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Primary Spoken Language and Neuraxial Labor Analgesia Use Among Hispanic Medicaid Recipients

Toledo, Paloma MD, MPH; Eosakul, Stanley T. MD, MS; Grobman, William A. MD, MBA; Feinglass, Joe PhD; Hasnain-Wynia, Romana PhD

doi: 10.1213/ANE.0000000000001079
Obstetric Anesthesiology: Research Report

BACKGROUND: Hispanic women are less likely than non-Hispanic Caucasian women to use neuraxial labor analgesia. It is unknown whether there is a disparity in anticipated or actual use of neuraxial labor analgesia among Hispanic women based on primary language (English versus Spanish).

METHODS: In this 3-year retrospective, single-institution, cross-sectional study, we extracted electronic medical record data on Hispanic nulliparous with vaginal deliveries who were insured by Medicaid. On admission, patients self-identified their primary language and anticipated analgesic use for labor. Extracted data included age, marital status, labor type, delivery provider (obstetrician or midwife), and anticipated and actual analgesic use. Household income was estimated from census data geocoded by zip code. Multivariable logistic regression models were estimated for anticipated and actual neuraxial analgesia use.

RESULTS: Among 932 Hispanic women, 182 were self-identified as primary Spanish speakers. Spanish-speaking Hispanic women were less likely to anticipate and use neuraxial anesthesia than English-speaking women. After controlling for confounders, there was an association between primary language and anticipated neuraxial analgesia use (adjusted relative risk: Spanish- versus English-speaking women, 0.70; 97.5% confidence interval, 0.53–0.92). Similarly, there was an association between language and neuraxial analgesia use (adjusted relative risk: Spanish- versus English-speaking women 0.88; 97.5% confidence interval, 0.78–0.99). The use of a midwife compared with an obstetrician also decreased the likelihood of both anticipating and using neuraxial analgesia.

CONCLUSIONS: A language-based disparity was found in neuraxial labor analgesia use. It is possible that there are communication barriers in knowledge or understanding of analgesic options. Further research is necessary to determine the cause of this association.

From the Northwestern University Feinberg School of Medicine, Chicago, Illinois.

Stanley T. Eosakul, MD, MS, is currently affiliated with Beth Israel Deaconess Medical Center, Boston, Massachusetts.

Romana Hasnain-Wynia, PhD, is currently affiliated with Disparities Program, Patient-Centered Outcomes Research Institute (PCORI), Washington, DC.

Accepted for publication September 18, 2015.

Funding: This study was completed with the following support: an Agency for Healthcare Research and Quality F32 award (HS020122, PI: Paloma Toledo, MD, MPH) and a Robert Wood Johnson Foundation Harold Amos Medical Faculty Development program (award 69779, PI: Paloma Toledo, MD, MPH). Stanley T. Eosakul was supported by a Foundation for Anesthesia Education and Research Medical Student Anesthesia Research Fellowship. The use of the Northwestern University Electronic Data Warehouse is supported by the National Center for Advancing Translational Sciences (NCATS) grant 8UL1TR000150. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Agency for Healthcare Research and Quality or the Robert Wood Johnson Foundation.

The authors declare no conflicts of interest.

This report was previously presented, in part, at the 44th Annual Meeting of the Society for Obstetric Anesthesia and Perinatology, Monterey, CA, and the 2012 American Society of Anesthesiologists Annual Meeting in Washington, DC, which was the subject of a press release by the American Society of Anesthesiologists.

Reprints will not be available from the authors.

Address correspondence to Paloma Toledo, MD, MPH, Northwestern University, Feinberg School of Medicine, 251 E. Huron St., F5-704, Chicago, IL 60611. Address e-mail to p-toledo@md.northwestern.edu.

There are racial and ethnic disparities in neuraxial labor analgesia use; Hispanic and African American women are less likely than non-Hispanic Caucasian women to use neuraxial labor analgesia.1,2 Multiple studies have shown that Hispanic women have the lowest rates of neuraxial labor epidural use.1–3 However, the cause(s) of this disparity remains unclear. We previously completed a qualitative study exploring the rationale for analgesic decision making among 509 parturients admitted for labor and found that the majority of women who did not anticipate using neuraxial labor analgesia based their decision on concerns about the procedure or potential complications from the procedure.4 Several of these concerns, such as an increased risk of back pain after neuraxial labor analgesia, are unsupported by the medical literature.5,6 More than 75% of the women who had concerns about back pain were of Hispanic ethnicity.4 Similar findings were found in a survey of 50 predominantly Hispanic parturients at University of Texas’ Lyndon B. Johnson hospital.7 Before analgesic counseling, 54% of the interviewed women were concerned about chronic back pain, 76% feared paralysis, and 36% indicated that their friends or family advised them against the use of epidural analgesia for labor.7 The findings from these 2 studies suggest that there is a significant misunderstanding about neuraxial labor analgesia among Hispanic parturients.

Hispanics are the largest minority group in the United States, and Spanish is the most-spoken non-English language in the United States.a Language barriers may lead to ineffective communication of poor quality. It is not known whether differences in primary spoken language contribute to the disparity in neuraxial analgesia use observed among Hispanic women. We therefore designed a retrospective cross-sectional study to evaluate anticipated and actual neuraxial analgesia use among Medicaid-insured, nulliparous Hispanic women at our institution. We hypothesized that Spanish-speaking Hispanic parturients would be less likely than English-speaking Hispanic parturients to anticipate and use neuraxial labor analgesia.

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METHODS

Northwestern University’s IRB approved this study. Deidentified electronic medical record data were extracted for all nulliparous self-identified Hispanic women who were insured by Medicaid and had spontaneous vaginal deliveries at Northwestern Memorial Hospital between January 1, 2007, and July 16, 2010, using the Northwestern University Electronic Data Warehouse. The start date was chosen to coincide with the first year for which there were electronic medical record data available for labor analgesia. Patients who delivered via cesarean or instrumental vaginal delivery, or for whom the delivery provider was unknown, were excluded from the analysis.

Data extracted from the medical record included age (<20, 20–34, and >35 years of age), marital status, obstetric provider type (midwife or obstetrician), and labor type (spontaneous versus induced labor). Upon hospital registration, all patients are asked by admitting personnel to self-identify their race/ethnicity and primary language. Subsequently, shortly after admission to the labor and delivery unit, the admitting nurse completes a standardized template, which contains the type of analgesia the patient anticipates using for labor (none, epidural analgesia, IV pain medications, breathing/relaxation techniques, or hydrotherapy). This information, as well as the actual mode of analgesia used for labor (neuraxial analgesia versus no neuraxial analgesia), was extracted from the electronic medical record. For patients who used neuraxial analgesia, the cervical dilation at the time of epidural catheter placement was extracted.

Annual household income was estimated through zip code tabulation areas (ZTCA) census data from geocoded addresses. Income was dichotomized at the median household income. The household income for 12 patients who had missing zip codes was imputed using multiple linear regression based on age, primary language, marital status, and insurance status.

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Statistical Analysis

Normal distribution for continuous variables was determined using the Shapiro-Wilk test. Data were stratified by primary spoken language (English versus Spanish). Categorical data were compared using the χ2 test, and income data were compared using the Mann-Whitney U test (Shapiro-Wilk test, P < 0.0001). P < 0.05 was used to define statistical significance.

Three multivariable logistic regression models were estimated. In the first model, the dependent variable was anticipated neuraxial analgesia use, and in the second model the dependent variable was actual neuraxial analgesia use. Neuraxial analgesia use among patients who made an intrapartum decision to use neuraxial analgesia was analyzed in the third model. The models were adjusted for primary spoken language, age, marital status, income, type of obstetric provider, and labor type, because all these variables, with the exception of primary language, have been shown previously to be associated with the use of neuraxial analgesia.1–3,8–10 All variables were entered into the model in a single step. Model discrimination was evaluated using the C statistic, and model fit calibration was evaluated using the Hosmer-Lemeshow goodness-of-fit test.11 Internal model validation was performed through bootstrapping using 500 repetitions.12 Because the incidence of both anticipated and actual neuraxial analgesia use was common, the relative risk was estimated using a modified Poisson regression approach with a robust error variance.13

Sensitivity analysis included evaluation of age as a continuous variable and evaluation of possible interactions between language and age and primary language and obstetric providers. To evaluate the effect of age as a continuous variable, univariate predictive fits were compared using age as a categorical variable versus as a continuous variable, using the test of equality of receiver operating curves. All data were analyzed using Stata SE (version 12, College Station, TX).

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RESULTS

One thousand four hundred twenty-four Hispanic women were identified, and 492 were excluded because the delivery provider was unknown. The final sample consisted of 932 women. Participant characteristics and clinical data, including anticipated and actual neuraxial analgesia use, stratified by primary language (English versus Spanish), are shown in Table 1. There were no differences between English- and Spanish-speaking Hispanic women, except that Spanish-speaking Hispanic women were more likely to be married than English-speaking women. There was no difference in cervical dilation at epidural catheter placement between English- and Spanish-speaking women. Despite the overall similarity between groups, Spanish-speaking Hispanic women were less likely to anticipate and use neuraxial anesthesia. Overall, 96% of women who wanted to use neuraxial labor analgesia received it.

Table 1

Table 1

Table 2

Table 2

Table 3

Table 3

Table 4

Table 4

Logistic regression results for the likelihood of anticipated and actual neuraxial analgesia use are presented in Table 2, and the corresponding relative risks are presented in Table 3. Primary language was associated with less anticipated and actual neuraxial analgesia use, even after adjusting for confounding variables in both models. Other factors that were independently associated with a lower incidence of anticipated and actual neuraxial analgesia use were delivery by a midwife and age younger than 20 years. In contrast, neither primary language nor age was associated with the intrapartum decision to use neuraxial labor analgesia, but the use of a midwife was associated with a lower incidence of neuraxial analgesia use (Table 4).

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DISCUSSION

The important finding of this study is that there is an association between primary spoken language and anticipated and actual neuraxial analgesia use among self-identified Hispanic women. This disparity persists, even after controlling for demographic and provider-level factors. This finding is significant because approximately 4 million women deliver annually in the United States and approximately 24% of all deliveries are women of Hispanic ethnicity.14 Previous studies have shown that Hispanic women have the lowest rates of neuraxial analgesia use,1–3 and, to our knowledge, this is the first study to evaluate analgesic intention based on spoken language among Hispanic women. Because disparities were found in both anticipated and actual use, it is important to understand the potential origins of language-based disparities.

Whether this difference is a disparity depends on the definition of disparity used. The Agency for Healthcare Research and Quality defines a disparity as a difference or gap experienced by one population in comparison with another.15 Using this definition, the language-based differences found in this study would constitute a disparity. Possible explanations for this disparity could arise from 3 levels: systems level, provider level, and patient level.16 A systems-level origin is unlikely because all patients admitted to Northwestern Memorial Hospital are seen by the obstetric anesthesia service, as well as counseled on neuraxial analgesia, and telephone interpreter services are available 24 hours a day. Furthermore, the overall neuraxial analgesia rate at our institution (approximately 93%) is much higher than the national average17; this high frequency supports the argument that there is no access barrier to neuraxial analgesia at our institution.

The language-based disparity observed in this study could originate from communication barriers with Spanish-speaking Hispanic parturients. Although there are several measures in place to ensure linguistic support to limited English proficiency (LEP) patients (e.g., the National Culturally and Linguistically Appropriate Services Standards in Health and Health Care,b which state that an interpreter must be available to patients at no cost, and the Title VI Provision Against National Origin Discrimination Affecting LEP Personsc), the extent to which communication with LEP patients in the labor and delivery setting is conducted in the patient’s primary or preferred language is unknown. Studies in the United States have explored patients’ preferences for language-concordant care. Data from the 2001 California Health Interview Survey suggested that Mexican immigrants living in California were more likely to seek medical, dental, and prescription drug services from Mexico.18 LEP was independently associated with seeking medical and dental care in Mexico, underscoring the importance of language concordance in medical care for LEP patients. Only one other study has evaluated language-based disparities in neuraxial analgesia use, and the authors of that study found that controlling for preferred spoken language mediated the effect of race/ethnicity on neuraxial analgesia use.19 The majority of the non-English speakers in that study were Hispanic; therefore, Spanish as a first language may create a communication barrier for the receipt of neuraxial labor analgesia, and more data are needed to determine whether there is a barrier with other languages.

In addition to language, other patient-level explanations include knowledge of analgesic options, educational level, access to prenatal education, and preexisting biases and misconceptions about neuraxial analgesia.3,8 There may be cultural differences in attitudes toward the use of analgesia for childbirth; however, previous qualitative work with Hispanic parturients at our institution did not reveal that culture played a significant role in analgesic decision making.4

At the provider level, it is possible that providers may make different recommendations to patients based on their language ability or that providers perceive patients’ pain differently, and this gap in perception results in different analgesic recommendations. In a prospective observational study, Jewish and Bedouin parturients were asked to report their labor pain using an 11-point visual analog scale.20 A Jewish doctor or midwife also estimated the patient’s exhibited pain using the same scale. Although the self-reported pain was similar between the Jewish and the Bedouin women, the medical providers rated the pain severity of the Bedouin women lower than that of the Jewish women (6.89 vs 8.52; P < 0.001).

A consistent finding in our study was that the use of a midwife compared with an obstetrician decreased the likelihood of both anticipating and using neuraxial labor analgesia, even after controlling for other factors, including language. In fact, the use of a midwife was the only factor that was significantly associated with the intrapartum decision to use neuraxial labor analgesia, underscoring the importance of provider type on analgesic decision making. Pregnant women can choose to deliver with an obstetrician, a family physician, or a midwife. At our institution, only obstetricians and midwives deliver patients. It is known that neuraxial analgesia rates are lower when midwives or family practitioners are the delivery providers compared with obstetricians,9 likely because of the noninterventional approach of midwives. A 1998 national survey of members of the American College of Nurse-Midwives found that the majority (53%) of respondents had a negative attitude toward the increased use of neuraxial analgesia in midwifery practice, and 53% of respondents agreed that experiencing labor pain was a valuable experience for most women.21 This bias against neuraxial analgesia is important because midwives may be recommending non-neuraxial pain management options to women, and this may influence patient’s ultimate decision making. This recommendation may have a greater impact on LEP patients than English-speaking parturients because qualitative studies have shown that Hispanic patients are more likely to view their medical providers as the primary decision maker for medical decisions than non-Hispanic Caucasian patients.22

It is important to consider this study’s limitations. These findings are from a single urban institution. It is not known whether patients in the current study had previous knowledge of neuraxial analgesia or what sources of information were used to investigate analgesic options. Furthermore, because of the retrospective study design, only the primary language preference (English or Spanish), but not the degree of English language proficiency, was known. In addition, the language in which analgesic counseling occurred, as well as whether an interpreter was used for the counseling, is unknown. Access to an interpreter, if one is necessary, is not problematic at our institution because a certified interpreter is available 24 hours a day through a telephone interpreter service. Another limitation is that variables that have been found to be associated with neuraxial labor analgesia use, such as knowledge of neuraxial analgesia options and patient education, were not available for this analysis.8,23 Furthermore, given the high use rate among women who anticipated neuraxial labor analgesia use, analgesic anticipation could not be included in the model of neuraxial labor analgesia use. A final limitation is that we were only able to measure language and not acculturation. A patient’s ability to speak English is not a proxy measure for acculturation.24 To fully investigate the effect of acculturation on neuraxial analgesia use, a prospective study is required.

Despite these limitations, the study has several strengths. The patients included in this analysis were all nulliparous. Patients who have previously used neuraxial analgesia are likely to use it again for subsequent deliveries,4 and inclusion of these patients would likely lead to an underestimation of a language-based disparity. All patients included in this study had spontaneous vaginal deliveries, thus eliminating those who were more likely to use neuraxial analgesia because of increased pain from dysfunctional labor (resulting in either instrumental or cesarean delivery).25,26 All patients included in this study were insured through Medicaid, thus reducing the effect of differential income and education on analgesic decision making.

Because Spanish-speaking Hispanic women were less likely to anticipate and use neuraxial labor analgesia, it is possible that language may be a barrier to effective counseling on and understanding of analgesic options. Evaluation of the systems in place to facilitate adequate education and communication should be evaluated, to provide safe, high-quality care for Hispanic patients.

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DISCLOSURES

Name: Paloma Toledo, MD, MPH.

Contribution: This author helped design the study, conduct the study, analyze the data, and write the manuscript.

Attestation: Paloma Toledo has seen the original study data, reviewed the analysis of the data, approved the final manuscript, and is the author responsible for archiving the study files.

Name: Stanley T. Eosakul, MD, MS.

Contribution: This author helped conduct the study, analyze the data, and write the manuscript.

Attestation: Stanley T. Eosakul has seen the original study data, reviewed the analysis of the data, and approved the final manuscript.

Name: William A. Grobman, MD, MBA.

Contribution: This author helped design the study, conduct the study, analyze the data, and write the manuscript.

Attestation: William A. Grobman has seen the original study data, reviewed the analysis of the data, and approved the final manuscript.

Name: Joe Feinglass, PhD.

Contribution: This author helped design the study, conduct the study, analyze the data, and write the manuscript.

Attestation: Joe Feinglass has seen the original study data, reviewed the analysis of the data, and approved the final manuscript.

Name: Romana Hasnain-Wynia, PhD.

Contribution: This author helped design the study, conduct the study, analyze the data, and write the manuscript.

Attestation: Romana Hasnain-Wynia has seen the original study data, reviewed the analysis of the data, and approved the final manuscript.

This manuscript was handled by: Steven L. Shafer, MD.

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FOOTNOTES

a Spanish is the most-spoken non-English language in U.S. homes, even among non-Hispanics. Available at: http://www.pewresearch.org/fact-tank/2013/08/13/spanish-is-the-most-spoken-non-english-language-in-u-s-homes-even-among-non-hispanics. Accessed September 4, 2014.
Cited Here...

b National Standards for Culturally and Linguistically Appropriate (CLAS) services in Health Care: U.S. Department of Health and Human Services: Office of Minority Health. Available at: https://www.thinkculturalhealth.hhs.gov/Content/clas.asp. Accessed March 17, 2014.
Cited Here...

c National Archives. Title VI, Prohibition Against National Origin Discrimination Affecting Limited English Proficient Persons. Available at: http://www.archives.gov/eeo/laws/title-vi.html. Accessed March 17, 2014.
Cited Here...

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REFERENCES

1. Rust G, Nembhard WN, Nichols M, Omole F, Minor P, Barosso G, Mayberry R. Racial and ethnic disparities in the provision of epidural analgesia to Georgia Medicaid beneficiaries during labor and delivery. Am J Obstet Gynecol. 2004;191:456–62
2. Glance LG, Wissler R, Glantz C, Osler TM, Mukamel DB, Dick AW. Racial differences in the use of epidural analgesia for labor. Anesthesiology. 2007;106:19–25
3. Toledo P, Sun J, Grobman WA, Wong CA, Feinglass J, Hasnain-Wynia R. Racial and ethnic disparities in neuraxial labor analgesia. Anesth Analg. 2012;114:172–8
4. Toledo P, Sun J, Peralta F, Grobman WA, Wong CA, Hasnain-Wynia R. A qualitative analysis of parturients’ perspectives on neuraxial labor analgesia. Int J Obstet Anesth. 2013;22:119–23
5. Macarthur AJ, Macarthur C, Weeks SK. Is epidural anesthesia in labor associated with chronic low back pain? A prospective cohort study. Anesth Analg. 1997;85:1066–70
6. Loughnan BA, Carli F, Romney M, Doré CJ, Gordon H. Epidural analgesia and backache: a randomized controlled comparison with intramuscular meperidine for analgesia during labour. Br J Anaesth. 2002;89:466–72
7. Orejuela FJ, Garcia T, Green C, Kilpatrick C, Guzman S, Blackwell S. Exploring factors influencing patient request for epidural analgesia on admission to labor and delivery in a predominantly Latino population. J Immigr Minor Health. 2012;14:287–91
8. Liu N, Wen SW, Manual DG, Katherine W, Bottomley J, Walker MC. Social disparity and the use of intrapartum epidural analgesia in a publicly funded health care system. Am J Obstet Gynecol. 2010;202:273.e1–8
9. Hueston WJ, McClaflin RR, Mansfield CJ, Rudy M. Factors associated with the use of intrapartum epidural analgesia. Obstet Gynecol. 1994;84:579–82
10. Obst TE, Nauenberg E, Buck GM. Maternal health insurance coverage as a determinant of obstetrical anesthesia care. J Health Care Poor Underserved. 2001;12:177–91
    11. Hosmer DW, Lemeshow S. A goodness-of-fit test for the multiple logistic regression model. Commun Stat. 1980;A10:1043–69
    12. Efron B, Tibshirani R. Bootstrap methods for standard errors, confidence intervals and other measures of statistical accuracy. Statist Sci. 1986;1:54–77
    13. Zou G. A modified poisson regression approach to prospective studies with binary data. Am J Epidemiol. 2004;159:702–6
    14. Martin JA, Hamilton BE, Ventura SJ, Osterman MJK, Wilson EC, Mathews TJ Births: Final Data for 2010. National Vital Statistics Reports.. 2012;Vol 61, No 1 Hyattsville, MD National Center for Health Statistics
    15. Agency for Healthcare Research and Quality. National Healthcare Disparities Report, 2008. 2008 Rockville, MD Agency for Healthcare Research and Quality
    16. Kilbourne AM, Switzer G, Hyman K, Crowley-Matoka M, Fine MJ. Advancing health disparities research within the health care system: a conceptual framework. Am J Public Health. 2006;96:2113–21
    17. Osterman MJ, Martin JA. Epidural and spinal anesthesia use during labor: 27-state reporting area, 2008. Natl Vital Stat Rep. 2011;59:1–13–16
    18. Wallace SP, Mendez-Luck C, Castañeda X. Heading south: why Mexican immigrants in California seek health services in Mexico. Med Care. 2009;47:662–9
    19. Caballero JA, Butwick AJ, Carvalho B, Riley ET. Preferred spoken language mediates differences in neuraxial labor analgesia utilization among racial and ethnic groups. Int J Obstet Anesth. 2014;23:161–7
    20. Sheiner EK, Sheiner E, Shoham-Vardi I, Mazor M, Katz M. Ethnic differences influence care giver’s estimates of pain during labour. Pain. 1999;81:299–305
    21. Graninger EM, McCool WP. Nurse-midwives’ use of and attitudes toward epidural analgesia. J Nurse Midwifery. 1998;43:250–61
    22. Katz JN, Lyons N, Wolff LS, Silverman J, Emrani P, Holt HL, Corbett KL, Escalante A, Losina E. Medical decision-making among Hispanics and non-Hispanic Whites with chronic back and knee pain: a qualitative study. BMC Musculoskelet Disord. 2011;12:78
    23. Ochroch EA, Troxel AB, Frogel JK, Farrar JT. The influence of race and socioeconomic factors on patient acceptance of perioperative epidural analgesia. Anesth Analg. 2007;105:1787–92
    24. Abraído-Lanza AF, Armbrister AN, Flórez KR, Aguirre AN. Toward a theory-driven model of acculturation in public health research. Am J Public Health. 2006;96:1342–6
    25. Alexander JM, Sharma SK, McIntire DD, Wiley J, Leveno KJ. Intensity of labor pain and cesarean delivery. Anesth Analg. 2001;92:1524–8
    26. Hess PE, Pratt SD, Soni AK, Sarna MC, Oriol NE. An association between severe labor pain and cesarean delivery. Anesth Analg. 2000;90:881–6
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