Epidurals, Emotional Support and Postpartum Depression

An article that appeared in the August, 2014 edition of Anesthesia and Analgesia (one of the most respected professional journals of anesthesia) reports that use of epidural analgesia is associated with a decreased risk of postpartum depression.  The study was performed in Beijing, China at the Peking University First Hospital.  Two hundred fourteen women were included in the study.  One hundred seven had natural childbirth and one hundred seven received epidural analgesia for their labors.  The Edinburgh Postnatal Depression Scale (EPDS) was used to evaluate the women 3 days and 6 weeks following delivery.

Thirty four percent of women who had natural childbirth developed postpartum depression while only 14.0% of women who received epidural analgesia developed depression.  Women who attended prenatal birthing classes and women who breast fed their babies also had lower EPDS scores, i.e. less risk for depression.  Epidural analgesia was associated with lower EPDS scores independent of birthing class attendance and breast feeding.

In a related article, Prevalence and Predictors of Women’s Experience of Psychological Trauma During Childbirth, the authors identify predictors of posttraumatic stress in women following childbirth.  The primary predictors are pain during childbirth, and the delivery of an ill or stillborn child.  Other factors that contribute to posttraumatic stress include hostile and uncaring medical personnel, the feeling of powerlessness, information being withheld from the parturient, interventions without her consent, greater medical intervention, absence of a partner, and lack of emotional support.  A supportive partner and the presence of a female support person are associated with more satisfaction and less stress during delivery.  While 20% to 30% of women experience childbirth as a traumatic event, the authors report that only 2%-6% of women develop posttraumatic stress disorder.

As an anesthesiologist it is nice to have clinical research that gives women additional support for choosing pain control for labor, if she feels she needs it.  I am fortunate to work in an environment where every care giver I know shows a commitment to ensuring that laboring women feel safe, and nurtured throughout their delivery.

The feeling of powerlessness women feel during labor may be caused by many things:  the inability to control and cope with her pain, the inability to participate in decisions about the management of her labor due to poor communication from the medical staff,  and the need for escalating interventions.  Nothing should be done to the laboring woman without her understanding and consent.  Ideally every parturient should have discussed with her physician, or midwife the possible courses her delivery might take before going into labor.  She should be given enough information so that she would understand the need for interventions when they arise, and trust that her care givers were acting knowledgeably in her best interest.  She and her partner should attend prenatal classes to learn and understand what she is about to experience.  Her obstetrician or midwife should take the time to understand her needs and desires for the upcoming delivery.  The care givers should articulate their understanding of their patients’ desires and explain potential decisions for circumstances that arise during labor.  Everyone should be on the same page, on the same team.  Choose your metaphor.

The most important relationship, though, should be between the woman giving birth and her partner.  And the partner’s purpose should be to support her emotional and physical needs at all times.

The pain of childbirth is very likely to be the most painful event of a woman’s life.  Until labor begins, it is impossible to anticipate how she will cope with it.  Before the day arrives a couple may have agreed on a birth plan of natural childbirth.  Good for them.  But when labor starts some women find that the intensity of the pain is something she cannot endure.  There is a difference between pain and suffering.  If she chooses to change her mind and ask for pain relief, be it intravenous medication or an epidural, she needs her partner’s support.

I have administered epidurals to women who remain in tears after the epidural has removed their pain.  When I have asked these women why they are still crying I’ve been told, “My husband is mad at me for getting an epidural.”  I’ve also watched an entire family badger a young woman trying to have natural childbirth to make her either have an epidural or have a cesarean section just to get it over with because, “We traveled a long way to be here for this.”  Women who feel guilt for letting down their partners or family are more likely to suffer postpartum depression or exhibit posttraumatic stress.

My message to pregnant women, their partners and family is this:

  1. Get as informed about your pregnancy and the process of birth as you can.  Learn what to expect.
  2. Choose a qualified obstetrician or midwife, one who is willing to listen and plan with you.
  3. I strongly suggest finding a doula, the female support person who will be there with every contraction.
  4. Agree on a birth plan, and agree to be flexible.  You won’t know what labor is like until you’re in it.  Don’t make any irrevocable agreements with anyone.
  5. The woman having the baby is in charge.  This is most importantly her day.  All others are there to support her needs, and decisions.
  6. If he, she, they cannot be supportive they are not welcome and should be kept away.
  7. The birth of your healthy child should be a joyous, exciting, happy event.  If the birth doesn’t follow your plan, don’t let it spoil a wonderful conclusion.

The Epidoula

P.S.  If you labor naturally for hours then decide to get an epidural you still get credit for all the natural childbirth you endured!  My rule.


Ding T, et. al.  Epidural Labor Analgesia Is Associated with a Decreased Risk of Postpartum Depression: A Prospective Cohort Study. Anesth Analg 2014;119:383-92.

Soet JE, Brack, GA, and Dilorio C. Prevalence and Predictors of Women’s Experience of Psychological Trauma During Childbirth. BIRTH 30:March 2003.

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