Labor Analgesia as a Predictor for Reduced Postpartum Depression Scores

A Retrospective Observational Study

Grace Lim, MD, MS; Lia M. Farrell, BS; Francesca L. Facco, MD, MS; Michael S. Gold, PhD; Ajay D. Wasan, MD, MSc


Anesth Analg. 2018;126(5):1598-1605. 

In This Article

Abstract and Introduction


Background: Using labor, epidural analgesia has been linked to a reduced risk of postpartum depression, but the role of labor pain relief in this association remains unclear. The goal of this study was to test the hypothesis that effective epidural analgesia during labor is associated with reduced postpartum depression symptomatology.

Methods: A single, institutional, retrospective, observational cohort design was chosen. The primary outcome was Edinburgh postnatal depression scale (EPDS) score, measured at the 6-week postpartum visit. Subjects included in the final analysis had (1) received labor epidural analgesia; (2) pain assessed during labor both before and during initiation of labor epidural analgesia by 0–10 numeric rating scores; and (3) depression risk assessed by the EPDS and documented at their 6-week postpartum visit. Simple and multiple linear regression was used to identify the best model for assessing the association between pain improvement, defined as percent improvement in pain (PIP), and depression, after adjusting for a history of anxiety or depression, other psychiatric history, abuse, trauma, mode of delivery, and other maternal or fetal comorbid diseases.

Results: Two hundred one patients were included in the final analysis. Women with higher improvements in pain were associated with lower EPDS scores (r = 0.025; P = .002). Variables known to be associated with depression (body mass index, anxiety and/or depression, third- and fourth-degree perineal lacerations, and anemia) were significantly correlated with EPDS score and included in the final model. After we adjusted for these covariates, PIP remained a significant predictor of EPDS score (r = 0.49; P = .008), accounting for 6.6% of the variability in postpartum depression scores. The full model including pain, body mass index, anxiety and/or depression, perineal lacerations, and anemia explained 24% of the variability in postpartum depression scores.

Conclusions: Although the extent of labor pain relief by epidural analgesia predicts lower postpartum depression scores, the relative contribution of PIP to risk for postpartum depression symptoms may be less than other established risk factors for depression. These data support that the clinical significance of labor analgesia in the development of postpartum depression needs to be more clearly defined.


Pain is a fundamental feature of childbirth, but little is known about the potential psychological ramifications of labor pain. In the nonobstetric population, the association between chronic pain and depression is well established, indicating bidirectional relationships: pain makes depression worse, and depression makes pain worse.[1] Yet, few studies in obstetric patients have investigated labor pain association with psychological outcomes such as postpartum depression. Postpartum depression places both mothers and children at risk for serious complications including suicide, infanticide, and childhood and adolescent developmental and behavioral problems.[2,3]

A few studies on this topic suggest that labor analgesia interventions may be associated with reduced postpartum depression risk.[4–6] Ding et al[5] found that labor epidural analgesia was associated with a reduced risk of postpartum depression compared to no epidural analgesia (odds ratio, 0.31; 95% confidence interval, 0.12–0.82). However, while labor pain scores were lower on average in the group that used epidural analgesia, the contribution of the intensity of pain to the risk for depression was not assessed. Furthermore, there is a wide range of interindividual variability in labor pain relief under neuraxial analgesia. Therefore, the degree to which labor pain improvement influences the risk for postpartum depression among women who use epidural analgesia needs to be further clarified. In assessing the relationship between changes in labor pain intensity under epidural analgesia and postpartum depression more explicitly, these previously noted associations between depression risk reduction and epidural analgesia can be better understood.

We hypothesized that postpartum depression is due, at least in part, to the pain experienced during labor. The goal of this study was to begin to test this hypothesis by assessing the veracity of a key prediction to arise from it: that effective epidural analgesia during labor is associated with reduced postpartum depression symptomatology, defined by the 6-week postpartum Edinburgh postnatal depression scale (EPDS) score.