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ORIGINAL ARTICLE
Year : 2017  |  Volume : 44  |  Issue : 1  |  Page : 15-19

Comparison of level of depression among mothers with lower segment cesarean section and vaginal delivery: A cross-sectional study


Department of OBG Physiotherapy, KLEU Institute of Physiotherapy, Belagavi, Karnataka, India

Date of Web Publication20-Mar-2017

Correspondence Address:
Jahnvi Ashokkumar Bhatt
KLEU Institute of Physiotherapy, Belagavi, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0974-5009.202547

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  Abstract 

Background and Objective: Postpartum depression (PPD) is very common among women and is a major public health problem. However, there is a wide range of the prevalence of postnatal depression among women from different countries. Women with lower segment cesarean section (LSCS) or vaginal delivery both undergo depression. However, no studies have compared the level of depression among LSCS and vaginal delivery in Indian as well Western scenario. Hence, the objective of the present study was to compare the level of depression among mothers with LSCS and vaginal delivery. Methodology: A total of 170 females were screened using Edinburgh Postnatal Depression Scale (EPDS) on the 7th day postpartum for PPD, of which 85 females had undergone LSCS and 85 females had undergone vaginal delivery. The EPDS consists of 10 items and each item is rated on a four-point scale, giving maximum scores of 30. Mothers who scored above 13 were likely to be suffering from a depressive illness of varying severity. Results: The results of the present study showed that 8.23% women with vaginal delivery had depression whereas 21.17% LSCS women showed significant depression. Conclusion: PPD was found to be higher among mothers with LSCS as compared to mothers with vaginal delivery.

Keywords: Edinburgh Postnatal Depression Scale, lower segment cesarean section, postpartum depression, vaginal delivery


How to cite this article:
Mahishale AV, Bhatt JA. Comparison of level of depression among mothers with lower segment cesarean section and vaginal delivery: A cross-sectional study. J Sci Soc 2017;44:15-9

How to cite this URL:
Mahishale AV, Bhatt JA. Comparison of level of depression among mothers with lower segment cesarean section and vaginal delivery: A cross-sectional study. J Sci Soc [serial online] 2017 [cited 2017 Jul 27];44:15-9. Available from: http://www.jscisociety.com/text.asp?2017/44/1/15/202547


  Introduction Top


Postpartum depression (PPD) is a type of clinical depression which can affect woman after childbirth. PPD is very common among women and is a major public health problem.[1] However, there is a wide range of the prevalence of PPD among mothers with lower segment cesarean section (LSCS) and vaginal delivery from different countries.[2],[3] PPD is found across the globe. According to the National Institutes of Mental Health studies, the childbearing years are when a woman is most likely to experience depression in her lifetime.[4] Approximately 15% of all women will experience PPD following the birth of a child.[4] Thus, the recognition and assessment of this psychological disorder is important. Symptoms of PPD can occur anytime in the postpartum period. These include sadness, hopelessness, low self-esteem, guilt, exhaustion, emptiness, social withdrawal, low or no energy, feeling of being overwhelmed, becoming easily frustrated, sleep and eating disturbances, inability to be comforted, and feeling inadequate in taking care of the baby.[5],[6] The etiology of PPD is not well understood. Sometimes, it is caused by a lack of vitamins.[7] Other studies tend to show that more possible causes are the significant changes in a woman's hormones during pregnancy. In 2009, researchers at the University of California, Irvine, reported the levels of placental corticotrophin-releasing hormone during the 25th week of pregnancy may help predict a woman's chances of developing PPD, while the causes of PPD among LSCS and vaginal delivery are not well understood.[8],[9] LSCS and vaginal delivery both undergo depression which is evaluated by a reliable scale, Edinburgh Postnatal Depression Scale (EPDS). The EPDS is a valuable and efficient way of identifying patients at risk for PPD.[10] However, no studies suggest/compare the level of depression among LSCS and vaginal delivery both in the Indian or western scenario. Hence, the present study was conducted to compare the level of depression among LSCS and vaginal delivery in immediate postpartum women.


  Methodology Top


Source of data

Tertiary Care Centre, Belagavi, Karnataka, India.

Target population

Females who have undergone LSCS and vaginal delivery after 7 days of postpartum.

Study design

An observational study.

Study type

A cross-sectional study.

Duration of study

(3 months) November 2014 to January 2015.

Sampling design and technique

Nonprobability sampling/convenience sampling.

Sample size

Total 170 subjects.

  • Eighty-five females with LSCS in Group A
  • Eighty-five females with vaginal delivery in Group B.


Methods

Participants

A total of 170 mothers were interviewed for PPD, of which 85 mothers were with LSCS and 85 mothers with vaginal delivery. The inclusion criteria for the study group were as follows: (1) All postnatal females who underwent LSCS and vaginal delivery. (2) Seven days of postpartum. (3) Mothers who willing to participate in the study.

Subjects were excluded if they had any of the following conditions: (1) Mothers whose babies are in the Neonatal Intensive Care Unit, (2) postpartum hemorrhage, (3) babies with birth trauma, (4) mothers with stillbirth, and (5) mothers who were on antipsychotic medications.

Procedure

The purpose of the study was explained, and written informed consent was obtained from all the study participants. As per the scale, data were collected in tertiary care center on the 7th postpartum day for all subjects who visited the OPD for regular follow-up and those who are admitted in the inpatient department of the tertiary care center since regular follow-up was not possible due to lack of transportation from their residence. Total samples of 186 subjects were screened for the inclusion and exclusion criteria before their enrollment into the study. Among those 186 subjects, 170 subjects met inclusion criteria, of which 85 mothers were with LSCS and 85 mothers were with vaginal delivery. EPDS was administered by the investigator to all the subjects to know the depression score in each group following which the two groups were compared, and level of depression among the two groups was analyzed [Figure 1].
Figure 1: Methodology flowchart

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Outcome measure

The EPDS contains 10 items, and each item was rated on a four-point scale, giving maximum scores of 30. A score of 13 or more was considered to be a significant case of postnatal depression, while scores of 10–12 represent borderline and 0–9 represent not depressed. Mothers who scored >13 are likely to be suffering from a depressive illness of varying severity.

Statistical analysis

Statistical analysis for the present study was done manually as well as using statistical package of social sciences (SPSS) version 16. Descriptive statistics including numbers, proportions, mean, and standard deviations were used to present data. PPD was compared between mothers after normal delivery and cesarean section. T-test was used for group comparisons.


  Results Top


A total of 170 women were interviewed for the study, of which 85 mothers had undergone LSCS and 85 had undergone vaginal delivery. The baseline characteristics of the subjects in the two groups are shown in [Table 1]. 18 (21.17%) of the 85 mothers with LSCS had a positive screening for PPD, of which 52.94% were primipara and 47.05% were multipara. Among those 85 mothers with LSCS, 50 (58.82%) mothers had undergone full-term emergency LSCS and 35 (41.17%) mothers had undergone full-term elective LSCS with the mean age of 23.91. 7 (8.23%) mothers with vaginal delivery reported positive PPD, of which 61.17% were primipara and 38.82% were multipara with the mean age of 23.65. Among those 85 mothers with vaginal delivery, 55 mothers (64.70%) were with episiotomy and 30 mothers (35.29%) were without episiotomy. The mother's scores on the EPDS 7 days of postpartum are shown in [Table 2].
Table 1: Baseline characteristics

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Table 2: Edinburgh Postnatal Depression Scale scores

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Comparing EPDS scores 7 days of postpartum, the PPD was found to be higher among mothers with LSCS as compared to mothers with vaginal delivery. The difference is considered to be highly statistically significant (P < 0.0001) [Table 3]. Among those 18 mothers who underwent LSCS had depression, 9 (10.5%) mothers showed positive depressive characteristics as they wanted a natural birth and pain over the suture site being a secondary reason. 5 (5.88%) mothers showed depressive characteristics because of pain over suture site, whereas 4 (4.70%) mothers showed positive characteristics because of pain over suture site and feeding problem. Of those 7 mothers with normal vaginal delivery who had depression, 4 (4.70%) mothers showed positive depressive characteristic because of episiotomy pain and sleep disturbance [Table 4].
Table 3: Mean score differences of Edinburgh Postnatal Depression Scale

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Table 4: Various reasons for postpartum depression

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  Discussion Top


The present study shows that mothers with LSCS have higher depression as compared to vaginal delivery. Petrosyan et al. studied about the incidence of PPD between vaginal delivery and LSCS. They screened 335 females and results showed that 21% of the women who had cesarean sections experienced PPD and 18% of women who had vaginal deliveries experienced PPD. Thus, they concluded that there was no significant difference in the incidence of PPD between two groups.[11] However, our study showed that there was difference between the level of depression among mothers after vaginal delivery and LSCS. Another study done by Sword et al. in which they investigated the correlation between the method of delivery and PPD and concluded that the incidence rate of PPD was not significantly associated with the method of delivery.[12] However, our study suggests that the PPD is associated with the method of delivery where LSCS females showed to have more depression as compared to vaginal delivery because of the various reasons told by the mothers such as they wanted a natural birth, pain over suture site, feeding problem in mothers who underwent LSCS. Furthermore, reasons such as episiotomy pain and sleep disturbance in mothers who underwent vaginal delivery lead to PPD. Adams et al. search for a correlation between the mode of delivery and maternal distress and how it changes throughout pregnancy and the postpartum period using Hopkins Symptom Checklist-8 (SCL-8)[13] and they concluded that the mode of delivery does not correlate with postpartum distress and they also said that SCL-8 tool has not been validated for use in specifically assessing distress during pregnancy or postpartum period. However, we used a reliable and validated EPDS to assess PPD as compared to Hopkins SCL-8. A study done by Rauh et al. investigated depression before and after delivery and how it varies based on the mode of delivery using EPDS with the help of telephone interview method and concluded that women who underwent cesarean section had the highest EPDS scores and those with spontaneous vaginal delivery had the lowest EPDS scores. They also said that phone interview method has potentially decreased the reliability as compared to the personal interviews.[14] The present study has used personal interview method and not telephonic interviewing to assess PPD which makes it more easier for recording data related to emotional and psychological aspects. It made the subjects to clearly express their discomforts/stresses related to the postpartum period. There is a wide range of the prevalence of postnatal depression among women from different countries. A recent review of 143 studies from forty countries demonstrated that the reported prevalence of postnatal depression ranged from almost 0% to 60%.[2],[15] However, of the forty countries included, Indian data lacked evidence. Hence, the present study found that PPD in women in Indian scenario was 21.17% in LSCS and 8.23% in vaginal delivery. The prevalence was found to be higher in LSCS as compared to vaginal delivery. Thus, the finding of this study could contribute to the existing literature and better understanding of maternal health-care outcomes.


  Conclusion Top


PPD is higher among mothers with LSCS as compared to mothers with vaginal delivery. This finding suggests the need for more resources to be directed toward the research, identification, and treatment of PPD.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Wisner KL, Chambers C, Sit DK. Postpartum depression: A major public health problem. JAMA 2006;296:2616-8.  Back to cited text no. 1
    
2.
Halbreich U, Karkun S. Cross-cultural and social diversity of prevalence of postpartum depression and depressive symptoms. J Affect Disord 2006;91:97-111.  Back to cited text no. 2
    
3.
Hobfoll SE, Ritter C, Lavin J, Hulsizer MR, Cameron RP. Depression prevalence and incidence among inner-city pregnant and postpartum women. J Consult Clin Psychol 1995;63:445-53.  Back to cited text no. 3
    
4.
Chasse JD. Washington Baby: A Collection of Studies and Research in Maternal/Perinatal Psychology, Health and Public Policy Issues. Beltsville, Maryland: Jill Chasse; 2006.  Back to cited text no. 4
    
5.
The Boston Women's Health Book Collective, Judi Norsigian. Our Bodies Ourselves. 2005; New York: Touchstone Book: 489-91.  Back to cited text no. 5
    
6.
Wiklund I, Edman G, Andolf E. Cesarean section on maternal request: Reasons for the request, self-estimated health, expectations, experience of birth and signs of depression among first-time mothers. Acta Obstet Gynecol Scand 2007;86:451-6.  Back to cited text no. 6
    
7.
McCoy SJ, Beal JM, Shipman SB, Payton ME, Watson GH. Risk factors for postpartum depression: A retrospective investigation at 4-weeks postnatal and a review of the literature. J Am Osteopath Assoc 2006;106:193-8.  Back to cited text no. 7
    
8.
Rich-Edwards JW, Mohllajee AP, Kleinman K, Hacker MR, Majzoub J, Wright RJ, et al. Elevated midpregnancy corticotropin-releasing hormone is associated with prenatal, but not postpartum, maternal depression. J Clin Endocrinol Metab 2008;93:1946-51.  Back to cited text no. 8
    
9.
Bloch M, Schmidt PJ, Danaceau M, Murphy J, Nieman L, Rubinow DR. Effects of gonadal steroids in women with a history of postpartum depression. Am J Psychiatry 2000;157:924-30.  Back to cited text no. 9
    
10.
Montazeri A, Torkan B, Omidvari S. The Edinburgh Postnatal Depression Scale (EPDS): Translation and validation study of the Iranian version. BMC Psychiatry 2007;7:11.  Back to cited text no. 10
    
11.
Petrosyan D, Armenian HK, Arzoumanian K. Interaction of maternal age and mode of delivery in the development of postpartum depression in Yerevan, Armenia. J Affect Disord 2011;135:77-81.  Back to cited text no. 11
    
12.
Sword W, Landy CK, Thabane L, Watt S, Krueger P, Farine D, et al. Is mode of delivery associated with postpartum depression at 6 weeks: A prospective cohort study. BJOG 2011;118:966-77.  Back to cited text no. 12
    
13.
Adams SS, Eberhard-Gran M, Sandvik ÅR, Eskild A. Mode of delivery and postpartum emotional distress: A cohort study of 55,814 women. BJOG 2012;119:298-305.  Back to cited text no. 13
    
14.
Rauh C, Beetz A, Burger P, Engel A, Häberle L, Fasching PA, et al. Delivery mode and the course of pre- and postpartum depression. Arch Gynecol Obstet 2012;286:1407-12.  Back to cited text no. 14
    
15.
Gotlib IH, Whiffen VE, Mount JH, Milne K, Cordy NI. Prevalence rates and demographic characteristics associated with depression in pregnancy and the postpartum. J Consult Clin Psychol 1989;57:269-74.  Back to cited text no. 15
    


    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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