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I recently saw an article that stated that the use of an epidural in vaginal deliveries was associated with a decrease in the risk for severe maternal morbidity, and this was true regardless of the woman’s race. That seems really significant. What is your take on this study?
—Caren
This is a very nice study; you can see it in full here. The big takeaway? Epidurals were linked to a 14% drop in severe maternal morbidity, mostly driven by a 9% decrease in the risk of postpartum hemorrhage (defined as a loss of more than 1,000 milliliters of blood). This can often be treated, but it is scary and dangerous. Since hemorrhage only happens in about 2% of births to begin with, the epidural essentially lowers that risk by 0.2%. In simpler terms, for every 1,000 people who get an epidural, about two will avoid a hemorrhage they otherwise would have had. This effect is significant, but it is small in magnitude.
The paper is an observational study — they compare women who had epidurals with those who did not — and as you would expect, the samples are quite different. Epidurals are more common among women who give birth in teaching hospitals, for example, and those hospitals have better resources on other dimensions, too. These differences are a concern, but what is effective about their analysis, though, is that they have a huge sample: seven years of all births in New York, for a sample size of almost 600,000. This allows them to better match the women with epidurals to those who do not have them.
When they do this matching, they are able to better compare across similar women, and they find this reduction in risk for those who use an epidural. Since they can’t see every detail of a patient’s life, they can’t be 100% certain that the epidural alone made the difference. The study doesn’t prove why this happens, though the authors have a solid theory. They suggest that because certain emergency interventions can be painful, doctors might be able to step in and help much faster if a patient already has an epidural in place.
These results were echoed in a 2024 study in Scotland with a very similar design — a comprehensive analysis of the relationship between epidural analgesia and severe maternal morbidity in general. That study didn’t focus on postpartum hemorrhage, but that would be one common cause of severe birth complications. As in the U.S. study, the group that got epidurals differed from the one that did not, making it hard to know how much of it was the epidural’s impact.Is this a reason to have an epidural if you otherwise do not want one? Perhaps not, given the small effects. But I share the view of the authors that it is a reason that epidurals should be available to everyone if they do want them. And certainly this deserves more research.
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Getting ready to birth second baby soon and there is Zero chance I would ever attempt that without an epidural. It’s a miracle of science and the result is little to no pain for pretty much the entire labor and delivery experience and recovery that day. I was fortunate to have a great anesthesiologist. My relatives and one or two friends have birthed without it and I think they are clinically insane.