A woman's risk of developing postpartum depression is influenced by several pain-related factors before and after childbirth, including poor pain management, their prenatal mental health and the quality of patient-provider communication, researchers at the University of Illinois Urbana-Champaign say.
Health and kinesiology professor Sandraluz Lara-Cinisomo and her co-authors, graduate students Sudhamshi Beeram and Melany E. Romero, identified seven interrelated risk factors of postpartum depression in racial and ethnic minority women in a recent study. The findings were based on their analyses of 23 U.S.-based research studies published during the past five years that explored various problems associated with PPD. The sample sizes of these studies ranged from 32 to more than 6,000 women.
"There are multiple interrelated factors that contribute to pain, particularly childbirth-related pain. And when it is severe, poorly managed or occurring in the context of discrimination or prenatal mental health vulnerability, it further contributes to postpartum depression and ongoing pain-related problems," Beeram said. "Our review highlights that there's a need for integrated, equitable, patient-centered and culturally sensitive treatments to address existing disparities as part of the postpartum mental health prevention process."
Lara-Cinisomo said the project was unique in that it explored persistent postpartum pain and PPD from the perspectives of both patients and clinicians. "The findings highlighted the multifactorial, multilevel factors that we need to consider at the structural, clinical and language levels," she said. "We know that how pain is managed intrapartum is important, and that providers' role is critical in this. That tells me that we still have a lot to learn about what is driving these issues. However, we do know that there are disparities in how pain is managed postpartum and that the provider's role is critical in ensuring that patients are heard and informed about pain management options."
The team reported its findings in the journal Current Psychiatry Reports.
Approximately 10-20% of women in the U.S. experience PPD, and while the rates rose significantly for all ethnic groups from 2010-2021, the highest rates were among racial and ethnic minority women, various studies indicated. However, few studies have explored the links between persistent postpartum pain and depression among racially diverse populations, "and this is concerning because we are a diverse nation," Romero said. "It's important to look at what minority populations need and what is missing for them to be healthy and live a content and happy life."
The team found that patient-provider communication problems can hinder pain management, increasing the risk for PPD. Across the studies they reviewed, the team found a pattern where Black and Latina women reported that providers overlooked, dismissed or ignored their pain-management concerns and preferences, ostensibly because of the patients' racial backgrounds. Conversely, patients also sometimes withheld or limited the information that they shared with their providers - such as having a history of opioid use disorder or their cultural beliefs about pain management - because of perceived discrimination, the team said.
Hmong women reported in one study that discussions about their cultural preferences were lacking and there were challenges balancing their cultural practices and Western treatment methods, leading to unplanned cesarean deliveries and other unexpected decisions. These mismatches in patients' and providers' beliefs about pain management practices can increase the risks of PPD as well, the team suggests.
"Clinicians have to rely on a number of indicators - what their patients report, what they observe, what they're measuring and what their clinical experience suggests," Lara-Cinisomo said. "And the literature showed that they are relying on these various factors to help inform how they are going to treat pain intrapartum during the delivery and then postpartum. We also found that patients had specific needs that went unmet, such as cultural needs and a safe space to report any kind of pain that they might have experienced."
While all providers preferred prescription medication for pain management, there were inconsistencies in their prescribing practices and medication preferences, the data indicated. Although 95% of the doctors in the studies reviewed believed that the majority of women who delivered by C-section required pain management, the methods they recommended most frequently were not opioids but ibuprofen, perineal ice packs and acetaminophen.
The team said that the selection of effective analgesics for addressing patients' pain levels is critical, particularly for those who deliver by C-section and are at higher risk of postpartum pain. Black and Asian women have a higher likelihood of undergoing unplanned C-sections compared with white women, contributing to disparities in their outcomes, the team wrote.
"Patients who are minorities may have different cultural preferences and needs that clinicians may not always be aware of," Romero said. "Many minorities view using medication as stigmatizing. They want an alternative to medication. That is another reason why we have to ensure that they feel like they are in a safe space and that they are being heard by their clinicians. There has to be meaningful communication and connection that can be trusted in order for patients to feel like they can get the best care available."
Physicians and nurses in various studies indicated they "relied on patient reports and clinical assessments to manage" pain. While nurses were the first line of defense, they did not always feel equipped to treat patients' pain, Lara-Cinisomo said. "It raised this issue of who is treating the pain, and do they have the skills and resources they need? But then are the patients also able to disclose what they are feeling and share their concerns about specific pain protocols or the levels of pain they might be experiencing? We know healthcare providers are very busy and that they have a limited time to address all of the patient's needs. But this paper shows us that there are questions that might be asked in those five minutes when a provider is seeing a patient, following up or setting a protocol."
Demographic factors also influenced medical residents' perceptions of women's pain responses while in labor, the team found. In one study, 36 racially and ethnically diverse obstetrics and gynecology residents said they viewed women positively who "were quiet and cooperative during childbirth, often labeling those who endured pain as heroic," the team wrote.
In a related research project, Lara-Cinisomo and her colleagues are investigating nonpharmacological interventions such as using mindfulness to manage postpartum pain and prevent the onset of PPD among racial and ethnically diverse women. That work is supported by a $30,000 grant from the Office of the Vice Chancellor for Research and Innovation at Illinois.
