Skip to main content
NCBI home page
Deutsches Ärzteblatt International logoLink to Deutsches Ärzteblatt International
. 2026 Sep 4;123(18):499–504. doi: 10.3238/arztebl.m2026.0089

Epidural Analgesia in Labor

A Nationwide Evaluation of Utilization in Germany

Armin N Flinspach 1,✉, Florian J Raimann 1, Thomas Jasny 1, Benjamin Friedrichson 1, Susan Bitok 1, Lea V Blum 1, Vanessa Neef 1, Peter Kranke 2, Kai Zacharowski 1, Jan A Kloka 1
PMCID: PMC13618805  PMID: 42265994

Summary

Background:

Lumbar epidural anesthesia (LEA) is considered the gold standard for the treatment of pain during vaginal delivery. Despite procedural advances and high maternal satisfaction in surveys, the extent of LEA utilization in Germany and its trend over time remain unclear.

Methods:

We carried out a nationwide retrospective cross-sectional analysis of routine administrative data reported by German hospitals from 1 January 2014 to 31 December 2023. Births were identified by ICD-10 and OPS codes. The data set included all women in Germany who were admitted to a hospital for childbirth. The data analysis was descriptive, with subgroup stratification by mode of delivery. The primary endpoint was the use of LEA for delivery.

Results:

Of the 6.6 million deliveries recorded, 4.5 million (68%) were vaginal. LEA was used in 1.2 million deliveries (18.4% of the total), including 922 510 in vaginal deliveries (20.5% of all vaginal deliveries). Women who received LEA were younger on average (median age 30 versus 31 years). LEA utilization was relatively stable throughout the study period. Women undergoing vaginal delivery were more likely to receive LEA if they had documented pre-existing conditions or comorbidities.

Conclusion:

The level of LEA utilization in Germany is stably low compared to other high-income industrialized countries. Better prenatal maternal education and standardized counseling on pain management options can raise awareness of this method of obstetrical analgesia and increase its use.

One of the greatest advances in modern medicine, especially in obstetrics, is adequate pain management (1). Approximately one in five pregnant women experience significant anxiety of childbirth, predominated by fear of labor pain (2). Use of lumbar epidural analgesia (LEA) can reduce labor pain effectively with relatively minor side effects, and is thus considered the gold standard for analgesia in vaginal deliveries (3–6).

The majority of births in Germany and most other European countries take place by vaginal delivery in some countries, vaginal delivery, as preferred by parturients in most European countries and recommended by professional bodies (7). According to data from the Federal Statistical Office, 692 989 children were born in Germany in 2023 (8).

Routinely reported data show that cesarean sections account for 32% of births in Germany, with a gradual increase over time (1995: 17.6%; 2005: 27.6%; 2015: 31.1%). It may therefore be inferred that LEA could considered as an analgesic option in approximately 400 000 deliveries per year (9).

The technique of LEA in vaginal delivery has been continually improved, in particular by optimizing the administration of local anesthetics. For example, modern injection pumps enable a programed intermittent epidural bolus (PIEB), which has been associated with fewer instrumental deliveries, reduced motor block, and higher maternal satisfaction (10).

Furthermore, a meta-analysis demonstrated low complication rates in deliveries with LEA (11).

The potential for effective online courses to help physicians learn how to administer LEA is unfortunately still far from being fulfilled, even though well supervised bedside teaching and local training opportunities may compensate this (12, 13).

The aim of this study was to analyze the rate of implementation of LEA in Germany over a period of 10 years.

Materials and methods

We conducted a nationwide retrospective crosssectional analysis of administrative data (14, 15). In accordance with legal requirements, diagnoses and procedures are coded using the International Statistical Classification of Diseases (ICD) and the German Procedure Classification (Operationen- und Prozeduren- schlüssel, OPS). These data are then transferred to the Federal Statistical Office (DESTATIS) and archived (16) (eTable). On request in line with §21 of the German Hospital Remuneration Act (Krankenhausentgeltgesetz, KHEntgG) the reimbursement data and made available for studies under a formal agreement on data use for research purposes. The authors had no access to the non-anonymized dataset or the individual patient data. Accordingly, the ethics committee of Frankfurt University waived the requirement for ethical approval. All data processing was performed in accordance with the Declaration of Helsinki (17).

eTable. ICD-10 and OPS codes.

Diagnosis OPS code ICD-10
Vaginal delivery 9–260, 9–261, 9–268
Cesarean delivery 5–74,5–741, 5–749
Cardiac arrhythmias I44.1, I44.2, I44.3, I45.6, I45.9, I47, I48, I49, R00.0, R00.1, R00.8, T82.1, Z45.0, Z95.0.-
Valvular defects A52.0, I05, I06, I07, I08, I09.1, I09.8, I34, I35, I36, I37, I38, I39, Q23.0, Q23.1, Q23.2, Q23.3, Z95.2, Z95.3, Z95.4
Overweight E66.-
Arterial hypertension, uncomplicated F17.2
Arterial hypertension I11, I12, I13, I15
Other neurological disorders G10, G11, G12, G13, G20, G21, G22, G25.4, G25.5, G31.2, G31.8, G31.9, G32, G35, G36, G37, G40, G41, G93.1, G93.4, R47.0, R56
Chronic pulmonary disease I27.8, I27.9, J40, J41, J42, J43, J44, J45, J46, J47, J60, J61, J62, J63, J64, J65, J66, J67, J68.4, J70.1, J70.3
Diabetes mellitus, uncomplicated E10.0, E10.1, E10.9, E11.0, E11.1, E11.9, E12.0, E12.1, E12.9, E13.0, E13.1, E13.9, E14.0, E14.1, E14.9
Liver disease B18, I85, I86.4, I98.2, K70, K71.1, K71.3, K71.4, K71.5, K71.7, K72, K73, K74, K76.0, K76.2, K76.3, K76.4, K76.5, K76.6, K76.7, K76.8, K76.9, Z94.4
Rheumatoid vascular diseases L94.0, L94.1, L94.3, M05, M06, M08, M12.0, M12.3, M30, M31.0, M31.1, M31.2, M31.3, M32, M33, M34, M35, M45, M46.1, M46.8, M46.9
Depression F20.4, F31.3, F31.4, F31.5, F32, F33, F34.1, F41.2, F43.2
Epidural analgesia 8–910
Monitoring of high-risk pregnancy Z35
Monitoring of pregnancy with a history of infertility Z35.0
Monitoring of pregnancy with a history of miscarriage Z35.1
Monitoring of pregnancy with other adverse obstetric or reproductive history Z35.2
Monitoring of pregnancy with a history of inadequate prenatal care Z35.3
Monitoring of pregnancy in grand multiparity Z35.4
Monitoring of pregnancy in an older primigravida (advanced maternal age) Z35.5
Monitoring of pregnancy in a very young primigravida Z35.6
Monitoring of other high-risk pregnancies Z35.8
Monitoring of high-risk pregnancy, unspecified Z35.9
Open in a new tab

Inclusion criteria

In this nationwide study, all women of childbearing age (≥ 14 years) who were admitted to hospitals in Germany between 1 January 2014 and 31 December 2023 to give birth were screened for the provision of an LEA during labor.

Study protocol and data acquisition

All births documented in the study period were subjected to analysis. The population was divided into subgroups —all deliveries and vaginal births, with documentation of LEA and without—to differentiate between primary and secondary cesarean sections. The variables collected included maternal age, comorbidities, complications, and length of hospital stay. Because DESTATIS allows only anonymous queries, it was not possible to trace a case back to a person, so no further analysis on individual cases was feasible. As the data were anonymized by the Federal Statistical Office, analysis was conducted remotely and the General Data Protection Regulation was not applicable.

Statistics

The data were analyzed descriptively. Categorical variables are presented as absolute numbers and percentages. Continuous variables were calculated using mean and standard deviation (SD). Group comparisons (between deliveries with and without LEA) were limited to categorical variables using χ2 tests with a two-sided α of 0.05; odds ratios with 95% confidence intervals were calculated. Excel 2019 (Microsoft Corp., Redmond, WA, USA) was used for data handling and SAS (Version 9.4M6, SAS Institute Inc., Cary, NC, USA) for statistical analysis.

The primary endpoint was the number of times LEA was provided during delivery. Secondary endpoints were age, inpatient stay, and comorbidities.

Results

Our nationwide data collection included 6.6 million births between 2014 and 2023, of which 4.5 million (68.0%) were vaginal deliveries. Overall, LEA was used in 1.2 million cases (18.4%). Of these, 922 510 epidural procedures were associated with vaginal births, corresponding to 20.5% of that subgroup. Over the observation period, 214 784 (± 7619) cesarean deliveries were performed annually. With a median age of 30 years (interquartile range [IQR] 27–34), women who received LEA were younger than those who did not (median age 31 years, IQR 27–34), and those with LEA had a longer mean inpatient stay (83.7 hours, QR 69.1–104.5 versus 73.8 hours, IQR 57.8–90.7) (Table 1). In a subgroup analysis of vaginal delivery, women with documented pre-existing conditions or comorbidities showed a higher likelihood of receiving LEA; detail can be found in Table 2.

Table 1. Patient demographics.

LEA No LEA p-value 1
Total patients, n 922510 3587017
Age, median (Q1; Q3) 30 (27; 34) 31 (27; 34) < 0.0001
Elixhauser score 0 (0;0) 0 (0;0)
Length of hospital stay (h), median (Q1; Q3) 84 (69; 104) 74 (58; 91) < 0.0001
Age groups
10–14; n,% 246 0.03 523 0.01
15–19; n,% 25 002 2.71 69 826 1.95
20–24; n,% 114 523 12.41 373 531 10.41
25–29; n,% 272 451 29.53 965 330 26.91
30–34; n,% 328 642 35.62 1 322 537 36.87
35–39; n,% 154 123 16.71 715 262 19.94
40–44; n,% 26 483 2.87 134 527 3.75
45–49; n,% 1001 0.11 5250 0.15
Pregnancy week
< 25; n,% 1610 0.18 10 806 0.31 < 0.0001
26–33; n,% 5980 0.65 31 120 0.87 < 0.0001
34–36; n,% 25 677 2.78 109 191 3.04 < 0.0001
37–41; n,% 771 888 83.67 3 071 536 85.63 < 0.0001
> 41; n,% 115 494 12.52 353 702 9.86 < 0.0001
Monitoring of high-risk pregnancies
High-risk pregnancy 52 344 5.67 196 833 < 0.0001
After a history of i nfertility 2235 0.24 5939 < 0.0001
With a history of miscarriage 13 580 1.47 48 797 < 0.0001
With adverse obstetric or reproductive history 3401 0.37 16 376 < 0.0001
With i nadequate prenatal care 730 0.08 6532 < 0.0001
Pregnancy in grand multiparity 3488 0.38 50 623 < 0.0001
Older primigravida 20 568 2.23 44 519 < 0.0001
Very young primigravida 3278 0.36 7092 < 0.0001
Other high-risk pregnancies 6607 0.72 23 897 < 0.0001
High-risk pregnancy, unspecified 1249 0.14 5526 < 0.0001
Open in a new tab

Patient characteristics for all births within the study period (2014–2023) by age, gestational week, and grounds for monitoring

LEA, Lumbar epidural analgesia

Table 2. Pre-existing morbidities among women with vaginal delivery in relation to utilization of lumber epidural analgesia (LEA).

LEA n = 922 510 Non-LEA n = 3 587 017 p-value
Cardiac arrhythmias 1589 (0.17%) 4669 (0.13%) < .0001
Heart valve defects 464 (0.05%) 1529 (0.04%) 0.0018
Art. hypertension, uncomplicated 1439 (0.16%) 4884 (0.14%) < .0001
Art. hypertension, complicated 72 (0.01%) 173 (0.00%) 0.0005
Neurological disorders 2361 (0.26%) 8061 (0.22%) < .0001
Depression 3162 (0.34%) 8920 (0.25%) < .0001
Diabetes mellitus, uncomplicated 41 659 (4.52%) 153 261 (4.27%) < .0001
Liver disease 1453 (0.16%) 7814 (0.22%) < .0001
Rheumatoid vascular disease 498 (0.05%) 1540 (0.04%) < .0001
Overweight 21 720 (2.35%) 62 376 (1.74%) < .0001
Chronic pulmonary disease 3090 (0.33%) 8803 (0.25%) < .0001
Open in a new tab

The mean annual number of deliveries between 1 January 2014 and 31 December 2023 was 663 647 (± 26 665), with a consistently stable median LEA usage rate of 18.7% (IQR 17.6–19.2%). A selective analysis that focussed exclusively on LEA during vaginal delivery (mean 450 953 [± 19 442] per year) showed a slightly higher rate of 20.8% (IQR 19.5–21.2%) on a median basis (Figure 1). Detailed analysis of the data on spontaneous vaginal delivery also revealed that very young and older nulliparous women with compulsory monitoring each accounted for 31.6% of LEA usage. The age-dependent overall LEA rate decreased with increasing age (Figure 2).

Figure 1.

Figure 1

Open in a new tab

Timeline of the utilization of epidural catheters for delivery.

Epidural analgesia: utilization of obstetric pain therapy, including the subgroup of vaginal deliveries.

Figure 2.

Figure 2

Open in a new tab

Age-dependent utilization of lumbar epidural analgesia (LEA) during vaginal delivery. Five-year cohorts illustrating the utilization for spontaneous vaginal deliveries during the study period.

Discussion

In our nationwide analysis of routine reimbursement data from German hospitals between 2014 and 2023, the overall utilization rate of LEA in obstetrics was 18.4%. This is much lower than earlier findings of a 25% rate of LEA in a survey of German obstetric units conducted in the late 1990s and 26–44% uptake in a single-center study from Berlin (18). Our data show an essentially consistent LEA usage rate of about 20%. This is well below recent and historical rates in other western industrialized nations (18, 19). The decline in use over time which this suggests, despite growing evidence of the safety of LEA and the current guideline recommendations appears contradictory in light of the desire for pain reduction during childbirth.

An analysis of German registry data (QUIPS) found that parturients gave a high pain rating of 8.68 (± 1.8) out of 10 on a numerical rating scale. Pharmacological analgesia was given in 62.6% of cases, but 40.7% of women wished they had received more pain relief during labor (20). In light of the relatively stable LEA utilization rate in vaginal deliveries over the past decade this seems counterintuitive, given that the medical and obstetric advantages of LEA, the most effective method of pain relief during childbirth, lead to an improvement in pain control and may improve the birth experience (21–23). Moreover, the cooperation of the woman giving birth is assured and systemic painkillers, with their adverse effects, are avoided. Furthermore, there is evidence of a reduction in complications during and after birth, particularly in women with medical indications for LEA and in premature births. The authors of the study concerned concluded that expanding access to LEA for all women in labor, especially those at highest risk, could improve maternal health (24).

However, LEA is a medical procedure and therefore involves risks such as accidental dural puncture (around 0.5–1.5%) and postpuncture headache (PDPH), which is reported in the literature as occurring in 0.7–3.0% of cases (e1–e4). The much feared epidural hematoma, entailing the risk of paraplegia, occurs very rarely in population-based data, with an incidence of ~2 per million. Maternal deaths associated with neuraxial analgesia/anesthesia have not been observed even in large population studies (25). Moreover, large meta-analyses have not shown an increased rate of secondary cesarean sections (relative risk [RR] 1.07, 95% confidence interval [0.96; 1.18]). Although LEA contributed to significantly higher satisfaction with pain relief, individual studies showed a possible prolongation of the first and second stages of labor by a matter of minutes (11). A particular feature of LEA is the option to rapidly extend an existing epidural block in order to achieve adequate anesthesia for cesarean section and provide effective treatment for the postoperative pain occurring in such cases (26).

Substantial differences in women’s preferences and use of analgesia during labor are well documented. In contrast to our findings, the application rates are much higher in the USA, in Israel, and in numerous European countries (60–80% for vaginal deliveries) (e5–e10). A project run by the European Cooperation in Science and Technology published registry data for different countries covering the year 2013 (Table 3) (27). A Dutch population-based cohort study reported that epidural analgesia use increased from 7.7% to 21.9% among nulliparous women over a decade, but remained low (6.8%) among multiparous women (28). However, this may also be due to the high rate of home births in the Netherlands (20–24%) compared with other countries such as Germany or the UK (0.4%) (29, 30).

Table 3. International use of lumbar epidural analgesia (LEA) during childbirth.

Country Nullipara LEA Multipara LEA Overall LEA rate
EU
Finland 21 942 83.4% 32 368 59.0% 54 310 68.9%
Sweden 48 834 44.6% 55 736 19.4% 104 570 31.2%
Norway 22 870 50.8% 32 081 23.2% 54 951 34.7%
Denmark 23 533 40.0% 27 159 17.0% 50 692 27.7%
Iceland 1,579 88.0% 2,408 31.5% 3,987 53.9%
Ireland 23 722 64.2% 38 870 38.2% 62 592 48.1%
Netherlands 68 187 29.9% 84 457 10.0% 152 644 18.9%
Belgium 48 722 82.3% 64 182 62.4% 112 904 71.0%
Median 50.8% 23.2% 41.4%
USA
1 393 855 78.8% 2 106 542 64.4% 3 500 397 70.1%
Open in a new tab

Utilization of LEA for pain relief during delivery: nulliparous, multiparous and overall (modified following Seijmonsbergen et al.) [1]

Utilization rates are most likely affected by multiple factors, e.g., patients’ expectations regarding pain relief, participation in antenatal education, continuous availability, and guidance provided by healthcare professionals, particularly midwives, during birth (31). The influence of cultural and religious acceptance of medication-based pain relief is difficult to determine from the data available. A Scandinavian study suggests that educational level and migration background also tend to influence the use of LEA (32).

Ultimately, when considering LEA it is also necessary to adequately inform the parturients, because, prepartal information largely rests on individual initiative. This may seem surprising given that guidelines clearly recommendations LEA as the most appropriate mode of analgesia in the perinatal period (33). Specifically, even the German guidelines with the highest level of recommendation (S1 [expert consensus] and S3 [clinical practice guidelines]) state: “Women in labor who require or request analgesia should be offered epidural analgesia.” Furthermore: “The timing of regional anesthesia placement should be determined by the woman in labor and may take place at any time. It is not recommended to wait for a defined stage of labor, as current evidence indicates that the timing of epidural catheter placement confers neither an objective advantage nor disadvantage regarding the course of labor.” This holds although the indication is always determined on an individual basis, taking into account the progress of labor and the clinical situation (33). Unfortunately, there is a significant lack of information available, as has been demonstrated by the authors’ working group on multiple occasions (13, 34).

The observed increased use of LEA in various subgroups with pre-existing comorbidities, e.g., cardiovascular disease, is initially surprising. This may rest on individual recommendation by a physician to use LEA for pain relief in order to prevent exacerbation of, for example, the cardiovascular situation by achieving adequate pain control. Anticoagulation, which is often required in this context, rarely hinders obstetric LEA.

The discrepancy between the decline in the use of LEA shown in Figure 2 and the nevertheless high usage among older nulliparous women may be explained by the rising proportion of multiparity in the cohort with increasing maternal age at delivery. It has often been reported that multiparous women more frequently give birth without LEA, and this explains our observation (35). This may be due to less pain in women with multiple vaginal deliveries and less anxiety about the birth process (36–38). The present findings indicate a low rate of LEA utilization in Germany, just under 20%, indicating a striking discrepancy from other industrialized nations regarding analgesic care during the peripartal period, as LEA rate is strongly and inversely correlated with the quality of analgesia and the desire for better pain relief (20).

Limitations

This study analyzed a national cohort using administrative reimbursement data. Although the underlying dataset may contain documentation errors with potential financial relevance for hospitals, such inaccuracies are expected to have only a minor impact on the overall findings due to the large sample size. However, the absence of comparable reference data from other countries for the period investigated limits direct international comparison, particularly with reference to the COVID-19 pandemic, which significantly hampered healthcare provision during part of the observation period. According to surveys, approximately 1.5% of deliveries in Germany take place out of hospital. These are not included in the present data set (39). The study design had limitations due to the data provided by the Federal Statistical Office, which were available only in aggregated, tabular form. No individualized data sets were available, so patient-related regression analysis was not feasible. Because of the aggregated and anonymized nature of the data, the analysis enables the assessment of incidences and associations but does not allow causal inferences. Given the large cohort (6.6 million), all the correlations are statistically significant, but some may have no clinical importance. We also could not determine with the data available how often the desire for a LEA during labor was expressed but for various reasons, e.g., capacity constraints, could not be implemented.

Conclusion

In Germany, LEA is used for analgesia during childbirth in 18.4% of all deliveries. This is so despite consistent recommendations from all national professional associations and particularly higher rates, exceeding 60%, in several European countries. It remains to be determined whether enhanced education and more effective dissemination of information regarding this treatment option may influence this trend, which has remained largely unchanged over the past decade.

Footnotes

Conflict of interest statement: ANF has received speaker fees from P.J. Dahlhausen & Co. GmbH, the Sedana Medical Research Grant 2020, and the Thieme Teaching Award 2022. He has received honoraria for travel expenses from University Hospital Frankfurt and Medizinische Congressorganisation Nürnberg GmbH (MCN), congress fees from DGAI, and support for publication costs from the Goethe University Frankfurt publication fund.

BF is deputy principal investigator of the EU Horizon 2020 project ENVISION (Intelligent plug-and-play digital tool for real-time surveillance of COVID-19 patients and smart decision-making in intensive care units) and the Horizon Europe 2021 project COVend (Biomarker and AI-supported FX06 therapy to prevent progression from mild and moderate to severe stages of COVID-19). Partner for the EU Horizon 2023 project EDiHTA.

FJR has received funding for clinical investigations from HemoSonics LLC; honoraria for lectures and/or travel expenses from HemoSonics LLC, Hesse Medical Association, Keller Medical GmbH, HELIOS GmbH, University Hospital Würzburg, University Hospital Frankfurt, MCN, CSL Behring, and Biotest AG; congress fees from DGAI and DIVI; financial support for patents from LifeSystems; consultation fees from pharma-consult Petersohn; and support for publication costs from the Goethe University Frankfurt publication fund.

JAK is deputy principal investigator of the EU Horizon 2020 project ENVISION (Intelligent plug-and-play digital tool for real-time surveillance of COVID-19 patients and smart decision-making in intensive care units) and the Horizon Europe 2021 project COVend (Biomarker and AI-supported FX06 therapy to prevent progression from mild and moderate to severe stages of COVID-19). Partner for the EU Horizon 2023 project EDiHTA.

KZ has received honoraria for participation in advisory board meetings for Haemonetics and Vifor and speaker fees from CSL Behring, Masimo, Pharmacosmos, Boston Scientific, Salus, iSEP, Edwards and GE Healthcare. He is the principal investigator of the EU Horizon 2020 project ENVISION (Intelligent plug-and-play digital tool for real-time surveillance of COVID-19 patients and smart decision-making in intensive care units) and the Horizon Europe 2021 project COVend (Biomarker and AI-supported FX06 therapy to prevent progression from mild and moderate to severe stages of COVID-19). He leads as CEO the Christoph Lohfert Foundation and the Health, Patient Safety & PBM Foundation.

PK has received consultation fees from TEVA Ratiopharm, Sintetica, Baxter, Amicus Clinical Development, and B. Braun, and compensation for lectures and educational activities from Fresenius Kabi, CSL Vifor, Senzyme, Grünenthal, CSL Behring, Pharmacosmos, Baxter, Pajunk, Gruenenthal, Livanova, and Norgine.

V.N. has received honoraria for lectures and travel expenses from Sysmex, Pharmacosmos, and MCN as well as support for publication costs from Goethe University Frankfurt.

The remaining authors declare that they have no conflicts of interest.

Data availability statement

The data on which the results of this study are based are available from the Federal Statistical Office with the restrictions applied. The dataset was used under license for this study and is therefore not generally accessible. However, the data are available from the authors on reasonable request and with permission from the Federal Statistical Office (DESTATIS).

Supplementary material

Complete list of full references

  • 1. Reena, Bandyopadhyay KH, Afzal M, Mishra AK, Paul A. Labor epidural analgesia: Past, present and future. Indian Journal of Pain. 2014;28:71–81. [Google Scholar]
  • 2. Geissbühler V, Zimmermann K, Eberhard J. Geburtsängste in der Schwangerschaft-Frauenfelder Geburtenstudie. Geburtshilfe und Frauenheilkunde. 2005;65:873–80. [Google Scholar]
  • 3. Bauer ME, Arendt K, Beilin Y, et al. The society for obstetric anesthesia and perinatology interdisciplinary consensus statement on neuraxial procedures in obstetric patients with thrombocytopenia. Anesth Analg. 2021;132:1531–44. doi: 10.1213/ANE.0000000000005355. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 4. Bremerich D, Annecke T, Chappell D, et al. S1-Leitlinie Die geburtshilfliche Analgesie und Anästhesie. Anaesthesiologie & Intensivmedizin. 2020;61:300–39. [Google Scholar]
  • 5. Finlay C, May S, Borkett-Jones C. A completed audit cycle investigating the adherence to national and local guidelines of ward based monitoring in patients with epidurals in situ in East and North Hertfordshire Trust. Anaesthesia 2014. 2014;69(Suppl 2):63. [Google Scholar]
  • 6. Hodnett ED. Pain and women‘s satisfaction with the experience of childbirth: A systematic review. Am J Obstet Gynecol. 2002;186(5 Suppl Nature):160–72. doi: 10.1067/mob.2002.121141. [DOI] [PubMed] [Google Scholar]
  • 7. Betran AP, Ye J, Moller AB, Souza JP, Zhang J. Trends and projections of caesarean section rates: Global and regional estimates. BMJ Glob Health. 2021;6:e005671. doi: 10.1136/bmjgh-2021-005671. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 8.Bundesamt S. Daten der Lebendgeborenen, Totgeborenen, Gestorbenen und der Gestorbenen im 1. Lebensjahr. [last accessed on April 14; 2025 ]. www.destatis.de/DE/Themen/Gesellschaft-Umwelt/Bevoelkerung/Geburten/Tabellen/lebend-geborene-gestorbene.html
  • 9. Fröhlich M, Koga C, Bührer C, et al. Differences in rate and medical indication of caesarean section between Germany and Japan. Pediatr Int. 2020;62:1086–93. doi: 10.1111/ped.14340. [DOI] [PubMed] [Google Scholar]
  • 10. Carvalho B, George RB, Cobb B, McKenzie C, Riley ET. Implementation of programmed intermittent epidural bolus for the maintenance of labor analgesia. Anesth Analg. 2016;123:965–71. doi: 10.1213/ANE.0000000000001407. [DOI] [PubMed] [Google Scholar]
  • 11. Anim-Somuah M, Smyth RM, Cyna AM, Cuthbert A. Epidural versus non-epidural or no analgesia for pain management in labour. Cochrane Database Syst Rev. 2018;5:CD000331. doi: 10.1002/14651858.CD000331.pub4. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 12. Flinspach AN, Merk J, Raimann FJ, et al. Public e-learning opportunities in anesthesia on YouTube. Front Med (Lausanne) 2024;11:1429093. doi: 10.3389/fmed.2024.1429093. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 13. Flinspach AN, Raimann FJ, Schalk R, et al. Epidural catheterization in obstetrics: A checklist-based video assessment of free available video material. J Clin Med. 2022;11:1726. doi: 10.3390/jcm11061726. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 14. Neef V, Friedrichson B, Jasny T, et al. Use of cell salvage in obstetrics in Germany: Analysis of national database of 305 610 cases with peripartum haemorrhage. Br J Anaesth. 2024;133:86–92. doi: 10.1016/j.bja.2023.12.014. [DOI] [PubMed] [Google Scholar]
  • 15. Kloka JA, Friedrichson B, Jasny T, et al. Anaemia and red blood cell transfusion in women with placenta accreta spectrum: An analysis of 38,060 cases. Sci Rep. 2024;14:4999. doi: 10.1038/s41598-024-55531-6. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 16.(DESTATIS) SÄdBudL: Fallpauschalenbezogene Krankenhausstatistik (DRG-Statistik) [last accessed on October 15; 2025 ]. www.forschungsdatenzentrum.de/de/gesundheit/drg
  • 17. World Medical Association Declaration of Helsinki: Ethical principles for medical research involving human participants. JAMA. 2025;333:71–4. doi: 10.1001/jama.2024.21972. [DOI] [PubMed] [Google Scholar]
  • 18. Kampe S, Auweiler M, Kiencke P, Kasper S, Diefenbach C. Wandel in der geburtshilflichen Periduralanalgesie. Anästhesiol Intensivmed. 2003;44:619–22. [Google Scholar]
  • 19. David M, Borde T, Brenne S, Breckenkamp J, Razum O. Differences in provision of epidural analgesia in childbirth among immigrant and nonimmigrant women: Prospective study from Berlin, Germany: Oliver Razum. Eur J Public Health. 2014;24(Suppl_2):cku161–013. [Google Scholar]
  • 20. Padrón LT, Emrich NLA, Strizek B, et al. Quality of analgesic care in labor: A cross-sectional study of the first national register-based benchmarking system. Int J Gynaecol Obstet. 2024;166:1077–85. doi: 10.1002/ijgo.15489. [DOI] [PubMed] [Google Scholar]
  • 21. Símonardóttir S, Rúdólfsdóttir AG. The “good” epidural: Women’s use of epidurals in relation to dominant discourses on “natural” birth. Feminism & Psychology. 2021;31:212–30. [Google Scholar]
  • 22. Schaal NK, Fehm T, Helbig M, Fleisch M, Hepp P. The influence of personality and anxiety traits on birth experience and epidural use in vaginal deliveries—a cohort study. Women Health. 2020;60:1141–50. doi: 10.1080/03630242.2020.1802640. [DOI] [PubMed] [Google Scholar]
  • 23. Yoshioka T, Yeo S, Fetters MD. Experiences with epidural anesthesia of Japanese women who had childbirth in the United States. J Anesth. 2012;26:326–33. doi: 10.1007/s00540-012-1328-3. [DOI] [PubMed] [Google Scholar]
  • 24. Kearns RJ, Kyzayeva A, Halliday LOE, Lawlor DA, Shaw M, Nelson SM. Epidural analgesia during labour and severe maternal morbidity: Population based study. BMJ. 2024;385:e077190. doi: 10.1136/bmj-2023-077190. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 25. Tunn R, Ramakrishnan R, Hartopp R, Knight M, Lucas DN, Plaat F. Neurological complications following obstetric neuraxial anaesthesia: A four-year United Kingdom population-based study of epidural haematoma and epidural abscess (2014-2017) Int J Obstet Anesth. 2025;63:104700. doi: 10.1016/j.ijoa.2025.104700. [DOI] [PubMed] [Google Scholar]
  • 26. Hillyard SG, Bate TE, Corcoran TB, Paech MJ, O‘Sullivan G. Extending epidural analgesia for emergency Caesarean section: A meta-analysis. Br J Anaesth. 2011;107:668–78. doi: 10.1093/bja/aer300. [DOI] [PubMed] [Google Scholar]
  • 27. Seijmonsbergen-Schermers AE, Van Den Akker T, Rydahl E, et al. Variations in use of childbirth interventions in 13 high-income countries: A multinational cross-sectional study. PLoS Med. 2020;17:e1003103. doi: 10.1371/journal.pmed.1003103. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 28. Wassen MMLH, Hukkelhoven CWPM, Scheepers HCJ, Smits LJM, Nijhuis JG, Roumen FJME. Epidural analgesia and operative delivery: A ten-year population-based cohort study in The Netherlands. Eur J Obstet Gynecol Reprod Biol. 2014;183:125–31. doi: 10.1016/j.ejogrb.2014.10.023. [DOI] [PubMed] [Google Scholar]
  • 29. Walker JJ. Planned home birth. Best Pract Res Clin Obstet Gynaecol. 2017;43:76–86. doi: 10.1016/j.bpobgyn.2017.06.001. [DOI] [PubMed] [Google Scholar]
  • 30. Verhoeven CJM, Boer J, Kok M, Nieuwenhuijze M, De Jonge A, Peters LL. More home births during the COVID-19 pandemic in the Netherlands. Birth. 2022;49:792–804. doi: 10.1111/birt.12646. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 31. Zhao P, Cai Z, Huang A, et al. Why is the labor epidural rate low and cesarean delivery rate high? A survey of Chinese perinatal care providers. PLoS One. 2021;16:e0251345. doi: 10.1371/journal.pone.0251345. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 32. Waldum ÅH, Jacobsen AF, Lukasse M, et al. The provision of epidural analgesia during labor according to maternal birthplace: A Norwegian register study. BMC Pregnancy Childbirth. 2020;20:321. doi: 10.1186/s12884-020-03021-8. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 33. Abou-Dakn M, Schäfers R, Peterwerth N, et al. Vaginal birth at term-part 1. Guideline of the DGGG, OEGGG and SGGG (S3-Level, AWMF Registry No. 015/083, December 2020) Geburtshilfe Frauenheilkd. 2022;82:1143–93. doi: 10.1055/a-1904-6546. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 34. Flinspach AN, Sterz J, Neef V, et al. Rise of public e-learning opportunities in the context of COVID-19 pandemic-induced curtailment of face-to-face courses, exemplified by epidural catheterization on YouTube. BMC Med Educ. 2023;23:406. doi: 10.1186/s12909-023-04409-8. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 35. Hung TH, Hsieh TT, Liu HP. Differential effects of epidural analgesia on modes of delivery and perinatal outcomes between nulliparous and multiparous women: A retrospective cohort study. PLoS One. 2015;10:e0120907. doi: 10.1371/journal.pone.0120907. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 36. Lowe N. Differences in first and second stage labor pain between nulliparous and multiparous women. J Psychosom Obstet Gynaecol. 1992;13:243–53. [Google Scholar]
  • 37. Nikpour M, Alijanpoor M, Behmanesh F, et al. A comparison of fear of childbirth and labor pain intensity among primiparous and multiparous women: A cross-sectional study. J Midwifery Reprod Health. 2025;13:5085–93. [Google Scholar]
  • 38. Deng Y, Li H, Dai Y, et al. Are there differences in pain intensity between two consecutive vaginal childbirths? A retrospective cohort study. Int J Nurs Stud. 2020;105:103549. doi: 10.1016/j.ijnurstu.2020.103549. [DOI] [PubMed] [Google Scholar]
  • 39. Bauer S, Kötter C. Update of criteria for out-of-hospital births in Germany-how to deal with higher than low risks in obstetrics. Der Gynäkologe. 2020;53:789–94. [Google Scholar]

Additional references (eReferences)

  • e1. Jagannathan DK, Arriaga AF, Elterman KG, et al. Effect of neuraxial technique after inadvertent dural puncture on obstetric outcomes and anesthetic complications. Int J Obstet Anesth. 2016;25:23–9. doi: 10.1016/j.ijoa.2015.09.002. [DOI] [PubMed] [Google Scholar]
  • e2. Poma S, Bonomo MC, Gazzaniga G, et al. Complications of unintentional dural puncture during labour epidural analgesia: A 10-year retrospective observational study. Anesth Analg Crit Care. 2023;3:42. doi: 10.1186/s44158-023-00127-1. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • e3. D’Angelo R, Smiley RM, Riley ET, Segal S. Serious complications related to obstetric anesthesia: The serious complication repository project of the society for obstetric anesthesia and perinatology. Anesthesiology. 2014;120:1505–12. doi: 10.1097/ALN.0000000000000253. [DOI] [PubMed] [Google Scholar]
  • e4. Arevalo-Rodriguez I, Muñoz L, Godoy-Casasbuenas N, et al. Needle gauge and tip designs for preventing post-dural puncture headache (PDPH) Cochrane Database Syst Rev. 2017;4:CD010807. doi: 10.1002/14651858.CD010807.pub2. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • e5. Osterman MJK, Martin JA. Epidural and spinal anesthesia use during labor: 27-state reporting area, 2008. Natl Vital Stat Rep. 2011;59:1-13, 16. [PubMed] [Google Scholar]
  • e6. Waldum ÅH, Jacobsen AF, Lukasse M, et al. The provision of epidural analgesia during labor according to maternal birthplace: A Norwegian register study. BMC Pregnancy Childbirth. 2020;20:321. doi: 10.1186/s12884-020-03021-8. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • e7. Chassard D, Langlois-Jacques C, Naaim M, et al. Anesthesia practices for management of labor pain and cesarean delivery in France (EPIDOL): A cross-sectional survey. Anaesth Crit Care Pain Med. 2023;42:101302. doi: 10.1016/j.accpm.2023.101302. [DOI] [PubMed] [Google Scholar]
  • e8. Guglielminotti J, Landau R, Daw J, Friedman AM, Chihuri S, Li G. Use of labor neuraxial analgesia for vaginal delivery and severe maternal morbidity. JAMA Netw Open. 2022;5:e220137. doi: 10.1001/jamanetworkopen.2022.0137. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • e9. Räisänen S, Kokki M, Kokki H, Gissler M, Kramer MR, Heinonen S. The use of epidural analgesia for intrapartum pain relief in publicly funded healthcare. Acta Anaesthesiol Scand. 2014;58:291–7. doi: 10.1111/aas.12268. [DOI] [PubMed] [Google Scholar]
  • e10. Abu Shqara R, Goldinfeld G, Biderman SN, et al. Factors affecting womens’ attitude towards labor epidural analgesia in a culturally diverse population: A prospective patient-reported outcome study. Int J Obstet Anesth. 2025;61:104329. doi: 10.1016/j.ijoa.2025.104329. [DOI] [PubMed] [Google Scholar]

References (abbreviated)

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

The data on which the results of this study are based are available from the Federal Statistical Office with the restrictions applied. The dataset was used under license for this study and is therefore not generally accessible. However, the data are available from the authors on reasonable request and with permission from the Federal Statistical Office (DESTATIS).

Articles from Deutsches Ärzteblatt International are provided here courtesy of Deutscher Arzte-Verlag GmbH

RESOURCES