The Association between Cesarean Section Delivery and Child Behavior: Is It Mediated by Maternal Post-Traumatic Stress Disorder and Maternal Postpartum Depression?

Cesarean sections (C-sections) account for up to 21% of births worldwide. Studies have linked delivery via C-section with an increased risk of child behavior problems, such as internalizing and externalizing behaviors. Maternal postpartum depression (PPD) is also linked to child behavioral problems and may play a mediating role in the association between the mode of delivery and child behavior. Mixed findings between mode of delivery and PPD may be due to a failure to distinguish between C-section types, as unplanned/emergency C-sections are linked to post-traumatic stress disorder (PTSD), which has been linked to PPD. The objectives of this study were to determine whether, (1) compared with spontaneous vaginal delivery (SVD) and planned C-section, unplanned/emergency C-sections are associated with increased child behavior problems at two to three years of age and (2) maternal PTSD and PPD mediate the association between delivery type and child behavior problems. A secondary data analysis was conducted on 938 mother-child dyads enrolled in the Alberta Pregnancy Outcomes and Nutrition (APrON) study. Conditional process modeling was employed. Child behavior was assessed using the Child Behavior Checklist (CBCL) 1.5-5 years, and maternal PPD and PTSD were assessed using the Edinburgh Postnatal Depression Scale (EPDS) and the Psychiatric Diagnostic Screening Questionnaire (PDSQ), respectively. No associations were found between delivery type and child behaviors; however, the indirect effect of emergency C-section on child behaviors was significant via the mediating pathway of maternal PTSD on PPD symptoms.

Association of cesarean section delivery with childhood behavior: a systematic review protocol.

OBJECTIVE: This review will evaluate the association between cesarean section delivery and child behavior problems. INTRODUCTION: Cesarean section (C-section) deliveries account for over 30% of deliveries in Canada and 21% of all births globally. Mode of delivery via C-section has been associated with altered maternal mental health in the postpartum period, and postpartum depression is linked to an increased risk of internalizing and externalizing behaviors in children. Given the high rates of C-section deliveries worldwide, it is important to determine how mode of delivery impacts child behavior. INCLUSION CRITERIA: The review will examine child behavior outcomes among preschool and school-aged children as determined by medical diagnosis or a standardized assessment tool. Multiple gestation pregnancies and pre-term delivery will be excluded. METHODS: A search will be conducted using APA PsycINFO (Ovid), MEDLINE (Ovid), Embase (Ovid), CINAHL (EBSCO), and Scopus. This review will evaluate peer-reviewed primary observational research studies specifically looking at C-section delivery. Two reviewers will independently screen titles, abstracts, and full-text studies to determine alignment with the inclusion and exclusion criteria. Data will be recorded using the standardized JBI data extraction tool and will be presented using figures, tables, and a summary. Where feasible, we will conduct a meta-analysis and subgroup analysis of suitable populations. Critical appraisal of studies will be performed for included studies. The certainty of the evidence will be assessed using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach. REVIEW REGISTRATION: PROSPERO CRD42022371294.

Associations among Caesarean Section Birth, Post-Traumatic Stress, and Postpartum Depression Symptoms.

Caesarean section (C-section) deliveries account for nearly 30% of births annually with emergency C-sections accounting for 7-9% of all births. Studies have linked C-sections to postpartum depression (PPD). PPD is linked to reduced quality of parent-child interaction, and adverse effects on maternal and child health. New mothers' perceptions of more negative childbirth experiences, such as unplanned/emergency C-sections, are linked to post-traumatic stress disorder (PTSD), which in turn is related to PPD. Our objectives were to determine: (1) the association between C-section type (unplanned/emergency vs. planned) and PPD symptoms, and (2) if postnatal PTSD symptoms mediate this association. Employing secondary analysis of prospectively collected data from 354 mother-child dyads between 2009 and 2013 from the Alberta Pregnancy Outcomes and Nutrition (APrON) study, conditional process modeling was employed. The Edinburgh Postnatal Depression Scale (EPDS) and the Psychiatric Diagnostic Screening Questionnaire (PDSQ) were administered at three months postpartum, to assess for postpartum depressive and post-traumatic stress symptoms. The direct effect of emergency C-section on PPD symptoms was non-significant in adjusted and non-adjusted models; however, the indirect effect of emergency C-section on PPD symptoms with PTSD symptoms as a mediator was significant after controlling for prenatal depression symptoms, social support, and SES (ß = 0.17 (SE = 0.11), 95% CI [0.03, 0.42]). This suggests that mothers who experienced an emergency or unplanned C-section had increased PTSD scores of nearly half a point (0.47) compared to mothers who underwent a planned C-section, even after adjustment. Overall, emergency C-section was indirectly associated with PPD symptoms, through PTSD symptoms. Findings suggest that PTSD symptoms may be a mechanism through which emergency C-sections are associated with the development of PPD symptoms.

Improving maternal postpartum mental health screening guidelines requires assessment of post-traumatic stress disorder.

Post-traumatic stress disorder (PTSD) has a prevalence of 4-17% in the postpartum period and, like better known postpartum depression (PPD), is linked to reduced quality maternal-child interactions, decreased maternal sense of life satisfaction and functioning, and negative impacts on child development. Currently, provincial and public health organizations throughout Canada screen new mothers for PPD with the Edinburgh Postpartum Depression Scale, which while laudable does not capture PTSD. PTSD is highly associated with PPD, 65% of women with PTSD also present with PPD, presenting a significant gap in postpartum maternal mental health screening. Numerous self-report PTSD screening questionnaires are available that could be incorporated into routine maternal postpartum mental health care. Furthermore, across Canada, regional differences in availability of maternal mental health screening, services, and programs suggest a gap in one of the tenets of Canadian health care-lack of universality. Not only does Canada require national maternal mental health screening, service and program guidelines, but PTSD screening must be incorporated, in order to identify and treat new mothers experiencing mental health problems.

RéSUMé: Le trouble de stress post-traumatique (TSPT) a une prévalence de 4 à 17 % durant la période post-partum et, comme la très connue dépression post-partum (DPP), est associé à la réduction de la qualité des interactions mère-enfant, à une diminution du sentiment de satisfaction de vie et de fonctionnement de la mère, et a un impact négatif sur le développement des enfants. Actuellement, les organismes de santé publique et provinciales à travers le Canada effectuent un dépistage de la DPP auprès des nouvelles mères à l'aide de l'échelle de dépression post-partum d'Édimbourg qui, quoi que valable, ne détecte pas le TSPT. Il existe une forte corrélation entre le TSPT et la DPP alors que 65 % des femmes souffrant d'un TSPT présentent aussi une DPP, ce qui démontre un manquement significatif dans le dépistage post-partum maternel dans le domaine de la santé mentale. Il y a plusieurs instruments disponibles pour l'auto-évaluation de TSPT, qui pourraient être intégrés dans la routine de dépistage en santé mentale post-partum maternel. De plus, des différences régionales à travers le Canada en ce qui a trait à la disponibilité du dépistage, aux services et aux programmes de santé mentale post-partum maternel démontrent une lacune dans l'un des principes des soins de santé du Canada, soit le manque d'universalité. Le Canada nécessite des directives concernant le dépistage ainsi que les services et les programmes de santé mentale post-partum maternel, mais le dépistage du TSPT doit être standardisé pour permettre l'identification et le traitement des nouvelles mères présentant des problèmes de santé mentale.