Association Between Epidural Labor Analgesia and Reduced Risk of Postpartum Depression in Primiparous Women: A Prospective Preference-Based Controlled Cohort Study

Association Between Epidural Labor Analgesia and Reduced Risk of Postpartum Depression in Primiparous Women: A Prospective Preference-Based Controlled Cohort Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Association Between Epidural Labor Analgesia and Reduced Risk of Postpartum Depression in Primiparous Women: A Prospective Preference-Based Controlled Cohort Study Yu-qian Chen, Dan-dan Chen, Yan-yu Wu, Xian-mei Zhong, Shun-yuan Li This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8778550/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 19 You are reading this latest preprint version Abstract Objective To evaluate the association between epidural labor analgesia (ELA) and postpartum depression (PPD) at 6 weeks postpartum, and to identify independent predictors of PPD in primiparous women planning vaginal delivery. Methods This prospective preference-based controlled cohort study enrolled 200 singleton primiparous women scheduled for vaginal delivery (July–December 2021). Participants chose whether to receive ELA and were grouped accordingly. Pain intensity was assessed using the numerical rating scale (NRS) at predefined intrapartum time points and on postpartum day 1. PPD at postpartum day 42 was assessed using the Edinburgh Postnatal Depression Scale (EPDS), with PPD defined as EPDS ≥ 9. Group comparisons used appropriate parametric/non-parametric tests. Multivariable logistic regression and a propensity score–based inverse probability of treatment weighting (IPTW) sensitivity analysis were performed to assess robustness to confounding. Results A total of 184 women completed follow-up (ELA group, n = 93; non-ELA group, n = 91). The overall incidence of PPD was 20.65% (38/184). Women in the ELA group reported significantly lower NRS scores at full cervical dilatation (T4) and on postpartum day 1, and higher satisfaction scores on postpartum day 1 (all P < 0.05). The incidence of PPD at 6 weeks was lower in the ELA group than in the non-ELA group (14.0% vs 27.5%, P = 0.008). After adjustment for potential confounders, ELA remained independently associated with a reduced risk of PPD (OR = 0.276, 95% CI 0.082–0.928, P = 0.038). Education ≤ 12 years, cesarean delivery, and antenatal fear of labor pain were independent risk factors. Conclusion Among singleton primiparous women planning vaginal delivery, receipt of epidural labor analgesia was associated with a lower risk of postpartum depression at 6 weeks postpartum. epidural labor analgesia postpartum depression Edinburgh Postnatal Depression Scale propensity score IPTW nomogram Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Postpartum depression (PPD) is a common perinatal mental disorder that can adversely affect maternal well-being, mother–infant bonding, infant development, and family functioning. Reported prevalence varies substantially across regions and studies, partly due to differences in populations, screening tools, cut-off values, and timing of assessment. Various preventive and therapeutic approaches have been explored, including psychosocial and internet-delivered interventions. [ 1 – 4 ] Labor pain is often one of the most intense painful experiences in a woman’s life. Severe labor pain may provoke neuroendocrine stress responses and contribute to the onset or aggravation of depressive symptoms. Labor pain has therefore been proposed as a potentially modifiable risk factor for PPD. [ 5 – 6 ] Epidural labor analgesia (ELA) is the most effective method for labor pain relief and is widely used. By reducing pain and stress responses, ELA may improve the childbirth experience and potentially reduce the risk of PPD. However, existing evidence remains inconsistent, and observational studies are prone to residual confounding and heterogeneity. [ 6 – 11 ] This prospective preference-based controlled cohort study was designed to examine the association between ELA and PPD at 6 weeks postpartum in singleton primiparous women planning vaginal delivery, and to identify independent predictors of PPD for risk stratification and early intervention. Methods Study design and setting This prospective preference-based controlled cohort study was conducted at Quanzhou First Hospital affiliated with Fujian Medical University between July 2021 and December 2021. The protocol was approved by the institutional ethics committee (Approval No. Quanyi-Lun (2021) 176), and written informed consent was obtained from all participants. This study is reported in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement. [ 12 ] Participants Inclusion criteria were: (1) singleton pregnancy; (2) primiparous; and (3) planned vaginal delivery. Exclusion criteria were: (1) age 35 years; (2) a history of depression, other psychiatric disorders, personality disorders, or brain disease diagnosed by a psychiatrist before or during pregnancy, or antenatal EPDS ≥ 9; (3) contraindications to ELA; (4) severe neonatal adverse outcomes (e.g., neonatal intensive care unit admission or neonatal death); and (5) inability to complete follow-up. Grouping and blinding After standardized counseling regarding labor analgesia, women chose whether to receive ELA and were grouped accordingly (ELA vs non-ELA). Peripartum data collection, implementation of ELA, and postpartum follow-up were performed by three independent anesthesiologists who were not involved in each other’s tasks. Epidural labor analgesia protocol When cervical dilatation reached ≥ 3 cm, women in the ELA group were managed in the delivery room with standard monitoring and intravenous access. An epidural catheter was placed at the L2–3 or L3–4 interspace. A test dose of 3 mL 2% lidocaine was administered. After 5–10 minutes, if intrathecal placement was excluded, 10–15 mL of 0.1% ropivacaine diluted with 0.9% saline was administered as a loading dose, targeting a sensory level below T10. Thirty minutes after the loading dose, a patient-controlled epidural analgesia pump (0.1% ropivacaine, total 100 mL) was connected with a background infusion of 10 mL/h, a lockout interval of 20 minutes, and a maximum hourly dose of 30 mL. Analgesia was discontinued at full cervical dilatation (10 cm). Women in the non-ELA group received routine peripartum care without neuraxial or systemic analgesics. If emergency cesarean delivery was required, combined spinal–epidural anesthesia was used in the non-ELA group; for women with an indwelling epidural catheter, epidural anesthesia was administered via the catheter. Postoperative epidural analgesia (0.1% ropivacaine at 8 mL/h for 24 hours) was provided as routine care. Data collection and outcomes Baseline variables included demographics, obstetric characteristics, socioeconomic factors, stressful life events, antenatal EPDS score, antenatal fear of labor pain, and antenatal expectation of labor analgesia. Pain intensity was assessed using an 11-point numerical rating scale (NRS; 0 = no pain, 10 = worst pain). NRS was recorded at T1 (before analgesia), T2 (10 minutes after analgesia), T3 (30 minutes after analgesia), and T4 (full cervical dilatation). For women without ELA, NRS was assessed at corresponding time points. [ 13 ] Peripartum outcomes included mode of delivery, oxytocin use, assisted vaginal delivery, labor stage durations, postpartum blood loss, and transfusion. Neonatal outcomes included sex, birth weight, and Apgar scores. Postpartum follow-up was performed on day 1 and day 42. On day 1, NRS and an 11-point satisfaction score were recorded. On day 42, depressive symptoms were assessed using the Edinburgh Postnatal Depression Scale (EPDS), a 10-item self-report measure with total scores ranging from 0 to 30, where higher scores indicate more severe depressive symptoms. PPD was defined as EPDS ≥ 9, consistent with validated cut-offs in Chinese populations. Additional items included spousal preference regarding infant sex and infant feeding pattern. [ 14 – 15 ] Sample size Assuming a PPD incidence of 10% in women receiving neuraxial labor analgesia and 25% in those without neuraxial analgesia, a total sample size of 194 was required (two-sided α = 0.05, power = 80%). Allowing for 5–10% loss to follow-up, 200 participants were planned. [ 6 , 8 , 16 ] Statistical analysis Analyses were performed using R (version 4.0.5). [ 17 ] Continuous variables are presented as mean ± SD when normally distributed and as median (IQR) otherwise. Student’s t test or the Wilcoxon rank-sum test was used as appropriate. Categorical variables are presented as n (%) and were compared using the χ² test or Fisher’s exact test. Standardized mean differences (SMDs) were used to assess baseline balance. The Mantel–Haenszel method was used to estimate a pooled odds ratio (OR) for the association between ELA and PPD stratified by mode of delivery. Multivariable logistic regression was used to identify independent predictors; model fit was assessed by the Hosmer–Lemeshow test. A nomogram was developed from the final model and evaluated using the AUC of the ROC curve. [ 18 ] As a sensitivity analysis, we applied propensity score–based inverse probability of treatment weighting (IPTW) to further reduce potential confounding. Propensity scores for receiving epidural labor analgesia (ELA) were estimated using a multivariable logistic regression model that included prespecified baseline covariates (i.e., all variables in Table 2 ). Stabilized weights were calculated as the marginal probability of treatment divided by the individual propensity score for participants who received ELA and by one minus the propensity score for those who did not. To limit the influence of extreme weights, weights were truncated at the 1st and 99th percentiles. Covariate balance after weighting was evaluated using standardized mean differences (SMDs), with an SMD < 0.10 indicating adequate balance. The association between ELA and postpartum depression (PPD) was then estimated using a weighted logistic regression model with robust (sandwich) standard errors. [ 18 – 19 ] Table 1 Study drugs and equipment. Item Manufacturer Specification Lidocaine hydrochloride injection Tianjin Jinyao Pharmaceutical Co., Ltd. 5 mL: 0.1 g Ropivacaine hydrochloride injection (Naropin) AstraZeneca 10 mL: 100 mg 0.9% sodium chloride injection Fujian Taipingyang Pharmaceutical Co., Ltd. 500 mL Electronic infusion pump set Jiangsu Apon Medical Technology Co., Ltd. ZZB-150 Automatic infusion pump driver Nantong Aipu Medical Device Co., Ltd. ZZB-I Disposable anesthesia puncture kit Zhuhai Fonia Medical Equipment Co., Ltd. AS-E/S II Table 2 Baseline characteristics. Variable Epidural analgesia (n = 93) No epidural analgesia (n = 91) t/χ² SMD P value Age (years) 6.431 0.381 0.04 18–25 22(23.66%) 9(9.89%) 26–30 46(49.46%) 56(61.54%) 31–35 25(26.88%) 26(28.57%) BMI(kg/m²) 26.82 ± 4.79 26.95 ± 4.77 0.486 0.072 0.627 Gestational age (days) 275.14 ± 6.78 275.30 ± 6.77 0.225 0.033 0.823 Married 90(96.77%) 85(93.41%) 0.156 0.327a Only child 8(8.60%) 2(2.20%) 2.53 0.286 0.112 Education > 12 years 79(84.95%) 66(72.53%) 3.536 0.307 0.06 Religious belief 4(4.30%) 4(4.40%) 0.005 1a Health insurance coverage 84(90.32%) 82(90.11%) 0.007 1a History of smoking/alcohol use 6(6.45%) 2(2.20%) 1.109 0.21 0.278 Residence 2.498 0.258 0.114 Urban 54(58.06%) 64(70.33%) Rural 39(41.94%) 27(29.67%) Satisfied with living conditions 85(93.41%) 79(84.95%) 2.581 0.275 0.108 Stable occupation 84(92.31%) 83(89.25%) 0.214 0.106 0.644 Monthly household income 3.139 0.263 0.371 10,000 CNY 34(36.56%) 27(29.67%) Declined to answer 18(19.35%) 14(15.38%) Stressful life events within 2 years 7(7.53%) 10(10.99%) 0.309 0.12 0.578 Antenatal EPDS score 6(5–6) 6(5–6) 0.894 0.061 0.741 Antenatal fear of labor pain 67 (72.04%) 70 (76.92%) 0.348 0.112 0.555 Antenatal expectation of labor analgesia 85 (91.40%) 77 (84.62%) 1.417 0.21 0.234 Notes: Data are presented as mean ± SD, n (%), or median (IQR). a Fisher’s exact test. Abbreviations: BMI body mass index, EPDS Edinburgh Postnatal Depression Scale, NRS numerical rating scale. Results Participant flow Among 200 enrolled women (ELA, n = 100; non-ELA, n = 100), 16 were excluded (ELA, n = 7; non-ELA, n = 9) due to neonatal ICU admission, antenatal EPDS ≥ 9, refusal of follow-up, or unreachable follow-up calls. A total of 184 women completed follow-up and were included in the analysis (ELA, n = 93; non-ELA, n = 91) (Fig. 1 ). Baseline characteristics Baseline characteristics are summarized in Table 2 . The proportion of women aged 18–25 years was higher in the ELA group (P < 0.05). Other baseline variables did not differ significantly. The SMD plot showed acceptable balance for most variables, with the largest imbalance observed for age (Fig. 2 ). Peripartum maternal and neonatal outcomes Peripartum outcomes are shown in Table 3 . Compared with the non-ELA group, the ELA group had significantly lower NRS scores at full cervical dilatation (T4) (P < 0.001) and longer first and second stages of labor (both P 0.05). Table 3 Peripartum maternal outcomes. Outcome Epidural analgesia (n = 93) No epidural analgesia (n = 91) Statistic P value Mode of delivery 3.853 0.051 Vaginal delivery 57(61.29%) 69(75.82%) Cesarean delivery 36(38.71%) 22(24.18%) T1 NRS 7.92 ± 0.76 7.88 ± 0.80 4081 0.658b T2 NRS 4.17 ± 0.79 - - - T3 NRS 2.74 ± 0.86 - - - T4 NRS 4.77 ± 1.08 9.32 ± 0.56 8463 < 0.001b First stage (min) 837.00 ± 397.86 207.50 ± 113.07 4.813 < 0.001 Second stage (min) 89.80 ± 56.45 17.60 ± 10.92 3.971 < 0.001 Third stage (min) 6.70 ± 2.50 8.40 ± 3.86 1.169 0.258 Oxytocin use during labor 66(70.97%) 64(70.33%) 0.009 0.924 Forceps-assisted delivery 4(4.30%) 2(2.20%) 0.682a Postpartum blood loss (mL) 200 (200–300) 200(200–315) 201.5 0.978b Postpartum transfusion 3(3.23%) 2(2.20%) 1a Notes: Data are presented as n (%) or median (IQR). a Fisher’s exact test. b Wilcoxon rank-sum test. Abbreviations: NRS numerical rating scale. Neonatal outcomes are summarized in Table 4 . Neonatal sex distribution, birth weight, and Apgar scores were comparable between groups (all P > 0.05). Table 4 Neonatal outcomes. Outcome Epidural analgesia (n = 93) No epidural analgesia (n = 91) Statistic P value Sex 3.121 0.077 Male 39(41.94%) 51(56.04%) Female 54(58.06%) 40(43.96%) Birth weight (g) 3391 ± 352.31 3352 ± 458.24 2.415 0.21 Apgar score (1 min) 10(10–10) 10(10–10) 253 0.051 Apgar score (5 min) 10(10–10) 10(10–10) 210 0.342 Apgar score (10 min) 10(10–10) 10(10–10) 215 0.38 Notes: Data are presented as mean ± SD or n (%). Postpartum follow-up outcomes Overall, 20.65% (38/184) of women met criteria for PPD at 6 weeks postpartum (EPDS ≥ 9). The incidence of PPD was lower in the ELA group than in the non-ELA group (14.0% vs 27.5%, P = 0.008) (Table 5 ). After stratification by mode of delivery, the Mantel–Haenszel pooled estimate suggested that ELA was associated with a lower risk of PPD (OR = 0.23, 95% CI 0.07–0.73, P = 0.015). On postpartum day 1, NRS pain scores were lower and satisfaction scores were higher in the ELA group (both P < 0.05). Table 5 Postpartum follow-up outcomes. Outcome Epidural analgesia (n = 93) No epidural analgesia (n = 91) Statistic P value Postpartum day 1 NRS 3(2–4) 5(4–5) 7345 < 0.001b Satisfaction score 8(7–8) 7(6–8) 3642 0.042b Postpartum day 42 NRS 0(0–0) 0(0–0) - - EPDS 8(4–8) 8(6–9) 5010.5 0.027b PPD incidence 13(14.00%) 25(27.47%) 7.06 0.008 Agreement with spouse’s preference for infant sex 74 (79.57%) 71 (78.02%) 0.006 0.939 Infant feeding pattern 2.83 0.243 Exclusive breastfeeding 53 (56.99%) 51 (56.04%) Formula feeding 5 (5.38%) 11 (12.09%) Mixed feeding 35 (37.63%) 29 (31.87%) Notes: Data are presented as n (%) or median (IQR). b Wilcoxon rank-sum test. Abbreviations: EPDS Edinburgh Postnatal Depression Scale, NRS numerical rating scale, PPD postpartum depression. Multivariable model and nomogram The final multivariable logistic regression model identified ELA as an independent protective factor for PPD (OR = 0.276, 95% CI 0.082–0.928, P = 0.038). Education ≤ 12 years, cesarean delivery, and antenatal fear of labor pain were independent risk factors (Table 6 ). A nomogram was constructed based on the final model (Fig. 3 ), and the model demonstrated acceptable discrimination (AUC = 0.759, 95% CI 0.679–0.839) (Fig. 4 ). Table 6 Multivariable logistic regression for postpartum depression at 6 weeks postpartum. Variable Reference Adjusted OR (95% CI) P value Epidural labor analgesia No epidural analgesia 0.276 (0.082–0.928) 0.038 Education ≤ 12 years Education > 12 years 2.471 (1.058–5.772) 0.037 Cesarean delivery Vaginal delivery 3.069 (1.079–8.731) 0.036 Antenatal fear of labor pain No fear 4.86 (1.378–17.144) 0.036 Notes: ORs are presented with 95% confidence intervals; *P < 0.05. Abbreviations: CI confidence interval, OR odds ratio. Sensitivity analysis The IPTW analysis produced results consistent with the primary model, supporting the robustness of the association between ELA and reduced PPD risk. A model comparison is presented in Table 7 . Table 7 Sensitivity analyses across analytic approaches. Model Adjusted OR (95% CI) P value IPTW-weighted (exposure only) 0.465 (0.218–0.992) 0.048 IPTW-weighted (trimmed at 1st/99th percentiles) 0.463 (0.217–0.988) 0.046 Doubly robust (IPTW + covariate adjustment) 0.562 (0.245–1.290) 0.174 Abbreviations: IPTW inverse probability of treatment weighting, PSM propensity score matching. Discussion In this prospective preference-based controlled cohort study of singleton primiparous women, epidural labor analgesia was associated with a lower risk of postpartum depression at 6 weeks postpartum. This association remained significant after multivariable adjustment and was supported by propensity score–based IPTW sensitivity analysis. At 6 weeks postpartum, women who received ELA had a lower incidence of PPD and lower EPDS scores than those who did not. These findings are broadly consistent with prior observational studies and systematic reviews suggesting that neuraxial labor analgesia may be associated with a reduced risk of postpartum depressive symptoms, although heterogeneity and residual confounding remain concerns. [ 6 – 10 , 20 – 21 ] In line with prior evidence, ELA provided effective pain relief during labor and was associated with better early postpartum satisfaction. Attenuation of pain-related stress responses, improved childbirth experience, and downstream effects on sleep, fatigue, and coping may plausibly contribute to the observed association with lower PPD risk. [ 20 , 22 ] We observed longer first- and second-stage labor durations in the ELA group, while the third stage did not differ. This pattern has been reported previously and may relate to neuroendocrine changes (e.g., oxytocin dynamics) and reduced pelvic floor tone affecting fetal descent and rotation. Importantly, ELA was not associated with worse obstetric or neonatal outcomes in our cohort. [ 22 – 26 ] Multivariable analysis identified four independent predictors of PPD: ELA use, education ≤ 12 years, cesarean delivery, and prenatal fear of labor pain. Prior evidence suggests that cesarean delivery—particularly unplanned or emergency cesarean—may increase the risk of postpartum depressive symptoms, potentially via surgical stress, postoperative pain, and disrupted expectations. Lower educational attainment may limit access to health information and timely help-seeking, while antenatal fear of childbirth can persist throughout the perinatal period and contribute to psychological distress. [ 20 , 27 – 28 ] Our survey indicated high awareness of PPD but limited knowledge of symptoms, prevention, and treatment. Most women reported obtaining information from online media, and many perceived inadequate postpartum support, family environment, and emotional problems as contributing factors. These perceptions align with evidence that low social support and family conflict are important risk factors for PPD, underscoring the need for antenatal education and early psychosocial support. [ 28 ] This study has limitations. First, it was a single-center study with a modest sample size and included only primiparous women with singleton pregnancies; generalizability to multiparous women or multiple gestations may be limited. Second, depressive symptoms were screened using EPDS rather than a structured clinical interview, which may introduce misclassification. Third, as an observational preference-based study, unmeasured confounding cannot be excluded, and causality cannot be established. Declarations Ethics approval and consent to participate: The study was approved by the Ethics Committee of Quanzhou First Hospital affiliated with Fujian Medical University (Approval No. Quanyi-Lun (2021) 176). Written informed consent was obtained from all participants. Funding: No specific funding was received for this study. Author Contribution YQC conceived and designed the study, developed the study protocol, performed the statistical analysis, interpreted the data, and drafted the manuscript. DDC, YYW, and XMZ contributed to participant recruitment and peri-partum clinical data collection, assisted with data verification, and critically revised the manuscript for important intellectual content. All authors read and approved the final manuscript. Acknowledgements: We thank WWH, JFQ, and LXH for their assistance with questionnaire administration and postpartum follow-up interviews. We also thank all participants and the clinical staff involved in participant care and data collection. Data Availability Available from the corresponding author on reasonable request. References Loughnan SA, Joubert AE, Grierson A, Andrews G, Newby JM. Internet-delivered psychological interventions for clinical anxiety and depression in perinatal women: a systematic review and meta-analysis. Arch Womens Ment Health. 2019;22(6):737–50. 10.1007/s00737-019-00961-9 . Norhayati MN, Hazlina NHN, Asrenee AR, Emilin WMAW. Magnitude and risk factors for postpartum symptoms: a literature review. J Affect Disord. 2015;175:34–52. 10.1016/j.jad.2014.12.041 . O'Hara MW, Wisner KL. Perinatal mental illness: definition, description and aetiology. Best Pract Res Clin Obstet Gynaecol. 2014;28(1):3–12. 10.1016/j.bpobgyn.2013.09.002 . 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8778550","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":595077661,"identity":"821d0028-700e-45e4-9a29-1d3743e82d8b","order_by":0,"name":"Yu-qian Chen","email":"","orcid":"","institution":"Quanzhou First Hospital","correspondingAuthor":false,"prefix":"","firstName":"Yu-qian","middleName":"","lastName":"Chen","suffix":""},{"id":595077663,"identity":"f41f6358-56ba-4208-817b-b247a9110f16","order_by":1,"name":"Dan-dan Chen","email":"","orcid":"","institution":"Quanzhou First Hospital","correspondingAuthor":false,"prefix":"","firstName":"Dan-dan","middleName":"","lastName":"Chen","suffix":""},{"id":595077664,"identity":"d633fe14-13b5-4313-a11a-88504573034d","order_by":2,"name":"Yan-yu Wu","email":"","orcid":"","institution":"Quanzhou First Hospital","correspondingAuthor":false,"prefix":"","firstName":"Yan-yu","middleName":"","lastName":"Wu","suffix":""},{"id":595077667,"identity":"6ccd2e4f-9014-4646-a0ef-b6bef8a190ba","order_by":3,"name":"Xian-mei Zhong","email":"","orcid":"","institution":"Quanzhou First Hospital","correspondingAuthor":false,"prefix":"","firstName":"Xian-mei","middleName":"","lastName":"Zhong","suffix":""},{"id":595077670,"identity":"bdc557c6-603a-4fce-a36b-5f7944ea872d","order_by":4,"name":"Shun-yuan Li","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAzElEQVRIiWNgGAWjYBAC+8PMBww+8PyXsz/eQKye42wJhTNkmI0ZzhwgVst5HoPPPDbMiQ03EojUwdjMY7iZJ4eNsXHm4403GGpsoglqYWZmKzacc4aHmVk6rdiC4VhabgMhLWzMzNsM3vZIsLFJ55hJMDYcJqyFh5nB/AfvPwMeHskzRGqRYGYxMOThSZCQkOAhUosBM1uC4QyeAwYGPEC/JBDjFwP+w6CoPFC/gf3wxhsfamwIa0HRLpFAinKIFlJ1jIJRMApGwcgAAIiGOjQT+6abAAAAAElFTkSuQmCC","orcid":"","institution":"Quanzhou First Hospital","correspondingAuthor":true,"prefix":"","firstName":"Shun-yuan","middleName":"","lastName":"Li","suffix":""}],"badges":[],"createdAt":"2026-02-03 16:53:14","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8778550/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8778550/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":103326461,"identity":"11b46c27-563d-4986-b6d8-e296615b8e12","added_by":"auto","created_at":"2026-02-24 12:56:44","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":529369,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eParticipant flow diagram.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-8778550/v1/dffad144ab4fe598f9308d46.png"},{"id":103326460,"identity":"2e0c7e1e-14f8-469b-9517-0c3ff9190a5d","added_by":"auto","created_at":"2026-02-24 12:56:43","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":272802,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eStandardized mean differences (SMDs) of baseline characteristics between groups.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-8778550/v1/360394af30ba8252d537807d.png"},{"id":103326494,"identity":"9de4f44f-6297-4e98-bb6b-0f9e311d12b5","added_by":"auto","created_at":"2026-02-24 12:56:49","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":185081,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eNomogram for predicting postpartum depression at 6 weeks postpartum.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-8778550/v1/842ab10225fefd3adecc6ea7.png"},{"id":103326365,"identity":"36f7c99c-90ba-426b-b1ef-79eb2480466b","added_by":"auto","created_at":"2026-02-24 12:56:29","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":62306,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eReceiver operating characteristic (ROC) curve of the nomogram model.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Figure4.png","url":"https://assets-eu.researchsquare.com/files/rs-8778550/v1/bd0793260cf8cbe6beaaa7d3.png"}],"financialInterests":"No competing interests reported.","formattedTitle":"Association Between Epidural Labor Analgesia and Reduced Risk of Postpartum Depression in Primiparous Women: A Prospective Preference-Based Controlled Cohort Study","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePostpartum depression (PPD) is a common perinatal mental disorder that can adversely affect maternal well-being, mother\u0026ndash;infant bonding, infant development, and family functioning. Reported prevalence varies substantially across regions and studies, partly due to differences in populations, screening tools, cut-off values, and timing of assessment. Various preventive and therapeutic approaches have been explored, including psychosocial and internet-delivered interventions. [\u003cspan additionalcitationids=\"CR2 CR3\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eLabor pain is often one of the most intense painful experiences in a woman\u0026rsquo;s life. Severe labor pain may provoke neuroendocrine stress responses and contribute to the onset or aggravation of depressive symptoms. Labor pain has therefore been proposed as a potentially modifiable risk factor for PPD. [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eEpidural labor analgesia (ELA) is the most effective method for labor pain relief and is widely used. By reducing pain and stress responses, ELA may improve the childbirth experience and potentially reduce the risk of PPD. However, existing evidence remains inconsistent, and observational studies are prone to residual confounding and heterogeneity. [\u003cspan additionalcitationids=\"CR7 CR8 CR9 CR10\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eThis prospective preference-based controlled cohort study was designed to examine the association between ELA and PPD at 6 weeks postpartum in singleton primiparous women planning vaginal delivery, and to identify independent predictors of PPD for risk stratification and early intervention.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design and setting\u003c/h2\u003e \u003cp\u003eThis prospective preference-based controlled cohort study was conducted at Quanzhou First Hospital affiliated with Fujian Medical University between July 2021 and December 2021. The protocol was approved by the institutional ethics committee (Approval No. Quanyi-Lun (2021) 176), and written informed consent was obtained from all participants.\u003c/p\u003e \u003cp\u003eThis study is reported in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement. [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eParticipants\u003c/h3\u003e\n\u003cp\u003eInclusion criteria were: (1) singleton pregnancy; (2) primiparous; and (3) planned vaginal delivery.\u003c/p\u003e \u003cp\u003eExclusion criteria were: (1) age\u0026thinsp;\u0026lt;\u0026thinsp;18 years or \u0026gt;\u0026thinsp;35 years; (2) a history of depression, other psychiatric disorders, personality disorders, or brain disease diagnosed by a psychiatrist before or during pregnancy, or antenatal EPDS\u0026thinsp;\u0026ge;\u0026thinsp;9; (3) contraindications to ELA; (4) severe neonatal adverse outcomes (e.g., neonatal intensive care unit admission or neonatal death); and (5) inability to complete follow-up.\u003c/p\u003e\n\u003ch3\u003eGrouping and blinding\u003c/h3\u003e\n\u003cp\u003eAfter standardized counseling regarding labor analgesia, women chose whether to receive ELA and were grouped accordingly (ELA vs non-ELA). Peripartum data collection, implementation of ELA, and postpartum follow-up were performed by three independent anesthesiologists who were not involved in each other\u0026rsquo;s tasks.\u003c/p\u003e\n\u003ch3\u003eEpidural labor analgesia protocol\u003c/h3\u003e\n\u003cp\u003eWhen cervical dilatation reached\u0026thinsp;\u0026ge;\u0026thinsp;3 cm, women in the ELA group were managed in the delivery room with standard monitoring and intravenous access.\u003c/p\u003e \u003cp\u003eAn epidural catheter was placed at the L2\u0026ndash;3 or L3\u0026ndash;4 interspace. A test dose of 3 mL 2% lidocaine was administered. After 5\u0026ndash;10 minutes, if intrathecal placement was excluded, 10\u0026ndash;15 mL of 0.1% ropivacaine diluted with 0.9% saline was administered as a loading dose, targeting a sensory level below T10.\u003c/p\u003e \u003cp\u003eThirty minutes after the loading dose, a patient-controlled epidural analgesia pump (0.1% ropivacaine, total 100 mL) was connected with a background infusion of 10 mL/h, a lockout interval of 20 minutes, and a maximum hourly dose of 30 mL. Analgesia was discontinued at full cervical dilatation (10 cm).\u003c/p\u003e \u003cp\u003eWomen in the non-ELA group received routine peripartum care without neuraxial or systemic analgesics. If emergency cesarean delivery was required, combined spinal\u0026ndash;epidural anesthesia was used in the non-ELA group; for women with an indwelling epidural catheter, epidural anesthesia was administered via the catheter. Postoperative epidural analgesia (0.1% ropivacaine at 8 mL/h for 24 hours) was provided as routine care.\u003c/p\u003e\n\u003ch3\u003eData collection and outcomes\u003c/h3\u003e\n\u003cp\u003eBaseline variables included demographics, obstetric characteristics, socioeconomic factors, stressful life events, antenatal EPDS score, antenatal fear of labor pain, and antenatal expectation of labor analgesia.\u003c/p\u003e \u003cp\u003ePain intensity was assessed using an 11-point numerical rating scale (NRS; 0\u0026thinsp;=\u0026thinsp;no pain, 10\u0026thinsp;=\u0026thinsp;worst pain). NRS was recorded at T1 (before analgesia), T2 (10 minutes after analgesia), T3 (30 minutes after analgesia), and T4 (full cervical dilatation). For women without ELA, NRS was assessed at corresponding time points. [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/p\u003e \u003cp\u003ePeripartum outcomes included mode of delivery, oxytocin use, assisted vaginal delivery, labor stage durations, postpartum blood loss, and transfusion. Neonatal outcomes included sex, birth weight, and Apgar scores.\u003c/p\u003e \u003cp\u003ePostpartum follow-up was performed on day 1 and day 42. On day 1, NRS and an 11-point satisfaction score were recorded. On day 42, depressive symptoms were assessed using the Edinburgh Postnatal Depression Scale (EPDS), a 10-item self-report measure with total scores ranging from 0 to 30, where higher scores indicate more severe depressive symptoms. PPD was defined as EPDS\u0026thinsp;\u0026ge;\u0026thinsp;9, consistent with validated cut-offs in Chinese populations. Additional items included spousal preference regarding infant sex and infant feeding pattern. [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eSample size\u003c/h2\u003e \u003cp\u003eAssuming a PPD incidence of 10% in women receiving neuraxial labor analgesia and 25% in those without neuraxial analgesia, a total sample size of 194 was required (two-sided α\u0026thinsp;=\u0026thinsp;0.05, power\u0026thinsp;=\u0026thinsp;80%). Allowing for 5\u0026ndash;10% loss to follow-up, 200 participants were planned. [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eAnalyses were performed using R (version 4.0.5). [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] Continuous variables are presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD when normally distributed and as median (IQR) otherwise. Student\u0026rsquo;s t test or the Wilcoxon rank-sum test was used as appropriate. Categorical variables are presented as n (%) and were compared using the χ\u0026sup2; test or Fisher\u0026rsquo;s exact test.\u003c/p\u003e \u003cp\u003eStandardized mean differences (SMDs) were used to assess baseline balance. The Mantel\u0026ndash;Haenszel method was used to estimate a pooled odds ratio (OR) for the association between ELA and PPD stratified by mode of delivery. Multivariable logistic regression was used to identify independent predictors; model fit was assessed by the Hosmer\u0026ndash;Lemeshow test. A nomogram was developed from the final model and evaluated using the AUC of the ROC curve. [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eAs a sensitivity analysis, we applied propensity score\u0026ndash;based inverse probability of treatment weighting (IPTW) to further reduce potential confounding. Propensity scores for receiving epidural labor analgesia (ELA) were estimated using a multivariable logistic regression model that included prespecified baseline covariates (i.e., all variables in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Stabilized weights were calculated as the marginal probability of treatment divided by the individual propensity score for participants who received ELA and by one minus the propensity score for those who did not. To limit the influence of extreme weights, weights were truncated at the 1st and 99th percentiles. Covariate balance after weighting was evaluated using standardized mean differences (SMDs), with an SMD\u0026thinsp;\u0026lt;\u0026thinsp;0.10 indicating adequate balance. The association between ELA and postpartum depression (PPD) was then estimated using a weighted logistic regression model with robust (sandwich) standard errors. [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eStudy drugs and equipment.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eItem\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eManufacturer\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSpecification\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLidocaine hydrochloride injection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTianjin Jinyao Pharmaceutical Co., Ltd.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 mL: 0.1 g\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRopivacaine hydrochloride injection (Naropin)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAstraZeneca\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 mL: 100 mg\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e0.9% sodium chloride injection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFujian Taipingyang Pharmaceutical Co., Ltd.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e500 mL\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eElectronic infusion pump set\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eJiangsu Apon Medical Technology Co., Ltd.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eZZB-150\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAutomatic infusion pump driver\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNantong Aipu Medical Device Co., Ltd.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eZZB-I\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDisposable anesthesia puncture kit\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eZhuhai Fonia Medical Equipment Co., Ltd.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAS-E/S II\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBaseline characteristics.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEpidural analgesia (n\u0026thinsp;=\u0026thinsp;93)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo epidural analgesia (n\u0026thinsp;=\u0026thinsp;91)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003et/χ\u0026sup2;\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSMD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6.431\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.381\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.04\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e18\u0026ndash;25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22(23.66%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9(9.89%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e26\u0026ndash;30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e46(49.46%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e56(61.54%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e31\u0026ndash;35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25(26.88%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26(28.57%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI(kg/m\u0026sup2;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26.82\u0026thinsp;\u0026plusmn;\u0026thinsp;4.79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26.95\u0026thinsp;\u0026plusmn;\u0026thinsp;4.77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.486\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.072\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.627\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGestational age (days)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e275.14\u0026thinsp;\u0026plusmn;\u0026thinsp;6.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e275.30\u0026thinsp;\u0026plusmn;\u0026thinsp;6.77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.225\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.033\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.823\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e90(96.77%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e85(93.41%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.156\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.327a\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOnly child\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8(8.60%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2(2.20%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.286\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.112\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEducation\u0026thinsp;\u0026gt;\u0026thinsp;12 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e79(84.95%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e66(72.53%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3.536\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.307\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.06\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReligious belief\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4(4.30%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4(4.40%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.005\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1a\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHealth insurance coverage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e84(90.32%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e82(90.11%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.007\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1a\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHistory of smoking/alcohol use\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6(6.45%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2(2.20%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.109\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.278\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eResidence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.498\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.258\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.114\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrban\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e54(58.06%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e64(70.33%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e39(41.94%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27(29.67%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSatisfied with living conditions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e85(93.41%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e79(84.95%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.581\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.275\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.108\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStable occupation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e84(92.31%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e83(89.25%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.214\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.106\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.644\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMonthly household income\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3.139\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.263\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.371\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;5,000 CNY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8(8.60%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6(6.59%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5,000\u0026ndash;10,000 CNY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33(35.48%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e44(48.35%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;10,000 CNY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e34(36.56%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27(29.67%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDeclined to answer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18(19.35%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14(15.38%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStressful life events within 2 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7(7.53%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10(10.99%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.309\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.578\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAntenatal EPDS score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6(5\u0026ndash;6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6(5\u0026ndash;6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.894\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.061\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.741\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAntenatal fear of labor pain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e67 (72.04%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e70 (76.92%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.348\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.112\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.555\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAntenatal expectation of labor analgesia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e85 (91.40%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e77 (84.62%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.417\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.234\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eNotes: Data are presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD, n (%), or median (IQR). a Fisher\u0026rsquo;s exact test.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eAbbreviations:\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eBMI body mass index, EPDS Edinburgh Postnatal Depression Scale, NRS numerical rating scale.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eParticipant flow\u003c/h2\u003e \u003cp\u003eAmong 200 enrolled women (ELA, n\u0026thinsp;=\u0026thinsp;100; non-ELA, n\u0026thinsp;=\u0026thinsp;100), 16 were excluded (ELA, n\u0026thinsp;=\u0026thinsp;7; non-ELA, n\u0026thinsp;=\u0026thinsp;9) due to neonatal ICU admission, antenatal EPDS\u0026thinsp;\u0026ge;\u0026thinsp;9, refusal of follow-up, or unreachable follow-up calls. A total of 184 women completed follow-up and were included in the analysis (ELA, n\u0026thinsp;=\u0026thinsp;93; non-ELA, n\u0026thinsp;=\u0026thinsp;91) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eBaseline characteristics\u003c/h2\u003e \u003cp\u003eBaseline characteristics are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. The proportion of women aged 18\u0026ndash;25 years was higher in the ELA group (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Other baseline variables did not differ significantly. The SMD plot showed acceptable balance for most variables, with the largest imbalance observed for age (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003ePeripartum maternal and neonatal outcomes\u003c/h2\u003e \u003cp\u003ePeripartum outcomes are shown in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. Compared with the non-ELA group, the ELA group had significantly lower NRS scores at full cervical dilatation (T4) (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and longer first and second stages of labor (both P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). There were no significant between-group differences in mode of delivery, oxytocin use, forceps-assisted delivery, postpartum blood loss, or transfusion (all P\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePeripartum maternal outcomes.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOutcome\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEpidural analgesia (n\u0026thinsp;=\u0026thinsp;93)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo epidural analgesia (n\u0026thinsp;=\u0026thinsp;91)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eStatistic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMode of delivery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.853\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.051\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVaginal delivery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e57(61.29%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e69(75.82%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCesarean delivery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e36(38.71%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22(24.18%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eT1 NRS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7.92\u0026thinsp;\u0026plusmn;\u0026thinsp;0.76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.88\u0026thinsp;\u0026plusmn;\u0026thinsp;0.80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4081\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.658b\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eT2 NRS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.17\u0026thinsp;\u0026plusmn;\u0026thinsp;0.79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eT3 NRS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.74\u0026thinsp;\u0026plusmn;\u0026thinsp;0.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eT4 NRS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.77\u0026thinsp;\u0026plusmn;\u0026thinsp;1.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.32\u0026thinsp;\u0026plusmn;\u0026thinsp;0.56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8463\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001b\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFirst stage (min)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e837.00\u0026thinsp;\u0026plusmn;\u0026thinsp;397.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e207.50\u0026thinsp;\u0026plusmn;\u0026thinsp;113.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.813\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSecond stage (min)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e89.80\u0026thinsp;\u0026plusmn;\u0026thinsp;56.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17.60\u0026thinsp;\u0026plusmn;\u0026thinsp;10.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.971\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThird stage (min)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6.70\u0026thinsp;\u0026plusmn;\u0026thinsp;2.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.40\u0026thinsp;\u0026plusmn;\u0026thinsp;3.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.169\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.258\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOxytocin use during labor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e66(70.97%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e64(70.33%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.009\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.924\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eForceps-assisted delivery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4(4.30%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2(2.20%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.682a\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostpartum blood loss (mL)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e200 (200\u0026ndash;300)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e200(200\u0026ndash;315)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e201.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.978b\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostpartum transfusion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3(3.23%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2(2.20%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1a\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eNotes: Data are presented as n (%) or median (IQR). a Fisher\u0026rsquo;s exact test. b Wilcoxon rank-sum test.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eAbbreviations: NRS numerical rating scale.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eNeonatal outcomes are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e. Neonatal sex distribution, birth weight, and Apgar scores were comparable between groups (all P\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eNeonatal outcomes.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOutcome\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEpidural analgesia (n\u0026thinsp;=\u0026thinsp;93)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo epidural analgesia (n\u0026thinsp;=\u0026thinsp;91)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eStatistic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.121\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.077\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e39(41.94%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e51(56.04%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e54(58.06%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40(43.96%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBirth weight (g)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3391\u0026thinsp;\u0026plusmn;\u0026thinsp;352.31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3352\u0026thinsp;\u0026plusmn;\u0026thinsp;458.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.415\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.21\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eApgar score (1 min)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10(10\u0026ndash;10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10(10\u0026ndash;10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e253\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.051\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eApgar score (5 min)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10(10\u0026ndash;10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10(10\u0026ndash;10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e210\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.342\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eApgar score (10 min)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10(10\u0026ndash;10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10(10\u0026ndash;10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e215\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.38\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eNotes: Data are presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD or n (%).\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003ePostpartum follow-up outcomes\u003c/h2\u003e \u003cp\u003eOverall, 20.65% (38/184) of women met criteria for PPD at 6 weeks postpartum (EPDS\u0026thinsp;\u0026ge;\u0026thinsp;9). The incidence of PPD was lower in the ELA group than in the non-ELA group (14.0% vs 27.5%, P\u0026thinsp;=\u0026thinsp;0.008) (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). After stratification by mode of delivery, the Mantel\u0026ndash;Haenszel pooled estimate suggested that ELA was associated with a lower risk of PPD (OR\u0026thinsp;=\u0026thinsp;0.23, 95% CI 0.07\u0026ndash;0.73, P\u0026thinsp;=\u0026thinsp;0.015). On postpartum day 1, NRS pain scores were lower and satisfaction scores were higher in the ELA group (both P\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePostpartum follow-up outcomes.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOutcome\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEpidural analgesia (n\u0026thinsp;=\u0026thinsp;93)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo epidural analgesia (n\u0026thinsp;=\u0026thinsp;91)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eStatistic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostpartum day 1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNRS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3(2\u0026ndash;4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5(4\u0026ndash;5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7345\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001b\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSatisfaction score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8(7\u0026ndash;8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7(6\u0026ndash;8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3642\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.042b\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostpartum day 42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNRS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0(0\u0026ndash;0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0(0\u0026ndash;0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEPDS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8(4\u0026ndash;8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8(6\u0026ndash;9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5010.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.027b\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePPD incidence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13(14.00%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25(27.47%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.008\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAgreement with spouse\u0026rsquo;s preference for infant sex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e74 (79.57%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e71 (78.02%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.006\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.939\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInfant feeding pattern\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.243\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExclusive breastfeeding\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e53 (56.99%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e51 (56.04%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFormula feeding\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (5.38%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (12.09%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMixed feeding\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35 (37.63%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29 (31.87%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eNotes: Data are presented as n (%) or median (IQR). b Wilcoxon rank-sum test.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eAbbreviations: EPDS Edinburgh Postnatal Depression Scale, NRS numerical rating scale, PPD postpartum depression.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eMultivariable model and nomogram\u003c/h2\u003e \u003cp\u003eThe final multivariable logistic regression model identified ELA as an independent protective factor for PPD (OR\u0026thinsp;=\u0026thinsp;0.276, 95% CI 0.082\u0026ndash;0.928, P\u0026thinsp;=\u0026thinsp;0.038). Education\u0026thinsp;\u0026le;\u0026thinsp;12 years, cesarean delivery, and antenatal fear of labor pain were independent risk factors (Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e). A nomogram was constructed based on the final model (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e), and the model demonstrated acceptable discrimination (AUC\u0026thinsp;=\u0026thinsp;0.759, 95% CI 0.679\u0026ndash;0.839) (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMultivariable logistic regression for postpartum depression at 6 weeks postpartum.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAdjusted OR (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEpidural labor analgesia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo epidural analgesia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.276 (0.082\u0026ndash;0.928)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.038\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEducation\u0026thinsp;\u0026le;\u0026thinsp;12 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEducation\u0026thinsp;\u0026gt;\u0026thinsp;12 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.471 (1.058\u0026ndash;5.772)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.037\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCesarean delivery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVaginal delivery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.069 (1.079\u0026ndash;8.731)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.036\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAntenatal fear of labor pain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo fear\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4.86 (1.378\u0026ndash;17.144)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.036\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eNotes: ORs are presented with 95% confidence intervals; *P\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eAbbreviations: CI confidence interval, OR odds ratio.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eSensitivity analysis\u003c/h2\u003e \u003cp\u003eThe IPTW analysis produced results consistent with the primary model, supporting the robustness of the association between ELA and reduced PPD risk. A model comparison is presented in Table\u0026nbsp;\u003cspan refid=\"Tab7\" class=\"InternalRef\"\u003e7\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab7\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 7\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSensitivity analyses across analytic approaches.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModel\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAdjusted OR (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIPTW-weighted (exposure only)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.465 (0.218\u0026ndash;0.992)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.048\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIPTW-weighted (trimmed at 1st/99th percentiles)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.463 (0.217\u0026ndash;0.988)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.046\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDoubly robust (IPTW\u0026thinsp;+\u0026thinsp;covariate adjustment)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.562 (0.245\u0026ndash;1.290)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.174\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003eAbbreviations: IPTW inverse probability of treatment weighting, PSM propensity score matching.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this prospective preference-based controlled cohort study of singleton primiparous women, epidural labor analgesia was associated with a lower risk of postpartum depression at 6 weeks postpartum. This association remained significant after multivariable adjustment and was supported by propensity score\u0026ndash;based IPTW sensitivity analysis.\u003c/p\u003e \u003cp\u003eAt 6 weeks postpartum, women who received ELA had a lower incidence of PPD and lower EPDS scores than those who did not. These findings are broadly consistent with prior observational studies and systematic reviews suggesting that neuraxial labor analgesia may be associated with a reduced risk of postpartum depressive symptoms, although heterogeneity and residual confounding remain concerns. [\u003cspan additionalcitationids=\"CR7 CR8 CR9\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eIn line with prior evidence, ELA provided effective pain relief during labor and was associated with better early postpartum satisfaction. Attenuation of pain-related stress responses, improved childbirth experience, and downstream effects on sleep, fatigue, and coping may plausibly contribute to the observed association with lower PPD risk. [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eWe observed longer first- and second-stage labor durations in the ELA group, while the third stage did not differ. This pattern has been reported previously and may relate to neuroendocrine changes (e.g., oxytocin dynamics) and reduced pelvic floor tone affecting fetal descent and rotation. Importantly, ELA was not associated with worse obstetric or neonatal outcomes in our cohort. [\u003cspan additionalcitationids=\"CR23 CR24 CR25\" citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eMultivariable analysis identified four independent predictors of PPD: ELA use, education\u0026thinsp;\u0026le;\u0026thinsp;12 years, cesarean delivery, and prenatal fear of labor pain. Prior evidence suggests that cesarean delivery\u0026mdash;particularly unplanned or emergency cesarean\u0026mdash;may increase the risk of postpartum depressive symptoms, potentially via surgical stress, postoperative pain, and disrupted expectations. Lower educational attainment may limit access to health information and timely help-seeking, while antenatal fear of childbirth can persist throughout the perinatal period and contribute to psychological distress. [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eOur survey indicated high awareness of PPD but limited knowledge of symptoms, prevention, and treatment. Most women reported obtaining information from online media, and many perceived inadequate postpartum support, family environment, and emotional problems as contributing factors. These perceptions align with evidence that low social support and family conflict are important risk factors for PPD, underscoring the need for antenatal education and early psychosocial support. [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eThis study has limitations. First, it was a single-center study with a modest sample size and included only primiparous women with singleton pregnancies; generalizability to multiparous women or multiple gestations may be limited. Second, depressive symptoms were screened using EPDS rather than a structured clinical interview, which may introduce misclassification. Third, as an observational preference-based study, unmeasured confounding cannot be excluded, and causality cannot be established.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003cstrong\u003eEthics approval and consent to participate:\u003c/strong\u003e \u003cp\u003e The study was approved by the Ethics Committee of Quanzhou First Hospital affiliated with Fujian Medical University (Approval No. Quanyi-Lun (2021) 176). Written informed consent was obtained from all participants.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding:\u003c/h2\u003e \u003cp\u003eNo specific funding was received for this study.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eYQC conceived and designed the study, developed the study protocol, performed the statistical analysis, interpreted the data, and drafted the manuscript. DDC, YYW, and XMZ contributed to participant recruitment and peri-partum clinical data collection, assisted with data verification, and critically revised the manuscript for important intellectual content. All authors read and approved the final manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgements:\u003c/h2\u003e \u003cp\u003eWe thank WWH, JFQ, and LXH for their assistance with questionnaire administration and postpartum follow-up interviews. We also thank all participants and the clinical staff involved in participant care and data collection.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eAvailable from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eLoughnan SA, Joubert AE, Grierson A, Andrews G, Newby JM. Internet-delivered psychological interventions for clinical anxiety and depression in perinatal women: a systematic review and meta-analysis. 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J Midwifery Womens Health. 2020;65(1):96\u0026ndash;108. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/jmwh.13067\u003c/span\u003e\u003cspan address=\"10.1111/jmwh.13067\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-anesthesiology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bane","sideBox":"Learn more about [BMC Anesthesiology](http://bmcanesthesiol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bane","title":"BMC Anesthesiology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"epidural labor analgesia, postpartum depression, Edinburgh Postnatal Depression Scale, propensity score, IPTW, nomogram","lastPublishedDoi":"10.21203/rs.3.rs-8778550/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8778550/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjective\u003c/h2\u003e \u003cp\u003eTo evaluate the association between epidural labor analgesia (ELA) and postpartum depression (PPD) at 6 weeks postpartum, and to identify independent predictors of PPD in primiparous women planning vaginal delivery.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis prospective preference-based controlled cohort study enrolled 200 singleton primiparous women scheduled for vaginal delivery (July\u0026ndash;December 2021). Participants chose whether to receive ELA and were grouped accordingly. Pain intensity was assessed using the numerical rating scale (NRS) at predefined intrapartum time points and on postpartum day 1. PPD at postpartum day 42 was assessed using the Edinburgh Postnatal Depression Scale (EPDS), with PPD defined as EPDS\u0026thinsp;\u0026ge;\u0026thinsp;9. Group comparisons used appropriate parametric/non-parametric tests. Multivariable logistic regression and a propensity score\u0026ndash;based inverse probability of treatment weighting (IPTW) sensitivity analysis were performed to assess robustness to confounding.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eA total of 184 women completed follow-up (ELA group, n\u0026thinsp;=\u0026thinsp;93; non-ELA group, n\u0026thinsp;=\u0026thinsp;91). The overall incidence of PPD was 20.65% (38/184). Women in the ELA group reported significantly lower NRS scores at full cervical dilatation (T4) and on postpartum day 1, and higher satisfaction scores on postpartum day 1 (all P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). The incidence of PPD at 6 weeks was lower in the ELA group than in the non-ELA group (14.0% vs 27.5%, P\u0026thinsp;=\u0026thinsp;0.008). After adjustment for potential confounders, ELA remained independently associated with a reduced risk of PPD (OR\u0026thinsp;=\u0026thinsp;0.276, 95% CI 0.082\u0026ndash;0.928, P\u0026thinsp;=\u0026thinsp;0.038). Education\u0026thinsp;\u0026le;\u0026thinsp;12 years, cesarean delivery, and antenatal fear of labor pain were independent risk factors.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eAmong singleton primiparous women planning vaginal delivery, receipt of epidural labor analgesia was associated with a lower risk of postpartum depression at 6 weeks postpartum.\u003c/p\u003e","manuscriptTitle":"Association Between Epidural Labor Analgesia and Reduced Risk of Postpartum Depression in Primiparous Women: A Prospective Preference-Based Controlled Cohort Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-24 12:53:35","doi":"10.21203/rs.3.rs-8778550/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-04-10T19:42:55+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-06T16:30:02+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-05T09:08:42+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"193221478473741278954452798835224259726","date":"2026-04-02T21:40:05+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-02T17:09:21+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"159343651524933670501795895191829985718","date":"2026-03-31T06:37:59+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"253461371324125294982014955709571010734","date":"2026-03-29T02:08:01+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"219922777376999856170058784466793140728","date":"2026-03-26T07:14:40+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"31652055541451977437040899108528291285","date":"2026-03-26T06:52:18+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-24T16:08:48+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"54943579581021728609843163686423737750","date":"2026-03-24T15:09:34+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"6997518689886638547818120646795575065","date":"2026-03-23T17:31:30+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-21T23:02:34+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"177347860720028791787191493614770537634","date":"2026-03-17T16:30:37+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-18T21:48:31+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-02-06T13:21:52+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-04T09:49:38+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-04T09:46:45+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Anesthesiology","date":"2026-02-03T16:28:37+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-anesthesiology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bane","sideBox":"Learn more about [BMC Anesthesiology](http://bmcanesthesiol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bane","title":"BMC Anesthesiology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e95e47d2-af56-4ccd-b43c-86c90af12319","owner":[],"postedDate":"February 24th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-18T14:38:20+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-24 12:53:35","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8778550","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8778550","identity":"rs-8778550","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}