SCOTLAND — Researchers at Glasgow Royal Infirmary and colleagues found no association between epidural analgesia during labor and neonatal neurological morbidity in a large-scale cohort study of Scottish births from 2007 through 2019. The findings, based on data from nearly half a million women, provide robust evidence that epidural use in labor does not increase the risk of serious neurological outcomes in newborns.

The cohort study analyzed data from 495,695 women in labor with singleton pregnancies in Scotland between January 2007 and December 2019. Of these, 114,897 received epidural analgesia, representing 23.2% of the Scottish patients analyzed. Epidural analgesia was defined as a conventional lumbar epidural administered at any point during labor.

Planned cesarean births were excluded from the study, as were births where the mode of delivery, child identity, or analgesia data were not recorded. The study included women with singleton pregnancies between 24+0 and 42+6 weeks' gestation, and researchers linked six Scotland-wide administrative databases to assemble the cohort.

The primary outcome was a composite of neonatal neurological morbidity occurring within 28 days of birth. This composite included conditions such as hypoxic ischemic encephalopathy, neonatal seizures, intraventricular hemorrhage, intraventricular infarction, periventricular leukomalacia, meningitis, encephalitis, kernicterus, hypotonia, birth asphyxia, or other cerebral diagnosis. Neonatal neurological morbidity occurred in 434 infants, representing a rate of 0.9 per 1,000 births (95% CI 0.8–1.0).

The crude event rate for this outcome was 0.07% for infants whose mothers received epidural analgesia compared to 0.09% for those who did not. After adjusting for potential confounders, the study found no association between epidural analgesia in labor and neonatal neurological morbidity, with an adjusted relative risk of 0.87 (95% CI 0.68–1.12).

Secondary outcomes also showed no links to epidural use. The study found no link between epidural use and other severe neonatal morbidity (adjusted relative risk 1.17, 95% CI 0.90–1.51), neonatal sepsis (adjusted relative risk 1.11, 95% CI 0.90–1.37), or an Apgar score of less than 4 at 5 minutes (adjusted relative risk 0.97, 95% CI 0.87–1.09). Additionally, there was no association between epidural use and neonatal mortality at 28 days (adjusted relative risk 0.81, 95% CI 0.62–1.06) or cerebral palsy in childhood (adjusted relative risk 0.80, 95% CI 0.60–1.06). All outcomes were identified using ICD-10 codes, ensuring standardized diagnostic classification across the dataset.

Subgroup analyses revealed that the findings were consistent across different modes of birth, maternal risk status, and gestational ages. This consistency strengthens the conclusion that epidural analgesia does not pose a neurological risk to newborns regardless of delivery circumstances. Rachel Kearns, MBChB, MD, of Glasgow Royal Infirmary, reported the study findings.

“These results should reassure parents and clinicians that epidural analgesia use in labor is safe for babies and support informed, evidence-based decision making about analgesic options in labor,” the study authors said. They added that the findings support widening availability and equitable access to epidural analgesia as a safe component of intrapartum care.

The study population had a median maternal age of 29. Women who received epidural analgesia tended to be younger, giving birth for the first time, have diabetes, preeclampsia, or a higher body mass index, and live in a more socioeconomically disadvantaged area. Area deprivation was used as a proxy for socioeconomic status in the study.

Researchers acknowledged that women who received epidurals differed systematically from those who did not, which reflects real-world clinical patterns rather than random assignment. Approximately 5% of women who received epidurals converted to spinal or general anesthesia during labor, typically for operative delivery.

Despite the study’s large size, researchers noted limitations. The low absolute incidence of neonatal outcomes limited statistical power, meaning rare adverse events could not be entirely ruled out. Ethnicity data was missing for nearly 40% of women in the study.

Scotland is predominantly white, which may limit the generalizability of findings to more ethnically diverse populations. Additionally, researchers lacked data on physiological variables and on factors influencing clinicians’ and patients’ decision making regarding epidurals, which could affect how results are interpreted in different care settings.

Epidural analgesia is the most effective pain relief during labor, yet concerns about potential harm to newborns have historically influenced patient decisions and clinical practice. This study addresses a long-standing uncertainty by providing high-quality evidence from a large, real-world population over a 12-year period. By demonstrating no increased risk of neonatal neurological morbidity or other serious outcomes, the findings support efforts to expand access to epidurals as part of equitable, evidence-based maternity care.

The research underscores the importance of administrative health data in answering critical clinical questions. Linking six Scotland-wide databases enabled comprehensive tracking of maternal and neonatal outcomes without relying on self-reported or fragmented records. While the study cannot eliminate all biases inherent in observational research, its consistency across subgroups and rigorous adjustment for confounders offer strong reassurance to both families and providers navigating pain management decisions during childbirth.