Epidurals and postpartum depression
A recent study has suggested an association between epidural use in labour and a reduced rate of postpartum depression. Hmmm...seems a little too good to be true...
The research paper, published here in Anesthesia & Analgesia, found that women who used epidural analgesia in labour had a 14% risk of postpartum depression, compared to nearly 35% of women who did not have an epidural. Sounds great! While I'm all in favour of women accessing highly effective pain relief in labour, this headline prompted me to read a little deeper...
The study was a prospective observational study, which means that confounding factors (other aspects that may contribute to the study findings) cannot be accounted for entirely (best achieved through a randomised controlled trial). Ok, not a biggie; but the authors rightfully describe their findings as an association, which doesn't infer a causal link between the exposure (epidurals) and the outcome (postpartum depression). This is an important limitation of all observational studies, which is generally overlooked in the media.
Additionally, the overall rates of postpartum depression described in the study are alarmingly high - around 25%. Partly this is because the authors defined postpartum depression according to a score on the Edinburgh Postnatal Depression Scale (EPDS). While the EPDS is a useful tool, it is a self-reported questionnaire designed to screen women for symptoms of emotional distress during or after pregnancy, and reflects the woman's experience over the preceding seven days. While it is very helpful in identifying women at risk, it is not equivalent to a diagnosis of clinical depression per se.
Finally, the authors suggest a possible biological link between pain, post-traumatic stress-type symptoms, and postnatal depression, citing previous studies that associate pain and depression. However, women in this study who chose not to have an epidural, received no other form of pain relief, as "other forms of analgesia are not available at our hospital". This is unlike any hospital I've ever worked in, and makes no sense; moreover, it limits the external validity, or "generalisability" of the study (medical speak for how well we can expect study findings in a particular population to apply to any other population - i.e. our patients).
So, overall, an interesting study that presents an intriguing association between epidural use and a (thankfully) positive birth outcome. But these findings must always be interpreted with measured caution and, hopefully, responsible journalism will prevail over attention-grabbing headlines that make sweeping statements that may unduly influence women's birth choices.
Epidurals and postpartum depression
David is a Fellow of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists, and undertook his specialist training in Queensland. He is highly skilled in the management of complex and high-risk pregnancies, and has special training in minimally-invasive surgery, endometriosis, pelvic floor and incontinence surgery. David has completed a Master of Reproductive Medicine and is skilled in the assessment and management of fertility problems, and can offer the full range of assisted reproductive treatments. He is a Senior Lecturer with The University of Queensland Medical School, and has published both medical journal and textbook contributions.
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