According to a new University of Michigan (U of M) study published in the Journal of the American Medical Association (JAMA), women who give birth and are prescribed opioids for postpartum pain are at risk for opioid addiction.
Experiencing pain after giving birth, also known as postpartum pain, is a normal experience for most women. The perinum that surrounds the vaginal opening might be bruised or torn after giving birth and a doctor may have to make an incision through the vaginal wall called an epistiotomy to help the birthing process. This damage will heal but may be the cause of pain. For women who give birth via cesarean section (aka C-section), which requires an incision through the full thickness of the abdominal wall, pain at the incision sight can make it painful to do everyday things like walking, laughing or coughing. The uterus also contracts after childbirth causing cramps known as afterpains. Postpartum pain for both C-section and vaginal births usually goes away by six weeks after the delivery.
While postpartum pain is perfectly normal, it can still make life uncomfortable for new mothers. For this reason, doctors prescribe painkillers to help manage postpartum pain. Sometimes doctors will prescribe acetaminophen (Tylenol) or nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen (Motrin, Advil). Other times, however, a woman experiencing postpartum pain may be prescribed an opioid. Herein lies the problem.
The U of M study, conducted by Dr. Alex Friedman Peahle, M.D., focused on women with private health insurance across America and found that among those who had a C-section, 76% would be prescribed an opioid. For vaginal l births, the figure was 27%. Of course, C-sections cause more postpartum pain so the difference in opioid prescription rates between the two groups is justifiable. The study’s other finding was more troubling: 2.2% of women who had gotten a C-section and 1.7% of women who gave birth naturally went on to refill their opioid prescription at least twice and up to a year after childbirth. That works out to more than 1 in 100 women becoming persistent opioid users after childbirth. Women who are younger and with a history of mental health/substance use disorders and/or other pain are more likely to develop an addiction after childbirth.
Another study published in 2019, this time of Tennessee women on Medicaid, from Vanderbilt University and published in the American Journal of Obstetrics and Gynecology (AJOG) found much higher rates of opioid prescriptions for postpartum pain: 89% for C-sections and 53% for vaginal births. Similar to the U of M study, the Tennessee study found that the rate of persistent opioid use among women prescribed opioids after childbirth was low but that rates were higher in women with C-sections than those who had vaginal births. Both studies focused on women who were opioid naive, meaning that they had not filled an opioid prescription within a certain period of time before giving birth (365 days in the U of M study, 180 days in the Tennessee study).
While the rate of persistent opioid users found in these studies may seem small, it is important to remember that there were almost four million births in the US last year. To convert percents to number, the 2.2% from the U of M study calculates out to 2,633 women who became persistent opioid users after their C-section. The rates in the U of M study may be lower than the actual rate of opioid misuse among new mothers, because the study did not include women with Medicaid or no health insurance, who are a more vulnerable population.
Doctors have the best of intentions when prescribing opioids to women after childbirth and these drugs can make life easier. However, opioids are extremely addictive. In fact, a 2017 government study found that after just three days of opioid use, the risk of addiction increases daily. There is some good news though. The U of M study found that doctors prescribed less opioids to women after childbirth in 2016 than they did in 2008, likely due to increased awareness of the problem of addiction. Additionally, the C-section rate is the lowest since 2009 and the number of women who previously had a C-section who choose vaginal birth during their next pregnancy increased by 13.3% between 2017 and 2018. While not always the case, vaginal births can have less postpartum pain than C-sections. Both the U of M and Tennessee studies show that doctors are less likely to prescribe opioids to women who give birth vaginally.
Fortunately, the medical community is taking notice of this issue. The Michigan Opioid Prescribing Engagement Network (Michigan OPEN) and other advocates are recommending that doctors prescribe less opioids when they do decide to prescribe them for postpartum pain (i.e. 20 pills instead of 30). When talking to Bridge Magazine about her study, Dr. Peahle said that she believes that doctors prescribe opioids to make womens’ lives easier after childbirth, meanwhile, the women take them because their doctor prescribed them. This well-intentioned but potentially risky cycle can be interrupted by a conversation between doctors and their patients experiencing postpartum pain.
Ali Safawi is a Workit Associate and former Intern. He is an alumni of the University of Michigan School of Public Health and is pursuing his masters degree at George Washington University in our nation's capitol. He is passionate about fighting the opioid epidemic and creating a more equitable health system for all Americans.
This blog was reviewed for medical accuracy by Dorothy Moore, FNP.