Postpartum Depression and Cesarean Section
Condition: Postpartum Depression
MeSH terms: Depression, Postpartum; Depression; Depressive Disorder
Study type: Observational

Summary: 
      The purpose of this retrospective study is to determine if there is an increase in postpartum
      depression (PPD) among women who undergo an emergency cesarean section as opposed to a
      planned cesarean section. We will analyze the hospital and clinic medical records of
      postpartum women who delivered by cesarean section (CS) at Tulsa Regional Medical Center
      between January 1, 2003, and June 1, 2005, and who obtained their postpartum care at the OSU
      Ob/Gyn Clinic in Tulsa, Oklahoma. We will record whether the cesarean was planned or
      emergent, and we will note the score they received on the Edinburgh Postnatal Depression
      Scale when they came to the clinic for their four-week postpartum visit. A score of 12 or
      lower on the EPDS will be considered "not depressed", and a score of 13 or higher will be
      considered "depressed." Numbers of depressed patients will be compared among the two types of
      cesarean sections and analyzed for statistical differences using the chi-squared method of
      analysis.
    

Detailed description: 
      The purpose of this retrospective study is to determine if there is an increase in postpartum
      depression (PPD) among women who undergo an emergency cesarean section as opposed to a
      planned cesarean section. All previous research documenting the rate of PPD in cesarean
      section patients looks only at the incidence of PPD in cesarean section versus vaginal
      delivery, and does not separate emergent versus planned cesarean section. The general study
      hypothesis is as follows: An emergent cesarean section can be an emotionally traumatic
      experience. Women who have a cesarean section for emergent causes are not psychologically
      prepared for surgery, and thus experience an increased rate of PPD. The null hypothesis is:
      There is no significant difference in the rate of PPD among women who have a cesarean section
      for emergent causes versus women who have their cesarean section at the previously scheduled
      time.

      Postpartum depression (PPD) is diagnosed in approximately 10-20% of women (DSM-IV-TR), and
      25% of these women still suffer from PPD twelve months after delivery (Gregoire et al, 1996).
      Risks for developing PPD include a higher subjective burden of childbirth, poor relationship
      with spouse, significant other, or father of the baby, unemployment or dissatisfaction with
      job, and low socioeconomic status.

      Obstetrical history risk factors include previous abortions, high-risk pregnancy, low birth
      weight, and cesarean section (Bergant et al, 1998).

      Delivery via cesarean section (CS) creates a much different emotional experience than does a
      vaginal delivery. Disappointment in the ability to have a natural birth, feelings of
      resentment towards the physician, altered treatment expectation, as well as, pain and trauma
      associated with surgery are all contributing factors (Al-Nuaim, 2004). A majority of women
      consider an emergency cesarean section (CS) to be a mentally traumatic encounter. One third
      of women who require an emergency CS will experience posttraumatic stress reactions during
      the postpartum period (Ryding et al, 1997). Fisher et al reported that there is a significant
      relationship between mode of delivery and negative psychological outcomes. A mother who has a
      CS instead of a vaginal delivery is more likely to have mood deterioration, lowered
      self-esteem, grief reaction, posttraumatic distress, and depression (Fisher et al, 1997).

      We propose to analyze the hospital and clinic medical records of 200 postpartum women who
      delivered by cesarean section (CS) at Tulsa Regional Medical Center between January 1, 2003,
      and June 1, 2005, and who obtained their postpartum care at the OSU Ob/Gyn Clinic in Tulsa,
      Oklahoma. Of the charts reviewed, 100 women will have had a CS for emergent causes, and the
      other 100 will have delivered via a planned CS.

      The hospital records will be reviewed to determine whether the cesarean delivery was for
      emergent causes or if it was a planned operation. Planned cesarean sections are performed on
      patients who have had a previous CS and are scheduled for a repeat, fetuses that are
      measuring greater than 4000 grams, prior uterine scars, and known breech presentations on
      patients not in labor. Emergent causes will include nonreassuring fetal heart tones,
      placental abruption, inductions that result in CS due to failure to progress or cephalopelvic
      disproportion, and malpresentations in active labor. Malpresentations include face, brow,
      shoulder, hand, breech, compound, or transverse lie.

      The patients will have their clinic chart reviewed for the following data from their
      antenatal and postpartum visits: date of delivery, breastfeeding status as a simple yes/no
      question without regard to whether or not the mother is supplementing with formula, mother's
      age, smoker/non-smoker, race, employment status, previous history psychological disorders,
      Edinburgh Postnatal Depression Scale score (routinely administered by obstetrician at the six
      week postpartum visit), other antepartum or postpartum complications.

      Postpartum depression will be diagnosed with the assistance of the Edinburgh Postnatal
      Depression Scale (EPDS). The OSU Ob/Gyn Clinic began routine use of the EPDS in 2003. As a
      result, all patient records used in this study will be from January 1, 2003 to June 1, 2005.
      A one-year time period has been allotted for collection of data as this will allow sufficient
      time to review the necessary records. In addition, one of the collaborating investigators is
      a resident, and the research assistants are medical students, therefore, the data collection
      must be completed in a timely manner. OSU Ob/Gyn and Tulsa Regional Medical Center are the
      only sites in this investigation to ensure that the diagnosis of postpartum depression is
      made using the same parameters.

      STUDY POPULATION

      Inclusion/Exclusion Criteria

      Our study population will include 200 postpartum women ages 15 to 43 who have given birth via
      cesarean section at Tulsa Regional Medical Center. In addition, these same individuals must
      have had their postpartum follow up visit(s) at the OSU Ob/Gyn Clinic in Tulsa, Oklahoma. The
      study population consists predominantly of Medicaid patients. These patients are generally of
      a lower socioeconomic status. The ethnic mix includes Caucasian, African-American, Hispanic,
      American Indian and Asian patients. Patients who deliver vaginally, have an intrauterine
      fetal demise, known anomalies in the delivered fetus, a known mood disorder during pregnancy,
      or drug use during pregnancy or the postpartum course will be excluded.

      Early Termination Criteria

      N/A

      METHODS/PROCEDURES

      Diagnosis

      The diagnosis of postpartum depression will be given based on the use of the Edinburgh
      Postnatal Depression Scale (EPDS). The EPDS has 10 questions, and possible scores range from
      0-30. We used its author's recommendation that scores higher than 12 be considered a positive
      screen for PPD and for which sensitivity and specificity have been found to be 86% and 78%,
      respectively (Cox et al). We are aware that other depression evaluations may be used to
      definitively diagnose PPD. The OSU Ob/Gyn clinic uses the EPDS for convenience, and it was
      the only data available in patient charts for this retrospective study.

      DATA

      Collection Collaborating investigators and research assistants will review each chart, and
      extract only the following data from the patient's postpartum visit: Edinburgh Postnatal
      Depression Scale score (routinely administered by obstetrician at the six week postpartum
      visit), breastfeeding status as a simple yes/no question without regard to whether or not the
      mother is supplementing with formula, date of delivery, mother's age, smoker/non-smoker,
      race, employment status, previous history psychological disorders, other antepartum or
      postpartum complications. No additional information will be collected from patient charts.
      The research assistants are OSU medical students employed in the work study program for the
      specific purpose of working on this research project. They will collect the data from clinic
      records. These assistants are under the OSU umbrella of individuals who may have access to
      patient charts, and they have basic human use research training as well as HIPAA training.

      Analysis Numbers of depressed patients will be compared among the two groups and analyzed for
      statistical differences using the chi-squared method of analysis.

      Confidentiality Patient's clinic records will be kept in the medical records department,
      which is under direct security supervision, or locked at all times. Hospital records will be
      kept in the health information management department at Tulsa Regional Medical Center, which
      is locked 24 hours a day. All study records will be de-identified by conversion to numbers
      before review, analysis, or interpretation. J. Martin Beal, D.O., Sarah McCoy, Ph.D., and
      Jennifer Howell, D.O. will have access to these numbers which will be kept locked in the OSU
      Ob/Gyn office, which is separate from both medical records departments. All documents linking
      patient names to charts will be destroyed after the data collection is complete.
    

Time perspective: Retrospective
Keywords: cesarean; planned; emergent; postpartum depression