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Are labor pain and birth experience associated with persistent pain and postpartum depression? A prospective cohort study

Leiv Arne Rosseland, Silje Endresen Reme, Tone Breines Simonsen, Magne Thoresen, Christopher Sivert Nielsen and Malin Eberhard Gran


Background and aims

A considerable research-literature focuses on pain during labor and associations with postpartum persistent pain and depression, with findings pointing in various directions. The aim of this study was to examine the role of labor pain and overall birth experience in the development of pain and depression 8 weeks after delivery.


The study sample was drawn from the Akershus Birth Cohort. Data from multiple sources were used, including the hospital’s birth record (n = 4,391), questionnaire data from gestational week 17 of pregnancy (n = 3,752), 8 weeks postpartum (n = 2,217), and two questions about pain and birth experience asked within 48 h after delivery (n = 1,221). The Edinburgh Postnatal Depression Scale was used to measure postpartum depression, a single question was used to measure persistent pain 8 weeks postpartum, while pain and birth experience were measured by numeric rating scales. A history of pre-pregnant depression and chronic pain were measured through self-report questions in gestational week 17. A total of 645 women had complete data from all sources. We applied multiple imputation techniques to handle missing responses on the two questions about pain and birth experience.


The results showed that neither labor pain nor birth experience were associated with persistent pain 8 weeks postpartum, whereas pain before pregnancy (OR 3.70; 95% CI 2.71–5.04) and a history of depression (OR 2.31; 95% CI 1.85–2.88) were statistically significant predictors of persistent pain. A negative birth experience was significantly (OR 1.16; 95% CI 1.04–1.29) associated with postpartum depression, whereas labor pain intensity was not. A history of depression (OR 3.95; 95% CI 2.92–5.34) and pre-pregnancy pain (OR 2.03; 95% CI 1.37–3.01) were important predictors of postpartum depression 8 weeks after delivery.

Conclusions and implications

Whilst the relationship between labor pain intensity and postpartum pain and depression remain unclear, our results do imply the need to screen for previous depression and chronic pain conditions in pregnant women, as well as consider preventive measures in those who screen positive.

*Corresponding author: Prof. Silje Endresen Reme, Department of Psychology, Faculty of Social Sciences, University of Oslo, Oslo, Norway; and Department of Pain Management and Research, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway

  1. Authors’ statements

  2. Research funding: While the original study was funded by the Norwegian Research Council (project number 191098), no funding was received for this particular study.

  3. Conflict of interest: The authors declare that they have no competing interests related to the work presented.

  4. Informed consent: Written informed consent was obtained from all participants, and all women invited to participate in the ABC study were informed that participation was voluntary.

  5. Ethical approval: The study was approved by Regional Committee for Ethics in Medical Research in Norway, approval number S-08013a. The study is performed and reported according to STROBE guidelines [24].

  6. Availability of data and material

  7. The dataset analysed during the current study is not publicly available due to data privacy restrictions and ethical restrictions established by the Norwegian Regional Committee for Ethics in Medical Research. Data are, however, available through application to the ABC study. All enquiries about access to data should be sent to the ABC steering group, attention: All requests to access personal data will be handled in accordance with the procedures by the Ethics Committee.

  8. Authors’ contributions

  9. All authors have read and approved the paper. The ABC study was designed by ME-G, while the current study was proposed by LAR and SER; TBS was responsible for the data collection in the ABC study, LAR and SER designed and put together the first draft, while MT and SER carried out the statistical analysis; all authors contributed towards writing and completing the manuscript and data interpretation.


[1] Vermelis JM, Wassen MM, Fiddelers AA, Nijhuis JG, Marcus MA. Prevalence and predictors of chronic pain after labor and delivery. Curr Opin Anaesthesiol 2010;23:295–9.10.1097/ACO.0b013e32833853e8Search in Google Scholar PubMed

[2] Eisenach JC, Pan P, Smiley RM, Lavand’homme P, Landau R, Houle TT. Resolution of pain after childbirth. Anesthesiology 2013;118:143–51.10.1097/ALN.0b013e318278ccfdSearch in Google Scholar PubMed PubMed Central

[3] Shorey S, Chee CYI, Ng ED, Chan YH, Tam WWS, Chong YS. Prevalence and incidence of postpartum depression among healthy mothers: a systematic review and meta-analysis. J Psychiatr Res 2018;104:235–48.10.1016/j.jpsychires.2018.08.001Search in Google Scholar PubMed

[4] Declercq E, Cunningham DK, Johnson C, Sakala C. Mothers’ reports of postpartum pain associated with vaginal and cesarean deliveries: results of a national survey. Birth (Berkeley, Calif) 2008;35:16–24.10.1111/j.1523-536X.2007.00207.xSearch in Google Scholar PubMed

[5] Martins C, Gaffan EA. Effects of early maternal depression on patterns of infant-mother attachment: a meta-analytic investigation. J Child Psychol Psychiatry 2000;41:737–46.10.1111/1469-7610.00661Search in Google Scholar

[6] Murray L, Fiori-Cowley A, Hooper R, Cooper P. The impact of postnatal depression and associated adversity on early mother-infant interactions and later infant outcome. Child Dev 1996;67:2512–26.10.2307/1131637Search in Google Scholar

[7] Pearson RM, Evans J, Kounali D, Lewis G, Heron J, Ramchandani PG, O’Connor TG, Stein A. Maternal depression during pregnancy and the postnatal period: risks and possible mechanisms for offspring depression at age 18 years. JAMA Psychiatry 2013;70:1312–9.10.1001/jamapsychiatry.2013.2163Search in Google Scholar PubMed PubMed Central

[8] Hiltunen P, Raudaskoski T, Ebeling H, Moilanen I. Does pain relief during delivery decrease the risk of postnatal depression? Acta Obstet Gynecol Scand 2004;83:257–61.10.1111/j.0001-6349.2004.0302.xSearch in Google Scholar PubMed

[9] Wisner KL, Stika CS, Clark CT. Double duty: does epidural labor analgesia reduce both pain and postpartum depression? Anesth Analg 2014;119:219–21.10.1213/ANE.0000000000000322Search in Google Scholar PubMed PubMed Central

[10] Orbach-Zinger S, Landau R, Harousch AB, Ovad O, Caspi L, Kornilov E, Ioscovich A, Bracco D, Davis A, Fireman S, Hoshen M, Eidelman LA. The relationship between women’s intention to request a labor epidural analgesia, actually delivering with labor epidural analgesia, and postpartum depression at 6 weeks: a prospective observational study. Anesth Analg 2018;126:1590–7.10.1213/ANE.0000000000002501Search in Google Scholar PubMed

[11] Lim G, Farrell LM, Facco FL, Gold MS, Wasan AD. Labor analgesia as a predictor for reduced postpartum depression scores: a retrospective observational study. Anesth Analg 2018;126:1598–605.10.1213/ANE.0000000000002720Search in Google Scholar PubMed PubMed Central

[12] Zhang Y, Johnston L, Ma D, Wang F, Zheng X, Xu X. An exploratory study of the effect of labor pain management on postpartum depression among Chinese women. Ginekol Pol 2018;89:627–36.10.5603/GP.a2018.0107Search in Google Scholar PubMed

[13] Nahirney M, Metcalfe A, Chaput KH. Administration of epidural labor analgesia is not associated with a decreased risk of postpartum depression in an urban Canadian population of mothers: a secondary analysis of prospective cohort data. Local Reg Anesth 2017;10:99–104.10.2147/LRA.S141569Search in Google Scholar PubMed PubMed Central

[14] Toledo P, Miller ES, Wisner KL. Looking beyond the pain: can effective labor analgesia prevent the development of postpartum depression? Anesth Analg 2018;126:1448–50.10.1213/ANE.0000000000002857Search in Google Scholar PubMed PubMed Central

[15] Guintivano J, Manuck T, Meltzer-Brody S. Predictors of postpartum depression: a comprehensive review of the last decade of evidence. Clin Obstet Gynecol 2018;61: 591–603.10.1097/GRF.0000000000000368Search in Google Scholar PubMed PubMed Central

[16] Beck CT. Predictors of postpartum depression: an update. Nurs Res 2001;50:275–85.10.1097/00006199-200109000-00004Search in Google Scholar PubMed

[17] Kainu JP, Halmesmaki E, Korttila KT, Sarvela PJ. Persistent pain after cesarean delivery and vaginal delivery: a prospective cohort study. Anesth Analg 2016;123:1535–45.10.1213/ANE.0000000000001619Search in Google Scholar PubMed

[18] Kainu JP, Sarvela J, Tiippana E, Halmesmaki E, Korttila KT. Persistent pain after caesarean section and vaginal birth: a cohort study. Int J Obstet Anesth 2010;19:4–9.10.1016/j.ijoa.2009.03.013Search in Google Scholar PubMed

[19] Landau R, Bollag L, Ortner C. Chronic pain after childbirth. Int J Obstet Anesth 2013;22:133–45.10.1016/j.ijoa.2013.01.008Search in Google Scholar PubMed

[20] Tuohy A, McVey C. Experience of pregnancy and delivery as predictors of postpartum depression. Psychol Health Med 2008;13:43–7.10.1080/13548500701294531Search in Google Scholar PubMed

[21] Weisman O, Granat A, Gilboa-Schechtman E, Singer M, Gordon I, Azulay H, Kuint J, Feldman R. The experience of labor, maternal perception of the infant, and the mother’s postpartum mood in a low-risk community cohort. Arch Womens Ment Health 2010;13:505–13.10.1007/s00737-010-0169-zSearch in Google Scholar PubMed

[22] Unsal Atan S, Ozturk R, Gulec Satir D, Ildan Calim S, Karaoz Weller B, Amanak K, Saruhan A, Sirin A, Akercan F. Relation between mothers’ types of labor, birth interventions, birth experiences and postpartum depression: a multicentre follow-up study. Sex Reprod Healthc 2018;18:13–8.10.1016/j.srhc.2018.08.001Search in Google Scholar PubMed

[23] Garthus-Niegel S, Knoph C, von Soest T, Nielsen CS, Eberhard-Gran M. The role of labor pain and overall birth experience in the development of posttraumatic stress symptoms: a longitudinal cohort study. Birth (Berkeley, Calif) 2014;41:108–15.10.1111/birt.12093Search in Google Scholar PubMed

[24] Von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP, Strobe initiative. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. PLoS Med 2007;4:e296.10.1097/EDE.0b013e3181577654Search in Google Scholar PubMed

[25] Breivik H, Borchgrevink PC, Allen SM, Rosseland LA, Romundstad L, Hals EK, Kvarstein G, Stubhaug A. Assessment of pain. Br J Anaesth 2008;101:17–24.10.1093/bja/aen103Search in Google Scholar PubMed

[26] Cox JL, Holden JM, Sagovsky R. Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale. Br J Psychiatry 1987;150:782–6.10.1192/bjp.150.6.782Search in Google Scholar PubMed

[27] Eberhard-Gran M, Eskild A, Tambs K, Schei B, Opjordsmoen S. The Edinburgh Postnatal Depression Scale: validation in a Norwegian community sample. Nord J Psychiatry 2001;55:113–7.10.1080/08039480151108525Search in Google Scholar PubMed

[28] Schafer JL, Graham JW. Missing data: our view of the state of the art. Psychol Methods 2002;7:147–77.10.1037/1082-989X.7.2.147Search in Google Scholar

[29] Sterne JA, White IR, Carlin JB, Spratt M, Royston P, Kenward MG, Wood AM, Carpenter JR. Multiple imputation for missing data in epidemiological and clinical research: potential and pitfalls. Br Med J 2009;338:b2393.10.1136/bmj.b2393Search in Google Scholar PubMed PubMed Central

[30] Hildingsson I, Blix E, Hegaard H, Huitfeldt A, Ingversen K, Olafsdottir OA, Lindgren H. How long is a normal labor? Contemporary patterns of labor and birth in a low-risk sample of 1,612 women from four nordic countries. Birth 2015;42:346–53.10.1111/birt.12191Search in Google Scholar PubMed

[31] Eisenach JC, Pan PH, Smiley R, Lavand’homme P, Landau R, Houle TT. Severity of acute pain after childbirth, but not type of delivery, predicts persistent pain and postpartum depression. Pain 2008;140:87–94.10.1016/j.pain.2008.07.011Search in Google Scholar PubMed PubMed Central

[32] Bijl RC, Freeman LM, Weijenborg PT, Middeldorp JM, Dahan A, van Dorp EL. A retrospective study on persistent pain after childbirth in the Netherlands. J Pain Res 2016;9:1–8.10.2147/JPR.S96850Search in Google Scholar PubMed PubMed Central

[33] Gatchel RJ, Peng YB, Peters ML, Fuchs PN, Turk DC. The biopsychosocial approach to chronic pain: scientific advances and future directions. Psychol Bull 2007;133:581–624.10.1037/0033-2909.133.4.581Search in Google Scholar PubMed

[34] Bell AF, Carter CS, Davis JM, Golding J, Adejumo O, Pyra M, Connelly JJ, Rubin LH. Childbirth and symptoms of postpartum depression and anxiety: a prospective birth cohort study. Arch Womens Ment Health 2016;19:219–27.10.1007/s00737-015-0555-7Search in Google Scholar PubMed PubMed Central

[35] Gaynes BN, Gavin N, Meltzer-Brody S, Lohr KN, Swinson T, Gartlehner G, Brody S, Miller WC. Perinatal depression: prevalence, screening accuracy, and screening outcomes. Evid Rep Technol Assess (Summ) 2005;119:1–8.Search in Google Scholar

[36] Hannah ME, Hannah WJ, Hodnett ED, Chalmers B, Kung R, Willan A, Amankwah K, Cheng M, Helewa M, Hewson S, Saigal S, Whyte H, Gafni A, Term Breech Trial 3-Month Follow-up Collaborative Group. Outcomes at 3 months after planned cesarean vs planned vaginal delivery for breech presentation at term: the international randomized Term Breech Trial. J Am Med Assoc 2002;287:1822–31.10.1001/jama.287.14.1822Search in Google Scholar PubMed

[37] Eckerdal P, Kollia N, Karlsson L, Skoog-Svanberg A, Wikstrom AK, Hogberg U, Skalkidou A. Epidural analgesia during childbirth and postpartum depressive symptoms: a population-based longitudinal cohort study. Anesth Analg 2020;130:615–24.10.1213/ANE.0000000000004292Search in Google Scholar PubMed

[38] Niven CA, Murphy-Black T. Memory for labor pain: a review of the literature. Birth 2000;27:244–53.10.1046/j.1523-536x.2000.00244.xSearch in Google Scholar PubMed

[39] Aksoy H, Yucel B, Aksoy U, Acmaz G, Aydin T, Babayigit MA. The relationship between expectation, experience and perception of labour pain: an observational study. SpringerPlus 2016;5:1766.10.1186/s40064-016-3366-zSearch in Google Scholar PubMed PubMed Central

[40] Chajut E, Caspi A, Chen R, Hod M, Ariely D. In pain thou shalt bring forth children: the peak-and-end rule in recall of labor pain. Psychol Sci 2014;25:2266–71.10.1177/0956797614551004Search in Google Scholar PubMed

[41] Ding T, Wang DX, Qu Y, Chen Q, Zhu SN. Epidural labor analgesia is associated with a decreased risk of postpartum depression: a prospective cohort study. Anesth Analg 2014;119:383–92.10.1213/ANE.0000000000000107Search in Google Scholar PubMed

[42] Suhitharan T, Pham TP, Chen H, Assam PN, Sultana R, Han NL, Tan EC, Sng BL. Investigating analgesic and psychological factors associated with risk of postpartum depression development: a case-control study. Neuropsychiatr Dis Treat 2016;12:1333–9.10.2147/NDT.S105918Search in Google Scholar

[43] Freeman LM, Bloemenkamp KW, Franssen MT, Papatsonis DN, Hajenius PJ, Hollmann MW, Woiski MD, Porath M, van den Berg HJ, van Beek E, Borchert OW, Schuitemaker N, Sikkema JM, Kuipers AH, Logtenberg SL, van der Salm PC, Oude Rengerink K, Lopriore E, van den Akker-van Marle ME, le Cessie S, et al. Patient controlled analgesia with remifentanil versus epidural analgesia in labour: randomised multicentre equivalence trial. Br Med J 2015;350:h846.10.1136/bmj.h846Search in Google Scholar

[44] Wang F, Shen X, Guo X, Peng Y, Gu X. Epidural analgesia in the latent phase of labor and the risk of cesarean delivery: a five-year randomized controlled trial. Anesthesiology 2009;111:871–80.10.1097/01.aoa.0000386852.21149.35Search in Google Scholar

[45] Lim G, Levine MD, Mascha EJ, Wasan AD. Labor pain, analgesia, and postpartum depression: are we asking the right questions? Anesth Analg 2020;130:610–4.10.1213/ANE.0000000000004581Search in Google Scholar

[46] Hodnett ED. Pain and women’s satisfaction with the experience of childbirth: a systematic review. Am J Obstet Gynecol 2002;186:S160–72.10.1016/S0002-9378(02)70189-0Search in Google Scholar

[47] Duncan LG, Cohn MA, Chao MT, Cook JG, Riccobono J, Bardacke N. Benefits of preparing for childbirth with mindfulness training: a randomized controlled trial with active comparison. BMC Pregnancy Childbirth 2017;17:140.10.1186/s12884-017-1319-3Search in Google Scholar

[48] Kehlet H, Jensen TS, Woolf CJ. Persistent postsurgical pain: risk factors and prevention. Lancet 2006;367:1618–25.10.1016/S0140-6736(06)68700-XSearch in Google Scholar

[49] Bair MJ, Robinson RL, Katon W, Kroenke K. Depression and pain comorbidity: a literature review. Arch Intern Med 2003;163:2433–45.10.1001/archinte.163.20.2433Search in Google Scholar PubMed

[50] Committee on Practice Bulletins–Obstetrics,Plante L, Gaiser R. Practice bulletin no. 177: obstetric analgesia and anesthesia. Obstet Gynecol 2017;129:e73–89.10.1097/AOG.0000000000002018Search in Google Scholar PubMed

[51] Sng BL, Leong WL, Zeng Y, Siddiqui FJ, Assam PN, Lim Y, Chan ES, Sia AT. Early versus late initiation of epidural analgesia for labour. Cochrane Database Syst Rev 2014;10:Cd007238.10.1002/14651858.CD007238.pub2Search in Google Scholar PubMed

[52] Jonsdottir SS, Steingrimsdottir T, Thome M, Oskarsson GK, Lydsdottir LB, Olafsdottir H, Sigurdsson JF, Swahnberg K. Pain management and medical interventions during childbirth among perinatal distressed women and women dissatisfied in their partner relationship: a prospective cohort study. Midwifery 2019;69:1–9.10.1016/j.midw.2018.10.018Search in Google Scholar PubMed

[53] Cooper G, MacArthur C, Wilson M, Moore P, Shennan A. Satisfaction, control and pain relief: short-and long-term assessments in a randomised controlled trial of low-dose and traditional epidurals and a non-epidural comparison group. Int J Obstet Anesth 2010;19:31–7.10.1016/j.ijoa.2009.05.004Search in Google Scholar PubMed

[54] Carvalho B, Zheng M, Harter S, Sultan P. A prospective cohort study evaluating the ability of anticipated pain, perceived analgesic needs, and psychological traits to predict pain and analgesic usage following cesarean delivery. Anesthesiol Res Pract 2016;2016:7948412.10.1155/2016/7948412Search in Google Scholar PubMed PubMed Central

[55] Carvalho B, Zheng M, Aiono-Le Tagaloa L. A prospective observational study evaluating the ability of prelabor psychological tests to predict labor pain, epidural analgesic consumption, and maternal satisfaction. Anesth Analg 2014;119:632–40.10.1213/ANE.0000000000000357Search in Google Scholar PubMed

Supplementary Material

The online version of this article offers supplementary material (

Received: 2020-02-07
Revised: 2020-04-17
Accepted: 2020-04-22
Published Online: 2020-05-29
Published in Print: 2020-07-28

©2020 Scandinavian Association for the Study of Pain. Published by Walter de Gruyter GmbH, Berlin/Boston. All rights reserved.

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