Vaginal delivery with neuraxial analgesia lowers risk for severe maternal morbidity
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Using neuraxial analgesia in women undergoing their first vaginal delivery was associated with a reduced risk for severe maternal morbidity, according to a retrospective cross-sectional study in JAMA Network Open.
“An old study conducted in France suggested that epidural analgesia during childbirth resulted in a decreased risk of postpartum hemorrhage — the first cause of preventable maternal morbidity and mortality,” Jean Guglielminotti, MD, PhD, assistant professor of anesthesiology at Columbia University Vagelos College of Physicians and Surgeons, told Healio. “We believed it was important to replicate this study in the United States because of the advances in obstetric and anesthesia care practices during the last 15 years, and because of the marked differences in the health care systems between the United States and France.”
Data collection
Guglielminotti and colleagues analyzed the medical records of 575,524 women (mean age, 28 years; 44.9% non-Hispanic white) who were hospitalized for vaginal delivery from January 2010 to December 2017 available through the New York State Inpatient Database. They noted whether patients received no anesthesia or neuraxial analgesia (47.4%), as well as the incidence of severe maternal morbidity (SMM) — defined by the CDC — and postpartum hemorrhage (PPH).
The researchers also stratified their analysis according to race and ethnicity and whether the women were at low or high risk based on the comorbidity index for obstetric patients (CMI-OB). The low-risk CMI-OB group comprised 69.6% of the study population.
Analysis of SMM risk
SMM occurred in 7,712 women (1.3%; 95% CI, 1.31-1.37), 2,748 (35.6%) of whom had PPH. In an unadjusted analysis, women with neuraxial analgesia had a lower risk of SMM compared with those who underwent labor without it (risk difference, 0.12%; 95% CI, 0.17 to 0.07). Even after the researchers adjusted their analysis, the odds remained lower for women with neuraxial analgesia (adjusted OR = 0.86; 95% CI, 0.82-0.9).
Neuraxial analgesia reduced risk of SMM similarly across high- and low-risk patients, as well as across races and ethnicities.
“We suggest that increasing access to and utilization of epidural during childbirth, especially for racial and ethnic minority women, could be a feasible strategy to improve maternal health and reduce disparities in maternal health,” Guglielminotti said.
However, according to the researchers, the decreased risk for PPH accounted for only 21% (95% CI, 14%-28%) of the protective association between neuraxial analgesia and SMM risk.
“Other possible mechanisms [responsible for this association] 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,” Guglielminotti and colleagues wrote in the study.
The researchers cautioned that the study was limited by its observational design — suggesting that the associations between neuraxial analgesia and SMM are not necessarily causal — and they did not specifically assess the risk for SMM by race because of the low number of cases in some patient groups. Moreover, they said the study did not examine neuraxial techniques, lacked specific data on hospital staffing, excluded women who had an intrapartum cesarean delivery and did not account for SMM occurring after discharge.
Despite these limitations, Guglielminotti called for “more research on the effect of possible interventions to increase the use of epidural analgesia during labor.”