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    1 Comment for this article
    Pain during labor
    Frederick Rivara, MD | University of Washingtonn
    This study shows tremendous variation in use of neuraxial anesthesia during labor and delivery, varying from 36% to 80%. What we don't know yet is WHY this variation exists. Is this related in any way to the large variation in maternal morbidity and mortality?
    CONFLICT OF INTEREST: Editor in Chief, JAMA Network Open
    Original Investigation
    December 28, 2018

    United States State-Level Variation in the Use of Neuraxial Analgesia During Labor for Pregnant Women

    Author Affiliations
    • 1Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California
    • 2Quantitative Sciences Unit, Stanford University School of Medicine, Stanford, California
    • 3Department of Anesthesia, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City
    • 4School of Public Health, Oregon Health & Science University–Portland State University, Portland
    JAMA Netw Open. 2018;1(8):e186567. doi:10.1001/jamanetworkopen.2018.6567
    Key Points español 中文 (chinese)

    Question  Does the prevalence of neuraxial labor analgesia vary across US states?

    Findings  In this population-based, cross-sectional analysis of 2 625 950 pregnant women who underwent labor, Maine had the lowest adjusted neuraxial analgesia prevalence (36.6%) and Nevada the highest (80.1%). The odds of receiving neuraxial analgesia were 1.5-fold higher if the same patient received neuraxial analgesia in a high-use vs a low-use state; and 5.4% of the overall variation in neuraxial analgesia prevalence is explained by US state.

    Meaning  Results of this study suggest that wide variation exists in neuraxial analgesia use across US states, with a small portion of the overall variation explained by US states.


    Importance  Neuraxial labor analgesia is recognized as the most effective method of providing pain relief during labor. Little is known about variation in the rates of neuraxial analgesia across US states. Identifying the presence and extent of variation may provide insights into practice variation and may indicate where access to neuraxial analgesia is inadequate.

    Objective  To test the hypothesis that variation exists in neuraxial labor analgesia use among US states.

    Design, Setting, and Participants  Retrospective, population-based, cross-sectional analysis using US birth certificate data. Participants were 2 625 950 women who underwent labor in 2015.

    Main Outcomes and Measures  State-specific prevalence of neuraxial analgesia per 100 women who underwent labor and variability in neuraxial analgesia use among states, assessed using multilevel multivariable regression modeling with the median odds ratio and the intraclass correlation coefficient to evaluate variation by state.

    Results  In the study population of 2 625 950 women, 0.1% (n = 2010) were younger than 15 years, 7.0% (n = 183 546) were between the ages of 15 and 19 years, 23.6% (n = 620 118) were between the ages of 20 and 24 years, 29.6% (n = 777 957) were between the ages of 25 and 29 years, 26.0% (n = 683 656) were between the ages of 30 and 34 years, 11.4% (n = 298 237) were between the ages of 35 and 39 years, 2.2% (n = 57 130) were between the ages of 40 and 44 years, and 0.1% (n = 3296) were between the ages of 45 and 54 years. More than 90% were privately insured or insured with Medicaid. Neuraxial analgesia was used by 73.1% (n = 1 920 368) of women. After adjustment for antepartum, obstetric, and intrapartum factors, Maine had the lowest neuraxial analgesia prevalence (36.6%; 95% CI, 33.2%-40.1%) and Nevada the highest (80.1%; 95% CI, 78.3%-81.7%). The adjusted median odds ratio was 1.5 (95% CI, 1.4-1.6), and the intraclass correlation coefficient was 5.4% (95% CI, 4.0%-7.9%).

    Conclusions and Relevance  Results of this study suggest that a small portion of the overall variation in neuraxial analgesia use is explained by US states. Unmeasured patient-level and hospital-level factors likely account for a large portion of the variation between states. Efforts should be made to understand what the main reasons are for this variation and whether the variation influences maternal or perinatal outcomes.