Is there a link between depression and unplanned caesareans?

According to recent studies it seems women having an unplanned caesarean are 15% more likely to experience depression postnatally.

This probably isn’t a big surprise to some readers, but it is rather depressing.

Back in 2008, J Lally identified a woman’s expectations of her birth as highly significant. She recommended the setting and management of expectations be viewed as a key factor in helping ensure women interpret their birth positively.

Yet 11 years on, studies are still saying the same thing, but birth education has changed little. Women continue to be bombarded with strong messages about natural birth, avoiding drugs, avoiding caesareans, avoiding the difficult ‘What if…’ conversations.

For many women, the less medical intervention the better, but not only is this not the preferred route for some women, but also the likelihood of achieving a totally natural birth is actually lower than most think. Many women have no idea about rates of intervention and what the can do about them.

In the UK, some form of medical intervention - be that drugs, instruments or surgery will be involved in 50% of births (NHS Information Centre 2008) and 61% of births will involve anaesthetic (2014/15 NHS figures). And in 2017, the Birth Dignity survey in Australia revealed over a quarter of women surveyed did not achieve the birth they wanted.

It is unfortunately the case that some educators and practitioners make decisions for women about what they should and should not be told ‘in case we frighten them’. The result is that many, many women plan a particular type of birth for themselves with little, to no understanding of:

  • the likelihood of achieving it
  • alternatives to it which might become necessary
  • ideas for ways to transition between preferences as the birth progresses
  • coping techniques for interventions
  • detailed plans for caesarean delivery

Understandably, for some women then, any deviation from their birth plan can come as a tremendous shock and carries the potential for huge emotional damage. A US survey in 2011 recorded rates of PTSD in mothers of between 1.7 – 9% which can have a significant impact not only on family life and bonding with the baby but also on subsequent family planning.

Women are often just not prepared for the alternative possible outcomes of their birth plan and can struggle to manage them as a result. As an example see cascade of intervention.

This recent study, by Dr Valentina Tonei from the Department of Economics at the University of York recommends the ongoing needs of women for mental health support should be factored in to birth costs. Realising that 15% of women are likely to be depressed after their birth as a direct result of the mis-match between expectation and the experience of an unplanned caesarean (never mind other forms of intervention) suggests this has “important implications for public health policy, with new mothers who give birth this way in need of increased support…While the financial costs associated with this surgical procedure are well recognized, there has been less focus on the hidden health costs borne by mothers and their families. ” Dr Valentina Tonei

I would go a step further and say that the hidden costs of caesarean and vaginal birth are conveniently ignored in funding and planning circles:

  • An unplanned caesarean is a hidden cost of vaginal birth attempt
  • Pelvic floor surgery is a hidden cost of vaginal birth
  • Mental health support is a hidden cost of any birth that does not match a woman’s expectations

It is great that yet another study is highlighting the link between birth experience and mental health, but studies are not enough. Many women go into their birth believing they are in control of their plan, but nature is simply not that predictable even in second and third pregnancies. Women need to know that plans are great, but they are not a guarantee and alternatives need to be considered and planned for. Antenatal education must change. But so too must the funding of maternity services, which need to take account of this additional mental health cost to some women.

“Only seven percent (7%) of women suffering with mental health problems during or after pregnancy are refereed to specialist care.” RCOG Maternal Mental Health – Women’s Voices report.

So, what could this mean?

There lots of things we can do to help ourselves manage our birth experience, somethings are readily talked about:

  • Accupressure
  • Massage
  • Visualisation
  • Breathing techniques
  • Writing a birth plan

But what is unpopular, yet which really needs to be added to this list is:

  • Information about rates of intervention
  • Ideas for ways to transition between preferences as ones birth progresses
  • Coping techniques for interventions
  • Detailed plans for caesarean delivery
  • Practical coping techniques for births which have involved some form of medical intervention

Educating women about such things does not for a minute mean we should accept interventions are going to happen as a matter of course – there are definitely situations where an intervention may be suggested but is not definitely needed. The Cascade of Intervention is definitely an effect and something women need to know about.

But we need to stop being paranoid about scaring women, we need to help them make better plans, help them manage their expectations and enable them to make informed decisions before and during their births in order to mitigate some of the mental health impact of births that change direction.

Dr Tonei said: “Unplanned caesareans may have a particularly negative psychological impact on mothers because they are unexpected, usually mentally and physically stressful and associated with a loss of control and unmatched expectations.” So, let’s help women understand caesareans, demystify them, talk about them in positive terms and most importantly help women to plan for their possibility so that, should them become necessary, they are ready and not afraid.