Depression and anxiety have the potential to impact the birthing process [1, 2, 3]. Many women experience symptoms of depression and anxiety prior to giving birth, and these symptoms can influence the decisions made by both mothers and healthcare providers during shared decision-making [1]. These symptoms could potentially result in a preference for a briefer labor or a feeling of inadequacy regarding the birthing process.

The World Health Organization (WHO) recommends screening for postpartum depression and anxiety as part of their guidelines on maternal and newborn care [4]. While efforts to address depression and anxiety have primarily focused on interventions during childbirth, such as immediate skin-to-skin care, there is a lack of strategies targeting the prevention and identification of these symptoms in the weeks leading up to birth [5, 6, 7].

Our study aimed to assess whether women who experience symptoms of peripartum depression or anxiety during the week preceding childbirth face an increased risk of undergoing an unplanned medical intervention, such as an unplanned cesarean section or operative vaginal birth.

Between January 2021 and February 2022, 201 eligible women participated in the study. Out of the 201 participants, 193 were European, 6 African American, and 2 Asian. They were admitted at different daytimes, 94 (46.8%) were admitted during the night, and 107 (53.2%) during the day. There were 56 (27.9%) cesarean births (48 primary cesarean births, and 8 secondary cesarean births), and 23 (11.4%) operative vaginal births (7 forceps, 15 vacuum, and 1 Thierry’s spatula assisted births). Labor started spontaneously in 128 (63.7%) women, labor induction was indicated in 60 (29.9%) women, and scheduled cesarean birth was indicated in 13 (6.5%) women. 66 (32.8%) births ended in unplanned cesarean or operative vaginal birth (43 (21.4%) cesarean and 23 (11.4%) operative vaginal births). 39 (90.7%) of the 43 unplanned cesarean births were performed after a failed trial of labor. The VAS score was 3 (2; 5).

Group 1 included 37 women (18.4%) experiencing depression symptoms during the peripartum period, of which 4 (10.8%) individuals out of this group presented severe depression symptoms. In contrast, group 2 included 164 women (81.6%) without depression symptoms within the previous 7 days. There were differences between group 1 and group 2 regarding the rate of unplanned medical interventions, previous cesarean births, prematurity, ART, awareness of possible baby admission, baby admissions, anxiety symptoms, and Apgar scores. There was no statistically significant difference in pain between the two groups based on the VAS results (Table 1).

None of the women had comorbidities that would determine the birth method, except for one case of genital herpes in the group without peripartum depression symptoms, which was the cause of an unplanned cesarean birth. Regarding complications during pregnancy, there were 9 (4.5%) women with gestational diabetes, 8 (4.9%) in the group without peripartum depression symptoms, and 1 (2.7%) in the group with peripartum depression symptoms (p = 1). 12 (6.0%) women had preeclampsia, 10 (6.1%) in group 2, and 2 (5.4%) in group 1 (p = 1). 3 babies (1.5%) were impacted by intrauterine growth restriction, 2 (1.2%) of which in group 2, and 1 (2.7%) in group 1 (p = 0.1612). There was 1 woman with intrahepatic cholestasis in the group without peripartum depression symptoms.

Regarding nutrition, all women followed an omnivorous diet, except for 1 vegetarian woman in the group without peripartum depression symptoms. All women followed the same analgesia protocol in the postpartum ward, based on paracetamol and ibuprofen or paracetamol and dexketoprofen.

Binary logistic regression revealed that peripartum depression symptoms were independently associated with a higher probability of unplanned cesarean or operative birth (odds ratio (OR), 3.263; 95% confidence interval (95% CI), 1.125–9.463) (Table 2).

Regarding anxiety symptoms, 86 (42.8%) women reported the symptoms, 11 (12.8%) of which reported severe symptoms (HADS-A). There were statistically significant differences between the women who had peripartum anxiety symptoms and those without symptoms in various aspects, including the rate of unplanned medical interventions (37 vs. 29, p = 0.008), maternal age (36.0 (32.0; 38.0) vs. 34.0 (30.0; 37.0), p = 0.016), rate of previous cesarean births (8 vs. 2, p = 0.020) , awareness of possible baby admission (14 vs. 8, p = 0.036), and baby admissions (17 vs. 10, p = 0.023) (Table 3).

In our study, women experiencing peripartum symptoms of depression were more likely to undergo unplanned medical interventions, such as unplanned cesarean or operative vaginal births. These depressive symptoms could have potentially impacted shared decision-making, leading to a decrease in both the quality and occurrence of joint decisions [14].

Women’s psychological symptoms can have an impact on shared decisiveness. Women experiencing depression and anxiety symptoms are more likely to have an unexpected delivery method. It is possible that these symptoms may lead to a desire for a shorter birth, or a perception of inadequacy for the birthing process. Previous studies have shown that unexpected medical interventions during birth can result in a poorer perception of respect, adequate care, and overall satisfaction [15, 16]. These negative birth experiences may increase the likelihood of postpartum depression, opting not to breastfeed, and limited mother-infant bonding [16, 17, 18, 19, 20]. Family-centered care, including careful decisions by healthcare providers and the mothers, is considered of utmost importance for a satisfying birth experience [21, 22]. Decision-making is most noticeably experienced when the birth proceeds as planned [23]. In our center, midwives provide care for laboring women, and obstetricians intervene when medical decisions, such as unplanned cesarean or operative births, need to be evaluated. Despite the undeniable importance of shared decision-making, the consequences of inadequate decision-making can be detrimental, including the potential worsening of preexisting symptoms. Moreover, it may contribute to an increased number of cesarean and operative births.

The period of childbirth is inherently sensitive and vulnerable. Anxiety, along with stress, depression, and fear, can profoundly impact a woman’s psychological well-being during this time [24]. It requires delicately balancing a woman’s right to self-determination with the necessity to consider medical intervention autonomously. In the specific context of anxiety, it can significantly alter a woman’s perception of pain during obstetric procedures, potentially increasing the inclination towards opting for a caesarean birth [13, 24]. Anxiety may heighten the anticipation of pain, making the prospect of a surgical procedure like a caesarean birth appear more appealing, as it offers a perceived sense of control and predictability over the birthing process.

Depression and anxiety are of multifactorial origin in the context of birth [16, 18, 25, 26, 27]. Among others, inadequate childbirth education and unexpected events play an important role [28]. Childbirth education emphasizes potential birth scenarios and equips women and companions with coping skills to navigate unexpected situations during birth. In our study, as the recruitment was consecutive, we found that 18.4% of the women suffered depression symptoms, and 42.8% women suffered anxiety symptoms close to birth. Women with psychological symptoms documented in their medical records were excluded from our study. However, it is conceivable that a considerable portion of these women may have experienced subthreshold symptoms during pregnancy. These subthreshold symptoms might not meet the criteria for a clinical diagnosis but hold significant importance as they are known to serve as indicators for identifying women susceptible to peripartum depression [29]. We believe that during childbirth education, many of these subthreshold symptoms, like panic, social anxiety, or eating-related issues can be discussed and prevented.

We did not find an increase in pain perception in women with peripartum depression or anxiety in our study. Regarding how pain was measured, the VAS is a subjective method that does not assess pain’s evolution over time [10]. We believe that the fact that women who were admitted to the reanimation or ICU for more than 6 hours after birth were excluded from the study may have influenced the results. This exclusion criterion meant that women who required general anesthesia or who had problems during anesthesia were excluded from the study, which are known risk factors for postpartum pain [13, 30]. Furthermore, in our center, the protocol is to start early ambulation, provide a suitable diet, offer education about the newborn within the initial 6 to 8 hours following a cesarean birth, and as soon as feasible after a vaginal birth. Therefore, collecting the VAS scores for pain after 12 hours implies that all women were in a similar recovery situation.

Women who were aware of the neonates’ admission to the NICU by the neonatologist were more likely to have experienced peripartum depression and anxiety symptoms. However, binary logistic regression showed that this was not an independent risk factor. We believe that our findings may be attributed to the fact that the neonatology department in our center has been actively involved in communication training through medical simulations for several years. Effective communication has demonstrated to enhance the experience of parents [31]. In addition, the NICU in our center is open 24 hours a day for the parents. Other studies have linked neonatal outcomes with an increased risk of postpartum depression or anxiety. However, there are no studies about depression or anxiety symptoms close to birth [32].

The main strength of our study is that it reflects the actual population that is cared for in the postpartum wards. The percentages of cesarean births, operative vaginal births, and prematurity coincide with those observed in our center. In addition, as the assessment was performed 12 hours after birth, we can assume that the intervention did not interfere with the results. It is an opportune moment to gather information about the experience and emotions surrounding childbirth, without unduly influencing its various stages.

The primary limitation of our study was the absence of a psychological prenatal assessment. Currently, routine psychological evaluations are not provided to pregnant women in our center. Certainly, if a psychological assessment had been conducted, some women might have received treatment, potentially influencing various obstetric outcomes, including the mode of delivery [33]. After the study, all women received postpartum care at their healthcare facility; we were not authorized to access their medical records outside the hospital setting.

Maternal symptoms of depression during the peripartum period, specifically close to birth, are independently related to a greater probability of unplanned medical interventions, either unplanned cesarean or operative vaginal birth. Proper communication by obstetricians, adequate childbirth education, or a psychological prenatal assessment could improve these results. More studies are needed to assess possible interventions.

HADS, hospital anxiety and depression scale; VAS, visual analog scale; ART, assisted reproduction techniques.

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

MJR and MJC: protocol/project development, data analysis, manuscript writing. MAP: data collection, manuscript editing. CV: data analysis; manuscript writing/editing. SF: validation of data analysis; manuscript reviewing and editing. JLB: protocol/project development, validation of data analysis, manuscript reviewing and editing. All authors contributed to editorial changes in the manuscript. All authors read and approved the final manuscript. All authors have participated sufficiently in the work and agreed to be accountable for all aspects of the work.

All subjects gave their informed consent for inclusion before they participated in the study. The study was conducted in accordance with the Declaration of Helsinki, and the protocol was approved by the Ethics Committee of Hospital Universitario La Paz, Madrid (approval number: PI-4518).

Special thanks to Mia Smith for providing proofreading and English editing services for the manuscript. Thanks to all the peer reviewers for their opinions and suggestions.

This research received no external funding.

The authors declare no conflict of interest.