Labor neuraxial analgesia may reduce the odds of postpartum hemorrhage, the leading indication for maternal blood transfusion during childbirth. This study tested the hypothesis that labor neuraxial analgesia is associated with reduced odds of maternal blood transfusion overall.


U.S. birth certificate data in the Natality File of the National Vital Statistics System for all 50 states from 2015 to 2018 for vaginal and intrapartum cesarean deliveries were analyzed. The exposure was labor neuraxial analgesia. The primary outcome was maternal blood transfusion, recorded on the birth certificate, which has low sensitivity for this outcome. Adjusted odds ratios and 95% CIs of blood transfusion associated with neuraxial analgesia were estimated using propensity score matching. The adjusted odds ratios were estimated overall and according to delivery mode, and treatment effect was compared between vaginal and intrapartum cesarean deliveries using an interaction term. Sensitivity analyses were performed using inverse propensity score weighting and quantitative bias analysis for outcome misclassification.


Of the 12,503,042 deliveries analyzed, 9,479,291 (75.82%) were with neuraxial analgesia, and 42,485 (0.34%) involved maternal blood transfusion. After propensity score matching, the incidence of blood transfusion was 0.30% in women without neuraxial analgesia (7,907 of 2,589,493) and 0.20% in women with neuraxial analgesia (5,225 of 2,589,493), yielding an adjusted odds ratio of 0.87 (95% CI, 0.82 to 0.91) overall. For intrapartum cesarean deliveries, the adjusted odds ratio was 0.55 (95% CI, 0.48 to 0.64), and for vaginal deliveries it was 0.93 (95% CI,. 0.88 to 0.98; P value for the interaction term < 0.001). The results were consistent in the sensitivity analyses, although the quantitative bias analysis demonstrated wide variation in potential effect size point estimates.


Labor neuraxial analgesia may be associated with reduced odds of maternal blood transfusion in intrapartum cesarean deliveries and, to a lesser extent, vaginal deliveries. The specific effect size varies widely by delivery mode and is unclear given the poor sensitivity of the data set for the maternal transfusion primary outcome.

Editor’s Perspective
What We Already Know about This Topic
  • Labor neuraxial analgesia may reduce the risk of postpartum hemorrhage
  • It is unclear whether labor neuraxial analgesia is associated with a lower risk of maternal transfusion compared to delivery without neuraxial analgesia
What This Article Tells Us That Is New
  • Using propensity score matching, U.S. birth certificate data for 12,503,042 patients from 2015 to 2018 demonstrated an adjusted maternal transfusion incidence of 30.5 per 10,000 for patients without labor neuraxial analgesia versus 20.2 per 10,000 for patients with labor neuraxial analgesia, a 13% reduction (95% CI, 18% to 9%)
  • This estimated reduction in maternal transfusion varied by delivery mode
  • Patients undergoing vaginal deliveries with labor neuraxial analgesia demonstrated a small 7% adjusted reduction (95% CI, 12% to 2%) in maternal transfusion
  • Patients undergoing intrapartum cesarean deliveries (after a trial of labor) with labor neuraxial analgesia demonstrated a 45% adjusted reduction (95% CI, 52% to 36%) in maternal transfusion