Influence of Neuraxial Anesthesia Technique During Vaginal and Cesarean Delivery and Association with Postpartum Depression: A Narrative Review of Literature

Abstract

Postpartum depression (PPD) is a prevalent mood disorder affecting 10–20% of women and represents a major contributor to maternal and infant morbidity. Labor pain, delivery mode, and anesthetic technique have been proposed as potential modifiers of postpartum psychological outcomes. Neuraxial anesthesia including epidural, spinal, and combined spinal–epidural techniques is the standard of care for labor analgesia and cesarean delivery, yet its association with PPD remains incompletely defined. This narrative review synthesizes current evidence evaluating the relationship between neuraxial anesthesia and dural puncture epidural (DPE) during vaginal and cesarean delivery and subsequent risk of postpartum depression. Across observational studies, cohort analyses, systematic reviews, and meta-analyses, neuraxial anesthesia does not appear to increase the risk of PPD at the population level. Many studies demonstrate a neutral association, while select analyses suggest modest protective effects, particularly among women experiencing severe labor pain or high intrapartum stress. Proposed mechanisms include attenuation of physiologic stress responses, improved pain control, and enhanced maternal satisfaction. These effects, however, are inconsistent across patient populations, and neuraxial anesthesia does not independently prevent PPD. In contrast, general anesthesia for cesarean delivery is consistently associated with higher rates of severe postpartum depression. Overall, postpartum depression is multifactorial condition in which anesthetic technique functions as a modifying rather than determining factor. Optimizing intrapartum pain management, minimizing unnecessary general anesthesia exposure, and implementing systematic postpartum mental health screening are essential components of comprehensive perinatal care.

Introduction

Pain management during childbirth is a critical aspect of obstetric care and plays a central role in shaping maternal experiences and outcomes.^1,2 Labor pain is among the most intense forms of pain experienced in a woman’s life and can produce significant physiological and psychological stress.^3,4 Over time, advances in obstetric anesthesia have transformed pain control during labor and delivery, contributing to improved maternal satisfaction and safety.^5,6

Neuraxial anesthesia, which includes epidural, spinal, and combined spinal–epidural techniques, is now considered the gold standard for intrapartum analgesia and anesthesia.⁵ These methods provide effective pain relief while allowing the mother to remain awake and participate in the birthing process.⁷ In cesarean delivery, neuraxial anesthesia has largely replaced general anesthesia because of its favorable safety profile for both mother and infant, reduced risk of aspiration, failed airway mask ventilation and endotracheal intubation, and lower rates of neonatal respiratory depression.⁸

As maternal comfort and safety have improved with modern anesthetic practices, increasing attention has turned toward the psychological and emotional health of mothers in the postpartum period. Postpartum depression (PPD) is a common mood disorder occurring within the first year after childbirth, with reported prevalence rates ranging from 10–20% globally, depending on population and timing of assessment.^9,10 It is characterized by persistent sadness, loss of interest, feelings of guilt or worthlessness, and in severe cases, thoughts of self-harm. PPD not only affects maternal well-being but also has long-term implications for infant development, bonding, and family health.⁴

PPD is typically assessed using validated screening tools such as the Edinburgh Postnatal Depression Scale (EPDS) and Patient Health Questionnaire (PHQ-9), with most studies evaluating symptoms between 4 weeks and 12 months postpartum. However, variability in the timing of assessment contributes to differences in reported prevalence, as early screening may capture transient “baby blues” rather than sustained depressive disorders. Current estimates suggest that PPD affects approximately 10–20% of women globally, with U.S.-based studies reporting rates of approximately 1 in 8 women within the first year postpartum.

The development of PPD is multifactorial, influenced by biological, psychological, and social determinants.^11,12 Hormonal fluctuations following delivery, particularly changes in estrogen and progesterone, have been implicated in mood regulation.¹³ In addition, activation of the hypothalamic–pituitary–adrenal (HPA) axis, inflammatory cytokine release, and disruptions in sleep and circadian rhythms may contribute to depressive symptoms.¹⁴ Psychosocial stressors such as lack of support, prior psychiatric history, and negative childbirth experiences further increase the risk of developing PPD.¹¹

Given these complex interactions, the experience of labor pain and its management have been proposed as possible contributors to postpartum mood outcomes. Severe or inadequately controlled pain during childbirth can increase maternal stress, elevate circulating stress hormones, and negatively influence the perception of the birth experience.¹⁵ Conversely, effective pain relief through neuraxial anesthesia may reduce physiological stress responses and improve maternal satisfaction.^15,16 These effects have led to growing interest in whether the use of neuraxial anesthesia during vaginal or cesarean delivery may influence the subsequent risk of PPD.¹⁶

Understanding this potential association is important for optimizing both the physical and mental health of postpartum patients. Exploring how anesthetic techniques interact with maternal psychological outcomes may help guide future clinical practice and identify opportunities for comprehensive perinatal care that addresses both pain management and emotional well-being.

To provide context for this narrative review, a targeted literature search was conducted using electronic databases including PubMed, Embase, and Google Scholar. Search terms included combinations of “postpartum depression,” “labor analgesia,” “epidural anesthesia,” “regional anesthesia,” and “labor pain.” Articles published between 2000 and 2025 were considered. Studies were selected based on relevance to the association between regional anesthesia during labor and the risk of postpartum depression, including observational studies, randomized controlled trials, and meta-analyses. Case reports and studies not directly addressing this relationship were excluded. As this is a narrative review, a formal systematic quality assessment was not performed; however, emphasis was placed on higher-quality evidence, including large cohort studies and meta-analyses.

Importantly, the relationship between anesthetic technique and postpartum depression is subject to significant confounding, including preexisting psychiatric history, severity of labor pain, and delivery characteristics such as emergency versus elective cesarean section. These factors may influence both the choice of anesthesia and the risk of postpartum depression, complicating interpretation of observed associations.

Neuraxial Anesthesia and Its Associations with Postpartum Depression

Neuraxial anesthesia is the most effective form of intrapartum analgesia and is commonly used for labor and delivery.¹ Four primary neuraxial techniques: epidural analgesia, spinal analgesia, Dural Puncture Epidural (DPE) and combined spinal-epidural (CSE) anesthesia all serve to block nociceptive transmission while maintaining maternal consciousness and participation in childbirth.¹⁷

Epidural analgesia is achieved through placement of a catheter into the lumbar epidural space, typically at the L3-L4 or L4-L5 space, allowing for continuous infusion alone or patient controlled analgesia with a continuous infusion and programmed bolus dose with lockout.^18,19 This method allows for titratable dosing throughout labor, with an onset occurring within 15–20 minutes.²⁰ Epidural analgesia is the most common neuraxial modality and is associated with substantial reductions in labor pain, improved maternal satisfaction, and attenuation of maternal and neonatal physiologic stress responses associated with childbirth.^3,21,22

Spinal anesthesia involves a single injection of anesthetic directly into the lumbar intrathecal space, allowing for a rapid onset of dense sensory and motor blockade.^23,24 Local anesthetic choices for spinal anesthesia by the obstetrician may include lidocaine, procaine, tetracaine, ropivacaine, and bupivacaine.²⁴ Related to efficacy and limited duration, spinal anesthesia is commonly used for cesarean deliveries.⁷

Combined spinal-epidural (CSE) anesthesia is a combination technique that takes advantage of the continuous dosing from epidural analgesia and the rapid onset of spinal anesthesia.²⁵ A low dose intrathecal injection provides near-immediate pain relief, while the epidural catheter enables continuous dosing for the remainder of labor.²⁵ This method is particularly useful in advanced labor, cases of early recovery of the neuraxial block, caesarean section, or when initial pain scores are high to provide rapid analgesia.^26,27

Dural Puncture Epidural (DPE) technique is a modification of the CSE technique, where the dura is perforated without administration of intrathecal drugs.²⁸ The perforation increases sacral spread and bilateral pain relief when compared to a standard epidural.²⁹ DPE provides rapid onset and superior sacral coverage when compared to traditional epidural analgesia, while maintaining a lower side-effect profile when compared to CSE.²⁸ Additionally, when compared to traditional epidural analgesia DPE effectively reduces the incidence of asymmetric blocks.²⁸

In contrast to neuraxial anesthesia, local anesthesia involves direct infiltration of anesthetic into tissue to block peripheral nerve endings and is commonly used for perineal repair, episiotomy, and minor obstetric procedures.^30–32 Local anesthesia provides targeted procedural pain control but is not commonly used to manage the visceral pain associated with labor. As a result, local anesthesia alone is unlikely to provide meaningful protection against PPD. General anesthesia induces unconsciousness and is now reserved primarily for emergent/STAT cesarean deliveries when neuraxial anesthesia is contraindicated, unavailable or when there is not enough time for neuraxial anesthesia to provide an adequate block.^33,34 General anesthesia has been associated with higher postoperative pain and increased risk of PPD compared with neuraxial anesthesia.^35,36

Across delivery modes, the relationship between neuraxial anesthesia and postpartum depression (PPD) appears complex but is best characterized as neutral at the population level, with potential protective effects in select clinical contexts has been described as either protective or neutral at various amounts of time postpartum across many studies.^37–51 A meta-analysis including over 86,000 participants, as well as multiple prospective cohort studies have observed significantly decreased rates of PPD in patients who underwent neuraxial labor analgesia compared to patients who did not, with difference seen as long as 2 years postpartum.^37,42,43 The reduction of severe intrapartum pain, and improvement in perceived control and childbirth satisfaction are recognized contributors to postpartum psychological well-being and may mitigate known risk factors for PPD, such as traumatic birth experiences and poorly controlled labor pain.^4,52

Importantly, some current evidence, including meta-analysis and prospective studies, does not support a direct relationship between neuraxial anesthesia and protection against postpartum depression.^46–49 However, evidence suggests that any neuraxial anesthesia in not uniform across all patients. Some studies demonstrate no significant association between neuraxial anesthesia and PPD, suggesting that analgesia alone may not independently influence postpartum mood when broader psychosocial factors dominate.^46,53 Notably, one historical cohort found an increased risk of PPD associated with neuraxial analgesia during labor, and one meta-analysis found that neuraxial analgesia was a possible risk factor for PPD in a low prevalence subgroup.^16,54 Taken together, neuraxial anesthesia appears to function as a modifying factor within a multifactorial risk framework, rather than as an independent preventive or causative determinant of postpartum depression.¹⁶ See Table 1.

Table 1.

Comparison of Anesthetic Techniques, Assessment Timing, and Reported Risk of PPD Across Select Studies

Study Author (Year)	Participants (N)	Study Design and Methods	Assessment Timing	Relationship	Key Findings and Additional Information
Ding et al (2014)37	214	Prospective Cohort; Edinburgh Postnatal Depression Scale (EDPS) ≥ 10 cutoff.	6 Weeks	Positive (Protective)	14% PPD with epidural labor analgesia vs 34.6% without
Sun et al (2020)38	423	Multicenter Prospective (Trial of Labor after cesarean) population); EPDS ≥ 10 cutoff.	42 Days	Positive (Protective)	Incidence significantly lower in epidural analgesia group (6.59%) vs in no epidural analgesia group (25.16%)
Suhitharan et al (2016)39	479	Case-Control study; EPDS ≥ 10 cutoff.	4–8 Weeks	Positive (Protective)	Odds of PPD with epidural anesthesia (10%), was significantly lower than in those with nonepidural analgesia (19.3%)
Lim et al (2018)40	201	Retrospective Observational. EPDS ≥ 10 cutoff.	6 Weeks	Positive (Protective)	Correlation between percentage improvement in pain (PIP) and lower EPDS scores (P = 0.002).
Hiltunen et al (2004)41	185 at 1 Week, 162 at 4 months	Prospective Follow-up; EPDS ≥ 13 cutoff.	1 Week, 4 Months	Positive (Protective) at 1 Week, No significant difference at 4 Months	Significant reduction in risk during the first postnatal week (Odds ratio = 0.25); no effect at 4 months.
Liu et al (2019)42	508	Multicenter, prospective, longitudinal cohort.	2 Years	Positive (Protective)	Neuraxial labor analgesia associated with lower depression rates (7.3%) at 2 years compared to those without (13.6%), corrected for confounding variables.
Li et al (2023)43	86,231	Systematic Review/Meta-analysis of 14 studies.	Variable	Positive (Protective)	Risk ratio = 0.75 for long-term and 0.55 for short-term incidence (1 week).
Wu et al (2018)44	40,303	Population-based, matched cohort; focus on medical visits.	1 Year	Neutral	No association with physician/hospital visits for depression or self-harm.
Eckerdal et al (2020)45	1,503	Longitudinal cohort; multivariable logistic regression.	6 Weeks	Neutral	No association after adjusting for fear of birth and antenatal symptoms (adjusted Odds ratio = 1.22).
Almeida et al (2020)46	4,442	Meta-analysis of 9 studies.	3 Months	Neutral	Odds ratio = 1.02; 95% CI, 0.62–1.66 (P = 0.94).
Kountanis et al (2020)47	85,928	Meta-analysis of 11 studies.	Variable	Neutral	Pooled adjusted OR = 1.03; 95% CI, 0.77–1.37.
Zheng et al (2025)48	146	Prospective observation and Mendelian randomization; EPDS ≥ 13 cutoff.	6 Weeks	Neutral	No significant difference in incidence of PPD at 6 weeks between epidural and non-epidural groups (P=0.219)
Nahirney et al (2017)49	206	Prospective; adjusted for selection bias.	6 Weeks, 6 Months	Neutral	Crude OR 0.86; adjusted OR 1.04; no observed association between epidural use and PPD
Tobin et al (2017)50	65	Prospective secondary analysis; Fisher’s exact test. EPDS ≥ 10 cutoff.	6–8 Weeks	Neutral	24% epidural labor analgesia group developed PPD vs 6.7% non-epidural labor analgesia group (P=0.27).
Ghanbari-Homaie et al (2024)51	12,064	Meta-analysis of 31 studies.	Up to 24 Months	Neutral	Mean Difference = 0.01; concluded neuraxial labor analgesia has no observed protective effect on PPD or PTSD.
Wang et al (2022)16	8758	Meta-analysis of 19 studies	Variable	Mixed	Neuraxial analgesia was protective (Odds ratio =0.61) in the subgroup with high prevalence of PPD (>14%), but also appeared to be a risk factor (Odds ratio = 1.56) in the low prevalence subgroup
Jin et al (2023)54	35,437	Historical cohort study, PPD rates were identified using perinatal records during second pregnancy.	Variable	Negative	Labor epidural analgesia was associated with increased odds of developing PPD when compared to not received labor epidural analgesia; adjusted odds ratio =1.29, 95% CI

Influence of Delivery Mode on Anesthesia and Postpartum Depression

When developing a birth plan, most women express a strong preference for vaginal delivery. In a cohort of 240 participants, over 90% stated a preference for vaginal delivery, even when informed of a 60–75% chance of requiring an unplanned cesarean delivery.⁵⁵ However, among this same cohort, their preferences in interventions to increase the likelihood of a vaginal delivery over a cesarean section varied substantially, indicating a necessity to educate patients on the complications and risks associated with delivery as a whole.⁵⁵

Vaginal and cesarean deliveries differ considerably in terms of management, anesthesia usage, postoperative care, and stress. By 2007, cesarean deliveries accounted for 31.8% of all live births—a large number considering the increased risk associated with necessary procedural anesthesia.⁵⁶ Neuraxial anesthesia is considered the gold standard technique for cesarean delivery, and patient-reported pain is more common with general anesthesia compared to spinal or combined spinal-epidural anesthesia.⁵⁷ This association may be partially explained by evidence demonstrating that women who underwent cesarean delivery under general anesthesia had a higher risk of PPD within 90 days than those who underwent neuraxial anesthesia.⁵⁸

In comparison, vaginal delivery accounts for the remaining 68.2% of deliveries, and epidural anesthesia is a well-established procedure used in almost every delivery room. Epidural anesthesia is offered as a safe option for pain relief without increasing morbidity and mortality; however, a 2023 review summarizing Cochrane and other meta‑analyses notes epidurals may extend the first stage by about 30 minutes and the second stage by about 15 minutes.^59,60 While these anesthesia methodologies are common in obstetrics, their specific relationship with PPD remains an area of ongoing investigation.

PPD is one of the most common postpartum diseases, and it has a strong impact on maternal functioning and family dynamics.⁶¹ Several studies indicate that mode of delivery may influence PPD risk. While findings can be controversial, recent meta-analyses show that women who give birth by cesarean section—especially emergency procedures—face a significantly higher risk of developing depressive symptoms compared to those who deliver vaginally.^61–63 Research indicates that cesarean delivery is associated with an approximately 12–33% higher risk of PPD.⁶⁴ Furthermore, another study demonstrate that this delivery mode is linked to a threefold higher risk of experiencing chronic pain, affecting 22% of women at one year postpartum, which may directly correlate with more severe depressive symptoms.^65,66 Additionally, mode of delivery may be linked to postpartum PTSD. Analysis of Variance (ANOVA) revealed weak effects of delivery method on PPD but medium to strong effects on PTSD.⁶⁷ Of patients who were found to have symptoms of PTSD, secondary cesarean section, emergency cesarean section, and assisted vaginal delivery were all associated with elevated levels of PTSD.⁶⁷ To minimize the psychological burden associated with childbirth, providers should monitor PPD and PTSD occurrence in all mothers, to ensure adequate support by providing quick access to mental health care. One study noted that although additional validation of screening tools in postpartum populations is needed, universal screening for both postpartum depression (PPD) and post-traumatic stress disorder (PTSD) is recommended using the Edinburgh Postnatal Depression Scale (EPDS) alongside a brief PTSD-specific tool during routine postpartum and newborn follow-up visits, with positive screens linked to appropriate referral and follow-up care.⁶⁸

Policymakers need accurate data on where women deliver, who provides their care, and whether facilities and providers can offer high-quality routine and emergency services.⁶⁹ In one cohort of 398 women, 28.9% of women preferred cesarean delivery over vaginal delivery, with variables such as planned pregnancy, young age, and primigravida enhancing this preference.⁷⁰ Improving measurement systems, reducing unnecessary interventions, and tailoring care models to patient needs are essential for improving maternal health outcomes and ensuring access to safe childbirth services worldwide.⁶⁹

Postpartum Depression: Incidence, Timing, and Relation to Anesthesia

It is important to distinguish between early postpartum depressive symptoms and diagnosable postpartum depression. The American College of Obstetricians and Gynecologists (ACOG) recommends universal screening for depression and anxiety during the perinatal and postpartum periods using validated screening tools, such as the Edinburgh Postnatal Depression Scale (EPDS) and Patient Health Questionnaire-2 (PHQ-2) and Patient Health Questionnaire-9 (PHQ-9).⁷¹ These different assessment tools are not interchangeable. The PHQ-2 a brief screening tool used to identify possible depression, including postpartum depression.⁷² It is often used as a first-step screening test, with positive results followed by a longer instrument such as the PHQ-9 or the EDPS.⁷² The PHQ-9 directly assesses DSM-5 criteria for major depressive disorder, including sleep, appetite, energy, concentration, and other symptoms, which all may be inflated during the postpartum period for non-psychiatric reasons.⁷³ In contrast, the EDPS was designed specifically for the perinatal population and tends to focus on symptoms such as anxiety while minimizing somatic items that can overlap with normal postpartum recovery.⁷³ Additionally, variability in assessment timing contributes to heterogeneity in reported prevalence and should be considered when interpreting associations with anesthesia exposure. Screening at a few days or weeks postpartum may capture fleeting “baby blues,” physical recovery, sleep deprivation, and acute hormonal shifts rather than sustained major depressive disorder. ACOG notes that “baby blues” typically begin around 3 days after childbirth and usually resolve within 1–2 weeks, so studies screening very early postpartum are not measuring the same construct as studies assessing women at 6 weeks, 3 months, or 6–12 months postpartum.⁷⁴

PPD exerts substantial short- and long-term effects on maternal, infant, and family outcomes. Adverse effects in infants include lower breastfeeding duration and initiation, along with poor maternal and infant bonding.⁷⁵ Additionally, patients who undergo cesarean delivery under general anesthesia have increased odds of severe PPD requiring hospitalization, suicidal ideation, and self-inflicted injury.³⁵ Among 428,204 cesarean deliveries, general anesthesia (8.0%) was associated with increased odds of severe postpartum depression (aOR 1.54, 95% CI 1.21–1.95) and suicidal ideation or self-inflicted injury (aOR 1.91, 95% CI 1.12–3.25) compared with neuraxial anesthesia, with no significant association observed for anxiety disorders or PTSD.³⁵ Given rising rates of hospital encounters for PPD, universal screening should begin early and continue for the first year postpartum to mitigate these adverse effects.⁷⁶ ACOG recommends universal perinatal mental health screening using validated instruments such as the Edinburgh Postnatal Depression Scale (EPDS), Patient Health Questionnaire-9 (PHQ-9), or Patient Health Questionnaire-2 (PHQ-2), with appropriate referral and follow-up for positive screens.⁷¹ By assessing PPD prevalence across multiple studies, including consideration of the timing of assessment, researchers can provide crucial data and trends to inform prevention and treatment strategies. A specific goal of the Center of Disease Control and Prevention (CDC) is to reduce the proportion of women who experience postpartum depression symptoms after delivering a live birth by providing additional support, such as additional screening for depression and access to counseling services, to women with characteristics associated with high prevalence.⁷⁵ Targeted screening, such as the EPDS, should be directed to mothers aged 19–24 years old, of American Indian/Alaska Native or Asian/Pacific Islander race/ethnicity, with fewer than 12 years of education, who are unmarried, who are postpartum smokers, who had exposure to three or more stressful life events in the year before birth, who gave birth to low-birthweight infants, and who had infants requiring neonatal intensive care unit admission at birth.⁷⁵

PPD prevalence at two months postpartum was 16.7%.⁷⁷ Factors associated with an increased risk for PPD are an age of 29 to 40, birth in North Africa, a lower level of health literacy, having a history of psychological disorders, receiving little/no support during pregnancy, reporting feelings of sadness, and having an instrumental vaginal delivery.⁷⁷ Many of these determinants are modifiable risk factors, highlighting opportunities for health care providers and policymakers to improve perinatal mental health outcomes. Another study examined PPD prevalence one, two, four, and six months postpartum by using the Japanese version of the Edinburgh Postnatal Depression Scale (EPDS), which showed that the peak prevalence of depressive symptoms was at one month postpartum.⁷⁸ This finding is another important indication for healthcare professionals to be aware of general peaks in depressive symptoms and to be sensitive to the duration of postpartum depression. One year postpartum, approximately one in eight women, a pooled prevalence of 12.1% in a meta-analytic study, experience depression, and one in fifteen of all women experience major depression.¹⁰ Together, these findings emphasize that the postpartum period represents a window of vulnerability during which obstetric and anesthetic exposure may influence psychiatric outcomes.

PPD prevalence appears to be steadily declining due to accessibility to information involving delivery methods and treatment options.⁷⁹ However, there is a correlation with anesthesia type, delivery mode, and PPD incidence that is less frequently considered in obstetric care.⁸⁰ Epidural anesthesia is the gold standard for pain management during labor.⁸¹ In one study of 91 patients, just under 50% received epidural anesthesia, with two-thirds of these patients learning about this treatment option through family members or social media.⁸² EPDS is a universal screening method that showed that nearly 40% of these mothers had depressive symptoms two days following delivery, and 38.5% of these mothers met the criteria for PPD at six weeks.⁸² Additionally, a large retrospective nationwide cohort study found that women who underwent cesarean delivery under general anesthesia had a higher risk of PPD within 90 days compared to those who received neuraxial anesthesia.⁵⁸ Although the precise mechanism linking anesthesia type with PPD is not fully understood, awareness of these associations is a proactive way to care for the patient. These findings highlight the burden of early-onset PPD in specific cohorts, despite overall improvements in population trends.

Special attention should also be devoted to women who experience prolonged second-stage births and/or suffer from postpartum fatigue, as both are associated with increased risk of postpartum psychopathology.⁸³ Additional factors such as primiparity, education, and prior psychological diagnosis should be considered to guide preventive efforts against postpartum psychopathology.⁸³ Comparison across studies is limited by substantial heterogeneity in postpartum depression ascertainment, including use of different screening instruments (EPDS vs. PHQ-9), variable cutoff thresholds, inconsistent postpartum assessment windows, and differing definitions of depression based on screening scores versus structured diagnostic interviews.⁷³ Together, these differences can alter measured prevalence and reduce the validity of direct pooled comparisons. A comprehensive approach that combines awareness of PPD prevalence, identification of high-risk demographics and obstetric characteristics, and understanding anesthesia indications can support individualized postpartum care. These efforts, along with enhanced long-term support systems, create meaningful opportunities to further reduce the rate of PPD.

Discussion

Collectively, available evidence indicates that neuraxial anesthesia likely does not increase the risk of postpartum depression and may exhibit either neutral or modest protective effects in labor.^37–51 However, this association is not independent of broader psychosocial and obstetric factors. Neuraxial anesthesia should therefore be understood as a facilitating component of comprehensive perinatal care, capable of modifying, but not determining, PPD risk.

This protective association appears consistent across delivery modes. For cesarean delivery, general anesthesia has been associated with 54% increased odds of PPD when compared with neuraxial analgesia.³⁵

However, several recent studies demonstrate no independent association between epidural use and PPD after adjustment for psychosocial confounding variables.^45–51 Additionally, one large historical cohort study reported an increased risk of PPD among epidural recipients, though these findings have not been shown repeatedly by current research at the time.⁵⁴

General anesthesia during cesarean delivery eliminates maternal participation in childbirth and is associated with delayed first skin-to-skin contact and delay in first breastfeeding attempt, which may contribute to the observed elevation in severe PPD risk.³⁵ Regardless, anesthetic technique does not act alone on PPD risk. PPD is related to factors including obstetric complications, psychosocial factors, hormonal changes, and physical health.^12,84 Neuraxial anesthesia appears to function as a modifying factor, rather than a primary determinant, of PPD outcomes.⁴⁸

Several limitations across existing evidence should be acknowledged. Most studies regarding neuraxial anesthesia and PPD are observational, increasing susceptibility to confounding variables.^43,47 Randomized controlled trials designed specifically to evaluate PPD outcomes are practically and ethically difficult to conduct.⁸⁵ Additionally, PPD assessment timing varies widely across studies, ranging from days of postpartum to two years after delivery, leading to variability in reported prevalence.^41,42 Importantly, confounding variables from unmeasured psychosocial variables, such as partner support, socioeconomic stress, prior trauma, and access to mental health care may influence reported associations.¹¹ While several biologically plausible mechanisms have been proposed, including modulation of the hypothalamic–pituitary–adrenal axis, inflammatory signaling, and neuroendocrine pathways, the current literature remains limited by a lack of mechanistic studies directly linking neuraxial anesthesia to postpartum mood outcomes. Additionally, the potential differential effects of specific anesthetic agents, including local anesthetics and opioids, on neurobiological pathways involved in mood regulation are not well characterized and warrant further investigation.

Despite limitations, the findings of this review carry important implications. The data strongly support the use of neuraxial anesthesia as the preferred anesthetic technique for both labor and cesarean delivery.⁸⁶ Additionally, women undergoing emergency cesarean delivery are associated with a 20% higher risk for PPD and should receive increased postpartum psychiatric screening with the Edinburgh Postnatal Depression Scale.⁶⁶

Future research should prioritize large, multiple center prospective studies with standardized timing of PPD assessment and uniform screening tools. Studies examining other physiological markers, including cortisol and inflammatory cytokines, may clarify a mechanistic link between analgesia and mood disorders. Stratified analyses based on parity, labor duration, delivery indication, and psychosocial factors would allow for more personalized risk prediction.

Conclusion

Current evidence indicates that neuraxial anesthesia is not associated with increased PPD risk and is more likely to confer protective psychological effects, particularly when compared with general anesthesia for cesarean delivery. While anesthesia alone does not determine postpartum mental health outcomes, effective neuraxial pain management reduces physiologic stress, improves childbirth satisfaction, and may lower vulnerability to postpartum depression when integrated within a broader framework of psychosocial support and systematic postpartum screening. While not a standalone cure, neuraxial analgesia’s clinical value lies in providing superior pain management that may impact the risk of mental health complications. By highlighting the link between an ideal birth experience and better psychological recovery, this evidence empowers families to make informed anesthetic choices that prioritize both physical comfort and long-term mental health.

Data Sharing Statement

Data sharing is not applicable to this article as no datasets were generated or analyzed during the current study.

Ethics Approval

This article is based on previously conducted studies and does not contain any new studies with human participants or animals performed by any of the authors.

Author Contributions

All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.

Disclosure

The authors report no conflicts of interest in this work.