Relation between delivery mode and maternal mental status one month after delivery at a perinatal center in Japan: A cross-sectional study

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: Mental health care may be necessary for women choosing elective cesarean section.

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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.

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 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. 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.

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

Amendments from Version 3
I have changed Table 1 with total data in line with the reviewer's comment.

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

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

Open Peer Review
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. 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.

5.
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? 6.

Is the work clearly and accurately presented and does it cite the current literature? Partly
Is the study design appropriate and is the work technically sound? 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 Are the conclusions drawn adequately supported by the results? Partly 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.
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