A study that was presented at the American Society of Anesthesiologist's Annual Meeting last month has been widely promoted as linking the use of epidural anesthesia to a lowered risk of postpartum depression. The idea that opting for an epidural could reduce the risk of a serious postpartum complication is an appealing one. Unfortunately, as with many popular reports of scientific findings, secondary sources have put an inaccurate spin on the findings.
In this study, only women who received epidurals were included. The amount of pain relief provided by the epidural was related to postpartum depression scores on the Edinburgh Postnatal Depression Scale (EPDS.) The study showed that women who got significant pain relief were less likely to have an elevated EPDS score than women who got less relief from their epidural. What this study suggests is the effectiveness of the epidural is inversely correlated with postpartum depression scores (i.e. better pain relief, less depression.) This makes sense. If a woman is in enough pain to request an epidural, and does not get good pain relief from it, it is likely that she will experience one of the major risk factors for postpartum depression: an emotionally traumatic birth. Rather than suggesting that epidurals reduce the risk of postpartum depression, we could say this study suggests that failed epidurals increase the risk of postpartum depression.
What this study does not show is that getting an epidural is going to reduce your likelihood of postpartum depression. Why? Because the study was limited only to women who got an epidural, excluding those who chose an unmedicated birth. Another, larger study found the opposite association: women who got an epidural had a higher likelihood of postpartum depression than women who did not.
What's a mother to believe? The issue is that it is very difficult for us to study the impact of epidurals. The gold standard of research, the randomized study, would not appeal to many women. Nor would it be particularly ethical or safe. So, when we look at epidural use, we face a number of confounds in the research. Women who seek an epidural may have pre-existing conditions or labor complications that are absent in women who have unmedicated births. Because of this, we can't be completely sure if outcomes associated with epidural anesthesia are due to the anestheisa itself or to another condition.
So, what should women know about getting an epidural? Simply, epidurals have risks and benefits. The risks include longer labor, more cesarean births and greater risk of perineal laceration (a.k.a. tearing your lady parts.) You can end up with an epidural that doesn't work, or only works on one side. You have a small (1.5%) chance of developing headaches due to an accidental misplacement of the injection. It is certain that use of an epidural impairs mobility during labor, making it harder to get in an ideal position for birth. Epidurals also impair mobility after labor, making it harder to parent in those early hours of motherhood. The benefits of epidurals are obvious: pain relief & the ability to rest. The reduction or elimination of pain during childbirth is an important choice for women to have, especially when used wisely (i.e. later in labor and when other methods of pain relief have been exhausted.)
Working with pregnant and postpartum women, I often hear feelings of disappointment, even shame, about the use of an epidural during labor. What every woman needs to know: labor and childbirth are not designed as a test of your strength or determination. They are, simply, a way to deliver your child into your arms. Surround yourself with people who support the birth you want. Prepare yourself to have the healthiest birth you can. Make peace with the birth you have. If you find yourself having trouble processing your feelings about childbirth, find someone you trust to talk to about this. Postpartum Support International can help you find a professional or support group near you.
Sarah L. Wesch, Ph.D.