Evaluating Pitocin Exposure in African American Women and its Contribution to Postpartum Depressive Symptoms Open Access
Thul, Taylor (Summer 2020)
Abstract
Pitocin (synthetic oxytocin) is a medication commonly administered perinatally to induce or augment labor and prevent postpartum hemorrhage. However, its long-term consequences, especially related to postpartum mood, are largely unknown. This is especially pertinent in African American mothers, a population at higher risk of postpartum depression. The aim of this study was to describe Pitocin exposure in African American women and any associations with postpartum depression. Data were collected from 259 socioeconomically diverse African American women. As part of two larger, longitudinal study, participants were recruited between 10-14 weeks gestation, when baseline demographic, health, and psychosocial data (including Childhood Trauma Questionnaire) were collected. Labor and delivery records were abstracted for data related to her prenatal course, labor complications and Pitocin exposure. Women were assessed for depression symptomatology at 1 week, 3- and 6- months postpartum by the Edinburgh Postnatal Depression Scale. Prenatal, intrapartum, and postpartum variables were combined in a novel dataset to describe Pitocin exposure and evaluate its relationship to postpartum depression.
Over half (56.4%) of the women in this sample were exposed to Pitocin during labor. Moreover, they received slightly higher average doses of Pitocin than has been reported in mixed race groups. Duration of Pitocin exposure during labor averaged 11 hours, which is also higher than in mixed race samples. An increase in childhood trauma was associated with an increase in the odds of longer Pitocin exposure during labor (p=.027) after controlling for parity, hypertension, cervical dilation at admission, BMI, and inductions status.
These results also provide preliminary evidence for a protective effect of Pitocin on development of depression symptoms in the first six months postpartum among women whose labor was induced. 32.4% of women screened positive for depression in the first six months postpartum, higher than estimates in the general population. Among induced women only, for each Unit reduction in Pitocin dose, the odds of screening positive for depressive symptoms within the first six months postpartum increased by a factor of 1.33 (p=.015) after controlling for prenatal depression, stress, and childhood trauma. Pitocin exposure did not have an effect on trajectory of depressive symptoms postpartum.
Table of Contents
Chapter 1- Introductions
Background................................................................................................................................ 1
Postpartum Depression Risk Factors..................................................................................... 2
Oxytocin................................................................................................................................ 3
Oxytocin in the Postpartum Period....................................................................................... 4
Pitocin Use in Labor.............................................................................................................. 5
Theoretical Model of Pitocin Central Feedback........................................................................ 6
Pitocin and Postpartum Depression............................................................................................ 9
Pitocin Use in African American Women................................................................................ 10
Theoretical/ Conceptual Framework........................................................................................ 12
Aims and Hypotheses............................................................................................................... 14
Chapter 2- Literature Review
Introduction.............................................................................................................................. 15
Methods.................................................................................................................................... 19
Criteria for Considering Studies in this Review.................................................................. 19
Quality Assessment............................................................................................................. 19
Literature Search Strategy................................................................................................... 20
Data Abstraction and Synthesis........................................................................................... 21
Results...................................................................................................................................... 22
Correlation of Maternal Endogenous Oxytocin Levels with Depressive Symptomatology 22
Early and late postpartum.................................................................................................... 33
Mixed prenatal and postpartum........................................................................................... 34
Intrapartum Intravenous Pitocin.......................................................................................... 38
Discussion................................................................................................................................ 43
Limitations................................................................................................................................ 46
Conclusions.............................................................................................................................. 46
Chapter 3- Methods
Design....................................................................................................................................... 47
Setting and Sample................................................................................................................... 47
Grady Memorial Hospital.................................................................................................... 48
Emory University Hospital Midtown.................................................................................. 48
Parent study recruitment...................................................................................................... 49
Planned sample.................................................................................................................... 50
Data Collection......................................................................................................................... 51
Inter-rater reliability............................................................................................................ 53
Human subjects................................................................................................................... 53
Operational Definition of Variables and Measures.................................................................. 54
Sociodemographic variables............................................................................................... 54
Health and psychosocial variables...................................................................................... 55
Delivery variables................................................................................................................ 57
Pitocin exposure variables................................................................................................... 59
Postpartum variables........................................................................................................... 60
Timeline.................................................................................................................................... 61
Data Analysis Preparation........................................................................................................ 62
Planned Analyses................................................................................................................ 62
Sample size.......................................................................................................................... 64
Chapter 4- Analysis
Sample...................................................................................................................................... 66
Aim 1........................................................................................................................................ 67
Exposure Types................................................................................................................... 67
Postpartum exposure...................................................................................................... 68
Labor exposure............................................................................................................... 69
Exposure categorization................................................................................................. 70
Missing Data........................................................................................................................ 72
General Demographics........................................................................................................ 72
Labor dose bivariate analyses............................................................................................. 72
Traditional Labor Outcome Data........................................................................................ 75
Duration of Pitocin Exposure Bivariate Analyses............................................................... 77
Logistic regression of predictors for duration of exposure............................................ 79
Duration of Pitocin exposure predictors in only induced women.................................. 83
Aim 2........................................................................................................................................ 84
Sample................................................................................................................................. 85
Description of Depressive Symptoms Postpartum.............................................................. 86
Bivariate Analyses of Demographic, Prenatal and Delivery Characteristics...................... 88
Pitocin Exposure in Aim 2 Sample..................................................................................... 91
Aim 2: Hypothesis 1................................................................................................................. 92
A2H1: Linear Regression.................................................................................................... 92
A2H1: Logistic Regression................................................................................................. 93
Logistic regression in induced women only................................................................... 97
A2H1: Multilevel Model..................................................................................................... 99
Aim 2: Hypothesis 2............................................................................................................... 104
A2H2: Linear Regression.................................................................................................. 105
A2H2: Logistic Regression............................................................................................... 105
A2H2: Multilevel Model................................................................................................... 106
Chapter 5- Discussion
Introduction............................................................................................................................ 108
Study Aims and Methodology Review.................................................................................. 109
Methodology Review........................................................................................................ 111
Discussion of Results............................................................................................................. 112
Aim 1................................................................................................................................. 112
Predictors of Labor Exposure............................................................................................ 115
Aim 2...................................................................................................................................... 118
Overall Phenomenon.............................................................................................................. 124
Clinical Indications................................................................................................................ 126
Strengths and Limitations of Study........................................................................................ 128
Strengths............................................................................................................................ 128
Limitations......................................................................................................................... 129
Future Directions.................................................................................................................... 131
References.................................................................................................................................. 133
Appendix
Chapter 2- Literature Review................................................................................................. 164
Chapter 4- Analysis................................................................................................................ 169
A2H1: Dose Multilevel Model.......................................................................................... 173
A2H2: Duration Multilevel Model.................................................................................... 174
Chapter 5- Discussion............................................................................................................ 176
IRB Approval......................................................................................................................... 178
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