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Is cesarean section a clinical marker for psychiatric and sleep disorder in young mothers? A cross-sectional study from rural South India
Sumalatha Ryali1, Mulinti S Kumar2, V.S S.R. Ryali3, Sreelatha Paspulati3
1 Department of Obstetrics and Gynaecology, PES Institute of Medical Sciences and Research, Kuppam, Andhra Pradesh, India
2 Civil Assistant Surgeon Specialist (Psychiatry), Area Hospital, Pulivendla, YSR Kadapa District, Andhra Pradesh, India
3 Department of Psychiatry, PES Institute of Medical Sciences and Research, Kuppam, Andhra Pradesh, India
|Date of Submission||21-Mar-2022|
|Date of Acceptance||14-Jun-2022|
|Date of Web Publication||14-Sep-2022|
V.S S.R. Ryali,
Department of Psychiatry, PES Institute of Medical Sciences and Research, Kuppam - 517 425, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Gestation and postnatal period are important stages in a woman's life. The type of delivery, vaginal delivery (VD) or cesarean Section (CS), is determined by maternal and fetal factors and their mutual fit. The type of delivery has consequences on the health and well-being of the mother and the newborn. Postpartum psychiatric disorders have been found to be both positively and negatively associated with the mode of delivery and demographic and clinical variables of the postpartum mothers. In view of the foregoing, a comprehensive investigation of the demographic and clinical variables and a range of psychiatric disorders among postpartum women delivered both vaginally and by CS in a rural tertiary care hospital in South India was proposed. Materials and Methods: All consecutive women delivered vaginally and by CS attending Maternal and Child Clinic within 42 days of delivery were approached. Following informed consent and application of inclusion and exclusion criteria, 121 women delivered vaginally and 124 women delivered by CS were assessed using Mini International Neuropsychiatric Interview (MINI) and Pittsburgh Sleep Quality Index (PSQI). The data obtained were entered into MS Excel 2010 version and further analyzed using STATA v13. Results: Both groups were matched on most demographic and clinical variables except age and whether pregnancy was planned or not. Postpartum depression was the most frequent diagnosis in both groups, with significantly more cases following CS compared to VD. Other psychiatric disorders were also found to be more following CS. The quality of sleep (QOS) was significantly poor following CS. QOS was significantly poor in the presence of a coexisting psychiatric disorder. Conclusion: This study has limitations in terms of being cross-sectional and disability being defined by cutoff scores on MINI and PSQI.
Keywords: Caesarean, delivery, depression, disorder, marker, psychiatric, sleep, vaginal
|How to cite this URL:|
Ryali S, Kumar MS, Ryali V, Paspulati S. Is cesarean section a clinical marker for psychiatric and sleep disorder in young mothers? A cross-sectional study from rural South India. Ind Psychiatry J [Epub ahead of print] [cited 2022 Nov 29]. Available from: https://www.industrialpsychiatry.org/preprintarticle.asp?id=355950
Gestation and postnatal period are important stages in a woman's life. The enormous physiological changes that take place in the mother's body, the fetus, and the newborn in a short span of time have implications on the health and well-being of the mother, the unborn fetus, and the newborn child. The type of delivery, vaginal delivery (VD) or cesarean section (CS), is determined by maternal and fetal factors and their mutual fit. The type of delivery has consequences on the health and well-being of both the mother and the newborn.
Studies found both an association and lack of it between CS and Postnatal Depression (PND). Dinesh and Swetha in a study on 200 patients found a significant association between of PND and CS. Sword et al. in a large prospective cohort study of 2560 women found that mode of delivery was not independently associated with PND. Hossein et al. in a meta analysis of 32 studies found CS to be a risk factor for PND.
Other studies found psychiatric disorders other than PND to be positively or negatively associated with the mode of delivery and other demographic and clinical variables. Liana Ples in a prospective study of 148 women from Bucharest reported positive evaluation of the obstetrician (58%), absence of impact on infant care (91%) or lactation problems (73%), subjective experience of minimal trauma (32%), desire to have more children (70%), and a desire for the same method of delivery (60%) being associated with the mode of delivery. Tuteja and Niyogi in a review article reported PND in 10–13%, maternal blues in 50–75%, and Postpartum Psychiatric Disorder (PPD) in 1– 2/1000 childbearing women. Deshmukh et al. in a study of 96 primiparous women reported a prevalence of 12% depression, 9% anxiety, and 4% psychosis. Suzuki in a cross-sectional study of 643 primiparous women found higher scores on the Edinburgh Postnatal Depression Scale (EPDS) and the Mother–Infant Bonding Scale (MIBS) in women choosing elective CS. Iranpour in a cross-sectional study of 360 women from Iran using the Pittsburgh Sleep Quality Index (PSQI) and the EPDS found depression being 3.34 times higher in those with poor sleep quality (odds ratio = 3.34; 95% confidence interval: 2.04–5.48; P < 0.001).
In view of such variable association of psychiatric morbidity and sleep quality with mode of delivery and other psychosocial factors, a comprehensive investigation of psychiatric problems among postpartum women delivered by VD and CS in a rural tertiary care hospital in South India was proposed.
| Materials and Methods|| |
For a 95% confidence interval and 80% power, a sample size of 117 each of mothers with CS and VD was calculated as required. Considering attrition, a total of 120 subjects in each group was proposed to be investigated. All consecutive mothers, aged between 16 and 35 years, delivered by CS and VD attending the Maternal and Child Clinic of the hospital for routine review or vaccination of the newborn within 42 days of delivery and giving informed consent for the study were included. Postpartum mothers having associated medical illnesses or mental retardation, interfering with the administration of the psychiatric tests or having a past history of psychiatric illness, or those on psychiatric treatment were excluded. All 245 women who underwent VD (121) and CS (124) were administered a specifically designed general proforma to obtain the sociodemographic data, the Mini-International Neuropsychiatric Interview (MINI) and the Pittsburgh Sleep Quality Index (PSQI). The MINI is a valid and reliable short-structured diagnostic interview developed jointly by psychiatrists and clinicians in the United States of America and Europe for DSM-IV and ICD-10 psychiatric disorders, comprising modules for 17 psychiatric diagnoses, with one or two screening questions to rule out each diagnosis. The PSQI is a validated test that differentiates poor from good sleep by measuring seven areas, including subjective sleep quality, sleep duration, sleep latency, sleep efficiency, sleep disturbance, use of sleep medication, and daytime dysfunction during the last 1 month with a total score of =>5 being indicative of poor-quality sleep. The data obtained were entered into MS Excel 2010 version and further analyzed using STATA v13. The categorical data were analyzed using percentages and the continuous data analyzed using mean and standard deviation. Inferential statistics were analyzed using Chi-square test, “t” test, and Fisher Freeman Hamilton test. A probability value of <0.05 was considered as statistically significant. Approval from the ethics committee is obtained as on 24.12.2018.
| Results|| |
This is an observational cross-sectional study done on 245 postpartum mothers of which 121 delivered vaginally and 124 by CS. Both groups were matched on most demographical variables, such as educational status, duration of marriage prior to child birth, employment, socioeconomic status, and type of family whether nuclear or joint family [Table 1]. The mean age of the sample was 24.82 years. However, the mean age of mothers who delivered vaginally at 23.84 years was significantly (P = 0.003) lesser than those delivered by CS at 25.77 years. Significantly (P = 0.003) more women, aged more than 30 years, underwent CS compared to VD (13.7% vs 4.1%).
|Table 1: Demographic variables of the VD and CS groups and its association|
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Both groups were matched on clinical variables, such as past history of abortions and still births, body mass index and parity, although primiparous women were more likely to undergo CS than VD (55.6% vs 46.3%, P = 0.143). A CS happened significantly more often than VD (14.4% vs 5.8%, P = 0.024) following an unplanned pregnancy [Table 2].
PND (major depressive disorder) was the most frequent diagnosis in both the groups with significantly more cases following CS than VD (32.3% Vs 11.6%, P < 0.001). Besides PND, Generalized Anxiety Disorder (GAD), panic disorder (PD), posttraumatic stress disorder (PTSD), and obsessive-compulsive disorder (OCD) have been found more often following CS. PTSD and OCD were not found following VD in this sample [Table 3].
|Table 3: Distribution of psychiatric morbidity among VD and CS groups and its association|
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Quality of sleep (QOS) was significantly poor following CS compared to VD (52.4% vs 26.5%, P < 0.001) in this study [Table 4].
|Table 4: Distribution of the study population based on QOS among VD and CS groups and its association|
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The presence of psychiatric disorder, irrespective of the type of delivery, had a significant negative impact on the QOS in this study. The QOS was good in just 1.4%, whereas it was poor in 81.4%, in the presence of any psychiatric disorder, with the difference being highly significant (P < 0.001). [Table 5].
| Discussion|| |
A cross-sectional study of QOS and psychiatric disorders in 121 women who delivered vaginally and 124 women who delivered by CS was conducted. Both groups matched each other in terms of educational status, duration of marriage prior to child birth, employment, socioeconomic status, type of family, past history of abortions and still births, current Body Mass Index, and parity. In a prospective study on 247 women 6 weeks following delivery using the EPDS, Zejnullahu et al. found similar absence of significant association between maternal education, employment, family type, smoking, previous abortion, household income, and PND. The findings of this study were partially similar to the findings of Arbabi et al. who conducted a study on 71 women who delivered by VD and 179 by CS and found that both groups matched each other in terms of age, education, employment, gender of the newborn, number of children prior to current childbirth, past and family history of mental illness and psychotropic medication, earlier PND, mother's addiction status, and child's physical health.
Women delivered by CS in this sample were significantly older than those delivered vaginally (25.77 vs 23.84 years, P < 0.005). Furthermore, among those more than 30 years, significantly more women delivered by CS compared to VD (13.7% vs 4.1%, P < 0.005). In contrast, Dinesh and Swetha Raghavan found that in women aged more than 30 years, significantly more delivered by VD than CS (26% vs 7%, P < 0.001). Similar to the findings of this study, Malik et al. in their study involving women delivered by VD (50) and CS (50) found mean age of women to be older among those delivered by CS (30.94 vs 28.42 years). Mahishale and Bhatt in their study of women delivered by VD (85) and CS (85) found no significant difference in mean age of both groups (23.65 vs 23.91 years).
In this study, it was found that an unplanned pregnancy was significantly associated with CS than VD (14.4% vs 5.8%, P = 0.024) [Table 2]. The authors have not come across any other study suggesting a similar association between unplanned pregnancy and CS.
Among all psychiatric diagnosis, PND was the most frequent diagnosis in both the groups [Table 3]. Furthermore, PND was more frequently reported following CS compared to VD (32.3% vs 11.6%, P < 0.001). Dinesh and Swetha Raghavan reported similar results in their study using the EPDS with significantly more women delivered by CS diagnosed with PND than those delivered vaginally (30% vs 15%, t value = 6.452). Madhusmita Nayak reported similar results in her study conducted on women delivered by VD (100) and CS (100) using EPDS with more women delivered by CS diagnosed with PND compared to those delivered vaginally (61% vs 48%). Similar findings were reported by Malik et al. in their study using EPDS with PND being significantly associated with CS than VD (58% vs 24%, P = 0.001). Mahishale and Bhatt also reported similar results using EPDS with significantly more women delivered by CS than VD being diagnosed with PND (21.17% vs 8.23%, P < 0.0001). Sujuki in his study using EPDS also reported significant association of CS, both elective and emergency (n = 80), with PND (39.4% vs 6.0%, P < 0.05) compared to VD (n = 387). However, in contrast to findings of this study, Arbabi et al. in their study on 71 women delivered vaginally and 179 delivered by CS found no significant association of CS with PND (25.1% vs 18.3%, P = 0.49). Zejnullahua et al. also did not find any significant association between CS and PND (17.81% vs 3.24%, P = 0.080) in their study using EPDS on 177 women delivered vaginally and 70 delivered by CS. In complete contrast to the findings of this study, Kefale et al. in their study of 238 women delivered vaginally and 70 delivered by CS, using EPDS, found PND to be significantly more common following VD compared to CS (9.1% vs 3.9%). Kaya and Cigdem, using EPDS, also found PND to be more often associated with VD (n = 164) than with CS (n = 80), although not significantly so (27.9% vs 13.1%, P = 0.827). The findings of this study are supported by a systematic review by Moameria et al. who reported an adjusted OR of depression following CS at 1.15 (95% CI: 1.00, 1.34) and the crude odds ratio at 1.36 (95% CI: 1.20, 1.55).
Following PND, PD was the most frequent disorder reported in this study with more women following CS reporting PD (6.5% vs 5%, P < 0.001). GAD was the next frequent disorder that was again more often associated with CS than VD (3.2% vs 2.5%, P < 0.001). In contrast to the findings of this study, Arbabi et al. found anxiety to be more often associated with VD than with CS (25.3% vs 22.9%, P = 0.74), although not significantly so. None in this VD group (n = 121) suffered either OCD or PTSD, whereas 2.42% each suffered OCD and PTSD in the CS group (n = 124) with the difference being significant (P < 0.001) [Table 3].
The arrival of the newborn, especially for a primiparous woman, is considered stressful. The varied feeding, excretion, and sleep rhythms of the newborn also interfere with the sleep rhythm and sleep needs of the new mother. The sleep quality of the sample was evaluated using PSQI. The sleep quality was significantly poorer following CS compared to VD (52.4% vs 26.5%, P < 0.001) [Table 4].
Tzeng et al. in a prospective evaluation of 139 women, once before and thrice after CS, using PSQI, reported that the mean total PSQI score at 8.4 (SD = 3.7) in late pregnancy, gradually increased to 9.3 (SD = 3.8) and 9.0 (SD = 4.2) at 1 day and 1 week postpartum, respectively decreased to 8.8 (SD = 3.1) at 4 weeks postpartum, and reached the lowest mean score of 7.3 (SD = 3.5) at 6 months postpartum. This study suggested that the poor sleep quality following CS is temporary and recovers to normalcy within 6 months.
Lee and Lee in their cross-sectional study of six Chinese American mothers after CS and 15 after VD, using Wrist Actigraphy, General Sleep Disturbance Scale, and Numerical Rating Scale-Fatigue, found that mothers after CS experienced 4 hours Total Sleep Time (TST) and 34% reported wake after sleep onset (WASO) compared to 6.5 hours TST and 14% reporting WASO after VD.
In the background of the findings mentioned above that early motherhood is an independent risk factor for the QOS after parturition, how the overlay of a psychiatric disorder modified QOS in the study sample was explored. The presence of psychiatric disorder, irrespective of the type of delivery, had a significant negative effect on the QOS in this study. In comparison to 98.6% of mothers without psychiatric disorder reporting good quality sleep, 81.4% of mothers with any psychiatric disorder reported poor quality sleep, in this sample (n = 245), with the difference being highly significant (P < 0.001) [Table 5].
There is evidence to suggest that poor quality sleep and depressed mood are associated with low progesterone stage of pregnancy. Lee et al. in a longitudinal prospective study, utilizing ambulatory polysomnography for two consecutive nights at seven time points, in 31 women, found mood state was most positive in the second trimester, corresponding to the high progesterone stage, whereas mood state was most negative and REM latency was significantly shorter at 1-month postpartum, corresponding to the low progesterone stage.
Dorheim et al. in their study of 4191 women, using PSQI and EPDS, found partially similar findings to this study that depression, previous sleep problems, being primiparous, not exclusively breastfeeding, or having a younger or male infant were associated with poor postpartum sleep quality. Bobbie Posmontier in their study of 23 women with PND and 23 without PND, using MINI and PSQI, found similar findings to this study that women with PND experienced poorer sleep quality, and poor sleep quality negatively affected the severity of depressive symptoms. Swanson et al. in a study of 257 pregnant and postpartum women seeking outpatient psychiatric treatment using Insomnia Severity Index, EPDS, and Penn State Worry Questionnaire for anxiety found, similar findings to this study, that insomnia was linked to the presence of anxiety as well as depression. Further to the findings of this study, Calgagni et al. in their study of 35 nulliparous and 34 multiparous mothers, using mood scales and actigraphy, found that mood and objective sleep to be better in multiparous compared to nulliparous, within 2 weeks after delivery.
| Conclusion|| |
In this study, a significant association between older age, unplanned pregnancy, PND, GAD, PD, OCD, PTSD, and CS was found. An independent and significant association between postnatal psychiatric disorder and poor quality sleep was also found.
All patients in this study were approached when they attended Maternal and Child Health Services in the hospital. None sought psychiatric services despite the availability of such services next door, despite a high prevalence of psychiatric morbidity and sleep disturbances in the evaluation. This is reflective of the poor psychological awareness or possibly stigma and negative valuation to complaints of psychological suffering among young mothers, caregivers, nurses, and the specialists in maternal and child outpatient departments.
This study suffers some limitations. Being a cross-sectional observational study, no cause and effect relationships can be drawn from the associations found. This study was conducted among lower socioeconomic and poorly educated women attending a tertiary care hospital attached to a rural medical college. The psychiatric and sleep disorders in the patients were identified by using cutoffs on MINI and PSQI and not by psychiatrist examination using diagnostic criteria. The findings of this study cannot be generalized to other sociocultural settings.
There is scope for better designed prospective cohort studies to understand the causal relationships between mode of delivery and occurrence of psychiatric and sleep disorders in postpartum period. There appears an urgent need to improve awareness by education of young mothers, caregivers, nurses, pediatricians, and obstetricians of PPDs especially depression, anxiety, and sleep disorders following delivery.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]