The association between epidural labour analgesia and postpartum depression: a reply

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We thank Rao et al. for their interest in our paper [1]. We collected the demographics and data on various questionnaires before delivery and allowed patients to recall and fill in any missing data (if any) given the dynamic and progressive nature of labour. Hence, we apologise for any confusion in the manuscript, whereby the phrase “assessed within 24 hours after delivery” was, in fact, referring to the period up to which data were collected as potential association factors. No significant differences in pain and psychological vulnerabilities (depressive symptoms; pain catastrophising; central sensitisation; fear-avoidance; anxiety; perceived stress; labour pain; and general health status) were found between patients allocated to the epidural and non-epidural groups. However, we agree that other factors that may govern the antenatal mental status, such as social support, body image and self-efficacy, should be explored to determine their clinical relevance in the relationship between labour epidural analgesia and postpartum depression. Notably, the study team comprised of senior consultant psychiatrists who are key opinion leaders for postpartum depression in our local population. The primary objective on the incidence of postpartum depression at 6–10 weeks utilised a cut-off of Edinburgh Postnatal Depression Scale (EPDS) ≥ 13 as recommended by a recent systematic analysis for postpartum women to indicate a positive screening on the mental symptoms [2]. Furthermore, we also used a lower EPDS cut-off of 10 to indicate probable postpartum depression, which could also reduce the number of false-negative cases [2]. We agree that the use of the EPDS is meant for screening rather than diagnosis (which is stated in the methods) and that the structured interview based on Manual of Mental Disorders-5 (DSM-5) such as the Mini-International Neuropsychiatric Interview (MINI) should remain the gold standard for diagnosing postpartum depression. However, studies have shown that EPDS can detect MINI disorders well (area under the curve 0.82–0.84) [3]. It is also more convenient for postpartum patients to complete a 10-item questionnaire rather than to attend physical/online video interviews. Hence, the EPDS should continue to serve as a valuable tool to screen for patients at risk of postpartum depression with further assessment using the MINI if required. We reported no serious adverse events during our study. However, it was not powered to investigate adverse outcomes, with the post-procedural complications collected only in those patients who received labour epidural analgesia regardless of the group allocation. Among the 690 patients who received labour epidural analgesia, the most common post-procedural complications were backache (n = 41, 5.9%) and urinary retention (n = 17, 2.5%) (Table 1). Nevertheless, our previous cohort study on labour epidural analgesia in our local population showed that post-procedural complications did not have significant association with postpartum depression at 5–9 weeks [4]. Hence, if a future trial is planned to further evaluate post-epidural complications (e.g. postdural puncture headache) with postpartum depression, a much larger sample size would be warranted.

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