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Keywords:

  • Cohort studies;
  • delivery;
  • pregnancy;
  • psychological;
  • stress

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Disclosure of interests
  9. Contribution to authorship
  10. Details of ethics approval
  11. Funding
  12. Acknowledgements
  13. References

Please cite this paper as: Adams S, Eberhard-Gran M, Sandvik Å, Eskild A. Mode of delivery and postpartum emotional distress: a cohort study of 55 814 women. BJOG 2011; DOI: 10.1111/j.1471-0528.2011.03188.x

Objective  To assess the association between mode of delivery and maternal postpartum emotional distress.

Design  A prospective study of women from 30 weeks of gestation to 6 months postpartum.

Setting  Pregnant women in Norway during the period 1998–2008.

Population  A total of 55 814 women from the Norwegian Mother and Child Cohort Study.

Methods  Emotional distress was reported in a short form of the Hopkins Symptom Checklist-25 (SCL-8) at 30 weeks of gestation and at 6 months postpartum. Information on mode of delivery was obtained from the Medical Birth Registry of Norway.

Main outcome measures  Changes in SCL-8 score from 30 weeks of gestation to 6 months postpartum and presence of emotional distress at 6 months postpartum.

Results  Women with instrumental vaginal, emergency caesarean or elective caesarean deliveries had similar changes in SCL-8 score between 30 weeks of gestation and 6 months postpartum, as compared with women with unassisted vaginal delivery (adjusted regression coefficient, 0.00, 95% CI –0.01 to 0.01; 0.01, 95% CI 0.00−0.02; and −0.01, 95% CI −0.02 to 0.00, respectively). The corresponding odds ratios (ORs) associated with the presence of emotional distress at 6 months postpartum (SCL-8 ≥ 2.0) were: OR 1.01, 95% CI 0.86−1.18; OR 1.13, 95% CI 0.97−1.32; and OR 0.96, 95% CI 0.79−1.16, respectively. These estimates were adjusted for emotional distress during pregnancy and other potential confounding factors. Emotional distress during pregnancy showed the strongest association with the presence of emotional distress at 6 months postpartum (adjusted OR 14.09, 95% CI 12.77−15.55).

Conclusions  Mode of delivery was not associated with a change in SCL-8 score from 30 weeks of gestation to 6 months postpartum or with the presence of emotional distress postpartum.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Disclosure of interests
  9. Contribution to authorship
  10. Details of ethics approval
  11. Funding
  12. Acknowledgements
  13. References

It has become increasingly common for pregnant women to request delivery by elective caesarean section for psychosocial reasons, despite an absence of obstetric indication.1–3 It is, however, largely unknown whether a planned caesarean delivery improves psychological well-being in the mother, or whether the possible beneficial effects on mental health outweigh the increased risk of complications associated with a surgical delivery.1,4,5

Caesarean and instrumental vaginal deliveries have been associated with higher levels of maternal psychological distress after delivery than normal vaginal deliveries.6–10 However, many of the studies lack information on the mental health of mothers prior to delivery.6,8,9 Thus, differences in mental health postpartum by mode of delivery may in fact reflect pre-existing differences between the groups.6 The estimated difference in mental health postpartum by mode of delivery may also be confounded by the medical indication for surgical delivery.

Although the primary aim of obstetric care is a physically healthy mother and neonate, the mother’s psychological well-being is important both for the mother herself and for her ability to take care of the infant. Some elective caesarean deliveries are being performed for the mental well-being of the mother.11 Therefore, it is important to know whether elective caesarean delivery has a more positive effect on maternal mental health after delivery than other modes of delivery.

In order to study the association of mode of delivery with maternal mental health postpartum, we included more than 55 000 pregnant women in a cohort study. We studied changes in mental health from the last trimester to 6 months postpartum by mode of delivery. In addition, we compared the presence of emotional distress 6 months after delivery according to mode of delivery, with and without an adjustment for the presence of emotional distress in the last trimester of pregnancy. We also made adjustments for other factors that may be associated with postpartum emotional distress.

Methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Disclosure of interests
  9. Contribution to authorship
  10. Details of ethics approval
  11. Funding
  12. Acknowledgements
  13. References

During the years 1998–2008, efforts were made to include all pregnant women scheduled to give birth at one of 50 hospitals in Norway in the Norwegian Mother and Child Cohort Study, conducted by the Norwegian Institute of Public Health. There are a total of 52 hospitals with a maternity ward in Norway. The women were recruited at the routine fetal ultrasound examination at 17 weeks of gestation. This examination is part of the public antenatal care programme, and is offered to all pregnant women in the country free of charge. The study had no exclusion criteria. The Norwegian Mother and Child Cohort Study is described in detail elsewhere.12,13

The Norwegian Mother and Child Cohort Study data were obtained through three self-administered questionnaires. The first questionnaire was completed at 17 weeks of gestation (mean 17.4 ± 2.8 weeks of gestation), and included questions about sociodemographic factors. At 30 weeks of gestation (30.6 ± 2.0 weeks) the women answered the second questionnaire, which included questions on the status of their health during pregnancy.12 The third questionnaire was completed 6 months postpartum (27.9 ± 2.0 weeks postpartum), and included questions about their present health status. All three questionnaires were returned by mail.

Information on mode of delivery was obtained by linking to the Medical Birth Registry of Norway, which holds information on all births in Norway after 16 weeks of gestation through compulsory notification.14,15

Of all women who gave birth in Norway during the study period, 41% participated in the study, of whom 84.8% completed all three questionnaires used in our data analysis (61 548 women). Women with missing information on mental health in pregnancy (702), mode of delivery (723), mental health 6 months after delivery (308), obstetric complications (2162), maternal wish for caesarean delivery (1015) and maternal education (1275) were excluded, resulting in a study sample of 55 814 women.

Mental health was measured at 30 weeks of gestation and at 6 months after delivery by the Symptom Checklist-8 (SCL-8). SCL-8 is a short form of the Hopkins Symptom Checklist-25, which is a self-administered instrument designed to measure symptoms of anxiety and depression in population surveys.16,17 SCL-25 is also an acceptable screening instrument for depression, as defined by the International Classification of Diseases (ICD) and the Diagnostic and Statistical Manual of Mental Disorders (DSM).18–20 SCL-8 correlates well with the Hopkins Symptom Checklist-25 (Pearson’s correlation coefficient 0.94),16 and consists of the following questions.

Have you been bothered by any of the following during the last 2 weeks: (1) feeling fearful; (2) nervousness or shakiness inside; (3) feeling hopeless about the future; (4) feeling blue; (5) worrying too much about things; (6) feeling everything is an effort; (7) feeling tense or keyed up; (8) suddenly scared for no reason.16

The response categories ranged from 1 (not bothered) to 4 (very bothered). Individual SCL-8 sum scores were calculated at 30 weeks of gestation and 6 months postpartum, separately, and divided by the number of items in the instrument. On both occasions we defined a mean score ≥ 2.0 as indicating the presence of emotional distress.17 The presence of emotional distress at 6 months postpartum was used as the outcome measure, and the presence of emotional distress at 30 weeks of gestation was used as a variable that could potentially confound the association of mode of delivery with postpartum emotional distress.

The individual change in SCL-8 score was calculated (SCL-8 score at 30 weeks of gestation − SCL-8 score at 6 months postpartum) and used as the outcome measure in a separate model. Also, mean SCL-8 scores in each delivery group before and after delivery were calculated.

Information on mode of delivery and obstetric complications was obtained from the Medical Birth Registry of Norway. Mode of delivery was coded as: (1) unassisted vaginal delivery (reference); (2) instrumental vaginal delivery (vacuum- or forceps-assisted delivery); (3) emergency caesarean delivery; and (4) elective caesarean delivery. Elective caesarean deliveries included all caesarean deliveries that were planned more than 8 hours before delivery. Emergency caesarean deliveries included all other caesarean deliveries.

Obstetric complications (coded as present or not) included: pre-eclampsia; eclampsia; haemolytic anaemia, elevated liver enzymes and low platelet count (HELLP); gestational hypertension; gestational diabetes; placenta praevia; placental abruption; preterm delivery (at <35 weeks of gestation); multiple pregnancy; and breech presentation. Information on parity (para 0 and para ≥ 1) and maternal age (<25, 25–35 and >35 years) was also obtained from the Medical Birth Registry of Norway. Years of education, as obtained from the Norwegian Mother and Child Cohort Study, were also coded: up to 9, 10–12 and >12 years. Women in continuing education were assumed to complete their present educational level, and were grouped accordingly. The wish for an elective caesarean delivery was based on the following question at 30 weeks of gestation, ‘If I could choose, I would have a caesarean delivery’, and the answers were coded: yes (agree completely, agree and agree somewhat) or no (disagree somewhat, disagree and disagree completely).

We compared the crude mean SCL-8 score between mode of delivery groups at 30 weeks of gestation and 6 months postpartum. We also compared the change in crude mean SCL-8 score from 30 weeks of gestation to 6 months after delivery in each mode of delivery group, and plotted the corresponding graphs. Differences in change in mean score between groups were tested by one-way analysis of variance (anova) with post hoc tests.

Furthermore, we estimated the relationship between mode of delivery and individual change in SCL-8 score from 30 weeks of gestation to 6 months after delivery as crude and adjusted unstandardised regression coefficients with 95% confidence intervals (95% CIs) using linear regression analysis. Firstly, we adjusted for SCL-8 scores at 30 weeks of gestation only. Thereafter, we also included obstetric complications, parity, maternal age, educational level and maternal wish for caesarean delivery in multivariate analyses. As mode of delivery, maternal age and educational level consisted of more than two categories, these variables were entered into the linear regression model as binary dummy variables. We also studied the prevalence of emotional distress, defined as a SCL-8 score ≥ 2.0, 6 months after delivery according to mode of delivery. Differences in prevalence (%) were examined using chi-square tests. The association of mode of delivery with presence of emotional distress 6 months postpartum (SCL-8 ≥ 2.0) was estimated as crude and adjusted odds ratios (ORs) with 95% confidence intervals (95% CIs) using logistic regression analyses. We report separately the ORs with adjustment for presence of emotional distress at 30 weeks of gestation (SCL-8 ≥ 2.0) only. Thereafter, the other study factors were also included in the multivariate analyses. The analyses were repeated in women with and in women without the wish for an elective caesarean delivery. The statistical package spss 15.0 was applied for the statistical analyses.

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Disclosure of interests
  9. Contribution to authorship
  10. Details of ethics approval
  11. Funding
  12. Acknowledgements
  13. References

In our study sample, the mean maternal age at delivery was 30.12 years (range 14–47 years; SD 4.50 years) and 44.4% (24 676 women) were first-time mothers. At 30 weeks of gestation, women who subsequently delivered by elective caesarean section had a higher crude mean SCL-8 score than women who delivered by emergency caesarean section, and both of these groups had significantly higher crude mean SCL-8 scores than women who subsequently delivered by unassisted or instrumental vaginal delivery (< 0.001, one-way anova with post hoc comparison using Tamhane’s test; Figure 1).

image

Figure 1.  Crude mean SCL-8 score at 30 weeks of gestation and 6 months postpartum among 55 814 women in the Norwegian Mother and Child Cohort Study, recruited in the period 1998–2008, according to mode of delivery.

Download figure to PowerPoint

The mean SCL-8 score decreased from 30 weeks of gestation to 6 months postpartum in the study sample as a whole, and in all delivery groups (Figure 1). The decline in mean SCL-8 score was more pronounced in women with elective caesarean delivery than in women who delivered by emergency caesarean, instrumental vaginal delivery or unassisted vaginal delivery (< 0.01, one-way anova with post hoc comparison using Tamhane’s test; Table 1). However, the effect size, calculated using eta squared, was only 0.0005.

Table 1.   Changes in mean SCL-8 score from 30 weeks of gestation to 6 months postpartum in each mode of delivery group, as estimated by anova with post hoc comparison using Tamhane’s test among 55 814 pregnant women in the Norwegian Mother and Child Cohort Study, recruited during 1998–2008
Mode of deliverynVaginalInstrumental vaginalEmergency caesarean deliveryElective caesarean delivery
Difference in mean95% CIPDifference in mean95% CIPDifference in mean95% CIPDifference in mean95% CIP
  1. All P values are two-sided.

Vaginal43 5810.00–0.01, 0.020.9380.00−0.01, 0.020.9810.040.02, 0.06<0.001
Instrumental vaginal50520.00−0.02, 0.010.9380.00−0.02, 0.021.0000.030.01, 0.050.002
Emergency caesarean section44820.00−0.02, 0.010.9810.00−0.02, 0.021.0000.030.01, 0.060.002
Elective caesarean section2699−0.04−0.06, −0.02<0.001−0.03−0.05, −0.010.002−0.03−0.06, −0.010.002

At 6 months postpartum, the mean SCL-8 score was significantly higher in women with elective caesarean section as compared with women with instrumental or unassisted vaginal delivery. The mean SCL-8 score was also higher in women with emergency caesarean section as compared with women with instrumental vaginal delivery (< 0.01, one-way anova with post hoc comparison using Tamhane’s test; Figure 1).

When using the individual change in SCL-8 score as the dependent variable, women with elective caesarean delivery had a significantly greater decline in their score from 30 weeks of gestation to 6 months postpartum than women with unassisted vaginal delivery in the crude data analysis (crude regression coefficient −0.04, 95% CI −0.05 to −0.02; Table 2). However, after adjustment for SCL-8 score at 30 weeks of gestation only, the association of elective caesarean delivery with decline in SCL-8 score was no longer significant (adjusted regression coefficient −0.01, 95% CI −0.02 to 0.01; Table 2). Further adjustment for the other study factors – obstetric complications, parity, maternal age, maternal education and wish for caesarean section – did not notably alter the estimated association of elective caesarean delivery (adjusted regression coefficient −0.01, 95% CI −0.02 to 0.00; Table 2). The SCL-8 score in pregnancy showed the strongest association with the decline in SCL-8 score (adjusted regression coefficient −0.46, 95% CI −0.47 to −0.45; Table 2). The analyses were repeated in women wishing for a caesarean section (5352 women) and in women with no such wish (50 462 women). In both groups, no association of elective caesarean delivery with decline in SCL-8 score was found (adjusted regression coefficients both −0.01, 95% CIs −0.04 to 0.01 and −0.02 to 0.01, respectively).

Table 2.   The association between each study factor and individual change in SCL-8 score from 30 weeks of gestation to 6 months postpartum among 55 814 women in the Norwegian Mother and Child Cohort Study
 Change in SCL-8 score from 30 weeks of gestation to 6 months postpartum
Crude coefficient95% CIAdjusted coefficients†95% CIAdjusted coefficients‡95% CI
  1. Associations are presented as crude and adjusted unstandardised coefficients with 95% confidence intervals, as estimated by linear regression analyses. Additionally, the association of mode of delivery and emotional distress at 30 weeks of gestation (SCL-8 score) with individual change in SCL-8 score from 30 weeks of gestation to 6 months postpartum are presented as adjusted unstandardised coefficients with 95% CIs.

  2. †Adjustment made for emotional distress at 30 weeks of gestation (SCL-8 score) only.

  3. ‡Adjustment made for all study factors.

  4. All P values are two-sided: *P < 0.05; **P < 0.01; ***P < 0.001.

Mode of delivery
 Vaginal0 0 0 
 Instrumental vaginal0.00−0.01, 0.01−0.01−0.02, 0.000.00−0.01, 0.01
 Emergency caesarean section0.00−0.01, 0.010.00−0.01, 0.010.010.00, 0.02
 Elective caesarean section−0.04***−0.05, −0.02−0.01−0.02, 0.01−0.01−0.02, 0.00
Emotional distress at 30 weeks of gestation (SCL-8 score)
  −0.45***−0.46, −0.45−0.45***−0.46, −0.45−0.46***−0.47. −0.45
Obstetric complications
 No0   0 
 Yes−0.01*−0.02, 0.00  −0.01−0.01, 0.00
Parity
 00   0 
 ≥10.01**0.00, 0.01  0.02***0.01, 0.02
Maternal age at delivery
 <25 years−0.02***−0.03, −0.01  0.02***0.01, 0.03
 25–35 years0   0 
 >35 years0.01**0.00, 0.02  0.010.00, 0.02
Maternal education
 Compulsory education0.01−0.01, 0.03  0.08***0.06, 0.10
 Secondary education−0.01**−0.02, 0.00  0.02**0.01, 0.02
 Higher education0   0 
Maternal wish for caesarean section
 No0   0 
 Yes−0.05***−0.06, −0.04  0.01*0.00, 0.02

The prevalence of emotional distress (SCL-8 ≥ 2.0) 6 months after delivery was higher in women with elective caesarean delivery (5.7%) than in women with unassisted vaginal delivery (4.4%) (χ2< 0.01; crude OR 1.31, 95% CI 1.11–1.55; Table 3). However, after adjustment for the presence of emotional distress (SCL-8 ≥ 2.0) at 30 weeks of gestation only, there was no significant association between elective caesarean delivery and the presence of emotional distress after delivery (adjusted OR 1.09, 95% CI 0.91–1.31; Table 2). Adjustment for the other study factors did not notably alter the associations (adjusted OR 0.96, 95% CI 0.79–1.16; Table 3). The presence of emotional distress (SCL-8 ≥ 2.0) at 30 weeks of gestation showed the strongest association with emotional distress 6 months postpartum (adjusted OR 14.09, 95% CI 12.77–15.55). Both in women who wished for a caesarean delivery and in women with no such wish, elective caesarean delivery was not associated with the presence of emotional distress postpartum after adjustment for the other factors (adjusted OR 0.89, 95% CI 0.68–1.17; adjusted OR 0.98, 95% CI 0.74–1.30, respectively).

Table 3.   The association between each study factor and the presence of emotional distress at 6 months postpartum (SCL-8 score ≥ 2.0) among 55 814 women in the Norwegian Mother and Child Cohort Study
 No n (%)Yes n (%)Total (%)PCrude OR95% CIAdjusted OR†95% CIAdjusted OR‡95% CI
  1. Associations are presented as crude and adjusted odds ratios with 95% confidence intervals. Additionally, the associations of mode of delivery and presence of emotional distress at 30 weeks of gestation with presence of emotional distress at 6 months postpartum are presented as adjusted ORs with 95% CIs.

  2. †Adjustment made for presence of emotional distress at 30 weeks of gestation only.

  3. ‡Adjustment made for all study factors.

  4. All P values are two-sided: *P < 0.05; **P < 0.01; ***P < 0.001.

Mode of delivery
 Vaginal41 645 (95.6)1936 (4.4)43 581 (100)0.0011.00 1.00 1.00 
 Instrumental vaginal4838 (95.8)214 (4.2)5052 (100)0.950.82, 1.100.950.82, 1.111.010.86, 1.18
 Emergency caesarean section4249 (94.8)233 (5.2)4482 (100)1.18*1.03, 1.361.140.98, 1.321.130.97, 1.32
 Elective caesarean section2544 (94.3)155 (5.7)2699 (100)1.31**1.11, 1.551.090.91, 1.310.960.79, 1.16
Presence of emotional distress at 30 weeks of gestation
 No51 663 (96.8)1690 (3.2)53 353 (100)<0.0011.00 1.00 1.00 
 Yes1613 (65.5)848 (34.5)2461 (100)16.07***14.60, 17.7016.01***14.54, 17.6314.09***12.77, 15.55
Obstetric complications
 No46 130 (95.5)2197 (4.5)48 327 (100)0.9981.00   1.00 
 Yes7146 (95.4)341 (4.6)7487 (100)1.000.89, 1.13  0.980.86, 1.12
Parity
 023 685 (95.7)1064 (4.3)24 749 (100)0.0131.00   1.00 
 ≥129 591 (95.3)1474 (4.7)31 065 (100)1.11*1.02, 1.20  1.15**1.05, 1.27
Maternal age at delivery
 <25 years5478 (92.1)472 (7.9)5950 (100)<0.0012.03***1.83, 2.26  1.56***1.38, 1.77
 25–35 years41 666 (95.9)1766 (4.1)43 432 (100)1.00   1.00 
 >35 years6125 (95.3)300 (4.7)6432 (100)1.15*1.02, 1.31  1.100.97, 1.26
Maternal education
 Compulsory education934 (88.4)122 (11.6)1056 (100)<0.0013.59***2.95, 4.36  2.18***1.74, 2.72
 Secondary education16 334 (93.7)1104 (6.3)17 438 (100)1.86***1.71, 2.01  1.40***1.28, 1.53
 Higher education36 008 (96.5)1312 (3.5)37 320 (100)1.00   1.00 
Maternal wish for caesarean section
 No48 355 (95.8)2107 (4.2)50 462 (100)<0.0011.00   1.00 
 Yes4921 (91.9)431 (8.1)5352 (100)2.01***1.81, 2.24  1.40***1.24, 1.59

We conducted subanalyses excluding the 11 342 women with somatic diseases during pregnancy, as reported to the Medical Birth Registry (i.e. cardiac disease, asthma, pre-gestational diabetes mellitus, chronic hypertension, chronic renal disease, recurrent urinary tract infections, rheumatoid arthritis, epilepsy or thyroid disease). However, the results remained essentially unchanged (data not shown).

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Disclosure of interests
  9. Contribution to authorship
  10. Details of ethics approval
  11. Funding
  12. Acknowledgements
  13. References

In this cohort study of more than 55 000 pregnant women, we found an overall decline in symptoms of emotional distress from 30 weeks of gestation to 6 months postpartum. Emotional distress was measured by SCL-8, and mode of delivery was not associated with a change in SCL-8 score or with the presence of emotional distress (SCL-8 ≥ 2.0) postpartum after adjustment for other study factors. This was true in the study sample as a whole and in women who wished for elective caesarean delivery. Emotional distress before delivery showed the strongest association with emotional distress after delivery.

Our study population of more than 55 000 pregnant women allowed us to compare associations between mode of delivery and emotional distress postpartum, and also adjust for potentially confounding factors. In particular, the level of emotional distress prior to delivery was an important confounding factor because women with a high SCL-8 score were more likely to be delivered by elective caesarean section. Several previous studies have not had the statistical power to differentiate between acute and elective caesarean deliveries.6–10 We measured emotional distress by SCL-8 scores as reported in questionnaires. Generally, questionnaire studies enable the use of larger study populations, and thus have more statistical power than studies using clinical interviews for measuring mental health. A clinical interview, however, remains the gold standard for diagnosing mental illness. SCL-8 is a screening tool and cannot be used to diagnose depression or anxiety because of low specificity. SCL-8 is strongly correlated with SCL-25 (0.94, Pearson’s correlation coefficient), but has not been validated in women in pregnancy or in the postpartum period.16,21 SCL-25, however, has been shown to correlate strongly with the Edinburgh Postnatal Depression Scale (EPDS), which is designed and has been validated for use during pregnancy and the postpartum period.22,23 Our study aim was to estimate associations of mode of delivery with mental health after delivery adjusted for mental health in pregnancy. It is unlikely that the validity of SCL-8 differs according to mode of delivery. Thus, our main finding – no influence of mode of delivery on postpartum SCL-8 scores – is unlikely to be biased.

In our crude data analyses, both emergency and elective caesarean deliveries were associated with emotional distress postpartum (crude OR 1.18, 95% CI 1.03–1.36; crude OR 1.31, 95% CI 1.11–1.55, respectively). The direction of these associations is in accordance with other studies.6–10 However, several prior studies did not adjust for mental health prior to delivery, and thus their reported association of mode of delivery with postpartum mental health may have been confounded.6,8,9 One previous prospective study has reported caesarean delivery to be associated with poor postpartum mental health after adjustment for mental health in pregnancy.7 This study, however, did not fully differentiate between elective and emergency caesarean delivery.7 No associations with mode of delivery were found in one study of maternal anxiety or in four studies of maternal depression after delivery.24 None of the studies included more than 200 women; therefore, type-2 errors may have occurred.24 Measurements and definitions of emotional distress are highly heterogeneous across studies. Perceived stress, stress symptoms, post-traumatic stress and self-esteem have all been used as measures, making comparison between studies difficult.6,24

Maternal psychopathology before delivery is a well-known risk factor of postpartum psychopathology.25 Hence, the association between antenatal and postpartum emotional distress seen in our study is expected. Also, a decline in levels of emotional distress from the last part of pregnancy to postpartum has been reported in well-conducted studies.26 In our study, the decline in emotional distress was most pronounced in women with elective caesarean delivery, and these women also had the highest mean SCL-8 score in pregnancy. The greatest decline in SCL-8 in women with elective caesarean section may be explained by natural regression towards the mean, and there was no significant difference in SCL-8 decline between mode of delivery groups after adjustment for the difference in SCL-8 score in pregnancy. Most previous studies on the association of delivery mode and mental health after delivery have measured mental health 4–8 weeks postpartum.7–9 Mental health during the first postpartum weeks may be influenced by recovery after pregnancy or delivery (operative delivery), or by lack of sleep. As our study measured emotional distress 6 months postpartum, our findings cannot be generalized to other times during the postpartum period. The level of emotional distress during labour also remains unknown.

Our study suggests that the performance of elective caesarean delivery is strongly associated with poor mental health in pregnancy. Women delivered by elective caesarean section had higher SCL-8 scores in pregnancy, and 55.0% (1485 out of 2699 women) did not have an obstetric indication for operative delivery. Emotional distress may be strongly related to fear of childbirth.27,28 Hence, our findings may be valid for women who fear childbirth and also have emotional distress.

We found no association of mode of delivery with postpartum emotional distress. This finding may have clinical implications, as many women request elective caesarean section for mental health reasons. These women may fear a worsening of their mental health as a consequence of birth trauma. Also, their doctors may fear such consequences. Our results, however, strongly suggest that even in women who wish for elective caesarean section, mode of delivery does not influence postpartum mental health. Interestingly, in women with instrumental vaginal delivery or emergency caesarean delivery, no increased prevalence of emotional distress postpartum was estimated after adjustment for emotional distress in pregnancy. This finding indicates that the trauma associated with an emergency operative delivery is not a determinant for postpartum emotional distress.

Conclusion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Disclosure of interests
  9. Contribution to authorship
  10. Details of ethics approval
  11. Funding
  12. Acknowledgements
  13. References

In this observational study, mode of delivery was not significantly associated with change in emotional distress from 30 weeks of gestation to 6 months postpartum, or with the presence of emotional distress at 6 months postpartum. Emotional distress in pregnancy was the factor that was most strongly associated with emotional distress after delivery. Our findings suggest that concern for maternal mental health after delivery should not influence clinical decisions regarding mode of delivery.

Contribution to authorship

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Disclosure of interests
  9. Contribution to authorship
  10. Details of ethics approval
  11. Funding
  12. Acknowledgements
  13. References

S.S.A. was the main author of the paper and undertook the initial drafting and performed the data analyses. All other authors contributed significantly to the design of the study, the assessment of data and development of the article, including approval of the final version.

Details of ethics approval

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Disclosure of interests
  9. Contribution to authorship
  10. Details of ethics approval
  11. Funding
  12. Acknowledgements
  13. References

The Norwegian Mother and Child Cohort Study was approved by all Regional Committees for Medical Research Ethics in Norway and by the Norwegian Data Inspectorate. All participants signed an informed consent form.

Funding

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Disclosure of interests
  9. Contribution to authorship
  10. Details of ethics approval
  11. Funding
  12. Acknowledgements
  13. References

The Norwegian Mother and Child Cohort Study is supported by the Norwegian Ministry of Health, NIH/NIEHS (grant no. N01-ES-85433), NIH/NINDS (grant no. 1 UO1-NS-047537-01) and the Norwegian Research Council/FUGE (grant no. 151918/S10). The present study was supported by the Norwegian Research Council.

Acknowledgements

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Disclosure of interests
  9. Contribution to authorship
  10. Details of ethics approval
  11. Funding
  12. Acknowledgements
  13. References

We are grateful to have been given access to the data held in the Norwegian Mother and Child Cohort Study and the Medical Birth Registry of Norway.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Disclosure of interests
  9. Contribution to authorship
  10. Details of ethics approval
  11. Funding
  12. Acknowledgements
  13. References