Do Epidurals Reduce the Risk of Postpartum Depression?

The August edition of the journal Anesthesia & Analgesia has an editorial and a research article on a study conducted in China by Dr. Ting Ding and other researchers discussing a possible link between epidurals and lowered risk of postpartum depression. Given the prevalence and impact postpartum depression has on families, any new research offering insight to reduce a mother’s risk of developing this mood disorder is important for doulas to know about. When the media starts reporting on that research, it’s even more critical that we as doulas have an understanding of the evidence including what it does and does not conclude. In our review of these articles, as well as some additional research on the topic, we found some interesting points valuable to doulas and families. You can find links to the full editorial, article and mainstream media references to the study, as well as other resources mentioned here, at the end of this post. We’d love to hear your thoughts on this topic in the comments.

After reviewing the articles and evaluating the research, it seems that the real question may not be do epidurals reduce the risk of postpartum depression, but does pain management by any means – including non-medical comfort measures – lower the likelihood a mother will experience depression during the postpartum period. Below is a summary of the research, additional background on the topic of pain and depression, as well as conclusions to help doulas and the families we serve better understand the implications of this research.

THE RESEARCH
The Chinese study by Ding et. al. described in the Anesthesia & Analgesia article entitled “Epidural Labor Analgesia Is Associated with a Decreased Risk of Postpartum Depression: A Prospective Cohort study” looked at whether women who had an epidural during their labor (107 women in this study) had a higher or lower incidence of postpartum depression as measured three days and six weeks after birth. The study found that the women who had epidurals were less likely to develop postpartum depression. In this study, 34.6% of the mothers who had an unmedicated birth experienced postpartum depression compared to 14% of those who had an epidural. The Edinburgh Postnatal Depression Scale, a widely used ten question self-assessment, was used to assess whether the women participating in the study were experiencing postpartum depression.

There are a few important things to note about this study. First, the sample size is small – only 214 women total. The study does not indicate if the mothers who did not receive an epidural were given any non-medical forms of pain relief or had any time of emotional/social support. The researchers also found that patients in the study who attended childbirth classes had a lower incidence of postpartum depression. Did those childbirth classes include comfort measures the mothers and their support people (if they had any) could employ during their labor? We don’t know from the published information on this study. Dr. Ding and his colleagues also found that women who were breastfeeding at six weeks postpartum were less likely to be assessed as experiencing postpartum depression. Other studies have also validated the link between childbirth classes and breastfeeding in reducing the risk of postpartum depression.

BACKGROUND
As with any research, it is important to look at the context of the study and what other information is known and unknown about the topic or question being explored. In the case of the Chinese study recently published, these elements help frame both the research and the researchers’ conclusions:

1) In 2008, the journal Pain published an article describing a US study of 1,288 women which found that high levels of pain 36 hours after delivery was associated with a 3 fold increase in the likelihood of developing postpartum depression. The type of delivery (vaginal versus cesarean) was not found to be correlated with either pain level or depression postpartum. Other than this study, there has been little research on the role perceived pain during and after birth has on a mother’s risk of postpartum depression. The study by Ding and his colleagues in China sought to explore this question further.

2) Many factors influence an individual woman’s risk for developing postpartum depression. A history of other mood disorders including depression and anxiety at other times in her life, as well as physical or sexual abuse, are strongly correlated to postpartum depression. Other factors that have been identified include experiencing other stressful life events and poor social support.

CONCLUSIONS
The Ding et. al. study published in Anesthesia & Analgesia and the 2008 study in the journal Pain raise a very interesting question about the role of pain during labor on a mother’s risk for experiencing postpartum depression. The article title and the media headlines about this topic seem to jump to a conclusion about epidurals as a tool to reduce the incidence of postpartum depression. Epidurals, both because of how commonly they are used for pain relief during labor and birth and their effectiveness at blocking sensation, are understandably the likely tool discussed in any conversation about pain management. However, as we doulas know, there are other methods that reduce pain during labor and birth. No other form of pain relief – analgesic or otherwise was evaluated in this study. The role of social and emotional support was also not explored. What would this study’s results have looked like if the non-epidural group had a support person with them providing non-medical comfort measures? We know that doula support can reduce the cesarean rate, but can it also reduce the postpartum depression rate? Inquiring doulas want to know!

The researchers themselves recommend that their study be repeated with a larger group of women. Additional research is needed to evaluate the hypothesis that epidurals, specifically, reduce the risk of postpartum depression, and other pain management techniques should be evaluated for their effectiveness in reducing the risk of postpartum depression. Further exploration of the relationship between pain and postpartum depression is also needed to better understand how the two are linked.

Resources:

Study: http://journals.lww.com/anesthesia-analgesia/Fulltext/2014/08000/Epidural_Labor_Analgesia_Is_Associated_with_a.21.aspx

Editorial: http://journals.lww.com/anesthesia-analgesia/Fulltext/2014/08000/Double_Duty___Does_Epidural_Labor_Analgesia_Reduce.1.aspx

2008 study published in Pain: http://www.ncbi.nlm.nih.gov/pubmed/18818022

Media Mentions: Here, here and here.

— Adrianne Gordon, MBA, CD(DONA)