Abstract
Objective
Postnatal depression is a common and serious mental health problem. Despite the existence of established risk factors for postnatal depression, the role of the mode of delivery in influencing its prevalence remains a topic of debate. This study investigated the potential association between postnatal depression and the mode of delivery, specifically comparing the prevalence of postnatal depression in women who had a vaginal delivery versus those who underwent either an emergency or elective cesarean section. This study aimed to explore how different modes of delivery affect the prevalence and severity of postnatal depression among women in Jordan.
Methods
A cross-sectional study was conducted at Jordan University Hospital between January and April 2024 to assess postnatal depression among women who delivered singleton fetuses 1 week after delivery. The participants completed a self-reported questionnaire, which collected demographic data and responses to the Edinburgh Postnatal Depression Scale. These responses were used to evaluate postnatal depression symptoms.
Results
A total of 267 women participated in the study. Results showed no significant association or difference in the postnatal depression scores between different modes of delivery (p = 0.459 and 0.441). Moreover, gestational age at the time of delivery and the infant feeding method after delivery showed no significant differences in the postnatal depression scores (p = 0.681 and 0.537, respectively). Results showed that the occurrence of intrapartum complications was associated with an approximately two times greater risk of developing postnatal depression (adjusted odds ratio = 1.96, p = 0.013).
Discussion
This study found no clear relationship between the mode of delivery and postnatal depression, with similar depression scores observed across vaginal and cesarean deliveries. Peripartum complications were linked to a higher risk of postnatal depression, whereas factors such as age, occupation, and infant feeding method showed inconsistent associations. The results highlight the complex, multifactorial nature of postnatal depression.
Conclusions
There was no significant association or difference in the postnatal depression scores between the modes of delivery. The results suggested that factors other than the mode of delivery played a more significant role in the development of postnatal depression among the women included in this study. Although our findings contribute to the understanding of maternal mental health, further research is needed to explore additional risk factors and interventions for postnatal depression.
Keywords
Introduction
Postpartum psychiatric disorders are traditionally classified into three main categories: maternity blues, postpartum depression, and puerperal psychosis. Postnatal depression (PND) is a highly prevalent condition affecting 10%–15% of new mothers globally, with a prevalence of 20%–25% in Jordan.1,2 International studies have highlighted that healthcare access, socioeconomic conditions, and cultural beliefs vary across regions. In high-income countries, there is an emphasis on the role of healthcare support, whereas low-income countries face barriers such as cultural perceptions and limited mental health services.3,4 Unlike other forms of depression, PND is related to childbirth, a period of life transition requiring physical and psychological adaptation. 5 It manifests as a spectrum of emotional and psychological symptoms, including mood swings, persistent sadness, changes in weight and sleep patterns,6,7 fatigue, difficulty bonding with the baby, breastfeeding problems, 8 and feelings of guilt or worthlessness. In severe cases, it may involve obsessive thoughts about harm to oneself or the baby. 9 PND not only affects the mother but also disrupts family dynamics and may lead to developmental delays and behavioral problems in infants.10,11 Various risk factors contribute to PND, such as a history of depression, stressful life events, lack of social support, sleep disturbances, pregnancy and childbirth complications, unplanned pregnancy, and a personal history of mental illness.12,13 However, some women may develop PND without identifiable risk factors, while others may not develop PND despite having these risk factors. The impact of obstetric factors, especially the mode of delivery, on PND, has been widely studied; however, it remains controversial with the rising rates of cesarean sections (CSs) worldwide, including in Jordan. It is important to determine whether CS increases the risk of PND compared with vaginal delivery. The present study specifically investigated how the mode of delivery, including distinguishing elective CS from emergency CS, influenced depressive symptoms, aiming to better identify at-risk mothers and improve the quality of postpartum care.
Methods
A cross-sectional study was conducted in Jordan between January and April 2024, targeting women who delivered singleton fetuses at the Jordan University Hospital. Participation was voluntary, and informed consent was obtained after a brief explanation of the study’s purpose and benefits. After obtaining consent, the participants provided their contact details, including names, phone numbers, and the baby’s date of birth. One week postdelivery, the participants were contacted and provided with a questionnaire via text message, allowing sufficient time to respond at their convenience.
Data collection focused on obtaining comprehensive information from women in the postpartum period. The questionnaire consisted of two sections. The first section focused on demographic characteristics such as age, place of residence, age at marriage, education level, employment status, monthly income, and relevant obstetric history, including number of pregnancies, number of children, number of miscarriages, gestational age, mode of delivery, number of fetuses, anesthesia during delivery, lactation status, delivery adverse effects, chronic illnesses, and history of psychological conditions.
The Edinburgh Postnatal Depression Scale (EPDS) questionnaire was used to assess PND. This questionnaire consists of 10 Likert-scale items that evaluate various aspects of mood and emotional well-being experienced by the participants over the past week. Each item is rated on a scale from 0 to 3, with “0” indicating the absence of symptom and “3” indicating the symptom occurring most or all of the time. Total scores range from 0 to 30, with scores ≥13 indicating the presence of depressive symptoms or a high risk of developing a depressive disorder.
Before being implemented in the study, the EPDS was translated into the local language and culturally adapted to ensure its relevance to the study population. Bilingual experts reviewed the translated version to confirm its accuracy and cultural appropriateness. Previous research, such as the study by Ghubash et al., has established the validity of the EPDS questionnaire in the Arabic-speaking population. 14
Participants were selected randomly from the Jordan University Hospital postpartum unit, and informed consent was obtained from all participants. A total of 278 participants initially completed the questionnaire, but only 267 women were included in the final analysis. The participants were excluded because of multiple gestation or their unwillingness to participate.
Participant data were handled with strict confidentiality; no individual outside of the designated research team had access to examine, manipulate, or transfer the data. Confidentiality and anonymity were strictly maintained throughout the data collection and analysis process. All patient details have been deidentified.
The study received approval from the Institutional Review Board (IRB) of the University of Jordan and Jordan University Hospital (reference number: 10/2024/8405, date of approval: 25 March 2024), ensuring compliance with ethical standards. Findings were reported based on the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines. 15 This study was conducted in accordance with the Helsinki Declaration of 1975, as revised in 2013.
Statistical analysis
The participants’ survey responses were downloaded from Google Forms into an Excel sheet and then coded into a database using the Statistical Package for the Social Sciences (SPSS), version 27.0.1 (IBM Corp., Armonk, New York, USA). Quantitative variables were reported as mean and standard deviation or median and interquartile range (IQR), and qualitative variables were presented as frequency and percentages.
Logistic regression was used to identify independent variables (age, educational level, employment, monthly income, gravidity, gestational age at the last pregnancy, and peripartum complications) associated with the development of PND, based on the EPDS scale (scores ≥13 indicating PND and scores <13 indicating no PND).
The analysis began with simple logistic regression, where variables with a p-value <0.25 were considered for inclusion in the multiple logistic regression model. Multiple logistic regression was conducted, and variables with a p-value ≤0.05 were considered statistically significant. To ensure the independence of variables, multicollinearity was assessed using a tolerance value <0.2 and a variance inflation factor <5.
Results
A total of 267 women participated in the study. Most of the participants were aged >31 years (n = 134, 50.2%), whereas 82 (30.7%) were aged between 25 and 30 years. More than half of the participants (n = 145, 54.3%) reported a monthly income between 500 and 1000 JD, and a substantial majority (n = 192, 71.9%) held a university degree. Furthermore, women aged between 26 and 30 years were more likely to have vaginal deliveries, whereas those aged ≥31 years commonly underwent CS (p = 0.022). Additional demographic details are provided in Table 1.
Sociodemographic characteristics and the mode of delivery.
Pearson’s chi-squared test; Fisher’s exact test. *Significance at alpha level of 0.05.
Table 2 outlines the obstetric history of the participants, including parameters such as gravidity, number of children, gestational age at last delivery, and infant feeding method. The majority of the women (84.3%) were multiparous, with 56.2% having experienced three or more previous pregnancies. Most participants (n = 169, 63.3%) did not report any history of abortion or miscarriage. Regarding the mode of delivery for the most recent pregnancy, CS was the most common mode, with 111 (41.6%) participants undergoing emergency CS and 60 (22.5%) undergoing elective CS. Only 96 (36%) participants delivered vaginally.
Obstetric and delivery characteristics and the mode of delivery.
Pearson’s chi-squared test; Fisher’s exact test. *Significance at alpha level of 0.05.
Additionally, a significant proportion of women who underwent elective CS delivered at a gestational age of 37 weeks or more (p = 0.002).
Analysis of the association between the mode of delivery and EPDS scores for PND revealed no significant differences in the PND scores among women who underwent vaginal deliveries, elective CS, and emergency CS (p = 0.459 and 0.441) (Table 3).
Association between postnatal depression using EPDS score and the mode of delivery.
OR: odds ratio; CI: confidence interval; EPDS: Edinburgh Postnatal Depression Scale.
To explore the potential association between sociodemographic and obstetric predictor variables and EPDS scores, univariate logistic regression analysis was conducted. The analysis found no significant association between higher EPDS scores and variables such as gravidity, parity, gestational age at delivery (p = 0.681), or infant feeding method (p = 0.537). However, age, educational level, and the occurrence of intrapartum complications showed significant association (p < 0.2) in the univariate model, qualifying these variables for inclusion in the multivariate analysis. Further details are provided in Table 4.
Association between sociodemographic and obstetric factors and postnatal depression on EPDS.
OR: odds ratio; CI: confidence interval; EPDS: Edinburgh Postnatal Depression Scale.
Significance at alpha level of 0.25
Multivariate logistic regression analysis was conducted on the variables that were significant in the univariate analysis. The results indicated that the occurrence of peripartum complications was associated with a two times higher risk of developing PND (adjusted odds ratio = 1.96, p = 0.013). No predictive value was found for age and educational level. Further detailed findings are presented in Table 5.
Multivariate regression of predictors of postnatal depression on EPDS scale.
OR: odds ratio; CI: confidence interval; EPDS: Edinburgh Postnatal Depression Scale.
Significance at alpha level of 0.05.
Discussion
PND is influenced by various risk factors, and there are conflicting findings regarding how the mode of delivery affects the risk of PND. In this study, analysis of the association between the mode of delivery and EPDS scores for PND showed no significant differences among women who underwent vaginal delivery, elective CS, and emergency CS. These results are consistent with findings from several studies.16,17
In a cohort study conducted by Faisal-Cury et al. involving pregnant women from low socioeconomic status background, the findings indicated that the mode of delivery was not associated with depressive symptoms between 6 and 16 months postpartum. 17 Similarly, Sadat et al. reported that although difficult deliveries were associated with an increase in depressive symptoms, they did not predict the risk of PND. 18
Several studies have revealed that PND is more prevalent among women who underwent cesarean delivery than among those who underwent vaginal delivery.18–20 This may be attributed to factors such as increased anxiety, postoperative pain, breastfeeding difficulties, complications, and sleep disturbances, which are more common following CS. 21
In a study by Najid et al., which assessed PND, its associated factors, and its relationship with maternal bonding among Malay women, they revealed that cesarean delivery could contribute to PND through various mechanisms. These include discrepancies in the oxytocin release, stress response following surgery, and complications arising from the procedure. Studies have suggested that the link between surgical stress-induced elevated cortisol levels and PND are related to lowering brain serotonin (5-HT) levels, which predisposes susceptible individuals to depression.5,22
Furthermore, a study by Sinulingga et al. found that women who undergo cesarean delivery generally have lower oxytocin levels than those who undergo vaginal deliveries. Oxytocin plays a crucial role in reducing stress and enhancing feelings of happiness, which reduces the vulnerability to postpartum psychological problems. 23
Our data analysis revealed that the majority of the participants who underwent vaginal delivery did not receive anesthesia, whereas those who underwent CS were administered either spinal or general anesthesia, and our study showed a significant association between anesthesia and PND, consistent with the study by Agarwal et al., which identified anesthetic complications as one of the factors contributing to the high prevalence of PND in the CS group. 21 Additionally, the study suggested that general anesthesia could precipitate depression through some biochemical mechanism acting at the molecular level. 5
Our study found no significant difference in the risk of PND between emergency and elective CS. This finding contrasts with the studies by Alturki et al. and Meky et al., which stated a higher prevalence of PND in emergency cesarean deliveries compared to elective CSs.5,24 Eckerdale et al. also noted that women undergoing emergency CS often report negative delivery experiences, which may indirectly increase the risk of PND. 25
The absence of a significant link between the mode of delivery and postnatal PND suggests that biological and psychosocial factors play a more influential role in maternal mental health. Although vaginal delivery is linked to higher oxytocin levels, research indicates that hormonal variations alone do not strongly impact PND risk. 23 Likewise, while cesarean delivery involves surgical stress and longer recovery, these factors have not been consistently associated with PND.2,21 Instead, maternal mental well-being is more strongly influenced by psychosocial factors such as expectations, social support, and pre-existing mental health conditions.4,13
The results of our study indicate no significant association between gravidity or parity and higher scores on the EPDS. However, Sinulingga et al. found that PND symptoms were more prevalent among multiparous women compared to primiparous women; this could be attributed to increased stress associated with having more children, as well as the financial burden that comes with meeting the needs of a larger family. 23 Conversely, Putriarsih et al. identified primiparity as a risk factor for PND, suggesting that new mothers, lacking prior experience in childcare, may feel overwhelmed, worried, and fearful of making mistakes. In contrast, multiparous women might be more psychologically prepared for the arrival of a new baby due to their previous experience. 26
Regarding demographic characteristics, maternal age is often considered a risk factor for PND. However, our study found no statistically significant relationship between age and PND, aligning with the findings by Kaya et al. 27 In contrast, other studies stated that there is an increased risk of PND among women under the age of 24 years compared to those aged 25 years and more.18,28,29
Occupational status is another factor that may influence the risk of PND. Women with professional careers are generally considered to be at a lower risk for PND, potentially due to increased social interaction and engagement. 27 However, research on this association has produced mixed results, and our data found no significant link between occupation and risk of PND. However, other studies have reported that being a housewife may increase the risk of PND, suggesting that returning to work, engaging in social activities, and earning an income could have protective effects against mood disturbances.30,31
Our results indicate that peripartum complications such as bleeding, hypertension, infections, stroke, urinary incontinence, and others are associated with a two-fold increase in the risk of PND. Sadat et al. found that difficult deliveries were associated with higher levels of depressive symptoms. 18 Blom et al. reported that women who experienced more than two perinatal complications were at particularly high risk of developing PND. 32 Specific complications that may individually elevate the incidence of PND include postpartum hemorrhage, subinvolution of the uterus, urinary tract infections, heart disease, anemia, asthma, and early onset of delivery. 33
The findings of this study correlate with the patterns observed in other Middle Eastern countries. For example, the significant association between peripartum complications and PND aligns with the finding of the research in Saudi Arabia and Iran, where similar complications are highlighted as major risk factors.18,24 Furthermore, the lack of a clear relationship between the mode of delivery and PND is consistent with the findings from studies in Iran and Armenia, which also reported no significant differences in depressive symptoms between vaginal and cesarean deliveries.18,29 Additionally, the study’s emphasis on the multifactorial nature of PND resonates with regional research, which attributes PND to a combination of socioeconomic, cultural, and healthcare accessibility factors. 1
Limitations
The study had several limitations. First, it relied on self-reported data rather than psychiatric evaluations, which may affect the accuracy of the findings. Additionally, the data were confined to the experiences of a single institution, limiting the generalizability of the results. This study did not differentiate the types of vaginal delivery (spontaneous or instrumental), which could influence the outcomes. Although the EPDS was used, it serves as a risk indicator rather than a definitive diagnostic tool. Furthermore, the assessment occurred at a single time point, 1 week postpartum, because of which the study may have underestimated the true prevalence of PND, particularly among those whose symptoms develop gradually. Additionally, early postpartum assessments may capture temporary emotional fluctuations due to hormonal shifts, sleep deprivation, or physical recovery rather than persistent depressive states. A follow-up at multiple time points (e.g. 1, 3, and 6 months postpartum) would offer a clearer picture of how delivery mode influences the development and course of depression.
Conclusion
Our study found no significant association between the modes of delivery and PND. However, peripartum complications were statistically significantly associated with a two-fold increase in the risk of PND. PND remains a serious and neglected issue in Jordan. Although our findings contribute to a better understanding of maternal mental health, further research is needed to explore additional risk factors and potential interventions for PND; identifying women at risk of postpartum depression provides valuable insights into their mental health status. Early detection may lead to more efficient support systems and mental health interventions, and healthcare providers should prioritize screening for PND, particularly in women who experience peripartum complications, and offer targeted mental health support, regardless of the delivery method, to ensure timely intervention and better maternal well-being. Fostering open discussions, encouraging help-seeking behaviors, and raising the standards of maternity care might better address the mental health needs of postpartum women.
Footnotes
Acknowledgments
The authors have no acknowledgments to disclose.
Author contributions
Data availability statement
Data can be accessed through the following link https://figshare.com/articles/dataset/Postpartum_Depression/28303889?file=52002680&fbclid=IwY2xjawIHLVRleHRuA2FlbQIxMQABHVnkKgqs7I7GjVOtbNE3NzC-Z_plxYYg2JcB0ORWCPfyiMKZH9dxrpEqWQ_aem_OF3veLJavNGFPjMmn55ekg
DOI: 10.6084/m9.figshare.28303889
Declaration of conflicting interests
The authors have no financial or other forms of conflict of interest to declare.
Funding
No funding was required throughout the conduct of the research.
