Biopsychosocial predictors of chronic pain after caesarean delivery: a prospective cohort evaluation of the SPACE (Sleep, Pain, Affect, Cognition, Energy)-Postpartum framework.

BACKGROUND

Chronic pain after caesarean delivery is associated with impaired maternal quality of life, yet validated risk assessment tools are lacking. We evaluated a novel symptom-based SPACE (Sleep, Pain, Affect, Cognition, Energy)-Postpartum framework, conceptualised as a multidomain symptom system through triangulation of qualitative interviews, prospective cohort observations, and prior literature, for predicting chronic pain at 3 months postpartum.

METHODS

In this prospective observational cohort study in participants undergoing caesarean delivery, psychosocial variables and the SPACE-Postpartum framework were evaluated via validated self-report questionnaires, including a single-item measure assessing perceived control, at 24-48 h, 2 weeks, and 3 months postpartum. Chronic pain was defined as pain persisting at 3 months. A five-item model, selecting one measure for each SPACE domain, was derived using ridge-regularised logistic regression. Latent class and mediation analyses explored clustering and pathways.

RESULTS

A total of 143 participants were enrolled between February and September 2024, with 70% remaining at the 3-month follow-up time point and 40% (40/100) reporting chronic pain. The SPACE-Postpartum framework, incorporating inpatient perceived control interference (odds ratio [OR], 1.13; 95% confidence interval [CI], 1.00-1.28; P=0.055), 2-week average pain intensity (OR, 1.43; 95% CI, 1.09-1.92; P=0.013), activity interference (OR, 1.24; 95% CI, 1.03-1.51; P=0.028), sleep disturbance (OR, 1.08; 95% CI, 1.01-1.15; P=0.029), and depressive symptoms, demonstrated moderate discrimination for predicting chronic pain (apparent area under the curve [AUC], 0.76; 95% CI, 0.67-0.85), with optimism-corrected AUC 0.71 and close-to-ideal calibration. A high-burden early latent profile (Sleep, Pain, Cognition) was associated with greater pain interference at 3 months (β=0.88, 95% CI, 0.12-1.64; P=0.024). Mediation analysis suggested acute pain had direct effects, while sleep disturbance was an independent risk marker for subsequent chronic pain.

CONCLUSIONS

We report that chronic pain after caesarean delivery is common. Early multidomain assessment may enable risk stratification and facilitate targeted intervention. The SPACE-Postpartum framework provides early proof-of-concept for a structured system of interacting symptom domains to support risk stratification, warranting multicentre validation.