Social inequity linked to lower use of epidural in childbirth

In a study of women in labor in the U. S., social inequity was associated with lower use of neuraxial analgesia—an epidural or spinal pain reliever— among non-Hispanic white women and, to a greater extent, among African American women, according to research at Columbia University Mailman School of Public Health and Columbia Vagelos College of Physicians and Surgeons (P&S). The results are published online in Obstetrics & Gynecology.

Neuraxial analgesia, which can be a combined spinal and epidural analgesia, is the most effective technique to relieve pain during labor. It also helps reduce severe maternal morbidity.

The new study suggests that addressing social inequity in education, employment, and criminal justice represents a promising pathway to improve pain management for childbirth and reduce racial disparities in maternal health outcomes.

About three-quarters of women in labor receive neuraxial analgesia in the U. S. Compared with white women, African American women are about 10% less likely to receive neuraxial analgesia during labor.

Mechanisms accounting for the lower use of labor neuraxial analgesia among African American women include patient preference—because of insufficient prenatal education on pain management options during labor—and reduced access to labor neuraxial analgesia in the delivery hospital which can be due to lack of a 24/7 dedicated obstetric anesthesia team.

“Social inequity and racism could be significant contributors to racial and ethnic disparities in labor neuraxial analgesia use,” said Jean Guglielminotti, MD, Ph.D., assistant professor of anesthesiology at Columbia P&S, and first author.

“Racism—including structural, institutional, and interpersonal racism- is suggested as a root cause of racial and ethnic disparities in perinatal care access and utilization in the U.S.”

To assess the association between social inequity and use of labor neuraxial analgesia, the researchers used data of 1.7 million African American and white women in labor in 45 U.S. states and the District of Columbia in 2017 provided by the CDC. Social inequity was calculated using an index based on Black-to-white inequity ratios in low education rates, unemployment rates, and incarceration rates.

The average age of the women was 29 years, of which 23% were African American. In counties with the highest social inequity index, labor neuraxial analgesia was used by 78% of white women and by 72% of African American women. After adjusting for demographic and clinical characteristics, African American women had a 17% decreased odds of receiving labor neuraxial analgesia compared with white women.

In the study, social inequity was measured based on data for the county of the delivery hospital. Compared to counties with low social inequity, giving birth in counties with high social inequity was associated with a 16 percent decreased use of neuraxial analgesia for white women and a 28% decreased used for African American women.

“A notable finding of our study is that social inequity negatively impacts both white and African American women.,” observed Guglielminotti. “A potential explanation is that inequities negatively impact all people that enter the health care system, because the system is not operating at an optimal level when racism undermines policies, practices, and procedures.”