“Both PMADs and C-sections have known morbidity and mortality for moms and their babies,” says Jessica M. Vernon, MD, a clinical assistant professor in the Department of Obstetrics & Gynecology at NYU Langone Health. “Understanding the correlation between PMADs and C-sections is important for both moms and their care team so that we can do better at increasing awareness and improving the dialogue with women about these risks.” While we don’t know the exact connection between perinatal mood and anxiety disorders and higher rates of first-time C-sections, it’s a cause for concern because both PMADs and C-sections come with health risks for the pregnant individual and their baby. According to the Centers for Disease Control and Prevention (CDC), postpartum depression affects about 13% of women in the United States. In addition, close to 32% of babies are born via a C-section. “Clarifying the health consequences associated with PMAD is important so that we can identify effective interventions—in this case the diagnosis and treatment of PMAD,” says senior author Vanessa Dalton, MD MPH, obstetrician gynecologist at University of Michigan Health Von Voigtlander Women’s Hospital. “C-section is an important pregnancy outcome and reducing C-section rate is a priority.” While Dr. Dalton wasn’t surprised by the findings, she points out that the study does address a knowledge gap that was important to clarify—namely, whether PMAD increases the risk of C-section in a large sample of women. “Prior studies have either focused on women specifically anxious about labor or have been conducted in single health systems where local practices are reflected,” Dr. Dalton explains. “This study indicates that C-section rates are increased in this group of women broadly and might provide an appropriate outcome to monitor when we test interventions.” Dr. Vernon agrees that the findings are important and hopes they will lead to practice changes during pregnancy, labor, and delivery. This will help to ensure health care providers are communicating with and supporting women at high risk for PMADs so that they can work to mitigate any additional risk of C-section.
Birth Outcomes of C-Sections
The World Health Organization (WHO) notes a trend in the increase in the number of cesarean rates in the United States since the 1990s. “These levels seem to have stabilized over the last few years, however, the overall C-section rate is still approximately 31% and the NTSV rate is approximately 25%,” says Dr. Vernon. (NTSV denotes a first baby, full-term, singleton, i.e. no twins or multiple pregnancies, and vertex, i.e. head presenting, not breech or transverse.) Dr. Vernon adds that around 85% of those who have had a prior C-section will have a repeat C-section. “This is in part due to the fact that many hospitals do not offer a trial of labor after C-section due to lack of staffing to provide this service,” she explains. This means that there needs to be an obstetrician and an anesthesiologist readily available throughout the whole labor in case of need for emergency C-section. All of this means that once you have one C-section, in many parts of the country you are destined to have more C-sections, Dr. Vernon says. Each additional C-section increases the risk of complications with future pregnancies and deliveries. C-sections are major abdominal surgery and as such have risks of complications. They should not be viewed lightly by health care practitioners or patients. According to data from The American College of Obstetricians and Gynecologists (ACOG), rates of severe maternal mortality are three times as high for a Cesarean birth as for a vaginal birth (2.7% versus 0.9%). Major C-section risks include placenta previa (where the baby’s placenta partially or totally covers the mother’s cervix) and placenta accreta (when the placenta grows too deeply into the uterine wall). These are both serious conditions that can lead to severe blood loss after delivery.
Making Perinatal Mental Health a Priority
The topic of perinatal mental health is close to Dr. Vernon’s heart, as she is not only an OB/GYN but also a mom who suffered from postpartum depression and had a primary C-section with the birth of her daughter. “Mental health care has always been a taboo topic that is just starting to gain the awareness that it deserves,” she says. Her own training only taught her to look out for severely depressed parents who had thoughts of killing themselves or their babies. When she developed severe anxiety, panic disorder, and obsessive-compulsive behaviors, insomnia, and subsequently severe depression, she had no clue that her symptoms were more than the hypervigilance of a new mom. “It took me almost two years and living through the epicenter of the COVID-19 pandemic in New York City before I reached the point where I was able to see my disorder for what it was,” Dr. Vernon says. She finally went online and administered the Edinburgh Postpartum Depression Scale (a screening tool used for determining who is at high risk) to herself. And she scored off the chart. “I had never really fully paid attention to the survey but instead focused on tabulating scores and making sure patients did not answer affirmative to the question regarding suicidal ideation,” she says. “When I had delivered my daughter, my obstetrician had never asked me pointed questions in regards to anxiety, depression, PTSD, or OCD." Although Dr. Vernon’s doctor was very compassionate, the topic of perinatal mood and anxiety disorders never once entered the conversation during her pregnancy or postpartum visits. “We are still a long way from where we need to be to have the necessary conversations, normalize, and destigmatize the diagnosis and treatment of mental health conditions, and improve access to basic mental health services,” she says. “Providers should counsel and create a safe space and a receptive environment where patients feel supported and not judged.” But the first step is to increase awareness because many people (including doctors) don’t realize that postpartum depression isn’t just depression, and it doesn’t just occur postpartum. “PPD includes depression, anxiety, bipolar, OCD, PTSD, and psychosis,” says Dr. Vernon. “Patients may experience symptoms at any time during pregnancy or postpartum up to the first year after giving birth.” It’s also crucial to be aware of the symptoms of this broad range of disorders, and the risk factors that make people high risk for postpartum depression, such as a history of anxiety or depression, infertility, prior loss, preterm delivery, trouble breastfeeding, and lack of support. In the US, due to socioeconomic disadvantages, Black and Latinx birthing parents may be between 40 and 80% more likely to develop PPD when compared to Non-Hispanic White birthing parents. “The Edinburgh Postpartum Depression Scale and PHQ-9 Depression Test Questionnaire are both good screening tools for providers, but often miss women who suffer mainly from anxiety or OCD,” says Dr. Vernon. So it’s important for providers to ask pregnant and postpartum patients how they are feeling—and let them know that PPD is common and they have help and support.
Talking About How You Feel
Rachael Benjamin, LCSW, a therapist at Tribeca Therapy in New York City, agrees that the perinatal health care system is not usually designed to ask specifically about mental health, anxiety, or feelings, but to address physical concerns. “There’s currently not enough emphasis on mental health during routine prenatal visits,” she says. She encourages patients to answer honestly about any feelings they’re having when the doctor, midwife, or provider asks, “How are you doing?” If you find it difficult to talk about how you’re feeling it might help to ask yourself some questions, like “What emotions have I experienced during this pregnancy?” and “Have I had any feelings or thoughts that I’ve been concerned about?” Benjamin would also like health care providers to have some trained next steps to guide a patient if they’re experiencing higher anxiety or lower moods, such as talking with a therapist, group work, education, or classes. Guilt and shame may prevent many people from admitting to PMAD symptoms, even if they know they are experiencing them. This is where online resources can really make a difference, such as the Perinatal Mental Health Discussion Tool from Postpartum Support International (PSI), which is designed to help people check off symptoms and describe how they are feeling. PSI also has free weekly support groups and a 24-hour warm call line so those suffering can find therapists and psychiatrists who work with patients in the peripartum period. “This is important as reproductive psychiatry is a newer, growing field and many mental health providers don’t have the knowledge or feel comfortable taking care of and prescribing medication for pregnant and breastfeeding women,” Dr. Vernon notes. If you don’t feel that you’re getting adequate mental health support from your provider, consider going elsewhere for your perinatal care. Having somebody else—your partner or a trusted friend or relative—to share your concerns is also important. You’re not alone if you have anxieties about giving birth, pregnancy, or parenting—or all three. And you don’t need to go through it alone, either.
