Date of Award

Fall 2011

Degree Type


Degree Name

Master of Science (MSc)


Mathematics and Statistics


Lehana Thabane


Roman Viveros-Aguilera, Gary Foster



Committee Member

Roman Viveros-Aguilera, Gary Foster


Postpartum depression has become a major public health concern for women within a specific time period after delivery. Depression is possibly associated with some risk factors such as socioeconomic status, social support, maternal mental and physical health, and history of anxiety. TOMIS III, funded by the Canadian Institutes of Health Research, is a prospective cohort to study the associations between delivery method and health and health resource utilization.

Clinically, we investigated the associations between mode of delivery and outcome of postnatal depression, maternal and infant health, and we implied the risk predictors for outcomes by statistical methodology of marginal model with generalized estimating equations (GEE). Statistically, a variety of regression models, namely, generalized linear mixed effect model (GLMM), hierarchical generalized linear model (HGLM) and Bayesian hierarchical model were applied for this analysis and results were compared with GEEs. Some imputation strategies, namely, mean imputation, last observation carrying forward (LOCF), hot-deck imputation and multiple imputation were employed for handling missing values in this study.

Analysis results demonstrated that there was no statistically significant association between mode of delivery and postpartum depression [OR 0.99, 95% CI (0.73, 1.34)]. However, the development of postpartum depression was found to be associated with low income, low mental and physical health functioning, lack of social support, the low number of unmet learning needs in hospital, and English or French spoken at home. Results were consistent for all regression models but GEE provided the best fit and an excellent discriminative ability. GEE models were constructed on different datasets imputed by mean, LOCF, hot-deck and multiple imputation, and LOCF was recommended to handle the missing data in this longitudinal study.

Analyses on the outcome of maternal health and infant health stated that method of delivery had a statistically significant influence on maternal health but no significant impact on infant health. Risks of maternal health problems were associated with cesarean delivery, good/fair/poor infant health, low maternal mental and physical health functioning, lack of care for maternal mental health, and good/fair/poor health before pregnancy. Risks of infant health problems were associated with good/fair/poor maternal health before pregnancy and after discharge, inadequate care or help for infant health, fair/poor community services after discharge, low maternal mental health functioning, non-English or non-French spoken at home, and mothers born outside of Canada.

McMaster University Library