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Hormonal Contraceptive Initiation Associated With Increased Risk of Depression Postpartum in First-Time Mothers
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Key Takeaways
- Initiating hormonal contraceptives postpartum is linked to increased depression risk, especially with COCs, CNOCs, and PNOCs, but not conclusively with POPs.
- The study involved 610,038 first-time mothers, excluding those with prior depression, multiple births, or certain medical conditions.
Because mothers are already at risk of depression postpartum, health care professionals must properly counsel mothers on hormonal contraceptives.
Hormonal contraceptive (HC) initiation in first-time mothers was associated with an increased risk of depression postpartum, wrote authors of a study published in JAMA Network Open. Interestingly, these associations were observed for combined oral contraceptives (COCs), combined nonoral contraceptives (CNOCs), and progestogen-only nonoral contraceptives (PNOCs), but were inconclusive for progestogen-only pills (POPs).1
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Approximately 248 million women worldwide are estimated by the WHO to use HC. Because currently marketed options have acceptable and similar efficacy in the prevention of unwanted pregnancies, safety is often a key consideration when health care professionals consider which option is most suitable for a patient. Not every birth control method is 100% safe, with different side effects potentially occurring depending on the individual patient and/or their medical and family histories.2,3
For example, prior research has demonstrated effects of HC methods on health, such as a recent Danish study that observed associations between an increased risk of ischemic stroke and myocardial infarction in patients who used contemporary estrogen-progestin and progestin-only contraceptive methods. In addition, HCs were linked to higher breast cancer risk in patients who were BRCA1 carriers.2,3
HCs have also previously been linked with depression; however, prior to the current study, it was unknown whether the same is true during the postpartum period when women have a heightened risk of depression and are often offered HC treatment. The investigators utilized Danish national health registers to investigate HC initiation postpartum and depression risk in a large, unselected population with a 1-year follow-up time. They also accounted for various potential confounders, such as medical indications for use. Specifically, the objective is to examine whether HC initiation postpartum is associated with an increased risk of depression in the postpartum period compared with no HC exposure and whether it depends on age, HC type, and timing of initiation postpartum.1
This population-based cohort study enrolled 610,038 primiparous women who gave birth from January 1, 1997, through December 31, 2022. Women were not included if they had depression within 24 months prior to delivery, multiple births or a stillbirth, or a diagnosis of breast cancer or liver tumor. HC was initiated for some participants within 12 months postpartum and treated as a time-varying exposure, with HC types categorized as COCs, CNOCs, POPs, and PNOCs. The outcome measure was depression within 12 months postpartum.1
Among the enrolled population, approximately 40.7% (n = 248,274) of women had initiated HC within 12 months postpartum (mean ages: 27.6 years for HC users vs 29.6 years for HC nonusers). The investigators observed an association between HC initiation and subsequent depression, with an AHR of about 1.49 (95% CI, 1.42–1.56) compared with no use, resulting in an increase in the 12-month absolute risk from approximately 1.36% (95% CI, 1.32%–1.39%) to 1.54% (95% CI, 1.50%–1.57%). Specifically, the AHRs for COC, CNOC, and PNOC were 1.72 (95% CI, 1.63–1.82), 1.97 (95% CI, 1.64–2.36), and 1.40 (95% CI, 1.25–1.56), respectively. Progestogen-only pill exposure was associated with an instantaneously reduced risk in the early study period; however, it increased later postpartum. The investigators observed that the earlier COCs were initiated postpartum, the higher the associated rate ratios of depression.1
Interestingly, the investigators wrote there was no observed age trend in the association between HC use and depression. They emphasized that the findings help raise awareness on the issue of postpartum depression and HC initiation, and as a result, health care professionals should be aware of these risks when educating patients on HC contraceptive use postpartum.1
