Investigating Factors Associated with the Development of Postnatal Depression After Cesarean Delivery: A Validation Cohort Study

Abstract

Purpose

This study aimed to validate a proposed association model previously published to determine the clinical relevance of pre-operative determinants in the development of PND after Cesarean delivery (CD).

Patients and Methods

Parturients undergoing elective CD under neuraxial anesthesia were recruited for a prospective cohort study between Oct 2021 and Oct 2022 at KK Women’s and Children’s Hospital, Singapore. Predelivery pain, psychological and mechanical temporal summation, and demographic data were recorded. A follow-up survey was conducted at 6 to 10 weeks after CD. The primary outcome was the incidence of PND, defined as an Edinburgh Postnatal Depression Scale (EPDS) score ≥ 10.

Results

A total of 180 patients were recruited for validation. PND 6 to 10 weeks post-delivery occurred in 18.9% of recruited parturients. Multivariate regression analyses showed that higher pre-operative CSI scores (p=0.0156), higher anxiety levels about upcoming surgery (p=0.0429), increased pre-operative pain scores on movement (p=0.0110), and higher pre-operative HADS subscale scores on anxiety (p=0.0041) were independently associated with the development of PND weeks post-CD. Lower anticipation of pain medication needs (p=0.0038) was independently associated with the development of PND post-CD. The area under curve (AUC) of this multivariable model (training cohort), internal cross validation (training cohort) and external cross validation (validation cohort) were 0.818 (95% CI, 0.746 to 0.889), 0.785 (95% CI, 0.707 to 0.864) and 0.604 (95% CI, 0.497 to 0.710) respectively.

Conclusion

The proposed model performed well in a local population. Further refinement is necessary to test the proposed model in populations with social and cultural differences.

Keywords:

• anxiety
• obstetrics
• pain
• postnatal depression

Abbreviations

PND, postnatal depression; CD, Cesarean delivery; ROC, receiver operating characteristic; STROBE, STrengthening the Reporting of Observational studies in Epidemiology; MTS, Mechanical temporal summation; PCS, Pain Catastrophizing Scale; CSI, Central Sensitization Inventory; HADS, Hospital Anxiety and Depression Scale; EPDS, Edinburgh Postnatal Depression Scale; NRS, numerical rating scale; SD, standard deviation; IQR, interquartile range; OR, odds ratio; 95% CI, 95% confidence interval; AUC, area under the curve.

Data Sharing Statement

The datasets generated and analyzed in this study are available to anyone who wishes to access the data by contacting the corresponding author.

Ethics Approval and Informed Consent

This study was approved by the SingHealth Centralized Institutional Review Board (SingHealth CIRB 2017/2381) and registered on ClinicalTrials.gov (NCT03645239) on 22 Jun 2017. The authors declare that all recruited patients provided informed consent and that this work was conducted in accordance with the Declaration of Helsinki.

Consent for Publication

All the patients provided informed consent for the use of de-identified data for publication.

Acknowledgments

We would like to thank Ms. Agnes Teo (Senior Clinical Research Coordinator), Ms. Mandaline Teo, Ms. Dianna Sri Dewi (Clinical Research Coordinators), and the staff of the major operating theatres for their support and assistance with the study.

Author Contributions

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

Disclosure

The authors report no conflicts of interest in this work.

Additional information

Funding

This study was supported by the SingHealth Duke-NUS Anesthesiology and Perioperative Sciences Academic Clinical Program Pilot Research Grant (reference number: ANAESPRG18/02). DJA Tan received support from the SingHealth Residency Supplementary Residency Training Fund (SRTF). SYX Chow and BL Sng are awarded the Academic Medicine - Enhancing Training, Healthcare, Outcomes and Standards (AM-ETHOS) Duke-NUS Medical Student Research Fellowship Award year 2023–24 (ref no. AM-ETHOS01/FY2023/23-A23).