Secondary Logo

Journal Logo

Institutional members access full text with Ovid®

Racial and Ethnic Inequities in Postpartum Pain Evaluation and Management

Johnson, Jasmine D. MD; Asiodu, Ifeyinwa V. PhD, RN; McKenzie, Christine P. MD; Tucker, Christine PhD, MPH; Tully, Kristin P. PhD; Bryant, Katherine MA, MSPH; Verbiest, Sarah DrPH, MSW; Stuebe, Alison M. MD, Msc

doi: 10.1097/AOG.0000000000003505
Contents: Health Disparities: Original Research

OBJECTIVE: To evaluate whether the frequency of pain assessment and treatment differed by patient race and ethnicity for women after cesarean birth.

METHODS: We performed a retrospective cohort study of all women who underwent cesarean birth resulting in a liveborn neonate at a single institution between July 1, 2014, and June 30, 2016. Pain scores documented and medications administered after delivery were grouped into 0–24 and 25–48 hours postpartum time periods. Number of pain scores recorded, whether any pain score was 7 of 10 or greater, and analgesic medication administered were calculated. Models were adjusted for propensity scores incorporating maternal age, body mass index, gestational age, nulliparity, primary compared with repeat cesarean delivery, classical hysterotomy, and admission to the neonatal intensive care unit.

RESULTS: A total of 1,987 women were identified, and 1,701 met inclusion criteria. There were 30,984 pain scores documented. Severe pain (7/10 or greater) was more common among black (28%) and Hispanic (22%) women than among women who identified as white (20%) or Asian (15%). In the first 24 hours after cesarean birth, non-Hispanic white women had more documented pain assessments (adjusted mean 10.2) than, black, Asian, and Hispanic women (adjusted mean 8.4–9.5; P<.05). Results at 25–48 hours were similar, compared with non-Hispanic white women (adjusted mean 8.3). Black, Asian, and Hispanic women and women who were identified as other all received less narcotic medication at 0–24 hours postpartum (adjusted mean 5.1–7.5 oxycodone tablet equivalents; P<.001–.05), as well as at 25–28 hours postpartum.

CONCLUSION: Racial and ethnic inequities in the experience, assessment and treatment of postpartum pain were identified. A limitation of our study is that we were unable to assess the role of patient beliefs about expression of pain, patient preferences with regards to pain medication, and beliefs and potential biases among health care providers.

We found race and ethnicity inequities in the experience, assessment, and management of postcesarean delivery pain.

Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, University of North Carolina, Chapel Hill, North Carolina; the Department of Family Health Care Nursing, University of California–San Francisco, San Francisco, California; and the University of North Carolina School of Medicine, the Carolina Global Breastfeeding Institute and the Department of Maternal and Child Health, Gillings School of Global Public Health, and the University of North Carolina School of Social Work, Chapel Hill, North Carolina.

Corresponding author: Jasmine D. Johnson, MD, Division of Maternal-Fetal Medicine, University of North Carolina School of Medicine, Chapel Hill, NC; email:

This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number R40MC29455 and R40 Maternal and Child Health Field-initiated Innovative Research Studies Program. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.

Financial Disclosure Alison Stuebe is a co-investigator for a Janssen Research and Development study, Optimizing Clinical Screening and Management of Maternal Mental Health: Predicting Women at Risk for Perinatal Depression. She is an inventor of the Couplet Care Bassinet technology and could receive royalties in the future. This relationship has been disclosed to and is under management by UNC Chapel Hill. Kristin Tully is an inventor on a patent-pending medical device, which has been disclosed to and is managed by UNC Chapel Hill. This UNC IP is not licensed or under negotiation. Institutional support for the Couplet Care Bassinet project is through the Gillings Entrepreneurship Award, University of North Carolina at Chapel Hill. She receives additional support through the One N.C. Small Business Program. She is a PI on: R34HD097017 from the NICHD and a Biotechnology Innovation Grant from the North Carolina Biotechnology Center. Additionally, she serves as a funded technical expert on a PCORI research project. Her time is additionally supported by awards from the UNC CTSA, the Global Health Foundation, and a CDC subcontract to UNC. The other authors did not report any potential conflicts of interest.

Presented at the Society for Maternal-Fetal Medicine’s Annual Meeting, January 29–February 3, 2018, Dallas, Texas; and at the Minority Health Conference, February 22, 2019, Chapel Hill, North Carolina.

The authors thank the NC Translational and Clinical Sciences (NC TraCS) Institute, which provided Electronic Health Record data through the Carolina Data Warehouse for Health. NC TraCS is supported by the National Center for Advancing Translational Sciences (NCATS), National Institutes of Health, through Grant Award Number UL1TR002489.

Each author has confirmed compliance with the journal's requirements for authorship.

Peer reviews and author correspondence are available at

© 2019 by the American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.