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Racial and Ethnic Disparities in Neuraxial Labor Analgesia

Toledo, Paloma, MD, MPH*,†; Sun, Jinglu, BA*; Grobman, William A., MD, MBA†,‡; Wong, Cynthia A., MD*; Feinglass, Joe, PhD†,§; Hasnain-Wynia, Romana, PhD†,§

doi: 10.1213/ANE.0b013e318239dc7c
Obstetric Anesthesiology: Research Reports
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BACKGROUND: Racial and ethnic disparities in the treatment of pain have been well documented, and there is evidence of such disparities in neuraxial analgesia use. Our objectives of this study were to analyze racial/ethnic disparities in neuraxial analgesia use, as well as anticipated use, among laboring Hispanic, African-American, and Caucasian women, and to evaluate sociodemographic, clinical, and decision-making predictors of actual and anticipated neuraxial analgesia use among these women.

METHODS: Laboring women, in a large urban academic hospital, were interviewed using a face-to-face survey to determine individual factors that may influence choice of labor analgesia. After delivery, the type of labor analgesia used was recorded. The primary outcome was use of neuraxial analgesia. Multivariable logistic regression models were estimated to test the likelihood that race and ethnicity were significantly associated with neuraxial analgesia use, anticipated neuraxial analgesia use, and the intrapartum decision to use neuraxial analgesia.

RESULTS: There was a univariate association between race/ethnicity and anticipated as well as actual use of neuraxial analgesia. However, there was no association between race/ethnicity and the intrapartum decision to use neuraxial analgesia. After controlling for confounders, the association between race/ethnicity and actual use of neuraxial analgesia no longer remained significant (adjusted odds ratio: Hispanic versus Caucasian women 0.66, 95% confidence interval [CI]: 0.24 to 1.80; African-American versus Caucasian women 0.93, 95% CI: 0.31 to 2.77). In contrast, Hispanic women were less likely than Caucasian women to anticipate using neuraxial analgesia even after controlling for confounders (adjusted odds ratio 0.40, 95% CI: 0.20 to 0.82).

CONCLUSIONS: After controlling for confounding variables, Hispanic women anticipated using neuraxial analgesia at a lower rate than other racial/ethnic groups; however, actual use was similar among groups.

Published ahead of print November 10, 2011

From the *Department of Anesthesiology, Center for Healthcare Equity/Institute for Healthcare Studies, Department of Obstetrics and Gynecology, and §Division of General Internal Medicine, Northwestern University, Feinberg School of Medicine, Chicago, IL.

Jinglu Sun is currently affiliated with West Virginia University School of Medicine.

Study funding is provided at the end of the article.

The authors declare no conflict of interest.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.anesthesia-analgesia.org).

This report was previously presented, in part, at the 42nd Annual Meeting of the Society for Obstetric Anesthesia and Perinatology (SOAP), San Antonio, TX, May 13, 2010; AcademyHealth Annual Research Meeting, Boston, MA, June 27, 2010; and the American Society of Anesthesiologists Annual Meeting, San Diego, CA, October 17, 2010.

Reprints will not be available from the authors.

Address correspondence to Paloma Toledo, MD, MPH, Department of Anesthesiology and Center for Healthcare Equity/Institute for Healthcare Studies, Northwestern University, Feinberg School of Medicine, 251 E. Huron St., F5-704 Chicago, IL 60611. Address e-mail to p-toledo@md.northwestern.edu.

Accepted September 16, 2011

Published ahead of print November 10, 2011

Racial and ethnic disparities in the treatment of both acute and chronic pain have been well documented.19 Neuraxial analgesia has been shown to be the most effective method for relieving pain in labor,10 and 2 large retrospective studies have found that there are racial/ ethnic disparities in neuraxial analgesia use.11,12 Though previous studies have examined whether there are disparities in labor analgesia use, to our knowledge, none has prospectively evaluated the underlying causes. At the patient level, the decision to use or not use neuraxial analgesia depends on a number of factors, including but not limited to knowledge of analgesic options, communication with and trust in providers, and outside influences (e.g., family influences).1119

Therefore, the aims of this study were to determine (1) whether there were racial/ethnic disparities in the proportion of patients who (a) used neuraxial analgesia for labor, (b) initially anticipated using neuraxial analgesia, or (c) among those who made an intrapartum decision to use neuraxial analgesia; and (2) to determine whether these disparities persisted after controlling for other clinical and sociodemographic factors.

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METHODS

Study Population

The study population consisted of English-speaking Caucasian, Hispanic, and African-American women with a term gestation and no contraindications to neuraxial analgesia who were admitted to Northwestern Memorial Hospital in Chicago for anticipated vaginal delivery. Women who had not had a preanesthetic assessment, or had not yet requested or received labor analgesia, were eligible to participate in the study. Women who self-reported belonging to a racial or ethnic group other than those specified above were ineligible for study participation. The study population was selected using a nonprobabilistic sampling of eligible patients who were present when one of the study investigators was present on the Labor and Delivery Unit. After screening to confirm eligibility, 1 of 3 trained interviewers administered the final survey via face-to-face interviews. Before initiating the study, interviewers were trained by the primary investigator (P.T.) to ensure a standardized approach to administration of the survey. The Northwestern University IRB approved the study, and written informed consent was obtained from all study participants before their participation.

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Survey Instrument Development

A 21-question survey instrument was developed by one of the investigators (P.T.) and underwent a panel review by experts in obstetrics (W.A.G.), obstetric anesthesia (C.A.W.), and health services research (R.H.W.) (see Web Supplement, Supplemental Digital Content 1, http://links.lww.com/AA/A338). The survey was designed to elucidate the decision-making process among women regarding labor analgesia. A Charles model was used to inform relevant domains for decision-making variables, such as information sources used by the patient that would contribute to preexisting knowledge.20,21 An additional decision-making measure, trust in providers, was also measured, given that trust is known to influence decision-making.13 Thus, final survey domains included sociodemographic, clinical, and decision-making measures. The final survey instrument was determined after 15 pilot cognitive interviews were conducted with patients to establish whether they understood the survey questions and interpreted the questions correctly, thereby establishing face and construct validity. The only modification made to the pilot survey was removal of 1 question that was found to be confusing to the pilot interview group.

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Sociodemographic Measures

Demographic items were adapted from the 2007 California Health Interview Survey.22 Women were asked which group best identified their race or ethnicity: Caucasian, Hispanic, or African-American. Per capita household income was determined by dividing household income by the number of household members, which was then grouped into 3 income categories to reflect low, middle, and high incomes: <$10,000, $10,000 to 50,000, and >$50,000. Patient age was categorized as ≤19 years, 20 to 29 years, and ≥30 years. Other measured demographics included the highest level of completed education (college educated/not), marital status (married/not), and insurance status (private insurance/not).

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Decision-Making Measures

To assess trust in providers, we used a previously validated statement from the Trust in Physician scale.13,23,24 Trust in physicians was characterized according to whether women completely agreed with the following statement: “I trust my physician to put my medical needs above all other considerations when treating my medical problems.” Respondents could answer this question on a 5-point scale: strongly agree, agree, no opinion, disagree, and strongly disagree. Questions on sources used to obtain information about labor analgesic options and intended method of pain relief for labor were developed by study investigators.

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Clinical Measures

After delivery, a data collector, different from the investigator who had administered the survey, abstracted the following information from the electronic medical record: type of delivery provider (obstetrician or midwife), gravidity, parity, gestational age, prior cesarean delivery, number of fetuses (singleton versus multiple gestation), and patient medical conditions. Medical conditions included hypertensive disorders of pregnancy (chronic hypertension, gestational hypertension, mild or severe preeclampsia), asthma, diabetes mellitus, cholestasis, or scoliosis. Additionally, type of labor initiation (spontaneous or induced), mode of delivery (vaginal or cesarean), and type of labor analgesia (none, systemic opioid, or neuraxial analgesia) were collected. For parturients who ultimately delivered via cesarean, the method of analgesia used during labor before the cesarean delivery was recorded as the analgesic for labor.

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Statistical Analysis

The primary outcome was the proportion of patients in each racial/ethnic group who used neuraxial analgesia for labor. The sample size was based on institutional estimates of neuraxial analgesia use for Caucasian and Hispanic women. We estimated that the neuraxial analgesia use would be 90% for Caucasian women and 70% for Hispanic women. A sample of 72 patients per group would have an 80% power to detect an absolute 20% difference in neuraxial analgesia use with a 2-sided t test with an α of 0.05. Expecting a similar difference between African-American and Caucasian women, we added a third group of 72 African-American women. Consecutive eligible patients admitted to the Labor and Delivery Unit when an investigator was present on the unit were recruited until the smallest racial/ethnic group (African-American) reached the desired sample size.

All independent categorical variables were compared by race and ethnicity using the χ2 test. Three multivariable logistic regression models were estimated. Actual neuraxial analgesia use was analyzed in model 1, anticipated neuraxial analgesia use was analyzed in model 2, and neuraxial analgesia use among patients who made an intrapartum decision to use neuraxial analgesia was analyzed in model 3. Candidate independent variables were selected for multivariate analysis if their bivariate association with each dependent variable (neuraxial analgesia use in model 1, anticipated neuraxial analgesia use in model 2, and neuraxial analgesia use when not initially anticipated in model 3) resulted in P < 0.1. Those candidate variables, and race/ethnicity, were then entered into a multivariable logistic regression model in a single step.

All models produced odds ratios, or adjusted odds ratios, with 95% confidence intervals (CI). Model discrimination was evaluated using the C statistic and model fit was evaluated using the Hosmer–Lemeshow goodness-of-fit test. Internal model validation was performed through bootstrapping using 500 repetitions. P < 0.05 was considered significant. All data were analyzed using Stata SE (Version 10, College Station, TX).

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RESULTS

Five hundred twenty women were approached for participation in this study, of whom 509 (98%) women consented to participate over a 15-month period between April 2008 and July 2009. Sixty-three percent of the women interviewed were Caucasian, 23% were Hispanic, and 14% were African-American. This distribution is comparable to the overall demographic characteristics of English-speaking patients who receive obstetric care at the hospital where the study occurred.

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Demographic, Decision-Making, and Clinical Characteristics Stratified by Race and Ethnicity

Participant characteristics were compared by race and ethnicity (Table 1). Caucasian women were more likely to be older, parous, married, college educated, and have a higher income and private insurance than the non-Caucasian women. There were also notable differences among the racial and ethnic groups with regard to measures relevant to sources of information used and decision-making.

Table 1

Table 1

The overall rate of neuraxial analgesia use was 89%. Women who anticipated using neuraxial analgesia were significantly more likely to receive it than those who did not anticipate its use (98% vs 63%, P < 0.001). There were significant racial/ethnic differences in anticipated and actual neuraxial analgesia use, but no differences by race/ethnicity among women who made an intrapartum decision to use neuraxial analgesia.

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Logistic Regression Results

Logistic regression results for the likelihood of actual and anticipated neuraxial analgesia use are presented in Tables 2 and 3. Whereas there were differences in the unadjusted neuraxial analgesia use rates, after controlling for other model covariates, race and ethnicity were no longer significantly associated with actual neuraxial analgesia use (adjusted odds ratio: Hispanic versus Caucasian women 0.66, 95% CI: 0.24 to 1.80; African-American versus Caucasian women 0.93, 95% CI: 0.31 to 2.77). In the full model, higher household incomes, induced labor, and the patient's use of her obstetrician or midwife as a source of information on labor analgesic options were independently associated with the likelihood of neuraxial analgesia use.

Table 2

Table 2

Table 3

Table 3

In contrast, race and ethnicity were predictive of anticipated neuraxial analgesia use (Table 3). Hispanic women were less likely than Caucasian women to anticipate using neuraxial analgesia, even after controlling for sociodemographic, decision-making, and clinical measures. Income and labor type remained significantly associated with anticipated neuraxial analgesia use in this analysis. Additionally, parturients who were parous, as well as those who chose to deliver with a midwife, were less likely to anticipate neuraxial analgesia use.

Logistic regression analysis found that no single factor was significantly associated with the intrapartum decision to use neuraxial analgesia for labor.

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DISCUSSION

The Agency for Healthcare Research and Quality defines health care disparity as a difference or gap experienced by one population in comparison with another.25 In the current study, there was a univariate association between race/ethnicity and anticipated, as well as actual, neuraxial analgesia use. However, after controlling for confounding socioeconomic, clinical, and decision-making factors in multivariable analyses, race and ethnicity were no longer associated with neuraxial analgesia use or the intrapartum decision to use neuraxial analgesia in women who initially anticipated foregoing it. In contrast, even after controlling for potential confounders such as income and education, we found that a racial/ethnic disparity persisted in anticipated neuraxial analgesia use, with Hispanic women being less likely to anticipate neuraxial analgesia use than Caucasian women.

The multivariable analysis revealing a lack of association between race/ethnicity and neuraxial analgesia use differs from the results of previous studies that have found that Hispanic or African-American patients were less likely to use neuraxial analgesia than were Caucasian women.11,12,1619,26 It may be that the retrospective nature of previous studies limited the ability to capture information that is important in the decision-making process such as information sources and communication with providers, which mediated the effect of race and ethnicity in our study. Another explanation is that interhospital variation in approaches to labor analgesia education and delivery contribute to racial/ethnic disparities. For example, at some institutions, the anesthesia service may wait to see parturients until the request for neuraxial analgesia is made; therefore, if the parturient had not had antepartum exposure to neuraxial analgesia through other information sources or through obstetric providers, she would not know or be motivated to request it. Additionally, there may be provider-level differences underlying the differences in neuraxial analgesia administration. There may be provider bias,27 or there may be financial disincentives to provide neuraxial analgesia to minority patients, who may be more likely to have public insurance. However, both the American Society of Anesthesiologists and the American College of Obstetricians and Gynecologists have asserted that a woman requesting neuraxial analgesia during labor should not be deprived of it on the basis of their insurance status or ability to pay.28 A final explanation for the lack of association between race/ethnicity and neuraxial analgesia use is that English-speaking Hispanic women may differ substantively from non-English-speaking Hispanic women in their attitudes and preferences for neuraxial analgesia.

To our knowledge, this is one of the first studies to evaluate predictors of anticipated analgesia use in the labor and delivery setting in a racially and ethnically diverse population. In addition to being Caucasian, factors increasing the likelihood of anticipating use of neuraxial analgesia included higher incomes, nulliparity, labor induction, and delivery with an obstetrician as opposed to a midwife. Parturients who choose midwives as their provider are probably desirous of a more natural childbirth experience and more motivated to pursue an unmedicated labor.29 In contrast, patients who agree to an induction of labor are probably more likely to accept neuraxial analgesia, because inductions are often conceived by women to be more painful than spontaneous labors, or perhaps these women are more amenable to medical interventions than are women who prefer unmedicated childbirths.

Other studies in nonobstetric settings show that there are racial/ethnic disparities in choice of treatment for pain, and that at least some of these disparities are related to different belief systems. For example, in a study of patients being treated for cancer-related pain, Hispanic patients were more likely to express concerns about taking too many analgesics, the side effects of medications, and fears of addiction.3 It is possible that similar factors, combined with decreased knowledge of options, may be driving the lower anticipation rate among the English-speaking Hispanic women interviewed in our study. Alternatively, there may have been cultural differences in attitudes toward birth and the pain of childbirth that were not elucidated by our survey.30

The most consistent finding was the association between income and actual and anticipated neuraxial analgesia use. This result is consistent with the findings of other investigators.18,31 Liu et al. recently reported, on the basis of a Canadian perinatal database, that socioeconomic status was predictive of labor neuraxial analgesia use.18 They found that neuraxial analgesia use decreased with decreasing neighborhood economic and educational levels. It is possible that women from lower-income neighborhoods may have less access to educational information on labor analgesic options (such as prenatal classes), thereby contributing to the association of income with choice of labor neuraxial analgesia. An alternative explanation is that patients with lower income have lower levels of health literacy. Literacy may mediate the effect of income seen in our study, because women with low health literacy may not have fully understood the true risks and benefits of medical procedures.32

It is important to consider our study's limitations. It is likely that our estimate of racial ethnic disparity is an underestimation of the overall racial and ethnic disparity in the United States. As demonstrated by Hasnain-Wynia et al., disparities may be the result of the location where minority patients seek care,33 and our analysis includes data from only 1 institution located in a nondepressed urban environment. Our institution has approximately 12,500 deliveries annually and an anesthesia service that sees and discusses labor analgesia with all parturients shortly after admission, regardless of planned mode of labor analgesia. This patient education, or another aspect of our institutional culture and practice, may lead to a higher neuraxial rate than the national average, and possibly lessen racial and ethnic differences in neuraxial analgesia use. Another possible limitation is that the patient population served by our hospital may not be reflective of the general population seen in the United States, because approximately half of the women were college educated and had a high annual income more than $50,000. Lastly, we limited our sampling to English-speaking parturients of 3 self-identified racial and ethnic groups. These limitations may have significantly affected the external validity of our findings.

While we sought to be as comprehensive as possible in variable inclusion, it is possible that we missed other domains that are relevant in analgesic decision making, such as health literacy. All of the parturients in our survey had an obstetrician or midwife from whom they received prenatal care, and therefore these findings may not be representative of those without adequate prenatal care or care from other types of providers (e.g., family practitioners). Additionally, many of the women in our study had a high level of education, which could limit the generalizability of our results to less-educated populations. Finally, while our study population was representative of the English-speaking patients at our hospital, it is possible that the minority women seen at Northwestern Memorial Hospital differ from minority women seen at other centers. Thus, there may be a true racial/ethnic disparity in neuraxial analgesia in other institutions, even after controlling for other factors, such as income.

Despite the limitations, the findings of this exploratory study generate many avenues for future research. Because income was the most consistent factor in all analyses, evaluation of the underlying etiology of this income-based disparity, as well as the role of health literacy on neuraxial analgesia use, is important to consider. We evaluated 3 groups of women: those who wanted and received neuraxial analgesia, those who did not want but ultimately received neuraxial analgesia, and those who did not want and did not receive neuraxial analgesia. It is possible that the last group of patients actually comprises 2 subgroups: those who were clearly educated on their options and chose not to receive neuraxial analgesia, and those who may not have understood their options (e.g., due to lower health literacy) and therefore had significant fears and misconceptions about labor analgesia. To ensure high-quality care for all of our patients, it is important to understand factors contributing to patients' lack of understanding regarding their analgesic options. That will allow the development of targeted education, which will ensure that all women are making informed decisions regarding labor analgesia.

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RECUSE NOTE

Cynthia A. Wong is the section Editor for Obstetric Anesthesiology for the Journal. This manuscript was handled by Steve Shafer, Editor-in-Chief, and Dr. Wong was not involved in any way with the editorial process or decision.

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STUDY FUNDING

This study was completed while the first author was a National Research Service Award postdoctoral fellow at the Institute for Healthcare Studies under an institutional award from the Agency for Healthcare Research and Quality, T-32 HS 000078 (principal investigator: Jane L. Holl, MD, MPH), and in part under F32HS020122 (principal investigator: Paloma Toledo, MD, MPH), and was supported by a grant from the Evergreen Invitational Grants Initiative. Jinglu Sun was supported by a Foundation for Anesthesia Education and Research (FAER) Medical Student Anesthesia Research Fellowship. 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.

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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: Jinglu Sun, BA.

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

Attestation: Jinglu Sun 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: Cynthia A. Wong, MD.

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

Attestation: Cynthia A. Wong 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 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.

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