Association of the United States Affordable Care Act Dependent Coverage Provision with Labor Neuraxial Analgesia Use

Structural Racism and Use of Labor Neuraxial Analgesia Among Non-Hispanic Black Birthing People

OBJECTIVE

To assess the association between structural racism and labor neuraxial analgesia use.

METHODS

This cross-sectional study analyzed 2017 U.S. natality data for non-Hispanic Black and White birthing people. The exposure was a multidimensional structural racism index measured in the county of the delivery hospital. It was calculated as the mean of three Black-White inequity ratios (ratios for lower education, unemployment, and incarceration in jails) and categorized into terciles, with the third tercile corresponding to high structural racism. The outcome was the labor neuraxial analgesia rate. Adjusted odds ratios and 95% CIs of neuraxial analgesia associated with terciles of the index were estimated with multivariate logistic regression models. Black and White people were compared with the use of an interaction term between race and ethnicity and the racism index.

RESULTS

Of the 1,740,716 birth certificates analyzed, 396,303 (22.8%) were for Black people. The labor neuraxial analgesia rate was 77.2% for Black people in the first tercile of the racism index, 74.7% in the second tercile, and 72.4% in the third tercile. For White people, the rates were 80.4%, 78.2%, and 78.2%, respectively. For Black people, compared with the first tercile of the racism index, the second tercile was associated with 18.4% (95% CI, 16.9-19.9%) decreased adjusted odds of receiving neuraxial analgesia and the third tercile with 28.3% (95% CI, 26.9-29.6%) decreased adjusted odds. For White people, the decreases were 13.4% (95% CI, 12.5-14.4%) in the second tercile and 15.6% (95% CI, 14.7-16.5%) in the third tercile. A significant difference in the odds of neuraxial analgesia was observed between Black and White people for the second and third terciles.

CONCLUSION

A multidimensional index of structural racism is associated with significantly reduced odds of receiving labor neuraxial analgesia among Black people and, to a lesser extent, White people.

Racial and Ethnic Disparities in Receipt of General Anesthesia for Cesarean Delivery

Importance

General anesthesia for cesarean delivery is associated with increased maternal morbidity, and Black and Hispanic pregnant patients have higher rates of general anesthesia use compared with their non-Hispanic White counterparts. It is unknown whether risk factors and indications for general anesthesia differ among patients of differing race and ethnicity.

Objective

To evaluate differences in general anesthesia use for cesarean delivery and the indication for the general anesthetic by race and ethnicity.

Design, Setting, and Participants

In this retrospective, cross-sectional, single-center study, electronic medical records for all 35 117 patients who underwent cesarean delivery at Northwestern Medicine's Prentice Women's Hospital from January 1, 2007, to March 2, 2018, were queried for maternal demographics, clinical characteristics, obstetric and anesthetic data, the indication for cesarean delivery, and the indication for general anesthesia when used. Data analysis occurred in August 2023.

Exposure

Cesarean delivery.

Main Outcomes and Measures

The rate of general anesthesia for cesarean delivery by race and ethnicity.

Results

Of the 35 117 patients (median age, 33 years [IQR, 30-36 years]) who underwent cesarean delivery, 1147 (3.3%) received general anesthesia; the rates of general anesthesia were 2.5% for Asian patients (61 of 2422), 5.0% for Black patients (194 of 3895), 3.7% for Hispanic patients (197 of 5305), 2.8% for non-Hispanic White patients (542 of 19 479), and 3.8% (153 of 4016) for all other groups (including those who declined to provide race and ethnicity information) (P < .001). A total of 19 933 pregnant patients (56.8%) were in labor at the time of their cesarean delivery. Of those, 16 363 (82.1%) had neuraxial labor analgesia in situ. Among those who had an epidural catheter in situ, there were no racial or ethnic differences in the rates of general anesthesia use vs neuraxial analgesia use (Asian patients, 34 of 503 [6.8%] vs 1289 of 15 860 [8.1%]; Black patients, 78 of 503 [15.5%] vs 1925 of 15 860 [12.1%]; Hispanic patients, 80 of 503 [15.9%] vs 2415 of 15 860 [15.2%]; non-Hispanic White patients, 255 of 503 [50.7%] vs 8285 of 15 860 [52.2%]; and patients of other race or ethnicity, 56 of 503 [11.1%] vs 1946 of 15 860 [12.3%]; P = .16). Indications for cesarean delivery and for general anesthesia were not different when stratified by race and ethnicity.

Conclusions and Relevance

Racial disparities in rates of general anesthesia continue to exist; however, this study suggests that, for laboring patients who had labor epidural catheters in situ, no disparity by race or ethnicity existed. Future studies should address whether disparities in care that occur prior to neuraxial catheter placement are associated with higher rates of general anesthesia among patients from ethnic and racial minority groups.