Interpretation
The temporal proximity of the traumatic event appears to increase the
risk of the onset of depression and of PTSD at 2 months and thus
suggests a response to the acute event (here the PPH).
The prevalence of postpartum depression at 2 months after delivery was
24.4% among the women with PPH, a prevalence higher than those reported
by Ricbourg et al. (15% and 23.5% at 1 and 3
months)20, Eckerdal et al. (13.8% at 6
weeks)19, and Thompson et al. (11% and 13% at 2 and
4 months).16 The different thresholds used for the
EPDS may explain these differences. A threshold ≥11 is recommended for
the French version, while the other studies used higher thresholds:
Thompson et al. >12 and Eckerdal et al.
≥12.16,19 The definition for PPH also varies with the
study.16,17,19,20,29
The prevalence of PTSD was 12.8% (IES-R≥30) among women with PPH at M2,
compared with the 45% at 1 month and 23.5% at 3 months reported by
Ricbourg et al., and the 5% at 2 months reported by Thompson et
al.16,20 These differences in prevalence may be
explained by the choice of questionnaire used. Thompson et al. used the
17-item PTSD Checklist (PCL).16 Ricbourg et al. used
the same scale and the same endpoint as we did: IES-R≥
30.20 Again, the definitions of PPH differed between
studies16,20 and the number of individuals was
sometimes low.20
At 2 months after delivery, the prevalence of generalised anxiety
disorder was 15.9% (GAD-7>7) among women with PPH and
11.7% in the control ground. As no study has used the GAD-7 to evaluate
generalised anxiety disorder among women who had a PPH, comparison was
difficult. The meta-analysis by Goodman et al. found an overall mean
prevalence of GAD in a population of women during the postpartum period
was 3.59% (95%CI, 1.85-6.66), lower than our
results.6 Our results for anxiety were close to those
of Thompson et al., who used a 6-item short form of the Spielberger
scale.16 At 2 months, the women in Thompson’s PPH
group had a median score of 10 [IQR, 9-11], indicative of low
anxiety (median <12); the mean score in our study was 33.0
(95%CI, 31.9-34.1) on Spielberger’s STAI Y-A scale — very low anxiety
(score<35).16
As expected, our 2 groups differed for the known risk factors for PPH,
that is, mode of delivery (more women with PPH had either an
instrumental vaginal or caesarean delivery), geographical origin and
smoking, etc. We therefore adjusted the analyses for these factors. We
did not observe any statistically significant differences at M2 or M6
for any of the disorders studied (table 1). At M12, the women with PPH
had higher adjusted mean scores for PTSD than the control group: 7.6,
95%CI, 6.3-9.1 vs 5.8%, 95%CI, 4.9-6.8, p=0.02. Sentilhes et
al.22 found that women with vaginal deliveries only
had an unadjusted median score for PTSD less than 5 (95%CI, 0-11) at
one year, via the unrevised version of the IES; we used the revised
IES.22 We did not find a statistically significant
difference in the risk of any one of these psychological disorders at
any assessment point between women with and without PPH (Table S8). This
lack of association could be linked not only to the exposure studied but
also to other potential confounding factors or clinical prognostic
factors might modify this risk (wanted or unplanned pregnancy, the
women’s investment in the pregnancy, etc). The only others to measure
this risk were Eckerdal et al., who found that PPH did not increase the
risk of postpartum depression (OR=1.81, 95%CI, 0.91-3.57)
(unadjusted/crude).19
Our work focused on 2 current major public health issues. Among maternal
deaths up to one year after giving birth, suicide is the second leading
cause in France and PPH the fifth leading cause.10 Few
publications have considered the psychological impact of immediate PPH,
and as discussed in the introduction, all have them have methodological
problems.16–20 Most of these studies are limited to
postpartum depression.17,19,20