Relationships between perineal pain and postpartum depressive symptoms: A prospective cohort study

https://doi.org/10.1016/j.ijnurstu.2016.02.012Get rights and content

Abstract

Background

The relationship between concurrent or previous postnatal pain and depressive symptoms remains controversial. To the best of our knowledge, no previous study has used validated measures and multiple scales to evaluate perineal pain, or examined its relationship with depressive symptoms during the postpartum period.

Objectives

We investigated the association between pain and previous postnatal pain with depression during the 6-month postpartum period, and the influence of previous postnatal depressive symptoms.

Design

A prospective cohort study design was used.

Setting

Maternity unit of a medical center.

Participants

This study included 432 participants; data regarding demographic characteristics, perineal pain, and any pain and depression during the 6-month postpartum period were collected.

Methods

Pain and depressive symptoms were measured using the Short Form-McGill Pain Questionnaire and Center for Epidemiologic Studies Depression Scale, respectively. A generalized estimating equation was used to examine factors associated with postpartum depression.

Results

After adjusting for covariates, women who had perineal pain at 4–6 weeks postpartum showed an increased risk for depression at 4–6 weeks (risk ratio [RR]: 1.9, 95% confidence limits [CL]: 1.2, 3.2) and 6 months (RR: 1.9, 95% CL: 1.1, 3.3) compared to those with no perineal pain. Perineal pain severity, 4–6 weeks postpartum, also predicted depressive symptoms at 6 months postpartum (β = 0.63, p = 0.02). Any pain intensity score at 3–5 days postpartum predicted depression at 3 months (β = 0.01, p = 0.04). Women with high depression scores at 3–5 days had a two- or three-fold higher risk for depression at 4–6 weeks and 3 and 6 months, respectively, compared to those with low depression scores (RR: 3.5, 95% CL: 2.2, 5.4; RR: 2.2, 95% CL: 1.3, 3.4; and RR: 2.8, 95% CL: 1.7, 4.8, respectively).

Conclusions

Our study provides robust evidence that perineal pain 4–6 weeks postpartum is associated with depressive symptoms 4–6 weeks and 6 months postpartum; pain at 3–5 days postpartum predicts depressive symptoms at 3 months postpartum; and previous postnatal depressive symptoms, particularly depressive symptoms 3–5 days postpartum, predict depressive symptoms during the 6-month postpartum period.

Introduction

Postpartum depression affects the health of mothers, the growth (Nasreen et al., 2013, Surkan et al., 2012) and development of their children (Ali et al, 2013, Fihrer et al., 2009), and their partner's mood (Pinheiro et al., 2006). Postpartum depression is a major depressive disorder with an onset within 4 weeks after childbirth (American Psychiatric Association, 2013). The prevalence of postpartum depression was reported as 3.8% at 4 weeks, as increasing to 5.6% at 26 weeks (Gaynes et al., 2005), as 10.9% at 6 months, and as falling to 6.1% at 12 months (Yawn et al., 2015). The increasing prevalence of depression up to 6 months postpartum indicates the existence of later-onset postpartum depression (Gaynes et al., 2005). Indeed, the prevalence rates of depressive symptoms at 3 months and 6 months postpartum were still high, at 42.2% and 35.5%, respectively (Chang et al., 2015).

Biopsychological and sociocultural factors are associated with depression during the postpartum period (Bener, 2013, Figueira et al., 2010, Glynn et al., 2013, Green et al., 2006, Howell et al., 2009, Rauh et al., 2012, Yang et al., 2011). In previous studies, women suffering from postpartum pain reported a poor quality of life (Baghirzada et al., 2013), and pain was associated with depressive symptoms during the postpartum period (Eisenach et al., 2013, Watkins et al., 2011, Woolhouse et al., 2014).

“Any pain” after childbirth (e.g., perineal pain, headaches, and pain related to abdominal incisions, the back, or nipples) (Ansara et al., 2005, Cheng and Li, 2008, Chien et al., 2009, Declercq et al., 2008, Woolhouse et al., 2014) is among the most common postpartum symptoms or health problems, reported by about 30–77% of women who are 1–12 months postpartum (Chien et al., 2009, Nikpour et al., 2013, Woolhouse et al., 2014). Concurrent experience of such pain was associated with delivery method (e.g., vaginal and cesarean delivery) (Chang et al., 2015), and depressive symptoms during the postpartum period (Woolhouse et al., 2014). In contrast, another recent study found no association between concurrent any pain and depressive symptoms during the postpartum period (Eisenach et al., 2013). Furthermore, previous postnatal any pain has been variously reported to be related (Eisenach et al., 2013, Gaudet et al., 2013, Woolhouse et al., 2014), and unrelated to postpartum depressive symptoms (Jardri et al., 2010). Localized pain during the postpartum period, such as severe breastfeeding pain, headaches, lumbopelvic pain, and pain from cesarean section, has been related to postpartum depression (Gutke et al., 2007, Gutke et al., 2011, Watkins et al., 2011, Woolhouse et al., 2014). However, whether the pain (e.g., concurrent pain, previous pain, “any pain,” localized pain, etc.) leads to depression has not been extensively studied.

Localized pain, such as perineal pain, is one of most common physical symptoms within the first 8 weeks after vaginal birth (Cooklin et al., 2015), and the incidence of acute and persistent perineal pain (8 weeks) after vaginal delivery is high (Soares et al., 2013). Our prior work showed that women with vaginal delivery had higher acute perineal pain (3–5 days) compared with the women with cesarean delivery (Chang et al., 2015). Perineal pain affects approximately one-third of primiparous women and is associated with perineal traumas (Francisco et al., 2014). Severe perineal trauma affects women's ability to care for their newborn child and their sexual relationship with their partner (Priddis et al., 2014). Perineal lacerations and depressed mood are correlated with each other (Dunn et al., 2015). However, previous studies found that perineal pain may not be associated with postpartum depression (Chien et al., 2009, Woolhouse et al., 2014).

The relationship between postnatal pain and depressive symptoms remains controversial or, at least, unverified. This may be to differences among studies with regard to the instruments used to measure pain, the dimensions of pain studied (e.g., prevalence, severity, or intensity), the use of a prospective versus a retrospective design, the selection of different postpartum time points, and the locations examined. To the best of our knowledge, the use of validated measures and multiple scales to evaluate concurrent or previous postnatal pain, both perineal pain and “any pain,” and to examine its relationship with depressive symptoms during the postpartum period has not been reported.

In addition, a personal history of depression, family history of depression (Beck, 2001, El-Hachem et al., 2014), and prenatal depression (Heron et al., 2004) have been associated with the development of postpartum depression. Few studies have found that previous postnatal depressive symptoms are associated with postpartum depressive symptoms (Beeghly et al., 2002, El-Hachem et al., 2014). However, none of the previous studies was conducted using a within-subject design, large sample size, and both short and long postpartum follow-up.

We examined two types of postnatal pain, perineal pain and “any pain,” and depressive symptoms during the 6-month postpartum period to investigate whether concurrent postnatal pain (both types) and previous postnatal pain (both types) are associated with depressive symptoms at 3–5 days, 4–6 weeks, and 3 and 6 months postpartum, and to identify how previous postnatal depressive symptoms are associated with depressive symptoms during the 6-month postpartum period.

This study tested the following hypotheses: (i) the prevalences of concurrent postnatal pain (i.e., perineal pain plus “any pain”), previous postnatal pain (of the same type), and postnatal depressive symptoms will be associated with the prevalence of depressive symptoms at 3–5 days, 4–6 weeks, and 3 and 6 months postpartum; (ii) the severity of concurrent postnatal pain (perineal pain plus “any pain”), previous postnatal pain (of the same type), and postnatal depressive symptoms will be associated with the prevalence of depressive symptoms during the 6-month postpartum period; and (iii) the intensity of concurrent postnatal pain (perineal pain plus “any pain”), previous postnatal pain (of the same type), and depressive symptoms will be associated with the prevalence of depressive symptoms during the 6-month postpartum period.

Section snippets

Study participants and procedure

This prospective cohort study was reviewed and approved by the Research Ethics Committee of the hospital involved. The study was part of a longitudinal research study regarding women's health after childbirth. The women were recruited when they delivered a baby in the maternity unit at a medical center in Taiwan from 2010 to 2011. The inclusion criteria were at least 18 years old and the ability to read traditional Chinese. During a face-to-face interview in the maternity unit, each woman was

Results

Table 1 presents the characteristics of the 432 participants at 3–5 days after delivery. Based on the generalized estimating equation, we examined the relationship between participants’ characteristics and depressive symptoms and found that depressive symptoms at 3–5 days, 4–6 weeks, and 3 and 6 months after delivery were, significantly associated with time-dependent variables (employment and feeding type) and fixed variables (delivery method and intended pregnancy) (all p < 0.05). These

Discussion

Using validated measures, this prospective within-subject study with multiple follow-up time points offers a clear profile of postpartum, including perineal pain and any pain, and it provides significant evidence regarding the risk of depressive symptoms associated with concurrent pain, previous postnatal pain, and previous postnatal depressive symptoms during the 6-month postpartum period.

Our study, using reliable measures, found that women with concurrent perineal pain according to the pain

Conclusions

Our study provides robust evidence that perineal pain prevalence 4–6 weeks postpartum is associated with depressive symptoms at 4–6 weeks; the prevalence or severity of perineal pain 4–6 weeks postpartum predicts depressive symptoms at 6 months postpartum; the severity or intensity of any type of pain 3–5 days after childbirth predicts depressive symptoms at 3 months postpartum; and previous postnatal depressive symptoms, particularly depressive symptoms at 3–5 days postpartum, predict

Acknowledgments

This study was supported by a grant from the Ministry of Science and Technology, Taiwan (NSC 100-2314-B-002-032). The authors thank Ms. Chiou-Ru Lin for data collection.
Conflict of interest: The authors declare that they have no conflicts of interest.
Funding: This study was supported by a grant from the Ministry of Science and Technology, Taiwan.
Ethical approval: This research project was reviewed and approved by the Research Ethics Committee of the National Taiwan University Hospital (Number:

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