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PapersOperativedeliveryandpostnataldepression:acohortstudyRoshniRPatel,DeirdreJMurphy,TimJPetersforALSPACAbstractObjectivesToassesstheassociationbetweenelectivecaesareansectionandpostnataldepressioncomparedwithplannedvaginaldeliveryandwhetheremergencycaesareansectionorassistedvaginaldeliveryisassociatedwithpostnataldepressioncomparedwithspontaneousvaginaldelivery.
DesignProspectivepopulationbasedcohortstudy.
SettingALSPAC(theAvonlongitudinalstudyofparentsandchildren).
Participants14663womenrecruitedantenatallywithaduedatebetween1April1991and31December1992.
MainoutcomemeasureEdinburghpostnataldepressionscalescore≥13ateightweekspostnatalonselfcompletedquestionnaire.
ResultsAlbeitwithwideconfidenceintervals,therewasnoevidencethatelectivecaesareansectionalteredtheoddsofpostnataldepressioncomparedwithplannedvaginaldelivery(adjustedoddsratio1.
06,95%confidenceinterval0.
66to1.
70,P=0.
80).
Amongplannedvaginaldeliveriestherewassimilarlylittleevidenceofadifferencebetweenwomenwhohaveemergencycaesareansectionorassistedvaginaldeliveryandthosewhohavespontaneousvaginaldelivery(1.
17,0.
77to1.
79,P=0.
46,and0.
89,0.
68to1.
18,P=0.
42,respectively).
ConclusionsThereisnoreasonforwomenatriskofpostnataldepressiontobemanageddifferentlywithregardtomodeofdelivery.
Electivecaesareansectiondoesnotprotectagainstpostnataldepression.
Womenwhoplanvaginaldeliveryandrequireemergencycaesareansectionorassistedvaginaldeliverycanbereassuredthatthereisnoreasontobelievethattheyareatincreasedriskofpostnataldepression.
IntroductionDepressionisamajorsourceofmorbidityinGreatBritainandacommoncauseforconsultationinprimarycare.
1Theprevalenceofdepressioninthepostnatalperiodissimilartobackgroundpopulationratesofdepressionandaffectsabout8-15%ofwomen.
2Postnataldepressionissimilartodepressionoccurringatothertimesinlifeandonlydistinguishablebythetimingofonset.
Depressionatanytimeisassociatedwithnegativesequelae.
Whatmakespostnataldepressionofparticularconcernisitspossibledetrimentallongtermeffectsonsubsequentchilddevelopment.
Infantsofdepressedmothershavebeenfoundtoperformlesswellonobjectconcepttasksandbemoreinsecurelyattachedtotheirmothers.
3Otherstudieshavefoundhigherratesofintellectualdeficitsat4yearsofage,45behaviouraldisturbancesupto5years,56andincreasedratesofspecialeducationalneedsat11years.
7Iflabouriscomplicatedandthedeliveryunexpectedlyperformedasanemergencypro-cedureitcouldpotentiallybestressfultothemother.
Insuchsce-nariostheremaybeanassociationbetweenemergencyoperativedeliveryandpostnataldepression.
Severalstudieshaveinvestigatedthisassociation,thoughthecurrentevidenceiscon-flicting,withsomestudiesreportinganassociation8–10andothersnot.
11–14Converselytheremaybeanassociationbetweenelectivecaesareansectionandareducedriskofpostnataldepression.
TheEdinburghpostnataldepressionscalewasinitiallydevel-opedasascreeningtoolandfocusesonthecognitiveandfunc-tionaleffectsofdepressiontofacilitatedetectionofwomenwithpostnataldepressioninthemonthsimmediatelypostpartum.
15Thescalecannotbeusedasadiagnostictoolalonebutascoreof≥13ishighlypredictiveofpostnataldepressioninaUKpopula-tionandwarrantsfurtherclinicalassessment.
Inalargecommu-nitystudyitwasfoundtohaveasensitivityof88%andaspecificityof92.
5%.
16Wecomparedtheratesofpostnataldepressioninwomenwhohadanelectivecaesareansectionandthosewhohadaplannedvaginaldelivery(thisincludedemergencycaesareansectionandassistedorspontaneousvaginaldelivery).
MethodsTheAvonlongitudinalstudyofparentsandchildren(ALSPAC)isacohortstudyofover14000womenrecruitedantenatallyin1990-2.
Fulldetailsofthestudyareavailableelsewhere.
1718Therewere14663womeninthecohort,ofwhom14051reached20weeks'gestationandcompletedatleastonequestionnaire.
Intheseanalyseswehaveincludedallwomenwithsingleton,liveborninfantsandtermpregnancies(37to44weeks)whocompletedtheeightweekpostnatalquestionnaire.
Electivecaesareansectionswerethosewithpriorplanning,andemergencycaesareansectionswerethosewithoutpriorplanningorthattookplaceafterlabourstarted.
Assistedvaginaldeliverycomprisedbothforcepsdeliveriesandvacuumextraction.
Wecalculatedthemean(SD)depressionscoreandtheproportionofscores≥13foreachmodeofdelivery.
Wethenusedunivariableanalysestocalculatecrudeoddsratios,95%confidenceintervals,andlikelihoodratioPvaluesfortheassociationbetweenmodeofdeliveryandpostnataldepressionusinglogisticregression.
Adjustedoddsratioswerecalculatedbytheadditionofconfoundersassociatedwithmodeofdeliveryintothestatisticalmodel.
Detailsoftheapproachusedinderiv-ingthesepotentialconfoundersareavailableelsewhere.
19Weusedcontinuousvariables(maternalage,gestationalageatdeliv-ery,parity,neonatalheadcircumference,andbirthweight),binary(yes/no)variables(previouscaesareansection,epiduralinlabour,previousmiscarriage/termination,antenatalclassattend-ance),andcategoricalvariables(diabetesmellitus,fetalpresenta-tion,outcomeoflastpregnancy,preferredlabourposition,perceivedlossofcontrolinlabour.
Wealsoinvestigatedhistoryofdepression(yes/no)andconsideredadditionalvariablesthatCitethisarticleas:BMJ,doi:10.
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D3(published25February2005)BMJOnlineFirstbmj.
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bmj.
com/BMJ:firstpublishedas10.
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38376.
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D3on25February2005.
Downloadedfromwereidentifiedbyaliteraturesearchasbeingassociatedwithpostnataldepressioninotherpopulations—namely,housingsta-tus(categorical)andantenataldepressionscoreat18and32weeks(<13or≥13).
Stata8.
0softwarewasusedforallanalyses.
ResultsOfthe12944womenwhometthestudycriteria,10934(84.
5%)completedthedepressionscaleateightweekspostnatally.
Theresponseratewassimilarforalldeliverygroups.
Ofthesewomen,8731(79.
9%)hadaspontaneousvaginaldeliveryand1242(11.
4%)hadanassistedvaginaldelivery.
Ofthe961responderswhohadacaesareansection,572hadanemergencyoperation(5.
2%)and389(3.
6%)hadanelectiveprocedure(fig-ure).
Electivecaesareansectionvplannedvaginaldelivery—Ahigherproportionofthewomenwhohadanelectivecaesareansectionhadadepressionscore≥13comparedwithwomenwhoplannedavaginaldelivery(table1),althoughthemeanscoresweresimilar.
Theunadjustedoddsratioofscore≥13inwomenwhohadelectivecaesareansectioncomparedwithwomenwhoplannedvaginaldeliverywas1.
31(95%confidenceinterval0.
96to1.
78).
Adjustmentfortheprenatalfactorsidentifiedasbeingassociatedwithelectivecaesareansection(seetable1)andhous-ingstatuscausedafallintheoddsratio(1.
06,0.
66to1.
70).
Nei-therahistoryofdepressionnorantenataldepressionat18and32weekswasassociatedwithelectivecaesareansectioninthisdataset.
Emergencycaesareansectionvspontaneousvaginaldelivery—About10%ofwomeninbothdeliverygroupshadadepressionscore≥13(table2).
Theunadjustedoddsratiooftheassociationbetweenemergencycaesareansectionanddepressionscore≥13was0.
99(0.
74to1.
32).
Adjustmentforthenineprenatalvariablesfoundtobeassociatedwithemergencycaesareansectionfromthepreviousanalysesofthisdataset(seetable2)andhousingstatusincreasedtheoddsratioto1.
17(0.
77to1.
79),butstillwithnostrongevidenceofanassociation.
Omissionofneonatalheadcircumference,whichwasmissinginalargenumberofcases,alsohadaminimaleffectontheresults(1.
14,0.
75to1.
73,n=7999).
Historyofdepressionordepressiondur-ingpregnancywasnotassociatedwithemergencycaesareansec-tion.
WomeninALSPACdataset(n=14663)Livebirths(n=14049)Miscarriages/stillbirths(n=614)Singletons(n=13678)Multiplepregnancies(n=371)Allwomenmeetinginclusioncriteria(n=12944)Missingdeliverydata(n=2)Termpregnancies(37to44weeks)(n=12946)Caesareansection(n=1153)Elective(n=468)Emergency(n=685)Assisted(n=1454)Spontaneous(n=10337)Vaginaldelivery(n=11791)Pretermpregnancies/missingdata(n=732)(n=389,83.
1%)(n=572,83.
5%)(n=1242,85.
4%)(n=8731,84.
5%)Responderstodepressionquestionnaireat8weekspostpartumExclusionalgorithmforstudycohortTable1AssociationbetweenelectivecaesareansectionandEdinburghpostnataldepressionscore*comparedwithplannedvaginaldeliveryDeliveryNoofwomenMean(SD)scoreNo(%)whoscored<13No(%)whoscored≥13Oddsratio(95%CI)UnadjustedVaginal109346.
0(4.
7)9520(90.
3)1025(9.
7)1.
00Electivecaesarean6.
1(5.
3)341(87.
7)48(12.
3)1.
31(0.
96to1.
78),P=0.
10AdjustedVaginal95025.
9(4.
7)8369(90.
7)857(9.
3)1.
00Electivecaesarean5.
8(5.
1)248(89.
9)28(10.
1)1.
06(0.
66to1.
70),P=0.
80*Scoreof≥13warrantsfurtherinvestigation.
Adjustedforvariablesassociatedwithelectivecaesareansection(maternalage,previouscaesareansection,diabetesmellitus,gestationalageatdelivery,non-cephalicpresentation)andvariablesidentifiedfromliteraturesearchtobeassociatedwithpostnataldepressionandeliminatedinmultivariablemodellinginidentificationofvariablesassociatedwithelectivecaesareansection(housing).
Paperspage2of4BMJOnlineFirstbmj.
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DownloadedfromAssistedvaginaldeliveryvspontaneousvaginaldelivery—Alowerproportionofwomenwhohadanassistedvaginaldeliveryhaddepressionscores≥13comparedwithwomenwhodeliveredspontaneously.
Theirmeanscores,however,werethesame(table3).
Theunadjustedoddsratiosbetweenassistedvaginaldeliveryanddepressionscore≥13was0.
85(0.
69to1.
05).
Adjustmentforthefactorsidentifiedasbeingassociatedwithassistedvaginaldeliveryinthisdataset(seetable3)hadminimaleffectontheresultsandsuggestedlittleevidenceofanassociation.
Omissionofneonatalheadcircumferencefromthemodelagainhadmini-maleffect(0.
84,0.
64to1.
10,n=8712),andneitherhistoryofdepressionnordepressionduringpregnancywasassociatedwithassistedvaginaldeliveryinthisdataset.
DiscussionThoughourresultshadwideconfidenceintervals,wecouldfindnoassociationbetweenpostnataldepressionateightweeksandelectivecaesareansectioncomparedwithplannedvaginaldeliv-ery.
Explorationofplannedvaginaldeliverysimilarlyfoundlittleevidenceofanassociationbetweenemergencycaesareansectionorassistedvaginaldeliveryandpostnataldepressioncomparedwithspontaneousvaginaldelivery.
StrengthsofstudyOurresearchhadseveraladvantagesoverotherstudiesinthisspecialty.
WeusedprospectivelycollecteddatatoevaluatetheassociationbetweenpostnataldepressionandoperativedeliveryinaBritishcohort,whichisimportanttoclinicalpracticegiventhehighprevalenceofbothmentalillnessandoperativedeliveryintheUKpopulation.
Ourcohortwasalsomuchlargerthaninmostothersimilarstudies.
TheEdinburghpostnataldepressionscalewasdevelopedandvalidatedintheUnitedKingdomandassuchisanappropriatescreeningtoolforpostnataldepressioninthispopulation.
Researchhasshown,however,thatselfreportedscreeningtoolsforpostnataldepressionyieldahigherrateofpositivecasesthanclinicalinterviewmethods.
20Antenataldepressionisknowntobeassociatedwithpostpartumdepression211andmustthereforebeconsideredinanyexplora-tionofriskfactorsofpostnataldepression.
Manyofthepublishedstudiesarelimitedbytheabsenceofdataonantenataldepression,whichwereavailableinourresearch.
Datawerealsoavailableonalltypesofoperativedelivery,whichallowedustoexaminemorespecificcomparisons.
Finally,weminimisedcon-foundingbyincorporatingfactorspreviouslyidentifiedtobeassociatedwitheachdeliverymethodstudied.
Theseanalyseswerebasedonobservationaldataandarethereforepotentiallysubjecttobias.
Therewasahighfollowuprate(85%),thoughoneconcernisthatwomenwithpostnataldepressionwerelesslikelytocompletethequestionnaire.
Thismaybeparticularlyrelevanttowomensufferingfromseveredepression,especiallyiftheywereresidentinapsychiatricunit.
ComparisonwithotherstudiesOurresultssupportthecurrentreviewofevidencebytheNationalInstituteforClinicalExcellencethatpostnataldepressionisnotasequelaeofcaesareansection.
21Severalotherstudieshavealsonotfoundevidenceofanassociationbetweenplannedmodeofdeliveryandpostnataldepression.
Oneprospectivecohortfoundaweakassociationbetweensomecomplicationsinpregnancyandpostnataldepressionbutnonewithmodeofdelivery.
12Saistoetaladjustedforantenataldepressionandfoundthatmodeofdeliverydidnotpredictpostnataldepressionat8to12weeks.
11Eachofthesestudiescomprisedfewerthan500women.
Twolargerprospectivestud-iesfoundnoassociationbetweendeliverycomplicationsanddepressionscores≥13,thoughthiswasassessedatfourmonthspostpartum.
1314Onestudyfoundsomeevidenceofhigherratesofraiseddepressionscoresatthreemonthspostpartuminwomenwhohadanemergencycaesareansectioncomparedwiththosewhohadaspontaneousvaginaldelivery.
10Thisstudy,however,involvedonly21womenwhohadanemergencycaesareansection.
AnAustralianstudyfoundthatbothelectiveandemergencycaesareandeliverywereassociatedwithasmallbutnotsignificantincreasedriskofpostnataldepressionateightweekspostpartum.
22OurresultsdifferfromthoseofasmallretrospectivecohortstudyinMalaysia.
Higherdepressionscoreswerefoundamongwomenwhohadanemergencydeliverycomparedwithnon-emergencydelivery,althoughtheformergroupincludedTable2AssociationbetweenemergencycaesareansectionandEdinburghpostnataldepressionscore*comparedwithspontaneousvaginaldeliveryDeliveryNoofwomenMean(SD)scoreNo(%)whoscored<13No(%)whoscored≥13Oddsratio(95%CI)UnadjustedSpontaneousvaginal93036.
0(4.
7)7868(90.
1)863(9.
9)1.
00Emergencycaesarean5.
9(4.
8)516(90.
2)56(9.
8)0.
99(0.
74to1.
32),P=0.
94AdjustedSpontaneousvaginal62956.
2(4.
9)5331(88.
5)694(11.
5)1.
00Emergencycaesarean6.
2(4.
9)239(88.
5)31(11.
5)1.
17(0.
77to1.
79),P=0.
46*Score≥13warrantsfurtherinvestigation.
Adjustedforvariablesassociatedwithemergencycaesareansection(maternalage,previouscaesareansection,outcomeoflastpregnancy,parity,neonatalbirthweight,neonatalheadcircumference,non-cephalicpresentation,inpreferredpositioninlabour,epiduralinlabour)andvariablesidentifiedfromliteraturesearchtobeassociatedwithpostnataldepression,andeliminatedinmultivariablemodellinginidentificationofvariablesassociatedwithelectivecaesareansection(housing)Table3AssociationbetweenassistedvaginaldeliveryandEdinburghdepressionscore*comparedwithspontaneousvaginaldeliveryDeliveryNoofwomenMean(SD)scoreNo(%)whoscored<13No(%)whoscored≥13Oddsratio(95%CI)UnadjustedSpontaneousvaginal99736.
0(4.
8)7868(90.
1)863(9.
9)1.
00Assistedvaginal6.
0(4.
7)1136(91.
5)106(8.
5)0.
85(0.
69to1.
05),P=0.
13AdjustedSpontaneousvaginal68886.
2(4.
9)5295(88.
6)683(11.
4)1.
00Assistedvaginal5.
8(4.
6)826(90.
8)84(9.
2)0.
89(0.
68to1.
18),P=0.
42*Score≥13warrantsfurtherinvestigation.
Adjustedforvariablesassociatedwithassistedvaginaldelivery(previousmiscarriage/termination,previouscaesareansection,outcomeoflastpregnancy,parity,housing,antenatalclassattendance,neonatalheadcircumference,non-cephalicpresentation,inpreferredpositioninlabour,lossofcontrolinlabour,andepiduralinlabour).
PapersBMJOnlineFirstbmj.
compage3of4on23February2021byguest.
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com/BMJ:firstpublishedas10.
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Downloadedfromemergencycaesareansectionandvacuumdelivery.
TheEdinburghscale,however,hasnotbeenvalidatedinaMalaysianpopulation.
9Lydon-Rochellealsofoundevidenceofanassocia-tionbetweencaesareandeliveryandlowermentalhealthscorescomparedwithspontaneousvaginaldelivery,althoughthisstudyusedadifferentselfreportedquestionnaireanddidnotseparateemergencyandelectiveprocedures.
8Unlikeourresearch,thesestudieshadsamplesoffewerthan1000womeneach.
8922Regardingassistedvaginaldeliveryourresultssupportotherstudiesthathavenotfoundanassociationwithpostnataldepres-sion.
1022Onesmallstudyof142womenfoundanon-significantassociationatsixweekspostpartumamongwomenwhodidnotdeliverspontaneously.
23ConclusionsOurworkaddsanimportantcomponenttothecounsellingofwomenwhoareplanningmodeofdelivery.
ItisespeciallyrelevantforwomenconsideringelectivecaesareansectionandinkeepingwithNICEguidelineshelps"womentomakeinformeddecisionsaboutchildbirth.
"21Thereisnoreasonforwomenwithahistoryofdepressionorthoseathighriskofdepressiontobemanageddifferentlywithregardtomodeofdelivery.
Furthermore,evenifemergencycae-sareansectionorassistedvaginaldeliveryisrequired,womencanbereassuredthatthereisnoreasontobelievethattheyaremorelikelytoexperiencepostnataldepression.
Weareextremelygratefultoallthemotherswhotookpartandtothemid-wivesfortheircooperationandhelpinrecruitment.
TheALSPACstudyteamcomprisesinterviewers,computertechnicians,laboratorytechnicians,clericalworkers,researchscientists,volunteers,andmanagerswhocontinuetomakethestudypossible.
WearegratefultoJeanGoldingfordiscussionsaboutthisresearchandtoJonHeronfordatapreparation.
Contributors:Allauthorsdesignedthestudy,contributedtotheanalysisandinterpretedthedata.
RPperformedtheanalysisandwrotethereportwithhelpfromtheotherauthors;sheisguarantor.
Funding:WellcomeTrust,MedicalResearchCouncil,UniversityofBristol,DepartmentofHealth,andDepartmentofEnvironment.
TheALSPACstudyispartoftheWHOinitiatedEuropeanLongitudinalStudyofPregnancyandChildhood.
RPreceivedaclinicalacademictrainingfellow-shipfromNHSSouthWestresearchanddevelopment.
Competinginterests:Nonedeclared.
Ethicalapproval:Theresearchprogrammeisgovernedbythefourlocalresearchethicscommittees.
TheALSPACethicscommitteeapprovedthisproject.
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6O'ConnorTG,HeronJ,GloverV,AlspacStudyTeam.
Antenatalanxietypredictschildbehavioral/emotionalproblemsindependentlyofpostnataldepression.
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7HayDF,PawlbyS,SharpD,AstenP,MillsA,KumarR.
Intellectualproblemsshownby11-year-oldchildrenwhosemothershadpostnataldepression.
JChildPsycholPsychia-try2001;42:871-89.
8Lydon-RochelleMT,HoltVL,MartinDP.
Deliverymethodandself-reportedpostpar-tumgeneralhealthstatusamongprimiparouswomen.
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9KooV,LynchJ,CooperS.
Riskofpostnataldepressionafteremergencydelivery.
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10BoycePM,ToddAL.
Increasedriskofpostnataldepressionafteremergencycaesareansection.
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11SaistoT,Salmela-AroK,NurmiJE,HalmesmakiE.
Psychosocialpredictorsofdisappointmentwithdeliveryandpuerperaldepression.
Alongitudinalstudy.
ActaObstetGynecolScand2001;80:39-45.
12VerdouxH,SutterAL,Glatigny-DallayE,MinisiniA.
Obstetricalcomplicationsandthedevelopmentofpostpartumdepressivesymptoms:aprospectivesurveyoftheMATQUIDcohort.
ActaPsychiatrScand2002;106:212-9.
13NielsenFD,VidebechP,HedegaardM,DalbySalvigJ,SecherNJ.
Postpartumdepres-sion:identificationofwomenatrisk.
BrJObstetGynaecol2000;107:1210-7.
14ThompsonJF,RobertsCL,CurrieM,EllwoodDA.
Prevalenceandpersistenceofhealthproblemsafterchildbirth:associationswithparityandmethodofbirth.
Birth2002;29:83-94.
15CoxJL,HoldenJM,SagovskyR.
Detectionofpostnataldepression.
Developmentofthe10-itemEdinburghpostnataldepressionscale.
BrJPsychiatry1987;150:782-6.
16MurrayL,CarothersAD.
ThevalidationoftheEdinburghpost-nataldepressionscaleonacommunitysample.
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(Accepted17January2005)doi10.
1136/bmj.
38376.
603426.
D3LevelD,DivisionofObstetricsandGynaecology,UniversityofBristol,StMichael'sHospital,BristolBS28EGRoshniRPatelclinicalacademictrainingfellowDivisionofMaternalandChildHealthSciences,UniversityofDundee,NinewellsHospitalandMedicalSchool,DundeeDD19SYDeirdreJMurphyprofessorofobstetricsandgynaecologyAcademicUnitofPrimaryHealthCare,DepartmentofCommunityBasedMedicine,UniversityofBristol,BristolBS81AUTimJPetersprofessorofprimarycarehealthservicesresearchCorrespondenceto:RPatelroshni.
patel@bristol.
ac.
ukWhatisalreadyknownonthistopicPostnataldepressionaffects8-15%ofwomenandmayhavelongtermeffectsonchilddevelopmentRatesofcaesareansectionareincreasingworldwideanditisimportanttoidentifyanylongtermrisksassociatedwiththeprocedureTheconflictingevidenceregardingoperativedeliveryandpostnataldepressionisbasedonsmallobservationalstudiesWhatthisstudyaddsElectivecaesareansectiondoesnotprotectwomenfrompostnataldepressionNeitheremergencycaesareansectionnorassistedvaginaldeliveryisassociatedwithanincreasedriskofpostnataldepressionUnderstandingtheassociationbetweenpostnataldepressionandcaesareansectionhelpswomentomakeinformedchoicesaboutmodeofdeliveryPaperspage4of4BMJOnlineFirstbmj.
comon23February2021byguest.
Protectedbycopyright.
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bmj.
com/BMJ:firstpublishedas10.
1136/bmj.
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Downloadedfrom
DesignProspectivepopulationbasedcohortstudy.
SettingALSPAC(theAvonlongitudinalstudyofparentsandchildren).
Participants14663womenrecruitedantenatallywithaduedatebetween1April1991and31December1992.
MainoutcomemeasureEdinburghpostnataldepressionscalescore≥13ateightweekspostnatalonselfcompletedquestionnaire.
ResultsAlbeitwithwideconfidenceintervals,therewasnoevidencethatelectivecaesareansectionalteredtheoddsofpostnataldepressioncomparedwithplannedvaginaldelivery(adjustedoddsratio1.
06,95%confidenceinterval0.
66to1.
70,P=0.
80).
Amongplannedvaginaldeliveriestherewassimilarlylittleevidenceofadifferencebetweenwomenwhohaveemergencycaesareansectionorassistedvaginaldeliveryandthosewhohavespontaneousvaginaldelivery(1.
17,0.
77to1.
79,P=0.
46,and0.
89,0.
68to1.
18,P=0.
42,respectively).
ConclusionsThereisnoreasonforwomenatriskofpostnataldepressiontobemanageddifferentlywithregardtomodeofdelivery.
Electivecaesareansectiondoesnotprotectagainstpostnataldepression.
Womenwhoplanvaginaldeliveryandrequireemergencycaesareansectionorassistedvaginaldeliverycanbereassuredthatthereisnoreasontobelievethattheyareatincreasedriskofpostnataldepression.
IntroductionDepressionisamajorsourceofmorbidityinGreatBritainandacommoncauseforconsultationinprimarycare.
1Theprevalenceofdepressioninthepostnatalperiodissimilartobackgroundpopulationratesofdepressionandaffectsabout8-15%ofwomen.
2Postnataldepressionissimilartodepressionoccurringatothertimesinlifeandonlydistinguishablebythetimingofonset.
Depressionatanytimeisassociatedwithnegativesequelae.
Whatmakespostnataldepressionofparticularconcernisitspossibledetrimentallongtermeffectsonsubsequentchilddevelopment.
Infantsofdepressedmothershavebeenfoundtoperformlesswellonobjectconcepttasksandbemoreinsecurelyattachedtotheirmothers.
3Otherstudieshavefoundhigherratesofintellectualdeficitsat4yearsofage,45behaviouraldisturbancesupto5years,56andincreasedratesofspecialeducationalneedsat11years.
7Iflabouriscomplicatedandthedeliveryunexpectedlyperformedasanemergencypro-cedureitcouldpotentiallybestressfultothemother.
Insuchsce-nariostheremaybeanassociationbetweenemergencyoperativedeliveryandpostnataldepression.
Severalstudieshaveinvestigatedthisassociation,thoughthecurrentevidenceiscon-flicting,withsomestudiesreportinganassociation8–10andothersnot.
11–14Converselytheremaybeanassociationbetweenelectivecaesareansectionandareducedriskofpostnataldepression.
TheEdinburghpostnataldepressionscalewasinitiallydevel-opedasascreeningtoolandfocusesonthecognitiveandfunc-tionaleffectsofdepressiontofacilitatedetectionofwomenwithpostnataldepressioninthemonthsimmediatelypostpartum.
15Thescalecannotbeusedasadiagnostictoolalonebutascoreof≥13ishighlypredictiveofpostnataldepressioninaUKpopula-tionandwarrantsfurtherclinicalassessment.
Inalargecommu-nitystudyitwasfoundtohaveasensitivityof88%andaspecificityof92.
5%.
16Wecomparedtheratesofpostnataldepressioninwomenwhohadanelectivecaesareansectionandthosewhohadaplannedvaginaldelivery(thisincludedemergencycaesareansectionandassistedorspontaneousvaginaldelivery).
MethodsTheAvonlongitudinalstudyofparentsandchildren(ALSPAC)isacohortstudyofover14000womenrecruitedantenatallyin1990-2.
Fulldetailsofthestudyareavailableelsewhere.
1718Therewere14663womeninthecohort,ofwhom14051reached20weeks'gestationandcompletedatleastonequestionnaire.
Intheseanalyseswehaveincludedallwomenwithsingleton,liveborninfantsandtermpregnancies(37to44weeks)whocompletedtheeightweekpostnatalquestionnaire.
Electivecaesareansectionswerethosewithpriorplanning,andemergencycaesareansectionswerethosewithoutpriorplanningorthattookplaceafterlabourstarted.
Assistedvaginaldeliverycomprisedbothforcepsdeliveriesandvacuumextraction.
Wecalculatedthemean(SD)depressionscoreandtheproportionofscores≥13foreachmodeofdelivery.
Wethenusedunivariableanalysestocalculatecrudeoddsratios,95%confidenceintervals,andlikelihoodratioPvaluesfortheassociationbetweenmodeofdeliveryandpostnataldepressionusinglogisticregression.
Adjustedoddsratioswerecalculatedbytheadditionofconfoundersassociatedwithmodeofdeliveryintothestatisticalmodel.
Detailsoftheapproachusedinderiv-ingthesepotentialconfoundersareavailableelsewhere.
19Weusedcontinuousvariables(maternalage,gestationalageatdeliv-ery,parity,neonatalheadcircumference,andbirthweight),binary(yes/no)variables(previouscaesareansection,epiduralinlabour,previousmiscarriage/termination,antenatalclassattend-ance),andcategoricalvariables(diabetesmellitus,fetalpresenta-tion,outcomeoflastpregnancy,preferredlabourposition,perceivedlossofcontrolinlabour.
Wealsoinvestigatedhistoryofdepression(yes/no)andconsideredadditionalvariablesthatCitethisarticleas:BMJ,doi:10.
1136/bmj.
38376.
603426.
D3(published25February2005)BMJOnlineFirstbmj.
compage1of4on23February2021byguest.
Protectedbycopyright.
http://www.
bmj.
com/BMJ:firstpublishedas10.
1136/bmj.
38376.
603426.
D3on25February2005.
Downloadedfromwereidentifiedbyaliteraturesearchasbeingassociatedwithpostnataldepressioninotherpopulations—namely,housingsta-tus(categorical)andantenataldepressionscoreat18and32weeks(<13or≥13).
Stata8.
0softwarewasusedforallanalyses.
ResultsOfthe12944womenwhometthestudycriteria,10934(84.
5%)completedthedepressionscaleateightweekspostnatally.
Theresponseratewassimilarforalldeliverygroups.
Ofthesewomen,8731(79.
9%)hadaspontaneousvaginaldeliveryand1242(11.
4%)hadanassistedvaginaldelivery.
Ofthe961responderswhohadacaesareansection,572hadanemergencyoperation(5.
2%)and389(3.
6%)hadanelectiveprocedure(fig-ure).
Electivecaesareansectionvplannedvaginaldelivery—Ahigherproportionofthewomenwhohadanelectivecaesareansectionhadadepressionscore≥13comparedwithwomenwhoplannedavaginaldelivery(table1),althoughthemeanscoresweresimilar.
Theunadjustedoddsratioofscore≥13inwomenwhohadelectivecaesareansectioncomparedwithwomenwhoplannedvaginaldeliverywas1.
31(95%confidenceinterval0.
96to1.
78).
Adjustmentfortheprenatalfactorsidentifiedasbeingassociatedwithelectivecaesareansection(seetable1)andhous-ingstatuscausedafallintheoddsratio(1.
06,0.
66to1.
70).
Nei-therahistoryofdepressionnorantenataldepressionat18and32weekswasassociatedwithelectivecaesareansectioninthisdataset.
Emergencycaesareansectionvspontaneousvaginaldelivery—About10%ofwomeninbothdeliverygroupshadadepressionscore≥13(table2).
Theunadjustedoddsratiooftheassociationbetweenemergencycaesareansectionanddepressionscore≥13was0.
99(0.
74to1.
32).
Adjustmentforthenineprenatalvariablesfoundtobeassociatedwithemergencycaesareansectionfromthepreviousanalysesofthisdataset(seetable2)andhousingstatusincreasedtheoddsratioto1.
17(0.
77to1.
79),butstillwithnostrongevidenceofanassociation.
Omissionofneonatalheadcircumference,whichwasmissinginalargenumberofcases,alsohadaminimaleffectontheresults(1.
14,0.
75to1.
73,n=7999).
Historyofdepressionordepressiondur-ingpregnancywasnotassociatedwithemergencycaesareansec-tion.
WomeninALSPACdataset(n=14663)Livebirths(n=14049)Miscarriages/stillbirths(n=614)Singletons(n=13678)Multiplepregnancies(n=371)Allwomenmeetinginclusioncriteria(n=12944)Missingdeliverydata(n=2)Termpregnancies(37to44weeks)(n=12946)Caesareansection(n=1153)Elective(n=468)Emergency(n=685)Assisted(n=1454)Spontaneous(n=10337)Vaginaldelivery(n=11791)Pretermpregnancies/missingdata(n=732)(n=389,83.
1%)(n=572,83.
5%)(n=1242,85.
4%)(n=8731,84.
5%)Responderstodepressionquestionnaireat8weekspostpartumExclusionalgorithmforstudycohortTable1AssociationbetweenelectivecaesareansectionandEdinburghpostnataldepressionscore*comparedwithplannedvaginaldeliveryDeliveryNoofwomenMean(SD)scoreNo(%)whoscored<13No(%)whoscored≥13Oddsratio(95%CI)UnadjustedVaginal109346.
0(4.
7)9520(90.
3)1025(9.
7)1.
00Electivecaesarean6.
1(5.
3)341(87.
7)48(12.
3)1.
31(0.
96to1.
78),P=0.
10AdjustedVaginal95025.
9(4.
7)8369(90.
7)857(9.
3)1.
00Electivecaesarean5.
8(5.
1)248(89.
9)28(10.
1)1.
06(0.
66to1.
70),P=0.
80*Scoreof≥13warrantsfurtherinvestigation.
Adjustedforvariablesassociatedwithelectivecaesareansection(maternalage,previouscaesareansection,diabetesmellitus,gestationalageatdelivery,non-cephalicpresentation)andvariablesidentifiedfromliteraturesearchtobeassociatedwithpostnataldepressionandeliminatedinmultivariablemodellinginidentificationofvariablesassociatedwithelectivecaesareansection(housing).
Paperspage2of4BMJOnlineFirstbmj.
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DownloadedfromAssistedvaginaldeliveryvspontaneousvaginaldelivery—Alowerproportionofwomenwhohadanassistedvaginaldeliveryhaddepressionscores≥13comparedwithwomenwhodeliveredspontaneously.
Theirmeanscores,however,werethesame(table3).
Theunadjustedoddsratiosbetweenassistedvaginaldeliveryanddepressionscore≥13was0.
85(0.
69to1.
05).
Adjustmentforthefactorsidentifiedasbeingassociatedwithassistedvaginaldeliveryinthisdataset(seetable3)hadminimaleffectontheresultsandsuggestedlittleevidenceofanassociation.
Omissionofneonatalheadcircumferencefromthemodelagainhadmini-maleffect(0.
84,0.
64to1.
10,n=8712),andneitherhistoryofdepressionnordepressionduringpregnancywasassociatedwithassistedvaginaldeliveryinthisdataset.
DiscussionThoughourresultshadwideconfidenceintervals,wecouldfindnoassociationbetweenpostnataldepressionateightweeksandelectivecaesareansectioncomparedwithplannedvaginaldeliv-ery.
Explorationofplannedvaginaldeliverysimilarlyfoundlittleevidenceofanassociationbetweenemergencycaesareansectionorassistedvaginaldeliveryandpostnataldepressioncomparedwithspontaneousvaginaldelivery.
StrengthsofstudyOurresearchhadseveraladvantagesoverotherstudiesinthisspecialty.
WeusedprospectivelycollecteddatatoevaluatetheassociationbetweenpostnataldepressionandoperativedeliveryinaBritishcohort,whichisimportanttoclinicalpracticegiventhehighprevalenceofbothmentalillnessandoperativedeliveryintheUKpopulation.
Ourcohortwasalsomuchlargerthaninmostothersimilarstudies.
TheEdinburghpostnataldepressionscalewasdevelopedandvalidatedintheUnitedKingdomandassuchisanappropriatescreeningtoolforpostnataldepressioninthispopulation.
Researchhasshown,however,thatselfreportedscreeningtoolsforpostnataldepressionyieldahigherrateofpositivecasesthanclinicalinterviewmethods.
20Antenataldepressionisknowntobeassociatedwithpostpartumdepression211andmustthereforebeconsideredinanyexplora-tionofriskfactorsofpostnataldepression.
Manyofthepublishedstudiesarelimitedbytheabsenceofdataonantenataldepression,whichwereavailableinourresearch.
Datawerealsoavailableonalltypesofoperativedelivery,whichallowedustoexaminemorespecificcomparisons.
Finally,weminimisedcon-foundingbyincorporatingfactorspreviouslyidentifiedtobeassociatedwitheachdeliverymethodstudied.
Theseanalyseswerebasedonobservationaldataandarethereforepotentiallysubjecttobias.
Therewasahighfollowuprate(85%),thoughoneconcernisthatwomenwithpostnataldepressionwerelesslikelytocompletethequestionnaire.
Thismaybeparticularlyrelevanttowomensufferingfromseveredepression,especiallyiftheywereresidentinapsychiatricunit.
ComparisonwithotherstudiesOurresultssupportthecurrentreviewofevidencebytheNationalInstituteforClinicalExcellencethatpostnataldepressionisnotasequelaeofcaesareansection.
21Severalotherstudieshavealsonotfoundevidenceofanassociationbetweenplannedmodeofdeliveryandpostnataldepression.
Oneprospectivecohortfoundaweakassociationbetweensomecomplicationsinpregnancyandpostnataldepressionbutnonewithmodeofdelivery.
12Saistoetaladjustedforantenataldepressionandfoundthatmodeofdeliverydidnotpredictpostnataldepressionat8to12weeks.
11Eachofthesestudiescomprisedfewerthan500women.
Twolargerprospectivestud-iesfoundnoassociationbetweendeliverycomplicationsanddepressionscores≥13,thoughthiswasassessedatfourmonthspostpartum.
1314Onestudyfoundsomeevidenceofhigherratesofraiseddepressionscoresatthreemonthspostpartuminwomenwhohadanemergencycaesareansectioncomparedwiththosewhohadaspontaneousvaginaldelivery.
10Thisstudy,however,involvedonly21womenwhohadanemergencycaesareansection.
AnAustralianstudyfoundthatbothelectiveandemergencycaesareandeliverywereassociatedwithasmallbutnotsignificantincreasedriskofpostnataldepressionateightweekspostpartum.
22OurresultsdifferfromthoseofasmallretrospectivecohortstudyinMalaysia.
Higherdepressionscoreswerefoundamongwomenwhohadanemergencydeliverycomparedwithnon-emergencydelivery,althoughtheformergroupincludedTable2AssociationbetweenemergencycaesareansectionandEdinburghpostnataldepressionscore*comparedwithspontaneousvaginaldeliveryDeliveryNoofwomenMean(SD)scoreNo(%)whoscored<13No(%)whoscored≥13Oddsratio(95%CI)UnadjustedSpontaneousvaginal93036.
0(4.
7)7868(90.
1)863(9.
9)1.
00Emergencycaesarean5.
9(4.
8)516(90.
2)56(9.
8)0.
99(0.
74to1.
32),P=0.
94AdjustedSpontaneousvaginal62956.
2(4.
9)5331(88.
5)694(11.
5)1.
00Emergencycaesarean6.
2(4.
9)239(88.
5)31(11.
5)1.
17(0.
77to1.
79),P=0.
46*Score≥13warrantsfurtherinvestigation.
Adjustedforvariablesassociatedwithemergencycaesareansection(maternalage,previouscaesareansection,outcomeoflastpregnancy,parity,neonatalbirthweight,neonatalheadcircumference,non-cephalicpresentation,inpreferredpositioninlabour,epiduralinlabour)andvariablesidentifiedfromliteraturesearchtobeassociatedwithpostnataldepression,andeliminatedinmultivariablemodellinginidentificationofvariablesassociatedwithelectivecaesareansection(housing)Table3AssociationbetweenassistedvaginaldeliveryandEdinburghdepressionscore*comparedwithspontaneousvaginaldeliveryDeliveryNoofwomenMean(SD)scoreNo(%)whoscored<13No(%)whoscored≥13Oddsratio(95%CI)UnadjustedSpontaneousvaginal99736.
0(4.
8)7868(90.
1)863(9.
9)1.
00Assistedvaginal6.
0(4.
7)1136(91.
5)106(8.
5)0.
85(0.
69to1.
05),P=0.
13AdjustedSpontaneousvaginal68886.
2(4.
9)5295(88.
6)683(11.
4)1.
00Assistedvaginal5.
8(4.
6)826(90.
8)84(9.
2)0.
89(0.
68to1.
18),P=0.
42*Score≥13warrantsfurtherinvestigation.
Adjustedforvariablesassociatedwithassistedvaginaldelivery(previousmiscarriage/termination,previouscaesareansection,outcomeoflastpregnancy,parity,housing,antenatalclassattendance,neonatalheadcircumference,non-cephalicpresentation,inpreferredpositioninlabour,lossofcontrolinlabour,andepiduralinlabour).
PapersBMJOnlineFirstbmj.
compage3of4on23February2021byguest.
Protectedbycopyright.
http://www.
bmj.
com/BMJ:firstpublishedas10.
1136/bmj.
38376.
603426.
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Downloadedfromemergencycaesareansectionandvacuumdelivery.
TheEdinburghscale,however,hasnotbeenvalidatedinaMalaysianpopulation.
9Lydon-Rochellealsofoundevidenceofanassocia-tionbetweencaesareandeliveryandlowermentalhealthscorescomparedwithspontaneousvaginaldelivery,althoughthisstudyusedadifferentselfreportedquestionnaireanddidnotseparateemergencyandelectiveprocedures.
8Unlikeourresearch,thesestudieshadsamplesoffewerthan1000womeneach.
8922Regardingassistedvaginaldeliveryourresultssupportotherstudiesthathavenotfoundanassociationwithpostnataldepres-sion.
1022Onesmallstudyof142womenfoundanon-significantassociationatsixweekspostpartumamongwomenwhodidnotdeliverspontaneously.
23ConclusionsOurworkaddsanimportantcomponenttothecounsellingofwomenwhoareplanningmodeofdelivery.
ItisespeciallyrelevantforwomenconsideringelectivecaesareansectionandinkeepingwithNICEguidelineshelps"womentomakeinformeddecisionsaboutchildbirth.
"21Thereisnoreasonforwomenwithahistoryofdepressionorthoseathighriskofdepressiontobemanageddifferentlywithregardtomodeofdelivery.
Furthermore,evenifemergencycae-sareansectionorassistedvaginaldeliveryisrequired,womencanbereassuredthatthereisnoreasontobelievethattheyaremorelikelytoexperiencepostnataldepression.
Weareextremelygratefultoallthemotherswhotookpartandtothemid-wivesfortheircooperationandhelpinrecruitment.
TheALSPACstudyteamcomprisesinterviewers,computertechnicians,laboratorytechnicians,clericalworkers,researchscientists,volunteers,andmanagerswhocontinuetomakethestudypossible.
WearegratefultoJeanGoldingfordiscussionsaboutthisresearchandtoJonHeronfordatapreparation.
Contributors:Allauthorsdesignedthestudy,contributedtotheanalysisandinterpretedthedata.
RPperformedtheanalysisandwrotethereportwithhelpfromtheotherauthors;sheisguarantor.
Funding:WellcomeTrust,MedicalResearchCouncil,UniversityofBristol,DepartmentofHealth,andDepartmentofEnvironment.
TheALSPACstudyispartoftheWHOinitiatedEuropeanLongitudinalStudyofPregnancyandChildhood.
RPreceivedaclinicalacademictrainingfellow-shipfromNHSSouthWestresearchanddevelopment.
Competinginterests:Nonedeclared.
Ethicalapproval:Theresearchprogrammeisgovernedbythefourlocalresearchethicscommittees.
TheALSPACethicscommitteeapprovedthisproject.
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2CooperPJ,MurrayL.
Postnataldepression.
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3WrateRM,RooneyAC,ThomasPF,CoxJL.
Postnataldepressionandchilddevelopment.
Athree-yearfollow-upstudy.
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4CogillS,CaplanH,AlexandraH,RobsonK,KumarR.
Impactofpostnataldepressiononcognitivedevelopmentofyoungchildren.
BMJ1986;292:1165-7.
5SharpD,HayDF,PawlbyS,SchmuckerG,AllenH,KumarR.
Theimpactofpostnataldepressiononboys'intellectualdevelopment.
JChildPsycholPsychiatry1995;36:1315-36.
6O'ConnorTG,HeronJ,GloverV,AlspacStudyTeam.
Antenatalanxietypredictschildbehavioral/emotionalproblemsindependentlyofpostnataldepression.
JAmAcadChildAdolescPsychiatry2002;41:1470-7.
7HayDF,PawlbyS,SharpD,AstenP,MillsA,KumarR.
Intellectualproblemsshownby11-year-oldchildrenwhosemothershadpostnataldepression.
JChildPsycholPsychia-try2001;42:871-89.
8Lydon-RochelleMT,HoltVL,MartinDP.
Deliverymethodandself-reportedpostpar-tumgeneralhealthstatusamongprimiparouswomen.
PaediatricPerinatEpidemiol2001;15:232-40.
9KooV,LynchJ,CooperS.
Riskofpostnataldepressionafteremergencydelivery.
JObstetGynaecolRes2003;29:246-50.
10BoycePM,ToddAL.
Increasedriskofpostnataldepressionafteremergencycaesareansection.
MedJAust1992;157:172-4.
11SaistoT,Salmela-AroK,NurmiJE,HalmesmakiE.
Psychosocialpredictorsofdisappointmentwithdeliveryandpuerperaldepression.
Alongitudinalstudy.
ActaObstetGynecolScand2001;80:39-45.
12VerdouxH,SutterAL,Glatigny-DallayE,MinisiniA.
Obstetricalcomplicationsandthedevelopmentofpostpartumdepressivesymptoms:aprospectivesurveyoftheMATQUIDcohort.
ActaPsychiatrScand2002;106:212-9.
13NielsenFD,VidebechP,HedegaardM,DalbySalvigJ,SecherNJ.
Postpartumdepres-sion:identificationofwomenatrisk.
BrJObstetGynaecol2000;107:1210-7.
14ThompsonJF,RobertsCL,CurrieM,EllwoodDA.
Prevalenceandpersistenceofhealthproblemsafterchildbirth:associationswithparityandmethodofbirth.
Birth2002;29:83-94.
15CoxJL,HoldenJM,SagovskyR.
Detectionofpostnataldepression.
Developmentofthe10-itemEdinburghpostnataldepressionscale.
BrJPsychiatry1987;150:782-6.
16MurrayL,CarothersAD.
ThevalidationoftheEdinburghpost-nataldepressionscaleonacommunitysample.
BrJPsychiatry1990;157:288-90.
17AvonLongitudinalStudyofParentandChildren,2003.
www.
alspac.
bris.
ac.
uk/(accessed9Feb2005).
18GoldingJ,PembreyM,JonesR,ALSPACStudyTeam.
ALSPAC—theAvonlongitudinalstudyofparentsandchildren.
I.
Studymethodology.
PaediatricPerinatEpidemiol2001;15:74-87.
19PatelRR,PetersTJ,MurphyDJ,ALSPACStudyteam.
Prenatalriskfactorsforcaesar-eansection.
AnalysesoftheALSPACcohortof12944womeninEngland.
IntJEpide-miol2004(inpress).
20O'HaraM,SwainA.
Ratesandrisksofpostpartumdepression:ameta-analysis.
IntRevPsychiatry1996;8:37-54.
21NationalCollaboratingCentreforWomen'sandChildren'sHealth.
Caesareansection.
Clinicalguideline.
London:RoyalCollegeofObstetriciansandGynaecologists,2004.
22JohnstoneSJ,BoycePM,HickeyAR,Morris-YateesAD,GHM.
Obstetricriskfactorsforpostnataldepressioninurbanandruralcommunitysamples.
AustralNZJPsychiatry2001;35:69-74.
23O'NeillT,MurphyP,GreeneVT.
Postnataldepression-aetiologicalfactors.
IrishMedJ1990;83:17-8.
(Accepted17January2005)doi10.
1136/bmj.
38376.
603426.
D3LevelD,DivisionofObstetricsandGynaecology,UniversityofBristol,StMichael'sHospital,BristolBS28EGRoshniRPatelclinicalacademictrainingfellowDivisionofMaternalandChildHealthSciences,UniversityofDundee,NinewellsHospitalandMedicalSchool,DundeeDD19SYDeirdreJMurphyprofessorofobstetricsandgynaecologyAcademicUnitofPrimaryHealthCare,DepartmentofCommunityBasedMedicine,UniversityofBristol,BristolBS81AUTimJPetersprofessorofprimarycarehealthservicesresearchCorrespondenceto:RPatelroshni.
patel@bristol.
ac.
ukWhatisalreadyknownonthistopicPostnataldepressionaffects8-15%ofwomenandmayhavelongtermeffectsonchilddevelopmentRatesofcaesareansectionareincreasingworldwideanditisimportanttoidentifyanylongtermrisksassociatedwiththeprocedureTheconflictingevidenceregardingoperativedeliveryandpostnataldepressionisbasedonsmallobservationalstudiesWhatthisstudyaddsElectivecaesareansectiondoesnotprotectwomenfrompostnataldepressionNeitheremergencycaesareansectionnorassistedvaginaldeliveryisassociatedwithanincreasedriskofpostnataldepressionUnderstandingtheassociationbetweenpostnataldepressionandcaesareansectionhelpswomentomakeinformedchoicesaboutmodeofdeliveryPaperspage4of4BMJOnlineFirstbmj.
comon23February2021byguest.
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bmj.
com/BMJ:firstpublishedas10.
1136/bmj.
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D3on25February2005.
Downloadedfrom
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