Poorer women 16% less likely to receive epidural pain relief during labour compared to middle class peers, study reveals
Whilst black women in England spend on average 48 hours in hospital following caesarean section compared with 35 hours for White women, a seperate study reveals.
Two studies published in Anaesthesia highlight differences in care experienced by different ethnic and socioeconomic groups during pregnancy.
The first study by Dr Lucy Halliday, and colleagues at the University of Glasgow, found that pregnant women in the poorest socioeconomic group were 16% less likely to receive an epidural for pain relief than women in the richest socioeconomic group.
Of 593,230 patients in labour, 131,521 (22.2%) received an epidural for pain relief.
Those from the most deprived areas were 16% less likely to receive an epidural than the most affluent (relative risk 0.84).
Amongst the 21,219 deliveries (16% of the total) with a documented medical indication for an epidural, the socio-economic gradient persisted, with the poorest 10% of women 21% less likely to receive an epidural than the richest 10%.
The study was a population-based study of National Health Service (NHS) data for all women in labour in Scotland between 1 January 2007 and 23 October 2020, excluding elective caesarean sections.
Socio-economic status deciles (groups of 10% from richest to poorest) were defined using the Scottish Index of Multiple Deprivation.
Commenting on their findings, the author’s said: “We found that women from areas of greater socioeconomic disadvantage were substantially less likely to receive an epidural for pain relief during labour.”
They added: “These results were consistent when the analysis was restricted to births occurring within an inner-city environment with uniform access to obstetric and obstetric anaesthetic services, or when restricted to only include births in women having their first child.”
Potential institutional biases
TThe difference between the most and least socio-economically deprived women was more marked in women of non-white ethnicity, with the poorest 10% of non-white women 37% less likely to receive an epidural during labour, compared to the richest 10% of non-white women.
Increasing socio-economic disadvantage was also associated with a stepwise increase in a range of adverse maternal characteristics known to be causally related to poor perinatal outcomes including maternal body mass index, comorbidities, smoking and illicit drug use.
Commenting on this, the study’s authors said: “We may have expected a weaker or no socio-economic gradient in women with a medical indication for an epidural during labour, but our results showed that, in these women, the socio-economic gradient persisted,”
They added: “Labour epidural analgesia, even when medically indicated, demonstrates a socio-economic gradient in Scotland is concerning and may highlight potential institutional biases contributing to maternal and perinatal health disparities.”
Analysing the potential reasons behind the differences found in the study, the authors said: “These women [in the poorest groups] may lack knowledge about indications for epidural analgesia; have life circumstances that may adversely impact antenatal care attendance; mistrust medical staff; feel disempowered during labour; hold misconceptions about epidural analgesia safety; or have differing expectations and societal pressures regarding the pain of childbirth.”
“Differences in healthcare professionals’ attitudes and potential institutional and structural biases might also influence use of epidurals during labour. Addressing implicit bias and ensuring cross-disciplinary education and appropriate patient information for all cultures and health literacy levels are crucial for effective shared decision-making. Group antenatal care may help achieve these goals. The scope of the problem in wider society is vast and requires strategies to address any systems and policies that might inadvertently perpetuate the economic divide. Modern epidural practices have been shown to be safe for both mother and baby, are associated with improved maternal outcomes and may be associated with improved neonatal outcomes. Understanding barriers to accessing and receiving high quality healthcare is imperative if all patients are to receive optimal maternal care.”
The authors concluded: “Socio-economic deprivation is associated with lower utilisation of epidural pain relief during labour, even when an epidural is advisable for maternal safety. Ensuring equitable access to an intervention that alleviates pain and potentially reduces adverse outcomes is crucial.”
A separate second study looked at outcomes following caesarean section deliveries in different ethnic groups, using data from 107 participating obstetric units within the National Health Service (NHS) in England during a two-week period in October 2021.
This study was conducted by Dr James O’Carroll, University College London Hospitals London UK and Stanford University School of Medicine, Stanford, CA, USA, and colleagues.
Data from 1000 patients who underwent caesarean delivery with ethnicity and deprivation information were included in this analysis.
There were more patients from Asian, Black and mixed ethnicity in the more deprived quintiles (patients divided into groups of 20% from richest to poorest). White patients had shorter postpartum length of hospital stay compared with Asian and Black patients, 35 hours vs. 44 hours vs. 49 hours, respectively.
In adjusted models at day 30, Asian patients had over twice the risk of moderate or severe pain compared to those of White ethnic groups with no differences in pain medication usage, at rest and on movement, respectively.
From the data analysed, there do not appear to be differences in the patient groups to explain these differences.
The authors conclude: “Further work is required to understand the underlying factors driving differences in postpartum pain and recovery, and to develop strategies to reduce these disparities in obstetric patients.”