Do epidurals prevent postpartum depression? That’s the intriguing conclusion some people are drawing from a study published in this month’s issue of Anesthesia and Analgesia. But is that conclusion correct?
In a study of 214 women at Peking First University Hospital in Beijing, researchers found that 14% of women who received epidural analgesia during labor reported symptoms of postpartum depression (PPD) six weeks later, compared with 34.6% of women who refused epidurals. The authors point out that their findings don’t necessarily prove that epidurals can prevent PPD, but the language in the discussion sure sounds like that’s what they believe.
But…the premise of this study is flawed from the start, because the investigators compared epidural analgesia to, well, nothing:
“Each parturient made a decision by herself to have epidural labor analgesia or no pain relief at all. Other forms of analgesia are not available at our hospital.”
What does “no pain relief at all” mean at Peking First University Hospital? Were spouses/doulas/other support people allowed in the room? Did the mothers labor alone? Does “no pain relief at all” mean no freedom to move about, no bath/massage/music/visualization exercises/birth balls, none of the myriad other comfort measures that can reduce pain during labor? It obviously means no nitrous oxide, and I presume no tylenol or ibuprofen, either. In this particular hospital it seems, the choice is pretty stark: you get an epidural or you tough it out.
Which means we’re left with a study of unaddressed labor pain and postpartum depression, not the benefits of epidurals.
It’s hardly news that uncontrolled pain can lead to postpartum depression. One of the main drivers in the “painless childbirth” movement of the mid-19th century and the development of Twilight Sleep in the early 20th century was the prevention of neurasthenia—a debilitating combination of anxiety and depression that haunted many postpartum women.*
This study would be more compelling if the authors had compared epidurals with other pain relief modalities in the setting of a well-supported labor. Otherwise we’re left with the conclusion that uncontrolled labor pain can make women miserable, and medically obliterated pain makes them less so.
I can’t think of any other form of human pain that would be studied in such an all-or-none way.
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* Department of Shameless Self-Promotion: You can read more about the history of painless childbirth, as well as what a lousy labor coach I was, in my book, Birth Day: A Pediatrician Explores the Science, the History, and the Wonders of Childbirth.