Study design: This repeated, cross-sectional, descriptive and etiological single-center
study will take place within a cohort of women giving birth at the Clermont-Ferrand
University Hospital Center (Psyche 1), and a cohort of their partners (psyche 2).
Principal endpoint: The prevalence of depression, measured by the Edinburgh postnatal
depression scale (EPDS), validated in French, with a discrimination threshold ≥ 11.
Study plan and procedures:
Psyche 1:
For each woman with a PPH (exposed), 2 women without PPH (not exposed) will be included:
the women who gave birth immediately before and immediate after her. If one of these 2
unexposed women eligible for the unexposed group also has a postpartum hemorrhage,
another woman immediately just before or after the woman with PPH will be included. The
PPH will be managed according to the national guidelines issued in December 2014.
The intervention will consist of 3 questionnaire surveys, at 2 months, 6 months, and 1
year postpartum.
Information and inclusion will take place in the immediate postpartum period at the
Clermont-Ferrand University Hospital Center, France. An investigator (midwife or
gynecologist-obstetrician in the maternity ward) will inform eligible women about the
study, in the postpartum period. This investigator will provide them with a written
information sheet and obtain their written consent. If the woman has already left the
maternity ward, an investigator will contact her by mail or telephone, and she will
receive the information sheet and consent form at her postnatal consultation in the
department.
The cohort will complete each questionnaire at the same times in relation to their date
of delivery (2 months, 6 months, and 12 months after). They will receive an email asking
them to complete the questionnaires, including a participation number and an internet
link to the self-administered questionnaires. This intervention is not usually performed
for women who give birth at our hospital, whether or not they had a PPH. The procedures,
other than the surveys, will be those provided habitually as usual care and will comply
with good clinical practices and French regulations (1992 decree, French early discharge
guideline from 2004). Should the questionnaire identify a woman in need of immediate
psychological care, she will be contacted, referred to, and encouraged to consult a
competent professional (psychologist, psychiatrist, child psychiatrist, etc.).
Psyche 2:
The cohort of partners will complete each questionnaire at the same times in relation to
the date of delivery (2nd month and 6th month). The "source" documents will be the
parturient's medical file (the part concerning both partners) and questionnaires, as the
study involves a survey of the partners of women giving birth. The relevant covariables
(confounding and prognostic factors) will also be collected from the women's medical
files (emergency cesarean, vascular embolization, etc.). These covariables are already
being collected as part of the Psyche 1 study.
Inclusion will take place in the immediate postpartum period. Accordingly, in the Psyche
1 study, for every woman with a PPH (exposed), 2 women without PPH (not exposed) are
eligible (the woman who gave birth before and after the exposed woman). In this ancillary
study, the partners, if eligible, of both the exposed and nonexposed women in the Psyche
1 study will be asked to participate.
The intervention will consist of 3 surveys by questionnaires: during the woman's
hospitalization during the immediate postpartum period, at 2 months, and at 6 months
after the delivery.
The partners of the women who had an immediate postpartum hemorrhage (PPH) will be
compared to the partners of the women who did not.
Data collection:
The source documents will be the medical file and the questionnaires. Clinicians will
make the data extraction from the medical files, including the relevant covariables:
confounding factors, prognostic factors (e.g., history of depression, anxiolytic
treatment before delivery, psychological or psychiatric care before and delivery and
after delivery, etc.).
Quality assurance plan:
The Investigator undertakes to conduct this study in compliance with Good Clinical
Practices and French public health law [Act n°2004-806 dated 9 August 2004
concerning biomedical research, its implementing decree n° 2006-477 dated
26/04/2006, which modifies the portion of the Public Health Code (specifically, Part
1, Book 1, Title II, Section 1) concerning biomedical research, as well as the
decrees in force]. The investigator also undertakes to conduct this research in
accordance with Declaration of Helsinki of the World Medical Association (Tokyo
2004, as revised).
The investigators guarantee the authenticity of the data collected in this study and
accept the legal provisions authorizing the study sponsor to set up quality control
procedures. During quality control inspections, the following items will be checked:
Informed consent.
Compliance with the research protocol and the procedures defined there.
Assurance of the quality of the data collected in the electronic CRF: accuracy,
missing data, consistency of the data with the source documents (such as paper
and electronic medical files and questionnaires completed by the midwives).
Reporting for adverse events:
In compliance with decree n° 2006-477 dated 26/04/2006, which modifies the portion of the
Public Health Code (specifically, Part 1, Book 1, Title II, Section 1) concerning
biomedical research, as well as the decrees in force, any suspected unexpected serious
adverse effect will be reported by the Sponsor to the competent, authority at the CPP, as
soon as the Sponsor is aware of it and at the latest 7 days after the event.
Sample size assessment:
Psyche 1: For a power of 90%, with a two-sided alpha of 5%, with 2 unexposed subjects for
1 exposed and according to the Australian study by JF Thompson et al. (2011) who found a
depression rate of 10% in unexposed and 16% in exposed women at 4 months postpartum, this
study requires:
1028 women in the unexposed group, with no hemorrhage
and 514 women in exposed group with a hemorrhage
A total of 1542 women must therefore be included.
Statistical analysis plan:
There will be 3 samples for analysis:
Respondents to the survey at 2 months
Respondents to the survey at 6 months
Respondents to the survey at 12 months (not for partners)
The participation and refusal rates will be calculated at each survey point, together
with the prevalence of the psychological states studied. Some women will be lost to
follow-up at the M6 and M12 surveys. These women will be included in the crude
descriptive analyses, and population lost to follow-up will be compared with the study
population to look for possible differences in the principal characteristics studied. We
plan to perform an interim analysis to assess the need to adjust the study calendar. This
interim analysis will be performed after half of the planned subjects have been included.
Statistical techniques:
The statistical methods used for the crude analyses will be a descriptive analysis of the
sample with a comparison of the exposed and unexposed groups, where we describe the
characteristics of the groups included in the study.
The Chi 2 test (or Fisher's exact test when appropriate) will be used to compare the
qualitative variables and Student's t test (or a Mann-Whitney test) for the quantitative
variables.
Prevalence rates and their 95% confidence intervals will be calculated for depression at
2 months, 6 months, and 1 year.
A multivariate analysis (logistic regression) will be conducted to take into account
confounding factors (smoking, cannabis, etc.) as well as clinically relevant prognostic
factors (history of depression, use of anxiolytic or antidepressant agents, etc.) for
depression at each survey interval (at 2 months, 6 months, and 1 year). The results will
be expressed as adjusted odds ratios (aOR).
At the end of the study, another multivariate analysis (generalized linear mixed model)
will be performed to study the trends in the prevalence of depression over the 3 study
periods.
Plan for missing data
The missing data will be treated as missing and excluded from the analyses.
