Are 6 more accurate than 4? The influence of different modes of delivery on postpartum depression and PTSD

Abstract

Background
Empirical evidence shows that 4.6–6.3% of all women develop a post-traumatic stress disorder (PTSD) and approximately 10–15% postpartum depression (PPD) following childbirth. This study explores the relationship between delivery mode and the occurrence of PTSD and PPD, specifically examining four distinct caesarean section (CS) modes: primary on maternal request (Grade 4), medically indicated primary (Grade 3), secondary CS from relative indication (Grade 2) and emergency secondary CS (Grade 1), compared to vaginal and assisted vaginal delivery (AVD). The research aims to understand how these six subcategories of delivery modes impact PPD and PTSD levels. Common predictors, including the need for psychological treatment before childbirth, fear of childbirth, planning of pregnancy, induction of labor, birth debriefing, and lack of social support after childbirth, will be analyzed to determine their association with postpartum mental health outcomes.

Methods
The study was planned and carried out by a research team of the psychology department at the Medical School Hamburg, Germany. Within an online-study (cross-sectional design) N = 1223 German speaking women with a baby who did not die before, during or after birth were surveyed once between four weeks and twelve months postpartum via an anonymous online questionnaire on demographic and gynecological data, delivery mode, PTSD (PCL-5) and PPD (EPDS).

Results
For both psychiatric disorders, ANOVA revealed significant differences between delivery mode and PPD and PTSD. With weak effects for PPD and medium to strong effects for PTSD. Post-hoc tests showed increased levels of PPD for two CS types (Grade 1, Grade 3) compared to vaginal delivery. For PTSD, secondary CS from relative indication (Grade 2), emergency secondary CS (Grade 1) and assisted vaginal delivery (AVD) were associated with elevated levels of PTSD. Regression analysis revealed delivery mode as a significant predictor of EPDS- (medium effect size) and PCL-5-Score (medium to high effect size).

Limitation
Delivery was considered as the potential traumatic event, and any previous traumas were not documented. Additionally, the categorization of delivery modes relied on subjective reports rather than medical confirmation.

Conclusion
The study highlights the influence of delivery mode on the mental health of postpartum mothers: different modes influence postpartum disorders in various ways. However, the definition of delivery mode was only stated subjectively and not medically confirmed. Further research should investigate which aspects of the different delivery modes affect maternal mental health and explore how the perception of childbirth may be influenced by specific delivery experiences.

Full text

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Beck-Hiestermann et al. BMC Pregnancy and Childbirth (2024) 24:118
https://doi.org/10.1186/s12884-024-06267-8 BMC Pregnancy and Childbirth
*Correspondence:
Franziska Marie Lea Beck-Hiestermann
fml.beck-hiestermann@psychologische-hochschule.de
Full list of author information is available at the end of the article
Abstract
Background Empirical evidence shows that 4.6–6.3% of all women develop a post-traumatic stress disorder (PTSD)
and approximately 10–15% postpartum depression (PPD) following childbirth. This study explores the relationship
between delivery mode and the occurrence of PTSD and PPD, specically examining four distinct caesarean section
(CS) modes: primary on maternal request (Grade 4), medically indicated primary (Grade 3), secondary CS from relative
indication (Grade 2) and emergency secondary CS (Grade 1), compared to vaginal and assisted vaginal delivery
(AVD). The research aims to understand how these six subcategories of delivery modes impact PPD and PTSD levels.
Common predictors, including the need for psychological treatment before childbirth, fear of childbirth, planning
of pregnancy, induction of labor, birth debrieng, and lack of social support after childbirth, will be analyzed to
determine their association with postpartum mental health outcomes.
Methods The study was planned and carried out by a research team of the psychology department at the Medical
School Hamburg, Germany. Within an online-study (cross-sectional design) N = 1223 German speaking women with
a baby who did not die before, during or after birth were surveyed once between four weeks and twelve months
postpartum via an anonymous online questionnaire on demographic and gynecological data, delivery mode, PTSD
(PCL-5) and PPD (EPDS).
Results For both psychiatric disorders, ANOVA revealed signicant dierences between delivery mode and PPD and
PTSD. With weak eects for PPD and medium to strong eects for PTSD. Post-hoc tests showed increased levels of
PPD for two CS types (Grade 1, Grade 3) compared to vaginal delivery. For PTSD, secondary CS from relative indication
(Grade 2), emergency secondary CS (Grade 1) and assisted vaginal delivery (AVD) were associated with elevated levels
of PTSD. Regression analysis revealed delivery mode as a signicant predictor of EPDS- (medium eect size) and PCL-
5-Score (medium to high eect size).
Limitation Delivery was considered as the potential traumatic event, and any previous traumas were not
documented. Additionally, the categorization of delivery modes relied on subjective reports rather than medical
conrmation.
Are 6 more accurate than 4? The inuence
of dierent modes of delivery on postpartum
depression and PTSD
Franziska Marie LeaBeck-Hiestermann1,2*, Lisa KathrinHartung1,3, NadineRichert1, SandraMiethe1,4 and
SilkeWiegand-Grefe5
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Beck-Hiestermann et al. BMC Pregnancy and Childbirth (2024) 24:118
Introduction
Although the act of giving birth has a predominantly pos-
itive connotation in Western society, it still poses a risk
for the development of a variety of mental disorders, such
as postpartum depression (PPD) or post-traumatic stress
disorder (PTSD) after a traumatic delivery (e.g. [1, 2]). .
Postpartum psychiatric disorders are relatively com-
mon, with 10–15% of mothers experiencing PPD [3], and
some studies reporting rates up to 19.8% [4]. Addition-
ally, 4.6–6.3% of mothers suer from PTSD related to
childbirth, with higher rates in at-risk groups (e.g. mater-
nal history of trauma, peripartum complications) [5, 6].
ese disorders not only aect mothers’ quality of life but
also extend to relationship problems with partners [7]
and impact on infant emotional regulation and develop-
ment [8–10].
Extensive research has been conducted to investigate
the prenatal and perinatal risk factors for various post-
partum mental disorders [11–17]. In particular for PPD
social risk factors (i.e., age, low socioeconomic status,
planning of pregnancy), psychological risk factors (i.e.,
history of mental disorders, fear of childbirth, lack of
social support after birth), and biological risk factors (i.e.,
chronic or medical illnesses) are considered well estab-
lished [17].
ere is less research on risk factors for the develop-
ment of PTSD following childbirth, but psychological
factors (history of mental disorders, fear of childbirth),
medical factors (induction of labor, birth debrieng) and
social factors (age, lack of social support after childbirth)
are also frequently observed [18, 19]. Part of the research
addresses the subjective birth experience as a possible
mediating factor [19, 20].
While various risk factors contribute to maternal men-
tal health, some studies have focused on the eect of
delivery modes and reviewed its inuence on maternal
mental health [21]. Caesarean sections (CS) were associ-
ated with a more negative view of childbirth, the self, and
the infant. Moreover, feelings of failure, self-blame and
reduced self-esteem have commonly been reported after
CS [21]. Such results show that CS may have adverse
eects on maternal mental health. However, as CS were
only categorized into two dierent types (CS on maternal
request and emergency CS) it remains unclear whether
further, more specic categorizations could provide addi-
tional insights.
A meta-analysis has shown that CS may increase the
risk of PPD [22]. Women who undergo CS, whether
planned or unplanned, tend to exhibit higher levels of
somatization, depression, and anxiety symptoms com-
pared to those with vaginal deliveries [5], indicating that
CS might lead to greater general distress and poorer
mental health, including PPD. Additionally, a systematic
review and meta-analysis found higher depression levels
associated with CS, regardless of categorization, com-
pared to vaginal deliveries [23, 24].
e increased risk of PPD following CS compared to
vaginal delivery is not fully understood. While CS dis-
rupts the normal labor process and hormonal environ-
ment, potentially aecting maternal mental health [25],
assisted vaginal deliveries (AVD) also impact mental
health [5], suggesting hormonal changes in CS may not
be the leading cause. Lower maternal satisfaction after
a CS could play an important role when assessing the
impact on maternal mental health. As mentioned above,
women who had a CS often battle with feelings of fail-
ure or reduced self-esteem [21], possibly because they
feel like they were not able to give birth “the right way”.
is could lead to repetitive negative thinking, a strong
predictor of depressive symptoms [26]. However, some
research has not reached the same conclusions. A review
found no evidence for a link between CS and PPD [27],
and no dierences in PPD levels between vaginal deliver-
ies, CS on maternal request or emergency CS were found
[28]. Another research group also concluded that a CS
does not pose a greater risk for PPD in the medium to
long-term after delivery [29]. However, comparability of
existing studies is low due to methodological dierences.
While some only compare CS and vaginal deliveries
[23], others dierentiate between maternal request and
emergency CS [28]. Not all studies distinguish between
normal vaginal delivery and AVD, although AVD is asso-
ciated with increased risk for traumatic potential [30,
31]. ese methodological discrepancies may explain the
inconclusiveness of existing evidence emphasizing the
need for further studies that more precisely distinguish
between specic types of CS [22].
e British Royal College of Obstetricians and Gyne-
cologists (RCOG) recommends to categorize CS in a
Conclusion The study highlights the inuence of delivery mode on the mental health of postpartum mothers:
dierent modes inuence postpartum disorders in various ways. However, the denition of delivery mode was only
stated subjectively and not medically conrmed. Further research should investigate which aspects of the dierent
delivery modes aect maternal mental health and explore how the perception of childbirth may be inuenced by
specic delivery experiences.
Keywords Postpartum depression (PPD), Post-traumatic stress disorder (PTSD), Caesarean section (CS), Vaginal
delivery, Assisted vaginal delivery (AVD), Birth, Postpartum psychological disorders
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Beck-Hiestermann et al. BMC Pregnancy and Childbirth (2024) 24:118
more comprehensive manner to account for their dif-
ferences based on the urgency with which a CS is per-
formed. is results in six dierent categories; (1) vaginal
delivery, (2) AVD (involving the use of vacuum or for-
ceps to guide the infant out of the birth canal), (3) CS
on maternal request (Grade 4), (4) medically indicated
CS (Grade 3), (5) secondary CS (Grade 2) and (6) emer-
gency CS (Grade 1) [32]. A CS on maternal request is
pre-planned and performed before labor begins at the
mother’s request, while a medically indicated CS is also
pre-planned but performed for medical reasons (e.g.,
transverse fetal presentation) without maternal or fetal
compromise. A secondary CS is conducted after labor
onset due to maternal or fetal compromise but without
immediate life-threatening risks (e.g., cord prolapse,
fetal distress, dystocia). Emergency CS are performed
in response to immediate threats to the mother or fetus
during labor, requiring quick decisions and often involv-
ing higher stress and potential complications. In contrast,
CS on maternal request are pre-scheduled, allowing for
better preparation and management, reducing unex-
pected complications and providing a more controlled
surgical environment.
e dierentiation proposed by the RCOG distin-
guishes more accurately the causes for dierent modes of
delivery and thus was used in this study to examine the
association between delivery mode and mothers’ psycho-
pathology and other psychological outcomes postpartum.
e following questions will be investigated:
1) What proportion of women meet the cut-o
criterion of the questionnaires used to measure PPD
(EPDS) and PTSD (PCL-5)?
2) Are there mean dierences between the six birth
modes in terms of the level of PPD or PTSD scores?
3) Do the six delivery modes predict levels of PPD and
PTSD beyond the common risk factors?
Methods
Sample
is study was planned and carried out by a research
team at the psychology department of the Medical
School Hamburg, Germany. Utilizing an online cross-
sectional design, a total of N = 1223 mothers who were
between four weeks and 12 months post-delivery par-
ticipated in the study. e participants were recruited
between 11/2018 and 03/2019 using social media (post-
ings the study-link in birth related groups on Facebook
and hashtags targeting new mothers on Instagram).
No nancial benet was oered, and the participation
was voluntary. e study is carried out according to the
Good Clinical Practice (GCP) guidelines, the Declara-
tion of Helsinki. In the initial phase of the survey, the
participants received detailed written explanation of
the study and were informed that some of the questions
might relate to unpleasant or even traumatic experiences,
which might trigger unwanted memories and emotions.
Participants could electronically give their consent, were
informed about their right to withdraw at any time and
were encouraged to seek professional help if needed
(informed consent included a list of mental health ser-
vices like the German National Crisis Line). e study
included all German-speaking mothers who were at
least 18 years old. Women who lost their child during or
shortly after birth were excluded so that possible symp-
toms are not due to a reaction of grief.
Measures
Demographic and gynecological data: included general
demographic data such as age, residential environment,
number of children, occupational situation, educational
and family status. In addition, gynecological data were
collected. ese included the date, place and type of
delivery and the desired delivery, the planning of preg-
nancy, high-risk or twin pregnancy, miscarriages, cur-
rent pregnancy, and induction of labor. Also, the need for
psychological treatment before childbirth and post-birth
debrieng were assessed with a yes/no question. Addi-
tionally, this study utilized specially created items, each
with a ve-level Likert scale, to examine fear of childbirth
(never – seldom – sometimes -often -always) and the
extent of social support after childbirth (not at all – not
very – sometimes – very – absolutely).
Mode of Delivery: e mothers had to indicate the
delivery mode via self-report. e distinction is made
between vaginal, assisted vaginal delivery and four CS
modes: primary CS on maternal request (Grade 4), pri-
mary CS with medical indication (Grade 3), secondary
CS without emergency character (Grade 2) and emer-
gency secondary CS (Grade 1).
Depression: was recorded with the Edinburg Postna-
tal Depression Scale [33]. e German version was used
[34], which has a Cronbach’s Alpha of α = 0.81. is is the
only validated German instrument for recording symp-
toms of PPD. e questionnaire contains ten items, each
are asked for using the Likert scale from 0 (not at all) to
3 (yes, very often). us, the range of the measured value
extends from 0 (no symptoms) to 30 (very severe symp-
toms). e recommended cut-o indicating the need of
further diagnostic assessment is ≥ 10 [33, 34], with a sen-
sitivity for PPD of 0.84 and a specicity of 0.84.
PTSD: was assessed using the Post-traumatic Stress
Disorder Checklist (PCL-5) [35], German version [36],
a newer diagnostic tool that has been adapted to the
changed criteria for diagnosing PTSD according to DSM-
5. Each item from the 20-item scale is assessed using a
ve-level Likert scale from 0 (not at all) to 4 (very strong).
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Beck-Hiestermann et al. BMC Pregnancy and Childbirth (2024) 24:118
Higher values represent a stronger expression of the
symptom, thus a maximum value of 80 is possible. Above
a cut-o value of ≥ 33, further assessment is recom-
mended [35, 36], e.g., in the form of a structured clinical
interview. At a cut-o value of ≥ 33 the PCL-5 has a sen-
sitivity of 0.86 and a specicity of 0.68 to identify PTSD.
Statistical analyses
All analyses were performed with IBM SPSS 25.
ANOVAs were used to compare the six delivery modes
regarding dierences in PCL-5- and EPDS-Scores. One
ANOVA was performed for the dependent variable
EPDS-Score and one ANOVA for the dependent variable
PCL-5-Score.
Block-wise, multiple regressions were conducted for
EPDS- and PCL-5-Score. After controlling for age and
educational level (dummy coded, high – medium – low,
with high as reference category) common predictors
were entered in the regression model (all coded: yes ver-
sus no). ose were for EPDS-Score: the need for psy-
chological treatment before childbirth, fear of childbirth,
planning of pregnancy, lack of social support after child-
birth and for PCL-5-Score: the need for psychological
treatment before childbirth, fear of childbirth, induction
of labor, birth debrieng and lack of social support after
childbirth. In a last step the delivery mode was entered in
both models (dummy coded, AVD – Grade 1 – Grade 2
– Grade 3 – Grade 4, with vaginal as reference category).
Statistical signicance was evaluated two-sided at the
5% level.
Results
Sample
A total of n = 1223 mothers took part in the survey, par-
ticipants were mothers with a median age of 28.89 years
(SD = 4.09), 66.6% were married, 39.1% had a high edu-
cational level, and the average number of children was
1.47 years (SD = 0.67). Table1 provides an overview of the
demographic and obstetric data. Additionally, wherever
Table 1 Sample characteristics
sample
n % M
(SD)
German
population*
total 1223
age 28.89
(4.09)
30.0
relationship status
married 815 66.6 51.2%
partner or engaged 371 30.3
no partner, widowed,
divorced
37 3.1
educational level
high 478 39.1 32%
medium 426 34.8 52%
low 319 26.1 16%
number of children 1.42
(0.67)
1.46
high-risk pregnancy 274 22.4 34.9%
twin pregnancies 74 6.1 1.7%
fetal presentation at childbirth 848
cephalic 739 87.1 92%
breech 90 10.6 5%
transversal 1 0.1 0.3%
unsure 18 2.1 /
delivery mode**:
vaginal 703 57.5 63.2%
AVD 145 11.9 6.1%
Grade 4 26 2.1
Grade 3 119 9.7
Grade 2 131 10.7
Grade 1 99 8.1
CS total 375 30.6 30.9%***
* Data originate from the German Federal Statistical Oce (2021), they are
presented a s no. or % unless otherwis e indicated
** delivery mode: CS = caesarean section, AVD = assisted vaginal delivery
(involving the use of vacuum or forceps to guide the infant out of the birth
canal), Grade 4 = CS on maternal request, Grade 3 = medically indicated CS,
Grade 2 = secondar y CS, Grade 1 = emergency CS
*** According to the Federal Statistical Oce, the types of CS (Grade 1 to 3)
in Germany are not surveyed individually; only CS on maternal request are
recorded individually
Table 2 Scores for postpartum depression and post-traumatic stress symptoms for the dierent types of delivery
N
total sample
EPDS
cut-o ≥ 10
fulllled
total sample nPCL-5
cut-o ≥ 33
fulllled
total
sample
n% M (SD) % M (SD)
total 1223 395 32.30 7.58 (5.57) 97 7.93 11.84 (12.10)
vaginal 703 207 29.45 7.35 (5.49) 30 4.27 9.53 (10.14)
AVD 145 43 29.66 7.08 (5.51) 19 13.10 14.65 (14.42)
Grade 4 26 8 30.77 6.31 (5.33) 0 0.00 8.54 (9.07)
Grade 3 131 43 32.82 7.82 (5.36) 6 5.04 11.71 (11.18)
Grade 2 119 40 33.61 7.18 (5.31) 13 9.92 13.08 (12.22)
Grade 1 99 54 54.55 10.53 (6.09) 29 29.29 23.59 (14.80)
AVD = assisted vaginal delivery (involving the use of vacuum or forceps to guide the infant out of the birth canal), Grade 4 = caesarean section (CS) on maternal
request, G rade 3 = medically indicate d CS, Grade 2 = se condary CS, Grade 1 = emergency CS
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Beck-Hiestermann et al. BMC Pregnancy and Childbirth (2024) 24:118
feasible, relevant comparisons were drawn with statistics
from the German population.
Modes of delivery
e six modes of delivery are represented as follows:
57.5% (n = 703) delivered vaginally, n = 145 (11.9%) had an
assisted vaginal delivery. e CS types were divided into
n = 26 women (2.1%) who had Grade 4, n = 119 women
(9.7%) who had Grade 3, n = 131 (10.7%) who had Grade
2 and n = 99 women (8.1%) who delivered per Grade 1. In
summary, this corresponds to a CS rate of 30.6%.
Of all participants, n = 1.082 (88.5%) wanted a vaginal
delivery. N = 49 (4%) expressed a preference for CS as
their chosen delivery mode, while n = 92 (7.5%) had no
xed preference.
On average, the delivery took place in the 39th week
of pregnancy (M = 39.36, SD = 2.27, minimum 25, maxi-
mum 43). 66.6% of the women (n = 814) were rst-time
mothers. 22.4% (n = 274) meet the criteria for high-risk
pregnancy.
Postpartum depression
e mean value of the EPDS sum score for the entire
sample is M = 7.58 (SD = 5.57), the maximum total score
is 30. Women with a Grade 4 CS achieve the lowest value
(M = 6.31; SD = 5.33). is is followed by the group with
an AVD (M = 7.08, SD = 5.51), followed by women with a
Grade 2 (M = 7.18; SD = 5.31). Women with vaginal deliv-
ery scored M = 7.35 (SD = 5.49), followed by women with
Grade 3 CS (M = 7.82; SD = 5.36). On average, women
with a Grade 1 (M = 10.52; SD = 6.09) achieved the high-
est score.
PTSD
e PCL-5 total mean value of all respondents is
M = 11.84 (SD = 12.10), with a total value of 80 represent-
ing the maximum value. Table2 gives an overview of the
mean values per delivery mode. e lowest mean value
for the Grade 4 group is M = 8.54 (SD = 9.07). For women
with vaginal delivery, this is M = 9.53 (SD = 10.14). Partici-
pants with Grade 3 have a value of M = 11.71 (SD = 11.18),
women with Grade 2 M = 13.08 (SD = 12.22), followed
by the group with an AVD with M = 14.65 (SD = 14.42).
e highest average value was achieved by women with
Grade 1 CS (M = 23.59, SD = 14.80).
Analysis of variance
Delivery modes and postpartum depression
e homogeneity of variance was tested by means of a
Levene’s test, according to which an equality of the vari-
ances could be assumed (p = .327).
A one-way ANOVA was performed. ere was a sta-
tistically signicant dierence in EPDS scores for the
dierent modes of delivery, F(5, 1217) = 6,552, p < .001,
with a small eect (ƞp² = 0.026).
Delivery modes and postpartum PTSD
First, the homogeneity of variance was tested by means of
a Levene’s test. According to this test, no homogeneity of
the variances can be assumed (p < .001).
Subsequently, a one-way ANOVA was carried out here
as well. e severity of PTSD (measured by PCL-5) dif-
fered statistically signicant for the dierent delivery
modes, F(5, 1217) = 28.99, p < .001, ƞp² = 0.11. ere was
a medium to strong eect of ƞp² = 0.11.
Regression analysis
EPDS
In order to explore the inuence of educational level, age,
the need for psychological treatment before childbirth,
fear of childbirth, planning of pregnancy, lack of social
support after childbirth and delivery mode on EPDS-
Score hierarchical multiple regression analyses were
conducted.
In the rst step potential control variables age (β =
− 0.064, p < .05) and educational level (medium: β = 0.132,
p < .001 and low: β = 0.105, p < .001) were entered in the
regression model to assess their inuence on EPDS-
Score. is rst step explained a signicant amount of
variance R² adjusted = 0.031, (p < .001).
Adding the need for psychological treatment
before childbirth (β = − 0.130, p < .001), fear of child-
birth (β = 0.208, p < .001), planning of pregnancy
(β = 0.058, p < .05) and lack of social support after
childbirth (β = 0.135, p < .001) in a second step, the
explained variance increased signicantly (p < .001) to
R² adjusted = 0.122 (meaning 12.2% more variance is
explained).
In a third step, the delivery mode variable was added
(AVD: β = − 0.013, p = .638, Grade 4: β = − 0.020, p = .466,
Grade 3: β = 0.003, p = .904, Grade 2: β = − 0.017, p = .538,
Grade 1: β = 0.121, p < .001). Adjusted R² in the nal
model for EPDS-Score was R² = 0.135 (meaning 13.5%
of variance is explained), thus also declaring a signicant
amount of variance (p < .001).
e R² for the overall model was R² =0.143 (adjusted
R² = 0.135), indicative for a mean goodness-of-t [37].
Accordingly, the nine predictors signicantly predicted
depression (as measured by the EPDS) and were able to
explain 13.5% of the variance.
Nevertheless, the change in R² from step 2 to step
3 amounts to only ΔR² = 0.016, which provides a small
amount of variance resolution despite signicance
(p < .05). See Table3 for a summary of the hierarchical
multiple regression analyses.
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Beck-Hiestermann et al. BMC Pregnancy and Childbirth (2024) 24:118
PCL-5
To investigate the inuence of the variables educational
level, age, the need for psychological treatment before
childbirth, fear of childbirth, lack of social support after
childbirth, delivery mode, induction of labor and birth
debrieng also on the PCL-5-Score, a stepwise hierarchi-
cal multiple regression analysis was performed.
In the rst step potentially confounding variables age
(β = − 0.131, p < .001) and educational level (medium:
β = 0.113, p < .001 and low: β = 0.087, p < .05) were entered
in the regression model. is step explained a signicant
amount of variance R² adjusted = 0.041, (p < .001).
With the addition of the predictors in a second step,
the explained variance increased signicantly to R²
adjusted = 0.119 (meaning 11.9% of variance is explained),
(p < .001). e beta weights of the predictors were as fol-
lows: the need for psychological treatment before child-
birth (β = − 0.090, p = .001), fear of childbirth (β = 0.166,
p < .001), induction of labor (β = 0.066, p = .013), bir th
debrieng (β = 0.067, p = .015) and lack of social support
after childbirth (β = 0.109, p < .001).
In a nal step, the delivery mode variable was added
(AVD: β = 0.132, p < .001, Grade 4: β = 0.011, p = .679,
Grade 3: β = 0.060, p = .027, Grade 2: β = 0.081, p < .05,
Grade 1: β = 0.293, p < .001). is addition signicantly
improved the explained variance to R² adjusted = 0.204,
(p < .001).
e R² for the overall model was R² =0.213 (adjusted
R² = 0.204), indicative for a mean to high goodness-of-t
according [37]. Accordingly, the nine predictors signi-
cantly predicted PTSD (as measured by the PCL-5) and
were able to explain 20.4% of the variance. e change in
R² from step 2 to step 3 amounts to ΔR² = 0.088, suggest-
ing that the delivery mode variable is a meaningful pre-
dictor for the PCL-5-Score.
See Table4 for a summary of the hierarchical multiple
regression analyses.
Discussion
is study investigated the relationship between delivery
modes and postpartum psychiatric symptoms associated
with PPD and PTSD.
It was tested as to whether the delivery mode (sub-
divided into six categories) aects the level of PPD and
PTSD and the impact as a risk factor beyond the com-
mon ones. Descriptive analyses showed that the depres-
sion score (measured by EPDS) was signicantly higher
than reported in the literature. Within the sample,
32.30% achieved a cut-o score ≥ 10, which contrasts with
the number of 10–15% literature-based prevalence [38].
However, it should be noted that in other countries a
higher cut-o value of 12 or 13 is suggested for the EPDS,
potentially impacting the interpretation of our results.
Analysis of variance showed a signicant dierence
between delivery modes with small eect size. However,
delivery modes need to be dierentiated. Post hoc tests
showed that women with Grade 1 (emergency CS) had
the highest depression scores (54.55% above cut-o), but
Grade 2 (secondary CS) and Grade 3 (CS for medical rea-
sons) were also associated with higher depressive scores
(Grade 3: 33.61%, Grade 4: 32.82% above cut-o). Grade
Table 3 EPDS- hierarchical multiple regression analyses
model predictors EPDS
β t R²adj
step 1 .031**
age − .064* -2.184
educational level
medium .132** 4.528
low .105** 3.632
step 2 .122**
age − .048 -1.684
educational level
medium .109** 3.927
low .068* 2.443
psychological
treatment before
childbirth
− .130** -4.783
fear of childbirth .204** 7.648
planning of
pregnancy
.058* 2.084
lack of social sup-
port after childbirth
.130** -4.783
step 3 .135**
age − .052 -1.815
educational level
medium .103** 3.708
low .065* 2.346
psychological
treatment before
childbirth
− .127** -4.675
fear of childbirth .198** 7.290
planning of
pregnancy
.057* 2.045
lack of social sup-
port after childbirth
.132** 4.912
delivery mode***
AVD − .013 -0.471
Grade 4 − .020 -0.730
Grade 3 .003 0.121
Grade 2 − .017 -0.616
Grade 1 .121** 4.409
ΔR² from step 1 to step 2 .093**
ΔR² from step 2 to step 3 .016*
The expla ined variances are repo rted as adjusted R²
**p < .01, *p < .05: signicance of increase in explain ed variance and signica nce
of beta weig hts
***delivery mode: AVD = assisted vaginal delivery (involving the use of vacuum
or forceps to gui de the infant out of the b irth canal), Gra de 4 = caesarean sec tion
(CS) on maternal r equest, Grade 3 = medically in dicated CS, Grade 2 = secondary
CS, Grade 1 = emergency C S
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Beck-Hiestermann et al. BMC Pregnancy and Childbirth (2024) 24:118
1 (emergency CS) arises from a critical situation for both
the mother and child, necessitating an immediate shift
from vaginal birth. ere is no alternative option for the
mother, which can lead to feelings of being abandoned.
Whereas in Grade 2 there is a soft indication and the sec-
ondary CS is one option among others. e mother can
be involved in the decision, although the decision-mak-
ing process can be overwhelming in the extreme situation
of childbirth. At Grade 3, the indication for a CS is made
before the onset of labor. e mother has more time to
mentally prepare for the CS. Nevertheless, not being able
to give birth in the desired mode could lead to higher
rates of depressive symptoms.
88.5% of the subjects expressed a preference for vagi-
nal delivery. Women with desired mode of delivery were
likely to experience themselves as self-ecacious and
therefore had a lower depression score. If women lack
this experience of giving birth in a “natural” (and often
socially idealized) way, they may blame themselves for
not making it and feel feelings of failure or guilt [39],
which in turn is associated with higher depression scores.
is is supported by the ndings of a recent German
study [40], indicating that women who do not undergo
a natural childbirth are more prone to experiencing feel-
ings of guilt and higher depressive symptomatology. Fol-
lowing on from this it seems explainable, that although
AVD is associated with worse delivery experiences [41],
women had no elevated depression levels. Because AVD
it is still a vaginal delivery and could lead to a sense of
pride and therefore be protective. It is also imaginable
that these eects could be due to more dicult attach-
ment, which occurs more frequently after CS [42, 43].
Another possible explanation for the elevated depres-
sion scores in Grade 1 is that the decision to perform an
emergency CS is often made under time pressure, pos-
sibly without the woman’s explicit consent. In addition
to lacking self-ecacy expectations, this delivery mode
is often associated with fear, especially fear for the life
of the child [44]. And this, in turn, is associated with a
higher likelihood of developing PPD. e overall small
eect of the analysis of variance (ƞp² = 0.026) allows for
the interpretation that there are other factors inuenc-
ing the development of PPD. is is also reected in the
regression analysis, in which delivery mode was a signi-
cant predictor, but the variance explained by it was small.
Regarding PTSD (measured with PCL-5), 7.93% of all
women met the cut-o of ≥ 33. is rate is also signi-
cantly higher than the prevalence reported in the litera-
ture, which is 2–6% on average [5, 45]. Nevertheless, it
should be noted that the PCL-5-Scores do not equate
to a conrmed diagnosis. About one third of the sub-
jects (29.29%) with Grade 1 (emergency CS) were above
the cut-o. is could be explained by the life-threaten-
ing nature of emergency CS. e subjectively perceived
threat, the danger of physical integrity for mother and
child as well as the actual injuries that occur in Grade 1
CS correspond to the trauma-criterion. Women with
secondary CS and thus soft indication (Grade 2), on the
other hand, meet the cut-o for PTSD more frequently
than reported prevalences (9.92%), but by far not as
Table 4 PCL-5 - hierarchical multiple regression analyses
model predictors PCL-5
β t R²adj
step 1 .041**
age − .131** -4.511
educational level
medium .113** 3.895
low .087* 3.042
step 2 .125**
age − .121** -4.331
educational level
medium .088* 3.136
low .057* 2.067
psychological
treatment before
childbirth
− .085* -3.140
fear of childbirth .192** 7.046
induction of labor .086* 3.204
birth debrieng 0.55* 1.918
lack of social
support after
childbirth
.115** 4.026
step 3 .204**
age − .135** -5.019
educational level
medium .058* 2.157
low .049 1.860
psychological
treatment before
childbirth
− .090* -3.484
fear of childbirth .166** 6.362
induction of labor .066* 2.498
birth debrieng .067* 2.428
lack of social
support after
childbirth
.109** 3.976
delivery mode***
AVD .132** 4.991
Grade 4 .011 0.414
Grade 3 .060* 2.212
Grade 2 .081* 3.043
Grade 1 .293** 11.087
ΔR² from step 1 to step 2 .081**
ΔR² from step 2 to step 3 .088**
The expla ined variances are repo rted as adjusted R²
**p < .01, *p < .05: signicance of increase in explain ed variance and signica nce
of beta weig hts
***delivery mode: AVD = assisted vaginal delivery (involving the use of vacuum
or forceps to gui de the infant out of the b irth canal), Gra de 4 = caesarean sec tion
(CS) on maternal r equest, Grade 3 = medically in dicated CS, Grade 2 = secondary
CS, Grade 1 = emergency C S
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Page 8 of 11
Beck-Hiestermann et al. BMC Pregnancy and Childbirth (2024) 24:118
frequently as women with emergency CS (Grade 1).
Hence, the latter appears to possess a distinct charac-
teristic in terms of trauma genesis. It stands out from all
other delivery modes due to its emergency nature and the
acute risk it poses to both mother and child.
is conrms by ndings, which revealed the absence
of perceived safety during childbirth as a signicant
predictor of the development of PTSD [46]. Childbirth
inherently represents an exceptionally intense situation,
involving both physical pain and psychological stress.
Also, the time period for the decision to have an emer-
gency CS is usually very short due to the indication. is
is often associated with minimal education of women
about the subsequent procedure and the reasons for a CS
by medical sta [47]. A low level of information provided
to women before or during childbirth can promote a neg-
ative birth experience [41] which, in turn, may serve as a
potential predictor for PTSD.
is explanation is supported by the lower proportion
of women above the cut-o with Grade 3 (medically indi-
cated) of 5.04% and Grade 4 (CS on maternal request),
0%. Both groups have a longer preparation time before
the CS is performed. is is mostly accompanied by
close attention and care by medical professionals during
pregnancy. Consequently, there is no time constraint for
decision making, nor is there a lack of education. ere-
fore, the subjectively perceived safety during childbirth
is probably higher. However, knowledge of the need for
Grade 3 medically indicated CS to avoid endangering
the infant or mother, or explicit desire at Grade 4, may
also strengthen acceptance and reduce mothers’ helpless-
ness and subjective distress. Both would be predictive of
PTSD, and their absence may be protective [48].
AVDs accounted for the second highest percentage
(13.10%), signicantly higher than vaginal births (4.27%),
which may suggest that AVDs are potentially more trau-
matizing than previous research suggests. It can be
assumed that women perceive the use of assistive devices
such as delivery forceps or a suction cup as an unnatural
and drastic intervention in childbirth. Also, these instru-
ments are typically used when the birth is not progress-
ing fast enough or when there is an imminent danger
to the child. Consequently, AVD presumably leads to
trauma-predictive sensations such as lack of subjective
safety, helplessness, or fear for the child and is associated
with an elevated PCL-5 Score [49]. is supports, for
example, the research who found negative delivery expe-
riences, inadequate education, and time pressure in the
expulsion phase of women giving birth via AVD [30, 50].
e signicant dierence between vaginal delivery
and secondary CS can probably be explained (similar to
emergency CS) by the medically indicated termination of
vaginal delivery, the brief decision-making window, and
potential lack of education. Since neither Grade 4 nor
Grade 3 showed a signicant dierence from the second-
ary CS, and they diered in particular by the urgency
time criterion and preparation, could account for the
slightly increased PCL-5 value of women with secondary
CS.
e mean eect of the analysis of variance (ƞp² = 0.11)
shows that the mode of delivery is an important fac-
tor inuencing the development of a PTSD. is is also
conrmed by the results of the regression analysis, in
which mode of delivery alone accounted for 8.8% of the
variance.
Limitations
e study’s reliance on self-report measures limits the
data’s reliability, due to the inability to verify the provided
information. Other associated problems could be social
desirability or the lack of clarity as to whether the ques-
tions were really understood by the participants. Fur-
thermore, the use of PCL-5 as a PTSD measure may be
a limitation, as it was not specically designed for the
postpartum period. For instance, sleep diculties are
included in the PCL-5, which might not be as appropri-
ate or relevant in the postpartum context – where fre-
quent disruptions to sleep are a common reality for most
mothers.
One of the main strengths of this study is the great
number of participants (N = 1223), which increases sta-
tistical power. However, almost half of the participants
did not complete the study, suggesting that the study
was tiring or not engaging and their responses had to
be discarded. Besides limiting the number of responses
available for statistical analysis, this might also create
selection bias through unknown common characteris-
tics of those who did complete the study. For instance,
individuals aected by a postpartum psychiatric disorder
might have a higher completion rate due to heightened
personal interest, potentially introducing bias into the
study results.
On the other hand, those who are experiencing men-
tal distress while responding might avoid active con-
frontation. For example, a key symptom of PTSD is the
avoidance of stimuli, therefore those with strong PTSD
symptoms may be unlikely to take part in a study inves-
tigating their traumatic experience. Future research could
potentially control this by asking participants to explain
their reasons for taking part in the study. 64% of the par-
ticipants were responding after the birth of their rst
child. is may cause a bias, as mothers are more likely to
develop postpartum psychiatric disorders after the rst
child, than after subsequent births [51]. us, results may
be biased and may not necessarily apply to mothers who
have more than one child.
Only 1.1% of the participants had an CS on maternal
request, which limits statistical power. However, this is
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Page 9 of 11
Beck-Hiestermann et al. BMC Pregnancy and Childbirth (2024) 24:118
close to the general rates in the overall German popula-
tion 1.9% of the women gave birth via CS on maternal
request [52], while the literature reports a rate of 2.3%
[53, 54]. e CS rate of this sample is 30.6%, which is
almost congruent with the CS rate in Germany in 2021
(30.9%) [55]. However, the number of AVD diered with
11.9% within the sample compared to 6.1% in the overall
population [56]. Nevertheless, delivery modes should be
represented equally to allow for a better and more con-
clusive comparison. e study categorized four CS types
and two vaginal delivery types, but it did not explore
other interventions during delivery that might impact the
birth experience, such as amniotomy, medication during
labor, etc.
Most of the participants (93.6%) were German. ere-
fore, the results cannot be generalized across dierent
cultures. Consequently, replicating the study across vari-
ous cultural contexts would provide a more comprehen-
sive understanding.
e cross-sectional design does not allow for causality
between higher symptom levels and the delivery mode
to be examined and established. erefore, it would be
benecial to investigate the development of postpartum
mental health within a longitudinal design. Again, it is
important to note that the study design means that sub-
jects above the specied cut o values are not equated
with conrmed diagnoses. e high number of partici-
pants due to the anonymous online format comes at the
expense of not having the mothers physically seen by
trained health professionals, leading to diagnoses that
are not medically conrmed. Moreover, postpartum
psychiatric disorders have been shown to decrease over
time, which can only be taken into account in a longitu-
dinal study. For example, PTSD symptoms decrease over
time and only a minority of mothers fail to recover [5].
In this study, the deliveries occurred anywhere between
four weeks to 12 months prior to the study. e period
of time between the delivery and the study may inuence
the results.
Moreover, other factors unrelated to the delivery also
ought to be considered. For instance, research has shown
that women who experienced trauma in their past are
more likely to develop PTSD [57]. erefore, it cannot
be conclusively stated that a particular mode of delivery
is traumatic per se, but rather that one mode of deliv-
ery, such as emergency CS, may have a higher traumatic
potential, other factors also contribute to the overall
experience.
Implications
e categorization of birth mode plays an important
role in understanding the nuanced impact on maternal
mental health. Our study delved into a more compre-
hensive classication by expanding the conventional
four-category division of birth modes into a more
detailed six-category framework. By subdividing the
delivery modes, we gained a deeper insight into the
divergent psychological implications of each mode. is
nuanced approach acknowledges the distinct physiologi-
cal, psychological, and emotional facets inherent the dif-
ferent modes, enabling a more precise analysis of their
respective impacts on postpartum psychological well-
being. We therefore recommend that this subdivision be
used in this form in future studies. is could also help to
explain previous inconsistencies in the research.
is study therefore oers a new explanation as to why
the type of delivery has an impact on the development of
PPD and PTSD. is has far-reaching implications. e
study suggests that apart from medical requirements, the
focus should be directed towards a mother’s preference,
with a particular emphasis on maternal mental health,
especially post-delivery.
Relative to vaginal delivery, almost every delivery mode
except for CS on maternal request seems to increase
the risk of PTSD. It is therefore important to carefully
consider when a CS should be performed. While it can
be essential and lifesaving, it should not be undertaken
without thorough consideration. An increase in CS
rates before holidays or the weekend due to sta short-
ages, convenience, or nancial considerations [58] is not
acceptable. Implementation should always include a risk-
benet consideration.
Several years ago, the WHO advised a permissible CS
rate of 19.1% beyond which there were no demonstrated
benets in reducing maternal and neonatal mortality
and morbidity compared to standard vaginal delivery
[59]. With a CS rate of about 30.2% Germany is above
the recommendation, which may imply that not all CS
are necessary. However, the World Health Organiza-
tion has undergone a signicant shift in its recommen-
dations, moving away from specic target rates. Instead,
it now emphasizes addressing the individual needs of
each woman during pregnancy and childbirth, suggest-
ing non-clinical measures to reduce the unnecessary use
of CS while highlighting the importance of maintain-
ing high-quality and respectful care. ese include, for
example: Implementing educational interventions for
active women involvement in birth planning, following
evidence-based clinical guidelines with routine audits of
CS practices, requiring a second medical opinion where
feasible, and adopting a collaborative midwifery-obstetri-
cian model of care [60].
It is essential to enhance the nancial support for vagi-
nal deliveries. Without such improvement, incorrect
incentives may be established, potentially compromis-
ing the ability to make an unbiased decision regarding
a potential CS. Also, this decision should not be made
solely on the basis of sta shortage or time pressure on
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Page 10 of 11
Beck-Hiestermann et al. BMC Pregnancy and Childbirth (2024) 24:118
the part of the hospital team but should always be based
on medical necessity and especially on the preferences
of the woman, since the subjective birth experience has
the greatest inuence on the development of PTSD after
delivery [19].
Routine screening for PPD and PTSD symptoms in
mothers in the rst postpartum year may lead to earlier
intervention and possibly prevent further mental health
impairment. As secondary CS were shown to increase
the risk of PPD, one could argue that after a second-
ary CS mothers should also be checked for symptoms
of depression. However, as there is no research yet to
explain why dierent types of CS have dierent eects,
routine screening should be performed in general. Future
research could investigate which aspects of the dier-
ent delivery modes impact maternal mental health and
explore how the perception of birth may be inuenced by
a specic delivery mode.
Author contributions
FMLBH, KH and NR conceived and designed the study. KH and NR designed
the questionnaire and conducted the data acquisition. FMLBH conducted the
analysis and wrote the manuscript. SM reviewed and revised the work. SWG
was the project manager of the research project. All authors reviewed and
approved the nal manuscript prior to submission.
Funding
No funding was received for conducting this study.
Open Access funding enabled and organized by Projekt DEAL.
Data availability
The datasets analyzed during the current study are not publicly available
because longitudinal data was collected within the framework of the
project, which is currently still being evaluated, but are available from the
corresponding author on reasonable request.
Declarations
Ethics approval and consent to participate
Informed consent was obtained from all subjects. The study questionnaire was
submitted to the Ethics Committee of the Medical School Hamburg, which
decided that no ethics vote was required.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Author details
1Department of Psychology, Medical School Hamburg, Hamburg,
Germany
2Department of Psychosomatic Medicine and Psychotherapy,
Psychologische Hochschule Berlin, Berlin, Germany
3Clinic of Psychiatry, Socialpsychiatry and Psychotherapy, Hannover
Medical School, Hannover, Germany
4Institute for Clinical Psychology and Psychotherapy, Medical School
Hamburg, Hamburg, Germany
5Department of Child and Adolescent Psychiatry and Psychotherapy,
University Medical Center Hamburg-Eppendorf, Hamburg, Germany
Received: 20 October 2023 / Accepted: 11 January 2024
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