Epidurals may do more than relieve pain—they could save lives

With childbirth being a leading cause of death in many areas of the world, expectant mothers have long tried to mitigate the fear and discomfort associated with having a baby. Historically, that’s meant using all manner of pain-relief interventions including hypnosis, opium, counterpressure, water immersion, and herbal remedies such as raspberry leaf and black cohosh.

Many women still use some of these options, but there are more choices today including pain-relieving narcotics, specialized massage therapy, acupuncture, and nitrous oxide. The most popular choice: receiving an injection in the lower back, known as an epidural.

“While there are a variety of other methods of pain relief available, nothing is as effective as the epidural,” says William Camann, a physician and director emeritus of obstetric anesthesiology at Brigham and Women’s Hospital in Boston.

Though pain relief is the primary reason most women choose an epidural, new research from scientists at the University of Glasgow and the University of Bristol shows that having an epidural also lowers the risk of serious complications in the weeks following childbirth—by as much as 35 percent.

“This finding underscores the importance of providing women with accurate information about epidurals and ensuring all women have equal access to them,” says Rachel Kearns, lead author of the study and an honorary professor at the University of Glasgow Medical School in Scotland.

The study also shows an epidural-related 50 percent risk reduction for women in complicated pregnancies and a 47 percent risk reduction among mothers delivering preterm.

“These are statistically very significant beneficial effects” for at-risk expectant mothers choosing to receive an epidural, says Mark Zakowski, chair of the American Society of Anesthesiologists’ committee on obstetric anesthesia, who was not involved in the study.

The research also addresses “a very important issue in maternal health, which is keeping pregnant people safe during childbirth,” adds Yalda Afshar, a maternal-fetal medicine specialist and the co-director of the cardio-obstetrics program at UCLA Health in California, who was also not involved in the research.

But the study has limitations, and its researchers only focused on birth complications related to the mother, not the newborn child. Some of these studied maternal complications included blood clotting, infections requiring hospitalization such as sepsis, excessive bleeding, hysterectomy, and risk of heart failure.

The researchers noted these and other major complications occurring during the six weeks following childbirth among 567,216 women who had babies in Scotland from 2007 through 2019.

While these results are encouraging for this population, because 93 percent of the women included in the research were white and living within one country, "it limits (the study’s) applicability to more ethnically diverse populations," Kearns notes.

Why epidurals are helpful

Among the reasons epidurals are thought to mitigate complications is that having one can alleviate the mother's stress response, "such as lowering stress hormone levels, blood pressure, and heart rate," explains Kearns. It can also ameliorate the physiological demands of cardiovascular and respiratory work, says Zakowski, which can provide "important physiologic protections to people with underlying and perhaps undiagnosed medical conditions."

In case of emergencies, epidurals also have the advantage of being localized and a safer alternative to general anesthesia—if the epidural was already in place when the emergency began.

"Since labor is unpredictable, if you need an emergency C-section, having an epidural will prevent complications or harm to mother or baby that’s sometimes associated with general anesthesia," says Meleen Chuang, chief of obstetrics and gynecology at NYU Langone Hospital in Brooklyn.

Epidurals can also provide an opportunity for mothers in especially long labors to rest and regain their strength to be able to potentially avoid a cesarean section altogether, "due to improved tolerance of a multi-hour or multi-day excruciating experience," says David Gutman, an obstetric anesthesiologist at the MUSC Health University Medical Center in South Carolina.

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In this way, an epidural may also provide a less traumatic experience for laboring mothers, which has been linked to decreased instances of postpartum depression.

Access to robust medical care

While epidurals can reduce complications, this new research also underscores the importance of access to competent medical care for more populations around the world.

"Although it is possible that the epidural medications studied in this research improved outcomes by reducing stress, I think it's more likely that having an anesthesia provider become part of the care team was the magic dust here," says Philip Hess, a physician and anesthesiology researcher at Harvard Medical School, who was not involved in the research.

He points to the extra pair of eyes and critical-care training that anesthesia providers receive as being especially helpful; plus being at a medical care center capable of providing epidurals usually means the presence of additional diagnostic and monitoring equipment that can prevent or catch many complications.

Kearns agrees that these external factors likely significantly improved the results of her teams’ research and adds that laboring women getting epidurals are also more likely to receive additional hydration and medication intravenously than mothers laboring without a dedicated injection site.

"From our data, we can’t fully separate the direct effect of the epidural from the package of care it involves as having an epidural during labor changes the woman's care pathway to enhance the ability to manage adverse events," she says.

Lingering questions

Alexandra Grosvenor Eller, a maternal-fetal medicine physician at Intermountain Health in Salt Lake City, also points to the fact that the study’s postpartum period of six weeks instead of the more commonly studied period of two to four weeks could also complicate the study’s findings.

"Other studies typically focus on complications immediately encountered during the delivery hospitalization," she explains. "Postpartum serious morbidity is complex, and while some later cases could plausibly be associated with labor and the presence of an epidural in ways we don't understand very well, many may not be related."

Gutman says there are also "innumerable confounding factors when evaluating on so broad a scale," as medical practices can vary from hospital to hospital and region to region. "It is therefore hard to extrapolate the population data from Scotland to, let's say, Charleston, South Carolina," he says.

Indeed, a JAMA study from 2022 showed a significantly more modest 14 percent reduction in complications stemming from epidural use, and that study similarly measured the data of more than half a million women—though in New York hospitals instead of Scottish ones.

If the new research results can be replicated in another country, however, it will be encouraging.

"Pregnancy is not without risk, and this is even more true for minority populations," says Elizabeth Mack, a physician and the head of the pediatric critical care unit at MUSC Children’s Health in South Carolina. She notes that the maternal mortality rate in 2022 in the United States was 22.3 deaths per 100,000 births, while that number was 13.4 deaths per 100,000 births in the United Kingdom. "Therefore, equitable adoption of factors that will mitigate birth-related risks such as epidural anesthesia are important to consider," she says.

Not getting an epidural is still okay

While epidurals are among the safest and most proven medical interventions available today, some of the reasons expectant mothers sometimes choose not to get them is a fear of needles, not wanting to "miss out" on the full birth experience, their high price tag—without insurance, the added cost of an epidural can range from $1,000 to $8,000—or religious or cultural beliefs, notes Zakowski.

"The sensation of numbness is also very unusual, and some women do not like it," adds Chuang. "One can also get what's called a 'spinal headache' after the epidural, which may be difficult to treat," says Mack. She adds that, in rare cases, nerve damage can also occur.

Regardless of one's reason for choosing not to get an epidural, Camann says there are "other methods of pain relief available—both pharmacological and nonpharmacological." Hess agrees that choosing whether to get an epidural for pain relief or not is "100 percent an individual decision," which healthcare providers should not try to influence unless preexisting conditions need to be considered.

"Women with low-risk pregnancies should feel empowered to make the choice that best suits their personal preference," Eller echoes. "I think it's premature to suggest that all women be strongly recommended to get an epidural to reduce severe maternal morbidity."

Afshar similarly stresses that the new research "in no way states that not choosing to have a labor epidural is unsafe;" rather, she hopes the results will reassure families choosing to get one that the procedure is effective, safe, and, in some cases, “may even reduce one's risk of serious complications.”