In a cross-sectional study of 575,524 women undergoing vaginal delivery in New York hospitals from 2010 to 2017, the use of neuraxial analgesia was associated with a 14% decrease in risk of severe maternal morbidity (SMM).  Investigators for the study published in February in JAMA Network Open sought to assess the association between the use of labor neuraxial analgesia for vaginal delivery and SMM.

As of 2021, postpartum hemorrhage (PPH) was the leading cause of preventable SMM and overall maternal mortality.  Labor neuraxial analgesia (ie, epidural or combined spinal-epidural analgesia) is used in 70% of birthing women in the US and its use has been associated with reduced risk of severe PPH.

At risk and rising

In 2020, US Department of Health and Human Services deemed addressing SMM a public health priority.  The reported incidence of SMM more than doubled between 1999 and 2017, and by 2017 affected approximately 1 in 60 women.  Racial and ethnic minority women are particularly affected with their risk of SMM at up to a 3-fold increase compared with non-Hispanic White women.

The population-based cross-sectional study, conducted by researchers at Columbia University Mailman School of Public Health and Columbia Vagelos College of Physicians and Surgeons, analyzed women aged 15 to 49 years who had undergone their first vaginal delivery.  Data were taken from hospital discharge records from New York between January 2010 and December 2017 and were analyzed from November 2020 to November 2021.

The study’s goal was to examine the potential benefit of labor neuraxial analgesia in reducing SMM.  The primary outcome was SMM, as defined by the CDC, which includes 16 maternal complications (eg, heart failure) and 5 procedures (eg, hysterectomy) and the secondary outcome was PPH.

Well powered and diverse

Of 575,524 women included in the study, the mean age was 28 years.  Enrollees were comprised of 46,065 (8.0%) non-Hispanic Asian or Pacific Islander women, 88,577 non-Hispanic Black (15.4%) women, 104,866 (18.2%) Hispanic women, 258,276 (44.9%) non-Hispanic White women, and 74,534 (13.0%) of the women were classified as “other race and ethnicity.”

Findings and further factors

A total of 272,921 women (47.4%) received neuraxial analgesia.  Study data showed that labor neuraxial analgesia was associated with a decreased risk of SMM, which was partially mediated through a decreased risk of PPH.  SMM occurred in 7,712 women (1.3 percent), of whom 2,748 (36 percent) had PPH.  Use of neuraxial analgesia for vaginal delivery was associated with a 14 percent decrease in the risk of SMM and the decreased risk was consistent across racial and ethnic groups and across risk groups.

Interestingly, decreased risk of PPH accounted for only 21% of the protective association of labor neuraxial analgesia with the risk of SMM, indicating that there are other mechanisms linking labor neuraxial analgesia to the decreased risk of SMM.  Other potential mechanisms the authors conjecture may include “sustained intrapartum hemodynamic monitoring of parturient women with neuraxial analgesia, which enhances maternal monitoring and early detection of blood loss immediately after delivery; adequate intravenous access and fluid resuscitation; and continuous anesthesia availability and oversight of the process of labor and delivery and preparedness for acute events.”

Neuraxial underutilized in the uninsured

The authors cite the literature demonstrating that lower labor neuraxial analgesia utilization has been repeatedly reported among racial and ethnic minority, uninsured, and low-income obstetric patients.  Approximately 80% of non-Hispanic White women receive labor neuraxial analgesia nationwide, compared with 70% of non-Hispanic Black women and only 65% of Hispanic women.  Further, approximately 75% of pregnant women with health insurance receive labor neuraxial analgesia but only 50% of uninsured pregnant women do.

Addressing the SMM gap

The senior study author suggests that several intervention programs could help increase access to and utilization of labor neuraxial analgesia, including prenatal maternal education, Medicaid expansions, and in-house obstetric anesthesia teams.

“Implementation of language-concordant educational programs have been associated with decreased misconceptions about neuraxial analgesia and increased neuraxial analgesia utilization among racial and ethnic minority women,” the authors write.

Cost is also a barrier to be surmounted, the researchers state, citing statistics that show that the mean cost of a labor neuraxial analgesia in the US is approximately $2,100.  In fact, they note that labor neuraxial analgesia is one of the most frequent surprise bills for childbirth.

Lastly, the authors advocate for the continuous availability of an in-house obstetric anesthesia team in order to provide uninterrupted access to labor neuraxial analgesia.  Noting that continuous in-house coverage of obstetric anesthesia services is available in ~86% of hospitals in which more than 1,500 deliveries are conducted annually, they cite that the majority of childbirths in the US occur in hospitals in which fewer than 1,000 deliveries take place per year (~60%) and in which such continuous coverage is far less available.

In summary, the authors posit that expanding access to and utilization of labor neuraxial analgesia may contribute to improving maternal health outcomes.

Be sure to read the full study, “Use of Labor Neuraxial Analgesia for Vaginal Delivery and Severe Maternal Morbidity” and its vital implications for women’s health at: https://pubmed.ncbi.nlm.nih.gov/35365403/