Association of obstetric practices with postpartum depressive symptoms: data from the Brazilian National Health Survey, 2019Abstract
This article aims to evaluate the association between mode of delivery, obstetric practices, and reason for cesarean section with depressive symptoms in postpartum women up to one year postpartum. Cross-sectional study using data from the 2019 National Health Survey, including women aged >15 years and up to 12 months postpartum. Variables: mode of delivery, obstetric interventions, reasons for cesarean section, and postpartum depressive symptoms. Depressive symptoms were assessed using the Patient Health Questionnaire-9 (PHQ-9>4 symptoms of mild depression and ≥9 as severe). STATA 15.0 was used for the analyses, with Directed Acyclic Graphs supporting confounding variables. A total of 986 postpartum women were analyzed. The prevalence of severe depressive symptoms was 13.1%. Of the total, 54.8% underwent cesarean section, 65.3% without appropriate indication. There was no association between type of delivery and depression, nor between obstetric practices during vaginal delivery and depression. The odds of mild depression symptoms (PHQ-9>4) were higher when cesarean section was the physician’s choice during prenatal care compared with cesarean sections indicated due to complications. Unnecessary cesarean sections may increase maternal psychological vulnerability. The importance of prenatal care focused on preparing women to make their decisions is emphasized.
Key words:
Vaginal birth; C-section; Postpartum depression; Postpartum period
Resumo
O objetivo deste artigo é avaliar associação entre via de parto, práticas obstétricas e motivo de cesariana com sintomas depressivos em puérperas até um ano pós-parto. Estudo transversal, com dados da Pesquisa Nacional de Saúde 2019, incluindo mulheres >15 anos, até 12 meses pós-parto. Variáveis: tipo de parto, intervenções obstétricas, motivos de cesariana e sintomas depressivos pós-parto. Sintomas depressivos foram avaliados pelo Patient Health Questionnaire-9 (PHQ-9>4 sintomas de depressão leve e ≥9 como grave). Para as análises, utilizou-se STATA 15.0, com apoio de Gráficos Acíclicos Direcionados para variáveis confundidoras. Foram analisadas 986 puérperas. A prevalência de sintomas depressivos moderados/graves foi 13,1%. Do total, 54,8% realizaram cesariana, sendo 65,3% sem indicação adequada. Não houve associação entre tipo de parto e depressão, nem entre práticas obstétricas no parto normal e depressão. A chance de sintomas de depressão leves (PHQ-9>4) foi maior quando a cesariana foi escolha do médico no pré-natal comparadas às cesarianas indicadas por complicações. Cesarianas desnecessárias podem aumentar a vulnerabilidade psicológica materna. Ressalta-se a importância do pré-natal voltado ao preparo da mulher, com respeito às suas decisões.
Palavras-chave:
Parto normal; Cesariana; Depressão pós-parto; Período pós-parto
Resumen
El objetivo de este artículo es evaluar la asociación entre el modo de parto, las prácticas obstétricas y el motivo de la cesárea con los síntomas depresivos en puérperas hasta un año después del parto. Estudio transversal con datos de la Encuesta Nacional de Salud de 2019, que incluyó mujeres mayores de 15 años y hasta 12 meses después del parto. Variables: modo de parto, intervenciones obstétricas, motivos de la cesárea y síntomas depresivos posparto. Los síntomas depresivos se evaluaron mediante el Cuestionario de Salud del Paciente-9 (PHQ-9>4 síntomas de depresión leve y ≥9 como grave). Se utilizó STATA 15.0 para los análisis, con gráficos acíclicos dirigidos que respaldaron las variables de confusión. Se analizaron 986 puérperas. La prevalencia de síntomas depresivos graves fue del 13,1%. Del total, el 54,8% se sometió a cesárea, el 65,3% sin indicación apropiada. No se observó asociación entre el tipo de parto y la depresión, ni entre las prácticas obstétricas durante el parto vaginal y la depresión. La probabilidad de síntomas de depresión leve (PHQ-9>4) fue mayor cuando la cesárea fue decisión del médico durante la atención prenatal en comparación con las cesáreas indicadas por complicaciones. Cesáreas innecesarias pueden aumentar la vulnerabilidad psicológica materna. Se enfatiza la importancia de la atención prenatal centrada en preparar a las mujeres para tomar sus propias decisiones.
Palabras clave:
Parto normal; Cesárea; Depresión Posparto; Periodo Posparto
Introduction
Pregnancy, childbirth, and the postpartum period are biopsychosocial events that are part of the sexual and reproductive lives of men and women throughout the world. They are singular, special, and memorable processes and constitute one of the most significant and potentially positive human experiences1. However, although they are seen as eminently happy phases, women’s mental health tends to become vulnerable during this period2.
Mental health is closely linked to reproductive health, especially regarding childbirth and the postpartum period. Any stressful event in these periods may be responsible for the emergence of unfavorable psychological events after birth2. Among the best-known conditions is postpartum depression (PPD)2,3.
PPD may be characterized by depressed mood, loss of pleasure and interest in everyday activities, weight loss, fatigue, psychomotor agitation or retardation, feelings of worthlessness, excessive guilt, difficulty concentrating or making decisions, and, in the most severe cases, thoughts of death or suicide4. The emergence of these symptoms is associated with several interrelated aspects, such as biological, obstetric, social, and psychological factors (partner abandonment or lack of emotional support, unplanned and/or unwanted pregnancy, unfavorable socioeconomic circumstances, traumatic or unsatisfactory childbirth, history of miscarriage in previous pregnancies, maternal and/or newborn hospital complications, among others)5,6.
Some studies indicate that the route of birth and the occurrence of operative and/or stressful deliveries-especially unplanned cesarean sections and instrumental vaginal births with excessive interventions, such as episiotomy and oxytocin use to accelerate labor-may also be associated with maternal psychological distress7,8. Also, there is evidence that disrespectful and abusive practices during childbirth, such as fundal pressure (Kristeller maneuver), movement restriction, lack of consent for the procedures performed, and prohibition of a companion’s presence, are also related to the development of PPD9,10. However, the available evidence remains inconclusive and inconsistent.
Given the scarce volume of Brazilian studies assessing the association between route of delivery and obstetric practices and the development of postpartum depressive symptoms, this study aimed to analyze this possible relationship. It aimed to analyze the association between delivery route, obstetric practices in vaginal birth, the reasons for cesarean section, and the occurrence of postpartum depressive symptoms, using population-based data, in order to support improvements in maternal health care.
Methods
The present study was conducted using data from the 2019 National Health Survey (PNS)11, in which the target population consisted of individuals older than 15 years residing in permanent private households. We excluded households located in special census tracts and/or with sparse populations from the sample, such as Indigenous settlements, barracks, military bases, jails, prisons, convents, quilombos, and long-term care institutions for older adults.
The PNS sampling plan is a three-stage cluster sample design, in which census tracts are the first-stage units, households are the second-stage units, and residents aged 15 years or older are the third-stage units. In all three stages, subsamples were selected by simple random sampling.
The questionnaires were administered in an average time of 30 minutes and consisted of three parts, namely: I) collection of household data and home visits performed by endemic disease workers; II) collection of socioeconomic, health, and health service use information for all household residents; and III) collection of data from the selected resident older than 15 years, covering themes related to lifestyle, work, chronic diseases, violence, among others. For the present study, data from part III, referring to the individual data of the resident older than 15 years, were analyzed. To be eligible, the resident had to be a woman who had given birth in the 12 months before the interview.
Since the PNS does not provide the date-of-interview variable, which would allow an exact estimate of the postpartum period, women who reported the date of their last delivery within the period from 365 days before the beginning of data collection (08/26/2018) until the day data collection ended (03/13/2020) were selected, and they also had to report having a child younger than one year living in the household. The postpartum period was estimated using the child’s age in months.
Women whose last delivery resulted in newborns with gestational age under 27 weeks and women who were pregnant at the time of the interview were excluded. A total of 986 eligible women remained after applying the inclusion and exclusion criteria.
The independent variables (exposures) evaluated were delivery route, obstetric practices, and reasons for cesarean section, and the dependent variable (outcome) was depressive symptoms.
Depressive symptoms were evaluated using the Patient Health Questionnaire-9 (PHQ-9). PHQ-9 is a screening instrument and severity assessment tool for depressive symptoms, originally conceived as a severity scale, allowing the use of different cutoff points according to the analytical objective. It is a tool used globally for depressive symptom screening, capable of screening for depression in primary health care. It shows excellent performance for identifying severe depression12.
PHQ-9 was classified into three categories: lack of depressive symptoms (≤4), mild depressive symptoms (>4 and <9), and moderate/severe depressive symptoms (≥9). The definition of the category of lack of symptoms (≤4) was based on the original PHQ-9 proposal described by Kroenke et al. 12, which suggests this cutoff to distinguish individuals without symptoms from those with depressive symptoms, even mild ones. The cutoff ≥9 for moderate/severe depression was based on Santos et al. 13, who validated the scale in Brazil. The authors found that the cutoff ≥9 yielded maximum sensitivity (77.5%) and specificity (86.7%).
For the bivariate logistic regression analyses, the categories were grouped so that the outcome became dichotomous. This strategy allowed analyses with greater sensitivity to detect associations between obstetric exposures and depressive symptoms. Thus, women with PHQ-9>4 were considered to have depression and compared with those without depression (PHQ-9≤4); and women with PHQ-9≥9 were considered to have severe depression and compared with those without depression or with mild depression (PHQ-9<9).
Regarding delivery route, three categorizations were performed, namely: per delivery route, per indication, and per labor. Regarding route, two categories were defined: vaginal birth and cesarean section, regardless of other variables. Three strata were defined for the indication of delivery: vaginal birth, cesarean section without adequate indication, and cesarean section with adequate indication. The variable used for this categorization was: “What was the main reason for having a cesarean delivery?” The responses “had previous cesarean section,” “wanted tubal ligation,” “did not want to feel labor pain,” “doctor’s choice during prenatal care,” and “medical indication because labor did not start” were categorized as “cesarean section without adequate indication,” since they are not among the standardized indications defined by the Ministry of Health14. Women who underwent cesarean section because they had complications during pregnancy or childbirth were categorized as “cesarean section with adequate indication.”
The third categorization of delivery type was “According to labor,” which considered whether or not the woman had gone into labor based on the variable “In this pregnancy, did you go into labor?” All women who had a vaginal birth were included in the category “went into labor”; postpartum women who underwent cesarean section were divided between those who went into labor before the surgical intervention and those who did not go into labor.
The obstetric practices evaluated were the use of pain relief methods (pharmacological and nonpharmacological), the presence of a companion, episiotomy, and skin-to-skin contact between mother and baby after birth. The sociodemographic data analyzed were age, race/skin color, marital status, access to health insurance, and income.
Age was categorized as: <20, ≥20 and <30 years, and ≥30 years. Per capita household income was recategorized into up to 1 minimum wage, 1 to 3 minimum wages, and more than 3 minimum wages, based on the question “Per capita household income range.”
Regarding maternal obstetric data, social support, diagnosis of sexually transmitted infection (STI) in the previous 12 months, body mass index (BMI), parity, childbirth complications, diabetes mellitus, arterial hypertension, and history of depression were included. Information on STI diagnosis, parity, childbirth complications, diabetes mellitus, arterial hypertension, and history of depression was self-reported by participants on the basis of direct questions asked by the interviewer. BMI was calculated from weight and height measured with a digital scale and portable stadiometer, using the formula of weight divided by height squared.
Social support was built by grouping questions from the database that investigated the availability of people the participant could count on in positive or adverse moments, including friends, family members, or relatives, as well as the level of participation in social activities in the 12 months preceding the survey. The responses were organized so that higher frequency and social participation levels corresponded to higher scores, with higher scores assigned to categories indicative of greater agreement or frequency. The final social support score was obtained by adding the scores assigned to each item, resulting in a continuous measure later categorized into two levels according to the median value: low social support (score <12) and high social support (score ≥12).
Statistical analyses were performed using the STATA statistical package, version 15.015. First, all variables were described for the total sample and according to the occurrence of depressive symptoms. Participants’ characteristics were described using absolute (n) and relative frequencies, according to the selected PHQ-9 categories and their respective 95% confidence intervals (95%CI).
Three Directed Acyclic Graphs (DAGs) were constructed in order to assess possible confounders for each of the three analytical models: (1) association between the delivery route and depressive symptoms; (2) association between obstetric practices in vaginal birth and depressive symptoms; and (3) association between obstetric practices in cesarean delivery and depressive symptoms. The selection of the minimum adjustment variables was based on the minimal sufficient adjustment sets identified in the DAGitty software16 . The DAGs were developed from theoretical assumptions and prior evidence in the literature on determinants of the delivery route, obstetric practices, and postpartum depressive symptoms. From these diagrams, we identified the minimum sets of variables needed to block confounding paths between each exposure and the outcome, avoiding adjustment for potential mediators or colliders. The DAGs for each of the three analytical models are available in the supplementary material (Figures 1S, 2S, and 3S).
The exposure variable used in the construction of Model 1 was route of delivery, and the outcome variable was depressive symptoms. Thus, the minimum necessary adjustment variables indicated by the DAG included chronic diseases, BMI, STI, age, childbirth complications, parity, and per capita income, because they are factors that may simultaneously influence the likelihood of cesarean delivery and the risk of depressive symptoms.
In Model 2, restricted to women who had vaginal births, the exposure variables were the presence of a companion, skin-to-skin contact, episiotomy, and (pharmacological and nonpharmacological) pain relief methods. The DAG indicated social support, age, childbirth complications, and per capita income as the minimum necessary adjustment variables. These conditions precede the occurrence of the obstetric practices analyzed and have an independent relationship with maternal mental health.
Model 3 investigated obstetric practices associated with depressive symptoms among women who underwent cesarean section. In addition to the variable “reason for cesarean section,” the following variables were included as exposures: skin-to-skin contact, presence of a companion, and labor. The minimum necessary adjustment indicated by the DAG included social support, diabetes and gestational hypertension, marital status, BMI, STI, gestational age at delivery, maternal age, and parity. Gestational age at delivery was considered a confounder because it is associated both with the indication for cesarean section and with the risk of postpartum depressive symptoms, since preterm or post-term pregnancies are related to a higher occurrence of obstetric interventions and greater maternal emotional vulnerability.
To estimate the association between variables, adjusted binary logistic regression analysis was performed using the minimum necessary adjustment variables indicated by the DAG. The data are presented as crude and adjusted Odds Ratios (OR) with their respective 95% CIs. Associations with p-value<0.05 were considered significant.
Results
The final sample consisted of 986 postpartum women after application of the eligibility criteria. The participant selection flowchart, including the sample size of each model, can be consulted in the supplementary material (Figure 4S). The prevalence of PPD symptoms was 34.1%, with 21% showing mild symptoms and 13.1% showing moderate/severe symptoms. Notably, the prevalence of total PPD symptoms includes mild symptoms, since the cutoff >4 was used for screening purposes and internal comparison between groups.
Most participants were between 20 and 30 years of age (47.4%), self-identified as Brown (51.7%), and lived with a partner (78.2%). We also observed that 73.7% of the women had an income of up to one minimum wage, 72.5% did not have health insurance, and 53.2% reported high social support. Women with moderate/severe PPD symptoms reported lower social support, with 70.0% indicating a low support level, compared with 57.5% of women without depression (p=0.0012) (Table 1).
As for nutritional status, 47.5% of the postpartum women were eutrophic, 34.3% were overweight, and 18.0% had obesity. Only 1.7% of the participants reported a diagnosis of STI in the past year, and this proportion was higher among women with mild PPD symptoms (4.7%; p=0.0453). Most (94.5%) denied diabetes, and 86.6% reported not having hypertension. Some 7.8% of the sample had a history of depression. This proportion was higher according to the PPD symptom categories, being 3.2% among those without depression, 11.5% among those with mild depression, and 23.5% among those with severe/moderate depression (Table 2).
Cesarean section was the most common delivery route (54.8%), and 19% of women had an adequate indication for this procedure, whereas in 35.8% of postpartum women, the cesarean section was performed without adequate obstetric indication. Concerning labor, 39.5% underwent cesarean section without having gone into labor. As for obstetric practices, the presence of a companion was reported by 88.0% of postpartum women, skin-to-skin contact occurred in 83.7% of cases, and episiotomy was performed in 38.9% of women. Most reported having had no complications during childbirth (90.2%) and postpartum (91.3%). Pain relief methods were used in 42.5% of women who went into labor, and in 90.1% of postpartum women; pharmacological methods were employed (data not shown).
There was no significant association between route of delivery and the occurrence of PPD symptoms (Table 3). Likewise, there was no significant association between the variables related to obstetric practices in vaginal birth and the development of PPD symptoms, either in crude or adjusted analyses (Table 4).
The doctor’s choice of delivery route was significantly associated with of PPD symptoms (adjusted OR=2.08; 95%CI=1.08-3.97), when compared with women who underwent cesarean section due to complications during pregnancy or childbirth. Postpartum women who did not have skin-to-skin contact after cesarean section had a higher chance of developing PPD symptoms in the crude analysis (OR=1.77; 95%CI=1.13-2.72), but this result lost significance in the adjusted analysis (OR=1.55; 95%CI=0.94-2.42). None of the variables analyzed was associated with severe PPD symptoms (Table 5).
Discussion
This study found a high prevalence of cesarean sections, many of them without adequate obstetric indication, and a high frequency of PPD symptoms, with a prevalence of 34.1% (21% mild and 13.1% moderate/severe). No association was found between the delivery route and postpartum depressive symptoms. Among women who had vaginal births, none of the obstetric practices was associated with depressive symptoms. Among women who underwent cesarean section, the reason for the surgery was related to PPD symptoms, indicating that when cesarean delivery was a doctor’s choice, the chance of mild PPD symptoms was approximately twice as high than with women who had an adequate indication (complications during pregnancy or childbirth).
A previous study documented up to a twofold greater risk of PPD symptoms in the immediate postpartum period among women who underwent cesarean section17. However, this result is controversial, with some studies reporting no association18,19. In a meta-analysis published in 2024, Ning et al. found a 20% higher risk of PPD in women who had undergone emergency cesarean sections compared with those who had vaginal births. On the other hand, elective cesarean section was not associated with depression20. In the present study, the available secondary data did not allow assessment of whether the cesarean sections were emergency or elective.
On the other hand, we had access to a variable that provides substantial information about the postpartum woman’s view regarding the reason for her cesarean section. Women who reported “doctor’s choice during prenatal care” as the reason for undergoing cesarean delivery presented a higher risk of mild PPD symptoms compared with those who believed the reason for their cesarean section was complications during pregnancy or childbirth. This result reflects how medical influence may compromise women’s autonomy, generating doubts and anxieties that can make them susceptible to the development of depressive symptoms21,22.
This finding also aligns with the literature that discusses the historical and sociocultural consolidation of cesarean section in Brazilian obstetric practice. Studies drawing on historical-critical and collective health approaches show that cesarean section, originally restricted to risk situations, was progressively normalized and incorporated as a central technique of the biomedical model of childbirth care, reinforcing medical authority in defining the route of delivery and reducing women’s autonomy. This process of medicalization and normalization of cesarean section contributes to the high prevalence of the procedure in the country and to the naturalization of decisions made predominantly by health professionals, even in the lack of clear clinical indications21,22. In this context, the association observed between cesarean sections attributed to doctor choice and greater occurrence of postpartum depressive symptoms may reflect not only individual aspects of the childbirth experience, but also structural dynamics of power, care, and the production of obstetric practices that adversely affect women’s subjective experience.
Women who reported doctor choice as the reason for the cesarean section were probably those who preferred vaginal birth but ultimately had a cesarean section without understanding a real justification for that medical choice. Few studies have evaluated the influence of preference for the delivery route on depressive symptoms, but some studies indicate that women whose preferred route of delivery is not respected are at greater risk of depression and post-traumatic stress disorder23. Houston et al. 24 conducted a cohort study with 160 women and concluded that women who had a strong preference for vaginal birth at the end of pregnancy but ended up having a cesarean section were at greater risk of developing postpartum depression.
Beyond the main objectives, some variables showed a significantly different distribution across PPD symptom categories, including social support, history of depression, STI diagnosis, and postpartum time. The analysis indicated that greater social support was inversely associated with PPD symptoms, corroborating other studies showing that social support reduces the prevalence of depressive symptoms and reinforcing the idea that support and follow-up during pregnancy and childbirth are essential to ensuring women’s psychological well-being25,26. Preexisting depression also proved to be an important factor associated with PPD symptoms, corroborating a vast literature indicating that women with a history of depression are two to three times more likely to develop postpartum depressive symptoms17,27. This underscores the importance of considering mental health from pregnancy onward5,27.
The relationship between STI diagnosis and postpartum depression has been little explored in the literature. In our search, we did not identify studies of this relationship in postpartum populations, but some studies do show the relationship between STIs and depression in other populations28,29. In a cross-sectional study of the general Canadian population, Cheng et al. 28 observed an 80% greater chance of depression among women who had a history of STI. Mo et al. 29 found a prevalence of depression of 43% among monogamous Chinese women diagnosed with STIs, whereas in the general population of China, the estimated prevalence of depression is only 4.2%. STI diagnosis carries a strong social stigma, especially among women, which can generate shame, low self-esteem, and stress30. Furthermore, diagnosis among monogamous women can generate marital problems, which reduce marital satisfaction and trigger the development of depression31.
Regarding postpartum time, in the present study, women evaluated 8 to 12 months postpartum showed the lowest prevalence of PPD symptoms, with 31.4% of mild or severe depression, compared with 35.6% and 36.9% among those evaluated between 0 to 3 months and 4 to 7 months, respectively. This reduced prevalence of PPD symptoms over the months after childbirth is seen in some longitudinal studies, but it is not a consensus, even when considering only Brazilian studies32-35. In more in-depth studies using the 2004 and 2015 Pelotas cohorts, we can observe that individual PPD trajectories may follow different patterns, and history of depression is one of the main determinants of persistent postpartum depressive symptoms33,36. Notably, in the present study, despite the slight reduction by the end of 12 months, the prevalence of PPD symptoms remained high throughout the entire period studied.
Some limitations should be pointed out. The number of postpartum months is not presented in the database, so the postpartum period had to be estimated using other variables. Moreover, the interval analyzed was 12 months, a long period during which factors associated with PPD symptoms may vary. Additionally, the reasons for cesarean section were categorized according to the variables available in the database, which do not allow precise discrimination between elective and non-elective cesarean sections. Another limiting issue is that PHQ-9 is a screening instrument for depressive symptoms, but it was not developed specifically for the postpartum period, and it counts some changes that are common during the postpartum period, even in the lack of depression, such as changes in sleep patterns. Therefore, few studies use PHQ-9 in this population, which hinders data comparison. We should also consider that the use of a more sensitive PHQ-9 cutoff (>4) may have contributed to overestimating the prevalence of depressive symptoms. However, the instrument was employed as a screening tool for depressive symptoms, and the association analyses were based on internal comparisons between groups, reducing the impact of this bias on effect estimates.
On the other hand, some strengths of the study deserve highlighting. The data come from a population-based survey with an expressive sample size. The development of DAGs to guide the theoretical model of the relationships studied brings transparency and support to the choice of model adjustments and may serve as a basis for other researchers in future analyses. Also, the variables related to obstetric practices and reasons for cesarean section are still little explored in the literature as possible determinants of PPD, underscoring the importance and the innovative theme studied.
The present study provides important data for Public Health, since it highlights the relevance of thinking about comprehensive women’s health by integrating physical and obstetric care without overlooking the psychological factors involved in the processes of gestating and giving birth. It also highlights the importance of improving the quality of national data on PPD and routes of delivery and their correlation.
Conclusion
Cesarean sections have become increasingly common around the world, since they are considered safer and risk-free in the minds of many pregnant women and even professionals. However, several studies show the negative impacts of such practices on maternal and newborn health, including psychological vulnerability. Although no significant relationship was found between the delivery route and PPD symptoms in the Brazilian population studied, it was shown that the reason leading women to cesarean section may be associated with PPD symptoms, specifically when attributed to doctor choice during prenatal care, compared with cesarean sections performed for clinical indications resulting from complications during pregnancy or childbirth.
The results of the present study demonstrate the importance of reducing the number of unnecessary cesarean sections, since they may be harmful to maternal mental health. We highlight the relevance of holistic, high-quality prenatal care, focusing on preparing women and strengthening their autonomy so that their wishes and decisions are respected, in order to reduce the psychological vulnerabilities linked to the processes of gestating and giving birth. There are still many aspects regarding risk factors for PPD that need to be clarified, as well as how the type of delivery and the experience lived during birth may affect maternal mental health in the postpartum period. Future investigations are needed, centering on expectations, choices, and experiences in different childbirth contexts and on how these affect puerperal mental health.
Additionally, the findings of this study reinforce the need to reflect critically on the biomedical, interventionist, and hospital-centered model that has historically guided professional training and the organization of obstetric care in Brazil. The centrality of medical decision-making regarding the delivery route, frequently dissociated from shared decision-making processes, may contribute to care experiences that weaken women’s autonomy and amplify psychological vulnerabilities in the pregnancy-childbirth-postpartum cycle. In this context, the importance of investments in the revision of obstetric teaching models and in strengthening the role of obstetric nurses and midwives in the care of low-risk births is highlighted as a strategy to improve care, reduce unnecessary interventions, and promote more positive childbirth experiences. Added to this setting is the enactment of Law No. 14,721/2023, which expands the right to psychological care within the Unified Health System during the pregnancy-childbirth-postpartum cycle, representing a relevant advance. However, its effective implementation will depend on investments in infrastructure, financing, and workforce, as well as on its coordination with prenatal and childbirth care, so as to ensure continuous psychological care integrated with women’s needs.
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