International migration is an ongoing challenge for providers of healthcare in industrialised countries. Migration is particularly relevant to the provision of obstetric care and presents numerous challenges for those providing healthcare.1 A number of studies have shown suboptimal obstetric and perinatal outcomes in the migrant population. In the studies performed to date on obstetric anaesthesia care, migratory status has been shown to strongly influence the use of neuraxial analgesia in labour with preferred language, ethnicity and region of origin established as strong determinants of analgesia usage.2,3 There are few data, however, on the types of anaesthesia used for caesarean section in this population. General anaesthesia is considered more hazardous than regional anaesthesia for patients undergoing caesarean section with the greatest risk existing in emergency cases. We sought to determine the incidence of caesarean section under general anaesthesia in migrants in a university centre with a high proportion of migrant patients.
Following research committee approval (Rotunda Hospital Dublin Approval # RAG – 2014-003), we retrieved data from an electronic database. All women who had a caesarean section between 1 January 2007 and 31 December 2013 were included. The outcome of primary interest was mode of anaesthesia for caesarean section. We also recorded region of origin, maternal age, parity and socioeconomic status.
Data were analysed with SigmaStat statistics software version 3.5 (Systat Software, Inc., Sigma Stat, Version 3.5, Jandel Corporation, San Rafael, CA, USA). Categorical data are presented as numbers and percentage. Continuous data were expressed as median (interquartile range). The relative risk for general anaesthesia compared with regional anaesthesia was calculated for patients from different geographic regions of origin compared with native Irish index population who were the defined control group.
Sixty-two thousand one hundred and eight patient records were obtained; 43 939 deliveries to 36 232 individual mothers were analysed. After exclusion of those who delivered vaginally, 12 361 caesarean sections were included in the final analysis (5942 elective, 6419 emergency). For elective caesarean section, regional anaesthesia was used in the vast majority of cases and did not differ between ethnic groups (Table 1). For emergency caesarean section, the incidence of general anaesthesia was highest in patients from Saharan Africa (38.1%) followed by Eastern Europe (20.2%), Middle East (19.0%), Western Europe (18.2%), North America (16.7%), Sub-Saharan Africa (13.1%), Irish (12.7%), Far East (12.0%), India (11.4%), Australia/New Zealand (10%) and South America (7.5%) (Table 1).
The data from the current study show that the use of general anaesthesia is uniformly low for elective caesarean sections but widely varies in emergency cases. The data are within the Royal College of Anaesthesia (UK) targets for best practice for rates of general anaesthesia in elective caesarean sections (less than 5%), but are outside these targets for nonelective surgery (less than 15%) in patients from Eastern and Western European countries as well as North America, North Africa and the Middle East.
There are a number of studies that examine the relationship between ethnicity or region of origin and intra-partum analgesia, postpartum pain and major maternal morbidity and mortality but have not examined the effect of these factors on anaesthetic interventions. In the current study, the increased incidence of general anaesthesia for emergency caesarean sections in patients from North Africa, the Middle East and Eastern Europe is striking. We have demonstrated in a separate study that our North African, Middle Eastern and Eastern European patients have low use of neuraxial analgesic techniques in labour and consequently epidural tops are, therefore, not an anaesthetic option in emergencies.4 It is likely that this, in association with a language barrier, contributes to higher use of general anaesthesia in these groups. However, this phenomenon does not fully explain why other groups, for example Sub-Saharan Africans who despite a low neuraxial analgesia rate, also have low general anaesthesia rates in emergency situations. The most likely explanation for this is effectiveness of communication through shared language. The majority of our population from Sub-Saharan Africa is from Anglophone countries and relatively few from Francophone or Portuguese-speaking areas. In contrast, our Saharan African and Middle Eastern patients spoke predominantly Arabic which is not commonly spoken by staff members in our institution. In other centres, the provision of onsite interpreters for commonly spoken foreign languages has previously been shown to reduce the need for obstetric interventions.5
We speculate that patients’ use of neuraxial analgesic techniques is influenced by their expectations that are strongly influenced by services available in their country of origin. Consequently, those coming from countries where neuraxial techniques are not commonly available on the labour ward are less likely to request them in the host country which inevitably increases the requirement for general anaesthesia. Other factors that might influence choice of intrapartum analgesia with downstream effect on general anaesthesia rates include previous experiences, cultural beliefs, lack of knowledge of availability of epidural services or perceived costs.
There is a clear difference in general anaesthesia rates between the groups when comparing elective and emergency cases that might be at least partially explained by lack of immediate availability of interpretation services. It is notable that the use of general anaesthesia was greater in patients from non-English-speaking countries.
There are a number of weaknesses in our study. It is retrospective and used a database that does not record information such as language, educational attainment, BMI, smoking history and comorbidities that may be confounders. Nor does the study quantify other potential confounders at patient, hospital or provider level. The number of patients in some of the subgroups is small and less statistically robust than the larger groups. The study does not directly measure the complications that occur during general anaesthesia or the quality of recovery.
We conclude that the use of general anaesthesia is disproportionately high in certain migrant groups, particularly in those from non-English-speaking countries. This might be improved by early identification of language needs, targeted antenatal educational regarding analgesia options in labour and increased availability of translation services.
Acknowledgements relating to this article
Assistance with the study: none.
Financial support and sponsorship: no external funding.
Conflicts of interest: none.
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