Main findings
Our prospective cohort study of Chinese women revealed that CS may be an important independent risk factor of postpartum PTSD. After adjusting for potential confounding factors, we found that both elective CS and emergency CS were associated with an increased risk of developing postpartum PTSD compared to VD. Additionally, nulliparous status, anxiety during pregnancy, depression during pregnancy, and fear of birth were identified as independent risk factors for PTSD.
Interpretations
Previous studies21,22 have shown that a woman’s birth experience is closely related to the onset of postpartum PTSD. Yakupova et al.21 found that women who had a cesarean birth, or a greater number of medical interventions, or experienced obstetric violence during childbirth, had higher levels of postpartum PTSD symptoms. According to Ertan et al.22, women could suffer from mental health disorders related to birth experience during the postpartum. Unpleasant birth experiences and the occurrence of postnatal PTSD often determine a woman’s willingness to have children again. In other words, the occurrence of postnatal PTSD is directly related to human reproduction and healthy population growth, especially for countries with aging problems and some developed countries23, such as China, Japan, Russia and South Korea. World Population Prospects 202223 showed that the fertility rates of Korea, China, Japan and Russia are 0.88, 1.16, 1.30 and 1.49, respectively. Our study in a cohort of Chinese women with high CS rate revealed that the prevalence of PTSD in postpartum women was 12.12%. This number was higher than that reported in a meta-analysis in 2023, which combined 18 studies of postpartum PTSD and indicated the pooled prevalence of postpartum PTSD was 11.2% in Mainland China, with a higher prevalence at the time point within first month postpartum (18.1%)24. We conducted a systematic review of 9 studies originating from 7 countries with a total of 1,134 women and found that the pooled prevalence of PTSD after CS was 10.7%, and pooled prevalence of PTSD after emergency CS was higher than that after elective CS13. Variations in test used to detect PTSD, time points at measurement of PTSD, geographical origin of study, risk profile of PTSD, and methodological quality may explain the differences in the reported PTSD prevalence rates.
This study supported that CS was a significantly risk factor of PTSD. Findings of this study suggest that the prevalence of PTSD was 17.55% in women delivered by CS, which was about two-times higher than that in women who delivered vaginally. Specifically, the prevalence of postpartum PTSD within 42 days after childbirth was 24.39% (20/82) in emergency CS mothers. A systematic review1 with a total of 24,267 women reported a prevalence of PTSD related to childbirth of 4.0% in community samples, suggesting that CS may be an important traumatic event. Besides, a prospective cohort study with 1824 women also identified CS as a risk factor for PTSD symptoms7. CS women show more frequent a feeling of disappointment, poor body feeling, and lower self-confidence. And a worsening of mood and a decrease in self-esteem could be detected in women who give birth by CS6. In addition, CS women worried more about the safety of their baby and felt less satisfied overall with their birthing experiences, which may lead to women may perceive CS as more traumatic than VD.
An elective CS is defined as a planned CS without strict medical indication and performed before the start of labour25. Elective CS is usually performed when medical indications such as placenta previa and pre-eclampsia present, but elective CS also be a traumatic event as it brings physical trauma even psychological to women26. Findings of this study suggest that the prevalence of PTSD was 15.19% in women delivered by elective CS. Nagle et al.27 reported an increased risk following CS for severe maternal morbidities, complications in newborn medical health. Besides, a study conducted by Dekel et al.6 showed that complications in psychologically derived factors such as maternal bonding are related to CS. Increased risk of PTSD following CS may in part reflect these negative impacts of CS.
Emergency cesarean birth is considered to be the most traumatic mode of birth, because of the stress associated with needing emergency surgery, often when a woman is in established labor28. Except for the same negative results as elective CS, emergency CS women usually have an unpleasant birth experience9. The negative emotions, fear, and painful experiences associated with emergency CS can contribute to the formation and consolidation of fear memories, potentially leading to postpartum PTSD30. Childbirth pain, particularly from cervical dilation, has been shown to be highly distressing27,28 and can stimulate the amygdala region of the limbic system, a key area involved in the formation of conditioned fear memories—a core symptom of PTSD31. A study conducted by Du et al.32 found that analgesia pump use was a protective factor against postpartum PTSD. The release of norepinephrine during stressful and traumatic events can increase the formation of event-related fear memories, thus inducing PTSD33. Sedative and analgesic drugs delivered via an analgesic pump may prevent the onset and development of PTSD by lowering the important source of norepinephrine in the central nervous system and reducing the consolidation, reinforcement and formation of conditioned fear memories during the early stage of trauma34. Besides, a mixed-methods systematic review and meta-analysis conducted by Carter et al.28 found that women who developed PTSD after emergency CS felt less in control and less supported than those who did not develop it after the same procedure. Therefore, ensuring that women feel supported and in control during CS may mediate against this risk21,22.
Our study also indicated that negative emotions during pregnancy were risk factors for developing PTSD, including fear of birth, anxiety and depressed during pregnancy. Fear of birth increased the risk of a negative subjective birth experience which in turn may lead to PTSD. Avignon V et al.35 found that fear of birth may result in fatigue and sleep deprivation during pregnancy, which may be another explanation for why women with fear of birth were more likely to suffer from PTSD. A cohort study conducted by Steetskamp J et al.5 also showed that negative emotions, distress and a generally negative experience of labor were connected with the development of PTSD. Therefore, paying attention to the psychological status of pregnant women and providing appropriate psychological intervention may contribute to reducing the prevalence of PTSD21,22,27. In addition, our study found that nulliparous women are more likely to suffer PTSD. Among primiparous women, the relative risk of developing a PTSD symptom profile after CS was 6.3 times higher compared to normal vaginal deliveries6. Nulliparous women have more uncertainty about birth, which may increase their perceived birth pain. A cohort study conducted by Steetskamp et al.5 found that birth pain was considered a highly predisposing factor for developing PTSD.
The best way to prevent the onset the disease is by active prevention. Therefore, on the basis of this study and literature reviews21,22,27, we give the following preventive recommendations: (1) strict control the indications of CS to reduce the CS rate; (2) conduct health education related to childbirth for pregnant women to make them know and understand the perinatal process as much as possible to eliminate the fear and anxiety of the unknown; (3) health education for the family members of pregnant women to popularize perinatal knowledge so that the pregnant women can obtain enough family support; (4) family members and medical personnel should pay close attention to maternal psychological changes in the perinatal period, find and provide timely help and support, when necessary, preventive psychological intervention.
Strengths and limitations
To the best of our knowledge, this is the first study that assessed the association between mode of birth and PTSD among women in Guangdong province of China. We carefully assessed potential confounders and performed appropriate methods to adjust for the effect of these confounders. The consistent results from different models in the adjustment suggest the robustness of the association between mode of birth and PTSD. In addition, design and analysis of this study was based on a systematic review that we conducted before.
Of course, there were several limitations for consideration in interpreting the results. (1) Limitations in analysis: while our analysis includes most of the important antepartum and intrapartum risk factors reported in the literature, some potential postpartum risk factors such as postpartum care provider and postpartum living environment, have not been taken into consideration in the regression analysis. Second, (2) Limitations in data collection: PCL-C was used to classify PTSD. It should be noted that this is a screening measure not a diagnosis. We chose the PCL-C as a screening tool primarily due to its reliability and validity in assessing PTSD symptoms across a broad range of populations. Instruments specifically designed for birth trauma, such as the Birth Trauma Scale (BTS), as well as a diagnostic tool may provide a more comprehensive picture of PTSD. (3) Limitations in sample selection: the study was conducted in a single medical institution. Whether the results could be generated to other regions of China remains to be explored.
link