F1000Research F1000Research 2046-1402 F1000 Research Limited London, UK 10.12688/f1000research.20677.3 Brief Report Articles Relation between delivery mode and maternal mental status one month after delivery at a perinatal center in Japan: A cross-sectional study

[version 3; peer review: 1 approved, 1 approved with reservations]

 Suzuki Shunji Conceptualization Data Curation Formal Analysis Funding Acquisition Investigation Methodology Project Administration Resources Software Supervision Validation Visualization Writing – Original Draft Preparation Writing – Review & Editing https://orcid.org/0000-0002-3996-2624 a 1 Japanese Red Cross Katsushika Maternity Hospital, Department of Obstetrics and Gynecology, 5-11-12 Tateishi, Katsushika-ku, Tokyo, 124-0012, Japan czg83542@mopera.ne.jp

No competing interests were disclosed.

 10 8 2020 2019 8 1755 7 8 2020 Copyright: © 2020 Suzuki S 2020 This is an open access article distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Background: Maternal mental status has been thought to be affected by the delivery modes. We examined the relation between delivery modes and the mental status of women who delivered at our institute in Japan.

Methods: Data were collected from the medical charts of 643 primiparous women without a history of mental disorders who delivered singleton babies and underwent a 1-month postpartum check-up at our institute from September 2018 to June 2019. The maternal mental status was examined based on the scores of the Edinburgh Postnatal Depression Scale (EPDS) and the Mother-Infant Bonding Scale (MIBS).

Results: The rate of high scores of the EPDS and the MIBS in women choosing elective cesarean section were higher than in women with vaginal delivery and emergency cesarean section.

Conclusion: A fulfilling birth-plan and birth-review may also be necessary for women choosing elective cesarean section.

 maternal mental status elective cesarean section birth-review The author(s) declared that no grants were involved in supporting this work. Amendments from Version 2

I would like to thank Dr Jacopo Lenzi for the comments and critique of my manuscript. I have been able to respond positively to each suggestion and I believe the paper has been strengthened. I have corrected the title using ‘relation’ instead of ‘influence’. The sample size is 643-I have corrected the number and percentage in the manuscript. I have added the references to indicate 9 points as the adequate EPDS cut-off. Unfortunately, I did not compare the maternal age among the 3 groups of this study although it may be one of the important limitations in the study. The birth-plan and birth-review for elective CS are not common. I have added the comments considering these.

 Introduction

Maternal mental status has been thought to be affected by the delivery modes because childbirth is an important event for both the mother and child, and it influences early mother-infant interaction 1, 2 . In this study, we examined the relation between delivery modes and the mental status of women who delivered at our institute in Japan.

 Methods Ethical issues

The protocol for this study was approved by the Ethics Committee of the Japanese Red Cross Katsushika Maternity Hospital. In addition, informed consent concerning analysis from a retrospective database was obtained from all subjects. In our institute, cesarean section is not performed without medical indication because cesarean section on maternal request for pain relief has not been generally recognized in Japan.

 Data collection

Data were collected from the medical charts of 643 primiparous women without a history of mental disorders who delivered singleton babies and underwent a 1-month postpartum check-up at our institute from September 2018 to June 2019. Of the 643 primiparous women, 387 women (60.1%) had vaginal deliveries, 80 (12.4%) had elective cesarean deliveries, and 176 (27.4%) had emergent cesarean deliveries. In this study, demographic data included maternal age. The maternal mental status was examined based on the scores of the Edinburgh Postnatal Depression Scale (EPDS) and the Mother-Infant Bonding Scale (MIBS), and the time required for psychiatric counseling by our midwives. Women with the EPDS ≥ 9 points according to the results of previous observations in Japan by Okano et al. 3, 4 , those with the MIBS ≥ 3 points, and the time required for psychiatric counseling ≥ 25 minutes were diagnosed with mental problems.

 Data analysis

Data are presented as mean ± SD or number (%). SPSS Statistics software version 20 (IBM Corp., Armonk, NY, USA) was used for statistical analyses. For statistical analysis, the Χ 2 test for categorical variables and the Student’s t-test for continuous variables were used. Differences with p < 0.05 were considered significant.

 Results

Table 1 shows the clinical description of primiparous women and the results of mental problems. The rates of high scores of the EPDS and the MIBS were higher in the emergency cesarean group than vaginal delivery group; in addition, the rate of high scores of the EPDS and the MIBS and a long time for psychiatric counseling in women choosing elective cesarean section were higher than in women with vaginal delivery and emergency cesarean section, as shown in Table 1.

One-month clinical evaluation for women who delivered a singleton baby between September 2018 and June 2019, overall and by method of delivery.
Variable Vaginal delivery Elective cesarean delivery Emergency cesarean delivery
Number 387 80 176
EPDS
  Average (points) 5.1±4.0 5.8±4.6 * 5.4±3.5
  ≥9 points 23 (6.0) 22 (27.5) * # 21 (11.9) *
MIBS
  Average (points) 1.8±1.8 2.7±2.9 * 2.4±2.4 *
  ≥3 points 33 (8.5) 21 (26.3) * 31 (17.6) *
Interview time
  Average (minutes) 15.4±9.0 18.5±8.0 * 14.0±6.2
  ≥25 minutes 31 (8.0) 12 (15.0) * # 8 (4.5)

[i] Data are presented as mean ± SD or number (%).

CS, cesarean delivery; EPDS, Edinburgh Postnatal Depression Scale; MIBS, Mother-Infant Bonding Scale. * P < 0.05: elective CS vs. vaginal delivery group. # P < 0.05: elective CS vs. vaginal delivery plus emergency CS groups.

 Discussion

This may be the first report to indicating that women received elective cesarean section are more prone to have mental problems. Although we predicted that the highest frequency of mental problems would be in the emergent cesarean delivery group, the women choosing elective cesarean delivery actually had the most mental problems. The reason for the results is not clear; however, based on the records of psychiatric counseling, it may be because there was no birth-plan or birth-review for women scheduled for elective cesarean delivery. In our institute, a birth-plan has been carried out for all pregnant women scheduled for vaginal delivery, and a birth-review that takes a long time during hospitalization has been performed especially for mothers undergoing emergency caesarean section in order to recover from the trauma of the sudden departure from normal labor 5 . This is because a birth-review is one of the concrete measures to learn about the ‘bruising’ of labor and promptly affirm the experience of delivery 5, 6 . A mother’s thought during birth-review about the experience of childbirth has been suggested to help express feelings of embarrassment and provide an opportunity to reconstruct the facts. On the other hand, pregnant woman scheduled to undergo elective cesarean section are given an explanation and birth-review of cesarean section solely from a surgical perspective. The absence of an adequate birth-plan or birth-review may lead to mental problems in postpartum women who receive elective cesarean section. To date, birth-plan and/or birth-review for elective cesarean section have been suggested to be effective in maternal feelings toward the baby 7 , they are not common. Therefore, a fulfilling birth-plan and birth-review may also be necessary for women choosing elective cesarean section.

We understand the small sample size for statistical analyses as one of serious limitations in this study. In addition, we did not compare the maternal age among the 3 groups of this study although it may be one of important limitations in the study. To examine our speculation, a large prospective study with birth-review in consideration of these things will be needed.

 Data availability Underlying data

Figshare: delivery mode and maternal mental status. https://doi.org/10.6084/m9.figshare.9956690.v1 8 .

This project contains data on the delivery method, EPDS and MIBS scores and counselling time for each participant.

Data are available under the terms of the Creative Commons Zero "No rights reserved" data waiver (CC0 1.0 Public domain dedication).

 Acknowledgements

The author wishes to thank all patients for their collaboration.

 Pilch D : [The influence of birth modus on the emotional state of the mother, bonding, and the newborn's neurobehavioural state]. Pomeranian J Life Sci. 2015;61(3):249–256. 27344865 Rowe-Murray HJ Fisher JR : Operative intervention in delivery is associated with compromised early mother-infant interaction. BJOG. 2001;108(10):1068–1075. 11702839 10.1111/j.1471-0528.2001.00242.x Okano T Nomura J Kumar R : An epidemiological and clinical investigation of postpartum psychiatric illness in Japanese mothers. J Affect Disord. 1998;48(2–3):233–240. 9543214 10.1016/s0165-0327(97)00158-4 Okano T : Perinatal depression-recent topics (in Japanese). Nihon Rinsho. 2007;65(9):1689–1693. 17876996 Nakamura M : Review of literature on birth review (Childbirth recall) of child-rearing period (in Japanease). Seisen J Nurs Stud. 2018;7:29–34. Reference Source Rubin R : Attainment of the maternal role. 2. Models and referrants. Nurs Res. 1967;16(4):342–346. 5341290 Azuma T : Borth-plan (in Japanese). Perinatal Care. 2013;32:S94–S97. Suzuki S : delivery mode and maternal mental status. figshare. Dataset.2019. https://doi.org/10.6084/m9.figshare.9956690.v1 10.5256/f1000research.28688.r69151 Reviewer response for version 3 Lenzi Jacopo 1 Referee https://orcid.org/0000-0003-2882-4223 Department of Biomedical and Neuromotor Sciences, Alma Mater Studiorum - University di Bologna, Bologna, Italy

Competing interests: No competing interests were disclosed.

 18 8 2020 Copyright: © 2020 Lenzi J 2020 This is an open access peer review report distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. recommendation approve-with-reservations

S. Suzuki addressed all the concerns I raised except one. Looking at the new version of the work, it seems to me that he reviewed the table header and footnotes, but not the table itself. In this way, the header does not match with the table (no estimate is provided for the whole sample). He should update the frame and content of the table following my previous comment, where columns are separated by '\' and rows are separated by '|' (I know it is tricky to read, but I could not paste the Word table in the online form).

If the author addresses this point, his work can be accepted without any further changes.

Is the work clearly and accurately presented and does it cite the current literature?

Partly

If applicable, is the statistical analysis and its interpretation appropriate?

No

Are all the source data underlying the results available to ensure full reproducibility?

Yes

Is the study design appropriate and is the work technically sound?

Partly

Are the conclusions drawn adequately supported by the results?

Partly

Are sufficient details of methods and analysis provided to allow replication by others?

Yes

Reviewer Expertise:

NA

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

 10.5256/f1000research.27256.r68783 Reviewer response for version 2 Lenzi Jacopo 1 Referee https://orcid.org/0000-0003-2882-4223 Department of Biomedical and Neuromotor Sciences, Alma Mater Studiorum - University di Bologna, Bologna, Italy

Competing interests: No competing interests were disclosed.

 6 8 2020 Copyright: © 2020 Lenzi J 2020 This is an open access peer review report distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. recommendation approve-with-reservations

The work by Shunji Suzuki analyzes the association between method of delivery and maternal mental status after one month. He found that elective C-sections are associated with higher levels of mental distress, and argued that this result might have to do with the absence of birth-plans and birth-reviews for women undergoing elective CS. Here are my comments:

I would not talk about “influence”, which implies causality. Please consider using “association” or “relationship” instead.

Are you sure that your sample size is 645? According to the data presented in Table 1 and uploaded to Figshare, the women enrolled in the study are 643.

No justification is provided for the cut-offs presented at the end of the Data Collection section. For instance, you used an EPDS cut-off of 9, but more commonly adopted thresholds are 10 (minor depression) and 13 (major depression) (Fellmeth G, et al.  J Affect Disord 2019;251:8-14). Please provide adequate references or update your cut-offs.

Table 1 and the data set you shared do not match. After analyzing the data uploaded to Figshare, I found very different results (see below). Please check consistency and review the entire Results section, if necessary. Please also consider adding a column for the entire sample, as I did here. Statistical significance should also be described differently in the table footnotes.

Table 1. One-month clinical evaluation for women who delivered a singleton baby between September 2018 and June 2019, overall and by method of delivery.

---

Variable \ All ( n = 643) \ Vaginal delivery ( n = 387) \ Elective CS ( n = 80) \ Urgent CS ( n = 176) |

EPDS score |

Mean ± SD \ 3.7 ± 3.4 \ 3.2 ± 2.7 \ 5.5 ± 4.9*# \ 4.0 ± 3.8* |

≥9, n (%) \ 66 (10.3) \ 23 (5.9) \ 22 (27.5)*# \ 21 (11.9)* |

MIBS score |

Mean ± SD \ 1.3 ± 2.1 \ 1.1 ± 2.1 \ 1.9 ± 2.4*# \ 1.3 ± 2.1 |

≥3, n (%) \ 86 (13.4) \ 33 (8.5) \ 22 (27.5)*# \ 31 (17.6)* |

Interview time (minutes) |

Mean ± SD \ 12.8 ± 7.3 \ 12.9 ± 7.8 \ 14.1 ± 8.3 \ 11.8 ± 5.3 |

≥25, n (%) \ 52 (8.1) \ 32 (8.3) \ 12 (15.0)# \ 8 (4.5) |

---

CS, cesarean section; EPDS, Edinburgh Postnatal Depression Scale; MIBS, Mother-Infant Bonding Scale.

* p <0.05 (elective CS vs. vaginal delivery).

# p <0.05 (elective CS vs. vaginal delivery + urgent CS).

What about maternal age? Was it similar across the three groups under study? If so, the association between method of delivery and outcomes should be adjusted for age.

What about the external validity (generalizability) of the study? The Katsushika Maternity Hospital does not have any “birth-path” for women undergoing elective C-section—is this a common or uncommon situation?

Is the work clearly and accurately presented and does it cite the current literature?

Partly

If applicable, is the statistical analysis and its interpretation appropriate?

No

Are all the source data underlying the results available to ensure full reproducibility?

Yes

Is the study design appropriate and is the work technically sound?

Partly

Are the conclusions drawn adequately supported by the results?

Partly

Are sufficient details of methods and analysis provided to allow replication by others?

Yes

Reviewer Expertise:

Medical statistics, Epidemiology

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

 10.5256/f1000research.27256.r64608 Reviewer response for version 2 Kınay Tuğba 1 Referee Department of Gynaecology, Etlik Zübeyde Hanım Education and Research Hospital, University of Health Sciences, Ankara, Turkey

Competing interests: No competing interests were disclosed.

 16 6 2020 Copyright: © 2020 Kınay T 2020 This is an open access peer review report distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. recommendation approve

I reviewed the revised manuscript. The author revised the manuscript based on my comment. I think that the paper is suitable for indexing in its current form.

Is the work clearly and accurately presented and does it cite the current literature?

Yes

If applicable, is the statistical analysis and its interpretation appropriate?

Yes

Are all the source data underlying the results available to ensure full reproducibility?

Yes

Is the study design appropriate and is the work technically sound?

Yes

Are the conclusions drawn adequately supported by the results?

No

Are sufficient details of methods and analysis provided to allow replication by others?

Yes

Reviewer Expertise:

Obstetrics and gynecology

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

 10.5256/f1000research.22741.r63674 Reviewer response for version 1 Kınay Tuğba 1 Referee Department of Gynaecology, Etlik Zübeyde Hanım Education and Research Hospital, University of Health Sciences, Ankara, Turkey

Competing interests: No competing interests were disclosed.

 8 6 2020 Copyright: © 2020 Kınay T 2020 This is an open access peer review report distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. recommendation approve-with-reservations

Thank you for the opportunity to evaluate this report. The paper is about the effect of  delivery mode on the postpartum mental status of women. The results of the study indicate that the women who underwent elective cesarean delivery had higher scores of the EPDS and MIBS than women with vaginal delivery and emergent cesarean delivery.  I have the following comment:

In discussion section,  the author state that – "We understand the small sample size for statistical analyses as one of serious limitations in this study. However, a fulfilling birth-plan and birth-review may also be necessary for women choosing elective cesarean section." I don’t think that the current study based on its methodology can support that statement .The conclusion paragraph including main outcomes of the study should be rewritten.

Is the work clearly and accurately presented and does it cite the current literature?

Yes

If applicable, is the statistical analysis and its interpretation appropriate?

Yes

Are all the source data underlying the results available to ensure full reproducibility?

Yes

Is the study design appropriate and is the work technically sound?

Yes

Are the conclusions drawn adequately supported by the results?

No

Are sufficient details of methods and analysis provided to allow replication by others?

Yes

Reviewer Expertise:

obstetrics and gynecology

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.