RCoA response to the 'Exposure to General Anesthesia for cesarean delivery and odds of severe postpartum depression requiring hospitalization' paper published in the journal of Anesthesia and Analgesia

Dr David Bogod, Consultant Anaesthetist and Council member at the Royal College of Anaesthetists said:

"The ‘Exposure to General Anesthesia for cesarean delivery and odds of severe postpartum depression requiring hospitalization’ paper has generated inaccurate media reporting. The paper is a large retrospective cohort study of patients undergoing caesarean section in New York State between 2006 and 2013.  As such, it is unable to determine causation as opposed to correlation, and the authors make this clear throughout the paper.

“It shows that general anaesthesia is associated with a 54% increased odds of postpartum depression and a 91% increased odds of suicidal ideation or self-inflicted injury. The authors point out that emergency versus elective is, in this study, an "unmeasured confounder" and cite evidence that "emergent cesarean delivery and adverse neonatal outcomes may constitute a traumatic childbirth experience, which has been associated with the subsequent development of mood disorders". A useful statistic indicates that any link between general anaesthesia and depression would be explained away if:

• emergency Caesarean delivery increases the risk of depression by at least 70%; or
• emergency Caesarean section is at least 70% more prevalent among general anaesthesia than among neuraxial anaesthesia [sic].  

“The authors go on to state: "Either association is clinically plausible". Indeed, a nationwide UK study published in 2010 shows that general anaesthesia was used for 51% of the most urgent (Category one ) Caesarean sections, and only 4% of the least urgent (Category four or elective) Caesarean sections (Anaesthesia 2010; 65: 362-368). The authors did not cite this critical paper in their discussion section.

“Unfortunately, this very obvious explanation of the findings, essentially that general anaesthesia is a marker for emergency Caesarean section and that emergency Caesarean section is a powerful predictor of postnatal depression, has been lost in the fog of media reporting, and also fails to come across in the presumably selective quotes from interviews with the authors.  The College has made firm representations to the relevant media organisations about the potential harm that this irresponsible reporting could cause mothers and babies in an emergency situation where there is no luxury of time to explain why they have been misled."