Postnatal pain and the link with postnatal depression

Next month I’ll be talking at the annual Birth Trauma conference organised by Dr Rebecca Moore in London, about the link between birth injury and postnatal depression.

Research presented at the Anesthesiology 2018 annual meeting suggested that the pain experienced by the mother following childbirth, rather than during the labour itself, possibly contributed to her mental health condition. Well… as far as I’m concerned this is pretty obvious, right? If you’re in pain and feeling isolated and confused about the state of your body after childbirth, whether you’ve had a ‘perfect birth’ or not, this is going to take its toll on your resilience.

Shockingly there simply hasn’t been much research in this area, about the link between birth injury and postnatal depression. Previous research has demonstrated that pain associated with giving birth may increase the risk of postpartum depression, but hasn’t specified which part of the labour process (e.g., before, during or after delivery) may be the source of the problem. This year’s research is the first study to differentiate post-childbirth pain from labour and delivery pain, and identify it as a significant risk factor for postnatal depression.

‘For many years, we have been concerned about how to manage labour pain, but recovery pain after labour and delivery often is overlooked’, said Jie Zhou, lead author of the study and assistant professor of anaesthesia at Brigham and Women’s Hospital and Harvard Medical School, Boston. ‘Our research suggests we need to focus more on helping new mothers manage pain after the baby is born.’

Symptoms of postpartum depression, including extreme sadness, low energy, anxiety, crying episodes, irritability and changes in sleep or eating patterns, affect about one in nine women (or, possibly more as we don’t really know how many women suffer in silence), according to the Centers for Disease Control and Prevention (CDC).

In the study, Dr Zhou’s research group reviewed pain scores (from the start of labour to hospital discharge) for 4,327 first-time mothers delivering a single child vaginally or by C-section at Brigham and Women’s Hospital in 2017. They compared pain scores to the mothers’ Edinburgh postnatal depression scale (EPDS) scores one week after delivery. (Source: American Society of Anesthsiologists)

Dr Zhou found postnatal depression was significantly associated with higher pain scores. Mothers with postnatal depression demonstrated more pain-related complaints during recovery and often needed additional pain medication. Women in the postpartum depression group were more likely to have delivered by C-section. They also had more reports of inadequate postpartum pain control.

Postnatal depression is complex, and there are myriad factors that can contribute to it. But pain is a definite influence. Researchers in this study determined postnatal depression was higher among women who were overweight or obese; who suffered from a torn perineum (the area of the pelvic floor which endures the most prolonged pressure and trauma in a vaginal birth); those had a history of depression, anxiety or chronic pain; and whose babies were smaller and had lower Apgar scores, a scoring system used to assess the physical health of newborns one minute and five minutes after birth.

I know that first time round I experienced a shocking amount of pain postnatally – which lasted for (I felt) a shocking amount of time (over a year) and wasn’t taken seriously when I went to the GP several times to question whether my healing was normal – ‘it’s fine, it’s all normal, you’ve had a baby, go away and stop being neurotic’ (if not literally what was said, this is the take home message). I found out over a year later, during a birth debrief, that I had had an extra vertical incision made on my caesarean incision, in order to facilitate the speedy exit of my son in time to save his life. Therefore this ‘extra’ pain I was experiencing was entirely legitimate – and even knowing this rather than being fobbed off would have made a difference to my mental health and experience.

(Image from artist @spiritysol)

This is so horrifyingly common that we need to make sure women are able to take their recovery into their own hands in terms of standing up for themselves and asking to be taken seriously. I have only this weekend received an email from a mum who is 15 months postnatal and suffered a tear which is still causing her pain and issues but has been told it was ‘just a graze’ and all is fine. Yet, 15 months later she is still in pain, and isn’t sure where to turn as she hasn’t been heard. This is not fine.

If you’re being fobbed off when you’re experiencing pain, that’s going to take its toll on your mental health. This is a multi-layered issue of awareness and referral pathways and the general societal dismissal of women’s issues. Postnatal health is a feminist issue. Even if that word turns you off, it IS. We need to learn to advocate for ourselves better, but it’s distressing having to fight to be heard.

It may be an issue partly of lack of adequate painkillers for the extent of the pain – or perhaps we are not well prepared psychologically managing pain of this type? Is it not talked about usefully enough in antenatal care perhaps, and tools offered to help deal with it? For example, breathing techniques would be a very simple yet powerful tool for kickstarting the healing process from the nervous system up, and could be a start at least if highlighted, and practised pre-birth.

Pain management is an area that mindfulness-based cognitive therapy (MBCT) focuses on: our awareness of our relationship with pain as well as dealing with the sensations themselves. Everyone has a different pain threshold and our relationship with pain is again complex and personal. But clearly some women are enduring post-birth pain in a way that is detrimental to their mental and emotional health.

What is your experience of postnatal pain management? Do you agree that postnatal care is a factor in postnatal depression developing? I’d love to hear from you.

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