Having an epidural during childbirth is associated with a noticeable reduction in complications in the first few weeks after giving birth.
This is according to a new study by researchers from the University of Bristol and the University of Glasgow that suggests expanding access to epidural analgesia could improve maternal health.
In the UK, severe maternal morbidity (SMM) has almost doubled from 0.9% of deliveries in 2009 to 1.7% in 2018.
Now, research shows that an epidural might help to reduce the risk of SMM complications such as heart attack, heart failure, sepsis and hysterectomy.
The researchers set out to determine the effect of labour epidural on SMM and explore whether this was greater in women with a medical indication for epidural in labour or those in preterm labour.
The findings are based on Scottish National Health Service data for 567,216 mothers in labour (average age 29, 93% white) delivering vaginally or via unplanned caesarean section in Scotland between 2007 and 2019.
Medical records were used to identify any of the 21 conditions defined as SMM by the US Centres for Disease Control and Prevention or a critical care admission from delivery to 42 days after giving birth.
Factors such as the mother’s age, ethnicity, weight, smoking history and pre-existing conditions, as well as birth location and gestational age at birth, were also taken into account.
Of the 567,216 women, 125,024 (22%) had an epidural in labour, and SMM occurred in (4.3 per 1000 births).
An epidural was associated with a 35% reduction in SMM in all women in the study. Greater reductions were seen among women with a medical indication for epidural (50% risk reduction) compared to those without (33% risk reduction) and in women delivering preterm (47% risk reduction) compared to term or post-term (no evidence of reduced risk).
Notably, among the 77,439 women in the study who were at higher risk of severe maternal morbidity, only 19,061 (24.6%) received an epidural.
Possible explanations for the benefits of an epidural on SMM include:
• Closer monitoring of women with an epidural
• Blunting of physiological stress responses to labour
• Avoidance of the need for spinal or general anaesthesia for caesarean section
• Faster escalation to definitive obstetric interventions.
The relatively low use of epidurals, particularly in those with clinical indications, may reflect women not fully understanding the potential benefits, as it is women’s choice that determines whether or not they have an epidural
This is an observational study, so no firm conclusions about cause and effect can be drawn. The authors acknowledge several limitations that may have influenced their results. The study also involved predominantly white women delivering in Scotland, which may limit generalisability to ethnically diverse populations or different healthcare settings, they add.
However, this large, well-designed study reflects contemporary obstetric and anaesthetic practices. Results were similar after further analyses, supporting the robustness of the findings.
The authors concluded: ‘These findings substantiate the current practice of recommending epidural analgesia during labour to women with known risk factors, underscores the importance of ensuring equitable access to such treatment. Taken together with previous research by the same group of lower use of labour epidural in women from more deprived areas and of non-white European ethnicity, they highlight the importance of supporting women from diverse backgrounds to be able to make informed decisions relating to epidural analgesia during labour.’
These findings suggest that epidural analgesia is a viable protective option for at-risk pregnancies, and decision-makers should consider this new benefit to improve maternal health outcomes, researchers said in a linked editorial.
They point to the importance of understanding the mechanisms behind this protective effect and recognising inequalities in uptake, with much lower rates in, for example, minority ethnic groups and socioeconomically deprived communities.
With this in mind, these findings ‘might serve as a catalyst for initiatives to improve equitable access to epidural analgesia during labour, potentially mitigating SMM and improving maternal health outcomes across diverse socioeconomic and ethnic backgrounds’.
Professor Rachel Kearns, lead author of the study from the University of Glasgow, said: ‘Our research reveals that epidural analgesia during labour is linked to a substantial decrease in severe maternal health complications. This finding underscores the need to ensure access to epidurals, particularly for those who are most vulnerable – women facing higher medical risks or delivering prematurely.’
Deborah Lawlor, Professor of Epidemiology at the University of Bristol and one of the study’s authors, added: ‘It is important that women and their partners have control over their treatment during pregnancy, including using an epidural during labour. It is also important that women who would benefit from an epidural to prevent them becoming seriously ill are provided with easy-to-understand information to help them make an informed decision.’
