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Original Investigation
September 28, 2021

Association of Epidural Analgesia During Labor and Delivery With Autism Spectrum Disorder in Offspring

Author Affiliations
  • 1Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, Canada
  • 2British Columbia Children’s Hospital Research Institute, University of British Columbia, Vancouver, Canada
  • 3Division of Developmental Pediatrics, Department of Pediatrics, University of British Columbia, Vancouver, Canada
  • 4School of Population and Public Health, University of British Columbia, Vancouver, Canada
  • 5Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
  • 6Department of Pediatrics, University of Alberta, Edmonton, Canada
JAMA. 2021;326(12):1178-1185. doi:10.1001/jama.2021.14986
Key Points

Question  Does use of epidural analgesia during labor and delivery increase the risk for autism spectrum disorder in offspring?

Findings  In this population-based retrospective cohort study that included 388 254 term singleton children born via vaginal delivery, the use of epidural analgesia during labor and delivery was significantly associated with a small increase in risk of autism spectrum disorder in offspring (1.53% in exposed children vs 1.26% in unexposed children; adjusted hazard ratio, 1.09).

Meaning  Maternal epidural analgesia use during labor and delivery was associated with a small increase in the risk of autism spectrum disorder in offspring that met the threshold for statistical significance; however, given the likelihood of residual confounding that may account for the results, these findings do not provide strong supporting evidence for this association.

Abstract

Importance  Evidence from studies investigating the association of epidural analgesia use during labor and delivery with risk of autism spectrum disorder (ASD) in offspring is conflicting.

Objective  To assess the association of maternal use of epidural analgesia during labor and delivery with ASD in offspring using a large population-based data set with clinical data on ASD case status.

Design, Setting, and Participants  This population-based retrospective cohort study included term singleton children born in British Columbia, Canada, between April 1, 2000, and December 31, 2014. Stillbirths and cesarean deliveries were excluded. Clinical ASD diagnostic data were obtained from the British Columbia Autism Assessment Network and the British Columbia Ministry of Education. All children were followed up until clinical diagnosis of ASD, death, or the study end date of December 31, 2016.

Exposures  Use of epidural analgesia during labor and delivery.

Main Outcomes and Measures  A clinical diagnosis of ASD made by pediatricians, psychiatrists, and psychologists with specialty training to assess ASD. Cox proportional hazards models were used to estimate the hazard ratio of epidural analgesia use and ASD. Models were adjusted for maternal sociodemographics; maternal conditions during pregnancy; labor, delivery, and antenatal care characteristics; infant sex; gestational age; and status of small or large for gestational age. A conditional logistic regression model matching women with 2 births or more and discordance in ASD status of the offspring also was performed.

Results  Of the 388 254 children included in the cohort (49.8% female; mean gestational age, 39.2 [SD, 1.2] weeks; mean follow-up, 9.05 [SD, 4.3] years), 5192 were diagnosed with ASD (1.34%) and 111 480 (28.7%) were exposed to epidural analgesia. A diagnosis of ASD was made for 1710 children (1.53%) among the 111 480 deliveries exposed to epidural analgesia (94 157 women) vs a diagnosis of ASD in 3482 children (1.26%) among the 276 774 deliveries not exposed to epidural analgesia (192 510 women) (absolute risk difference, 0.28% [95% CI, 0.19%-0.36%]). The unadjusted hazard ratio was 1.32 (95% CI, 1.24-1.40) and the fully adjusted hazard ratio was 1.09 (95% CI, 1.00-1.15). There was no statistically significant association of epidural analgesia use during labor and delivery with ASD in the within-woman matched conditional logistic regression (839/1659 [50.6%] in the exposed group vs 1905/4587 [41.5%] in the unexposed group; fully adjusted hazard ratio, 1.07 [95% CI, 0.87-1.30]).

Conclusions and Relevance  In this population-based study, maternal epidural analgesia use during labor and delivery was associated with a small increase in the risk of autism spectrum disorder in offspring that met the threshold for statistical significance. However, given the likelihood of residual confounding that may account for the results, these findings do not provide strong supporting evidence for this association.

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