Background

Neuraxial analgesia provides effective pain relief during labor. However, it is unclear whether neuraxial analgesia prevalence differs across U.S. hospitals. The aim of this study was to assess hospital variation in neuraxial analgesia prevalence in California.

Methods

A retrospective cross-sectional study analyzed birthing patients who underwent labor in 200 California hospitals from 2016 to 2020. The primary exposure was the delivery hospital. The outcomes were hospital neuraxial analgesia prevalence and between-hospital variability, before and after adjustment for patient and hospital factors. Median odds ratio and intraclass correlation coefficients quantified between-hospital variability. The median odds ratio estimated the odds of a patient receiving neuraxial analgesia when moving between hospitals. The intraclass correlation coefficients quantified the proportion of the total variance in neuraxial analgesia use due to variation between hospitals.

Results

Among 1,510,750 patients who underwent labor, 1,040,483 (68.9%) received neuraxial analgesia. Both unadjusted and adjusted hospital prevalence exhibited a skewed distribution characterized by a long left tail. The unadjusted and adjusted prevalences were 5.4% and 6.0% at the 1st percentile, 21.0% and 21.2% at the 5th percentile, 70.6% and 70.7% at the 50th percentile, 75.8% and 76.6% at the 95th percentile, and 75.9% and 78.6% at the 99th percentile, respectively. The adjusted median odds ratio (2.3; 95% CI, 2.1 to 2.5) indicated substantially increased odds of a patient receiving neuraxial analgesia if they moved from a hospital with a lower odds of neuraxial analgesia to one with higher odds. The hospital explained only a moderate portion of the overall variability in neuraxial analgesia (intraclass correlation coefficient, 19.1%; 95% CI, 18.8 to 20.5%).

Conclusions

A long left tail in the distribution and wide variation exist in the neuraxial analgesia prevalence across California hospitals that is not explained by patient and hospital factors. Addressing the low prevalence among hospitals in the left tail requires exploration of the interplay between patient preferences, staffing availability, and care providers’ attitudes toward neuraxial analgesia.

Editor’s Perspective
What We Already Know about This Topic
  • Neuraxial analgesia is highly effective for treating labor pain and is associated with other important maternal benefits
  • The American College of Obstetricians and Gynecologists recommends that anesthesia services, including neuraxial analgesia, be accessible to all birthing patients in maternity hospitals
What This Article Tells Us That Is New
  • A retrospective, population-based, cross-sectional study examined the hypothesis of wide variation in the neuraxial labor analgesia prevalence across California hospitals that is not fully explained by differences in patient case mix and fixed hospital characteristics
  • Of 1,510,750 delivery hospitalizations across 200 hospitals from 2016 to 2020, 1,040,483 patients (68.9%) received neuraxial labor analgesia
  • The hospital prevalence had a skewed distribution, with low values in the left tail (unadjusted prevalence at the first and fifth percentiles were 5.4% and 21.0%, respectively)
  • The adjusted median odds ratio (95% CI) of 2.3 (2.1 to 2.5) indicated substantially increased odds of a patient receiving neuraxial analgesia if moved from a hospital with lower odds of neuraxial analgesia to a hospital with higher odds, a difference not explained by patient case mix and hospital characteristics