Emily Oster

5 min Read Emily Oster

Emily Oster

Is There a Link Between Epidurals and Autism Diagnosis?

A new paper implies suffering is the only way to be a good parent

Emily Oster

5 min Read

If you’re parenting in the modern age, one thing you should know for sure is that suffering is a signal that you’re a good parent. This was reinforced for me best in an essay I read several years ago in which someone noted that being an attentive parent sometimes requires you to hold your pee in for several hours. Because it might not be best for your kids if you took a break to use the bathroom. (Frankly I do not get this at all because in my experience children have no problem being in the bathroom with you.)

This starts during gestation, when being a good parent means giving up things you enjoy, like coffee, sushi and sleeping on your back. With this background, it was no surprise to me to read this new study on how epidurals raise the risk of autism. Being a good mother should definitely mean going through an un-medicated labor. Honestly, it’s really not that bad. As my husband can tell you, I only clawed a small portion of my face off to distract myself. It’s a small price to pay!

Still, I thought it might be useful to review this study for people just in case it turns out to, maybe, not be 150% convincing.

[Snark over; data review commence.]

What does the study on epidurals and autism say?

This study, which was published in JAMA Pediatrics includes almost 150,000 children born in California between 2008 and 2015. At the most basic level, the paper correlates use of epidural during labor with a later autism diagnosis. The ability to do this actually reflects a nice aspect of the data, which is that it comes from one integrated health system (in California). This allows the authors to link medical record data on epidural usage to later autism diagnosis for a large sample and without relying on self-reports.

The top line conclusion of the study is a 37% increase in risk of autism diagnosis with epidural usage. Put in perhaps more useful terms: the share of children in the non-epidural group with autism is 1.3%, versus 1.9% in the epidural group.

This study is not a randomized trial. The approach the authors take is to compare children of women who have an epidural to those who do not. The problem, of course, is that other things differ. You can check out all the differences in their Table 1, but I’ve pulled of the top of it below. You can see there are very notable difference in racial and ethnic make-up of the two groups. If you look at the whole table, there are sizable income differences, among other things.

Like with all studies of this type, it is extremely difficult — read, virtually impossible — to conclude that it is the epidural that is driving the differences as opposed to some other feature of the data. The authors do control for differences across women but, as always, what about the differences we do not see?

Indeed, for this reason this study has been pilloried. Several national associations, including ACOG, came out strongly to argue that the study was not causal and should not be used to influence practice patterns. In addition to these issues of differences across women, these organizations point out that there is no biological reason to think there would be a link here.

It will perhaps not surprise you that I agree. Observational studies like this are really difficult to rely on for causal conclusions. But I thought it might be interesting to dig a little deeper into what, actually, might be driving the results.

Option 1: The link is due to other conditions

In Table 1 of the paper, in addition to these differences across baseline characteristics, we also see differences in pregnancy and infant complications. For example, children in the epidural group are 1.3 percentage points more likely to have a birth defect (they do not say what kind). Moms in the epidural group are more likely to have pre-eclampsia and diabetes before pregnancy.

What this tells me is that — on average — this is a group with more complicated pregnancies. Without more details about these pregnancies, it will be very hard to fully control for these differences.

Option 2: The link is due to differences in autism diagnosis

A basic fact from their Table 1 is that women with high socioeconomic status are more likely to have an epidural. For example, a much larger share of the epidural group has a yearly household income over $90,000. My hunch is that this means that differences in diagnosis rate drive a lot of these results. Families with more resources may be more likely to get an autism diagnosis, simply because they have more resources to access medical care.

Of course, it is also possible that there is a true causal effect here. I think if there is, it’s likely to be extremely small. The measured effect is already small, and after more careful adjustment, it would surely be smaller. Is it possible that there is some tiny causal effect buried in here? It is possible. But it it something to base decisions on? I would say no.

P.S. I am well known for being on the bandwagon of “observational studies are a problem”. However: I often feel I’m yelling into the void about this, especially in pregnancy. Studies of, say, caffeine are subject to basically the same critiques as the above. ACOG and others virtually never come out to say, hey, a lot of these restrictions are based on observational data which might be flawed. So I was heartened, I guess, to see such a strong negative reaction to this study. Still, it is perhaps too much to hope that we’ll see a more general push for causality.

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The list of what not to do while pregnant feels longer than a CVS receipt. At ParentData, we want to empower you to make the right decisions for you. 

What an amazing group of women, and an honor to speak at the #MomsFirstSummit debunking parenting myths. 

What are some pregnancy rules you chose to bend after being empowered by data?

#emilyoster #parentdata #pregnancyproblems #pregnancymyths

The list of what not to do while pregnant feels longer than a CVS receipt. At ParentData, we want to empower you to make the right decisions for you.

What an amazing group of women, and an honor to speak at the #MomsFirstSummit debunking parenting myths.

What are some pregnancy rules you chose to bend after being empowered by data?

#emilyoster #parentdata #pregnancyproblems #pregnancymyths
...

Looking for Memorial Day Weekend plans? Might be the perfect time to give potty training a shot. Potty training is notoriously difficult, and we unfortunately don’t have a lot of evidence-based guidance on what works best. So I asked the ParentData community to fill out a survey and share their knowledge — about 6,000 people responded.

👉Comment “Link” for a DM to an article that summarizes all of the best potty training advice we collected. 

Remember, you are not alone in the potty training struggle! It can be incredibly challenging, so please give yourself some grace.

#emilyoster #parentdata #pottytraining #pottytrainingtips #toddlertips

Looking for Memorial Day Weekend plans? Might be the perfect time to give potty training a shot. Potty training is notoriously difficult, and we unfortunately don’t have a lot of evidence-based guidance on what works best. So I asked the ParentData community to fill out a survey and share their knowledge — about 6,000 people responded.

👉Comment “Link” for a DM to an article that summarizes all of the best potty training advice we collected.

Remember, you are not alone in the potty training struggle! It can be incredibly challenging, so please give yourself some grace.

#emilyoster #parentdata #pottytraining #pottytrainingtips #toddlertips
...

We’re hiring an Associate Editor at ParentData! More details at my link in bio. Please share with the great writers and data-loving people in your network. 📊💻

We’re hiring an Associate Editor at ParentData! More details at my link in bio. Please share with the great writers and data-loving people in your network. 📊💻 ...

Do you brand things a certain way to get your kid to accept it? Like calling carrots “rabbit popsicles”? Or telling them to put on their “super speed socks” in the morning? Share your rebrands in the comments below! You never know who you might be helping out 👇

#emilyoster #funnytweets #relatabletweets #parentingjokes #kidssaythedarndestthings

Do you brand things a certain way to get your kid to accept it? Like calling carrots “rabbit popsicles”? Or telling them to put on their “super speed socks” in the morning? Share your rebrands in the comments below! You never know who you might be helping out 👇

#emilyoster #funnytweets #relatabletweets #parentingjokes #kidssaythedarndestthings
...

Have you ever panic-googled a parenting question when everyone else is asleep? If so, you’re not alone. 

Today is the first episode of a new biweekly series on my podcast: Late-Night Panic Google. On these mini-episodes, you’ll hear from some familiar names about the questions keeping them up at night, and how data can help. First up: @claireholt!

Listen and subscribe to ParentData with Emily Oster in your favorite podcast app 🎧

#parentdata #emilyoster #claireholt #parentingstruggles #parentingtips #latenightpanicgoogle

Have you ever panic-googled a parenting question when everyone else is asleep? If so, you’re not alone.

Today is the first episode of a new biweekly series on my podcast: Late-Night Panic Google. On these mini-episodes, you’ll hear from some familiar names about the questions keeping them up at night, and how data can help. First up: @claireholt!

Listen and subscribe to ParentData with Emily Oster in your favorite podcast app 🎧

#parentdata #emilyoster #claireholt #parentingstruggles #parentingtips #latenightpanicgoogle
...

Sun safety is a must for all ages, especially babies! Here are my tips for keeping your littlest ones protected in the sunshine:
☀️ Most importantly, limit their time out in hot weather. (They get hotter than you do!)
☀️ Keep them in the shade as much as possible when you’re out.
☀️ Long-sleeve but lightweight clothing is your friend, especially on the beach, where even in the shade you can get sunlight reflecting off different surfaces.
☀️ If you want to add a little sunscreen on their hands and feet? Go for it! But be mindful as baby skin tends to more prone to irritation.

Comment “Link” for a DM to an article on the data around sun and heat exposure for babies.

#sunsafety #babysunscreen #babyhealth #parentdata #emilyoster

Sun safety is a must for all ages, especially babies! Here are my tips for keeping your littlest ones protected in the sunshine:
☀️ Most importantly, limit their time out in hot weather. (They get hotter than you do!)
☀️ Keep them in the shade as much as possible when you’re out.
☀️ Long-sleeve but lightweight clothing is your friend, especially on the beach, where even in the shade you can get sunlight reflecting off different surfaces.
☀️ If you want to add a little sunscreen on their hands and feet? Go for it! But be mindful as baby skin tends to more prone to irritation.

Comment “Link” for a DM to an article on the data around sun and heat exposure for babies.

#sunsafety #babysunscreen #babyhealth #parentdata #emilyoster
...

I’m calling on you today to share your story. I know that many of you have experienced complications during pregnancy, birth, or postpartum. It’s not something we want to talk about, but it’s important that we do. Not just for awareness, but to help people going through it feel a little less alone.

That’s why I’m asking you to post a story, photo, or reel this week with #MyUnexpectedStory and tag me. I’ll re-share as many as I can to amplify. Let’s fill our feeds with these important stories and lift each other up. Our voices can create change. And your story matters. 💙

#theunexpected #emilyoster #pregnancycomplications #pregnancystory

I’m calling on you today to share your story. I know that many of you have experienced complications during pregnancy, birth, or postpartum. It’s not something we want to talk about, but it’s important that we do. Not just for awareness, but to help people going through it feel a little less alone.

That’s why I’m asking you to post a story, photo, or reel this week with #MyUnexpectedStory and tag me. I’ll re-share as many as I can to amplify. Let’s fill our feeds with these important stories and lift each other up. Our voices can create change. And your story matters. 💙

#theunexpected #emilyoster #pregnancycomplications #pregnancystory
...

OUT NOW: My new book “The Unexpected: Navigating Pregnancy During and After Complications” is available on April 30th. All of my other books came out of my own experiences. I wrote them to answer questions I had, as a pregnant woman and then as a new parent. “The Unexpected” is a book not to answer my own questions but to answer yours. Specifically, to answer the thousands of questions I’ve gotten over the past decade from people whose pregnancies were more complicated than they had expected. This is for you. 💛 Order now at my link in bio!

OUT NOW: My new book “The Unexpected: Navigating Pregnancy During and After Complications” is available on April 30th. All of my other books came out of my own experiences. I wrote them to answer questions I had, as a pregnant woman and then as a new parent. “The Unexpected” is a book not to answer my own questions but to answer yours. Specifically, to answer the thousands of questions I’ve gotten over the past decade from people whose pregnancies were more complicated than they had expected. This is for you. 💛 Order now at my link in bio! ...

OUT NOW: My new book “The Unexpected: Navigating Pregnancy During and After Complications” is available on April 30th. All of my other books came out of my own experiences. I wrote them to answer questions I had, as a pregnant woman and then as a new parent. “The Unexpected” is a book not to answer my own questions but to answer yours. Specifically, to answer the thousands of questions I’ve gotten over the past decade from people whose pregnancies were more complicated than they had expected. This is for you. 💛 Order now at my link in bio!

OUT NOW: My new book “The Unexpected: Navigating Pregnancy During and After Complications” is available on April 30th. All of my other books came out of my own experiences. I wrote them to answer questions I had, as a pregnant woman and then as a new parent. “The Unexpected” is a book not to answer my own questions but to answer yours. Specifically, to answer the thousands of questions I’ve gotten over the past decade from people whose pregnancies were more complicated than they had expected. This is for you. 💛 Order now at my link in bio! ...

OUT NOW: My new book “The Unexpected: Navigating Pregnancy During and After Complications” is available on April 30th. All of my other books came out of my own experiences. I wrote them to answer questions I had, as a pregnant woman and then as a new parent. “The Unexpected” is a book not to answer my own questions but to answer yours. Specifically, to answer the thousands of questions I’ve gotten over the past decade from people whose pregnancies were more complicated than they had expected. This is for you. 💛 Order now at my link in bio!

OUT NOW: My new book “The Unexpected: Navigating Pregnancy During and After Complications” is available on April 30th. All of my other books came out of my own experiences. I wrote them to answer questions I had, as a pregnant woman and then as a new parent. “The Unexpected” is a book not to answer my own questions but to answer yours. Specifically, to answer the thousands of questions I’ve gotten over the past decade from people whose pregnancies were more complicated than they had expected. This is for you. 💛 Order now at my link in bio! ...

Is side sleeping important during pregnancy? Comment “Link” for a DM to an article on whether sleep position affects pregnancy outcomes.

Being pregnant makes you tired, and as time goes by, it gets increasingly hard to get comfortable. You were probably instructed to sleep on your side and not your back, but it turns out that advice is not based on very good data.

We now have much better data on this, and the bulk of the evidence seems to reject the link between sleep position and stillbirth or other negative outcomes. So go ahead and get some sleep however you are most comfortable. 💤

Sources:
📖 #ExpectingBetter pp. 160-163
📈 Robert M. Silver et al., “Prospective Evaluation of Maternal Sleep Position Through 30 Weeks of Gestation and Adverse Pregnancy Outcomes,” Obstetrics and Gynecology 134, no. 4 (2019): 667–76. 

#emilyoster #pregnancy #pregnancytips #sleepingposition #pregnantlife

Is side sleeping important during pregnancy? Comment “Link” for a DM to an article on whether sleep position affects pregnancy outcomes.

Being pregnant makes you tired, and as time goes by, it gets increasingly hard to get comfortable. You were probably instructed to sleep on your side and not your back, but it turns out that advice is not based on very good data.

We now have much better data on this, and the bulk of the evidence seems to reject the link between sleep position and stillbirth or other negative outcomes. So go ahead and get some sleep however you are most comfortable. 💤

Sources:
📖 #ExpectingBetter pp. 160-163
📈 Robert M. Silver et al., “Prospective Evaluation of Maternal Sleep Position Through 30 Weeks of Gestation and Adverse Pregnancy Outcomes,” Obstetrics and Gynecology 134, no. 4 (2019): 667–76.

#emilyoster #pregnancy #pregnancytips #sleepingposition #pregnantlife
...

My new book, “The Unexpected: Navigating Pregnancy During and After Complications” is available for preorder at the link in my bio!

I co-wrote #TheUnexpected with my friend and maternal fetal medicine specialist, Dr. Nathan Fox. The unfortunate reality is that about half of pregnancies include complications such as preeclampsia, miscarriage, preterm birth, and postpartum depression. Because these are things not talked about enough, it can not only be an isolating experience, but it can also make treatment harder to access.

The book lays out the data on recurrence and delves into treatment options shown to lower risk for these conditions in subsequent pregnancies. It also guides you through how to have productive conversations and make shared decisions with your doctor. I hope none of you need this book, but if you do, it’ll be here for you 💛

#pregnancy #pregnancycomplications #pregnancyjourney #preeclampsiaawareness #postpartumjourney #emilyoster

My new book, “The Unexpected: Navigating Pregnancy During and After Complications” is available for preorder at the link in my bio!

I co-wrote #TheUnexpected with my friend and maternal fetal medicine specialist, Dr. Nathan Fox. The unfortunate reality is that about half of pregnancies include complications such as preeclampsia, miscarriage, preterm birth, and postpartum depression. Because these are things not talked about enough, it can not only be an isolating experience, but it can also make treatment harder to access.

The book lays out the data on recurrence and delves into treatment options shown to lower risk for these conditions in subsequent pregnancies. It also guides you through how to have productive conversations and make shared decisions with your doctor. I hope none of you need this book, but if you do, it’ll be here for you 💛

#pregnancy #pregnancycomplications #pregnancyjourney #preeclampsiaawareness #postpartumjourney #emilyoster
...

We are better writers than influencers, I promise. Thanks to our kids for filming our unboxing videos. People make this look way too easy. 

Only two weeks until our book “The Unexpected” is here! Preorder at the link in my bio. 💙

We are better writers than influencers, I promise. Thanks to our kids for filming our unboxing videos. People make this look way too easy.

Only two weeks until our book “The Unexpected” is here! Preorder at the link in my bio. 💙
...