Twelve Peer-Reviewed Articles on Postpartum Depression, the impact that Cesarean Section and other operative delivery procedures and anesthesia has on its development 

The effect of PPD on the mother-child relationship, breastfeeding and other child development problems 

Traumatic Childbirth and Post-traumatic Stress Syndrome

Psychological Aspects of Cesarean Delivery 

Aust N Z J Psychiatry 1997 Oct;31(5):728-38
Adverse psychological impact of operative obstetric interventions: a prospective longitudinal study.

Fisher J, Astbury J, Smith A. Key Centre for Women's Health, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Victoria, Australia.

OBJECTIVE: This paper reports the findings of a prospective longitudinal study of 272 nulliparous pregnant women, which investigated as one of its objectives the psychological sequelae of obstetric procedures. METHOD: Participants completed structured interviews and standardised, published psychometric questionnaires, including the Rosenberg Self-Esteem Scale and the Profile of Mood States late in pregnancy and again early in the postpartum period. 

RESULTS: Little evidence was found to support the notion that the total number of obstetric interventions was linked to a deterioration in postpartum mood. Significant adverse psychological effects were associated with the mode of delivery. Those women who had spontaneous vaginal deliveries were most likely to experience a marked improvement in mood and an elevation in self-esteem across the late pregnancy to early postpartum interval. In contrast, women who had Caesarean deliveries were significantly more likely to experience a deterioration in mood and a diminution in self-esteem. The group who experienced instrumental intervention in vaginal deliveries fell midway between the other two groups, reporting neither an improvement nor a deterioration in mood and self-esteem. 

CONCLUSIONS: The findings of this study suggest that operative intervention in first childbirth carries significant psychological risks rendering those who experience these procedures vulnerable to a grief reaction or to posttraumatic distress and depression.

PMID: 9400879 [PubMed - indexed for MEDLINE] 


CMAJ 1997 Mar 15;156(6):831-5
Post-traumatic stress disorder after childbirth: the phenomenon of traumatic birth.

Reynolds JL. Department of Family Medicine, University of Western Ontario, London.

CHILDBIRTH CAN BE A VERY PAINFUL EXPERIENCE, often associated with feelings of being out of control. It should not, therefore, be surprising that childbirth may be traumatic for some women. Most women recover quickly postpartum; others appear to have a more difficult time. 

The author asserts that post-traumatic stress disorder (PTSD) may occur after childbirth. He calls this variant of PTSD a "traumatic birth experience." There is very little literature on this topic. The evidence available is from case series, qualitative research and studies of women seeking elective cesarean section for psychologic reasons. Elective cesarean section exemplifies the avoidance behaviour typical of PTSD. There are many ways that health care professionals, including physicians, obstetric nurses, midwives, psychologists, psychiatrists and social workers, can address this phenomenon. These include taking a careful history to determine whether a woman has experienced trauma that could place her at risk for a traumatic birth experience; providing excellent pain control during childbirth and careful postpartum care that includes understanding the woman's birth experience; and ruling out postpartum depression. Much more research is needed in this area.

 PMID: 9084390 [PubMed - indexed for MEDLINE] 

Baillieres Best Pract Res Clin Obstet Gynaecol 2001 Feb;15(1):109-26
Psychological aspects of caesarean section.

Clement S. Department of General Practice and Primary Care, Guy's, King's and St Thomas' School of Medicine, King's College London, 5 Lambeth Walk, London, SE11 6SP, UK.

This chapter gives an overview of research relating to psychological aspects of caesarean section. It focuses on four main questions: 

*What are the psychological effects of caesarean section on the mother, her partner and her relationship with her infant? 
*What factors (obstetric, psychological, attitudinal, and health care-related) make women more vulnerable to adverse psychological outcomes after a caesarean section? 
*What are women distressed about when they have had a caesarean section? 
*How can post-caesarean psychological distress be prevented or managed?

A methodological critique of existing studies on psychological aspects of caesarean section is also given. In conclusion, recommendations for practice and for future research are made. Copyright 2001 Harcourt Publishers Ltd.

PMID: 11359318 [PubMed - indexed for MEDLINE] 


BMJ 2000 Oct 28;321(7268):1043-7
Comment in: BMJ. 2000 Oct 28;321(7268):1032-3 Small R, Lumley J, Donohue L, Potter A, Waldenstrom U.

Randomised controlled trial of midwife led debriefing to reduce maternal depression after operative childbirth.

Centre for the Study of Mothers' and Children's Health, School of Public Health, La Trobe University, Carlton Vic 3053, Australia.

OBJECTIVE: To assess the effectiveness of a midwife led debriefing session during the postpartum hospital stay in reducing the prevalence of maternal depression at six months postpartum among women giving birth by caesarean section, forceps, or vacuum extraction. 

DESIGN: Randomised controlled trial. 
SETTING: Large maternity teaching hospital in Melbourne, Australia

PARTICIPANTS: 1041 women who had given birth by caesarean section (n= 624) or with the use of forceps (n= 353) or vacuum extraction (n= 64). MAIN OUTCOME MEASURES: Maternal depression (score >/=13 on the Edinburgh postnatal depression scale) and overall health status (comparison of mean scores on SF-36 subscales) measured by postal questionnaire at six months postpartum. 

RESULTS: 917 (88%) of the women recruited responded to the outcome questionnaire. More women allocated to debriefing scored as depressed six months after birth than women allocated to usual postpartum care (81 (17%) v 65 (14%)), although this difference was not significant (odds ratio=1.24, 95% confidence interval 0.87 to 1.77). They were also more likely to report that depression had been a problem for them since the birth, but the difference was not significant (123 (28%) v 94 (22%); odds ratio=1. 37, 1.00 to 1.86). Women allocated to debriefing had poorer health status on seven of the eight SF-36 subscales, although the difference was significant only for role functioning (emotional): mean scores 73.32 v 78.98, t= -2.31, 95% confidence interval -10.48 to -0.84).

CONCLUSIONS: Midwife led debriefing after operative birth is ineffective in reducing maternal morbidity at six months postpartum. The possibility that debriefing contributed to emotional health problems for some women cannot be excluded.
PMID: 11053173 [PubMed - indexed for MEDLINE] 


J Womens Health Gend Based Med 1999 Dec;8(10):1257-64
The obstetrical and postpartum benefits of continuous support during childbirth.

Scott KD, Klaus PH, Klaus MH. Division of Public Health, County of Sonoma Department of Health Services, Santa Rosa, California 95404, USA.

The purpose of this article is to review the evidence regarding the effectiveness of continuous support provided by a trained laywoman (doula) during childbirth on obstetrical and postpartum outcomes. Twelve individual randomized trials have compared obstetrical and postpartum outcomes between doula-supported women and women who did not receive doula support during childbirth. Three meta-analyses, which used different approaches, have been performed on the results of the clinical trials. Emotional and physical support significantly shortens labor and decreases the need for cesarean deliveries, forceps and vacuum extraction, oxytocin augmentation, and analgesia. 

Doula-supported mothers also rate childbirth as less difficult and painful than do women not supported by a doula. Labor support by fathers does not appear to produce similar obstetrical benefits. Eight of the 12 trials report early or late psychosocial benefits of doula support. Early benefits include reductions in state anxiety scores, positive feelings about the birth experience, and increased rates of breastfeeding initiation. Later postpartum benefits include decreased symptoms of depression, improved self-esteem, exclusive breastfeeding, and increased sensitivity of the mother to her child's needs. The results of these 12 trials strongly suggest that doula support is an essential component of childbirth. A thorough reorganization of current birth practices is in order to ensure that every woman has access to continuous emotional and physical support during labor.

PMID: 10643833 [PubMed - indexed for MEDLINE] 


Gynakol Geburtshilfliche Rundsch 1998;38(4):232-7
Prevalence of depressive disorders in early puerperium.

[Article in German] Bergant A, Nguyen T, Moser R, Ulmer H. Universitatsklinik fur Frauenheilkunde Innsbruck, Osterreich.

OBJECTIVE: The aims of this investigation were to detect the prevalence and influencing factors of early postpartal depressive disorders in a large hospital sample. METHODS: By means of an interview we acquired information on sociodemographic data, physical and psychiatric anamnesis, obstetric and psychological variables. The German version of the Edinburgh Postnatal Depression Scale (EPDS) served to determine the depressive disorder of our patients. The interview was carried out on 1,250 women at the maternity ward 5 days after delivery. 

RESULTS: According to the results of the German validation of the EPDS, 254 (20.3%) women at the maternity ward had an at least mild depressive disorder. A comparison between nondepressed women (n = 996, 79.7%) and depressed women (n = 254, 20.3%) revealed the following risk factors for the development of an early postpartal depressive disorder: higher subjective burden of childbirth, higher trait anxiety, poorer couple compatibility, lower job satisfaction and lower social status. Of all the obstetric variables previous abortions, elevated pregnancy risks, low weight of the newborn at delivery and cesarean section were of significant influence. 

CONCLUSIONS: Early postpartal depressive disorder appears in 20% of all women 5 days after delivery. According to previous studies this group seems to be at highest risk for developing a later postpartum depression. Considering the psychosocial and obstetric risk factors, preventive psychotherapeutic interventions at the maternity ward are indicated.

PMID: 10325529 [PubMed - indexed for MEDLINE] 


Gaoxiong Yi Xue Ke Xue Za Zhi 1994 May;10(5):229-38
An exploration of postpartum depression model using LISREL.

Chen CH. School of Nursing, Kaohsiung Medical College, Kaohsiung City, Taiwan, Republic of China.

The purpose of this study was to examine whether the postpartum depression model fits the data. A total of 129 Chinese women at 6 weeks postpartum were recruited to participate in this study from the Kaohsiung City area, Taiwan, Republic of China. Five instruments were used to collect data: the Demographic Data Form, the Cohen's Perceived Stress Scale, the Cohen's Interpersonal Support Evaluation List, the Coopersmith's Self-Esteem Inventory, and the Beck Depression Inventory. In testing the postpartum depression model, tests of covariance structures for type of delivery (vaginal delivery vs. Cesarean delivery) by LISREL (LInear Structural RELations) indicated that covariance matrices for the two groups were significantly different. 

Therefore, multi-sample LISREL analysis was used to analyze data from the two groups simultaneously and it demonstrated that the basic model of the two groups fit the data well. In all, 54% of variance in postpartum depression for the vaginal delivery group and 44% of variance in postpartum depression for the Cesarean delivery group was explained.

PMID: 8040925 [PubMed - indexed for MEDLINE] 


Rev Chil Obstet Ginecol 1993;58(3):239-44
Gyneco-obstetric aspects in women developing postpartum depression.

[Article in Spanish]Alvarado R, Perucca E, Rojas M, Monardes J, Olea E, Neves E, Vera A. Servicio de Obstetricia y Ginecologia, Hospital Barros Luco-Trudeau.

The relationship between different variables was studied related to pregnancy, labor, puerperium, newborn and breast-feeding with the development of a depressive disorders during pregnancy, in a sample of 125 pregnant women. No relationship it's found with the presence of disease during the gestation period, except urinary tract infection. The same happens with other variable of labor, puerperium and newborn, Nevertheless, the major stress situations (urgent cesarean section, use of anesthesia during labor, diseases of the newborn, etc.) systematically present a higher incidence of depression. It is observer a relationship between the development of a depressive disorders and a decrease of the natural lactation period.

PMID: 7991839 [PubMed - indexed for MEDLINE] 


J Psychosom Obstet Gynaecol 2001 Jun;22(2):103-12
Predictors, prodromes and incidence of postpartum depression.

Chaudron LH, Klein MH, Remington P, Palta M, Allen C, Essex MJ. Department of Psychiatry, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA.

The purpose of this study was to determine the incidence of clinically significant depression occurring between 1 and 4 months postpartum and to investigate whether somatic complaints, subsyndromal depressive symptoms, or birth-related concerns among non-depressed women at 1 month were predictive of postpartum depression. This is a prospective cohort study of 465 women from the Wisconsin Maternity Leave and Health Project (WMLHP). Women who were not depressed at 1 month postpartum were reassessed 3 months later for depression occurring at any time in the interval between 1 and 4 months postpartum. Depression was defined as either meeting the criteria for major depression on the National Institute of Mental Health (NIMH) Diagnostic interview Schedule (DIS) or scoring above 15 on the Center for Epidemiologic Studies Depression Scale (CES-D). Physical symptoms were assessed by an adapted Health Responses Scale. Other measures were developed specifically for the WMLHP. Of 465 women, 27 (5.8%) became clinically depressed between 1 and 4 months postpartum. 

In a logistic regression analysis, four variables (maternal age, depression during pregnancy, thoughts of death and dying at 1 month postpartum, and difficulty falling asleep at 1 month postpartum) were predictive of depression at 4 months postpartum. Breast-feeding, mode of delivery, family income, parity and mother's education did not predict depression. The existence of subsyndromal depressive symptoms, particularly thoughts of death and dying, may represent a prodromal phase of depression and should alert clinicians to the possibility of future postpartum depression. Women with a history of depression during pregnancy should be monitored for signs of postpartum depression for a minimum of 4 months. Obstetricians are in a unique position during the postpartum check-up to screen women for these predictors of future postpartum depression and possibly to avert the development of a clinically significant depressive episode.

PMID: 11446151 [PubMed - in process] 


Lakartidningen 2001 Mar 28;98(13):1534-8
Do not minimize signs of postpartum depression! Early intervention essential to prevent negative consequences for the child.

[Article in Swedish] Wickberg B, Hwang P. Psykologiska institutionen, Goteborgs universitet.

Recent clinical research reveals that postnatal depression is associated with disturbances in the mother-infant relationship. These disturbances have in turn an adverse impact on the child's cognitive and emotional development. Postnatal depression affects 8-15 percent of women in the first months after delivery. The use of the Edinburgh Postnatal Depression Scale (EPDS) has proven useful in Swedish child health care to help nurses identify mothers with symptoms of depression. Weekly counselling visits by trained nurses are effective as the first treatment of choice for most women with postnatal depression.

PMID: 11330150 [PubMed - indexed for MEDLINE] 


Women Health 2000;31(2-3):37-56
Singing "the baby blues": a content analysis of popular press articles about postpartum affective disturbances.

Martinez R, Johnston-Robledo I, Ulsh HM, Chrisler JC. Connecticut College, New London 06320, USA.

A content analysis was conducted to evaluate the description of postpartum mood disturbances in magazine articles that appeared during the years 1980-1998. Nineteen articles about postpartum depression and eight articles about "the baby blues" were identified and analyzed for their discussion of etiologies, symptoms, treatments, resources, and demographic assumptions about their readers. The results indicate a strong bias in favor of the medical model of postpartum affective disorders. The articles contained contradictory information about the definition, prevalence, onset, duration, symptoms, and treatment of postpartum disorders, and the authors generally assumed that their readers were heterosexual, married, and middle class. Although the purpose of the articles was to educate readers about an important topic in women's health, they failed to provide accurate information, and thus are not a sufficient resource for new mothers who are seeking to learn about psychosocial aspects of the postpartum period.

PMID: 11289685 [PubMed - indexed for MEDLINE] 


J Affect Disord 2001 Mar;63(1-3):201-7
Infant massage improves mother-infant interaction for mothers with postnatal depression.

Onozawa K, Glover V, Adams D, Modi N, Kumar RC. Section of Perinatal Psychiatry, Institute of Psychiatry, De Crespigny Park, London SE5 8AF, UK.

BACKGROUND: Postnatal depression can have long term adverse consequences for the mother-infant relationship and the infant's development. Improving a mother's depression per se has been found to have little impact on mother-infant interaction. The aims of this study were to determine whether attending regular massage classes could reduce maternal depression and also improve the quality of mother-infant interaction. 

METHOD: Thirty-four primiparous depressed mothers, median 9 weeks postpartum, identified as being depressed following completion of the Edinburgh Postnatal Depression Scale (EPDS) at 4 weeks postpartum, were randomly allocated either to an infant massage class and a support group (massage group) or to a support group (control group). Each group attended for five weekly sessions. Changes in maternal depression and mother-infant interaction were assessed at the beginning and the end of the study by comparing EPDS scores and ratings of videotaped mother-infant interaction. 

RESULTS: The EPDS scores fell in both groups. Significant improvement of mother-infant interaction was seen only in the massage group. LIMITATION: The sample size was small and had relatively high dropout. It was not possible to distinguish which aspects of the infant massage class contributed to the benefit. 

CONCLUSION: This study suggests that learning the practice of infant massage by mothers is an effective treatment for facilitating mother-infant interaction in mothers with postnatal depression.

 PMID: 11246096 [PubMed - indexed for MEDLINE]