Journal of Womens Health, Issues and Care ISSN: 2325-9795

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Research Article, J Womens Health Issues Care Vol: 6 Issue: 3

Maternal 3-Month Postpartum Physical Health Problems, Depression, and their Relations to the Mode of Delivery: A Cohort Study in Jeddah

Ghadi Faisal Subahi* and Bakr Kalo

HESN Coordinator Deputy, Jeddah, Saudi Arabia

*Corresponding Author : Dr. Ghadi Faisal Subahi
HESN Coordinator Deputy, Ministry of Health, Jeddah, Saudi Arabia
Tel: 00966542110066
E-mail:
[email protected]

Received: May 02, 2016 Accepted: June 16, 2017 Published: June 20, 2017

Citation: Subahi GF, Kalo B (2017) Maternal 3-Month Postpartum Physical Health Problems, Depression, and their Relations to the Mode of Delivery: A Cohort Study in Jeddah. J Womens Health, Issues Care 6:3. doi: 10.4172/2325-9795.1000274

Abstract

Background: Postpartum physical and emotional health remains unaddressed by researchers, clinicians and women themselves. An important factor that affects postpartum recovery is the method of delivery. The objectives of this study were to estimate the incidence of postpartum physical health problems and depression in the first three months after delivery and to identify their relationship with mode of delivery along with other factors associated with the incidence of postpartum depression (PPD).
Methods: In this prospective cohort study, women were recruited from three public hospitals within 24-48 hours after delivery. Edinburgh postpartum depression scale (EPDS) and structured validated questionnaires were used. Follow-ups were conducted at 1-week and 3-months after delivery.
Results: The most prevalent 3-month physical health problems were insomnia (75%), fatigue (70%), and back pain (65%). There was a high incidence of nipple pain (73%) and vaginal itch (25%) in the spontaneous vaginal delivery (SVD) group during the immediate (1-week) postpartum period, whereas wound pain was
higher in the cesarean section (CS) group during the immediate (94%) and 3-month follow-up (55%) postpartum period. The incidence of 3-month PPD (EPDS>=12) was 28% in SVD group and 24% in CS group. There was no effect of the delivery mode on EPDS scores (p=0.59). Wanted pregnancy (OR=0.507), higher number of living children (OR=0.631), gravidity (OR=1.36), and income (OR= 0.536) were protective factors for immediate PPD.
Conclusions: Postpartum physical health problems and depression are common after delivery. Health care providers should be aware of these to perform early screening and interventions to alleviate them.

Keywords: Cesarean section; Edinburgh postpartum depression scale; Postpartum depression

Abbreviations

AVD: Assisted/Instrumental Vaginal Delivery; CS: Cesarean Section; PPD: Postpartum Depression; SVD: Spontaneous Vaginal Delivery; MCH: Maternity and Children’s Hospitals; KAUH: King Abdul-Aziz University Hospital; EPDS: Edinburgh Postnatal Depression Scale; OR: Odd Ratios

Introduction

The experience of having a baby and becoming a mother is a transformative event for most women, but unfortunately, it has not received the attention warranted [1]. It can affect the mother’s selfesteem, sense of success, emotional connection with the child, and the health of the family [2]. After the birth and mother’s initial recovery, her postpartum physical and mental health is largely ignored, without recognizing their impact on the lives of new mothers and their families [1].

An important factor to be considered in the overall health of the mother is her experience during the delivery period, particularly the method by which she delivers the baby, including elective cesarean section, emergency cesarean, normal or spontaneous vaginal delivery (SVD), and assisted/instrumental vaginal delivery (AVD). The mode of delivery may influence the physical and mental issues in mothers during their postpartum period [3]. Worldwide, there is a rising trend of deliveries by cesarean section (CS). In the United States, 32.7% of the women underwent a cesarean delivery while, approximately 3.3% underwent AVD by vacuum or forceps in 2013; signaling a rise in CSs and a decline in assisted vaginal birth rates compared to 20.7% CS in 1996 [3,4]. Given the rising rates of cesarean deliveries; there is a need to investigate the effects of cesarean birth on women’s postpartum health [1].

Most women suffer physical as well as psychological problems during the postpartum period. The major physical problems are related to generalized or local pelvic/perineal pain symptoms, fatigue, urinary symptoms with incontinence, hemorrhoids and breast problems [5]. The main psychological problem is postpartum depression (PPD) with prevalence rates reaching up to 30% [6]. In addition, disturbed sleep patterns and feeling lack of social support have been noted [7,8].

Although most studies show no associations between the delivery mode and incidence of PPD, yet a study on 245 British women revealed birth experiences affecting maternal satisfaction. In this study, women who delivered by normal SVD, experienced better feelings of fulfillment and low levels of distress after 72 hours since delivery. These feelings persisted until after 6 months, and these women’s perceptions of difficulties at delivery reduced. Women who undergo assisted vaginal birth or CS experience low levels of fulfillment and higher levels of distress, perception of delivery difficulties, and a sense of being cheated at 72 hours and 6 months postpartum [9].

The relationship between mode of delivery and postpartum symptoms, particularly PPD, is still controversial. The investigation of this relationship is complicated by the multi-factorial etiology of PPD, with a series of confounding factors that need to be accounted for in all epidemiological investigations on this issue [8,9]. Several of these factors are culture sensitive, which need to be investigated in different contexts accounting for societal norms of the community in which the study is conducted. Extensive literature search showed no such cohort study performed in the Jeddah region. Thus, the current study provides valid and reliable information on the magnitude of physical health problems and depression among women living in Jeddah after one week and three months of delivery, and the associated factors.

Methods

This study was designed as a prospective cohort study and was conducted in the following government maternity and children’s hospitals (MCH) in Jeddah: Al-Musaedia MCH, King Abdul-Aziz University Hospital (KAUH) and Al-Aziziya MCH. The study was implemented for 4 months beginning February 2, 2015, to June 5, 2015. All women who delivered recently (within 24-48 hours) at the gestation age of 36 weeks or higher during the study period were eligible for inclusion. The study sample consisted of 3 different cohorts:

■ CS group: women who delivered by CS, whether elective or emergency;

■ SVD group: women who delivered vaginally, with or without episiotomy.

■ AVD group: women in whom delivery was induced by ventouse or forceps.

The following eligibility criteria were considered:

Inclusion criteria:

■ Women who gave birth within the last 24-48 hours;

■ Aged 18-45 years;

■ 36+ weeks of gestation;

■ Singleton or twin birth;

■ Speaking Arabic (Saudi or non-Saudi).

Exclusion criteria:

■ Critically ill, e.g. psychotic illness or severe preeclampsia;

■ History of stillbirth or infants with congenital anomalies;

■ History of diagnosed depression or psychiatric problems.

Using Epi info version 7 (Centers for Disease Control and Prevention, Atlanta, Georgia), a sample size was calculated using PPD incidence in women with spontaneous vaginal delivery (SVD) (8%) and those with assisted or CS deliveries (21%) [10,11] at 95% level of confidence and 80% power using unequal groups since the number of women who delivered by CS or AVD were lower than those who delivered by SVD. Accordingly, the sample size calculated was 184 women with SVD, 92 with assisted labor, and 92 with CS. The numbers were adjusted to 200, 100, and 100 respectively, to account for a dropout rate of about 10%. The total sample size collected by the researcher in this study was 210 [126 SVD, 80 CS and 4 AVD (1 forceps and 3 ventouse)].

After obtaining informed consent from the participants and permission from the hospital administration; all women who delivered at one of the study centers (from February, 2nd to March 5th, 2015) were consecutively recruited within 24-48 hours after delivery by a simple random sampling technique. One bed in each room was selected and recruited to one of the three groups according to the inclusion and exclusion criteria. If the randomly selected woman was not eligible, another woman was selected randomly from the same room. The researcher trained nine house officers to recruit as many cases as possible, who were granted a certificate of appreciation after completing data collection.

A structured close ended questionnaire was developed by extensive literature search [12,13]. This questionnaire addressing physical complaints/problems in the postpartum period was revised by consultants in Obstetrics and Gynecology and in Family and Community Medicine for face and content validation. A selfreporting/ direct interview ten-item validated scale; Edinburgh postnatal depression scale (EPDS), developed by Cox et al. 1987 [14] was used in this study to characterize PPD. The point prevalence of depressive symptoms at each time point was based on EPDS scores ≥ 13. However, to include mild depressive symptoms, the original authors recommended a cut-off score of ≥ 10 [15]. The overall reliability (Cronbach’s alpha) of the EPDS was 0.79. A reliable and validated Arabic version of the EPDS was used without any modification [16].

A pilot study to test the feasibility of the study as well as clarity and practicality of the data collection tools was performed on 20 women at KAUH. The follow up was conducted at 1-week and 1-month postdelivery and the results were not included in the main study.

Data entry and statistical analyses were carried out using SPSS 18.0 (SPSS Inc., Chicago, IL). Data were presented using descriptive statistics in the form of frequencies and percentages for qualitative variables, mean, and standard deviation for quantitative variables. Quantitative data were compared using the Student’s t-test for comparisons between two groups. When normal distribution of the data could not be assumed, the non-parametric Mann-Whitney or Kruskal-Wallis tests were used instead. Qualitative categorical variables were compared using chi-square or Fisher’s exact tests as appropriate. Odds ratios (OR) with 95% confidence limits were calculated for risk factors.

Results

Two-hundred and ten women were recruited and followedup from three hospitals. These included women who had normal vaginal (SVD=126), assisted vaginal (AVD=4), and cesarean (CS=80) deliveries. As only four women underwent assisted vaginal deliveries, they could not form a group for comparison and were hence, excluded. Dropouts at the one-week (18.4%) and 3-month (20.2%) follow-up visits are shown in Figure 1.

Figure 1: Sample characteristics & Dropout rates.

Table 1 shows differences in the immediate and 3-month postpartum systemic symptoms. As illustrated, the symptoms of insomnia, fatigue and back pain were the common immediate physical symptoms in both groups. Meanwhile, statistically significant differences were observed at 1-week after delivery between the two groups in the incidences of nipple pain (p-value=0.004), vaginal itch (p-value=0.04), and wound pain (p-value <0.001). At the 3-month follow-up (Table 1), the incidences of physical symptoms had a similar pattern to that at one-week. However, statistically significant differences were observed between the two groups only in the incidence of wound pain (p-value<0.001), which was higher in the CS group.

  1st week 3rd month
Symptoms Normal Delivery
(SVD)
n=126 (%)
Cesarean
(CS)
n=80 (%)
p value Normal Delivery
(SVD)
n= 126 (%)
Cesarean
(CS)
n=80 (%)
pvalue
General symptoms:
Recurrent colds 29 (28.2) 21 (32.3) 0.57 21 (26.6) 16 (29.1) 0.75
Severe headache 56 (54.4) 37 (56.9) 0.75 44 (55.7) 31 (56.4) 0.94
Insomnia 73 (70.9) 49 (75.4) 0.52 55 (69.6) 44 (80.0) 0.18
Musculoskeletal:
Fatigue 74 (71.8) 46 (70.8) 0.88 54 (68.4) 39 (70.9) 0.75
Back pain 82 (79.6) 50 (76.9) 0.68 56 (70.9) 32 (58.2) 0.13
Neck pain 28 (27.2) 26 (40.0) 0.08 42 (53.2) 28 (50.9) 0.80
Breast:
Mastitis 11 (10.7) 5 (7.7) 0.52 7 (8.9) 5 (9.1) 1.00
Nipple pain 75 (72.8) 33 (50.8) 0.004* 16 (20.3) 7 (12.7) 0.26
Engorgement 38 (36.9) 23 (35.4) 0.84 6 (7.6) 4 (7.3) 1.00
GIT:
Nausea 9 (8.7) 8 (12.3) 0.45 13 (16.5) 6 (10.9) 0.37
Gastric pain 17 (16.5) 18 (27.7) 0.08 17 (21.5) 15 (27.3) 0.44
Constipation 47 (45.6) 22 (33.8) 0.13 34 (43.0) 20 (36.4) 0.44
Hemorrhoids 16 (15.5) 14 (21.5) 0.32 17 (21.5) 11 (20.0) 0.83
Stool incontinence 4 (3.9) 3 (4.6) 1.00 3 (3.8) 4 (7.3) 0.44
Flatus incontinence 33 (32.0) 15 (23.1) 0.21 24 (30.4) 12 (21.8) 0.27
Urinary tract:
Urine incontinence 12 (11.7) 8 (12.3) 0.90 9 (11.4) 2 (3.6) 0.20
Dysuria 33 (32.0) 28 (43.1) 0.15 8 (10.1) 9 (16.4) 0.29
Genital:
Vaginal itch 26 (25.2) 8 (12.3) 0.04* 14 (17.7) 14 (25.5) 0.28
Pelvic pain 43 (41.7) 27 (41.5) 0.98 17 (21.5) 12 (21.8) 0.97
Perineal/CS wound pain 72 (69.9) 61 (93.8) <0.001* 13 (16.5) 30 (54.5) <0.001*
Dyspareunia N/A N/A N/A 20 (25.6) 21 (38.2) 0.12
Loss of libido N/A N/A N/A 28 (35.9) 20 (36.4) 0.96

Table 1: Incidence of immediate (one-week) and 3-month postpartum partum physical symptoms among women according to mode of delivery.

Table 2 illustrates no statistically significant differences between the two groups with respect to the immediate (1-week) and 3 months’ postpartum depressive symptoms. With the least conservative cutoff (EPDS ≥ 10), more women in the SVD group had PPD (49.5% immediate & 38.5% after 3 months) compared to those in the CS group (38.5% immediate and 27.3% after 3 months), but the difference was not statistically significant.

  1st week 3rd month
EPDS Normal Delivery
(SVD)
n= 126 (%)
Cesarean
(CS)
n=80 (%)
p value Normal Delivery
(SVD)
n= 126 (%)
Cesarean (CS)
n=80 (%)
p value
Immediate depression: 3-month FU depression:
Edinburgh >=14 19 (18.4) 12 (18.5) 1.00 10 (12.7) 8 (14.5) 0.75
Edinburgh >=12 30 (29.1) 17 (26.2) 0.68 22 (27.8) 13 (23.6) 0.59
Edinburgh >=10 51 (49.5) 25 (38.5) 0.16 30 (38.0) 15 (27.3) 0.20
Mean (SD) 9.6 ± 4.3 8.6 ± 5.4 0.06* 8.6 ± 4.6 8.3 ± 5.2 0.57
Median 9.0 8.0   8.0 8.0  

Table 2: Incidence of immediate (one-week) and 3-month postpartum partum depression symptoms among women according to mode of delivery.

In multivariate analysis (Table 3), a wanted pregnancy was the statistically significant independent negative predictor (protective factor) against immediate (1-week) PPD at both cutoff points: 10 and 14. A higher number of living children was also a protective factor at the cutoff score of 10. Meanwhile, gravidity and income were protective factors for immediate PPD at cutoff score 14. The mode of delivery had no significant influence on PPD.

  Immediate 3 Month Follow Up
  Wald Df P OR 95.0% CI for OR Wald Df P OR 95.0% CI for OR
Upper Lower Upper Lower
Having PPD (score 10+)
Constant 1.367 1 .242 1.627     6.621 1 .010 .004    
Gravidity 2.987 1 .084 1.362 .959 1.933 4.108 1 .043 9.036 1.075 75.943
No. of living children 4.383 1 .036 .631 .410 .971            
Wanted pregnancy 3.869 1 .049 .507 .258 .998            
Employed             4.108 1 .043 9.036 1.075 75.943
Had Abortion             4.777 1 .029 2.458 1.097 5.507
Had pregnancy problems             3.566 1 .059 2.088 .973 4.483
Nagelkerke R Square: 0.06 Nagelkerke R Square: 0.12
Hosmer and Lemeshow Test: p=0.269 Hosmer and Lemeshow Test: p=0.943
Omnibus Tests of Model Coefficients: p<0.001 Omnibus Tests of Model Coefficients: p=0.002

Table 3: Best fitting multiple logistic regression model for the risk of immediate and follow up PPD (score 10+).

As regards the multivariate analysis at follow-up (3-month) PPD, Table 4 demonstrates that being employed and a history of abortion were the statistically significant independent positive predictors (risk factors) for delayed PPD at the cutoff point of 10. Previous occurrence of pregnancy problems was also a risk factor (p-value=0.059). In terms of follow-up PPD at a cutoff point of 14, income was the only statistically significant independent negative predictor (protective factors) against it.

  Immediate 3 Month Follow Up
  Wald Df P OR 95.0% CI for OR Wald Df P OR 95.0% CI for OR
Upper Lower Upper Lower
Having PPD (score 10+)
Constant 1.367 1 .242 1.627     6.621 1 .010 .004    
Gravidity 2.987 1 .084 1.362 .959 1.933 4.108 1 .043 9.036 1.075 75.943
No. of living children 4.383 1 .036 .631 .410 .971            
Desired pregnancy 3.869 1 .049 .507 .258 .998            
Employed             4.108 1 .043 9.036 1.075 75.943
Previously had Abortion             4.777 1 .029 2.458 1.097 5.507
Previously had pregnancy problems             3.566 1 .059 2.088 .973 4.483
Nagelkerke R Square: 0.06 Nagelkerke R Square: 0.12
Hosmer and Lemeshow Test: p=0.269 Hosmer and Lemeshow Test: p=0.943
Omnibus Tests of Model Coefficients: p <0.001 Omnibus Tests of Model Coefficients: p=0.002

Table 4: Best fitting multiple logistic regression model for the risk of immediate and follow up PPD (score 10+).

Discussion

A prospective cohort study was conducted to estimate the incidences of common postpartum physical health problems and depression symptoms in the first 3 months after childbirth, and to identify their risk factors. The study findings largely point to a high incidence of PPD, both immediate and delayed, with no difference between vaginal and cesarean deliveries. Women’s obstetric history seemed to influence the incidence of PPD.

Insomnia, fatigue, and back pain were the most common physical complains in both delivery-mode groups. Similar findings were reported in a population-based cohort study conducted in Australia by Woolhouse et al. at 3 months after delivery [15]. Moreover, our findings are consistent with those from a study in France and Italy observed at 5 months after childbirth [17].

According to the present study findings, the incidences of nipple pain and vaginal itch were significantly higher among women in the vaginal delivery group. The higher incidence of vaginal itch may be attributed to the manipulations (like episiotomy) and associated trauma in this group. Meanwhile, the more common nipple pain among them may be due to their earlier initiation of breastfeeding, which may cause nipple pain at the start. In congruence with this explanation, a study in Saudi Arabia by Al Bokhari et al indicated that women who delivered vaginally were more likely to breastfeed within the first 24 hours after birth, causing nipple pain, compared to those who had a CS [18].

The symptoms of urinary incontinence and dysuria showed no significant differences between the two groups, which is inconsistent with the results of a prospective cohort study in the Netherlands, [19] which reported that urinary incontinence was significantly higher in the vaginal delivery group than the CS group at 3-months postdelivery. Meanwhile, Citgez et al found that both vaginal and cesarean deliveries were independent risk factors of urinary incontinence in a study conducted in Turkey [20].

Postpartum sexual problems were assessed at 3-months postdelivery. One third or more of the women in both groups complained of dyspareunia and decreased libido. Although the differences were not significant between the two groups, dyspareunia trended towards a higher incidence in the normal vaginal delivery group. In contrast, McDonald et al found that dyspareunia was significantly more frequent among women who delivered by cesarean section in Australia [21]. Conversely, another study in Iran by Khajehei et al showed that the incidence of postpartum reduced libido was higher (80%) in women with vaginal delivery than in women with CS (35%) [22].

A main objective of the present study was to measure the incidence of PPD in women who delivered vaginally vs. cesarean section. The findings revealed that with a conservative cutoff point of 14, approximately one-fifth of the women in both delivery mode groups’ experienced immediate (1-week) PPD symptoms. However, using less conservative cutoffs showed higher PPD incidence rates. For instance, at cutoff 12, the rates rose to more than one-fourth, while at cutoff 10, the rates reached to approximately one-half of women in the SVD group and slightly fewer in the CS group experiencing immediate PPD. These figures are comparable to those reported in the study by Dindar and Erdogan in Turkey, where the prevalence was reported as 25.6%, using a cutoff of 12 [23]. Conversely, a few other studies have found a significant association between the mode of delivery and incidence of PPD. For example, a study by Yang et al. [24] reported a significant association between CS (elective or emergency) and PPD. Another study in Beirut by Chaaya et al, demonstrated that women who delivered by CS had significantly higher incidence rates of PPD than women who delivered vaginally (21% versus 7%) [25].

A few limitations of the current study include the follow-up and finding women who underwent AVD. Most of the non-responders during follow-up were because of incorrect information (telephone numbers). The follow-up was expected to continue until 6 months after delivery, but due to shortage of time, we could not pursue it. Women who underwent AVD were intended to be added to the study cohorts, but their numbers were minimal in comparison to the other groups.

This prospective cohort study revealed a high incidence of postpartum physical health problems, predominantly fatigue and back pain, regardless of the mode of delivery. The study also showed a high incidence of PPD that declined slightly over the 3-month followup; the incidence was unrelated to the mode of delivery. A higher number of living children wanted a pregnancy, and gravidity were protective factors against immediate PPD, whereas being employed and a history of abortion were risk factors for delayed PPD.

Careful assessment of the physical and emotional health issues in women after childbirth is required to improve the quality of postpartum care. Health care providers should be aware of the nature and extent of postpartum health problems, which could be achieved through continuing medical education and seminars.

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