Cesarean section and postpartum depression: a review of the evidence examining the link

Prevalence of depression among pregnant women and its correlation with the choice of delivery method

Background

Caesarean section is usually limited to cases where natural vaginal delivery is not possible or poses a serious risk to the foetus and mother. Psychological health of mothers is likely to play an important role in the method of delivery. This study aims to investigate the prevalence of depression in pregnant women and its relationship with the choice of delivery method and other demographic parameters.

Methods

In this descriptive cross-sectional study, 250 mothers referring to the hospitals of Shahid Beheshti University of Medical Sciences, Tehran, Iran, were selected, and their demographic information and level of depression was collected using a questionnaire. Statistical analysis was conducted to evaluate the correlation between depression, method of delivery and other associated parameters.

Results

Among 250 pregnant women, 225 (90%) had no depression, 25 (10%) had mild depression and no moderate or severe depression was reported in any pregnant mother. Also, 146 (58.4%) were willing to have a caesarean section and 104 (41.6%) wanted to have a normal delivery. The choice of delivery method was not significantly associated with depression. Analyzes showed that increasing maternal age is associated with a greater tendency to caesarean delivery. The incidence and higher depression scores of mothers showed a significant association with the history of previous abortions.

Conclusion

Although in this study no significant association was observed between depression in pregnant mothers and the choice delivery, due to the high prevalence of caesarean section in the country and its progression to higher percentages, it seems that the design and implementation of effective programs and interventions is required.

Are 6 more accurate than 4? The influence of different modes of delivery on postpartum depression and PTSD

BACKGROUND

Empirical evidence shows that 4.6-6.3% of all women develop a post-traumatic stress disorder (PTSD) and approximately 10-15% postpartum depression (PPD) following childbirth. This study explores the relationship between delivery mode and the occurrence of PTSD and PPD, specifically examining four distinct caesarean section (CS) modes: primary on maternal request (Grade 4), medically indicated primary (Grade 3), secondary CS from relative indication (Grade 2) and emergency secondary CS (Grade 1), compared to vaginal and assisted vaginal delivery (AVD). The research aims to understand how these six subcategories of delivery modes impact PPD and PTSD levels. Common predictors, including the need for psychological treatment before childbirth, fear of childbirth, planning of pregnancy, induction of labor, birth debriefing, and lack of social support after childbirth, will be analyzed to determine their association with postpartum mental health outcomes.

METHODS

The study was planned and carried out by a research team of the psychology department at the Medical School Hamburg, Germany. Within an online-study (cross-sectional design) N = 1223 German speaking women with a baby who did not die before, during or after birth were surveyed once between four weeks and twelve months postpartum via an anonymous online questionnaire on demographic and gynecological data, delivery mode, PTSD (PCL-5) and PPD (EPDS).

RESULTS

For both psychiatric disorders, ANOVA revealed significant differences between delivery mode and PPD and PTSD. With weak effects for PPD and medium to strong effects for PTSD. Post-hoc tests showed increased levels of PPD for two CS types (Grade 1, Grade 3) compared to vaginal delivery. For PTSD, secondary CS from relative indication (Grade 2), emergency secondary CS (Grade 1) and assisted vaginal delivery (AVD) were associated with elevated levels of PTSD. Regression analysis revealed delivery mode as a significant predictor of EPDS- (medium effect size) and PCL-5-Score (medium to high effect size).

LIMITATION

Delivery was considered as the potential traumatic event, and any previous traumas were not documented. Additionally, the categorization of delivery modes relied on subjective reports rather than medical confirmation.

CONCLUSION

The study highlights the influence of delivery mode on the mental health of postpartum mothers: different modes influence postpartum disorders in various ways. However, the definition of delivery mode was only stated subjectively and not medically confirmed. Further research should investigate which aspects of the different delivery modes affect maternal mental health and explore how the perception of childbirth may be influenced by specific delivery experiences.

[Evaluation of Psychological Distress in Obstetric Patients during the Visit Ban in Hospitals in the SARS-CoV-2 Pandemic: A Prospective, Multicentre, Controlled Study]

INTRODUCTION

Risk factors for postpartum depression include a lack of social support and perceived social isolation. We would like to determine whether the isolation of inpatients on the maternity wards during Covid-19 leads to increased psychological stress.

METHODS

This is a multicentre, controlled study of obstetric patients who gave birth during an inpatient stay. Patients were included during the visitation ban (study group) and after the visitation ban (control group). Psychological stress was evaluated with the Edinburgh Postnatal Depression Scale (EPDS) during the inpatient stay and six to eight weeks postpartum.

RESULTS

A total of 194 women were included, 107 in the study group and 87 in the control group. The overall result of the first EPDS shows a higher score in the study group compared to the control group (7.0 vs. 4.9 points). Primipara show a higher score in the first EPDS compared to multipara (7.28 vs. 4.82). Caesarean section, regardless of isolation, shows a higher score in the first EPDS than vaginal birth (8.42 vs. 5.11). Comparison of vaginal birth shows a higher score only in the study group (5.97 vs. 4.07).

CONCLUSION

In the context of Covid-19, women giving birth and new mothers, especially primipara, are exposed to increased psychological stress in the clinics. Caesarean section leads to increased psychological stress.

The Association between Cesarean Section Delivery and Child Behavior: Is It Mediated by Maternal Post-Traumatic Stress Disorder and Maternal Postpartum Depression?

Cesarean sections (C-sections) account for up to 21% of births worldwide. Studies have linked delivery via C-section with an increased risk of child behavior problems, such as internalizing and externalizing behaviors. Maternal postpartum depression (PPD) is also linked to child behavioral problems and may play a mediating role in the association between the mode of delivery and child behavior. Mixed findings between mode of delivery and PPD may be due to a failure to distinguish between C-section types, as unplanned/emergency C-sections are linked to post-traumatic stress disorder (PTSD), which has been linked to PPD. The objectives of this study were to determine whether, (1) compared with spontaneous vaginal delivery (SVD) and planned C-section, unplanned/emergency C-sections are associated with increased child behavior problems at two to three years of age and (2) maternal PTSD and PPD mediate the association between delivery type and child behavior problems. A secondary data analysis was conducted on 938 mother-child dyads enrolled in the Alberta Pregnancy Outcomes and Nutrition (APrON) study. Conditional process modeling was employed. Child behavior was assessed using the Child Behavior Checklist (CBCL) 1.5-5 years, and maternal PPD and PTSD were assessed using the Edinburgh Postnatal Depression Scale (EPDS) and the Psychiatric Diagnostic Screening Questionnaire (PDSQ), respectively. No associations were found between delivery type and child behaviors; however, the indirect effect of emergency C-section on child behaviors was significant via the mediating pathway of maternal PTSD on PPD symptoms.

Prevalence and correlates of perinatal depression

PURPOSE

This systematic review of systematic reviews aims to provide the first global picture of the prevalence and correlates of perinatal depression, and to explore the commonalities and discrepancies of the literature.

METHODS

Seven databases were searched from inception until April 2022. Full-text screening and data extraction were performed independently by two researchers and the AMSTAR tool was used to assess the methodological quality.

RESULTS

128 systematic reviews were included in the analysis. Mean overall prevalence of perinatal depression, antenatal depression and postnatal depression was 26.3%, 28.5% and 27.6%, respectively. Mean prevalence was significantly higher (27.4%; SD = 12.6) in studies using self-reported measures compared with structured interviews (17.0%, SD = 4.5; d = 1.0) and among potentially vulnerable populations (32.5%; SD = 16.7, e.g. HIV-infected African women) compared to the general population (24.5%; SD = 8.1; d = 0.6). Personal history of mental illness, experiencing stressful life events, lack of social support, lifetime history of abuse, marital conflicts, maternity blues, child care stress, chronic physical health conditions, preeclampsia, gestational diabetes mellitus, being exposed to second-hand smoke and sleep disturbance were among the major correlates of perinatal depression.

CONCLUSION

Although the included systematic reviews were all of medium-high quality, improvements in the quality of primary research in this area should be encouraged. The standardisation of perinatal depression assessment, diagnosis and measurement, the implementation of longitudinal designs in studies, inclusions of samples that better represent the population and better control of potentially confounding variables are encouraged.

Planned mode of birth after previous caesarean section and women's use of psychotropic medication in the first year postpartum: a population-based record linkage cohort study

BACKGROUND

Policy in many high-income settings supports giving pregnant women with previous caesarean section a choice between an elective repeat caesarean section (ERCS) or planning a vaginal birth after previous caesarean (VBAC), provided they have no contraindications to VBAC. Despite the potential for this choice to influence women's mental health, evidence about the associated effect to counsel women and identify potential targets for intervention is limited. This study investigated the association between planned mode of birth after previous caesarean and women's subsequent use of psychotropic medications.

METHODS

A population-based cohort study of 31 131 women with one or more previous caesarean sections who gave birth to a term singleton in Scotland between 2010 and 2015 with no prior psychotropic medications in the year before birth was conducted using linked Scottish national datasets. Cox regression was used to investigate the association between planned mode of birth and being dispensed psychotropic medications in the first year postpartum adjusted for socio-demographic, medical, pregnancy-related factors and breastfeeding.

RESULTS

Planned VBAC (n = 10 220) compared to ERCS (n = 20 911) was associated with a reduced risk of the mother being dispensed any psychotropic medication [adjusted hazard ratio (aHR) 0.85, 95% confidence interval (CI) 0.78-0.92], an antidepressant (aHR 0.83, 95% CI 0.76-0.90), and at least two consecutive antidepressants (aHR 0.83, 95% CI 0.75-0.91) in the first year postpartum.

CONCLUSIONS

Women giving birth by ERCS were more likely than those having a planned VBAC to be dispensed psychotropic medication including antidepressants in the first year postpartum. Further research is needed to establish the reasons behind this new finding.

Postpartum depression, mode of delivery, and indication for unscheduled cesarean delivery: a retrospective cohort study

OBJECTIVES

To examine the relationship between postpartum depression (PPD), mode of delivery (MOD), and indication for unscheduled cesarean delivery (uCD).

METHODS

Patients with antenatal and postpartum Edinburgh Postnatal Depression Scale (EPDS) scores were compared by MOD and indication for uCD if applicable. Patients with an antenatal EPDS>12 were excluded to ascertain the incidence of new depression. The primary outcome was EPDS≥13 by MOD. The secondary outcome was EPDS≥13 by indication for uCD.

RESULTS

Seven hundred and thirty eight patients met inclusion criteria. There were statistically significant differences in MOD by age, race, BMI, and multi-gestation pregnancy. Patients delivered via uCD had a higher rate of peripartum complications and NICU admission. There were no differences in medical comorbidities or use of psychiatric medications by MOD. There was no difference in EPDS by MOD. The rate of PPD was higher in patients with uCD for non-reassuring fetal heart tones (NRFHT) compared to other indications for uCD (p=0.02).

CONCLUSIONS

While there was no difference in the incidence of PPD by MOD, the incidence of PPD was higher among patients delivered via uCD for NRFHT. These findings may have implications for patient counseling, post-operative mental health surveillance, and support of postpartum patients.

Associations among Caesarean Section Birth, Post-Traumatic Stress, and Postpartum Depression Symptoms

Caesarean section (C-section) deliveries account for nearly 30% of births annually with emergency C-sections accounting for 7-9% of all births. Studies have linked C-sections to postpartum depression (PPD). PPD is linked to reduced quality of parent-child interaction, and adverse effects on maternal and child health. New mothers' perceptions of more negative childbirth experiences, such as unplanned/emergency C-sections, are linked to post-traumatic stress disorder (PTSD), which in turn is related to PPD. Our objectives were to determine: (1) the association between C-section type (unplanned/emergency vs. planned) and PPD symptoms, and (2) if postnatal PTSD symptoms mediate this association. Employing secondary analysis of prospectively collected data from 354 mother-child dyads between 2009 and 2013 from the Alberta Pregnancy Outcomes and Nutrition (APrON) study, conditional process modeling was employed. The Edinburgh Postnatal Depression Scale (EPDS) and the Psychiatric Diagnostic Screening Questionnaire (PDSQ) were administered at three months postpartum, to assess for postpartum depressive and post-traumatic stress symptoms. The direct effect of emergency C-section on PPD symptoms was non-significant in adjusted and non-adjusted models; however, the indirect effect of emergency C-section on PPD symptoms with PTSD symptoms as a mediator was significant after controlling for prenatal depression symptoms, social support, and SES (β = 0.17 (SE = 0.11), 95% CI [0.03, 0.42]). This suggests that mothers who experienced an emergency or unplanned C-section had increased PTSD scores of nearly half a point (0.47) compared to mothers who underwent a planned C-section, even after adjustment. Overall, emergency C-section was indirectly associated with PPD symptoms, through PTSD symptoms. Findings suggest that PTSD symptoms may be a mechanism through which emergency C-sections are associated with the development of PPD symptoms.

Emergency cesarean section is a risk factor for depressive symptoms when breastfeeding is limited

OBJECTIVE

Previous studies indicated associations between cesarean section (CS), breastfeeding, and depressive symptoms. There is, however, little research integrating these variables into one model to analyze their interrelations. The aim of this observational prospective longitudinal study is to examine whether the effect of CS on postpartum depressive symptoms is mediated by difficulties with breastfeeding.

METHODS

The participants were recruited in 5 maternity hospitals during their prenatal medical check-ups. Breastfeeding status was self-reported by the mothers six weeks postpartum. Screening for depressive symptoms was performed at six weeks (N = 404) and nine months (N = 234) postpartum using the Edinburgh Postnatal Depression Scale. Path analysis was used to model the relations between CS, breastfeeding, and depressive symptoms.

RESULTS

No direct effects of CS on depressive symptoms at six weeks or nine months postpartum were found. CS was associated with a lower probability of exclusive breastfeeding, which was, in turn, associated with higher levels of depressive symptoms six weeks postpartum. The analysis stratified by type of CS revealed that the effect on breastfeeding only occurred with emergency, not planned, CS. The effect of CS on breastfeeding was noticeably stronger in women without versus with a history of depression.

CONCLUSION

Emergency CS predicts breastfeeding difficulties, which are, in turn, associated with higher levels of depressive symptoms. Support should be provided to mothers with emergency CS and breastfeeding problems to reduce the risk of postpartum depressive symptoms in the early postpartum period.

Clinician-reported childbirth outcomes, patient-reported childbirth trauma, and risk for postpartum depression

Childbirth trauma is common and increases risk for postpartum depression (PPD). However, we lack brief measures to reliably identify individuals who experience childbirth trauma and who may be at greater prospective risk for PPD. To address this gap, we used data from a racially diverse prospective cohort (n=1082). We collected survey data during pregnancy and at 12 weeks postpartum, as well as clinician-reported data from medical records. A new three-item measure of patient-reported childbirth trauma was a robust and independent risk factor for PPD, above and beyond other known risk factors for PPD, including prenatal anxiety and depression. Cesarean birth, greater blood loss, and preterm birth were each associated with greater patient-reported childbirth trauma. Finally, there were prospective indirect pathways whereby cesarean birth and higher blood loss were related to higher patient-reported childbirth trauma, in turn predicting greater risk for PPD. Early universal postpartum screening for childbirth trauma, targeted attention to individuals with childbirth complications, and continued screening for depression and anxiety can identify individuals at risk for PPD. Such efforts can inform targeted interventions to improve maternal mental health, which plays a vital role in infant development.

"I felt like I was left on my own": A mixed-methods analysis of maternal experiences of cesarean birth and mental distress in the United States

BACKGROUND

Postpartum depression (PPD) is the most common complication of childbearing. Understanding potential contributors, such as cesarean deliveries, is essential to improving maternal mental health. This study investigated the relationship between unplanned versus planned cesarean birth and postpartum depressive symptoms.

METHODS

We employed a sequential, mixed-methods approach wherein the Edinburgh Postnatal Depression Scale (EPDS) was first administered to participants who had experienced a cesarean birth within the previous 12 months. EPDS scores among those in the unplanned vs. planned cesarean groups were compared by means of SPSS. Twenty-five participants with EPDS scores >8 were then interviewed to provide subjective measures of maternal well-being. Interview data were subjected to thematic qualitative analysis using a modified grounded theory approach.

RESULTS

The average EPDS score from 120 participants with unplanned cesareans was 10.7 ± 6.4, with 68.5% scoring >8. The average EPDS score from 93 participants with planned cesarean births was 8.96 ± 5.7, with 52.7% scoring >8. The difference in mean score was statistically significant (P < 0.05). Interview findings revealed several important themes including: support, medical interaction, stress, recovery, breastfeeding, and sleep. In several cases, participants were not properly screened, or screening tool responses were ignored. Numerous participants reported medical interactions where they felt ignored by practitioners, including one interviewee who stated, "I got my tubes tied because it was so traumatizing that I never wanted to give birth again."

DISCUSSION

Findings suggest that unplanned cesareans have a higher incidence and severity of postpartum depressive symptoms. Interview analyses highlight important areas for improvement and concern about the current state of postpartum mental health care and physician-guided supports in this US sample.

Caesarean delivery and the use of antidepressants

BACKGROUND

The high ratio of caesarean sections (C-sections) is a major public health issue in the developed world; but its implications on maternal mental health are not well understood.

METHODS

We use individual-level administrative panel data from Hungary between 2010 and 2016 to analyze the relationship between caesarean delivery and antidepressant consumption, an objective indicator of mental health. We focus on low-risk deliveries of mothers without subsequent birth in 3 years, and include around 135 000 observations.

RESULTS

After controlling for medical and socio-economic variables, antidepressant use before delivery is associated with an elevated risk of C-section (adjusted OR = 1.10, 95% CI 1.05-1.14) and C-section is associated with a higher probability of antidepressant use within 1-3 years after delivery (e.g. adjusted OR = 1.21, 95% CI 1.12-1.30, within 3 years after delivery, among mothers without pre-delivery antidepressant consumption). Our data restriction ensures that the results are not driven by a mechanical impact of decreasing fertility on the continuation of antidepressant use after a C-section.

CONCLUSIONS

The results suggest that C-section is associated with worse mental health over the 1- to 3-year horizon after birth. This relationship is particularly important if a caesarean delivery is not necessary due to medical reasons, and physicians as well as expectant mothers should be made aware of the potential mental health implications of the mode of delivery.

Association between mode of delivery and postpartum depression: A systematic review and network meta-analysis

BACKGROUND

Postpartum depression is one of the most common postpartum diseases, which has an important impact on the interaction between mother, infant, partner and family, as well as the long-term emotional and cognitive development of infants. However, there are still great disagreements on whether the delivery mode will affect the risk of postpartum depression. The purpose of this study is to explore whether the mode of delivery will affect the risk of postpartum depression through the comprehensive network meta-analysis of elective cesarean section, emergency cesarean section, instrumental vaginal delivery and spontaneous vaginal delivery.

METHODS

We searched in three electronic databases: PubMed, EMBASE and Cochrane Library.

RESULTS

This paper included 43 studies with a total sample size of 1,827,456 participants. Direct meta-analysis showed that the odds ratio of postpartum depression risk was 1.33 (95% confidence interval = [1.21, 1.46]) between cesarean section and vaginal delivery. The odds ratios of high Edinburgh Postpartum Depression Scale score between cesarean section and vaginal delivery in the three postpartum periods (within 2 weeks, within half a year and over half a year) were basically the same. There was no difference between cesarean section and vaginal delivery in the risk of severe postpartum depression at the Edinburgh Postpartum Depression Scale cut-off point ⩾13 (odds ratio = 1.07; 95% confidence interval = [0.99, 1.16]). Network meta-analysis showed that the risk of postpartum depression in the pairwise comparisons emergency cesarean section vs spontaneous vaginal delivery and elective cesarean section vs spontaneous vaginal delivery was odds ratio = 1.53 (95% confidence interval = [1.22, 1.91]) and 1.47 (95% confidence interval = [1.16, 1.86]).

CONCLUSION

The mode of delivery has a significant effect on the occurrence of mild postpartum depression. Women who give birth by cesarean section, especially who give birth by emergency cesarean section, are at a higher risk of mild postpartum depression. We should carefully monitor the progress of postpartum mental disorders in women who delivered by cesarean section and make it possible for women to have a quick access to mental healthcare.

Prevalence of Postpartum Depression and Associated Predictors Among Taiwanese Women in a Mother-Child Friendly Hospital

Postpartum depression (PPD) is a highly prevalent disorder characterized by increased vulnerability to morbidity and mortality. This study explores the predictors and prevalence of PPD among Taiwanese women. A total of 914 postpartum women was recruited from a mother-child-friendly hospital. These participants completed self-report questionnaires at 1 month postpartum, and their medical records were also examined for relevant information. Multivariate analyses were used to identify independent predictors of PPD. At 1 month postpartum, 18.8% had developed PPD. Multivariate analysis showed that the odds ratios for PPD were significantly lower among women who were breastfeeding, had more family support, and attended a postpartum care center, while those who were younger, primiparous, and who experienced gestational complications had a higher prevalence of PPD. Meanwhile, structural equation modeling showed that family support from partners, parents, and parents-in-law diminished depression scores through direct effects.

Development and validation of a machine learning algorithm for predicting the risk of postpartum depression among pregnant women

OBJECTIVE

There is a scarcity in tools to predict postpartum depression (PPD). We propose a machine learning framework for PPD risk prediction using data extracted from electronic health records (EHRs).

METHODS

Two EHR datasets containing data on 15,197 women from 2015 to 2018 at a single site, and 53,972 women from 2004 to 2017 at multiple sites were used as development and validation sets, respectively, to construct the PPD risk prediction model. The primary outcome was a diagnosis of PPD within 1 year following childbirth. A framework of data extraction, processing, and machine learning was implemented to select a minimal list of features from the EHR datasets to ensure model performance and to enable future point-of-care risk prediction.

RESULTS

The best-performing model uses from clinical features related to mental health history, medical comorbidity, obstetric complications, medication prescription orders, and patient demographic characteristics. The model performances as measured by area under the receiver operating characteristic curve (AUC) are 0.937 (95% CI 0.912 - 0.962) and 0.886 (95% CI 0.879-0.893) in the development and validation datasets, respectively. The model performances were consistent when tested using data ending at multiple time periods during pregnancy and at childbirth.

LIMITATIONS

The prevalence of PPD in the study data represented a treatment prevalence and is likely lower than the illness prevalence.

CONCLUSIONS

EHRs and machine learning offer the ability to identify women at risk for PPD early in their pregnancy. This may facilitate scalable and timely prevention and intervention, reducing negative outcomes and the associated burden.

Birth signalling hormones and the developmental consequences of caesarean delivery

Rates of delivery by caesarean section (CS) are increasing around the globe and, although several epidemiological associations have already been observed between CS and health outcomes in later life, more are sure to be discovered as this practice continues to gain popularity. The components of vaginal delivery that protect offspring from the negative consequences of CS delivery in later life are currently unknown, although much attention to date has focused on differences in microbial colonisation. Here, we present the case that differing hormonal experiences at birth may also contribute to the neurodevelopmental consequences of CS delivery. Levels of each of the 'birth signalling hormones' (oxytocin, arginine vasopressin, epinephrine, norepinephrine and the glucocorticoids) are lower following CS compared to vaginal delivery, and there is substantial evidence for each that manipulations in early life results in long-term neurodevelopmental consequences. We draw from the research traditions of neuroendocrinology and developmental psychobiology to suggest that the perinatal period is a sensitive period, during which hormones achieve organisational effects. Furthermore, there is much to be learned from research on developmental programming by early-life stress that may inform research on CS, as a result of shared neuroendocrine mechanisms at work. We compare and contrast the effects of early-life stress with those of CS delivery and propose new avenues of research based on the links between the two bodies of literature. The research conducted to date suggests that the differences in hormone signalling seen in CS neonates may produce long-term neurodevelopmental consequences.

Prevalence of postpartum depression at the clinic for obstetrics and gynecology in Kosovo teaching hospital: Demographic, obstetric and psychosocial risk factors

INTRODUCTION

Postpartum depression affects 10 up to 15 % of women of childbearing age in industrialized countries and presents significant public health problem which leads to short and long-term consequences for mother, child and her family. However, social determinants, including poverty, gender stereotypes, domestic violence, gender discrimination and cultural differences make this medical issue more problematic in less developed countries. The aim of this study was to examine the prevalence and risk factors of postpartum depression at the Clinic for Obstetrics and Gynecology in Pristina, Kosovo (a tertiary referral center).

MATERIAL AND METHODS

A prospective observational cohort study was conducted from June 2019 to October 2019 at the Clinic for Obstetrics and Gynecology in Pristina, Kosovo. A total of 247 delivery women were screened for postpartum depression at 6 weeks following delivery using the Edinburg Postnatal Depression Scale (EPDS). Socio-demographic, obstetric and psychologic factors were tested as predictors of PPD using bivariate or multivariate logistic regression analysis (Logit model). Odds ratio (OR) with 95 % confidence intervals were calculated for each risk factor. The p values < 0.05 were considered statistically significant.

RESULTS

The prevalence of PPD at the Clinic for Obstetrics and Gynecology in Kosovo teaching hospital was 21 % at 6 weeks following childbirth. The bivariate and multivariate logistic regression analysis identified four predictor variables for postpartum depression: pregnancy complications (OR 1.057; 95 % CI; 1.002-1.114 and P = 0.040); fear of childbirth (OR 1.121; 95 % CI; 1.057-1.190 and P = 0.00016); prenatal depression or anxiety (OR 1.088; 95 % CI; 1.032-1.147 and P = 0.0018); poor marital relation (OR 1.085, 95 % CI; 1.002-1.174 and P = 0.044). No statistically significant association was found between the postpartum depression (PPD) and maternal age, education, employment, family type, smoking, previous abortion, parity, household income, social support, child gender, birthweight, and breast feeding.

CONCLUSIONS

The high prevalence of postpartum depression in our setting and its known adverse effects on woman, infant and her family implies an urgent need for evidence-based interventions. Such interventions are needed to promote knowledge of perinatal mental illness and improve maternal mental health in particular in less developed countries. Future efforts should address early identification of high-risk women, assessment of risk factor during the antenatal period, early postpartum depression screening and timely therapeutic approaches, to improve social and psychological functioning of the woman.

Association between habitual weekday sleep duration and depressive symptoms among Chinese adolescents:The role of mode of birth delivery

BACKGROUND

Depressive symptoms among adolescents are common. This study aimed to assess, among Chinese adolescents, the associations of habitual weekday sleep duration with depressive symptoms and whether these associations varied with the mode of birth delivery.

METHODS

Data were from the 2015 School-based Chinese Adolescents Health Survey, and 150,053 students' questionnaires were qualified for analysis. Multi-level logistic regression models were performed.

RESULTS

A weekday sleep duration of ≤5 h/night was associated with depressive symptoms (adjusted odds ratio [aOR]=2.98, 95% CI=2.75-3.24), and adolescents who reported a weekday sleep duration of 5-7 h/night (aOR=1.69, 95% CI=1.60-1.79) and >9 h/night (aOR=1.28, 95% CI=1.11-1.45) were also at a higher risk of depressive symptoms. Stratification analyses showed that in both adolescents delivered by vaginal birth and cesarean section (CS), a weekday sleep duration of ≤5 h/night, 5-7 h/night, and >9 h/night were associated with the increased risk of depressive symptoms in the adjusted models, and the magnitudes of the aORs in adolescents delivered by CS were slightly higher than those in adolescents delivered by vaginal birth.

LIMITATIONS

The cross-sectional study design and self-reported sleep duration and depressive symptoms.

CONCLUSION

This study demonstrates a significant U-shaped association between weekday sleep duration and depressive symptoms among Chinese adolescents. In both adolescents delivered by vaginal birth and CS, those who reported having abnormal sleep duration were at a high risk of depressive symptoms. Based on the findings of this study, we suggest sleep duration and mode of delivery should be a matter of concern for public health authorities.

Factors Associated with the Development of Postnatal Depression After Cesarean Delivery: A Prospective Study

PURPOSE

Pre-operative association factors (pain and psychological vulnerability) could significantly contribute to post-Cesarean pain; however, limited information is available on the development of postnatal depression (PND). We aimed to investigate the development of PND and its association with pain vulnerability and psychological vulnerability factors.

PATIENTS AND METHODS

Women undergoing Cesarean delivery under spinal anesthesia were given pre-operative questionnaires, psychological and pain assessments including pain on local anesthetic injection during spinal anesthesia and mechanical temporal summation. Post-operative assessments were administered at 6 to 10 weeks post-Cesarean delivery via follow-up survey to assess post-Cesarean psychological and pain outcomes.

RESULTS

PND occurred in 21.1% (43 of 205) of patients who underwent elective Cesarean delivery. An increased pre-operative pain score with movement (Odds ratio (OR) 1.65, 95% CI 1.12-2.44, p = 0.0110), anxiety about upcoming surgery (OR 1.02, 95% CI 1.00-1.04, p = 0.0429), higher pre-operative Hospital Anxiety and Depression Scale (HADS) subscale on anxiety (OR 1.25, 95% CI 1.07-1.45, p = 0.0041) and higher pre-operative central sensitization inventory (CSI) scores (OR 1.05, 95% CI 1.01-1.09, p = 0.0156) were independently associated with an increased risk of PND. Anticipated pain medication needs were associated with reduced risk of PND (OR 0.48, 95% CI 0.29-0.79, p = 0.0038) (Receiver operating characteristic (ROC) = 0.8177).

CONCLUSION

Higher pre-operative anxiety, pain score, central sensitization and lower anticipated pain medication needs were associated with increased risks of PND. Further work using larger sample size will be needed to validate the model in predicting PND development after Cesarean delivery.

Delivery mode is associated with maternal mental health following childbirth

Childbirth is a life-transforming event often followed by a time of heightened psychological vulnerability in the mother. There is a growing recognition of the importance of obstetrics aspects in maternal well-being with the way of labor potentially influencing psychological adjustment following parturition or failure thereof. Empirical scrutiny on the association between mode of delivery and postpartum well-being remains limited. We studied 685 women who were on average 3 months following childbirth and collected information concerning mode of delivery and pre- and postpartum mental health. Analysis of variance revealed that women who had cesarean section or vaginal instrumental delivery had higher somatization, obsessive compulsive, depression, and anxiety symptom levels than those who had natural or vaginal delivery as well as overall general distress, controlling for premorbid mental health, maternal age, education, primiparity, and medical complication in newborn. Women who underwent unplanned cesarean also had higher levels of childbirth-related PTSD symptoms excluding those with vaginal instrumental. The risk for endorsing psychiatric symptoms reflecting clinically relevant cases increased by twofold following unplanned cesarean and was threefold for probable childbirth-related PTSD. Maternal well-being following childbirth is associated with the experienced mode of delivery. Increasing awareness in routine care of the implications of operative delivery and obstetric interventions in delivery on a woman's mental health is needed. Screening at-risk women could improve the quality of care and prevent enduring symptoms. Research is warranted on the psychological and biological factors implicated in the mode of delivery and their role in postpartum adjustment.

Type of delivery is not associated with maternal depression

Although many women experience depressive symptoms during the first year after childbirth, the relationship between type of delivery and maternal depression is not clear. The purpose of this study is to evaluate relationship between type of delivery and maternal depression, between 6 to 16 months after childbirth. We performed a prospective cohort study of 558 low-socioeconomic status pregnant women without depression. All participants were recruited from primary care clinics of the public sector in three administrative districts in the Western area of the city of São Paulo, Brazil. Depressive symptoms were assessed using the Self-Report Questionnaire (SRQ-20). Type of delivery was classified as uncomplicated spontaneous vaginal delivery (UVD) (no episiotomy and no more than a first-degree perineal laceration), complicated vaginal delivery (CVD) (episiotomy or more than a second-degree perineal laceration), and cesarean delivery (CD). Data about type of delivery were extracted from medical charts. Crude and adjusted risk ratios with 95% confidence intervals were estimated using Poisson regression with robust variance estimates to examine the association between type of delivery with maternal depression. Among 482 women reassessed during 6 to 16 months after delivery, 18% had symptoms of depression. According to the type of delivery, 250 (51.8%), 85 (21.7%), and 147 (30.5%) were UVD, CVD, and CD, respectively. There was no association between type of delivery and maternal depression. In comparison with women submitted to uncomplicated vaginal, women who had a cesarean or perineal trauma/episiotomy did not show greater risk of maternal depression, in the medium to long term after delivery.

What If Pregnancy Is Not Seventh Heaven? The Influence of Specific Life Events during Pregnancy and Delivery on the Transition of Antenatal into Postpartum Anxiety and Depression

Introduction: Postpartum symptoms of anxiety and depression are known to have a negative impact on mother and child, and major life events constitute a major risk factor for these symptoms. We aimed to investigate to what extent specific life events during pregnancy, delivery complications, unfavorable obstetric outcomes, and antenatal levels of anxiety or depression symptoms were independently associated with postpartum levels of anxiety and depression symptoms. Methods: Within a prospective population-based cohort study (n = 3842) in The Netherlands, antenatal symptoms of anxiety or depression were measured at the end of the first trimester and at five months postpartum. Antenatal life events were assessed during the third trimester, and information on delivery and obstetric outcomes was obtained from midwives and gynecologists. Linear regression analyses were performed to quantify the associations. Results: Antenatal levels of both anxiety and depression symptoms were associated with postpartum levels of anxiety and depression symptoms. Life events related to health and sickness of self or loved ones, to the relation with the partner or conflicts with loved ones, or to work, finance, or housing problems were significantly associated with higher postpartum levels of anxiety symptoms (p < 0.001) and depression symptoms (p < 0.001) adjusted for antenatal levels. No statistically significant results were observed for pregnancy-related events, delivery complications, or unfavorable obstetric outcomes. Conclusions: Women with increased antenatal levels of anxiety or depression symptoms are at increased risk of elevated levels of both postpartum depression and anxiety symptoms. Experiencing life events during pregnancy that were not related to the pregnancy was associated with higher levels of anxiety and depression in the postpartum period, as opposed to pregnancy-related events, delivery complications, or unfavorable obstetric outcomes. These results suggest that events during pregnancy but not related to the pregnancy and birth are a highly important predictor for postpartum mental health.

Personality Traits and Postnatal Depression: The Mediated Role of Postnatal Anxiety and Moderated Role of Type of Birth

This study investigated how personality traits are related to postnatal depression 2 weeks after giving birth and whether these relations are mediated by postnatal anxiety, measured after 3–4 days after giving birth and moderated by the type of birth. New mothers (N = 672, Mage = 29.33) completed scales assessing their personality traits, postnatal anxiety, and postnatal depression 3 or 4 days after giving birth (T1). They also reported postnatal depression 2 weeks after giving birth (T2). Path analysis indicated that postnatal anxiety explained the link between personality traits (i.e., neuroticism) and postnatal depression 2 weeks after childbirth. The type of birth moderated the relation among, personality traits, postnatal anxiety and depression. Neuroticism and consciousness, in the natural birth’s group, and neuroticism and agreeableness, in the cesarean birth’s group, were associated with postnatal depression. Further, anxiety explained the relation between neuroticism and postnatal depression in both natural and cesarean birth groups. In addition, postnatal anxiety mediated the relation between extraversion and postnatal depression in the cesarean birth group. Our findings highlight that postnatal anxiety is a potential mechanism explaining how personality traits (i.e., neuroticism, extraversion) are related to postnatal depression, and that these relations may depend on the type of childbirth.

Early breastfeeding is associated with low risk of postpartum depression in Taiwanese women

Breastfeeding during the first week postpartum is recognised as essential, affecting the mother's mental health. The human milk from early breastfeeding also protects against infections via the secretory IgA antibodies and plays an important role in the newborn's development. At a Baby-Friendly Hospital, early breastfeeding was promoted to increase the benefits for the newborn, but few focussed on the mother's health. The association between breastfeeding and postpartum depression (PPD) has not been fully addressed. This study aimed to investigate the relationship between breastfeeding and postpartum depression (PPD) and it included 333 Taiwanese pregnant women. Women who had a higher score of Edinburgh Postnatal Depression Scale (EPDS) were significant older (age ≥ 35, p < .037), had a caesarean section delivery (p < .001), and a higher score of Brief Symptom Rating Scale-5 (p < .001). Higher scores on EPDS were significantly associated with lower rates of breastfeeding, which reflected cessation of breastfeeding as an important risk factor for PPD (Odds ratio: 2.159, CI: 1.220-3.821, p = .008). Other risk factors included caesarean section delivery (Odds ratio: 2.814, CI: 1.617-4.899, p < .001) and age ≥35 years (Odds ratio: 1.821, CI: 1.057-3.137, p = .031).IMPACT STATEMENTWhat is already known on this subject: Breastfeeding during the first week postpartum is recognised as essential, affecting the mother's mental health. The human milk from early breastfeeding also protects against infections via the secretory IgA antibodies and plays an important role in the newborn's development. The detail association between breastfeeding and postpartum depression has not yet been fully addressed.What the results of this study add: Higher scores on EPDS were significantly associated with lower rates of breastfeeding, which reflected cessation of breastfeeding as an important risk factor for PPD (Odds ratio: 2.159, CI: 1.220-3.821, p = .008). Other risk factors included caesarean section delivery (Odds ratio: 2.814, CI: 1.617-4.899, p < .001) and age ≥35 years (Odds ratio: 1.821, CI: 1.057-3.137, p = .031).What the implications are of these findings for clinical practice and/or further research? The early breastfeeding was significantly associated with postpartum depression. Other risk factors included caesarean section delivery and age ≥35 years.

Prevalence of postpartum depression regarding mode of delivery: a cross-sectional study

Purpose: To explore the prevalence of postpartum depression (PPD), as well as the relationship between delivery mode and postpartum depression among postnatal women utilizing the Arabic validated version of the Edinburgh Postnatal Depression Scale (EPDS).Materials and methods: 412 women with singleton gestation during their 3rd trimester without medical or psychological problems preceding or during pregnancy were included. All pregnant women were asked to fill out the Arabic version of Edinburgh Postnatal Depression Scale. Only women with EPDS score <13 during pregnancy were allowed to complete the study. 370 women were asked to repeat the EPDS at 8 and 16 weeks postnatal. The patients were divided into three groups according to their delivery mode; normal vaginal delivery, emergency or elective caesarian section.Results: Prevalence of postpartum depression was found to be significantly higher in emergency caesarian section group at the 8th and 16th postnatal weeks (25% and 19%, respectively) when compared to elective caesarian section group (21% and 13%, respectively) or normal vaginal delivery group (7% and 1.7%, respectively). The mean score of the EPDS in the normal vaginal delivery group at both assessments was significantly lower than those of the emergency and elective caesarian section groups.Conclusions: There was a strong relation between delivery mode and postpartum depression. Emergency CS showed a stronger correlation than elective caesarian section.

Mother's mental health after childbirth: Does the delivery method matter?

The dramatic increase in the utilization of caesarean section has raised concerns on its impact on public expenditure and health. While the financial costs associated with this surgical procedure are well recognized, less is known on the intangible health costs borne by mothers and their families. We contribute to the debate by investigating the effect of unplanned caesarean deliveries on mothers' mental health in the first nine months after the delivery. Differently from previous studies, we account for the unobserved heterogeneity due to the fact that mothers who give birth through an unplanned caesarean delivery may be different than mothers who give birth with a natural delivery. Identification is achieved exploiting exogenous variation in the position of the baby in the womb at the time of delivery while controlling for hospital unobserved factors. We find that mothers having an unplanned caesarean section are at higher risk of developing postnatal depression and this result is robust to alternative specifications.

Commonly occurring adverse birth outcomes and maternal depression: a longitudinal study

OBJECTIVES

Little is known about whether commonly occurring adverse birth outcomes have a long-term impact on the mental health of mothers. The aim of this study was to investigate whether commonly occurring adverse birth outcomes predicted mothers' depressive-symptom trajectories over a 27-year period following the birth of a baby.

STUDY DESIGN

Longitudinal study.

METHODS

Participants comprised a sub-group of women from the longitudinal cohort of the Mater and University of Queensland Study of Pregnancy. Maternal depression was measured at six time points from the first clinic visit of an index pregnancy to 27 years after birth. A semi-parametric mixture model was used to identify three symptom trajectories of low-stable, moderate-stable and moderate-rising depression. Multinomial logistic regression was then used to determine whether a number of commonly occurring birth outcomes predicted moderate-stable and/or moderate-rising depression trajectories over the subsequent 27 years. Sociodemographic and behavioural factors were used to adjust for possible confounding.

RESULTS

After adjustment for potential confounders, none of the adverse birth outcomes predicted subsequent maternal depression trajectories. Teenage pregnancy, not completing high school, low family income, obesity, poorer quality partnership and not exercising, measured at women's first clinic visit, and small social networks at three to five days after birth, were significantly associated with women's moderate-rising depressive-symptoms trajectory over 27 years.

CONCLUSIONS

Commonly occurring adverse birth outcomes do not predict long-term depressive trajectories. A number of sociodemographic and behavioural factors present at the index pregnancy predict women's long-term pattern of depression throughout their reproductive life course.

Understanding the relationship between cesarean birth and stress, anxiety, and depression after childbirth: A nationwide cohort study

BACKGROUND

Women who undergo cesarean birth might have an increased risk for poor mental health after childbirth, possibly because of maternal and neonatal physical problems, low parental confidence, and decreased levels of oxytocin. However, this relationship remains controversial and requires further examination. The study aimed to examine the effect of cesarean birth on postpartum stress, anxiety, and depression.

METHODS

This nationwide population-based cohort study was conducted using the Taiwan National Health Insurance Database. A total of 12 619 women who underwent cesarean birth and 12 619 control women who underwent vaginal birth were matched by propensity score based on age, socioeconomic status, residential urbanicity, antepartum comorbidity, and index year of delivery. We compared the incidence of stress, anxiety, and depression during the first postpartum year between cesarean and comparison groups by calculating incidence rate ratios (IRRs).

RESULTS

The cesarean group showed a significantly higher risk for stress symptoms (IRR 1.4 [95% confidence interval {CI} 1.02-1.92]), but not anxiety (IRR 1.14 [95% CI 0.95-1.38]) or depression (IRR 1.32 [95% CI 0.94-1.87]), although the IRRs were also greater than one. The cesarean group had a significantly higher risk of any of the above-listed three disorders than the comparison group (incidence 27.6 vs 23.4 per 1000 person-years; IRR 1.18 [95% CI 1.01-1.38]).

CONCLUSIONS

Cesarean birth was associated with an increased risk of postpartum stress symptoms. Health professionals should avoid unnecessary cesarean birth, pay attention to women who deliver by cesarean, and intervene appropriately in an attempt to improve mental health among postpartum women.

The synergistic effect of breastfeeding discontinuation and cesarean section delivery on postpartum depression: A nationwide population-based cohort study in Korea

BACKGROUND

The relationships between breastfeeding discontinuation and cesarean section delivery, and the occurrence of postpartum depression (PPD) remain unclear. Therefore, we aimed to investigate the association of breastfeeding discontinuation and cesarean section delivery with PPD during the first 6 months after delivery.

METHODS

Data were extracted from the Korean National Health Insurance Service-National Sample Cohort for 81,447 women who delivered during 2004-2013. PPD status was determined using the diagnosis code at outpatient or inpatient visit during the 6-month postpartum period. Breastfeeding discontinuation and cesarean section delivery were identified from prescription of lactation suppression drugs and diagnosis, respectively. Cox proportional hazards models were used to calculate adjusted hazard ratios.

RESULTS

Of the 81,447 women, 666 (0.82%) had PPD. PPD risk was higher in women who discontinued breastfeeding than in those who continued breastfeeding (hazard ratio=3.23, P<0.0001), in women with cesarean section delivery than in those with vaginal delivery (hazard ratio=1.26, P=0.0040), and in women with cesarean section delivery who discontinued breastfeeding than in those with vaginal delivery who continued breastfeeding (hazard ratio=4.92, P<0.0001).

LIMITATIONS

Study limitations include low PPD incidence; use of indirect indicators for PPD, breastfeeding discontinuation, and working status, which could introduce selection bias and errors due to miscoding; and potential lack of adjustment for important confounders.

CONCLUSIONS

Breastfeeding discontinuation and cesarean section delivery were associated with PPD during the 6-month postpartum period. Our results support the implementation of breastfeeding promoting policies, and PPD screening and treatment programs during the early postpartum period.

Cesarean section and risk of postpartum depression: A meta-analysis

OBJECTIVE

The association of cesarean section (CS) with the risk of postpartum depression (PPD) remains controversial. Therefore, we conducted a meta-analysis to explore the association between CS and the risk of PPD.

METHODS

A systematic literature search was performed in PubMed, Web of Science and Embase databases for relevant articles up to November 2016. Pooled odds ratios (ORs) with 95% confidence intervals (CIs) were calculated with fixed-effects model or random-effects model.

RESULTS

A total of 28 studies from 27 articles involving 532,630 participants were included in this meta-analysis. The pooled OR of the association between CS and PPD risk was 1.26 (95% CI: 1.16-1.36). In subgroup analyses stratified by study design [cohort studies: (1.25, 95% CI: 1.10-1.41); case-control studies: (1.25, 95% CI: 1.00-1.56); cross-sectional studies: (1.44, 95% CI: 1.14-1.82)] and adjustment status of complications during pregnancy [adjusted for: (1.29, 95% CI: 1.12-1.48); not-adjusted for: (1.24, 95% CI: 1.13-1.36)], the above-mentioned associations remained consistent. The pooled ORs of PPD were 1.15 (95% CI: 0.92-1.43) for elective cesarean section (ElCS) and 1.47 (95% CI: 1.33-1.62) for emergency cesarean section (EmCS).

CONCLUSION

This meta-analysis suggests that CS and EmCS increase the risk of PPD. Further evidence is needed to explore the associations between the specific types of CS and the risk of PPD.

The impact of prenatal psychologic and obstetric parameters on postpartum depression in late-term pregnancies: A preliminary study

OBJECTIVE

To determine the prenatal psychologic (anxiety and depression) and perinatal obstetric (pregnancy and labor complications) predictors of postpartum depression (PPD) in late-term pregnancies.

MATERIALS AND METHODS

A total of 149 women with late-term gestation who were hospitalized for antenatal fetal surveillance were included. All participants were asked to complete Hospital Anxiety and Depression Scale immediately after hospitalization and Edinburgh Postnatal Depression Scale in the postpartum period. Demographic, psychologic, and obstetric variables were tested as predictors of PPD by regression analysis.

RESULTS

High scores for prenatal anxiety, depression, and PPD were detected in 17.4%, 12.8%, and 23.5% of the participants, respectively. The mode of delivery was not associated with PPD for late-term pregnancies. Women having urgent cesarean, planned cesarean, and vaginal delivery had similar rates of PPD (28.1%, 23.8%, and 21.9%, respectively). In the multivariant analysis, prenatal depression [odds ratio (OR), 9.85; 95% confidence interval (CI), 2.72-35.65], prenatal anxiety (OR, 4.95; 95% CI, 1.59-15.39) and suspicion of fetal distress (OR, 4.44; 95% CI, 1.13-13.64) were found to be independent predictors of PPD.

CONCLUSION

For late-term pregnancies, women with prenatal anxiety or depression and had cesarean delivery due to the suspicion of fetal distress were at risk for PPD.

Sociodemographic and delivery risk factors for developing postpartum depression in a sample of 3233 mothers from the Czech ELSPAC study

BACKGROUND

In the postpartum period, certain groups of women are at a higher risk for developing depressive episodes. Several studies have described risk factors for developing postpartum depression (PPD). However, these studies have used limited numbers of participants, and therefore the estimated prevalence of PPD varies greatly.

METHODS

The objective of this study is to identify the main risk factors for developing PPD by using data collected via the Czech version of the European Longitudinal Study of Pregnancy and Childhood (ELSPAC). This database provides a representative sample (n = 7589) observed prospectively and a large amount of data on depressive symptoms and on biological, socioeconomic, and environmental factors. The Edinburgh Postnatal Depression Scale (EPDS) was used to screen for incidence of PPD. The affective pathology was examined at three time points: before delivery, 6 weeks after delivery, and 6 months after delivery.

RESULTS

The prevalence of depressive symptoms before delivery was 12.8%, 6 weeks after delivery 11.8%, and 6 months after delivery 10.1%. The prevalence rates are based on women who completed questionnaires at all three time-points (N = 3233). At all three time points, the main risk factors for developing PPD identified as significant by both univariate and multivariate analysis were personal history of depressive episodes and mothers experiencing psychosocial stressors. Other risk factors occurring in both types of analysis were: family history of depression from expectant mother's paternal side (prenatal), mothers living without partners (6 weeks postpartum) and feelings of unhappiness about being pregnant (6 months postpartum). Several protective factors were also observed: male child gender (prenatal), primiparous mothers (6 months postpartum), and secondary education (prenatal, only by multivariate analysis). Significant risk factors found solely by univariate analysis were family history of depression in both parents of the expectant mother (prenatal and 6 weeks postpartum), family history of depression from subject's maternal side (6 months postpartum), unintentional pregnancy (prenatal and 6 weeks postpartum), feelings of unhappiness about being pregnant (prenatal and 6 weeks postpartum), primary education (prenatal and 6 weeks postpartum), mothers who opted not to breastfeed (6 months postpartum) and mothers living without partners (prenatal and 6 months postpartum). Family savings were identified as protective factor (prenatal and 6 months postpartum).

CONCLUSIONS

We identified significant predictors of PPD. These predictors can be easily detected in clinical practice, and systematic screening can lead to identifying potentially at risk mothers. Since the risk is linked with experience of psychosocial stressors it seems that they might benefit from increased psychosocial support to prevent affective pathology.

The birth experience and women's postnatal depression: A systematic review

BACKGROUND

maternal postnatal depression confers strong risk for impaired child development. Little is known about the association between women's postnatal birth experience and postnatal depression.

PURPOSE

to systematically identify and review studies examining the association between the birth experience and postnatal depression.

METHODS

a systematic search strategy was employed using the Matrix Method (Garrard, 2014) and guided by the PRISMA reporting process.Criteria included broad search terms, English language, and publication years 2000-2015. The search revealed 1536 abstracts narrowed to full-text review of 112 studies.

FINDINGS

eleven of the 15 studies meeting search criteria demonstrated a significant association between women's postnatal birth experience and postnatal depression. Results show heterogeneity in birth experience instruments. Strength of evidence and potential for bias are discussed.

KEY CONCLUSIONS

in spite of methodological limitations, the weight of evidence suggests that a negative birth experience may contribute to postnatal depression. Further research is warranted.

IMPLICATIONS FOR PRACTICE

to promote a positive birth experience healthcare providers should provide supportive, nurturing care that promotes women's confidence, trust, respect, privacy, shared decision making, and feeling of safety. Healthcare policy that promotes quality caregiving may reduce risk of postnatal depression.

Childbirth and symptoms of postpartum depression and anxiety: a prospective birth cohort study

We investigated associations between aspects of childbirth and elevated postpartum symptoms of depression and anxiety. We employed secondary analysis of perinatal data (N = 4657-4946) from the Avon Longitudinal Study of Parents and Children (ALSPAC) birth cohort. Multivariable logistic regression models (adjusted for covariates) examined predictors of elevated symptoms of postpartum depression and anxiety. Predictors included the following: type of delivery (normal physiological vs. interventive non-physiological), immediate postpartum complications, and maternal perception of the recent birth experience. The Edinburgh Postnatal Depression Scale assessed elevated symptoms of depression (score ≥ 13), and the Crown-Crisp Experiential Index assessed elevated symptoms of anxiety (score ≥ 9) at 2 and 8 months after delivery. A more negative perception of the recent birth experience was associated with elevated symptoms of anxiety at 2 months [odds ratio (OR) 1.52, 95 % confidence interval (CI) 1.25-1.85] and 8 months (OR 1.30, 95 % CI 1.06-1.60) postpartum but was not associated with elevated symptoms of depression at either time point. Type of delivery (physiological vs. non-physiological) and immediate postpartum complications were not associated with elevated symptoms of depression or anxiety. Our findings suggest that improving women's childbirth experience may decrease the likelihood of postpartum anxiety, but not postpartum depression.

Trajectories and predictors of women's depression following the birth of an infant to 21 years: a longitudinal study

Little is known about the long-term mental health of women following the birth of an infant. This study describes the 21 year trajectory of women's depression following the birth of an infant and identifies early predictors of post-birth maternal depression trajectories. The sample comprises 2,991 women from the Mater and University of Queensland Study of Pregnancy. Using the Delusions-Symptoms-States-Inventory, depression was measured at 6 months, 5, 14 and 21 years after the birth. These measures were clustered and in addition bivariate and multivariate analyses were used to test for significant association between the groups and a range of maternal socio-demographic, psychological and pregnancy-related factors. Two depression trajectories were produced, a no-low depression group (79.0 %) and a high-escalating depression group (21.0 %). The strongest predictors for a high-escalating depression group were conflict in the partner-relationship (p < 0.001), anxiety (p < 0.001) and stress (p < 0.001) in the antenatal period, having many pregnancy symptoms (p < 0.001), being younger (p < 0.001) and having poorer social networks (p < 0.001). To a lesser extent not completing high school (p < 0.05), being unsure about wanting the pregnancy (p < 0.05) and not wanting contact with the infant following the birth (p < 0.05) were also predictors for high-escalating depression trajectory. Our findings suggest a sub-sample of mothers experience persistent depressive symptoms over a 21 year period following the birth of their infant. Partner conflict, inadequate social supports and poor mental health during the pregnancy, rather than factors relating to the birth event, contribute to women's depressive symptoms in the long-term. Given the identification of early markers for persistent depression, there may be opportunities for intervention for at-risk pregnant women.

Sociodemographic, pregnancy, obstetric, and postnatal predictors of postpartum stress, anxiety and depression in new mothers

BACKGROUND

The purpose of this paper was to evaluate relationships between sociodemographic, pregnancy, obstetric, and postnatal variables and postpartum depression, anxiety and stress levels in new mothers.

METHOD

One-hundred-thirty-nine women completed the baseline questionnaire and 105 completed the follow-up questionnaire at 4-6 months postpartum. Sociodemographic and pregnancy factors were assessed at baseline, birth and postnatal factors were assessed at time 2, and depression, anxiety, and stress were assessed at both time points.

RESULTS

Caesarean delivery was associated with high postpartum depression, anxiety, and stress levels. Child sleep problems was related to depression, child health problems were related to anxiety, more SLE related to high stress, and maternal sleep problems were related to PPD. However, the results became non-significant after controlling for antenatal distress levels. Finally, women who underwent caesarean delivery had higher antenatal stress, anxiety, and depression levels, relative to women who did not undergo the procedure.

CONCLUSION

Psychological stress and distress tended to persist in the women from the third-trimester of pregnancy to 4-6 months postpartum. It tended to occur in the context of caesarean delivery, maternal sleep problems, child's health and sleep problems, and stressful life-events.

Mode of delivery and postpartum depression: the role of patient preferences

OBJECTIVE

The purpose of this study was to explore the relationship between strength of preference for vaginal delivery, delivery mode undergone, and postpartum depression.

STUDY DESIGN

We conducted a secondary analysis of data from a longitudinal study of delivery-mode preferences. During an interview between 24-36 weeks of gestation, participants were asked whether they preferred vaginal or cesarean delivery; the strength of this preference was measured by the standard gamble metric. Depression was assessed antepartum and at 8-10 weeks and 6-8 months after delivery by using the Patient Health Questionnaire (PHQ-9). The primary outcome was PHQ-9 score at 8-10 weeks after delivery. We used multivariable regression analysis to assess the effect of strength of preference for vaginal delivery and delivery mode undergone on postpartum depression.

RESULTS

Of 160 participants, 33.1% were nulliparous, and 30.6% had a previous cesarean delivery. Most of the participants (92.4%) preferred vaginal delivery, but the strength of preference varied substantially. The mean strength-of-preference score (0-1 scale; higher scores denote stronger vaginal delivery preference) was 0.658 (SD, ±0.352). A significant interaction emerged between the effects of delivery mode and vaginal delivery preference score on postpartum PHQ-9 score (P = .047). Specifically, a stronger preference for vaginal delivery was associated with higher PHQ-9 scores among women who underwent cesarean delivery (P = .027) but not among women who underwent vaginal delivery (P = .761). The interaction between delivery mode and vaginal delivery preference score was no longer significant at 6-8 months after delivery.

CONCLUSION

Women who have a strong antepartum preference for vaginal delivery and deliver by cesarean may be at increased risk for depression in the early postpartum period.

In search of neural endophenotypes of postpartum psychopathology and disrupted maternal caregiving

This is a selective review that provides the context for the study of perinatal affective disorder mechanisms and outlines directions for future research. We integrate existing literature along neural networks of interest for affective disorders and maternal caregiving: (i) the salience/fear network; (ii) the executive network; (iii) the reward/social attachment network; and (iv) the default mode network. Extant salience/fear network research reveals disparate responses and corticolimbic coupling to various stimuli based upon a predominantly depressive versus anxious (post-traumatic stress disorder) clinical phenotype. Executive network and default mode connectivity abnormalities have been described in postpartum depression (PPD), although studies are very limited in these domains. Reward/social attachment studies confirm a robust ventral striatal response to infant stimuli, including cry and happy infant faces, which is diminished in depressed, insecurely attached and substance-using mothers. The adverse parenting experiences received and the attachment insecurity of current mothers are factors that are associated with a diminution in infant stimulus-related neural activity similar to that in PPD, and raise the need for additional studies that integrate mood and attachment concepts in larger study samples. Several studies examining functional connectivity in resting state and emotional activation functional magnetic resonance imaging paradigms have revealed attenuated corticolimbic connectivity, which remains an important outcome that requires dissection with increasing precision to better define neural treatment targets. Methodological progress is expected in the coming years in terms of refining clinical phenotypes of interest and experimental paradigms, as well as enlarging samples to facilitate the examination of multiple constructs. Functional imaging promises to determine neural mechanisms underlying maternal psychopathology and impaired caregiving, such that earlier and more precise detection of abnormalities will be possible. Ultimately, the discovery of such mechanisms will promote the refinement of treatment approaches toward maternal affective disturbance, parenting behaviours and the augmentation of parenting resiliency.

Early identification of women at risk of postpartum depression using the Edinburgh Postnatal Depression Scale (EPDS) in a sample of Lebanese women

BACKGROUND

During the postpartum period, women are vulnerable to depression affecting about 10 to 20% of mothers during the first year after delivery. However, only 50% of women with prominent symptoms are diagnosed with postpartum depression (PPD). The Edinburgh Postnatal Depression Scale (EPDS) is the most widely used screening instrument for PPD . The main objectives of this study are to assess whether an EPDS score of 9 or more on day 2 (D2) postpartum is predictive of a depressive episode between days 30 and 40 postpartum (D30-40), to determine the risk factors as well as the prevalence of PPD in a sample of Lebanese women and to determine a threshold score of EPDS predictive of PPD.

METHODS

A sample of 228 women were administered the EPDS on D2. An assessment for PPD was done on D30-40 during a telephone interview.

RESULTS

On D2, the average score on EPDS was 7.1 (SD = 5.2) and 33.3% of women had an EPDS score ≥ 9. On D30-40 postpartum, the average score was 6.5 (SD = 4.7) and 19 women (12.8%) presented with PPD. A positive correlation was shown between scores on EPDS on D2 and D30-40 (r = 0.5091, p < 0.0001). A stepwise regression shows that an EPDS score ≥9 on D2 (p < 0.001) and a personal history of depression (p = 0.008) are significantly associated with the diagnosis of PPD on D30-40.

CONCLUSION

The EPDS may be considered as a reliable screening tool on as early as D2 after delivery. Women with EPDS score ≥ 9 and/or a positive personal history of major depressive disorder should benefit from a closer follow-up during the rest of the post-partum period.

Factors associated with depressive symptoms in the early postpartum period among women with recent gestational diabetes mellitus

Women with gestational diabetes mellitus (GDM) have a substantial risk of subsequently developing type 2 diabetes. This risk may be mitigated by engaging in healthy eating, physical activity, and weight loss when indicated. Since postpartum depressive symptoms may impair a woman's ability to engage in lifestyle changes, we sought to identify factors associated with depressive symptoms in the early postpartum period among women with recent GDM. The participants are part of the baseline cohort of the TEAM GDM (Taking Early Action for Mothers with Gestational Diabetes Mellitus) study, a one-year randomized trial of a lifestyle intervention program for women with a recent history of GDM, conducted in Boston, Massachusetts between June 2010 and September 2012. We administered the Edinburgh Postnatal Depression Scale (EPDS) at 4-15 weeks postpartum to women whose most recent pregnancy was complicated by GDM (confirmed by laboratory data or medical record review). An EPDS score ≥9 indicated depressive symptoms. We measured height and thyroid stimulating hormone, and administered a questionnaire to collect demographic data and information about breastfeeding and sleep. We calculated body mass index (BMI) using self-reported pre-pregnancy weight and measured height. We reviewed medical records to obtain data about medical history, including history of depression, mode of delivery, and insulin use during pregnancy. We conducted bivariable analyses to identify correlates of postpartum depressive symptoms, and then modeled the odds of postpartum depressive symptoms using multivariable logistic regression. Our study included 71 women (mean age 33 years ± 5; 59 % White, 28 % African-American, 13 % Asian, with 21 % identifying as Hispanic; mean pre-pregnancy BMI 30 kg/m(2) ± 6). Thirty-four percent of the women scored ≥9 on the EPDS at the postpartum visit. In the best fit model, factors associated with depressive symptoms at 6 weeks postpartum included cesarean delivery (aOR 4.32, 95 % CI 1.46, 13.99) and gestational weight gain (aOR 1.21 [1.02, 1.46], for each additional 5 lbs gained). Use of insulin during pregnancy, breastfeeding, personal history of depression, and lack of a partner were not retained in the model. Identifying factors associated with postpartum depression in women with GDM is important since depression may interfere with lifestyle change efforts in the postpartum period. In this study, cesarean delivery and greater gestational weight gain were correlated with postpartum depressive symptoms among women with recent GDM (Clinicaltrials.gov NCT01158131).

Antenatal maternal mental health as determinant of postpartum depression in a population based mother-child cohort (Rhea Study) in Crete, Greece

PURPOSE

Antenatal maternal mental health has been identified as an important determinant of postpartum depression (PPD). We investigated the occurrence of depression both antenatally and postnatally and examined whether maternal trait anxiety and depression during pregnancy were associated with PPD at 8 weeks postpartum in a prospective mother-child cohort (Rhea Study) in Crete, Greece.

METHODS

438 women completed the Edinburgh Postnatal Depression Scale (EPDS) and the Trait subscale of the State-Trait Anxiety Inventory (STAI-Trait) questionnaires assessing antenatal depression and anxiety, respectively, during the third trimester of pregnancy as well as the EPDS at 8 weeks postpartum.

RESULTS

The prevalence of women with probable depression (EPDS score ≥13) was 16.7 % at 28-32 weeks of pregnancy and 13.0 % at 8 weeks postpartum. A per 5 unit increase in the STAI-Trait subscale increased the odds for PPD by 70 % (OR = 1.70, 95 % CI 1.41, 2.05), whereas a per unit increase in EPDS during pregnancy increased the odds for PPD by 27 % (OR = 1.27, 95 % CI 1.19, 1.36).

CONCLUSIONS

Our findings suggest that antenatal maternal psychological well-being has a significant effect on PPD, which might have important implications for early detection during pregnancy of women at risk for postpartum depression.

Predictors of postpartum depression: prospective study of 264 women followed during pregnancy and postpartum

The prevalence of postpartum depression is approximately 13%. Postpartum depression is associated with a higher maternal morbidity and mortality, and also with pervasive effects on the emotional, cognitive and behavioral development of the child. The aim of our study was to identify socio-demographic, psychosocial and obstetrical risk factors of postpartum depression in a middle class community sample, using a prospective design. We enrolled consecutively 312 pregnant outpatients in a single maternity unit. The first assessment was conducted between 32 and 41 weeks gestation, and a second time between 6 and 8 weeks after delivery. Depressive symptoms were measured using the French version of the Edinburgh Postnatal Depression Scale (EPDS). A cut-off score of 12/30 or above was considered as indicative of Major Depression. Of the initial sample of 312 women, 264 (84.6%) were followed-up between 6 and 8 weeks after delivery and considered for analysis. Depression during pregnancy, migrant status, and physical abuse by the partner were independently associated with postpartum depression when considered together, whereas physical complications were significantly associated with postpartum depression only when adjusting for antenatal depression. Depression during pregnancy, history of physical abuse, migrant status and postpartum physical complications are four major risk factors for postpartum depression.