Association of General Anesthesia for Cesarean Delivery with Postpartum Depression and Suicidality

BACKGROUND: Compared to neuraxial anesthesia, general anesthesia (GA) for cesarean delivery is associated with an increased risk of postpartum depression (PPD) requiring hospitalization. However, obstetric complications occurring during childbirth (eg, stillbirth) are associated with both increased use of GA and increased risk of PPD, and may account for the reported association between GA and PPD. This study assessed the association of GA for cesarean delivery with PPD requiring hospitalization, outpatient visit, or emergency department (ED) visit, accounting for obstetric complications. METHODS: This retrospective cohort study included women who underwent a cesarean delivery in New York State between January 2009 and December 2017. Women were followed for 1 year after discharge for readmission, outpatient visit, or ED visit. The primary outcome was PPD requiring readmission, outpatient visit, or ED visit. The 2 secondary outcomes were (1) PPD requiring readmission, and (2) suicidality. Obstetric complications included severe maternal morbidity, blood transfusion, postpartum hemorrhage, preterm birth, and stillbirth. Adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs) of PPD, PPD requiring readmission, and suicidality associated with GA were estimated using the propensity score matching and the overlap propensity score weighting methods. RESULTS: Of the 325,840 women included, 19,513 received GA (6.0%; 95% CI, 5.9–6.1). Complications occurred in 43,432 women (13.3%) and the GA rate for these women was 9.7% (95% CI, 9.4–10.0). The incidence rate of PPD was 12.8 per 1000 person-years, with 24.5% requiring hospital readmission, and was higher when an obstetric complication occurred (17.1 per 1000 person-years). After matching, the incidence rate of PPD was 15.5 per 1000 person-years for women who received neuraxial anesthesia and 17.5 per 1000 person-years for women who received GA, yielding an aHR of 1.12 (95% CI, 0.97–1.30). Use of GA was associated with a 38% increased risk of PPD requiring hospitalization (aHR: 1.38; 95% CI, 1.07–1.77) and with a 45% increased risk of suicidality (aHR 1.45; 95% CI, 1.02–2.05). Results were consistent when using the overlap propensity score weighting. CONCLUSIONS: Use of GA for cesarean delivery is independently associated with a significantly increased risk of PPD requiring hospitalization and suicidality. It underscores the need to avoid using GA whenever appropriate and to address the potential mental health issues of patients after GA use, specifically by screening for PPD and providing referrals to accessible mental health providers as needed.