Anesthesia in the News
  • Disparities in OB Outcomes and Anesthetic Techniques for Deliveries

    Non-Hispanic black women have rates of severe maternal morbidity (SMM) more than twice as high as non-Hispanic white women.  Further, rates of SMM are steadily climbing, rising from 28.6 per 10,000 deliveries in 1993 to 35.0 per 10,000 deliveries in 2014, when blood transfusion was excluded from the analysis.  One recent study published in Journal of Clinical Anesthesia sought to evaluate racial and ethnic disparities in SMM and administered anesthesia techniques.

    8 years, 6.8 million patients, 707 hospitals

    This retrospective cohort study compiled 8 years of data from 2007 to 2014 from the California, Florida, New York, Maryland, and Kentucky State Inpatient Databases (SID), Healthcare Cost and Utilization Project (HCUP).

    After applying exclusion criteria, 6,879,332 cases within 707 hospitals were available for analysis.  Parturients aged ≥18 years old who underwent deliveries were identified by International Classification of Disease, 9th Revision, Clinical Modification (ICD-9-CM) codes: V27.0 and V27.1 for singleton deliveries, and V27.2 through V27.8 for multiple births.

    Demographic characteristics and comorbidities were compared after categorizing patients by race/ethnicity (White, Black, Hispanic, other or missing).  Exploratory analyses of racial/ethnic disparities in the anesthesia technique used for cesarean deliveries were performed, and the study also evaluated the use of analgesia in vaginal deliveries.

    The authors’ exploratory analyses of anesthesia type using New York State data, found that black women were more likely than white women to receive general anesthesia vs. regional anesthesia for cesarean delivery, and more likely than white women to not receive analgesia for vaginal delivery.

    Confirmation of past data

    They state that these findings are in line with previous literature: Butwick and colleagues found that, out of all racial and ethnic groups, African-Americans had the highest adjusted odds of receiving general anesthesia in cesarean delivery compared to whites (Butwick et al, 2016); the risk of maternal mortality at cesarean delivery is higher in patients receiving general versus regional anesthesia (Guglielminotti et al, 2019) (Deneux-Tharaux et al, 2006).

    Further, Glance and colleagues found that black parturients were 22% less likely than whites to receive epidural analgesia (Glance et al, 2007); the use of a labor epidural for vaginal delivery is superior to opioid analgesia for pain relief (Halpern et al, 1998).

    The researchers note that, while this may represent a personal preference or cultural trend or bias, the anesthesia provider can play a key role in counseling and providing information on the benefits and advantages of regional analgesia for labor and delivery, compared to other techniques

    Findings and the future

    Black women were found to be more likely than White women to experience an SMM (adjusted odds ratio [aOR] 1.38), which was consistent in stratified analyses.  Black women were also more likely than White women to receive general anesthesia for cesarean delivery (aOR 1.44) and to receive no analgesia for vaginal delivery (aOR 1.45).

    Additional analyses showed that Black women were more likely to receive a blood transfusion, have severe anesthesia complications, have a hysterectomy, or experience adult respiratory distress syndrome or sepsis.

    “Of note,” write the authors, “our findings suggest that black women are more likely than white women to experience an SMM regardless of anesthesia type received.  Further research is necessary to uncover the factors leading to disparities in anesthesia and analgesia in obstetric care.”

    Read the details of this well-powered study, “Racial and ethnic disparities in severe maternal morbidity and anesthetic techniques for obstetric deliveries: A multi-state analysis, 2007-2014.” J Clin Anesth. 2020 Oct;65:109821. via this link: 

    https://pubmed.ncbi.nlm.nih.gov/32408963/

    References

    Butwick AJ, Blumenfeld YJ, Brookfield KF, Nelson LM, Weiniger CF. Racial and ethnic disparities in mode of anesthesia for cesarean delivery. Anesth Analg 2016;122(2):472.

    Guglielminotti J, Landau R, Wong CA, Li G. Patient-, hospital-, and neighborhood-level factors associated with severe maternal morbidity during childbirth: a cross-sectional study in New York state 2013–2014. Matern Child Health J2019;23(1):82–91.

    Deneux-Tharaux C, Carmona E, Bouvier-Colle M-H, Bréart G. Postpartum maternal mortality and cesarean delivery. Obstet Gynecol 2006;108(3):541–8.

    Glance LG, Wissler R, Glantz C, Osler TM, Mukamel DB, Dick AW. Racial differences in the use of epidural analgesia for labor. Anesthesiology 2007;106(1):19–25.

    Halpern SH, Leighton BL, Ohlsson A, Barrett JF, Rice A. Effect of epidural vs parenteral opioid analgesia on the progress of labor: a meta-analysis. JAMA 1998;280(24):2105–10.