WHO recommendation on epidural analgesia for pain relief during labour

Close up of epidural analgesia.

WHO recommendation on epidural analgesia for pain relief during labour

 

Recommendation

Epidural analgesia is recommended for healthy pregnant women requesting pain relief during labour, depending on a woman’s preferences.

(Recommended)

 

Publication history

First published: February 2018

Updated: No update planned 

Assessed as up-to-date: February 2018 

 

Remarks

  • The GDG agreed that while there is limited evidence on the impact of epidural analgesia compared with no epidural analgesia for pain relief during labour, epidural analgesia is a proven method for relieving pain related to surgery, including abdominal surgery, and chose to recommend it as a pain relief option.
  • Health care professionals should be aware that women’s desire for epidural analgesia might be moderated by the clinical context in which they receive antenatal and intrapartum care, whether labour is spontaneous or not, and their access to and knowledge of a range of other forms of pain relief measures. 
  • It is likely that the care context and the type of care provision and care provider have a strong effect on the need for labour pain relief, and on the kinds of choices women make in relation to this need. 
  • Both commonly used pharmacological options for pain relief during labour – epidural and opioid analgesic options – have advantages and disadvantages. Epidural analgesia appears to be the more effective pain relief option but compared with opioid analgesia it also requires more resources to implement and to manage its adverse effects, which are more common with epidural analgesia. 
  • To avoid complications and preserve as much motor function as possible, the lowest possible effective concentration of local anaesthetic should be used when administering epidural analgesia (1). 
  • For women with epidural analgesia in the second stage of labour, it is recommended that a birth position of the individual woman’s choice be facilitated, including an upright birth position. For women with epidural analgesia in the second stage of labour, delaying pushing for one to two hours after full dilatation or until the woman regains the sensory urge to bear down is recommended.

 

Background

Globally, approximately 140 million births occur every year (2). The majority of these are vaginal births among pregnant women with no identified risk factors for complications, either for themselves or their babies, at the onset of labour (3,4). However, in situations where complications arise during labour, the risk of serious morbidity and death increases for both the woman and baby. Over a third of maternal deaths and a substantial proportion of pregnancy-related life-threatening conditions are attributed to complications that arise during labour, childbirth or the immediate postpartum period, often as result of haemorrhage, obstructed labour or sepsis (5,6). Similarly, approximately half of all stillbirths and a quarter of neonatal deaths result from complications during labour and childbirth (7). The burden of maternal and perinatal deaths is disproportionately higher in low- and middle-income countries (LMICs) compared to high-income countries (HICs). Therefore, improving the quality of care around the time of birth, especially in LMICs, has been identified as the most impactful strategy for reducing stillbirths, maternal and newborn deaths, compared with antenatal or postpartum care strategies (8).

Over the last two decades, women have been encouraged to give birth in health care facilities to ensure access to skilled health care professionals and timely referral should the need for additional care arise. However, accessing labour and childbirth care in health care facilities may not guarantee good quality care. Disrespectful and undignified care is prevalent in many facility settings globally, particularly for underprivileged populations, and this not only violates their human rights but is also a significant barrier to accessing intrapartum care services (9). In addition, the prevailing model of intrapartum care in many parts of the world, which enables the health care provider to control the birthing process, may expose apparently healthy pregnant women to unnecessary medical interventions that interfere with the physiological process of childbirth.

As highlighted in the World Health Organization (WHO) framework for improving quality of care for pregnant women during childbirth, experience of care is as important as clinical care provision in achieving the desired person-centred outcomes 10).

This up-to-date, comprehensive and consolidated guideline on intrapartum care for healthy pregnant women and their babies brings together new and existing WHO recommendations that, when delivered as a package of care, will ensure good quality and evidence-based care in all country settings. In addition to establishing essential clinical and non-clinical practices that support a positive childbirth experience, the guideline highlights unnecessary, non-evidence-based and potentially harmful intrapartum care practices that weaken women’s innate childbirth capabilities, waste resources and reduce equity.

To ensure that each recommendation is correctly understood and applied in practice, the context of all context-specific recommendations is clearly stated within each recommendation, and the contributing experts provided additional remarks where needed.

In accordance with WHO guideline development standards, these recommendations will be reviewed and updated following the identification of new evidence, with major reviews and updates at least every five years.

 

Methods

These recommendations were developed using standard operating procedures in accordance with the process described in the WHO handbook for guideline development (11). Briefly, these procedures include: (i) identification of priority questions and outcomes; (ii) evidence retrieval and synthesis; (iii) assessment of the evidence; (iv) formulation of the recommendations; and (v) planning for implementation, dissemination, impact evaluation and updating of the guideline.

The quality of the scientific evidence underpinning the recommendations was graded using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) (12) and Confidence in the Evidence from Reviews of Qualitative research (CERQual) (13) approaches, for quantitative and qualitative evidence, respectively. Up-to-date systematic reviews were used to prepare evidence profiles for priority questions.

The GRADE evidence-to-decision (EtD) framework (14), an evidence-to-decision tool that includes intervention effects, values, resources, equity, acceptability and feasibility criteria, was used to guide the formulation of recommendations by the Guideline Development Group (GDG) – an international group of experts assembled for the purpose of developing this guideline – at two technical consultations in May and September 2017. In addition, relevant recommendations from existing WHO guidelines approved by the Guidelines Review Committee (GRC) were systematically identified and integrated into this guideline for the purpose of providing a comprehensive document for end-users.

 

Further information on procedures for developing this recommendation are available here.

 

Recommendation question

For this recommendation, we aimed to answer the following question:

  • For healthy pregnant women requesting pain relief during labour (P), should epidural analgesia (I), compared with no pain relief or other forms of pain relief (C), be offered to relieve labour pain and improve birth outcomes (O)?

 

Evidence summary

This evidence is derived from a Cochrane systematic review, to which 43 trials contributed data (15).

 

Any epidural analgesia compared with placebo or no epidural analgesia

 Seven trials involving 897 women compared epidural analgesia with no analgesia. Trials were conducted in hospital settings in China (3 trials) and in Brazil, India, Mexico and Turkey (1 trial each). Sample sizes of individual trials ranged from under 100 to just over 300 women. One trial took place between 1990 and 2000, three from 2010 onwards, and dates were not stated in the other three trials. All trials used bupivacaine or ropivacaine for the epidural analgesia. Ropivacaine was supplemented with sufentanil in one trial; bupivacaine was supplemented with fentanyl in one trial and with tramadol in another. Patient-controlled epidural analgesia was used in two trials. Three trials used the combined spinal–epidural technique. Control groups included: no analgesia (4 trials, 637 women); no epidural analgesia but other analgesia (not specified) offered (2 trials, 190 women); and continuous support with non-pharmacological analgesia offered to both groups (1 trial, 70 women).

Maternal outcomes

Pain relief: It is uncertain whether epidural analgesia compared with no analgesia reduces pain scores, pain intensity or the need for additional analgesia during labour because the certainty of the evidence for all of these outcomes is very low.

Mode of birth: Moderate-certainty evidence suggests that epidural analgesia probably leads to fewer women undergoing caesarean birth compared with no analgesia (5 trials, 578 women, RR 0.46, 95% CI 0.23–0.90). It is uncertain whether epidural has an effect on instrumental births because the certainty of this evidence is very low.

Duration of labour: It is not clear whether epidural analgesia makes any difference to the length of the first or second stages of labour compared with placebo, as the certainty of the evidence is very low.

Augmentation of labour: Low-certainty evidence suggests that epidural analgesia may make little or no difference to whether or not women receive oxytocin for labour augmentation (3 trials, 415 women, RR 0.89, 95% CI 0.63–1.24).

Birth experience: Low-certainty evidence from a single trial suggests that epidural may increase the proportion of women reporting they were satisfied or very satisfied with pain relief in labour (70 women, RR 1.32, 95% CI 1.05–1.65). Compared with no analgesia, it is uncertain whether epidural affects women’s perceived feelings of poor control in childbirth because the certainty of this evidence is very low.

Side-effects: Review evidence on the relative effect of epidural compared with placebo or no intervention on hypotension, vomiting, fever, drowsiness or urinary retention is very uncertain.

Fetal and neonatal outcomes

Perinatal hypoxia-ischaemia: It is uncertain whether epidural analgesia has an effect on the number of babies born with Apgar scores of less than 7 at 5 minutes because the certainty of this evidence is very low.

Long-term outcomes: These were not reported in the included studies. Mother–baby interaction and breastfeeding: These were not reported in any of the included trials.

Values

In a review of qualitative studies looking at what matters to women during intrapartum care (17), findings suggest that most women, especially those giving birth for the first time, are apprehensive about childbirth (high confidence in the evidence), and in certain contexts and/or situations may welcome interventions that provide relief from pain (low confidence in the evidence). When interventions are being considered, women would like to be informed about the nature of the interventions and, where possible, given a choice (high confidence in the evidence). A review of qualitative studies on women’s experiences of the use of epidural analgesia when they request pain relief (from HICs only) highlights that women desire and value epidural analgesia when its use alleviates labour pain effectively, and they also value that it enables them to retain control over childbirth (moderate confidence in the evidence) (18). However, some women are fearful of receiving an epidural injection due to potential pain and complications, and there were mixed views on whether the pain relief provided was actually effective or ineffective in their experience (low confidence in the evidence). Some women perceive that epidural analgesia helped them to have a positive childbirth experience (moderate confidence in the evidence). Women value the opportunity to make a choice about this method of pain relief and value the support of professionals and family members for their decision on pain-relief (low confidence in the evidence).

Additional considerations

All the included qualitative studies on the use of epidural analgesia were undertaken in high-income settings. Six were undertaken in the USA. It was not possible to identify, within the included studies, whether women had had augmentation, induction of labour or other forms of intervention that may have influenced how they valued the outcomes associated with this form of pain relief. In some cultures, women might consider labour pain an integral part of childbirth and view physical expression of pain or discomfort as a sign of weakness. In addition, some women might view the use of epidural analgesia as an intervention that negatively impacts their sense of control during labour and childbirth.

Resources

No recent reviews on costs and cost-effectiveness were found; however, a 2002 USA review of the cost-effectiveness of epidural compared with opioid analgesia suggests that providing epidural analgesia for labour pain relief costs more than opioid analgesia (19). In the review, the mean cost of a hospital-based vaginal birth was US$ 3117, and the incremental expected cost of providing epidural analgesia was estimated at US$ 338 (1998 values), primarily due to higher costs for health care professionals (estimated at US$ 238) and increased costs associated with complications (estimated at US$ 120). The costs modelled for epidural analgesia assumed more instrumental vaginal births (14% vs 10%), fever (24% vs 6%), oxytocin augmentation (45% vs 35%), urinary retention (2.7% vs 0.13%), postural puncture headache (1.5% vs 0%), hypotension requiring treatment (30% vs 0%) and a longer duration of labour (7 hours versus 6 hours for the first stage, and 1.75 hours versus 1.5 hours for the second stage) than opioid analgesia, in addition to a higher rate of less-common complications. Opioid analgesia costs assumed a higher incidence of respiratory depression among women receiving opioids (14% vs 2%), a higher incidence of neonatal resuscitation due to respiratory depression (4.5% vs 0.5%) and more pruritis (14% vs 12%). Caesarean section was assumed to occur at the same rate for epidural and opioid analgesia (20%).

Additional considerations Findings from other studies suggest that costs per birth are substantially higher with epidural analgesia (20, 21). For example, in an Australian study, epidural analgesia use alone was shown to increase the average cost of childbirth by up to 36% depending on the type of health care facility (21). For nulliparous women giving birth in a public health care facility, epidural analgesia increased birth costs by 20%, and when combined with labour augmentation it attracted an additional 24% increase in costs (i.e. 44% increase in total). Findings from a Dutch study comparing routine epidural analgesia with analgesia on request reported that birth costs were higher by €322 (€60 to €355) with routine epidural analgesia, due to higher medication costs, a longer stay in hospital, and more caesarean sections and instrumental vaginal births (22). The health care professionals required to administer and monitor epidural analgesia, and to perform instrumental births, are probably the main cost component of this intervention. In the Dutch study, costs attributed to the procedure itself were much higher for epidural analgesia (€122) compared with opioid analgesia (€15). In many settings, women undergoing epidural analgesia cannot be managed in midwife-led birthing units but, rather, are managed at a higher level of care (i.e. hospital obstetric units), such that bed costs are also likely to be higher. Labour ward stays are also likely to be longer with epidural, due to the potential for longer duration of labour and postpartum monitoring.

Equity

No direct evidence was found on the impact of pain relief via epidural analgesia on equity. Indirect evidence from a review of facilitators and barriers to facility-based birth (9) indicates that “neglect and delays in receiving care” probably acts as a barrier to facility-based birth (moderate confidence in the evidence). Such neglect and delays might be applicable to labour pain management. In addition, the review also highlights that many women in LMICs fear “unfamiliar and undesirable” birth practices, which are barriers to facility-based birth (high confidence in the evidence) (9). Some women could perceive epidural injections and other types of injections as unfamiliar and undesirable practices.

Additional considerations

WHO’s 2015 State of inequality report concluded that there are still large gaps in skilled birth attendance coverage (23). Epidural analgesia for pain relief is commonly used in HICs and among more advantaged women in LMICs. Due to its high resource implications, its availability within countries often varies between facilities and, for example, it is often not available in rural areas where women cannot afford it and the expertise is lacking (19). Limited findings from one USA study suggest that women with different sociodemographic characteristics might receive a different level of access to epidural analgesia and/or a different level of participation in decision-making in relation to epidural use (24). Providing effective and timely labour pain relief to disadvantaged women might help to reduce inequalities in intrapartum care directly. Based on the evidence above, it might also impact equity indirectly, by encouraging more disadvantaged women to access facility-based care. However, particularly in LMIC settings, epidural analgesia might be perceived by some women as an unfamiliar and undesirable practice and could act as a barrier to facility-based birth, particularly for women who believe that labour and childbirth are natural processes that do not need intervention, and those who would prefer a traditional approach to pain management. It has been argued that changing the attitudes of health care professionals and women surrounding labour pain and reducing the medicalization of labour discomfort could empower women to rediscover their innate birthing capabilities (25), which might positively impact equity by reducing epidural analgesia use in high-resource settings.

Acceptability

In a qualitative systematic review exploring women’s experiences of epidural analgesia usage (18) there were mixed views. Views were influenced by the availability of epidural analgesia and by accounts of others (moderate confidence in the evidence). Some women expressed an a priori desire for an epidural analgesia to help with a pain-free labour, to alleviate a fear of pain and/or to remain in control during labour (moderate confidence in the evidence), while others requested an epidural as a last resort, when the level of pain and/or sense of control over the labour was overwhelming and unmanageable (low confidence in the evidence). There was evidence that epidural analgesia could help to facilitate a positive labour and childbirth experience by helping women to relax, restore/ renew their energy levels and have a sense of control (moderate confidence in the evidence). However, although some women felt supported by health care professionals in their decision to use epidural analgesia, others felt pressurized or persuaded to do so (by health care professionals, through messages received via antenatal education or from family members) (low confidence in the evidence). Some women who made a decision to receive an epidural analgesia had fears over the procedure and potential risks for themselves and/or their babies (low confidence in the evidence). They experienced negative physiological effects including pain and other complications associated with needle insertion (low confidence in the evidence). Some also felt disconnected from the baby and experienced a range of negative emotions including conflict, guilt, disappointment and a sense of failure (low confidence in the evidence). Some women reported restricted mobility following administration of epidural analgesia (low confidence in the evidence). Pain relief afforded by epidural analgesia was considered effective for some, but not for all (low confidence in the evidence). Perceived lack of effectiveness was attributed to continuing pain, breakthrough pain and/or timing of administration (e.g. when it was administered too late for it to take effect). Another qualitative systematic review on women’s and health care professionals’ experiences of labour and childbirth included health care professionals’ views on epidural analgesia (26); however, the evidence was of very low confidence. The evidence suggests that some midwives feel that epidural analgesia is incongruous with the midwifery philosophy, and associate it with side-effects, disconnection from the baby and the potential for further intervention. Evidence also suggests that some health care professionals believe that, if it is used, it may be more appropriate for nulliparous women or for those with an abnormal labour.

Additional considerations

The qualitative review findings on epidural analgesia (26, 18) are all from studies conducted in HIC settings where epidural usage is common.

Feasibility

Findings from a qualitative systematic review exploring women’s and providers’ experiences of labour and childbirth (26) indicate that some health care professionals in HICs may encourage women to use epidural analgesia because of a heavy workload and a lack of time to provide supportive options (very low confidence in the evidence). A perceived lack of effectiveness of epidural analgesia use reported by women in some studies in another qualitative systematic review (18) was partly attributed to late administration (low confidence in the evidence), suggesting that there might be logistical issues in implementing this pain relief method.

Additional considerations

All of the findings on epidural analgesia in the qualitative reviews (26, 18) came from HIC settings where epidural analgesia is widely available. In lower-resource settings, where it is not so widely used, there are likely to be financial implications as well as additional training considerations, which may negatively impact on the feasibility of implementing this intervention.

 

Epidural analgesia compared with parenteral opioid analgesia

Thirty-five trials involving 10 835 women compared epidural analgesia with opioids (15). Trials were conducted in hospital settings in Canada (3 trials), China (2), Egypt (2), Finland (2), India (2), Israel (2), the Netherlands (3), the United Kingdom (2) and the USA (10), and one trial each in Denmark, France, Iran, Kuwait, Malaysia, Norway and Sweden. Sample sizes in individual trials varied considerably, ranging from less than 50 to more than 1000 women. Eleven trials were conducted between 1990 and 2000, six between 2000 and 2010, three between 2010 and 2013, and the dates were not stated in 14 trials. Bupivacaine or levobupivacaine was used for the epidural analgesia in most of the studies when reported. Bupivacaine was supplemented with fentanyl in 10 of the studies and with tramadol in one study. Levobupivacaine was supplemented with fentanyl in one study. Only four of the studies used the combined spinal–epidural technique. Epidural use was discontinued in the second stage of labour in three studies. Opioids compared included pethidine (17 trials, 6889 women), butorphanol (1 trial, 100 women), fentanyl (3 trials, 447 women) and remifentanil (9 trials, 3462 women), while other opioids were used in the remaining trials. Opioids were administered as patient-controlled intravenous analgesia in 19 trials, intravenous injection in 10 trials, and intramuscular injection in 5 trials (the route of administration was unclear in 1 trial).

Maternal outcomes

Pain relief: Low-certainty evidence suggests that epidural analgesia may reduce pain scores in women during labour compared with parenteral opioid analgesia (5 trials, 1133 women, standardized mean difference [SMD] -2.64, 95% CI -4.56 to -0.73; this equates to a difference of approximately 3 points lower on a 10-point scale). Low-certainty evidence suggests that women who receive epidural may be more likely than those receiving opioids to rate pain relief as excellent or very good (7 trials, 1911 women, RR 1.47, 95% CI 1.03–2.08). Low-certainty evidence suggests epidural may reduce the need for any additional analgesia (16 trials, 5099 women, RR 0.10, 95% CI 0.04–0.25).

Mode of birth: Low-certainty evidence suggests that epidural may increase instrumental vaginal birth, with 13.2% in the epidural analgesia group having an instrumental vaginal birth compared with 9.6% in the parenteral opioids group (31 trials, 10 343 women, RR 1.43, 95% CI 1.29–1.59). Moderate-certainty evidence suggests that epidural analgesia probably leads to little or no difference in the numbers of women undergoing caesarean birth (34 trials, 10 745 women, RR 1.07, 95% CI 0.97–1.19).

Duration of labour: Moderate-certainty evidence suggests that the length of the first stage of labour is probably increased by approximately 30 minutes for women receiving epidural analgesia compared with parenteral opioids (10 trials, 2654 women, MD 29.79 minutes, 95% CI 12.79–46.79) and low-certainty evidence suggests that the length of the second stage may be increased by approximately 15 minutes (MD 14.96, 95% CI 8.96–20.96).

Augmentation of labour: Low-certainty evidence suggests that augmentation of labour with oxytocin may be increased with epidural analgesia compared with parenteral opioids (20 trials, 8746 women, RR 1.11, 95% CI 1.01–1.22).

Birth experience: Low-certainty evidence from a single trial suggests that epidural analgesia may make little or no difference to women’s perception of poor control in childbirth (334 women, RR 1.17, 95% CI 0.62–2.21) or to the number of women reporting they were satisfied or very satisfied with their childbirth experience (332 women, RR 0.95, 95% CI 0.87–1.03).

Side-effects: Low-certainty evidence suggests that epidural analgesia may increase the likelihood of hypotension, although there was considerable inconsistency across trials in the numbers of women reported to have hypotension (10 trials, 4212 women, RR 11.34, 95% CI 1.89–67.95). Moderate-certainty evidence suggests that epidural analgesia is probably associated with a reduced risk of respiratory depression requiring oxygen compared with opioids (5 trials, 2031 babies, RR 0.23, 95% CI 0.05–0.97). It is not clear whether, compared with opioid analgesia, epidural analgesia reduces nausea and vomiting, or maternal drowsiness, as the certainty of the evidence is very low. Low-certainty evidence suggests fever (temperature > 38 °C) may be increased with epidural analgesia (10 trials, 4671 women, RR 2.60, 95% CI 1.82–3.73). Moderate-certainty evidence suggests that, compared with parenteral opioids, the risk of urinary retention is probably increased with epidural analgesia (4 trials, 343 women, RR 9.20, 95% CI 2.28–37.11).

Fetal and neonatal outcomes

Perinatal hypoxia-ischaemia: Low-certainty evidence suggests that there is little or no difference in Apgar scores less than 7 at 5 minutes (23 trials, 9147 babies, RR 0.80, 95% CI 0.58–1.10). Moderate-certainty evidence suggests the number of babies with a cord arterial pH less than 7.2 is probably fewer with epidural analgesia than opioid analgesia (8 trials, 4783 babies, RR 0.81, 95% CI 0.69–0.94); however, low-certainty evidence suggests that there was little or no difference between groups for cord arterial pH less than 7.15 (3 trials, 480 babies, RR 1.17, 95% CI 0.64–2.14). Moderate-certainty evidence suggests that babies whose mothers received epidural analgesia rather than parenteral opioids are probably less likely to need naloxone administration (10 trials, 2645 babies, RR 0.15, 95% CI 0.10–0.23).

Long-term neonatal outcomes: These were not reported in any of the included trials.

Mother–baby interaction and breastfeeding: These were not reported in any of the included trials.

Values

In a review of qualitative studies looking at what matters to women during intrapartum care (17), findings suggest that most women, especially those giving birth for the first time, are apprehensive about childbirth (high confidence in the evidence), and in certain contexts and/or situations may welcome interventions that provide relief from pain (low confidence in the evidence). When interventions are being considered, women would like to be informed about the nature of the interventions and, where possible, given a choice (high confidence in the evidence). Findings from a review of qualitative studies on women’s experiences during labour and childbirth (evidence derived from HICs only) highlights that women desire and value epidural analgesia when its use alleviates labour pain effectively, and they also value that it enables them to retain control over childbirth (moderate confidence in the evidence) (26). However, some women are fearful of receiving an epidural injection due to potential pain and complications, and expressed mixed views on whether the pain relief provided was actually effective or ineffective in their experience (low confidence in the evidence). Some women perceive that epidural analgesia helped them to have a positive childbirth experience (moderate confidence in the evidence). Women value the opportunity to make a choice about this method of pain relief and value the support of professionals and family members for their decision on pain-relief (low confidence in the evidence).

Additional considerations

All the included qualitative studies on the use of epidural analgesia were undertaken in high-income settings. Six were undertaken in the USA. It was not possible to identify, within the included studies, whether women had had augmentation, induction of labour or other forms of intervention that may have influenced how they valued the outcomes associated with this form of pain relief. In some cultures, women might consider labour pain as an integral part of childbirth and view physical expression of pain or discomfort as a sign of weakness. In addition, some women might view the use of epidural analgesia as an intervention that negatively impacts their sense of control during labour and childbirth.

Resources

No recent reviews on costs and cost-effectiveness were found; however, a 2002 USA review of the cost-effectiveness of epidural compared with opioid analgesia suggests that providing epidural analgesia for labour pain relief costs more than opioid analgesia (127). In the review, the mean cost of a hospital-based vaginal birth was US$ 3117, and the incremental expected cost of providing epidural analgesia was estimated at US$ 338 (1998 values), primarily due to higher costs for health care professionals (estimated at US$ 238) and increased costs associated with complications (estimated at US$ 120). Costs modelled for epidural analgesia assumed more instrumental vaginal births (14% vs 10%), fever (24% vs 6%), oxytocin augmentation (45% vs 35%), urinary retention (2.7% vs 0.13%), postural puncture headache (1.5% vs 0.0%), hypotension requiring treatment (30% vs 0%), and a longer duration of labour (7 vs 6 hours for the first stage, and 1.75 vs 1.50 hours for the second stage) than opioid analgesia, in addition to a higher rate of less-common complications. Opioid analgesia costs assumed a higher incidence of respiratory depression among women receiving opioids (14% vs 2%), a higher incidence of neonatal resuscitation due to respiratory depression (4.5% vs 0.5%) and more pruritis (14% vs 12%). Caesarean section was assumed to occur at the same rate for epidural and opioid analgesia (20%).

Additional considerations

Findings from other studies suggest that costs per birth are substantially higher with epidural analgesia (20, 21). For example, in an Australian study, epidural analgesia use alone was shown to increase the average cost of childbirth by up to 36% depending on the type of facility (21). For primiparous women giving birth in a public health facility, epidural analgesia increased birth costs by 20%, and when combined with labour augmentation it attracted an additional 24% increase in costs (i.e. 44% increase in total). Findings from a Dutch study comparing routine epidural analgesia with analgesia on request reported that birth costs were higher by €322 (€60 to €355) with routine epidural analgesia, due to higher medication costs, a longer stay in hospital, and more caesarean sections and instrumental vaginal births (23). The health care professionals required to administer and monitor epidural analgesia, and to perform instrumental births, are probably the main cost component of this intervention. In the Dutch study, costs attributed to the procedure itself were much higher for epidural analgesia (€122) compared with opioid analgesia (€15). In many settings, women undergoing epidural analgesia cannot be managed in midwife-led birthing units but, rather, are managed at a higher level of care (i.e. hospital obstetric units), such that bed costs are also likely to be higher. Labour ward stays are also likely to be longer with epidural, due to the potential for longer duration of labour and postpartum monitoring.

Equity

No direct evidence was found on the impact of pain relief via epidural analgesia on equity. Indirect evidence from a review of facilitators and barrier to facility-based birth (9) indicates that “neglect and delays in receiving care” probably acts as a barrier to facility-based birth (moderate confidence in the evidence). Such neglect and delays might be applicable to labour pain management. In addition, the review also highlights that many women in LMICs fear “unfamiliar and undesirable” birth practices, which are barriers to facility-based birth (high confidence in the evidence) (9). Some women could perceive epidural injections and other types of injections as unfamiliar and undesirable practices.

Additional considerations

WHO’s 2015 State of inequality report concluded that there are still large gaps in skilled birth attendance coverage (23). Epidural analgesia for pain relief is commonly used in HICs and among more advantaged women in LMICs. Due to its high resource implications, its availability within countries often varies between facilities and, for example, it is often not available in rural areas where women cannot afford it and the expertise is lacking (19). Limited findings from one USA study suggest that women with different sociodemographic characteristics might receive a different level of access to epidural analgesia and/or a different level of participation in decision-making related to epidural use (24). Providing effective and timely labour pain relief to disadvantaged women might help to reduce inequalities in intrapartum care directly. Based on the evidence above, it might also impact equity indirectly, by encouraging more disadvantaged women to access facility-based care. However, particularly in LMIC settings, epidural analgesia might be perceived by some women as an unfamiliar and undesirable practice and could act as a barrier to facility-based birth, particularly for women who believe that labour and childbirth are natural processes that do not need intervention, and those who would prefer a traditional approach to pain management. It has been argued that changing the attitudes of health care professionals and women surrounding labour pain (and reducing the medicalization of labour discomfort) could empower women to rediscover their innate birthing capabilities (25), which might positively impact equity by reducing epidural analgesia use in high-resource settings.

Acceptability

In a qualitative systematic review exploring women’s intrapartum care experiences (18), there were mixed views of epidural analgesia usage. Views were influenced by the availability of epidural analgesia, and by accounts of others (moderate confidence in the evidence). Some women expressed an a priori desire for an epidural analgesia to help with a pain-free labour, to alleviate a fear of pain and/ or to remain in control during labour (moderate confidence in the evidence), while others requested an epidural as a last resort, when the level of pain and/or sense of control over the labour was overwhelming and unmanageable (low confidence in the evidence). There was evidence that an epidural could help to facilitate a positive labour and childbirth experience by helping women to relax, to restore/renew their energy levels, and to have a sense of control (moderate confidence in the evidence). However, although some women felt supported by health care professionals in their decision to use epidural analgesia, others felt pressurized or persuaded to do so (by health care professionals, through messages received via antenatal education of from family members) (low confidence in the evidence). Some women who made a decision to receive an epidural analgesia had fears over the procedure and potential risks for themselves and/or their babies (low confidence in the evidence). They experienced negative physiological effects including pain and other complications associated with needle insertion (low confidence in the evidence). Some also felt disconnected from the baby and experienced a range of negative emotions including conflict, guilt, disappointment and a sense of failure (low confidence in the evidence). Some women reported restricted mobility following administration of epidural analgesia (low confidence in the evidence). Pain relief afforded by epidural analgesia was considered effective for some, but not for all (low confidence in the evidence). Perceived lack of effectiveness was attributed to continuing pain, breakthrough pain and/or timing of administration (e.g. when it was administered too late for it to take effect).

Another qualitative systematic review on women’s and health care providers’ experiences of labour and childbirth included health care professionals’ views on epidural analgesia (26); however, the evidence was of very low confidence. The evidence suggests that some midwives feel that epidural analgesia is incongruous with the midwifery philosophy, and associate it with side-effects, disconnection from the baby and the potential for further intervention. Evidence also suggests that some health care professionals believe that, if it is used, it may be more appropriate for nulliparous women or for those with an abnormal labour.

Additional considerations

The qualitative review findings (26, 18) are all from studies conducted in HIC settings where epidural usage is common.

Feasibility

Findings from a qualitative systematic review of intrapartum care experiences (26) indicate that some health care professionals in HICs may encourage women to use epidural analgesia because of a heavy workload and a lack of time (very low confidence in the evidence). A perceived lack of effectiveness of epidural analgesia use reported by women in some studies included in another systematic review (18) was partly attributed to late administration (low confidence in the evidence), suggesting that there might be logistical issues in implementing this pain relief method.

Additional considerations

All of the findings on epidural use in the qualitative reviews (26, 18) came from HIC settings where epidural analgesia is widely available. In lower-resource settings, where it is not so widely used, there are likely to be financial implications as well as additional training considerations, which may negatively impact on the feasibility of implementing this intervention.

 

Further information and considerations related to this recommendation can be found in the WHO guidelines, available at:

http://apps.who.int/iris/bitstream/10665/250796/8/9789241549912-websupplement-eng.pdf?ua=1

http://apps.who.int/iris/bitstream/handle/10665/260178/9789241550215-eng.pdf;jsessionid=7E800B590A164DC7FC879E73B480D6FC?sequence=1

 

Implementation considerations

The successful introduction of evidence-based policies related to intrapartum care into national programmes and health care services depends on well-planned and participatory consensus-driven processes of adaptation and implementation. These processes may include the development or revision of national guidelines or protocols based on this recommendation.

The recommendation should be adapted into locally-appropriate documents and tools that are able to meet the specific needs of each country and health service. Modifications to the recommendation, where necessary, should be justified in an explicit and transparent manner.

An enabling environment should be created for the use of this recommendation, including changes in the behaviour of health care practitioners to enable the use of evidence-based practices.

Local professional societies may play important roles in this process and an all-inclusive and participatory process should be encouraged.

 

Health policy considerations 

  • A firm government commitment to increasing coverage of maternity care for all pregnant women giving birth in health care facilities is needed, irrespective of social, economic, ethnic, racial or other factors. National support must be secured for the whole package of recommendations, not just for specific components.
  • To set the policy agenda, to secure broad anchoring and to ensure progress in policy formulation and decision-making, representatives of training facilities and professional societies should be included in participatory processes at all stages. 
  • To facilitate negotiations and planning, situation-specific information on the expected impact of the new intrapartum care model on service users, providers and costs should be compiled and disseminated.
  • To be able to adequately ensure access for all women to quality maternity care, in the context of universal health coverage (UHC), strategies for raising public funding for health care will need revision. In low-income countries, donors could play a significant role in scaling up implementation.

 

Organizational or health-system-level considerations 

  • Long-term planning is needed for resource generation and budget allocation to address the shortage of skilled midwives, to improve facility infrastructure and referral pathways, and to strengthen and sustain good-quality maternity services.
  • Introduction of the model should involve training institutions and professional bodies so that preservice and in-service training curricula can be updated as quickly and smoothly as possible. 
  • Standardized labour monitoring tools, including a revised partograph, will need to be developed to ensure that all health care providers (i) understand the key concepts around what constitutes normal and abnormal labour and labour progress, and the appropriate support required, and (ii) apply the standardized tools.
  • The national Essential Medicines Lists will need to be updated (e.g. to include medicines to be available for pain relief during labour). 
  • Development or revision of national guidelines and/or facility-based protocols based on the WHO intrapartum care model is needed. For health care facilities without availability of caesarean section, context- or situation-specific guidance will need to be developed (e.g. taking into account travel time to the higher-level facility) to ensure timely and appropriate referral and transfer to a higher level of care if intrapartum complications develop. 
  • Good-quality supervision, communication and transport links between primary and higher-level facilities need to be established to ensure that referral pathways are efficient. 
  • Strategies will need to be devised to improve supply chain management according to local requirements, such as developing protocols for obtaining and maintaining stock of supplies. 
  • Consideration should be given to care provision at alternative maternity care facilities (e.g. on-site midwife-led birthing units) to facilitate the WHO intrapartum care model and reduce exposure of healthy pregnant women to unnecessary interventions prevalent in higher-level facilities. 
  • Behaviour change strategies aimed at health care providers and other stakeholders could be required in settings where non-evidence-based intrapartum care practices are entrenched. 
  • Successful implementation strategies should be documented and shared as examples of best practice for other implementers. User-level considerations 

 

Community-level sensitization activities should be undertaken to disseminate information about: 

  • respectful maternity care (RMC) as a fundamental human right of pregnant women and babies in facilities; 
  • facility-based practices that lead to improvements in women’s childbirth experience (e.g. RMC, labour and birth companionship, effective communication, choice of birth position, choice of pain relief method);
  • and unnecessary birth practices that are not recommended for healthy pregnant women and that are no longer practised in facilities (e.g. liberal use of episiotomy, fundal pressure, routine amniotomy).

 

Research implications

The GDG did not identify any priority question related to this recommendation.

 

Related links

WHO recommendations on intrapartum care for a positive childbirth experience

(2018) - full document and evidence tables

Managing Complications in Pregnancy and Childbirth: A guide for midwives and doctors

Pregnancy, Childbirth, Postpartum and Newborn Care: A guide for essential practice

WHO Programmes: Sexual and Reproductive health

Maternal Health

 

References

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Citation: WHO Reproductive Health Library. WHO recommendation on epidural analgesia for pain relief during labour (February 2018). The WHO Reproductive Health Library; Geneva: World Health Organization.