Race inequality in epidural use and regional anesthesia failure in labor and birth: An examination of women's experience

Quality of analgesic care in labor: A cross-sectional study of the first national register-based benchmarking system

OBJECTIVE

Unlike other types of acute pain, labor pain is considered physiological. Due to the heterogeneous management during labor, there is a lack of intention to define quality of care of peripartal analgesia. This study presents the first results of the national register for this evaluation.

METHODS

This prospective cross-sectional study, conducted in five different German level-three hospitals, included women after vaginal childbirth between January 2020 and January 2022. A validated questionnaire was completed 24 h postpartum, including information about labor pain, satisfaction, and expectations regarding analgesia. Data were centrally recorded with obstetric records using the database of the QUIPS (Quality Improvement in Postoperative Pain Management) Project.

RESULTS

A total of 514 women were included. On an 11-point Numerical Rating Scale, pain intensity during labor was severe (8.68 ± 1.8) while postpartal pain was 3.9 (±2.1). The second stage of labor was considered the most painful period. Only 62.6% of the parturients obtained pharmacological support, with epidural being the most effective (reduction of 3.8 ± 2.8 points). Only epidural (odds ratio [OR] 0.22) and inhalation of nitrous oxide (OR 0.33) were protective for severe pain. In benchmarking, a relation between satisfaction, pain intensity, and the use of epidural was found; 40.7% of the women wished they had received more analgesic support during labor.

CONCLUSION

This study highlights deficiencies in analgesic management in high-level perinatal centers, with more than 40% of parturients considering actual practices as insufficient and wishing they had received more analgesic support, despite the availability of analgesic options. Using patient-reported outcomes can guarantee qualitative tailored analgesic care in women.

Postanesthesia Care Unit and Anesthetic Management Outcomes Among Patients Undergoing Noncardiac Surgery: Differences by Race and Ethnicity

PURPOSE

To investigate the association of patient race and ethnicity with postanesthesia care unit (PACU) outcomes in common, noncardiac surgeries requiring general anesthesia.

DESIGN

Single tertiary care academic medical center retrospective matched cohort.

METHODS

We matched 1:1 1836 adult patients by race and/or ethnicity undergoing common surgeries. We compared racial and ethnic minority populations (62 American Indian, 250 Asian, 315 Black or African American, 281 Hispanic, and 10 Pacific Islander patients) to 918 non-Hispanic White patients. The primary outcomes were: the use of an appropriate number of postoperative nausea and vomiting (PONV) prophylactics; the incidence of PONV; and the use of a propofol infusion as part of the anesthetic (PROP). Secondary outcomes were: the use of opioid-sparing multimodal analgesia, including the use of regional anesthesia for postoperative pain control; the use of any local anesthetic, including the use of liposomal bupivacaine; the duration until readiness for discharge from the PACU; the time between arrival to PACU and first pain score; and the time between the first PACU pain score of ≥4 and administration of an analgesic. Logistic and linear regression were used for relevant outcomes of interest.

FINDINGS

Overall, there were no differences in the appropriate number of PONV prophylactics, nor the incidence of PONV between the two groups. There was, however, a decreased use of PROP (OR = 0.80; 95% CI: 0.69, 0.94; P = .005), PACU length of stay was 9.56 minutes longer (95% CI: 2.62, 16.49; P = .007), and time between arrival to PACU and first pain score was 2.30 minutes longer in patients from racial and ethnic minority populations (95% CI: 0.99, 3.61; P = .001). There were no statistically significant differences in the other secondary outcomes.

CONCLUSIONS

The rate of appropriate number of PONV prophylactic medications as well as the incidence of PONV were similar in patients from racial and ethnic minority populations compared to non-Hispanic White patients. However, there was a lower use of PROP in racial and ethnic minority patients. It is important to have a health equity lens to identify differences in management that may contribute to disparities within each phase of perioperative care.

Racial/Ethnic Disparities in Peripartum Pain Assessment and Management

OBJECTIVE

This study was conducted to determine if there were racial/ethnic disparities in pain assessment and management from labor throughout the postpartum period.

METHODS

This was a retrospective cohort study of all births from January 2019 to December 2021 in a single urban, quaternary care hospital, excluding patients with hysterectomy, ICU stay, transfusion of more than 3 units of packed red blood cells, general anesthesia, or evidence of a substance abuse disorder. We characterized and compared patterns of antepartum and postpartum pain assessments, epidural use, pain scores, and postpartum pain management by racial/ethnic group with bivariable analyses. Multivariable regression was performed to test for an association between race/ethnicity and amount of opioid pain medication in milligram equivalent units, stratified by delivery mode.

RESULTS

There were 18,085 births between 2019 and 2021 with available race/ethnicity data. Of these, 58.3% were white, 15.0% were Hispanic, 11.9% were Asian, 7.4% were Black, and the remaining 7.4% were classified as Other/Declined. There were no significant differences by race/ethnicity in the number of antepartum or postpartum pain assessments or the proportion of patients who received epidural analgesia. Black and Hispanic patients reported the highest maximum postpartum pain scores after vaginal and cesarean birth compared to white and Asian patients. However, Black and Hispanic patients received lower daily doses of opioid medications than white patients, regardless of delivery mode. After adjusting for patient factors and non-opioid medication dosages, all other racial/ethnic groups received less opioid medication than white patients.

CONCLUSION

Inequities were found in postpartum pain treatment, including among patients reporting the highest pain levels.

Using incident reports to diagnose communication challenges for precision intervention in learning health systems: A methods paper

Introduction

Poor communication is a leading root cause of preventable maternal mortality in the United States. Communication challenges are compounded with the presence of biases, including racism. Hospital administrators and clinicians are often aware that communication is a problem, but understanding where to intervene can be difficult to determine. While clinical leadership routinely reviews incident reports and acts on them to improve care, we hypothesized that reviewing incident reports in a systematic way might reveal thematic patterns, providing targeted opportunities to improve communication in direct interaction with patients and within the healthcare team itself.

Methods

We abstracted incident reports from the Women's Health service and linked them with patient charts to join patient's race/ethnicity, birth outcome, and presence of maternal morbidity and mortality to the incident report. We conducted a qualitative content analysis of incident reports using an inductive and deductive approach to categorizing communication challenges. We then described the intersection of different types of communication challenges with patient race/ethnicity and morbidity outcomes.

Results

The use of incident reports to conduct research on communication was new for the health system. Conversations with health system-level stakeholders were important to determine the best way to manage data. We developed a thematic codebook based on prior research in healthcare communication. We found that we needed to add codes that were equity focused, as this was missing from the existing codebook. We also found that clinical and contextual expertise was necessary for conducting the analysis-requiring more resources to conduct coding than initially estimated. We shared our findings back with leadership iteratively during the work.

Conclusions

Incident reports represent a promising source of health system data for rapid improvement to transform organizational practice around communication. There are barriers to conducting this work in a rapid manner, however, that require further iteration and innovation.

Bystander Acknowledgment Mitigates the Psychological and Physiological Pain of Racial Discrimination for Black Young Adults: A Randomized Controlled Trial

Racism increases pain sensitization and contributes to racialized pain inequities; however, research has not tested interventions targeting racism to reduce pain. In this study, we examined whether White bystanders can act to mitigate racism's pain-sensitizing effects. To simulate racial exclusion in the laboratory, Black young adults (age 18-30; N = 92) were randomly assigned to be included or excluded by White players in a ball-tossing game (Cyberball). For half of the excluded participants, White bystanders acknowledged and apologized for the racial exclusion. Participants completed a cold pressor task to assess pain threshold, tolerance, and unpleasantness, and completed a survey assessing psychological needs (ie, belongingness, self-esteem, meaningful existence, and self-control). Participants who experienced racial exclusion reported significantly more threatened psychological needs and increased laboratory pain sensitization (ie, lower pain threshold and tolerance) than those who were included. However, when a White bystander acknowledged the racism, excluded participants reported higher levels of self-control, self-esteem, and decreased pain sensitization (pain threshold and tolerance) relative to excluded participants whose experience was not acknowledged. Our findings support that racism increased Black people's pain sensitivity and provide initial evidence for White bystander acknowledgment as a health intervention. PERSPECTIVE: Continual exposure to racism likely contributes to inequities in pain sensitization. We demonstrate that acute exposure to mild racism increases acute pain sensitization. Results suggest that a bystander acknowledging witnessed racism can buffer the acute sensitizing effects of racism on pain, pointing to the potential of interpersonal interventions targeting racism. TRIAL REGISTRATION: Clinicaltrials.gov NCT06113926.

The intersection of traumatic childbirth and obstetric racism: A qualitative study

BACKGROUND

Traumatic childbirth experiences are common in the United States - affecting a third to a fourth of mothers - with significant negative impacts on maternal health. Yet most research on traumatic childbirth focuses on white mothers' experiences. Drawing on a racially and ethnically diverse sample of mothers who experienced traumatic childbirth, this exploratory qualitative study examined Black, Latina, and Asian mothers' traumatic birth experiences and the role of obstetric racism in shaping these experiences.

METHODS

In-depth, semi-structured interviews were conducted in 2019-2020 with 30 mothers who identified as women of color (37% Black, 40% Latina, and 23% Asian) who gave birth in the US and self-identified as having experienced a traumatic childbirth. Data were analyzed using qualitative content analysis.

RESULTS

Mothers reported obstetric racism as core to their traumatic birth experiences. This racism manifested through practitioners' use of gendered and racialized stereotypes, denying and delegitimizing mothers' needs. Mothers shared key consequences of the obstetric racism they experienced, including postpartum anxiety and depression, increased medical mistrust, and decreased desire for future children.

CONCLUSIONS

Mothers' reports suggest that obstetric racism played a role in their traumatic birth experiences. Particularly, practitioners' deployment of gendered and racialized stereotypes influenced mothers' treatment during birth. These findings point to opportunities to address obstetric racism during childbirth and improve patients' experiences through enhancing their agency and empowerment. The findings, in addition, highlight the need for increased practitioner training in anti-racist practice and cultural humility.

The Racial Disparities in Maternal Mortality and Impact of Structural Racism and Implicit Racial Bias on Pregnant Black Women: A Review of the Literature

BACKGROUND

The maternal mortality rate (MMR) in the United States (USA) continues to increase despite medical advances and is exacerbated by stark racial disparities. Black women are disproportionately affected and are three times more likely to experience a pregnancy-related death (PRD) compared to Non-Hispanic White (NHW) women.

METHODS

A literature review was conducted to examine the racial disparities in the United States' MMR, specifically among pregnant Black women. PubMed and key organizations (World Health Organization, Center for Disease Control and Prevention, American College of Obstetricians and Gynecologists, Alliance for Innovation on Maternal Health, Association of American Medical Colleges, U.S. Census Bureau, and U.S. Congress) were searched for publications after 2014.

RESULT

Forty-two articles were reviewed to identify the role of structural racism, implicit biases, lack of cultural competence, and disparity education on pregnant Black women. This review highlights that maternal health disparities for Black women are further impacted by both structural racism and racial implicit biases. Cultural competence and educational courses targeting racial disparities among maternal healthcare providers (MHCP) are essential for the reduction of PRDs and pregnancy-related complications (PRC) among this target population. Additionally, quality and proper continuity of care require an increased awareness surrounding the risk of cardiovascular diseases for pregnant Black women.

CONCLUSIONS

The surging MMR for Black women is a public health crisis that requires a multi-tiered approach. Interventions should be implemented at the provider and healthcare institution level to dismantle implicit biases and structural racism. Improving patient-provider relationships through increased cultural competency and disparity education will increase patient engagement with the maternal healthcare (MHC) system.

Disparities in Pain Management

Health disparities in pain management remain a pervasive public health crisis. Racial and ethnic disparities have been identified in all aspects of pain management from acute, chronic, pediatric, obstetric, and advanced pain procedures. Disparities in pain management are not limited to race and ethnicity, and have been identified in multiple other vulnerable populations. This review targets health care disparities in the management of pain, focusing on steps health care providers and organizations can take to promote health care equity. A multifaceted plan of action with a focus on research, advocacy, policy changes, structural changes, and targeted interventions is recommended.

Effect of the COVID-19 pandemic on racial disparities in neuraxial labor analgesia at a Texas level IV maternal care center

We hypothesized that racial disparities in labor epidural analgesia at our hospital that existed prior to the COVID-19 pandemic would be exacerbated during the COVID-19 pandemic. We examined patients who delivered vaginally at our hospital for the last 6 months of 2019 and the last 6 months of 2020. We performed joint testing of coefficient P values, and the interaction term between race and year of delivery was not significant (0.364). A multivariate logistic regression model found that Hispanic patients (odds ratio 0.555 [0.408, 0.756], P < 0.001) and Black or African American patients (odds ratio 0.613 [0.408, 0.921], P = 0.018) were less likely to receive labor epidural analgesia compared to White or Caucasian patients. Odds ratios of receiving labor epidural analgesia were higher with increasing gestational age (1.116 [1.067, 1.168], P < 0.001) and lower with increasing parity (0.789 [0.719, 0.867], P < 0.001). The year of birth that corresponded to before or during the COVID-19 pandemic did not predict whether a patient received labor epidural analgesia (1.247 [0.941, 1.652], P = 0.124). Because the interaction between race and year of birth was not statistically significant, we conclude that the COVID-19 pandemic did not exacerbate racial disparities in labor epidural analgesia at our hospital.

Racial Disparities in the Use of Peripheral Nerve Blocks for Postoperative Analgesia After Total Mastectomy: A Retrospective Cohort Study

BACKGROUND

Peripheral nerve blocks (PNBs) are used to provide postoperative analgesia after total mastectomy. PNBs improve patient satisfaction and decrease postoperative opioid use, nausea, and vomiting. Few studies have examined whether there is racial-ethnic disparity in the use of PNBs for patients having total mastectomy. We hypothesized that non-Hispanic Asian, non-Hispanic Black, non-Hispanic patients of other races, and Hispanic patients would be less likely to receive a PNB for postoperative analgesia compared to non-Hispanic White patients having total mastectomy. Secondarily, we hypothesized that PNBs would be associated with reduced odds of major complications after total mastectomy.

METHODS

We performed a retrospective cohort study using National Surgical Quality Improvement Program (NSQIP) data from 2015 to 2019. Patients were included if they underwent total mastectomy under general anesthesia. Unadjusted rates of PNB use were compared between race-ethnicity groups. Multivariable logistic regression was performed to determine whether race-ethnicity group was independently associated with receipt of a PNB for postoperative analgesia. Secondarily, we calculated crude and risk-adjusted odds ratios for major complications in patients who received a PNB.

RESULTS

There were 64,103 patients who underwent total mastectomy and 4704 (7.3%) received a PNB for postoperative analgesia. Patients who received a PNB were younger, more commonly women, were less likely to have diabetes and hypertension, and had less disseminated cancer (all P < .05). In our regression analysis, the odds of receiving a PNB differed significantly by race-ethnicity group (P < .001). Non-Hispanic Asian and non-Hispanic Black patients had reduced odds of receiving a PNB compared to non-Hispanic White patients (odds ratio [OR], 0.41; 95% confidence interval [CI], 0.33-0.49 and OR, 0.37 [0.32-0.44]), respectively. Non-Hispanic patients of other races, including American Indian, Alaskan Native, and Pacific Islander, also had reduced odds of receiving a PNB (OR, 0.73 [95% CI, 0.64-0.84]) compared to non-Hispanic White patients, as did Hispanic patients (OR, 0.62 [0.56-0.69]). Patients who received a PNB did not have reduced odds of major complications after mastectomy (crude OR, 0.83 [0.65-1.08]; P = .17 and adjusted OR, 0.85 [0.65-1.10]; P = .21).

CONCLUSIONS

Significant disparity exists in the use of PNBs for postoperative analgesia in patients of different race-ethnicity who undergo total mastectomy in the United States. Continued efforts are needed to better understand the causes of disparity and to ensure equitable access to PNBs.

Community-based doulas for migrant and refugee women: a mixed-method systematic review and narrative synthesis

BACKGROUND

Community-based doulas share the same cultural, linguistic, ethnic backgrounds or social experiences as the women they support. Community-based doulas may be able to bridge gaps for migrant and refugee women in maternity settings in high-income countries (HICs). The aim of this review was to explore key stakeholders' perceptions and experiences of community-based doula programmes for migrant and refugee women during labour and birth in HICs, and identify factors affecting implementation and sustainability of such programmes.

METHODS

We conducted a mixed-method systematic review, searching MEDLINE, CINAHL, Web of Science, Embase and grey literature databases from inception to 20th January 2022. Primary qualitative, quantitative and mixed-methods studies focusing on stakeholders' perspectives and experiences of community-based doula support during labour and birth in any HIC and any type of health facility were eligible for inclusion. We used a narrative synthesis approach to analysis and GRADE-CERQual approach to assess confidence in qualitative findings.

RESULTS

Twelve included studies were from four countries (USA, Sweden, England and Australia). There were 26 findings categorised under three domains: (1) community-based doulas' role in increasing capacity of existing maternity services; (2) impact on migrant and refugee women's experiences and health; and (3) factors associated with implementing and sustaining a community-based doula programme.

CONCLUSION

Community-based doula programmes can provide culturally-responsive care to migrant and refugee women in HICs. These findings can inform community-based doula organisations, maternity healthcare services and policymakers. Further exploration of the factors that impact programme implementation, sustainability, strategic partnership potential and possible wider-reaching benefits is needed.

Workforce solutions to address health disparities

PURPOSE OF REVIEW

This review focuses on physician workforce racial & ethnic diversity as a solution to improve perioperative and peripartum health equity.

RECENT FINDINGS

Black, Indigenous, and Hispanic physicians remain underrepresented in medicine (URiM) and anesthesiology, and efforts to expand this workforce have had limited impact. Psychological forces, including implicit bias, aversive racism, outgroup bias, racial attention bias, stereotype threat, and imposter syndrome all act to reinforce structural racism and decrease opportunity for advancement. Evidence based solutions are emerging, but require institutional commitment and widespread engagement of the entire medical community.

SUMMARY

Academic medicine has recognized the need to diversify the physician workforce for more than 50 years, and yet Black, Indigenous, and Hispanic physicians remain URiM. Foundational assumptions and power structures in medicine limit entry, advancement, and retention of URiM physicians. Solutions require leadership and institutional commitment to change the policies, procedures, priorities, and culture of academic medicine.

Health equity research in obstetric anesthesia

PURPOSE OF REVIEW

Health equity is an important priority for obstetric anesthesia, but describing disparities in perinatal care process and health outcome is insufficient to achieve this goal. Conceptualizing and framing disparity is a prerequisite to pose meaningful research questions. We emphasize the need to hypothesize and test which mechanisms and drivers are instrumental for disparities in perinatal processes and outcomes, in order to target, test and refine effective countermeasures.

RECENT FINDINGS

With an emphasis on methodology and measurement, we sketch how health systems and disparity research may advance maternal health equity by narrating, conceptualizing, and investigating social determinants of health as key drivers of perinatal disparity, by identifying the granular mechanism of this disparity, by making the economic case to address them, and by testing specific interventions to advance obstetric health equity.

SUMMARY

Measuring social determinants of health and meaningful perinatal processes and outcomes precisely and accurately at the individual, family, community/neighborhood level is a prerequisite for healthcare disparity research. A focus on elucidating the precise mechanism driving disparity in processes of obstetric care would inform a more rational effort to promote health equity. Implementation scientists should rigorously investigate in prospective trials, which countermeasures are most efficient and effective in mitigating perinatal outcome disparities.

Racial/Ethnic Inequities in Pregnancy-Related Morbidity and Mortality

Racism in America has deep roots that impact maternal health, particularly through pervasive inequities among Black women as compared with White, although other racial and ethnic groups also suffer. Health care providers caring for pregnant women are optimally positioned to maintain vigilance for these disparities in maternal care, and to intervene with their diverse skillsets and knowledge. By increasing awareness of how structural racism drives inequities in health, these providers can encourage hospitals and practices to develop and implement national bundles for patient safety, and use bias training and team-based training practices aimed at improving care for racially diverse mothers.

On anesthesia and race

Racial tensions continue to ignite social unrest in the United States. Structural racism is increasingly recognized as a public health issue. It is therefore necessary to continue addressing the interaction of race and medicine, including anesthesiology. While many may overlook the impact that racial discrimination has had on the development of anesthesiology, understanding pain through a racialized lens has always been entwined with this medical specialty since its origins. Considering the first public demonstration of ether anesthesia in 1846 occurred 15 years before the American Civil War (1861-1865), it is naïve to pretend that anesthesia has been insulated from racial prejudice. We increasingly recognize the effects of variables, such as housing and education, which are important as social determinants of health. Across ethnic and racial lines, statistically significant differences persist in pain assessment and analgesia delivery. To understand these irregularities without relying on unsupported theories, we must challenge our current understanding of race in medicine. By reviewing the history of anesthesia through a racialized lens, we may better explore our biases and develop strategies towards racially equitable care. This article focuses on anesthesia's roots on the plantation in the American South, the medical perpetuation of racial disparities, and the challenges we face in healthcare today.

Efficacy and safety of non-pharmacological interventions for labour pain management: A systematic review and Bayesian network meta-analysis

AIMS AND OBJECTIVES

To compare and rank the efficacy and safety of non-pharmacological interventions in the management of labour pain.

BACKGROUND

Recently, various non-pharmacological interventions have been applied to manage labour pain and have shown positive effects. However, evidence identifying which type of non-pharmacological intervention is more efficient and safer is limited.

DESIGN

Systematic review and Bayesian network meta-analysis based on PRISMA-NMA.

METHODS

Seven databases were searched from database inception-March 2020. Two reviewers independently performed study selection, quality appraisal and data extraction. Conventional meta-analysis was conducted using either fixed-effects model or random-effects model according to statistical heterogeneity. The Bayesian network meta-analysis was conducted using the consistency model.

RESULTS

43 studies involving nine non-pharmacological interventions were included. The Bayesian network meta-analysis showed that acupressure (SMD = -2.00, 95% CrI -3.09 to -0.94), aromatherapy (SMD = -2.01, 95% CrI -3.70 to -0.35) and massage therapy (SMD = -1.26, 95% CrI -2.26 to -0.30) had significant positive effects on alleviating labour pain, with aromatherapy being the most effective. The results also revealed that yoga (SMD = -130.85, 95% CrI -212.01 to -59.32) and acupressure (SMD = -10.14, 95% CrI -20.24 to -0.41) were the most effective interventions for shortening the first stage and the second stage of labour, respectively. There were no significant differences between non-pharmacological interventions and usual care or placebo control on the use of pharmacological methods and neonatal 5-min Apgar score.

CONCLUSIONS

The evidence in this network meta-analysis illustrates that non-pharmacological interventions are effective and safe for labour pain management in low-risk pregnant women. In the future, well-designed studies are needed to validate the conclusion of this network meta-analysis.

RELEVANCE TO CLINICAL PRACTICE

The results support the use of non-pharmacological interventions, especially aromatherapy and acupressure, to relieve labour pain in low-risk pregnant women. Non-pharmacological interventions for labour pain management are recommended to apply according to maternal women's preference and values.

Neuraxial Analgesia in Pregnant Hispanic Women: An Assessment of Their Beliefs and Expectations

Background

The presence of racial/ethnic disparities in the use of neuraxial labor analgesia for childbirth has been previously described. The purpose of this study was to assess the childbirth pain management beliefs among a small sample of pregnant Hispanic women and to evaluate the Spanish translation accuracy of the Childbirth Pain Scale (CPBS).

Methods

To collect data, we interviewed 20 pregnant Spanish-speaking women using an interview guide, a demographic datasheet, and the CPBS a 15-item survey. Interviews were transcribed verbatim, translated, and uploaded to ethnograph v6. Descriptive statistics and thematic analysis were used to analyze the data.

Results

Most of the participants were from Mexico (n=16) and Central America (n=4), mean age was 28.3, and all (n=20) spoke Spanish as their primary language. In this sample, 80% of nulliparous and 100% of multiparous women saw pain as having a positive role in delivery. Four major themes emerged from the data: Theme 1: Normalcy of childbirth pain (pain is good), Theme 2: Availability and role of pain medication, Theme 3: Naturalistic strategies to endure pain, and Theme 4: Fear of the unknown/childbirth process. In this sample, 18 of 20 women stated they did not want epidural analgesia unless medically indicated. During labor and delivery 100% of nulliparous and 25% of multiparas chose to receive epidural analgesia. No changes were requested by the participants regarding the translation of the CPBS.

Conclusion

Childbirth pain was seen as a valuable component of the birthing process. The majority of participants believed pain medication should be avoided unless medically necessary. These results suggest that racial/ethnic disparities in the use of epidural analgesia may partially reflect patient beliefs and preferences. It is crucial to be aware of these differences to optimize shared decision-making for women in this vulnerable patient population.

Racial and Ethnic Disparities in Severe Maternal Morbidity: A Qualitative Study of Women's Experiences of Peripartum Care

INTRODUCTION

Racial and ethnic disparities in rates of maternal morbidity and mortality in the United States are striking and persistent. Despite evidence that variation in the quality of care contributes substantially to these disparities, we do not sufficiently understand how experiences of perinatal care differ by race and ethnicity among women with severe maternal morbidity.

METHODS

We conducted focus groups with women who experienced a severe maternal morbidity event in a New York City hospital during their most recent pregnancy (n = 20). We organized three focus groups by self-identified race/ethnicity ([1] Black, [2] Latina, and [3] White or Asian) to detect any within- and between-group differences. Discussions were audiotaped and transcribed. The research team coded the transcripts and used content analysis to identify key themes and to compare findings across racial and ethnic groups.

RESULTS

Participants reported distressing experiences and lasting emotional consequences after having a severe childbirth complication. Many women appreciated the life-saving care they received. However, poor continuity of care, communication gaps, and a perceived lack of attentiveness to participants' physical and emotional needs led to substantial concern and disappointment in care. Black and Latina women in particular emphasized these themes.

CONCLUSIONS

This study highlights missed opportunities for improved clinician communication and continuity of care to address emotional trauma when severe obstetric complications occur, particularly for Black and Latina women. Enhancing communication to ensure that women feel heard and informed throughout the birth process and addressing implicit bias, as a part of the more systemic issue of institutionalized racism, could both decrease disparities in obstetric care quality and improve the patient experience for women of all races and ethnicities.

Birth Observation Among African American Women Prior to Pregnancy

A focused ethnography among African American college students who had observed a live birth prior to their own pregnancy was pursued. Women described two reasons to attend births: curiosity about birth, or a desire to support the birth mother. Women attended the births of friends, family members, or saw their mother give birth to a younger sibling. Themes included pain, operative or traumatic birth, and surprise at the length and/or stages of labor. Some language suggested lingering trauma. Future expectations included painful labor, operative birth or damage, or traumatic labor and birth. Other women felt closer to the infant, or felt more prepared for their own births after observing birth. Prior personal experiences at birth should be explored prenatally.

Mixed-methods systematic review: Childbearing women's views, experiences, and decision-making related to epidural analgesia in labour

AIMS

To investigate childbearing women's views, experiences and decision-making related to epidural analgesia in labour.

DESIGN

Mixed-methods systematic review.

DATA SOURCES

A comprehensive literature search was implemented across Medline, CINAHL and EMBASE from 2000 to September 2018. The literature search was undertaken in January 2018 and updated in September 2018. Thirty papers were selected.

RESULTS

Four overarching synthesized findings were identified: (a) choice; (b) pain management experience; (c) lack of information; and (d) information provision and consent.

REVIEW METHODS

Quality appraisal was conducted using JBI levels of evidence and other established tools. NVivo was used to independently dual code and thematically synthesize qualitative data. A narrative synthesis of the quantitative findings from the included studies was undertaken. The GRADE-CERQual approach was used to assess confidence in the review findings based on the qualitative data. A set of integrated mixed-methods synthesized findings was produced.

CONCLUSION

Recommendations for practice based on the systematic review findings are that midwives should dedicate time to discuss epidural with women and birth partners, ideally during the second or third trimester of pregnancy, asking women what coping strategies or pain relief they have been considering, if any. The factors which may influence the woman's choice of epidural, including pain threshold, ability to cope with pain, timing of epidural and length of labour should be continuously evaluated during labour. The midwife should remain with women after an epidural has been sited, demonstrating understanding of the woman's choice and providing an opportunity for discussion of plans for the remaining labour and birth.

IMPACT

The findings of this systematic review can inform both healthcare professionals and service users on various aspects of the decision-making process about the use of epidural analgesia in labour. Data can be transferable to similar settings in high-income countries.

Cultural conceptions of Women's labor pain and labor pain management: A mixed-method analysis

AIM

We assess American cultural beliefs about labor pain and labor pain management, including stereotypical and disparate beliefs about labor pain of women from different racial groups.

RATIONALE

Understanding cultural beliefs about labor pain is critical as these beliefs influence experience, interpretation, and treatment of labor pain.

METHOD

We used an online survey with quantitative and qualitative questions about American labor pain beliefs. Participants were recruited and compensated using TurkPrime's Panels during the first week in August 2017 and the last week in May 2018. The completion rate was 76.86 percent (n = 214). After screening using quality control items, the final sample included 200 respondents.

RESULTS

Qualitative results indicate that 56.5 percent (n = 113) of respondents have an accurate understanding of nociceptive/sensory drivers of labor pain, and 55.8 percent (n = 63) of those respondents focused on the second stage of labor. However, only two respondents (1%) mentioned non-sensory (i.e., psychological) causes of labor pain - reflecting a lack of cultural knowledge of the biopsychosocial nature of pain. Categorical responses indicate almost all respondents (95%; n = 190) believe women have a right to labor pain relief, and the majority believe labor pain has value (68%; n = 136) and should be treated medically (87%; n = 174). Quantitative results document stereotypical beliefs that women of color experience less labor pain than white women. Belief that there is value in experiencing labor pain and that pain should not be treated medically were both associated with greater racial disparities in beliefs about labor pain severity. Beliefs were not related to respondent sociodemographic identity, suggesting they are American cultural constructs.

CONCLUSION

Future consideration of the influence of dominant American cultural beliefs about labor pain - including misunderstanding of the nature of labor pain and racial bias in expectations of labor pain - on individuals, norms, and structures is expected to improve quality of patient care.

Women's epidural decision-making in labour: A Townsville perspective

BACKGROUND

Despite being an efficacious means of pain relief, there is a broad range of usage rates of epidural analgesia among countries worldwide. Australia sits between common usage in North America and more conservative usage in the UK. The reason for this is unclear, raising the question of whether there is a difference between Australia and other Western countries in pregnant women's attitudes toward epidural use, or the hospital context.

AIM

To explore predictors for epidural analgesia request among pregnant women in Townsville, Australia.

MATERIALS AND METHODS

A three-phase mixed methods exploratory study design, with Phase One involving 12 one-on-one interviews with pregnant and post-partum women regarding attitudes toward labour analgesia decision-making and epidural preferences. Interview data were analysed thematically to develop a survey distributed to 265 third-trimester women in Phase Two. Phase Three involved a chart review of survey participants to record delivery mode, epidural request and indication. Bivariate and logistic regression analysis of Phases Two and Three data were used to develop predictive models for epidural decision-making.

RESULTS

Interviews revealed several themes influencing analgesia preferences in Townsville women: concerns regarding personal safety, trust in health professionals, and previous experiences with labour. The logistic regression identified epidural request in labour to be predicted by: primiparity, epidural experience, induction or augmentation of labour, and perceived sense of control associated with epidural use.

CONCLUSIONS

This study suggests that the most significant influencers on Townsville women's epidural decision-making were parity, induction or augmentation of labour, previous experience of epidurals and attitude toward epidurals.

The Association Of Race With Outcomes Among Parturients Undergoing Cesarean Section With Perioperative Epidural Catheter Placement: A Nationwide Analysis

Background: In obstetrical health care, disparities have been documented in different aspects of maternal care and outcomes. Prior epidemiological studies have shown that labor analgesia is underused in African-American and Hispanic groups, which means there may be inadequate labor pain control in these groups. Differences in usage have been attributed primarily to insurance, educational levels and perceptional influences such as fear of paralysis and chronic low back pain. In cesarean section deliveries, race and ethnicity affect the choice of anesthesia considered. How race and ethnicity affect maternal outcomes in cesarean sections with epidural placements generally has been unexplored. Disparities in health care utilization are shown to contribute to the disparities in health outcomes.

Methods: This is a retrospective analysis using data from the Agency for Healthcare Research and Quality Healthcare Cost and Utilization Project (AHRQ-HCUP), the National Inpatient Sample (NIS) database from January 2003 to December 2013, which is a 20% stratified sample of the nonfederal hospitals in the United States. Women undergoing cesarean section (International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) procedure codes 74.0, 74.1, 74.2, 74.4, 74.99) with perioperative epidural catheter placement (ICD-9-CM procedure codes 3.90, 3.91) were included for analysis.

Results: The final cohort used for analysis included 87,076 patients. There were significant differences in the distribution of patient characteristics across the race groups. The majority of health care coverage for Caucasians and Asians was private insurance, while for African-American, Hispanic and Native American was Medicare and Medicaid. Almost all the examined comorbid conditions were statistically significant and highest in the African-American group, including hypertension, obesity, diabetes, and renal failure, except for congestive heart failure that was highest in the Asian group. Cesarean sections took place mostly in an urban teaching hospital across all groups. Discharge to home was the predominant destination after recovery. The mean cost of hospitalization was 14,604 dollars per stay and the mean length of stay was 3.7 days. In our cohort, the adverse event rate was very small. Our findings indicate racial differences in comorbidities which occurred more often in minorities. Adverse maternal outcomes of hematoma, blood transfusion, cardiac arrest, and ventricular fibrillation occurred more frequently in minority groups undergoing cesarean sections with epidural catheter placements throughout the period of 2003-2013.

Conclusion: From using the NIS database, our findings indicate racial differences in comorbidities which occurred more often in minorities. Adverse maternal outcomes of hematoma, blood transfusion, cardiac arrest, and ventricular fibrillation occurred more frequently in minority groups undergoing cesarean sections with epidural catheter placements throughout the period of 2003-2013. Further population studies are warranted to determine the biological or perception etiologies that are contributing to these disparities.

Education Program Regarding Labor Epidurals Increases Utilization by Hispanic Medicaid Beneficiaries

Editor’s Perspective

What We Already Know about This Topic

What This Article Tells Us That Is New

Background

Hispanic women choose epidural labor analgesia less commonly than non-Hispanic women. This may represent a healthcare disparity related to a language barrier and inadequate opportunities for labor analgesia education. It was hypothesized that a language-concordant, educational program regarding labor epidurals would improve epidural utilization in two independent cohorts of Hispanic and non-Hispanic women.

Methods

A randomized controlled trial, blinded to anesthesia, nursing, and obstetric providers, was completed at an academic hospital (February 2015 to February 2017). Two cohorts of Medicaid beneficiaries of Hispanic (English- and/or Spanish-speaking) and non-Hispanic ethnicity were enrolled concurrently. The patients were randomized to routine care alone or routine care and an additional educational program comprised of three components: a video show, corresponding pamphlet, and in-person counseling. The primary endpoint was use of epidural labor analgesia. The secondary endpoint was change in response before and after delivery on common misconceptions based on a 12-point epidural questionnaire.

Results

Hispanic women randomized to the intervention group were 33% more likely to choose epidural analgesia compared to the routine care group (40 of 50 [80%] vs. 30 of 50 [60%]; risk ratio, 1.33 [95% CI, 1.02 to 1.74]; P = 0.029). For the non-Hispanic cohort, no difference was detected in epidural use between the intervention and routine care groups (41 of 50 [82%] vs. 42 of 49 [86%]; risk ratio, 0.96 [95% CI, 0.80 to 1.14]; P = 0.62), but the study was underpowered to determine a result of no difference. Patients assigned to the intervention had a greater improvement in epidural understanding compared with routine care, among both Hispanic (2.26 vs. 0.74, respectively; difference in change from baseline, 1.52 [95% CI, 0.77 to 2.27]; P &lt; 0.001) and non-Hispanic (1.36 vs. 0.33, respectively; difference in change from baseline, 1.03 [95% CI, 0.23 to 1.75]; P = 0.005) cohorts. There were no adverse events during the trial.

Conclusions

The educational program increased epidural use among Hispanic women. The educational program reduced misconceptions regarding epidural analgesia in both Hispanic and non-Hispanic cohorts.

The Giving Voice to Mothers study: inequity and mistreatment during pregnancy and childbirth in the United States

BACKGROUND

Recently WHO researchers described seven dimensions of mistreatment in maternity care that have adverse impacts on quality and safety. Applying the WHO framework for quality care, service users partnered with NGOs, clinicians, and researchers, to design and conduct the Giving Voice to Mothers (GVtM)-US study.

METHODS

Our multi-stakeholder team distributed an online cross-sectional survey to capture lived experiences of maternity care in diverse populations. Patient-designed items included indicators of verbal and physical abuse, autonomy, discrimination, failure to meet professional standards of care, poor rapport with providers, and poor conditions in the health system. We quantified the prevalence of mistreatment by race, socio-demographics, mode of birth, place of birth, and context of care, and describe the intersectional relationships between these variables.

RESULTS

Of eligible participants (n = 2700), 2138 completed all sections of the survey. One in six women (17.3%) reported experiencing one or more types of mistreatment such as: loss of autonomy; being shouted at, scolded, or threatened; and being ignored, refused, or receiving no response to requests for help. Context of care (e.g. mode of birth; transfer; difference of opinion) correlated with increased reports of mistreatment. Experiences of mistreatment differed significantly by place of birth: 5.1% of women who gave birth at home versus 28.1% of women who gave birth at the hospital. Factors associated with a lower likelihood of mistreatment included having a vaginal birth, a community birth, a midwife, and being white, multiparous, and older than 30 years. Rates of mistreatment for women of colour were consistently higher even when examining interactions between race and other maternal characteristics. For example, 27.2% of women of colour with low SES reported any mistreatment versus 18.7% of white women with low SES. Regardless of maternal race, having a partner who was Black also increased reported mistreatment.

CONCLUSION

This is the first study to use indicators developed by service users to describe mistreatment in childbirth in the US. Our findings suggest that mistreatment is experienced more frequently by women of colour, when birth occurs in hospitals, and among those with social, economic or health challenges. Mistreatment is exacerbated by unexpected obstetric interventions, and by patient-provider disagreements.

The Giving Voice to Mothers study: inequity and mistreatment during pregnancy and childbirth in the United States

BACKGROUND

Recently WHO researchers described seven dimensions of mistreatment in maternity care that have adverse impacts on quality and safety. Applying the WHO framework for quality care, service users partnered with NGOs, clinicians, and researchers, to design and conduct the Giving Voice to Mothers (GVtM)-US study.

METHODS

Our multi-stakeholder team distributed an online cross-sectional survey to capture lived experiences of maternity care in diverse populations. Patient-designed items included indicators of verbal and physical abuse, autonomy, discrimination, failure to meet professional standards of care, poor rapport with providers, and poor conditions in the health system. We quantified the prevalence of mistreatment by race, socio-demographics, mode of birth, place of birth, and context of care, and describe the intersectional relationships between these variables.

RESULTS

Of eligible participants (n = 2700), 2138 completed all sections of the survey. One in six women (17.3%) reported experiencing one or more types of mistreatment such as: loss of autonomy; being shouted at, scolded, or threatened; and being ignored, refused, or receiving no response to requests for help. Context of care (e.g. mode of birth; transfer; difference of opinion) correlated with increased reports of mistreatment. Experiences of mistreatment differed significantly by place of birth: 5.1% of women who gave birth at home versus 28.1% of women who gave birth at the hospital. Factors associated with a lower likelihood of mistreatment included having a vaginal birth, a community birth, a midwife, and being white, multiparous, and older than 30 years. Rates of mistreatment for women of colour were consistently higher even when examining interactions between race and other maternal characteristics. For example, 27.2% of women of colour with low SES reported any mistreatment versus 18.7% of white women with low SES. Regardless of maternal race, having a partner who was Black also increased reported mistreatment.

CONCLUSION

This is the first study to use indicators developed by service users to describe mistreatment in childbirth in the US. Our findings suggest that mistreatment is experienced more frequently by women of colour, when birth occurs in hospitals, and among those with social, economic or health challenges. Mistreatment is exacerbated by unexpected obstetric interventions, and by patient-provider disagreements.

Women's experiences of pharmacological and non-pharmacological pain relief methods for labour and childbirth: a qualitative systematic review

BACKGROUND

Many women use pharmacological or non-pharmacological pain relief during childbirth. Evidence from Cochrane reviews shows that effective pain relief is not always associated with high maternal satisfaction scores. However, understanding women's views is important for good quality maternity care provision. We undertook a qualitative evidence synthesis of women's views and experiences of pharmacological (epidural, opioid analgesia) and non-pharmacological (relaxation, massage techniques) pain relief options, to understand what affects women's decisions and choices and to inform guidelines, policy, and practice.

METHODS

We searched seven electronic databases (MEDLINE, CINAHL, PsycINFO, AMED, EMBASE, Global Index Medicus, AJOL), tracked citations and checked references. We used thematic and meta-ethnographic techniques for analysis purposes, and GRADE-CERQual tool to assess confidence in review findings. We developed review findings for each method. We then re-analysed the review findings thematically to highlight similarities and differences in women's accounts of different pain relief methods.

RESULTS

From 11,782 hits, we screened full 58 papers. Twenty-four studies provided findings for the synthesis: epidural (n = 12), opioids (n = 3), relaxation (n = 8) and massage (n = 4) - all conducted in upper-middle and high-income countries (HMICs). Re-analysis of the review findings produced five key themes. 'Desires for pain relief' illuminates different reasons for using pharmacological or non-pharmacological pain relief. 'Impact on pain' describes varying levels of effectiveness of the methods used. 'Influence and experience of support' highlights women's positive or negative experiences of support from professionals and/or birth companions. 'Influence on focus and capabilities' illustrates that all pain relief methods can facilitate maternal control, but some found non-pharmacological techniques less effective than anticipated, and others reported complications associated with medication use. Finally, 'impact on wellbeing and health' reports that whilst some women were satisfied with their pain relief method, medication was associated with negative self-reprisals, whereas women taught relaxation techniques often continued to use these methods with beneficial outcomes.

CONCLUSION

Women report mixed experiences of different pain relief methods. Pharmacological methods can reduce pain but have negative side-effects. Non-pharmacological methods may not reduce labour pain but can facilitate bonding with professionals and birth supporters. Women need information on risks and benefits of all available pain relief methods.

Translating Maternal Mortality Review Into Quality Improvement Opportunities in Response to Pregnancy-Related Deaths in California

OBJECTIVE

To describe quality improvement opportunities (QIOs) associated with the five leading causes of pregnancy-related death in California and the methods by which the QIOs were collected by the California Pregnancy-Associated Mortality Review committee.

DESIGN

Qualitative, descriptive design using thematic analysis.

SAMPLE

A total of 907 QIOs identified from 203 cases of pregnancy-related deaths from cardiovascular disease, preeclampsia/eclampsia, hemorrhage, venous thromboembolism, and sepsis that occurred in California from 2002 to 2007.

METHODS

We coded and thematically organized QIO data using three of the four domains commonly applied in quality improvement initiatives for maternal health care: Readiness, Recognition, and Response. Data did not include reporting issues, so the Reporting domain was excluded from the analysis. We refer to the domains collectively as the 4R Framework.

RESULTS

We identified key themes across the five leading causes of death. In the Readiness domain, themes were related to overall facility readiness and helping women be prepared and knowledgeable about pregnancy and childbirth. Themes that emerged as central in the Recognition domain addressed the need for clinicians to better recognize risk factors and women's signs and symptoms to ensure an accurate diagnosis. In the Response domain, three themes were predominant, and they were related to the coordination of care, timing of treatment, and follow-up care.

CONCLUSION

Results from our study show the utility and transferability of the first three domains of the 4R Framework as applied to quality improvement data from a large statewide maternal mortality review. Nursing leadership is necessary to support and guide national, statewide, and local efforts to improve the quality of maternity care through the implementation of quality improvement at the system, facility, clinician, and patient levels.

Bearing witness: United States and Canadian maternity support workers' observations of disrespectful care in childbirth

BACKGROUND

Disrespectful care and abuse during childbirth are acknowledged global indicators of poor quality care. This study aimed to compare birth doulas' and labor and delivery nurses' reports of witnessing disrespectful care in the United States and Canada.

METHODS

Maternity Support Survey data (2781 respondents) were used to investigate doulas' and nurses' reports of witnessing six types of disrespectful care. Multivariate analysis was conducted to examine the effects of demographics, practice characteristics, region, and hospital policies on witnessing disrespectful care.

RESULTS

Nearly two-thirds of respondents reported witnessing providers occasionally or often engaging in procedures without giving a woman time or option to consider them. One-fifth reported witnessing providers occasionally or often engaging in procedures explicitly against the patient's wishes, and nurses were more likely to report witnessing this than doulas. Doulas and nurses who expected to leave their job within three years were significantly more likely to report that they witness most types of disrespectful care occasionally or often (OR 1.78-2.43).

CONCLUSIONS

Doulas and nurses frequently said that they witnessed verbal abuse in the form of threats to the baby's life unless the woman agreed to a procedure, and failure to provide informed consent. Reports of witnessing some types of disrespectful care in childbirth were relatively uncommon among respondents, but witnessing disrespectful care was associated with an increased likelihood to leave maternity support work within three years, raising implications for the sustainability of doula practice, nursing work force shortages, and quality of maternity care overall.

Racial and Socioeconomic Differences Manifest in Process Measure Adherence for Enhanced Recovery After Surgery Pathway

BACKGROUND

Adherence to care processes and surgical outcomes varies by population subgroups for the same procedure. Enhanced recovery after surgery pathways are intended to standardize care, but their effect on process adherence and outcomes for population subgroups is unknown.

OBJECTIVE

This study aims to demonstrate the association between recovery pathway implementation, process measures, and short-term surgical outcomes by population subgroup.

DESIGN

This study is a pre- and post-quality improvement implementation cohort study.

SETTING

This study was conducted at a tertiary academic medical center.

INTERVENTION

A modified colorectal enhanced recovery after surgery pathway was implemented.

PATIENTS

Patients were included who had elective colon and rectal resections before (2013) and following (2014-2016) recovery pathway implementation.

MAIN OUTCOME MEASURE

Thirty-day outcomes by race and socioeconomic status were analyzed using a difference-in-difference approach with correlation to process adherence.

RESULTS

We identified 639 cases (199 preimplementation, 440 postimplementation). In these cases, 75.2% of the patients were white, and 91.7% had a high socioeconomic status. Groups were similar in terms of other preoperative characteristics. Following pathway implementation, median lengths of stay improved in all subgroups (-1.0 days overall, p ≤ 0.001), but with no statistical difference by race or socioeconomic status (p = 0.89 and p = 0.29). Complication rates in both racial and socioeconomic groups were no different (26.4% vs 28.8%, p = 0.73; 27.3% vs 25.0%, p = 0.86) and remained unchanged with implementation (p = 0.93, p = 0.84). By race, overall adherence was 31.7% in white patients and 26.5% in nonwhite patients (p = 0.32). Although stratification by socioeconomic status demonstrated decreased overall adherence in the low-status group (31.8% vs 17.1%, p = 0.05), white patients were more likely to have regional pain therapy (57.1% vs 44.1%, p = 0.02) with a similar trend seen with socioeconomic status.

LIMITATIONS

Data were collected primarily for quality improvement purposes.

CONCLUSIONS

Differences in outcomes by race and socioeconomic status did not arise following implementation of an enhanced recovery pathway. Differences in process measures by population subgroups highlight differences in care that require further investigation. See Video Abstract at http://links.lww.com/DCR/A386.