Labor neuraxial analgesia and maternal morbidity

The use of labor neuraxial analgesia for vaginal delivery was associated with a 14% decrease in the risk of severe maternal morbidity (SMM), including postpartum hemorrhage (PPH), compared to vaginal delivery without neuraxial analgesia, according to a study published in JAMA Network Open.

The study1 was inspired by an older study conducted in France and published in 2011 in the journal Obstetrics & Gynecology2, “suggesting that epidural analgesia for pain management during labor resulted in a decreased risk of PPH, which is the first cause of preventable SMM and maternal mortality,” said Jean Guglielminotti, MD, PhD, an assistant professor in the Department of Anesthesiology at Columbia University Irving Medical Center in New York City, who was principal investigator of the new study.

“We believed it was important to replicate the older study here in the US because of the advances in obstetric and anesthesia care over the past 15 years,” Guglielminotti told Contemporary OB/GYN®. “Also, because of the marked differences in healthcare systems between the US and France.”

The current study comprised 575524 women between the ages of 15 and 49, with a mean age of 28, undergoing their first vaginal delivery at New York state hospitals from January 2010 and December 2017, based on hospital discharge records.

Overall, 69.6% of women were in the low-risk group, based on the comorbidity index for obstetric patients, and 30.4% were in the high-risk group.

Before weighting with the inverse propensity score-weighting method, 47.4% of women received neuraxial analgesia, for which the incidence of SMM was 1.3%, compared to 1.4% without neuraxial analgesia.

After weighting, the adjusted odds ratio of SMM linked to neuraxial analgesia was 0.86 (95% confidence interval: 0.82 to 0.90).

Decreased risk of SMM connected to neuraxial analgesia was comparable between non-Hispanic White women and racial and ethnic minority women and between low-risk and high-risk women.

Overall, 21% of the observed association of neuraxial analgesia to SMM risk was mediated through the decreased risk of PPH.

“The study results confirm our initial hypothesis that women would benefit from neuraxial analgesia, so we were not surprised by the findings,” Guglielminotti said. “But it contains important information for mothers when they have to assess the risk/benefit balance of the analgesic techniques offered to them for labor pain management.”

Increasing access to and use of epidural during childbirth, especially among racial and ethnic minority women, “could be a feasible strategy to improve maternal health and reduce disparities in maternal health,” Guglielminotti said. “For example, 80% of non-Hispanic White women receive an epidural nationwide, 70% of non-Hispanic Black and only 65% of Hispanic women.”

However, not all women are candidates for an epidural, due to contraindications like being on blood thinners, or they simply decline, according to Guglielminotti.

“We would like to see more research on the effect of possible interventions to increase the use of epidural analgesia during labor, such as educational programs on epidural analgesia for pregnant women,” he said. “Indeed, many women do not want an epidural, due to the misconceptions about the possible risk of complications with this technique, including paralysis.”

Reference

  1. Guglielminotti J, Landau R, Daw J, et al. Use of labor neuraxial analgesia for vaginal delivery and severe maternal morbidity. JAMA Netw Open. Published online February 22, 2022. doi:10.1001/jamanetworkopen.2022.0137
  2. Driessen M, Bouvier-Colle MH, Dupont C, et al. Postpartum hemorrhage resulting from uterine atony after vaginal delivery: factors associated with severity. Obstet Gynecol., 2011 Jan;117(1):21-31. doi:10.1097/AOG.0b013e318202c845