Effect of maternal country of birth on intrapartum epidural use - A population-based register study of 602 095 deliveries

Socio-economic disadvantage and utilisation of labour epidural analgesia in Scotland: a population-based study†

Socio-economic deprivation is associated with adverse maternal and childhood outcomes. Epidural analgesia, the gold standard for labour analgesia, may improve maternal well-being. We assessed the association of socio-economic status with utilisation of epidural analgesia and whether this differed when epidural analgesia was advisable for maternal safety. This was a population-based study of 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 were defined using the Scottish Index of Multiple Deprivation. Medical conditions for which epidural analgesia is advisable for maternal safety (medical indications) and contraindications were defined according to national guidelines. Of 593,230 patients in labour, 131,521 (22.2%) received epidural analgesia. Those from the most deprived areas were 16% less likely to receive epidural analgesia than the most affluent (relative risk 0.84 [95%CI 0.82-0.85]), with the inter-decile mean change in receiving epidural analgesia estimated at -2% ([95%CI -2.2% to -1.7%]). Among the 21,219 deliveries with a documented medical indication for epidural analgesia, the socio-economic gradient persisted (relative risk 0.79 [95%CI 0.75-0.84], inter-decile mean change in receiving epidural analgesia -2.5% [95%CI -3.1% to -2.0%]). Women in the most deprived areas with a medical indication for epidural analgesia were still less likely (absolute risk 0.23 [95%CI 0.22-0.24]) to receive epidural analgesia than women from the most advantaged decile without a medical indication (absolute risk 0.25 [95%CI 0.24-0.25]). Socio-economic deprivation is associated with lower utilisation of epidural analgesia, even when epidural analgesia is advisable for maternal safety. Ensuring equitable access to an intervention that alleviates pain and potentially reduces adverse outcomes is crucial.

Migrant-Native Disparities in Obstetric Neuraxial Analgesia Use: The Role of Host-Country Language Proficiency

BACKGROUND

Neuraxial analgesia (NA) is the most effective modality in managing labor pain with widespread availability in high-income countries. Previous research has reported a differential obstetric NA use among migrant and native women, but the contribution of language barriers is not well understood. We aimed to investigate whether host-country language proficiency among migrant women influences NA use and satisfaction with pain management during labor, when compared to natives.

METHODS

We conducted a secondary analysis of data collected from 1024 native and 1111 migrant women who had singleton vaginal deliveries between 2017 and 2019 and were enrolled in the nationwide Portuguese baMBINO prospective cohort study. Obstetric NA use, satisfaction with labor pain management, and migrants' Portuguese language proficiency were self-reported. Data were analyzed using robust multilevel Poisson regression, adjusted for maternal region of birth (characterized by the Human Development Index), age, and education.

RESULTS

Overall, 84.4% of native women gave birth with NA, compared to 81.6%, 71.3%, and 56.9% of migrant women with full, intermediate, and limited language proficiency, respectively. Compared to native women, migrants with intermediate (adjusted risk ratio [aRR] = 0.91 [95% confidence interval {CI}, 0.82-0.99]) and limited (aRR = 0.73 [95% CI, 0.56-0.94]) proficiency were less likely to receive NA. However, no significant differences were observed in pain management satisfaction by language proficiency level.

CONCLUSIONS

Compared to native women, we observed a differential obstetric NA use across migrant women with different host-country language proficiency levels in Portugal, without affecting satisfaction with labor pain management. Although defining the mechanisms underlying NA use discrepancies requires further research, our findings support systematically evaluating pregnant migrant women's linguistic skills and ensuring their access to adequate obstetric analgesia-related information and interpretation services.

Obstetric Anesthesia Practice in the Tertiary Care Center: A 7-Year Retrospective Study and the Impact of the COVID-19 Pandemic on Obstetric Anesthesia Practice

There are many benefits of neuraxial anesthesia (NA) in the obstetric population. We performed a retrospective analysis of anesthesia provided to obstetric patients in the tertiary care center between 1 January 2014 and 31 December 2020 and the influence of the COVID-19 pandemic on anesthetic practice. A total of 15,930 anesthesia procedures were performed. A total of 2182 (17.52%) cesarean sections (CS) required general anesthesia (GA), including 383 (3.07%) of emergency conversion from NA. NA for CS consisted of 9971 (80.04%) spinal anesthesia (SA) and 304 (2.44%) epidural anesthesia (EPI). We found a decrease in the GA rate for CS in 2020 (11.87% vs. 14.81%; p < 0.001). The conversion rate from NA to GA for CS was 2.39% for SA and 31.38% for EPI. The conversion rate from labor EPI to SA for CS increased in 2020 (3.10% vs. 1.24%; p < 0.001), as well as the SA rate for other obstetric procedures (61.32%; p < 0.001). We report 2670 NA for vaginal delivery, representing 31.13% of all vaginal deliveries. NA constituted the vast majority of obstetric anesthesia. However, we report a relatively high incidence of GA. There was a decrease in GA use in the obstetric population during the pandemic. Further reduction in GA use is possible, including an avoidable conversion from NA to GA.

Use of labour neuraxial analgesia according to maternal immigration status: a national cross-sectional retrospective population-based study in France

BACKGROUND

Disparities in neuraxial analgesia use for childbirth by maternal origin have been reported in high-resource countries. We explored the association between maternal immigrant status (characterised separately by geographic continental origin and Human Development Index [HDI] of maternal country of birth) and neuraxial analgesia use. We hypothesised that immigrant women from low-resource countries may have more limited access to neuraxial analgesia than native French women.

METHODS

The study population, extracted from the 2016 National Perinatal Survey, a cross-sectional study of a representative sample of births in France, included only women who initially wished to deliver with neuraxial analgesia. We used multivariable multilevel logistic regression to explore the association between immigrant status and both use of neuraxial analgesia and its timely administration.

RESULTS

Among the 6070 women included, 88.1% gave birth with neuraxial analgesia and 15.8% were immigrants. There was no difference in neuraxial analgesia use between native French women and either immigrant women by geographic continental region of origin, or immigrants from countries with low HDI. However, immigrants from countries with very high HDI were more likely to give birth with neuraxial analgesia (adjusted odds ratio [aOR]=2.6; 95% confidence interval (CI), 1.2-5.8; P=0.018) and its timeliness <60 min after admission (aOR=1.8; 95% CI, 1.2-2.7; P=0.005) compared with native French women.

CONCLUSIONS

In France, immigrant women from low-resource countries have similar access to labour neuraxial analgesia to native French women. Our results suggest differential neuraxial analgesia use in favour of immigrant women from very high HDI countries compared with native women.

Could Subtle Obstetrical Brachial Plexus Palsy Be Related to Unilateral B Glenoid Osteoarthritis?

Background: Several factors associated with B glenoid are also linked with obstetrical brachial plexus palsy (OBPP). The purpose of this observational study was to determine the incidence of OBPP risk factors in type B patients. Methods: A cohort of 154 patients (68% men, 187 shoulders) aged 63 ± 17 years with type B glenoids completed a questionnaire comprising history of perinatal characteristics related to OBPP. A literature review was performed following the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) to estimate the incidence of OBPP risk factors in the general population. Results: Twenty-seven patients (18%) reported one or more perinatal OBPP risk factors, including shoulder dystocia (n = 4, 2.6%), macrosomia >4 kg (n = 5, 3.2%), breech delivery (n = 6, 3.9%), fetal distress (n = 8, 5.2%), maternal diabetes (n = 2, 1.3%), clavicular fracture (n = 2, 1.3%), and forceps delivery (n = 4, 2.6%). The comparison with the recent literature suggested that most perinatal OBPP risk factors were within the normal range, although the incidence of shoulder dystocia, forceps and vaginal breech deliveries exceeded the average rates. Conclusion: Perinatal factors related to OBPP did not occur in a higher frequency in patients with Walch type B OA compared to the general population, although some of them were in the high normal range.