H.A.
        • Yoo H.
        • Marcus S.M.
        • Davis M.M.
        Risk factor for depressive symptoms during pregnancy: a systematic review.
        Am J Obstet Gynecol. 2010; 202: 5-14
        • Adams S.S.
        • Eberhard-Gran M.
        • Sandvik A.R.
        • Eskild A.
        Mode of delivery and postpartum emotional distress: a cohort study of 55814 women.
        BJOG. 2012; 119: 298-305
        • Carter F.A.
        • Frampton C.M.A.
        • Mulder R.T.
        Cesarean section and postpartum depression: a review of the evidence examining the link.
        Psychosom Med. 2006; 68: 321-331
        • Goker A.
        • Yanikkerem E.
        • Murat Demet M.
        • Dikayak S.
        • Yildirim Y.
        • Koyuncu F.M.
        Postpartum depression: is mode of delivery a risk factor?.
        ISRN Obstet Gynecol. 2012; 2012: 616759
        • Patel R.R.
        • Murphy D.J.
        • Peters T.J.
        Operative delivery and postnatal depression: a cohort study.
        BMJ. 2005; 330: 879
        • Rauh C.
        • Beetz A.
        • Burger P.
        • et al.
        Delivery mode and the course of pre- and postpartum depression.
        Arch Gynecol Obstet. 2012; 286: 1407-1412
        • Sword W.
        • Kurtz Landy C.
        • Thabane L.
        • et al.
        Is mode of delivery associated with postpartum depression at 6 weeks: a prospective cohort study.
        BJOG. 2011; 118: 966-977
        • Uplong D.I.
        • Owolabi A.T.
        Postpartum emotional distress: a controlled study of Nigerian women after caesarean childbirth.
        J Obstet Gynaecol. 2006; 26: 127-129
        • Wiklund I.
        • Edman G.
        • Andolf E.
        Cesarean section on maternal request: reasons for the request, self-estimated health, expectations, experience of birth and signs of depression among first-time mothers.
        Acta Obstret Gynecol Scand. 2007; 86: 451-456
        • Yang S.N.
        • Shen L.J.
        • Ping T.
        • Wang Y.C.
        • Chien C.W.
        The delivery mode and seasonal variation are associated with the development of postpartum depression.
        J Affect Disord. 2001; 132: 158-164
        • Yee L.M.
        • Kaimal A.J.
        • Nakagawa S.
        • Houston K.
        • Kuppermann M.
        Predictors of postpartum sexual activity and function in a diverse population of women.
        J Midwifery Womens Health. 2013; 58: 654-661
        • Wu E.
        • Kaimal A.J.
        • Houston K.
        • Yee L.M.
        • Nakagawa S.
        • Kuppermann M.
        Strength of preference for vaginal birth as a predictor of delivery mode among women who attempt vaginal delivery.
        Am J Obstet Gynecol. 2014; 210: 440.e1-440.e6
        • Spitzer R.L.
        • Kroenke K.
        • Williams J.B.W.
        Validation and utility of a self report version of PRIME-MD: the PHQ primary care study.
        JAMA. 1999; 282: 1737-1744
        • Spitzer R.L.
        • Williams J.B.W.
        • Kroenke K.
        • Hornyak R.
        • McMurray J.
        Validity and utility of the PRIME-MD patient health questionnaire in assessment of 3000 obstetric-gynecologic patients: the PRIME-MD Patient Health Questionnaire Obstetrics-Gynecology Study.
        Am J Obstet Gynecol. 2000; 183: 759-769
        • Torrance G.W.
        Measurement of health state utilities for economic appraisal.
        J Health Econ. 1986; 5: 1-30
        • Wu J.M.
        • Fulton R.G.
        • Amundsen C.L.
        • Knight S.K.
        • Kuppermann M.
        Patient preferences for different severities of and treatments for overactive bladder.
        Female Pelvic Med Reconstr Surg. 2011; 17: 184-189
        • Allison P.D.
        Missing data.
        Sage Publications, Thousand Oaks, CA2002
        • Rubin D.B.
        Multiple imputation for nonresponse in surveys.
        Wiley, New York1987
        • Meng X.L.
        • Rubin D.B.
        Performing likelihood ratio tests with multiply-imputed data sets.
        Biometrika. 1992; 79: 103-111
        • Kroenke K.
        • Spitzer R.L.
        • Williams J.B.W.
        The PHQ-9: validity of a brief depression severity measure.
        J Gen Intern Med. 2001; 16: 606-613
        • Yawn B.D.
        • Pace W.
        • Wollan P.C.
        • et al.
        Concordance of Edinburgh postnatal depression scale (EPDS) and patient health questionnaire (PHQ-9) to assess increased risk of depression among postpartum women.
        J Am Board Fam Med. 2009; 22: 483-491