Socio-economic disadvantage and utilisation of labour epidural analgesia in Scotland: a population-based study†

Influence of smoking and socioeconomic status on labor analgesia: a nationwide register-based study in Finland

PURPOSE

Labor pain can be treated by medical and non-medical analgesia. Smoking during pregnancy has been shown to increase the incidence of several complications and may influence analgesic effectiveness. Previous studies have linked socioeconomic status to the use of epidurals for labor analgesia. We aimed to determine whether smoking and socioeconomic status influence the use of labor analgesia in Finland.

METHODS

From January 1, 2004 to December 31, 2018, we collected data from the national Finnish Medical Birth Register on smoking status, labor analgesia, and socioeconomic status during pregnancy. These categorized variables were presented as absolute numbers and percentages. We included data on singleton pregnancies and excluded any data on pregnancies that missed smoking or socioeconomic status.

RESULTS

71,603 women smoked during the first trimester, 42,079 women continued to smoke after the first trimester, and 641,449 were non-smokers. The four most used labor analgesia were nitrous oxide, epidural, other medical analgesia, and non-medical analgesia. The most frequently used analgesia was nitrous oxide, which was used by 60.8% of the group of smokers after the first trimester, 58.8% of smokers during the first trimester, and 54.5% of non-smokers. There were no substantial differences between socioeconomic status classes and labor analgesia used.

CONCLUSION

Women who continued smoking after the first trimester used labor analgesia more often than non-smokers. There were no clear differences between socioeconomic status classes and labor analgesia used. These findings highlight the need to reduce maternal smoking during pregnancy, and universal social healthcare systems should promote equality in labor analgesia.

Epidural analgesia during labour and severe maternal morbidity: population based study

OBJECTIVES

To determine the effect of labour epidural on severe maternal morbidity (SMM) and to explore whether this effect might be greater in women with a medical indication for epidural analgesia during labour, or with preterm labour.

DESIGN

Population based study.

SETTING

All NHS hospitals in Scotland.

PARTICIPANTS

567 216 women in labour at 24+0 to 42+6 weeks' gestation between 1 January 2007 and 31 December 2019, delivering vaginally or through unplanned caesarean section.

MAIN OUTCOME MEASURES

The primary outcome was SMM, defined as the presence of ≥1 of 21 conditions used by the US Centers for Disease Control and Prevention (CDC) as criteria for SMM, or a critical care admission, with either occurring at any point from date of delivery to 42 days post partum (described as SMM). Secondary outcomes included a composite of ≥1 of the 21 CDC conditions and critical care admission (SMM plus critical care admission), and respiratory morbidity.

RESULTS

Of the 567 216 women, 125 024 (22.0%) had epidural analgesia during labour. SMM occurred in 2412 women (4.3 per 1000 births, 95% confidence interval (CI) 4.1 to 4.4). Epidural analgesia was associated with a reduction in SMM (adjusted relative risk 0.65, 95% CI 0.50 to 0.85), SMM plus critical care admission (0.46, 0.29 to 0.73), and respiratory morbidity (0.42, 0.16 to 1.15), although the last of these was underpowered and had wide confidence intervals. Greater risk reductions in SMM were detected among women with a medical indication for epidural analgesia (0.50, 0.34 to 0.72) compared with those with no such indication (0.67, 0.43 to 1.03; P<0.001 for difference). More marked reductions in SMM were seen in women delivering preterm (0.53, 0.37 to 0.76) compared with those delivering at term or post term (1.09, 0.98 to 1.21; P<0.001 for difference). The observed reduced risk of SMM with epidural analgesia was increasingly noticeable as gestational age at birth decreased in the whole cohort, and in women with a medical indication for epidural analgesia.

CONCLUSION

Epidural analgesia during labour was associated with a 35% reduction in SMM, and showed a more pronounced effect in women with medical indications for epidural analgesia and with preterm births. Expanding access to epidural analgesia for all women during labour, and particularly for those at greatest risk, could improve maternal health.