INTRODUCTION
Globally, about 20% of parturients experience postnatal depression (PND) within the first year, with rates around 10% after vaginal delivery and 18% after caesarean delivery.[1,2] Studies investigating the use of labour epidural analgesia (LEA) and risk of PND are conflicting, with some finding reduced risk while others have no association.[3,4] We examined whether intention for LEA was associated with PND and greater pain vulnerability.
METHODS
This exploratory analysis is part of a clinical trial investigating the association between LEA and PND.[5] The study was approved by the Centralised Institutional Review Board (2017/2090) and registered at ClinicalTrials.gov (NCT03167905). Parturients aged 21–50 years with a singleton foetus at ≥36 weeks gestation were recruited between December 2019 and July 2021. Exclusion criteria included non-cephalic foetal presentation, obstetric complications, uncontrolled medical conditions, contraindications to neuraxial blockade, or elective caesarean delivery. Written informed consent was obtained from all patients for participation and use of data for research and education. The study adhered to the principles of the Declaration of Helsinki (2013) and Good Clinical Practice guidelines.
Validated questionnaires were dispensed before delivery: Edinburgh Postnatal Depression Scale (EPDS), Pain Catastrophising Scale (PCS), Central Sensitisation Inventory (CSI), and Angle-Labour Pain Questionnaire (A-LPQ). An online survey was conducted at 6–10 weeks postpartum to assess PND. Intention for LEA was determined as ‘wanted LEA’, ‘did not want LEA’, and ‘hesitated on LEA’; while actual use of LEA was grouped as ‘received LEA’ and ‘did not receive LEA’. A 3 × 2 table of intention and actual use of LEA showed 86.2% of ‘hesitated on LEA’ and 91.3% of ‘wanted LEA’ group received LEA. Hence, we combined the ‘hesitated on LEA’ and ‘wanted LEA’ groups during analyses following categorisation similar to Orbach-Zinger et al. based on parturients’ expectations.[6] To characterise unmet expectations, we divided the parturients based on initial intention for LEA and actual use of LEA. Parturients with mismatched expectations were from groups ‘Wanted/Did not Receive’ (W/DR) and ‘Did not Want/Received’ (DW/R), while those who had delivered as intended were from groups ‘Wanted/Received’ (W/R) and ‘Did not Want/Did not Receive’ (DW/DR).
The primary outcome of PND at 6–10 weeks postpartum was analysed as binary data (EPDS ≥10 vs EPDS <10). Secondary outcomes included satisfaction score, subacute pain, pain catastrophising, and central sensitisation. All analyses used SAS version 9.4 (SAS Institute, NC, USA). Group differences were assessed using two-sample t-tests or Mann–Whitney U-tests for continuous data, and Chi-square tests for categorical data. Univariate and multivariable regression identified factors associated with PND. Secondary outcomes were analysed using linear regression, reported as β estimates with 95% confidence intervals (CIs). Variables with P < 0.10 in the univariate analysis were included in multivariable models. Statistical significance was set at P < 0.05, two-tailed.
RESULTS
A total of 410 parturients were recruited, with 48 parturients excluded due to loss of follow-up (n = 47) or incomplete data (n = 1). Among them, 173 wanted LEA, 87 hesitated, and 102 did not want LEA. At 6–10 weeks postpartum, 14 failed to follow up, leaving 348 parturients for analysis. The following factors were significantly different in the groups with and without intention for LEA: age, ethnicity, other family mental history, A-LPQ subscales (uterine contraction pain, back pain, enormity of pain), and total A-LPQ scores.
Among those with PND, 93 (68.4%) parturients intended for LEA, while 43 (31.6%) did not. No significant association existed between intention for LEA, satisfaction, sub-acute pain, pain catastrophising, central sensitisation, and PND at 6–10 weeks postpartum [Table 1]. Multivariable analysis showed that intention for LEA was not significantly associated with central sensitisation nor pain catastrophising magnification [Table 2]. A subgroup analysis examining the mismatch between the intended and actual use of LEA showed a highest mean EPDS score of 9.8 [standard deviation (SD: 5.6] in DW/R, followed by 9.0 (SD: 4.0) in W/DR, 8.1 (SD: 4.5) in W/R, and 7.6 (SD: 4.3) in DW/DR, leading to significant difference across the groups (P = 0.04).
Table 1.
Outcomes at 6–10 weeks postpartum based on labour intention for LEA
| Variable | Wanted LEA n=260 | Did not want LEA n=102 | Mean difference (95%CI) | P |
|---|---|---|---|---|
| EPDS | 8.2 (4.5) | 8.9 (5.2) | 1.05 (−0.08, 2.18) | 0.229 |
| Postnatal depression (EPDS ≥10) | 0.294 | |||
| No | 156 (62.7) | 56 (56.6) | -- | -- |
| Yes | 93 (37.3) | 43 (43.4) | -- | -- |
| Satisfaction score | 92.5 (8.6) | 89.9 (14.5) | −0.54 (−1.32, 0.24) | 0.225 |
| Sub-acute pain | 35 (14.1) | 16 (16.2) | -- | 0.616 |
| PCS Helplessness | 5.1 (4.7) | 5.4 (4.5) | 1.04 (−0.18, 2.26) | 0.621 |
| PCS Magnification | 2.4 (2.3) | 3.0 (2.8) | 0.33 (−0.32, 0.98) | 0.063 |
| PCS Rumination | 4.5 (3.9) | 5.0 (4.3) | 0.29 (−0.73, 1.31) | 0.257 |
| Total PCS score | 12.0 (10.2) | 13.4 (10.7) | 1.70 (−0.91, 4.32) | 0.260 |
| Total CSI score | 50.3 (12.9) | 53.6 (14.4) | 1.48 (−1.89, 4.85) | 0.052 |
Data is expressed as mean (standard deviation) or number (percentage). CSI=Central Sensitisation Inventory; EPDS=Edinburgh Postnatal Depression Scale; LEA=Labour Epidural Analgesia; PCS=Pain Catastrophising Scale; SD=Standard Deviation, CI=confidence interval
Table 2.
Multivariable linear regression analysis for central sensitisation and pain catastrophising – magnification
| Variables | Central Sensitisation | Pain Catastrophising – Magnification | ||
|---|---|---|---|---|
|
|
|
|||
| Adjusted estimate (95%CI) | P | Adjusted estimate (95%CI) | P | |
| Intention for LEA | −1.15 (−3.62, 1.31) | 0.358 | −0.05 (−0.59, 0.49) | 0.855 |
| Pre-delivery EPDS total score | 0.77 (0.46, 1.08) | <0.0001 | 0.13 (0.07, 0.19) | <0.0001 |
| Pre-delivery CSI total score | 0.42 (0.32, 0.52) | <0.0001 | - | - |
| Pre-delivery A-LPQ enormity of pain score | 0.09 (0.01, 0.16) | 0.020 | 0.03 (0.01, 0.04) | 0.001 |
| Pre-delivery PCS magnification score | - | - | 0.19 (0.10, 0.28) | <0.0001 |
| Use of intramuscular pethidine for labour analgesia | - | - | 0.81 (0.23, 1.39) | 0.006 |
A-LPQ=Angle Labour Pain Questionnaire; CI=Confidence Interval, CSI=Central Sensitisation Inventory; EPDS=Edinburgh Postnatal Depression Scale; LEA=Labour Epidural Analgesia; PCS=Pain Catastrophising Scale
DISCUSSION
We found no significant association between intention for LEA and PND, nor between intention for LEA and pain vulnerabilities, while the EPDS score was statistically highest in the DW/R group at 6–10 weeks postpartum. Orbach-Zinger et al. found no association between intention for LEA and PND, but an increased risk of PND in women who received LEA despite not wanting it (risk difference: 8.6%).[6] In a Chinese cohort, women with unfulfilled childbirth intentions had similar rates of PND as other groups.[7] The elevated EPDS in the DW/R group suggests that receiving an unwanted LEA may be more distressing than not receiving a desired intervention. This may reflect a stronger aversion to medical interventions, intensifying feelings of disappointment. A qualitative study found that parturients felt a sense of failure when birth plans changed due to medical reasons.[8] Conversely, the DW/DR group had the lowest EPDS scores, aligning with evidence that fulfilling expectations and retaining control enhances satisfaction.[9,10]
A higher EPDS score may increase pain sensitivities and catastrophising by lowering the pain threshold.[11] However, parturients who interpret pain as purposeful are associated with positive emotions, improving their ability to cope.[12] In our study, the intention to use LEA was not associated with pain vulnerabilities. Conversely, parturients may view labour pain as an exaggerated threat and hence may focus on their emotions and doubt their coping abilities, resulting in high pain catastrophising and central sensitisation.
Our study has several limitations. While hesitation may indicate no strong aversion to LEA, we combined those who ‘hesitated on LEA’ and ‘wanted LEA’, forming groups W/R and W/DR. This was done because our study had a high proportion (86.2%) of parturients who hesitated but subsequently received LEA. However, the EPDS increase was observed mainly in the DW/R group, which captured their indicated aversion to LEA. We also did not consider the qualitative aspects of the decision-making process.
CONCLUSION
Intention for LEA was not associated with PND and pain vulnerabilities (pain catastrophising, central sensitisation) at 6–10 weeks postpartum. However, high EPDS scores were observed in those who did not want LEA but received it, emphasising the need for offering greater support in this group.
Study data availability
De-identified data may be requested with reasonable justification from the authors (via email to the corresponding author) and will be shared upon request.
Conflicts of interest
There are no conflicts of interest.
Acknowledgements
Assistance with the study: We would like to thank Ms. Agnes Teo (Senior Clinical Research Coordinator), Ms. Mandaline Teo and Ms. Dianna Sri Dewi (Clinical Research Coordinators), administrative and major operating theatre staff for their support.
Funding Statement
This study was supported by KKH Academic Medicine Research Start-Up Grant (ref no. KKH-AM/2022/01) and Singapore National Medical Research Council (NMRC) Clinician Scientist award (ref no. CSAINV16may004).
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