Is there a relationship between the use of epidural analgesia during childbirth and breastfeeding in the first week postpartum? How about in the first 24 weeks?

When Australian researcher Siranda Torvaldsen and her colleagues heard from lactation consultants in her area that a new formulation of epidural analgesia containing the opioid fentanyl seemed to cause difficulty establishing breastfeeding, they decided to take a closer look at the problem.

Using data from a prospective cohort study of 1280 women who each gave birth to a single live infant in the Australian Capital Territory in 1997, they sought to determine whether, in fact, there was any relationship between the use of epidural analgesia during childbirth and subsequent breastfeeding behavior.

Defining Breastfeeding
Participants were categorized as breastfeeding fully, partially, or not at all. Fully breastfeeding mothers were those who breastfed their babies at the breast and/or gave them expressed breast milk. Partially breastfeeding mothers were those who gave their babies both breast milk and formula. All other women were categorized as not at all breastfeeding. (In follow-up surveys, those who had ceased breastfeeding were asked when they had stopped.)

Defining Analgesia
The type of pain relief used by participants during labor was categorized as: 1) non-pharmacological only (e.g., breathing exercises, massage, moving about, hypnosis), 2) gas (nitrous oxide only), 3) pethidine (with or without gas), 4) epidural (analgesia or anesthesia, with or without pethidine, with or without gas), or 5) general anesthetic (with or without any of the above). However, the researchers did not have specific information about the dosage or timing of the analgesic agents used for each of the study participants.

Considering the Results
Of the 85 women who did not breastfeed at all, nearly half (48%, n=41) said they had not planned to breastfeed. No childbirth-related factors were associated with not breastfeeding; only the mother’s education was determined to be significant. From this, Torvaldsen and her colleagues surmise that not breastfeeding may be primarily influenced by the mother’s preference.

Turning our attention to those participants who did breastfeed, we find that the vast majority (93%) reported breastfeeding—fully or partially—at one week. Still, the news wasn’t all good. Several characteristics related to childbirth significantly increased the mothers’ risk of partially, rather than fully, breastfeeding their babies: receiving epidurals, having general anesthesia, and/or having a cesarean birth.

As noted by Torvaldsen, partial breastfeeding should probably be viewed as a red flag by health care providers who support breastfeeding, since it may indicate difficulty establishing breastfeeding. Women who have difficulty establishing breastfeeding may be more likely to quit. In fact, in this study, two-thirds of the women who were partially breastfeeding in the first week were not breastfeeding at all by 24 weeks. By comparison, just one-third of the women who were fully breastfeeding in the first week had quit by 24 weeks.

Understanding the Meaning
What does this study tell us? The truth is: We don’t know for sure. This study is in line with other studies which have suggested that the use of epidural analgesia is associated with cessation of breastfeeding by 24 weeks. However, we can’t really know that the association here wasn’t related to confounding factors, such as differences in women who choose different methods of pain relief. We also have no way of knowing what postpartum lactation support was available to and/or used by the study participants, so we can’t say for sure that any (or more) support would have made a difference in their breastfeeding behavior.

What we do know is this: In this study, women who used epidural analgesia were more likely to partially breastfeed their babies initially and to stop breastfeeding before 24 weeks. It seems that epidural use during childbirth may be associated with a higher risk of breastfeeding difficulties.

That doesn’t mean that women in childbirth need to give up their epidurals. Rather, as Torvaldsen explains, “Women’s comfort and satisfaction in labor and optimal infant nutrition are not mutually exclusive goals….[the] most important message for pregnant women is to get good advice and help with breastfeeding.”

This study tells us that such women may benefit from breastfeeding assistance and support in the week and the months following delivery.