Association of postpartum depression and cesarean section: A systematic review and meta-analysis

Published:March 02, 2019DOI:https://doi.org/10.1016/j.cegh.2019.02.009

      Abstract

      Objectives

      Postpartum depression (PPD) is a major depressive disorder. Its symptoms begin 4 weeks after delivery. Several studies have evaluated the association of the type of delivery with PPD; however, there are controversies regarding this association. Therefore, the aim of this systematic review was to estimate the overall association between cesarean section (CS) and PPD.

      Methods

      The international databases of Medline, Scopus, Web of Science, Science Direct, EMBASE and Ovid were searched until May 2017. Quality assessment was done using the Newcastle-Ottawa Scale. The pooled odds ratio in case-control and relative risk in cohort studies were used as the measures of association. A random-effects model was applied for the report of the results with 95% confidence intervals.

      Results

      Of 989 studies, 32 articles met the eligibility criteria and were included in the review. The adjusted OR of the association between CS and PPD was 1.15 (95% CI: 1.00, 1.34) and the crude odds ratio of this association was 1.36 (1.20, 1.55). The odds ratio of the association of elective and emergency CS and PPD was 1.29 (1.12, 1.49) and 1.36 (1.20, 1.55), respectively. In addition, the pooled relative risk of the association between CS and PPD was 1.22 (0.94, 1.58) in cohort studies.

      Conclusions

      Based on the results of this meta-analysis, it seems CS, regardless of the type of cesarean, is a risk factor for PPD.

      Keywords

      1. Introduction

      According to the last report of the World Health Organization, depression is one of the most common diseases affecting more than 300 million people in the world.
      • WHO
      Depression: Let's Talk Vol 22.
      In addition, depression is the most important cause of suicide-related death and results in 800,000 deaths annually.
      • WHO
      Depression. Vol 22.
      (PPD) is a common disorder among women in the world. The symptoms of this disease usually begin four weeks after delivery.
      • Association A.P.
      Diagnostic and Statistical Manual of Mental Disorders (DSM-5®).
      Some of the symptoms include anxiety, feeling inefficient in the care of the newborn, inability to cope with the new situation, loss of control, obsessive thoughts, irrational fear, and disappointment.
      • Miller L.J.
      Postpartum depression.
      In addition to negative effects on the mother-infant relationship, inappropriate nutrition, and inadequate growth of the newborn, PPD may cause learning problems for the children of affected mothers.
      • Gaffney K.F.
      • Kitsantas P.
      • Brito A.
      • Swamidoss C.S.
      Postpartum depression, infant feeding practices, and infant weight gain at six months of age.
      Moreover, the risk of suicide-related deaths among postpartum depressive women is more than healthy mothers.
      • Almond P.
      Postnatal depression: a global public health perspective.
      On the other hand, mothers who experience PPD are more susceptible to depression in the later stages of their lives.
      • Woods N.F.
      • Smith-DiJulio K.
      • Percival D.B.
      • Tao E.Y.
      • Mariella A.
      • Mitchell E.S.
      Depressed mood during the menopausal transition and early postmenopause: observations from the Seattle Midlife Women's Health Study.
      The burden of PPD in lower and middle-income countries is more than high-income countries.
      • Lara M.A.
      • Navarrete L.
      • Nieto L.
      Prenatal predictors of postpartum depression and postpartum depressive symptoms in Mexican mothers: a longitudinal study.
      There are two types of CS including elective and emergent. Elective CS is a medically unnecessary CS, where the pregnant women or her doctor requests this method for delivery. Emergent CS has been defined as an unplanned CS, for example, CS accomplished before the planned date of delivery because of clinical conditions of pregnant women.
      • Lagrew D.C.
      • Bush M.C.
      • McKeown A.M.
      • Lagrew N.G.
      Emergent (crash) cesarean delivery: indications and outcomes.
      Several studies have assessed the association of cesarean section (CS) and PPD. Based on the results of some studies, the type of delivery is associated with PPD.
      • Cirik D.A.
      • Yerebasmaz N.
      • Kotan V.O.
      • et al.
      The impact of prenatal psychologic and obstetric parameters on postpartum depression in late-term pregnancies: a preliminary study.
      Mothers who undergo vaginal delivery have a lower risk of PPD than mothers with a CS. The risk of PPD after elective CS is higher than its risk after vaginal delivery, and emergency CS.
      • 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.
      Other studies have reported a higher incidence of PPD in mothers with emergency CS compared to elective cesarean and vaginal delivery.
      • Najafian M.
      • Cheraghi M.
      • Namazi M.
      A study on the relationship of postpartum depression and method of delivery.
      • Blom E.
      • Jansen P.
      • Verhulst F.
      • et al.
      Perinatal complications increase the risk of postpartum depression.
      • Iwata H.
      • Mori E.
      • Tsuchiya M.
      • et al.
      Predicting early post‐partum depressive symptoms among older primiparous Japanese mothers.
      Some studies have not shown an association between the type of delivery and PPD.
      • Alharbi A.A.
      • Abdulghani H.M.
      Risk factors associated with postpartum depression in the Saudi population.
      • Goker A.
      • Yanikkerem E.
      • Demet M.M.
      • Dikayak S.
      • Yildirim Y.
      • Koyuncu F.M.
      Postpartum depression: is mode of delivery a risk factor?.
      • Josefsson A.
      • Angelsiöö L.
      • Berg G.
      • et al.
      Obstetric, somatic, and demographic risk factors for postpartum depressive symptoms.
      Due to the controversy in the results of the studies and lack of a universal consensus regarding the association between CS and PPD, this systematic review aimed to investigate the overall association of CS with PPD.

      2. Methods

      2.1 Search strategy

      The international electronic databases were searched using a predesigned search strategy. We combined a set of keywords including CS, PPD, cohort, and case-control studies. The databases of Medline (from January 1950 to May 2017), Scopus (from January 1973 to May 2017), Web of Science (from January 1945 to May 2017), Science Direct (from January 1823 to May 2017), EMBASE (from January 1974 to May 2017), and Ovid (from January 1860 to May 2017) were searched. In order to access more resources, the reference lists of selected articles were also scanned and the authors of selected studies were contacted.

      2.2 Selection criteria for studies

      All cohort and case-control studies that assessed the association of the type of delivery and PPD regardless of time, and language of publication were included in this systematic review. The primary outcome was PPD confirmed using standard tools.

      2.3 Data collection and assessment of validity

      Two researchers (HM and MOG) were responsible for screening the retrieved studies independently. They read the titles and abstracts of the studies in order to identify the studies that met the eligibility criteria. Then, the full texts of the selected studies were reviewed and the articles that met the inclusion criterion completely were included in the meta-analysis. Any disagreement between authors was resolved by discussion and judgment of a third author (ADI). The agreement and inter-reliability of the two authors were assessed using the Kappa statistics. The kappa value was 82%.
      The following variables were extracted from the selected studies for data analysis. The name of first author, the year of publication, the sample size, average age of the mothers, number of patients of the followings: PPD (+); CS (+) depression (−); CS (+) depression (+); vaginal delivery (+) depression (+); vaginal delivery (+) depression (−). The time of PPD measurement, instruments used to diagnose depression, the adjusted odds ratio (OR) and relative risk (RR) for the association of type of delivery and PPD. Moreover, the adjusted variables for the relationship between CS and depression were extracted. The crude OR and RR of studies that did not report the adjusted OR or RR was calculated.

      2.4 Risk of bias assessment

      We assessed the risk of the bias of the studies using the Newcastle-Ottawa Scale (NOS).
      • Stang A.
      Critical evaluation of the Newcastle-Ottawa scale for the assessment of the quality of nonrandomized studies in meta-analyses.
      The following items were for cohort studies: 1) The representativeness of the exposed cohort; 2) Selection of the non-exposed cohort; 3) Ascertainment of exposure; 4) Demonstration that outcome of interest was not present at start of study; 5) Comparability of cohorts on the basis of the design or analysis, 6) Assessment of outcome, 7) Was follow-up long enough for outcomes to occur, and 8) Adequacy of the follow up of cohort studies. In addition, the following items were used for case-control studies: 1) Is the case definition adequate, 2) Representativeness of the cases, 3) Selection of Controls, 4) Definition of Controls, 5) Comparability of cases and controls on the basis of the design or analysis, 6) Ascertainment of exposure, 7) the same method of ascertainment for cases and controls, 8) Non-Response rate.

      3. Data analysis

      3.1 Heterogeneity and publication bias

      Chi-square test was applied at a significance level of 10% to assess heterogeneity in the results of the studies. Tau
      • WHO
      Depression. Vol 22.
      was used to investigate heterogeneity between the results of studies. Finally, heterogeneity was quantitatively reported using I2 statistics.
      • Higgins J.P.
      • Thompson S.G.
      • Deeks J.J.
      • Altman D.G.
      Measuring inconsistency in meta-analyses.
      Publication bias was assessed using the funnel plot visually and Egger test.
      • Egger M.
      • Smith G.D.
      • Schneider M.
      • Minder C.
      Bias in meta-analysis detected by a simple, graphical test.
      ,
      • Begg C.B.
      • Mazumdar M.
      Operating characteristics of a rank correlation test for publication bias.

      3.2 Measure of association

      A meta-analysis was performed to obtain the pooled measure of association. The pooled odds ratio (OR) and relative risk (RR) were calculated separately with 95% confidence intervals (CI). A random effects model was applied to report the pooled results. The Stata 11 (Stata Corp, College Station, TX, USA) was used for data analysis.

      4. Results

      4.1 Description of included studies

      In this systematic review, we retrieved 989 cohort and case-control studies, including 905 studies from electronic databases and 84 studies from the list of sources. Of 989 studies, 280 were duplicates, 613 irrelevances to the aim of the study, 55 did not meet the inclusion criteria, and nine lacked the information required to estimate the indicators. Finally, 32 studies (25 cohort studies and 7 case-control studies) remained for meta-analysis [Fig. 1].
      • Lara M.A.
      • Navarrete L.
      • Nieto L.
      Prenatal predictors of postpartum depression and postpartum depressive symptoms in Mexican mothers: a longitudinal study.
      ,
      • Cirik D.A.
      • Yerebasmaz N.
      • Kotan V.O.
      • et al.
      The impact of prenatal psychologic and obstetric parameters on postpartum depression in late-term pregnancies: a preliminary study.
      ,
      • 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.
      ,
      • Najafian M.
      • Cheraghi M.
      • Namazi M.
      A study on the relationship of postpartum depression and method of delivery.
      ,
      • Blom E.
      • Jansen P.
      • Verhulst F.
      • et al.
      Perinatal complications increase the risk of postpartum depression.
      ,
      • Iwata H.
      • Mori E.
      • Tsuchiya M.
      • et al.
      Predicting early post‐partum depressive symptoms among older primiparous Japanese mothers.
      ,
      • Alharbi A.A.
      • Abdulghani H.M.
      Risk factors associated with postpartum depression in the Saudi population.
      ,
      • Josefsson A.
      • Angelsiöö L.
      • Berg G.
      • et al.
      Obstetric, somatic, and demographic risk factors for postpartum depressive symptoms.
      ,
      • Räisänen S.
      • Lehto S.M.
      • Nielsen H.S.
      • Gissler M.
      • Kramer M.R.
      • Heinonen S.
      Fear of childbirth predicts postpartum depression: a population-based analysis of 511 422 singleton births in Finland.
      ,
      • Patel R.R.
      • Murphy D.J.
      • Peters T.J.
      Operative delivery and postnatal depression: a cohort study.
      ,
      • Adams S.
      • Eberhard‐Gran M.
      • Sandvik Å.
      • Eskild A.
      Mode of delivery and postpartum emotional distress: a cohort study of 55 814 women.
      ,
      • Adewuya A.O.
      • Fatoye F.O.
      • Ola B.A.
      • Ijaodola O.R.
      • Ibigbami S.-M.O.
      Sociodemographic and obstetric risk factors for postpartum depressive symptoms in Nigerian women.
      ,
      • Astbury J.
      • Brown S.
      • Lumley J.
      • Small R.
      Birth events, birth experiences and social differences in postnatal depression.
      ,
      • Boyee P.
      • Todd A.
      Increased risk of postnatal depression after emergency Cesarean section.
      ,
      • Chaaya M.
      • Campbell O.
      • El Kak F.
      • Shaar D.
      • Harb H.
      • Kaddour A.
      Postpartum depression: prevalence and determinants in Lebanon.
      ,
      • Edwards D.R.
      • Porter S.-A.M.
      • Stein G.S.
      A pilot study of postnatal depression following caesarean section using two retrospective self-rating instruments.
      ,
      • Hiltunen P.
      • Raudaskoski T.
      • Ebeling H.
      • Moilanen I.
      Does pain relief during delivery decrease the risk of postnatal depression?.
      ,
      • Houston K.A.
      • Kaimal A.J.
      • Nakagawa S.
      • Gregorich S.E.
      • Yee L.M.
      • Kuppermann M.
      Mode of delivery and postpartum depression: the role of patient preferences.
      ,
      • Kamranpour S.B.
      • Shakiba M.
      Cesarean section and post partum depression.
      ,
      • Malik F.R.
      • Malik B.B.
      • Irfan M.
      Comparison of postnatal depression in women following normal vaginal delivery and caesarean section: a pilot study.
      ,
      • McCoy S.J.B.
      • Beal J.M.
      • Shipman S.B.M.
      • Payton M.E.
      • Watson G.H.
      Risk factors for postpartum depression: a retrospective investigation at 4-weeks postnatal and a review of the literature.
      ,
      • Meltzer-Brody S.
      • Maegbaek M.
      • Medland S.
      • Miller W.
      • Sullivan P.
      • Munk-Olsen T.
      Obstetrical, pregnancy and socio-economic predictors for new-onset severe postpartum psychiatric disorders in primiparous women.
      ,
      • Nielsen D.
      • Videbech P.
      • Hedegaard M.
      • Dalby J.
      • Secher N.
      Postpartum depression: identification of women at risk.
      ,
      • Petrosyan D.
      • Armenian H.K.
      • Arzoumanian K.
      Interaction of maternal age and mode of delivery in the development of postpartum depression in Yerevan, Armenia.
      ,
      • Sadat Z.
      • Kafaei Atrian M.
      • Masoudi Alavi N.
      • Abbaszadeh F.
      • Karimian Z.
      • Taherian A.
      Effect of mode of delivery on postpartum depression in Iranian women.
      ,
      • Silverman M.E.
      • Reichenberg A.
      • Savitz D.A.
      • et al.
      The risk factors for postpartum depression: a population‐based study.
      ,
      • Sword W.
      • Kurtz Landy C.
      • Thabane L.
      • et al.
      Is mode of delivery associated with postpartum depression at 6 weeks: a prospective cohort study.
      ,
      • Sylvén S.
      • Thomopoulos T.
      • Kollia N.
      • Jonsson M.
      • Skalkidou A.
      Correlates of postpartum depression in first time mothers without previous psychiatric contact.
      ,
      • Weisman O.
      • Granat A.
      • Gilboa-Schechtman E.
      • et al.
      The experience of labor, maternal perception of the infant, and the mother's postpartum mood in a low-risk community cohort.
      ,
      • Xie R-h
      • Lei J.
      • Wang S.
      • Xie H.
      • Walker M.
      • Wen S.W.
      Cesarean section and postpartum depression in a cohort of Chinese women with a high cesarean delivery rate.
      ,
      • Zanardo V.
      • Giliberti L.
      • Volpe F.
      • Parotto M.
      • Luca F.
      • Straface G.
      Cohort study of the depression, anxiety, and anhedonia components of the Edinburgh Postnatal Depression Scale after delivery.
      ,
      • Dolatian M.M.P.
      • Alavi Majd H.
      • Yazdjerdi M.
      Relationship between type of delivery and postpartum depression.
      The included studies involved 1710494 participants. The characteristics of the selected studies are presented in Table 1.
      Fig. 1
      Fig. 1A flow chart depicting the stages of retrieving articles and checking eligibility criteria for Meta-analyze.
      Table 1Characteristics of the included studies in systematic review of the association between postpartum depression and cesarean section.
      authorPublish yearStudy TypeSample sizeAge MeanPostnatal depression numberReported type CesareanOR (CI)RR (CI)Adjusted VariableQuestionnaireQuality
      Michael E. Silverman2016cohort70770129.34397Elective Cesarean1.37 (.96–1.97)maternal depression history, year of delivery, maternal age, cohabitation with father of the infant, hypertensive diseases, diabetic diseases, prolonged labor, mode of delivery, gestational age, birth weight for gestational age, congenital malformations, and sphincter rupture.International Classification of Diseases (ICD)*****
      Emergency Cesarean.95 (.84–1.08)
      Phili M boyce1992cohort17926.719Emergency Cesarean2.2 (.82–5.86)NOEdinburgh********
      S.Meltzer Broby2017Cohort39245826.92983Elective Cesarean1.32 (1.13–1.53)NOEdinburgh****
      Ri-hua Xie2011Cohort38528.2689Elective Cesarean1.82 (1.04–3.17)maternal age, household income, gestational age at delivery, pregnancy complications, delivery complications, birth weight, infant sex, and total postnatal social support score as the independent variables.Edinburgh******
      Kamran pur. B2011Cohort31026.8320Elective Cesarean2.53 (.93–6.88)maternal age, Abortion history, Premenstrual syndromeEdinburgh********
      Roshni R Patel2005Cohort109341129Elective Cesarean Emergency Cesarean1.06 (.66–1.7) 1.17 (.77–1.79)maternal age, gestational age at delivery, parity, neonatal head circumference, and birth weight, previous cesarean section, epidural in labour, previous miscarriage, antenatal class attendance, diabetes mellitus, fetal presentation, outcome of last pregnancy, preferred labour position, perceived loss of control in labour.Edinburgh******
      Sari Raisanen2013case-control51133429447Elective Cesarean1.32 (1.06–1.43)Depression before pregnancy, Depression during pregnancy, Nulliparous, Smoking status, Socioeconomic status, Fear of childbirthInternational Classification of Diseases (ICD)*****
      Zohre Sadat2014Cohort32126.5347Elective Cesarean.81 (.46–1.41)maternal age, Number of children, Unwanted pregnancy, Unwanted sex of baby, Level of educationEdinburgh********
      Dolatian. M2005Cohort14822.7130Elective Cesarean2 (1.2–3.9)BMI, employment status, exposure to secondhand smoke, child care anxiety score and self-esteem scoreEdinburgh********
      abeer a alharbi2014Case-control35229.92117Elective Cesarean.96 (.56–1.64)Hemoglobin, Pregnancy period, Sex of child, Anemia during pregnancy, Iron pills given during pregnancyEdinburgh***
      SS Adams2011Cohort5581430.122538Elective Cesarean.96 (.79–1.16)maternal age, mode of delivery, obstetric complications, parity, educational level and maternal wish for cesarean deliverySCL-8 score********
      Emergency Cesarean1.13 (.97–1.32)
      EA Blom2010Cohort494131396Elective Cesarean.99 (.56_1.75)General psychopathological symptoms, family functioning, maternal ethnicity and age, education level mother, and family incomeEdinburgh********
      Emergency Cesarean1.53 (1.02–2.31)
      Diana Petrosyan2011Case-control494163Elective Cesarean.59 (.21–1.65)maternal age, Premenstrual syndrome, Social support, socioeconomic status, marriage age, Spouse's age, Mother's occupationEdinburgh********
      M. Chaaya2002Cohort39628.583Elective Cesarean.14 (.03-.56)Depression during pregnancy, Chronic problems, Area, Stressful life events, Social support, Life time depression, Education, Working, BreastfeedingEdinburgh****
      W Sword2011Cohort189731.3144Elective Cesarean1.06 (.61–1.85)Mother's age, any previous depression, social support, country of birth, total household incomeEdinburgh*******
      Kathryn A. Houston2014Cohort10631.910Elective Cesarean1.13 (.01–2.26)Parity, preterm delivery age, race/ethnicity, education, income, employment status, relationship status.PHQ-9*******
      S.M. sylvan2016Cohort53034Elective Cesarean1.1 (.5–2.4)NOEdinburgh********
      Szu-Nian Yang2011Case-control1053529.732107Elective Cesarean1.48 (1.07–2.03)NOInternational Classification of Diseases (ICD)*******
      Hiroko IWATA2014Cohort47937.71103Elective Cesarean.8 (.35–1.84)NOEdinburgh********
      Emergency Cesarean2.87 (1.47–5.6)
      ABIODUN O. ADEWUYA2005Case-control87628.37127Elective Cesarean1.47 (.31–6.99)NOEdinburgh********
      Emergency Cesarean3.85 (1.72–7.48)
      Jill Astbury1994Case-control779118Elective Cesarean1.88 (1.22–2.86)NOEdinburgh****
      Maria Asuncion Lara2016Cohort21029.536Elective Cesarean1.19 (.55–2.54)NOPHQ-9******
      Najafian. M2013Cohort60026.3862Elective Cesarean2.22 (.99–4.95)NOEdinburgh*******
      Emergency Cesarean4.34 (2.05–9.18)
      Vincenzo Zanardo2017Cohort95033.12216Elective Cesarean1.52 (1.1–2.24)NOEdinburgh********
      Farhat Rehana Malik2015Cohort10029.6841Elective Cesarean5.52 (2.38–12.76)NOEdinburgh*****
      Sarah J. Breese McCoy2006Cohort20981Elective Cesarean1.81 (.94–3.48)NOEdinburgh****
      Omir Weisman2010Cohort164830.5337Elective Cesarean1.25 (.97–1.61)NOBeck Depression Inventory****
      Derya Akdag Cirik2016Cohort149253535Elective Cesarean1.11 (.38–3.3)NOEdinburgh****
      Emergency Cesarean1.39 (.57–3.42)
      DENZIL R. L. EDWARDS1994Cohort19626.735Elective Cesarean1.08 (.52–2.24)NOBromley Postnatal Depression Scale****
      Paulina Hiltune2004Cohort1622921Elective Cesarean1.37 (.29–6.52)NOEdinburgh*********
      Emergency Cesarean.7 (.06–7.74)
      Ann Josefsson2002Case-control39629.6123Elective Cesarean1.66 (.64–4.31)NOEdinburgh*********
      Emergency Cesarean1.24 (.58–2.61)
      Nielsen Forman2000Cohort5091281Emergency Cesarean1.1 (.7–1.9)NOEdinburgh******

      4.2 Heterogeneity test

      There was heterogeneity among the results of included studies. The I
      • WHO
      Depression. Vol 22.
      was 57.1% for studies that reported an odds ratio (OR) and 78.7% for studies that reported a relative risk (RR). In order to reduce heterogeneity and achieve greater convergence, we performed subgroup analysis based on the type of study, type of CS (elective CS/emergency CS), type of reported indicator (adjusted/crude), method of outcome recognition (self-report/questionnaire), tools used to diagnose depression, and the quality of studies.

      4.3 Publication bias

      The results of statistical tests for both OR (Begg: p = 0.642, Egger: p = 0.182) and RR (Begg: p = 0.497, Egger: p = 0.408) indicated a lack of publication bias. In addition, in the funnel plot, the results of studies scattered nearly symmetrically on both sides of the null lines [Fig. 2].
      Fig. 2
      Fig. 2Funnel Plot of included studies for the association of postpartum depression and cesarean section; A: OR and B: RR.

      4.4 Measures of association

      The adjusted pooled OR was 1.15 (95% CI: 1.00, 1.34) and the crude pooled OR ratio was 1.36 (95% CI: 1.20, 1.55), for CS [Fig. 3]. The overall odds ratio based on the type of CS was 1.29 (95% CI: 1.12, 1.49) and 1.36 (95% CI: 1.20, 1.55) for the elective CS and emergency CS respectively [Fig. 4]. Moreover, the pooled relative risk (RR) was 1.22 (95% CI: 0.94, 1.58) for CS.
      Fig. 3
      Fig. 3Forest plot for the association of postpartum depression and cesarean section based on the crude and adjusted OR.
      Fig. 4
      Fig. 4Forest plot of the pooled odds ratio for the association of postpartum depression and cesarean section based on the type of cesarean.
      In addition, we performed a subgroup analysis based on the type of tools applied to diagnose depression and the quality of the included studies. The pooled odds ratio for studies using Edinburgh Postnatal Depression Scale and other tools was 1.46 (95% CI: 1.21, 1.76; I2 = 54.7%) and 1.19 (95% CI: 1.07, 1.32; I2 = 22.8%), respectively (Table 2). The pooled odds ratio based on the type of study was 1.34 (95.1% CI: 1.15, 1.56) and 1.45 (95% CI: 1.15, 1.83) for cohort and case-control studies respectively [Fig. 5].
      Table 2Subgroup analysis for the relationship between postpartum depression and cesarean section, based on the type of the used questionnaire and quality of the included studies.
      VariableOR95% CII2 (%)p-value*
      Used questionnaire
       Edinburgh Postnatal Depression Scale1.461.21, 1.7654.7<0.001
       Other questionnaires1.191.07, 1.3222.8<0.24
      Quality of studies
       High1.401.21, 1.6156.1<0.001
       Low1.23.90, 1.6751.5<0.16
      *p-value for heterogeneity test.
      Fig. 5
      Fig. 5Forest plot of the pooled odds ratio for the association of postpartum depression and cesarean section based on the type of study design.

      5. Discussion

      We found an association between CS and PPD. This association was observed in the meta-analysis of both case-control and cohort studies. CS is associated with some biological changes in the mother's body, including a decrease in the level of prolactin and an increase in the level of interleukin-6.
      • Hebisch G.
      • Neumaier-Wagner P.M.
      • Huch R.
      • von Mandach U.
      Maternal serum interleukin-1β,-6 and-8 levels and potential determinants in pregnancy and peripartum.
      These changes sever risk factors for PPD.
      • Triebel J.
      • Martínez de la Escalera G.
      • Clapp C.
      • Bertsch T.
      Vasoinhibins may contribute to postpartum depression.
      In addition, the CS is a risk factor for hemorrhage that increases the probability of PPD.
      • Eckerdal P.
      • Kollia N.
      • Löfblad J.
      • et al.
      Delineating the association between heavy postpartum haemorrhage and postpartum depression.
      Moreover, CS increases the risk of infant mortality
      • Xie Rh
      • Gaudet L.
      • Krewski D.
      • Graham I.D.
      • Walker M.C.
      • Wen S.W.
      Higher cesarean delivery rates are associated with higher infant mortality rates in industrialized countries.
      ; therefore, this factor might increase the risk of PPD and explain our results.
      Failure in breastfeeding
      • Wallenborn J.T.
      • Masho S.W.
      The interrelationship between repeat cesarean section, smoking status, and breastfeeding duration.
      and postpartum bleeding
      • Belachew J.
      • Eurenius K.
      • Mulic-Lutvica A.
      • Axelsson O.
      Placental location, postpartum hemorrhage and retained placenta in women with a previous cesarean section delivery: a prospective cohort study.
      are two reasons for maternal complications after delivery, which may also affect PPD after. In this regard, our results are in line with the findings of other studies.
      • Räisänen S.
      • Lehto S.M.
      • Nielsen H.S.
      • Gissler M.
      • Kramer M.R.
      • Heinonen S.
      Fear of childbirth predicts postpartum depression: a population-based analysis of 511 422 singleton births in Finland.
      Moreover, the results of our analysis showed that mothers who had an emergency CS had a higher risk of PPD than those who had an elective CS. Among factors affecting the choice of CS are social support, high household income, mother's education, father's education, and occupation.
      • Rajabi A.
      • Maharlouei N.
      • Rezaianzadeh A.
      • Rajaeefard A.
      • Gholami A.
      Risk factors for C-section delivery and population attributable risk for C-section risk factors in Southwest of Iran: a prospective cohort study.
      On the other hand, low socioeconomic status is a risk factor for PPD.
      • Jin Q.
      • Mori E.
      • Sakajo A.
      Risk factors, cross‐cultural stressors and postpartum depression among immigrant Chinese women in Japan.
      Therefore, it is likely that mothers who have an emergency CS have a lower socioeconomic status than those who undergo selective surgery and are more prone to PPD. This relationship was also confirmed in a study conducted in the Netherlands in which the odds ratio of PPD was higher mothers with CS (OR = 1.53).
      • Blom E.
      • Jansen P.
      • Verhulst F.
      • et al.
      Perinatal complications increase the risk of postpartum depression.
      However, a study in Taiwan reported the opposite; in this study, the odds ratio of depression was higher in mothers that received elective CS (OR = 1.48) than mothers who underwent emergency CS.
      • 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.
      Our results indicated CS is a risk factor for PPD; however, other justification might be as follow: women with a tendency of depression may be generally anxious about delivery. Nowadays high request of CS is a major problem. However, the high rate of CS is not limited to the CS on request; women with some background tendencies may more frequently choose CS. Thus, not the CS itself but the temper/physiological background that leads to CS may also be associated with depression on some pregnant women.
      The strengths of this study were the appropriate number of studies included in the final analysis, especially cohort studies, reporting adjusted and crude indicators separately, presenting the relationship between the type of CS and PPD separately, and analyzing studies based on their quality.
      There are some limitations for this systematic review and meta-analysis. Firstly, 25% of the included studies had low quality; this issue may increase the risk of information bias. Secondary, the use of different tools for the diagnosis of PPD in the included studies so the pooled measure of association may increase the risk of information bias. However, we categorized studies based on the used tool for diagnosis of depression, 32 studies have been used Edinburgh Postnatal Depression Scale and 10 studies have been used the Patient Health Questionnaire (PHQ-9), the Beck Depression Inventory (BDI), and the Bromley Postnatal Depression Scale (BPDS). In the latter group because of the low number of studies, we could not conduct subgroup analysis. The third limitation was related to the type of reported measure of association, 18 studies reported the crude measure of association, so the confounding variables in these studies may affect the association of CS and PPD.

      6. Conclusion

      Based on the results of this meta-analysis, it seems CS is a risk factor for PPD. Therefore, it is recommended that decision-makers in the health system pay more attention to the CS and design long-term plans to reduce the rate of unnecessary CSs.

      Funding

      None.

      Conflicts of interest

      All authors declare no conflict of interest.

      Acknowledgement

      We would like to thanks from department of epidemiology and biostatistics of school of public health in Tehran University of medical sciences for the technical support.

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