Racial Disparities in Postpartum Pain Management

Clinician Perspectives on the Assessment and Management of Postpartum Pain

Postpartum pain management practices have significant variation and are known to be influenced by nonclinical factors. We aimed to examine factors that contribute to clinicians' assessment and management of postpartum pain, including the role of opioids.We conducted a qualitative study of obstetric clinicians providing postpartum care at a single, large, tertiary care center (November 2021-June 2022). Attending and trainee OB/GYN physicians and advanced practice providers (APPs) completed in-depth interviews using a semistructured interview guide. Purposive sampling was employed to ensure a representative sample of each clinician type was included. Participants were asked about factors that influence postpartum pain management. Data were analyzed using the constant comparative method.Of 46 participants, 48% were attending physicians, 32% trainee physicians, and 20% APPs. The analysis demonstrated three key themes related to postpartum assessment and management: influencing factors (knowledge or experiences that influence practice), objective findings, and the role of counseling. While clinicians reported guidelines and patient satisfaction as major influencing factors, several also shared the inherent conflict that may arise between them. Objective findings, specifically the impact of pain on patients achieving functional goals, also influenced clinician decision-making. Conversely, many participants reported the limited utility of the numeric pain scale as an objective metric. Additionally, the role of counseling in shared decision-making and providing anticipatory guidance was emphasized. Finally, clinicians had a range of opinions on the role of opioids in pain management, but many spoke to the value of opioids as second-line treatment and the impact of the opioid epidemic on prescribing practices.The factors that influence clinicians' assessment and management of postpartum pain are occasionally in conflict. Furthermore, objective measures, such as the numeric pain scale, have significant limitations. · Guidelines and patient satisfaction influence care.. · Guidelines and patient satisfaction can conflict.. · The numeric pain scale has significant limitations.. · Opioids are valuable as second-line pain treatment..

Disparities and longitudinal complications in opioid prescriptions after dermatologic surgery: An international propensity score-matched, retrospective cohort study

BACKGROUND

In dermatology, the majority of opioid prescriptions occur in dermatologic surgery. Even short courses of opioids are linked to substance abuse. Reported rates of opioid prescription in dermatologic surgery are variable, with no consensus on when they should be prescribed. Little population data currently exists on opioids in dermatologic surgery and the potentially serious complications that result. Here, we use an international patient data network to evaluate trends in postoperative opioid prescription in the setting of dermatologic surgery and complications that may result.

METHODS

This retrospective cohort study analyzed patients within the TriNetX research network. A total of 1,160,223 dermatologic surgery patients were extracted. Risk analyses were conducted examining (1) oral opioid prescription within 2 days postsurgery; (2) adverse events related to opioid use 3 months to 5 years postsurgery. Propensity score matching included variables: age, gender, race, ethnicity, complex regional pain syndrome, back pain, osteoarthritis, and malignancy.

RESULTS

A total of 124,292 (13.6%) patients received postsurgical opioids. Black or African American race, female gender, and Latino ethnicity were associated with significantly higher absolute risk of postsurgical opioid prescription. A positive history of prior opioid prescription, opioid abuse or dependence, or substance abuse yielded a significant increase in the absolute risk of receiving postsurgical opioids (P < 0.0001). Patients prescribed postsurgical opioids had a statistically significantly higher risk of subsequent oral opioid prescription (P < 0.0001), opioid abuse (P = 0.0005), substance abuse (P < 0.0001), overdose by opioids (P = 0.031), constipation (P < 0.0001), and chronic pain (P < 0.0001) 3 months to 5 years after surgery.

CONCLUSIONS

This study finds female, African American, and Latino populations have a higher risk of being prescribed opioids postoperatively. This prescription may confer risks of potentially serious complications related to opioid use. Dermatologic surgeons should be aware of the risks these populations face when determining candidacy for postsurgical opioid analgesia.

Racial Disparities in the Adherence to an Enhanced Recovery After Cesarean Protocol (ERAC): A Retrospective Observational Study at Two NYC Hospitals, 2016-2020

Enhanced recovery after surgery programs for cesarean deliveries (ERAC) aim to optimize the quality of care for all patients. Race is not routinely monitored in ERAC programs. Given the extensive reports of racial disparities in obstetrical care, the goal of this study was to investigate racial differences in adherence rates to individual ERAC protocol elements.A cohort study was performed among cesarean delivery patients enrolled in an ERAC program at two hospitals from October 2016 to September 2020. Compliance with anesthesia-specific ERAC metrics, including ketorolac, ondansetron, and active warming methods, were compared by race. Race was self-reported by all patients. Logistic regression models stratified by pre- and post-ERAC status were used to assess relationships.The sample consisted of 7,812 cesarean delivery patients, of which 4,640 were pre-ERAC (59.4%) and 3,172 were post-ERAC (40.6%). There were no racial differences found in overall ERAC protocol adherence, active warming methods, or ondansetron administration in the pre- and post-ERAC groups. The odds of ketorolac administration in Black patients (adjusted odds ratio [aOR]: 0.72; 95% confidence interval [CI]: 0.55-0.95; p = 0.020) and Asian patients (aOR: 0.81; 95% CI: 0.68-0.98; p = 0.027) pre-ERAC were significantly lower compared with white patients. In the post-ERAC group, this disparity persisted in Black (aOR: 0.80; 95% CI: 0.65-0.99; p = 0.042) and Asian patients (aOR: 0.85; 95% CI: 0.73-0.98; p = 0.023).Appropriate implementation and adherence to all elements of the ERAC program may provide a practical approach to reducing disparities in outcomes and ensuring equitable treatment for all patients. · No racial differences were found in ondansetron administration pre- and post-ERAC.. · No racial differences were found in active warming methods pre- and post-ERAC.. · Black patients had significantly lower odds of ketorolac administration pre- and post-ERAC.. · Asian patients had significantly lower odds of ketorolac administration pre- and post-ERAC.. · ERAC metrics must be routinely monitored by race to resolve any observed inequities..

Racism and Inequities in Maternal Health

Racial inequities in maternal care persist despite decades of enhanced focus on understanding why they exist. Anesthesiologists are ideally positioned to influence Black women's and birthing people's care through their near-ubiquitous presence in many labor and delivery environments. Through intentionally addressing drivers of increased maternal morbidity and mortality, such as inequities in labor analgesia and anesthesia and postpartum pain management, anesthesiologists have a powerful role in changing lives.

Labor epidural analgesia among Han and Uyghur parturients: a prospective observational study in China

BACKGROUND

Disparities in pain sensitivity and tolerance have been described, however little is known about variability in the experience of labor pain and childbirth in China.

METHODS

This prospective observational study was conducted at a tertiary hospital in Xinjiang, China with two major ethnic groups: Han and Uyghur women. Women with a vaginal delivery with labor epidural analgesia were enrolled. The primary outcome was cervical dilation at labor epidural analgesia request, and multivariable linear regression analysis was performed to determine associated variables. Secondary outcomes were pain score at epidural request and epidural analgesics use. Data presented as mean ± standard deviation.

RESULTS

Cervical dilatation at labor epidural analgesia request was significantly lower (1.2 ± 0.7 vs. 0.8 ± 0.6 cm; P=0.0095), and pain score (numerical pain scale 0-10) was significantly higher (0.8 ± 1.0 vs. 4.2 ± 1.2; P=0.0002) among Uyghur compared to Han women. In the multivariate model, Uyghur women had a lower cervical dilation (P=0.0392) and a higher pain score (P <0.0001) at epidural request. During the labor process, a larger proportion of Uyghur women used the patient-controlled epidural analgesia (PCEA) pump (77.8% vs. 53.6%, P=0.0011). They pressed the pump in a significantly shorter time (61.3 ± 41.2 vs. 104.0 ± 105.2 min, P=0.0015) and for more times (1.9 ± 1.7 vs. 1.2 ± 1.4, P=0.0022), contributing to significantly more epidural analgesic use (sufentanil: 0.06 ± 0.02 vs. 0.07 ± 0.03 μg/kg/h, P=0.0150, ropivacaine: 0.11 ± 0.04 vs. 0.14 ± 0.06 mg/kg/h, P=0.0003, respectively).

CONCLUSIONS

Our findings suggest that Uyghur women experience labor pain with higher levels of pain and with higher use of epidural analgesics than Han women. Further studies are needed to evaluate whether these differences are clinically relevant.

Examining Disparities in the Evaluation and Management of Cesarean Birth Pain Among Patients With and Without a Psychiatric Condition

Background Postoperative pain management is an important aspect of postpartum care following cesarean delivery (CD). This study aimed to determine whether differences exist in pain assessments and opioid administration after CD between patients with psychiatric illness and those without. Methodology This was a retrospective cohort study of 490 patients who underwent CD at an urban tertiary care center. Demographic and delivery data were collected by chart review. The primary outcomes were the number of pain assessments performed, average pain score, and amount of morphine milligram equivalents (MMEs) administered to patients with and without psychiatric illness. Results A total of 389 patients without a psychiatric diagnosis were compared to 101 patients with a psychiatric diagnosis. After adjusting for baseline characteristics in all models, psychiatric history had a significant effect on pain severity (β = 0.25; 95% confidence interval (CI) (0.00, 0.49); p = 0.046) and number of pain assessments (β = -2.41; 95% CI (-4.42, -0.41); p = 0.018), but not on MME administration (incidence rate ratio = 1.31; 95% CI (0.60, 2.92); p = 0.466). Patients with a psychiatric history reported more severe pain after CD and received fewer pain assessments. There was no significant difference in the amount of pain medication administered between groups. Conclusions In this study, patients with a psychiatric diagnosis received fewer pain assessments and reported more severe post-CD pain compared to those without. Despite this difference, both groups received similar amounts of pain medication, raising concern for bias and inadequate treatment of pain in patients with a psychiatric diagnosis.

Sociogeographic determinants of rapid opioid reduction or discontinuation among patients on high-dose long-term opioid therapy in North Carolina, 2006-2018

OBJECTIVE

Rapid opioid reduction or discontinuation among patients on high-dose long-term opioid therapy (HD-LTOT) is associated with increased risk of heroin use, overdose, opioid use disorder, and mental health crises. We examined the association of residential segregation and health care access with rapid opioid reduction or discontinuation among patients on HD-LTOT and examined effect measure modification of individual-level characteristics.

METHODS

Using 2006-2018 North Carolina private insurance claims data, we conducted a retrospective cohort study of patients who were 18-64 years of age and on HD-LTOT (≥90 morphine milligram equivalents for 81 of 90 consecutive days), with 1-year follow-up. The outcome was rapid opioid reduction or discontinuation (versus maintenance, increase, or gradual reduction/discontinuation). Individual-level characteristics included age, sex, and clinical diagnoses (post-traumatic stress disorder [PTSD], depression, anxiety, and substance use disorder). Neighborhood-level characteristics included health care access (measured as geographic distance to health care facilities) and residential segregation (operationalized with the Index of Concentration at the Extremes). We conducted bivariate linear regression to estimate 1-year risk differences and 95% confidence intervals.

RESULTS

Of 13 375 patients on HD-LTOT, 48.6% experienced rapid opioid reduction or discontinuation during 1-year follow-up. Female patients and those diagnosed with PTSD who lived in areas of least racial and economic privilege had higher risks of rapid opioid reduction or discontinuation than did those living in areas with the most racial and economic privilege.

CONCLUSION

Health care providers need to address potential biases toward patients living in underserved and marginalized communities, as well as intersectionality with mental health stigma, by prioritizing training and education in delivering unbiased care during opioid tapering.

Racial and Ethnic Disparities in Epidural Blood Patch Utilization Among Obstetric Patients in the United States: A Nationwide Analysis, 2016-2020

BACKGROUND

Racial and ethnic disparities in health care delivery can lead to inadequate peripartum pain management and associated adverse maternal outcomes. An epidural blood patch (EBP) is the definitive treatment for moderate to severe postdural puncture headache (PDPH), a potentially debilitating neuraxial anesthesia complication associated with significant maternal morbidity if undertreated. In this nationwide study, we examine the racial and ethnic disparities in the inpatient utilization of EBP after obstetric PDPH in the United States.

METHODS

In this retrospective observational study, we used the National Inpatient Sample, a nationally representative database of discharge records for inpatient admissions in the United States, from 2016 to 2020. We analyzed delivery hospitalizations of women of childbearing age (15-49 years) diagnosed with PDPH. Adjusting for maternal and hospitalization characteristics as confounders, we used a multilevel mixed-effects logistic regression model to compare the rates of EBP utilization by race and ethnicity. Secondarily, among hospitalizations with an EBP, we examined the association between race and ethnicity and the timing of the EBP procedure.

RESULTS

We analyzed 49,300 delivery hospitalizations with a diagnosis of PDPH. An EBP was performed in 24,075 (48.8%; 95% confidence interval [CI], 47.8%-49.9%) of these hospitalizations. EBP was performed in 52.7% (95% CI, 51.3%-54.1%) of White non-Hispanic patients with PDPH. Compared to White non-Hispanic patients, Black non-Hispanic (adjusted odds ratio [aOR] = 0.69; 99% CI, 0.56-0.84), Hispanic (aOR = 0.80, 99% CI, 0.68-0.95), and Asian or Pacific Islander patients (aOR = 0.74, 99% CI, 0.58-0.96) were less likely to receive an EBP. The median (interquartile range [IQR]) time to perform an EBP was 2 (1-3) days after admission, with 90% of EBP procedures completed within 4 days of admission. There was no significant association between race and ethnicity and the timing of EBP placement.

CONCLUSIONS

In this nationwide analysis of delivery hospitalizations from 2016 to 2020 in the United States with a diagnosis of PDPH, we identified racial and ethnic disparities in the utilization of EBP. Minoritized patients identified as Black non-Hispanic, Hispanic, or Asian or Pacific Islander were less likely to receive an EBP for the treatment of PDPH compared to White non-Hispanic patients. Suboptimal treatment of PDPH may be associated with adverse long-term outcomes such as postpartum depression, posttraumatic stress disorder, and chronic headaches. Racial and ethnic disparities in EBP utilization should be further investigated to ensure equitable health care delivery.

Leveraging an equity birth plan as a communication tool to address health equity and improve health outcomes in black birthing people

BACKGROUND

Black birthing people in the United States are disproportionately impacted by maternal mortality and more frequently report physical and verbal mistreatment during intrapartum care. Birth plans for prenatal and postpartum care promote autonomy and agency but have not been used as tools to address disparities in perinatal care.

METHODS

We reviewed the literature on the use of birth plans and communication in the pregnancy care setting. We provide an expert analysis and a recommendation for a comprehensive birth plan that incorporates patient preferences and individualizes patient risks as a communication tool.

RESULTS

In this expert opinion we outline how an equity birth plan can address social determinants of health, promote respectful communication and prioritize attention to patient narratives. This instrument can be used to address systemic problems that result in health inequities on a community, provider and institutional level.

CONCLUSIONS

A birth plan with attention to equity serves as a new paradigm for care which can empower patients and reduce racial inequities in perinatal and postpartum outcomes.

Racial Disparities in Opioid Prescribing in the United States from 2011 to 2021: A Systematic Review and Meta-Analysis

Background

This meta-analysis is an update to a seminal meta-analysis on racial/ethnic disparities in pain treatment in the United States (US) published in 2012. Since then, literature has accumulated on the topic and important policy changes were made.

Objective

Examining racial/ethnic disparities in pain management and investigating key moderators of the association between race/ethnicity and pain outcomes in the US.

Methods

We performed a systematic search of publications (between January 2011 and February 2021) from the Scopus database. Search terms included: race, racial, racialized, ethnic, ethnicity, minority, minorities, minoritized, pain treatment, pain management, and analgesia. All studies were observational, examining differences in receipt of pain prescription medication in various settings, across racial or ethnic categories in US adult patient populations. Two binary analgesic outcomes were extracted: 1) prescription of "any" analgesia, and 2) prescription of "opioid" analgesia. We analyzed these outcomes in two populations: 1) Black patients, with White patients as a reference; and 2) Hispanic patients, with non-Hispanic White patients as a reference.

Results

The meta-analysis included twelve studies, and the systematic review included forty-three studies. Meta-analysis showed that, compared to White patients, Black patients were less likely to receive opioid analgesia (OR 0.83, 95% CI [0.73-0.94]). Compared to non-Hispanic White patients, Hispanic patients were less likely to receive opioid analgesia (OR 0.80, 95% CI [0.72-0.88]).

Conclusion

Despite a decade's gap, the findings indicate persistent disparities in prescription of, and access to opioid analgesics for pain among Black and Hispanic populations in the US.

Optimizing Diversity, Equity and Inclusion in Pragmatic Clinical Trials: Findings from the Pain Management Collaboratory

The National Institutes of Health, U.S. Department of Defense, and U.S. Department of Veterans Affairs established a Pain Management Collaboratory (PMC) in 2017, with the purpose of implementing and evaluating nonpharmacological approaches for management of pain and co-occurring conditions in military and veteran healthcare systems through the execution of pragmatic clinical trials. The purpose of the current study is to detail and critically examine recruitment and retention procedures across the PMC's large-scale multi-site pragmatic clinical trials, with attention to efforts made by trialists to diversify their study samples. Team members from 11 pragmatic clinical trials completed semi-structured interviews that focused on the meaning of diversity to the trial teams when planning the composition of their samples, methods used to recruit and retain diverse samples of patients, and planned analyses that take into consideration diverse subgroups of patients. Nearly 18,000 patients have been enrolled across trials, 22% of whom were assigned female sex at birth and 34% of whom identify with a marginalized race or ethnicity. Respondents highlighted study site selection, formation of partnerships with patient groups, and leveraging of data informatics as strategies that aided in the recruitment of patients diverse in terms of birth sex, race, and ethnicity. Notably, trialists adopted a narrow definition of diversity that did not take into consideration multiple intersecting identities of trial participants. Based on experiences of the PMC, we provide 14 recommendations on ways to diversify patient samples in clinical pain research. PERSPECTIVE: This article describes challenges posed, and opportunities provided, with pain pragmatic clinical trial designs, emphasizing approaches that optimize the inclusion of social identity groups that have historically been under-represented in pain research.

Prospective Study of Preoperative Negative Affect and Postoperative Pain in Patients Undergoing Thoracic Surgery: The Moderating Role of Sex

Objective: Preoperative negative affect is a risk factor for worse postoperative pain, but research investigating this association among patients undergoing thoracic surgery is inconsistent. Additionally, female patients often report greater negative affect and postoperative pain than males. This prospective observational study investigated the association between preoperative negative affect and postoperative pain after thoracic surgery and whether this association differed by sex. Methods: Patients (n = 105) undergoing thoracic surgery completed preoperative assessments of pain and negative affect (PROMIS anxiety and depression short forms). Patients reported their daily worst pain over the first 7 postoperative days, and an index score of acute postoperative pain was created. Six months after surgery, a subsample of patients (n = 60) reported their worst pain. Results: Higher levels of preoperative anxiety (r = 0.25, p = 0.011) and depression (r = 0.20, p = 0.042) were associated with greater acute postoperative pain, but preoperative negative affect was not related to chronic postsurgical pain (anxiety: r = 0.19, p = 0.16; depression: r = -0.01, p = 0.94). Moderation analyses revealed that the associations between both preoperative anxiety (b = 0.12, 95% CI [0.04, 0.21], p = 0.004) and depression (b = 0.15, 95% CI [0.04, 0.26], p = 0.008) with acute postoperative pain were stronger among females than males. Similarly, the association between preoperative anxiety and chronic postsurgical pain was stronger among females (b = 0.11, 95% CI [0.02, 0.20], p = 0.022), but the association between preoperative depression and chronic pain did not differ based on sex (b = 0.13, 95% CI [-0.07, 0.34], p = 0.201]). Conclusions: Our findings suggest that negative affect may be especially important to the experience of pain following thoracic surgery among female patients, whose degree of preoperative anxiety may indicate vulnerability to progress to a chronic pain state. Preoperative interventions aimed at reducing negative affect and pain may be particularly useful among females with high negative affect before thoracic surgery.

Listening to Black Women's Perspectives of Birth Centers and Midwifery Care: Advocacy, Protection, and Empowerment

INTRODUCTION

Black women in Texas experience high rates of adverse maternal outcomes that have been linked to health inequities and structural racism in the maternal care system. Birth centers and midwifery care are highlighted in the literature as contributing to improved perinatal care experiences and decreased adverse outcomes for Black women. However, compared with White women, Black women underuse birth centers and midwifery care. Black women's perceptions in Texas of birth center and midwifery care are underrepresented in research. Thus, this study aimed to highlight the views of Black women residing in Texas on birth centers and midwifery care to identify their needs and explore ways to increasing access to perinatal care.

METHODS

Semistructured interviews were conducted with 10 pregnant and postpartum Black women residing in Texas. Questions focused on the women's access, knowledge, and use of birth centers and midwifery care in the context of their lived maternal care experiences. Interview transcripts were reviewed and analyzed using inductive, qualitative content analysis.

RESULTS

The Black women interviewed all shared experiences of discrimination and bias while receiving obstetric care that affected their interest in and overall perceptions of birth center and midwifery care. Participants also discussed financial and institutional barriers that impacted their ease of access to birth center and midwifery care services. Additionally, participants highlighted the need for culturally sensitive and respectful perinatal health care.

DISCUSSION

The Black women interviewed in this study emphasized the prevalence of racism and discrimination in perinatal health care encounters, a reflection consistent with current literature. Black women also expressed a desire to use birth centers and midwifery care but identified the barriers in Texas that impede access. Study findings highlight the need to address barriers to promote equitable perinatal health care access for Black women.

Drivers of variation in postpartum opioid prescribing across hospitals participating in a statewide maternity care quality collaborative

BACKGROUND

We describe variation in postpartum opioid prescribing across a statewide quality collaborative and assess the proportion due to practitioner and hospital characteristics.

METHODS

We assessed postpartum prescribing data from nulliparous, term, singleton, vertex births between January 2020 and June 2021 included in the clinical registry of a statewide obstetric quality collaborative funded by Blue Cross Blue Shield of Michigan. Data were summarized using descriptive statistics. Mixed effect logistic regression and linear models adjusted for patient characteristics and assessed practitioner- and hospital-level predictors of receiving a postpartum opioid prescription and prescription size. Relative contributions of practitioner and hospital characteristics were assessed using the intraclass correlation coefficient.

RESULTS

Of 40,589 patients birthing at 68 hospitals, 3.0% (872/29,412) received an opioid prescription after vaginal birth and 87.8% (9812/11,177) received one after cesarean birth, with high variation across hospitals. In adjusted models, the strongest patient-level predictors of receiving a prescription were cesarean birth (aOR 899.1, 95% CI 752.8-1066.7) and third-/fourth-degree perineal laceration (aOR 25.7, 95% CI 17.4-37.9). Receiving care from a certified nurse-midwife (aOR 0.63, 95% CI 0.48-0.82) or family medicine physician (aOR 0.60, 95%CI 0.39-0.91) was associated with lower prescribing rates. Hospital-level predictors included receiving care at hospitals with <500 annual births (aOR 4.07, 95% CI 1.61-15.0). A positive safety culture was associated with lower prescribing rates (aOR 0.37, 95% CI 0.15-0.88). Much of the variation in postpartum prescribing was attributable to practitioners and hospitals (prescription receipt: practitioners 25.1%, hospitals 12.1%; prescription size: practitioners 5.4%, hospitals: 52.2%).

DISCUSSION

Variation in postpartum opioid prescribing after birth is high and driven largely by practitioner- and hospital-level factors. Opioid stewardship efforts targeted at both the practitioner and hospital level may be effective for reducing opioid prescribing harms.

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.

Stigma in functional neurological disorder (FND) - A systematic review

OBJECTIVE

The purpose of this systematic review was to evaluate stigma and Functional Neurological Disorder (FND) regarding: 1) prevalence and associated factors, 2) the nature and context of stigma in FND, and 3) stigma-reduction interventions.

METHODS

We searched four relevant databases from inception to December 2023, using search terms relevant to FND and stigma themes. We employed the method of synthesis by "aggregation and configuration" to synthesise and analyse the data into emergent themes.

RESULTS

We found 127 studies, spanning 148 countries, involving 18,886 participants. Of these, 4889 were patients, 13,123 were healthcare professionals, and 526 were caregivers. Quantitatively, stigma has been mainly studied in patients with functional seizures, and was higher than patients with epilepsy in three studies. Stigma experienced by patients is associated with poorer quality of life and caregiver burden. We found 10 themes and 29 subthemes revealing stigma as a systemic process, with intrapersonal, interpersonal and structural aspects. Few studies examined the perspective of caregivers, the public or online community. We identified six anti-stigma interventions.

CONCLUSION

Stigma in FND is a layered process, and affects patient quality of life and provision of care. Stigma needs to be addressed from the top structures, at governmental level, so that appropriate care pathways can be created, giving patients with FND parity of esteem with other medical conditions.

Racial and Ethnic Patient Care Disparities in Anesthesiology: History, Current State, and a Way Forward

Disparities in patient care and outcomes are well-documented in medicine but have received comparatively less attention in anesthesiology. Those disparities linked to racial and ethnic identity are pervasive, with compelling evidence in operative anesthesiology, obstetric anesthesiology, pain medicine, and critical care. This narrative review presents an overview of disparities in perioperative patient care that is grounded in historical context followed by potential solutions for mitigating disparities and inequities.

A Call to Action: Supporting Black Maternal and Infant Health Using the Collective Impact Model

This commentary advocates for a comprehensive approach to addressing the Black maternal and infant health crisis, utilizing the collective impact model with health equity at its center. Black women in the United States face alarmingly high rates of maternal morbidity and mortality compared to white women. Black women are twice as likely to have premature and low birthweight babies than white women, exposing both the expectant woman and child to various health risks. This crisis stems from systemic racism, implicit bias in healthcare, and a lack of targeted health communications for pregnant Black women. The urgency of this situation requires a bold and unified response through collaboration and coordination among healthcare providers, local and grassroots community-based organizations (CBOs), and digital health communicators. A comprehensive Black maternal and infant health campaign embedded within the collective impact model and led by a dedicated backbone organization would facilitate the coordination and involvement of diverse stakeholders. Central to these efforts should be the acknowledgment that systemic racism perpetuates health inequities. Consequently, any initiatives to improve health outcomes should prioritize health equity by valuing and incorporating Black women's perspectives. This involves crafting a responsive strategy and placing Black women at the forefront of content creation, program strategy, and evaluation. Through a collaborative effort involving healthcare partners, CBOs, and health communicators, we can have an impact far more significant than any single initiative. Immediate action is needed to dismantle systemic barriers and ensure every Black woman and infant receives the care and support they deserve. Black maternal health disparities in the United States have been widely acknowledged and studied. It is well-established that Black women face significantly higher rates of maternal morbidity and mortality compared to their white counterparts, indicative of a severe healthcare crisis. This opinion piece contributes to the discourse by proposing a comprehensive solution grounded in the collective impact model, which emphasizes collaboration and coordination across various stakeholders. This approach represents a shift from past siloed efforts, aiming to tackle the urgent issue of Black maternal and infant health with a multidisciplinary approach centered on health equity.

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.

PBPK-PD model for predicting morphine pharmacokinetics, CNS effects and naloxone antagonism in humans

Morphine and morphine-6-glucuronide (M6G) produce central nervous system (CNS) effects by activating mu-opioid receptors, while naloxone is used mainly for the reversal of opioid overdose, specifically for the fatal complication of respiratory depression, but also for alleviating opioid-induced side effects. In this study we developed a physiologically-based pharmacokinetic-pharmacodynamic (PBPK-PD) model to simultaneously predict pharmacokinetics and CNS effects (miosis, respiratory depression and analgesia) of morphine as well as antagonistic effects of naloxone against morphine. The pharmacokinetic and pharmacodynamic parameters were obtained from in vitro data, in silico, or animals. Pharmacokinetic and pharmacodynamic simulations were conducted using 39 and 36 clinical reports, respectively. The pharmacokinetics of morphine and M6G following oral or intravenous administration were simulated, and the PBPK-PD model was validated using clinical observations. The Emax model correlated CNS effects with free concentrations of morphine and M6G in brain parenchyma. The predicted CNS effects were compared with observations. Most clinical observations fell within the 5th-95th percentiles of simulations based on 1000 virtual individuals. Most of the simulated area under the concentration-time curve or peak concentrations also fell within 0.5-2-fold of observations. The contribution of morphine to CNS effects following intravenous or oral administration was larger than that of M6G. Pharmacokinetics and antagonistic effects of naloxone on CNS effects were also successfully predicted using the developed PBPK-PD model. In conclusion, the pharmacokinetics and pharmacodynamics of morphine and M6G, antagonistic effects of naloxone against morphine-induced CNS effects may be successfully predicted using the developed PBPK-PD model based on the parameters derived from in vitro, in silico, or animal studies.

Multiple marginalized identities: A qualitative exploration of intersectional perinatal experiences of birthing people of color with substance use disorder in Massachusetts

INTRODUCTION

Racial and ethnic inequities persist in receipt of prenatal care, mental health services, and addiction treatment for pregnant and postpartum individuals with substance use disorder (SUD). Further qualitative work is needed to understand the intersectionality of racial and ethnic discrimination, stigma related to substance use, and gender bias on perinatal SUD care from the perspectives of affected individuals.

METHODS

Peer interviewers conducted semi-structured qualitative interviews with recently pregnant people of color with SUD in Massachusetts to explore the impact of internalized, interpersonal, and structural racism on prenatal, birthing, and postpartum experiences. The study used a thematic analysis to generate the codebook and double coded transcripts, with an overall kappa coefficient of 0.89. Preliminary themes were triangulated with five participants to inform final theme development.

RESULTS

The study includes 23 participants of diverse racial/ethnic backgrounds: 39% mixed race/ethnicity (including 9% with Native American ancestry), 30% Hispanic or Latinx, 26% Black/African American, 4% Asian. While participants frequently names racial and ethnic discrimination, both interpersonal and structural, as barriers to care, some participants attributed poor experiences to other marginalized identities and experiences, such as having a SUD. Three unique themes emerged from the participants' experiences: 1) Participants of color faced increased scrutiny and mistrust from clinicians and treatment programs; 2) Greater self-advocacy was required from individuals of color to counteract stereotypes and stigma; 3) Experiences related to SUD history and pregnancy status intersected with racism and gender bias to create distinct forms of discrimination.

CONCLUSION

Pregnant and postpartum people of color affected by perinatal SUD faced pervasive mistrust and unequal standards of care from mostly white healthcare staff and treatment spaces, which negatively impacted their treatment access, addiction medication receipt, postpartum pain management, and ability to retain custody of their children. Key clinical interventions and policy changes identified by participants for antiracist action include personalizing anesthetic plans for adequate peripartum pain control, minimizing reproductive injustices in contraceptive counseling, and addressing misuse of toxicology testing to mitigate inequitable Child Protective Services (CPS) involvement and custody loss.

'It was horrible to watch, horrible to be a part of': Midwives' perspectives of obstetric violence

BACKGROUND

Obstetric violence, including unconsented interventions, coercion and disrespect, violates human rights; impacting the physical and psychosocial health of women. The perspective and experience of midwives related to obstetric violence have been explored in low and middle-income countries, with limited research into the experience of midwives in high income nations.

AIM

To explore Australian midwives' perspectives of obstetric violence.

METHODS

Thematic analysis of qualitative in-depth interviews with 15 midwives experienced in supporting women during birth. Critical feminist theory underpinned each stage of the research.

FINDINGS

Interviews with 15 Australian midwives from diverse care settings were analysed thematically. Four key themes were developed from the data: 'the operationalisation of obstetric violence', 'the impact of obstetric violence' 'the historical and situational context' and 'hope for the future'. Midwives considered entrenched patriarchal structures and gender inequity as fundamental to the occurrence of obstetric violence. This societal scaffold is intensified within health care systems where power imbalances facilitate maternal mistreatment through coercion and grooming women for compliance in the antenatal period. Fragmented care models expose women to mistreatment with continuity models being protective only to a point. Midwives experience their own trauma, as a result of what they have witnessed, and due to the lack of support they receive when advocating for women.

CONCLUSIONS

Obstetric violence occurs in Australian maternity systems with unconsented interventions, overmedicalisation, coercion, and disrespect observed by midwives. Care-related trauma impacts on the mental health of midwives, raising workforce concerns for policy makers, consumer advocates and professional bodies.

The impact of devaluing Women of Color: stress, reproduction, and justice

This commentary is in response to the Call for Papers put forth by the Critical Midwifery Studies Collective (June 2022). We argue that due to a long and ongoing history of gendered racism, Women of Color are devalued in U.S. society. Devaluing Women of Color leads maternal healthcare practitioners to miss and even dismiss distress in Women of Color. The result is systematic underdiagnosis, undertreatment, and the delivery of poorer care to Women of Color, which negatively affects reproductive outcomes generally and birth outcomes specifically. These compounding effects exacerbate distress in Women of Color leading to greater distress. Stress physiology is ancient and intricately interwoven with healthy pregnancy physiology, and this relationship is a highly conserved reproductive strategy. Thus, where there is disproportionate or excess stress (distress), unsurprisingly, there are disproportionate and excess rates of poorer reproductive outcomes. Stress physiology and reproductive physiology collide with social injustices (i.e., racism, discrimination, and anti-Blackness), resulting in pernicious racialized maternal health disparities. Accordingly, the interplay between stress and reproduction is a key social justice issue and an important site for theoretical inquiry and birth equity efforts. Fortunately, both stress physiology and pregnancy physiology are highly plastic-responsive to the benefits of increased social support and respectful maternity care. Justice means valuing Women of Color and valuing their right to have a healthy, respected, and safe life.

Evaluating feedback from an implementation advisory board to assess the rollout of a postpartum patient navigation program

BACKGROUND

Patient navigation is an individualized intervention to facilitate comprehensive care which has not yet been fully implemented in obstetric or postpartum care.

METHODS

We aimed to develop and evaluate a mechanism to incorporate feedback regarding implementation of postpartum patient navigation for low-income birthing individuals at an urban academic medical center. This study analyzed the role of an Implementation Advisory Board (IAB) in supporting an ongoing randomized trial of postpartum navigation. Over the first 24 months of the trial, the IAB included 11 rotating obstetricians, one clinic resource coordinator, one administrative leader, two obstetric nurses, one primary care physician, one social worker, and one medical assistant. Members completed serial surveys regarding program implementation, effects on patient care, and areas for improvement. Quarterly IAB meetings offered opportunities for additional feedback. Survey responses and meeting notes were analyzed using the constant comparative method and further interpreted within the Exploration, Preparation, Implementation, Sustainment (EPIS) Framework.

RESULTS

Members of the IAB returned 37 surveys and participated in five meetings over 24 months. Survey analysis revealed four themes among the inner context: reduced clinician burden, connection of care teams, communication strategies, and clinic workflow. Bridging factors included improved patient access to care, improved follow-up, and adding social context to care. Innovation factors included availability of navigators, importance of consistent communication, and adaptation over time. Meeting notes highlighted the importance of bidirectional feedback regarding implementation, and members expressed positive opinions regarding navigators' effects on patient care, integration into clinic workflow, and responsiveness to feedback. IAB members initially suggested changes to improve implementation; later survey responses demonstrated successful program adaptations.

CONCLUSIONS

Members of an implementation advisory board provided key insights into the implementation of postpartum patient navigation that may be useful to promote dissemination of navigation and establish avenues for the engagement of implementing partners in other innovations.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03922334 . Registered April 19, 2019. The results here do not present the results of the primary trial, which is ongoing.

Risk of Death at 1 Year Following Postpartum Opioid Exposure

OBJECTIVE

Opioids are commonly prescribed to women for acute pain following childbirth. Postpartum prescription opioid exposure is associated with adverse opioid-related morbidities but the association with all-cause mortality is not well studied. This study aimed to examine the association between postpartum opioid prescription fills and the 1-year risk of all-cause mortality among women with live births.

METHODS

In a retrospective cohort study of live births among women enrolled in Tennessee Medicaid (TennCare) between 2007 and 2015, we compared women who filled two or more postpartum outpatient opioid prescriptions (up to 41 days of postdelivery discharge) to women who filled one or fewer opioid prescription. Women were followed from day 42 postdelivery discharge through 365 days of follow-up or date of death. Deaths were identified using linked death certificates (2007-2016). We used Cox's proportional hazard regression and inverse probability of treatment weights to compare time to death between exposure groups while adjusting for relevant confounders. We also examined effect modification by delivery route, race, opioid use disorder, use of benzodiazepines, and mental health condition diagnosis.

RESULTS

Among 264,135 eligible births, 216,762 (82.1%) had one or fewer maternal postpartum opioid fills and 47,373 (17.9%) had two or more fills. There were 182 deaths during follow-up. The mortality rate was higher in women with two or more fills (120.5 per 100,000 person-years) than in those with one or fewer (57.7 per 100,000 person-years). The risk of maternal death remained higher in participants exposed to two or more opioid fills after accounting for relevant covariates using inverse probability of treatment weighting (adjusted hazard ratio: 1.46 [95% confidence interval: 1.01, 2.09]). Findings from stratified analyses were consistent with main findings.

CONCLUSION

Filling two or more opioid prescriptions during the postpartum period was associated with a significant increase in 1-year risk of death among new mothers.

KEY POINTS

· Opioid prescribing in the postpartum period is common.. · Prior studies show that >1 postnatal opioid fill is associated with adverse opioid-related events.. · > 1 opioid fill within 42 days of delivery was associated with an increase in 1-year risk of death..

Ethnicity, socio-economic deprivation and postpartum outcomes following caesarean delivery: a multicentre cohort study

Disparities relating to postpartum recovery outcomes in different socio-economic and racial ethnic groups are underexplored. We conducted a planned analysis of a large prospective caesarean delivery cohort to explore the relationship between ethnicity, socio-economic status and postpartum recovery. Eligible patients were enrolled and baseline demographic, obstetric and medical history data were collected 18 h and 30 h following delivery. Patients completed postpartum quality of life and recovery measures in person on day 1 (EuroQoL EQ-5D-5L, including global health visual analogue scale; Obstetric Quality of Recovery-10 item score; and pain scores) and by telephone between day 28 and day 32 postpartum (EQ-5D-5L and pain scores). Socio-economic group was determined according to the Index of Multiple Deprivation quintile of each patient's usual place of residence. Data from 1000 patients who underwent caesarean delivery were included. There were more patients of Asian, Black and mixed ethnicity in the more deprived quintiles. Patients of White ethnicities had shorter postpartum duration of hospital stay compared with patients of Asian and Black ethnicities (35 (28-56 [18-513]) h vs. 44 (31-71 [19-465]) h vs. 49 (33-75 [23-189]) h, respectively. In adjusted models at day 30, patients of Asian ethnicity had a significantly greater risk of moderate to severe pain (numerical rating scale ≥ 4) at rest and on movement (odds ratio (95%CI) 2.42 (1.24-4.74) and 2.32 (1.40-3.87)), respectively). There were no differences in readmission rates or incidence of complications between groups. Patients from White ethnic backgrounds experience shorter postpartum duration of stay compared with patients from Asian and Black ethnic groups. Ethnic background impacts pain scores and recovery at day 1 postpartum and following hospital discharge, even after adjusting for socio-economic group. Further work is required to understand the underlying factors driving differences in pain and recovery and to develop strategies to reduce disparities in obstetric patients.

Prioritizing Maternal Mental Health in Addressing Morbidity and Mortality

Importance

The rate of maternal mortality in the United States is 2-fold to 3-fold greater than that in other high-income countries. While many national initiatives have been developed to combat maternal mortality, these efforts often fail to include mental illness.

Objective

To highlight the underrecognized contribution of mental illness to maternal mortality, which is nearly double that of postpartum hemorrhage.

Evidence Review

A topic outline was developed to include challenges in measuring perinatal mental conditions and mortality rates; contributions of social determinants of health to mental conditions and mortality; perinatal psychiatric disorder characterization; mechanisms by which maternal mental illness increases mortality, specifically, suicide and addictive disorders; access limitations and care "deserts"; prenatal stress and its impact on reproductive outcomes; increasing clinician expertise through cross-disciplinary education; intervention sites and models; and asserting that mental health is fundamental to maternal health. Publications in the last 3 years were prioritized, particularly those relating to policy. References were selected through consensus. Sources were PubMed, Ovid, direct data published on government websites, and health policy sources such as the Policy Center for Maternal Mental Health.

Findings

Priority was given to recent sources. Citations from 2022-2023 numbered 26; within the last 5 years, 14; and historical references, 15. Recommendations to address each topic area serve as concluding statements for each section. To mitigate the contributions of mental illness to the maternal mortality risk, a coordinated effort is required across professional and governmental organizations.

Conclusions and Relevance

Concrete programmatic and policy changes are needed to reduce perinatal stress and address trauma, standardize the collection of social determinant of health data among perinatal patients, increase access to reproductive psychiatry curricula among prescribers, reduce perinatal mental health and obstetrical deserts, institute paid parental leave, and support seamless integration of perinatal and behavioral health care. Moreover, instead of focusing on a relatively minor portion of the contributors to health that current medical practice targets, fortifying the social foundation strengthens the prospects for the health of families for our current and future generations.

Lessons from Mortality Reviews: Nonbiologic Contributors to Maternal Deaths

Based on years of review and analysis of severe maternal morbidity and maternal mortality cases, it is clear that the high rates of maternal mortality in this country are due to more than obstetrical emergencies gone awry. Many nonmedical factors contribute to these poor outcomes including complex and ineffectual health care systems, poor coordination of care, and structural racism. In this article we discuss what physicians can and cannot accomplish on their own, the role of race and racism, and barriers built into the manner in which health care is delivered. We conclude that while obstetricians must continue to focus on the area where their expertise lies, reducing deaths by educating and training physicians to deal with the downstream consequences of upstream events, they must also focus increased attention on educating themselves and their trainees about the effect of racism, social disadvantage, and poor coordination of care on health, as well as their role in resolving these issues. Physicians must also reach out to their representatives in government to partner with them. Those leaders must recognize that when they hear about disparities in maternal mortality, focusing only on events in hospitals ignores the more dispositive issues that put Black women at risk in the first instance. KEY POINTS: · Structural racism contributes to maternal deaths.. · Coordination of postpartum care is critically important.. · U.S. health care system is complex and not patient friendly..

Reducing inpatient opioid consumption after caesarean delivery: effects of an opioid stewardship programme and racial impact in a community hospital

Caesarean section is the most common inpatient surgery in the USA, with more than 1.1 million procedures in 2020. Similar to other surgical procedures, healthcare providers rely on opioids for postoperative pain management. However, current evidence shows that postpartum patients usually experience less pain due to pregnancy-related physiological changes. Owing to the current opioid crisis, public health agencies urge providers to provide rational opioid prescriptions. In addition, a personalised postoperative opioid prescription may benefit racial minorities since research shows that this population receives fewer opioids despite greater pain levels. Our project aimed to reduce inpatient opioid consumption after caesarean delivery within 6 months of the implementation of an opioid stewardship programme.A retrospective analysis of inpatient opioid consumption after caesarean delivery was conducted to determine the baseline, design the opioid stewardship programme and set goals. The plan-do-study-act method was used to implement the programme, and the results were analysed using a controlled interrupted time-series method.After implementing the opioid stewardship programme, we observed an average of 80% reduction (ratio of geometric means 0.2; 95% CI 0.2 to 0.3; p<0.001) in inpatient opioid consumption. The institution designated as control did not experience relevant changes in inpatient opioid prescriptions during the study period. In addition, the hospital where the programme was implemented was unable to reduce the difference in inpatient opioid demand between African Americans and Caucasians.Our project showed that an opioid stewardship programme for patients undergoing caesarean delivery can effectively reduce inpatient opioid use. PDSA, as a quality improvement method, is essential to address the problem, measure the results and adjust the programme to achieve goals.

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.

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.

Disparities by Race in Pregnancy Care and Clinical Outcomes in Women With Multiple Sclerosis: A Diverse Multicenter Cohort

BACKGROUND AND OBJECTIVES

Racial disparities exist in both neurologic and obstetric populations, underscoring the importance of evaluating pregnancy outcomes in diverse women with multiple sclerosis (MS). The objective of this multicenter retrospective study was to compare pregnancy care and outcomes between Black and Hispanic (underrepresented) and White women with MS.

METHODS

Demographic and clinical data were extracted from medical records of 9 US MS centers for women with MS/clinically isolated syndrome who delivered live births between 2010 and 2021. Sites identified at last 15 consecutive Black/Hispanic women and a matching number of White women. Socioeconomic factors, pregnancy, and MS care/outcomes were compared between groups (underrepresented and White and then Black and Hispanic) using Wilcoxon rank sum (U statistic and effect size r reported), χ2, t tests and logistic regressions as appropriate to data type. Multiple imputation by chained equation was used to account for missing data.

RESULTS

Overall, 294 pregnancies resulting in live births were analyzed ( 81 Black, 67 Hispanic, and 146 White mothers). Relative to underrepresented women, White women lived in areas of higher median (interquartile range [IQR]) Child Opportunity Index (79 [45.8] vs 22 [45.8], U = 3,824, r = 0.56, p < 0.0001) and were more often employed (84.9% vs 75%, odds ratio [OR] 2.57, CI 1.46-4.50, p = 0.0008) and privately insured (93.8% vs 56.8%, OR 11.6, CI 5.5-24.5, p < 0.0001) and more received a 14-week ultrasound (98.6% vs 93.9%, OR 4.66, CI 0.99-21.96, p = 0.027). Mode of delivery was significantly different between the three groups (X2(10,294) = 20.38, p = 0.03); notably, Black women had the highest rates of emergency cesarean deliveries, and Hispanic women highest rates of uncomplicated vaginal deliveries. Babies born to underrepresented women had lower median (IQR) birthweights than babies born to White women (3,198 g [435.3 g] vs 3,275 g [412.5 g], U = 9,255, r = 0.12, p = 0.04) and shorter median (IQR) breastfeeding duration (4.5 [3.3] vs 6.0 [4.2] months, U = 8,184, r = 0.21, p = 0.003). While underrepresented women were younger than White women (mean [SD] 30.9 [4.8] vs 33.8 [4.0], t = 1.97, CI 1.96-3.98, p < 0.0001), their median (Q1-Q3, IQR) Expanded Disability Status Scale was higher (1.5 [1-2.5, 1.5] vs 1 [0-1.5, 1.5], U = 7,260, r = 0.29, p < 0.0001) before pregnancy. Finally, medical records were missing more key data for Black women (19.7% missing vs 8.9% missing, OR 2.54, CI 1.25-5.06, p = 0.008).

DISCUSSION

In this geographically diverse multicenter cohort, underrepresented women entered pregnancy with higher disability and fewer health care resources. Pregnancy represents a pivotal window where structural factors affect maternal and fetal health and neurologic trajectories; it is a critical period to optimize care and health outcomes.

Society for Maternal-Fetal Medicine Consult Series #68: Sickle cell disease in pregnancy

Pregnant individuals with sickle cell disease have an increased risk of maternal and perinatal morbidity and mortality. However, prepregnancy counseling and multidisciplinary care can lead to favorable maternal and neonatal outcomes. In this consult series, we summarize what is known about sickle cell disease and provide guidance for sickle cell disease management during pregnancy. The following are Society for Maternal-Fetal Medicine recommendations.

Air Pollution and Racial Disparities in Pregnancy Outcomes in the United States: A Systematic Review

BACKGROUND

Exposure to air pollutants and other environmental factors increases the risk of adverse pregnancy outcomes. There is growing evidence that adverse outcomes related to air pollution disproportionately affect racial and ethnic minorities. The objective of this paper is to explore the importance of race as a risk factor for air pollution-related poor pregnancy outcomes.

METHODS

Studies investigating the effects of exposure to air pollution on pregnancy outcomes by race were reviewed. A manual search was conducted to identify missing studies. Studies that did not compare pregnancy outcomes among two or more racial groups were excluded. Pregnancy outcomes included preterm births, small for gestational age, low birth weight, and stillbirths.

RESULTS

A total of 124 articles explored race and air pollution as risk factors for poor pregnancy outcome. Thirteen percent of these (n=16) specifically compared pregnancy outcomes among two or more racial groups. Findings across all reviewed articles showed more adverse pregnancy outcomes (preterm birth, small for gestational age, low birth weight, and stillbirths) related to exposure to air pollution among Blacks and Hispanics than among non-Hispanic Whites.

CONCLUSION

Evidence support our general understanding of the impact of air pollution on birth outcomes and, specifically, of disparities in exposure to air pollution and birth outcomes for infants born to Black and Hispanic mothers. The factors driving these disparities are multifactorial, mostly social, and economic factors. Reducing or eliminating these disparities require interventions at individual, community, state, and national level.

Understanding the Postpartum Cesarean Pain Experience Among Individuals With Publicly Funded Insurance: A Qualitative Investigation

INTRODUCTION

Pain is the most common postpartum concern and has been associated with adverse outcomes, such as difficulty with neonatal bonding, postpartum depression, and persistent pain. Furthermore, racial and ethnic disparities in the management of postpartum pain are well described. Despite this, less is known regarding patients' lived experiences regrading postpartum pain. The purpose of this study was to assess patient experiences related to postpartum pain management after cesarean birth.

METHODS

This is a prospective qualitative study of patients' experiences with postpartum pain management after cesarean birth at a single large tertiary care center. Individuals were eligible if they had publicly funded prenatal care, were English or Spanish speaking, and underwent a cesarean birth. Purposive sampling was used to ensure a racially and ethnically diverse cohort. Participants underwent in-depth interviews using a semistructured interview guide at 2 time points: postpartum day 2 to 3 and 2 to 4 weeks after discharge. Interviews addressed perceptions and experiences of postpartum pain management and recovery. Data were analyzed using the constant comparative method.

RESULTS

Of 49 participants, 40.8% identified as non-Hispanic Black and 40.8% as Hispanic. The majority (59.2%) had experienced a cesarean birth with a prior pregnancy. Thematic analysis yielded 2 overarching domains: (1) experience of pain after cesarean birth and (2) pain management and opioid use after cesarean birth. Themes related to the experience of pain included pain as a meaningful experience, pain not aligned with expectations, and limitations caused by pain. All participants discussed limitations caused by their pain, voicing frustration with pursuing activities of daily living, caring for home and family, caring for neonate, and impact on mood. Themes related to pain management and opioid use addressed a desire for nonpharmacologic pain management, positive and negative experiences using opioids, and hesitancy and perceived judgement regarding opioid use. Several participants described experiences of judgement regarding the request for opioids and needing stronger pain medications, such as oxycodone.

DISCUSSION

Understanding experiences regarding postpartum cesarean pain management and recovery is essential to improving patient-centered care. The experiences identified by this analysis highlight the need for individualized postpartum pain management, improved expectation counseling, and the expansion of multimodal pain management options.

Pregnancy-related risk factors and receipt of postpartum care among Texas Medicaid pregnant enrollees: Opportunities for pharmacist services

BACKGROUND

The United States (US) experiences the highest rate of maternal mortality of similar countries. Postpartum care (PPC) focused on chronic disease management is potentially lifesaving, especially among pregnancies complicated by risk factors such as diabetes, hypertension, and mental health conditions (MHCs), which are conditions in which pharmacists can have an impact.

OBJECTIVE

To evaluate the prevalence of maternal mortality risk factors and their relationships with receipt of PPC among Texas Medicaid enrollees.

METHODS

A retrospective study included women with a delivery between 3/25/2014-11/1/2019 who were continuously enrolled in Texas Medicaid during the study period from 84 days pre-delivery to 60 days post-delivery. PPC was defined as ≥1 visit associated with postpartum follow-up services. Maternal mortality risk factors (diabetes, hypertension, and MHCs) during and after pregnancy were identified using diagnoses and medication utilization. Age, race/ethnicity, cesarean delivery, and preterm birth served as covariates. Multivariable logistic regression was used to address the study objective.

RESULTS

The sample (N = 617,010) was 26.5±5.7 years, primarily (52.8%) Hispanic, and 33.0% had cesarean deliveries and 9.3% had preterm births. Risk factor prevalence included: diabetes (14.0%), hypertension (14.3%), and MHCs during (6.3%) and after (9.1%) pregnancy. A majority (77.9%) had a PPC visit within 60 days of delivery. The odds of receiving PPC were 1.2 times higher for patients with diabetes (OR = 1.183; 95% CI = 1.161-1.206; P < 0.0001), 1.1 times higher for patients with hypertension (OR = 1.109; 95% CI= 1.089-1.130; P < 0.0001), and 1.1 times higher for patients with MHCs (OR=1.138; 95% CI = 1.108-1.170; P < 0.0001) than patients without, respectively.

CONCLUSION

Over three-quarters of Texas Medicaid pregnant enrollees received PPC within 60 days of delivery and risk factors were prevalent and predictive of receipt of PPC. Pharmacists can have a positive impact on maternal health by addressing hypertension, diabetes, and MHC risk factors.

Exploring Black Undergraduate Students' Communication and Biology Education Experiences about COVID-19 and COVID-19 Vaccines During the Pandemic

Effective communication about science is a core skill undergraduates should learn, but little research has explored how students communicate about culturally controversial science topics. In this study, we explored how Black undergraduate science students took on the role of science communicators in their communities during the COVID-19 pandemic. We interviewed 23 Black students about their experiences learning about COVID-19 vaccines and communicating about COVID-19 vaccines to their communities. We found that students' racial/ethnic and science backgrounds made them feel a responsibility to be effective communicators about COVID-19 vaccines as potential trusted messengers within their communities. However, students were using limited strategies when communicating and were unsure how to communicate about COVID-19 topics effectively to those who were vaccine-hesitant or doubted the severity of the pandemic. Finally, students described ways that their biology instructors could have helped them be more confident when communicating about COVID-19 vaccines with their communities. Findings suggest that biology instructors could teach science communication principles in addition to content knowledge about culturally controversial science topics in their undergraduate classes to build on students' developing science communication skills.

Racial disparities in pain management: Historical maleficence and solutions for equity

ABSTRACT

Medical journals from the 1800s described differences in disease susceptibility, skin thickness, and pain tolerance among races. These misconceptions about biologic differences, the historical exploitation of minorities in research, and implicit biases among healthcare workers have all affected patient care. Discrepancies still exist in pain assessment and management for minority patients compared with their White counterparts and lead to poor health outcomes. By implementing specific changes in policy and practice, including standardization, implicit bias training, and building a diverse workforce, clinicians can begin to provide care that more equitably manages pain for all patients, regardless of race.

Health disparities in ethnic and racial minority populations with pain and opioid use disorder

Healthcare providers are not prepared to address health disparities among ethnic and racial minority populations with either persistent and chronic pain or substance use disorder (SUD). Recognizing biases from policies to provide pain management and treatment for SUD in our healthcare systems, from our individual state laws and federal guidelines, is necessary. Biases are embedded in the screening and treatment of patients with chronic pain through the use of screening tools, opioid treatment agreements, and prescription drug monitoring programs. Additionally, the punitive treatment of people of ethnic and racial minority populations who experience persistent and chronic pain, opioid use disorders, or other SUDs needs to be redirected to facilitate solutions rooted in equity.

Labeled as "drug-seeking": nurses use harm reduction philosophy to reflect on mending mutual distrust between healthcare workers and people who use drugs

Introduction

Over 50 years of approaching drug use from the "War on Drugs" has led to ignoring the systemic structural and social determinants of health, enforced drug use stigma, and damaging stereotypes of people who use drugs or are labeled as "drug-seeking," and sorely failed to support those needing assistance.

On philosophy of harm reduction and power

People who use drugs are often disenfranchised and pathologized by being labeled as "a drug addict," which then serves as a rationalization for mistreatment by healthcare providers. This is in opposition to a harm-reduction approach. Harm reduction philosophy is an epistemic valuation necessary for drug use stigma and our moral obligation to reduce harm from interlocking systems of power that perpetuate harm.

On drug-seeking mistrust and human rights

We have encountered many clients who use drugs that report harmful interactions with healthcare providers. Harm reduction is an issue of health equity, social justice, and fundamental human rights. This paper presents three vignettes, the author's experiences of being labeled as-and advocating for family members labeled as "drug-seeking."

Discussion

To better serve as healthcare providers, workers must be equipped to work with people who use drugs and reinforce the social justice commitment against medical stigma, neglect, racism, and inadequate pain coverage and withdrawal treatment. Nurses and our epistemic lens can meet the challenge of complex intersectional issues affecting our use of power to develop more just and equitable health systems and advance our rebuilding of a trusting relationship with the people we serve.

Standardized Order Sets Do Not Eliminate Racial or Ethnic Inequities in Postpartum Pain Management

Objective

To quantify the extent to which a standardized pain management order set reduced racial and ethnic inequities in post-cesarean pain evaluation and management.

Methods

We conducted a retrospective cohort study to quantify racial and ethnic differences in pain evaluation and management before (July 2014-June 2016) and after implementation of a standardized post-cesarean order set (March 2017-February 2018). Electronic medical records were queried for pain scores >7/10, number of pain assessments, and opioid, nonsteroidal anti-inflammatory drug (NSAID), and acetaminophen doses. Outcomes were grouped into 0 to <24 and 24-48 h postpartum, and stratified by race/ethnicity (Hispanic, non-Hispanic Black [NHB], non-Hispanic White [NHW], Asian, and other), as documented in the electronic health record. Analyses included logistic regression for the categorical outcome of pain score >7 (severe pain), and linear regression, with propensity score adjustment. Main effect and interaction terms were used to calculate the difference-in-difference in pain process and outcome measures between the baseline and follow-up periods.

Results

After order set implementation (N=888), severe pain remained more common among NHB patients (% pain scores >7 NHW vs. NHB 0 to <24 h: 22% vs. 33%, p=0.003; 24-48 h: 26% vs. 40%, p<0.001). Among all patients, pain management processes changed after implementation of the order set, with overall fewer assessments, less Opioids, and more nonopioid analgesics. However, racial and ethnic inequities in a number of assessments and in treatment were unchanged (all p for interaction >0.05), with the exception of a modest increase in NSAID doses 24-48 h postpartum for Hispanic patients.

Conclusion

A standardized pain management order set reduced overall postpartum opioid use, but did not reduce racial and ethnic disparities in pain evaluation and management. Future work should investigate racial equity-focused education and interventions designed to eliminate disparities in pain management.

Cultural Framing and the Impact On Acute Pain and Pain Services

PURPOSE OF REVIEW

Optimal treatment requires a thorough understanding of all factors contributing to pain in the individual patient. In this review, we investigate the influence of cultural frameworks on pain experience and management.

RECENT FINDINGS

The loosely defined concept of culture in pain management integrates a predisposing set of diverse biological, psychological and social characteristics shared within a group. Cultural and ethnic background strongly influence the perception, manifestation, and management of pain. In addition, cultural, racial and ethnic differences continue to play a major role in the disparate treatment of acute pain. A holistic and culturally sensitive approach is likely to improve pain management outcomes, will better cover the needs of diverse patient populations and help reduce stigma and health disparities. Mainstays include awareness, self-awareness, appropriate communication, and training.

Race-based reporting and participation of Black individuals in registered pain clinical trials, United States, 2000 to 2019

ABSTRACT

There are numerous, well-established racial disparities in the management of pain. The degree to which these are evident at the stage of conducting clinical trials is unknown. To address this knowledge gap, we examined race-based reporting, participation of Black individuals, and the factors associated with reporting and participation in pain clinical trials in the United States. Data were extracted from Clinicaltrials.gov and published articles. One thousand two hundred trials met our inclusion criteria; 482 (40.2%) reported participant race. More recent, publicly funded, and larger trials were more likely to report race. Of 82,468 participants included in pain clinical trials that reported race, 15,101 were Black individuals (18.3%). Participation of Black individuals was significantly associated with pain type (ß = +27% in cardiovascular disease pain compared with acute pain, P < 0.05), study population (ß = +33% and +7% in pain in minoritized populations and women, respectively, compared with general population, P < 0.05), pain intervention (ß = +7.5% for trials of opioid interventions compared with nonopioid interventions, P < 0.05), and a diverse team of investigators (ß = +8.0% for studies incorporating a visible non-White investigator compared with those that did not, P < 0.05). Our results indicate that representation of Black participants in pain clinical trials generally aligns with national demographics in the United States. Increased representation corresponds with health conditions more prevalent among Black individuals (eg, cardiovascular disease) and with a diverse study team composition. Despite these encouraging results, less than half of pain trials reported race, which introduces potential publication bias and limits external validity.

Investigating disparities in compliance of nursing pain reassessment for obstetrics and gynecology patients

BACKGROUND

Racial and socioeconomic disparities, exacerbated during the COVID-19 pandemic and surrounding socio-political polarization, affect access to, delivery of, and patient perception of healthcare. Perioperatively, the bedside nurse carries the greatest responsibility of direct care, which includes pain reassessment, a metric tracked for compliance.

OBJECTIVE

This study aimed to critically assess disparities in obstetrics and gynecology perioperative care and how these have changed since March 2020 using nursing pain reassessment compliance within a quality improvement framework.

STUDY DESIGN

A retrospective cohort of 76,984 pain reassessment encounters from 10,774 obstetrics and gynecology patients at a large, academic hospital from September 2017 to March 2021 was obtained from Tableau: Quality, Safety and Risk Prevention platform. Noncompliance proportions were analyzed by patient race across service lines; a sensitivity analysis was performed excluding patients who were of neither Black nor White race. Secondary outcomes included analysis by patient ethnicity, body mass index, age, language, procedure, and insurance. Additional analyses were performed by temporally stratifying patients into pre- and post-March 2020 cohorts to investigate potential pandemic and sociopolitical effects on healthcare disparities. Continuous variables were assessed with Wilcoxon rank test, categorical variables were assessed with chi-squared test, and multivariable logistic regression analyses were performed (P<.05).

RESULTS

Noncompliance proportions of pain reassessment did not differ significantly between Black and White patients as an aggregate of all obstetrics and gynecology patients (8.1% vs 8.2%), but greater differences were found within the divisions of Benign Subspecialty Gynecologic Surgery (Minimally Invasive Gynecologic Surgery + Urogynecology) (14.9% vs 10.70%; P=.03) and Maternal Fetal Medicine (9.5% vs 8.3%; P=.04). Black patients admitted to Gynecologic Oncology experienced lower noncompliance proportions than White patients (5.6% vs 10.4%; P<.01). These differences persisted after adjustment for body mass index, age, insurance, timeline, procedure type, and number of nurses attending to each patient with multivariable analyses. Noncompliance proportions were higher for patients with body mass index ≥35 kg/m2 within Benign Subspecialty Gynecology (17.9% vs 10.4%; P<.01). Non-Hispanic/Latino patients (P=.03), those ≥65 years (P<.01), those with Medicare (P<.01), and those who underwent hysterectomy (P<.01) also experienced greater noncompliance proportions. Aggregate noncompliance proportions differed slightly pre- and post-March 2020; this trend was seen across all service lines except Midwifery and was significant for Benign Subspecialty Gynecology after multivariable analysis (odds ratio, 1.41; 95% confidence interval, 1.02-1.93; P=.04). Though increases in noncompliance proportions were seen for non-White patients after March 2020, this was not statistically significant.

CONCLUSION

Significant race, ethnicity, age, procedure, and body mass index-based disparities were identified in the delivery of perioperative bedside care, especially for those admitted to Benign Subspecialty Gynecologic Services. Conversely, Black patients admitted to Gynecologic Oncology experienced lower levels of nursing noncompliance. This may be in part be related to the actions of a Gynecologic Oncology nurse practioner at our institution who helps coordinate care for the division's postoperative patients. Noncompliance proportions increased after March 2020 within Benign Subspecialty Gynecologic Services. Although this study was not designed to establish causation, possible contributing factors include implicit or explicit biases regarding pain experience across race, body mass index, age, or surgical indication, discrepancies in pain management across hospital units, and downstream effects of healthcare worker burnout, understaffing, increased use of travelers, or sociopolitical polarization since March 2020. This study demonstrates the need for ongoing investigation of healthcare disparities at all interfaces of patient care and provides a way forward for tangible improvement of patient-directed outcomes by utilizing an actionable metric within a quality improvement framework.

Narcotic Utilization After Cleft Lip Repair: Does Local Anesthetic Choice Matter?

To analyze whether the choice of intraoperative local anesthetic for cleft lip repair is associated with the amount of perioperative narcotic utilization.

Retrospective cohort study.

Hospitals participating in the Pediatric Health Information System.

Primary cleft lip repairs performed in the United States from 2010 to 2020.

Local anesthesia injected-treatment with lidocaine alone, bupivacaine alone, or treatment with both agents.

Perioperative narcotic administration.

During the study interval, 8954 patients underwent primary cleft lip repair. Narcotic utilization for unilateral (P < .001) and bilateral (P = .004) cleft lip repair has decreased over the last 5 years. Overall, 21.8% (n = 1950) of infants were administered perioperative narcotics for cleft lip repair, such that 14.3% (n = 1282) required narcotics on POD 0, and 7.2% (n = 647) required narcotics on POD 1.In this study, 36.5% (n = 3269) patients received lidocaine, 22.0% (n = 1966) patients received bupivacaine, and 19.7% (n = 1762) patients received both local anesthetics. Administration of any perioperative narcotic was significantly lower in patients receiving both lidocaine and bupivacaine than those receiving only lidocaine (P = .001, 17.5% vs 21.7%) or only bupivacaine (P < .001, 17.5% vs 22.9%). Narcotic utilization on the day of surgery was significantly lower in patients receiving both lidocaine and bupivacaine than those receiving only lidocaine (P < .001, 11.5% vs 15.1%) or only bupivacaine (P = .004, 11.5% vs 14.6%). Narcotic utilization on the first postoperative day was significantly lower in patients receiving both lidocaine and bupivacaine than those receiving only bupivacaine (P = .009, 5.9% vs 8.1%).

CONCLUSIONS

In children undergoing cleft lip repair, local anesthetic combination of lidocaine and bupivacaine is associated with decreased perioperative narcotic use compared to lidocaine or bupivacaine alone.

Examining the Critical Need for Tailored Adolescent Opioid Education: A National Study

OBJECTIVE

Prescription opioid education can be a preventative measure for opioid misuse. However, most research focuses on adult perspectives rather than adolescents. This study aimed to understand adolescents' attitudes, perceptions, knowledge about prescription opioids, and preferences and prior educational exposure to opioid safety.

METHODS

Data were collected from November to December 2020. Quota sampling through Qualtrics was used to recruit a national sample of 13- to 18-year-old adolescents who lived in the United States and could understand English.

RESULTS

A total of 774 responses were analyzed. The most frequently reported source of opioid information was speaking with parents (72%). More than half (54.7%) of participants preferred technology-based education. Participants with a personal history of opioid prescription scored no differently on safe handling and storage of opioids. There was a strong relationship between participants who reported prior knowledge of what opioids are and stopping their friend from using an opioid medication for non-medical purposes (χ2 (1, N = 684) = 3.5; p = 0.042). Participants with prior education on opioid disposal did not know that -returning opioids to the pharmacy was correct (χ2 (1, N = 425) = 3.8; p = 0.254).

CONCLUSIONS

Participants were less knowledgeable about safe storage and disposal of opioids, preferred technology-based education, and were extremely likely to talk to their parents about opioid information. Findings reaffirm the significance of opioid safety education and communication between adolescents and parents. Adolescent demographic characteristics, preferences, and prior knowledge should be considered when providing opioid safety education.

Opioid-Sparing Multimodal Analgesia Use After Cesarean Delivery Under General Anesthesia: A Retrospective Cohort Study in 729 US Hospitals

BACKGROUND

Optimizing analgesia after cesarean delivery is essential to quality of patient recovery. The American Society of Anesthesiologists and the Society for Obstetric Anesthesia and Perinatology recommend multimodal analgesia (MMA). However, little is known about clinical implementation of these guidelines after cesarean delivery under general anesthesia (GA). We performed this study to describe the use of MMA after cesarean delivery under GA in the United States and determine factors associated with use of MMA, variation in analgesia practice across hospitals, and trends in MMA use over time.

METHODS

A retrospective cohort study of women over 18 years who had a cesarean delivery under GA between 2008 and 2018 was conducted using the Premier Healthcare database (Premier Inc). The primary outcome was utilization of opioid-sparing MMA (osMMA), defined as receipt of nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen with or without opioids and without the use of an opioid-combination drug. Any use of either agent within a combination preparation was not considered osMMA. The secondary outcome was use of optimal opioid-sparing MMA (OosMMA), defined as use of a local anesthetic technique such as truncal block or local anesthetic infiltration in addition to osMMA. Mixed-effects logistic regression models were used to examine factors associated with use of osMMA, as well as variation across hospitals.

RESULTS

A total of 130,946 patients were included in analysis. osMMA regimens were used in 11,133 patients (8.5%). Use of osMMA increased from 2.0% in 2008 to 18.8% in 2018. Black race (7.9% vs 9.3%; odds ratio [OR] [95% confidence interval {CI}] 0.87 [0.81-0.94]) and Hispanic ethnicity (8.6% vs 10.0%; OR, 0.86 [0.79-0.950]) were associated with less receipt of osMMA compared to White and non-Hispanic counterparts. Medical comorbidities were generally not associated with receipt of osMMA, although patients with preeclampsia were less likely to receive osMMA (9.0%; OR, 0.91 [0.85-0.98]), while those with a history of drug abuse (12.5%; OR, 1.42 [1.27-1.58]) were more likely to receive osMMA. There was moderate interhospital variability in the use of osMMA (intraclass correlation coefficient = 38%). OosMMA was used in 2122 (1.6%) patients, and utilization increased from 0.8% in 2008 to 4.1% in 2018.

CONCLUSIONS

Variation in osMMA utilization was observed after cesarean delivery under GA in this cohort of US hospitals. While increasing trends in utilization of osMMA and OosMMA are encouraging, there is need for increased attention to postoperative analgesia practices after GA for cesarean delivery given low percentage of patients receiving osMMA and OosMMA.

Ensuring Racial and Ethnic Inclusivity in Facial Vascularized Composite Allotransplantation

Facial vascularized composite allotransplantation (fVCA) represents a valuable surgical option for reconstruction of the most devastating facial defects. There is a mounting body of evidence suggesting that healthcare disparities exist for a variety of other surgical and nonsurgical procedures. We aimed to investigate the potential existence of racial and ethnic disparities in the field of fVCA.

Methods

A comprehensive literature review was conducted by the authors of this review on PubMed/MEDLINE, and Embase databases from database inception to December 1, 2022 for studies published in the English and French languages. The search terms were (1) "face" OR "facial" AND (2) "transplant" OR "VCA" OR "vascularized composite allotransplantation" OR "vascularized composite allograft" OR "graft."

Results

Upon assessment of the racial and ethnic demographics of the 47 global cases of fVCA between 2005 and 2020, 36 were White, 10 were Asian, and one was Black. Sixteen of the 17 fVCA procedures performed in the United States involved White patients. The other patient self-identified as Black, equaling 6% of all US fVCA recipients.

Conclusion

Our analysis showed that the ethnic and racial distribution of fVCA has not proportionally reflected the racial and ethnic demographics of the general US population, underscoring the risk of such healthcare imbalances. Although large-scale studies are needed before drawing definitive conclusions, leaders in the field should take preventive steps to avoid potential disparities. Further investigations into the factors that facilitate or prohibit access to fVCA referral and surgery will be necessary moving forward.

Antepartum depressive symptoms are associated with significant postpartum opioid use

BACKGROUND

Antepartum depression is common, and outside of childbirth preoperative anxiety and depression have been associated with heightened postoperative pain. In light of the national opioid epidemic, the relationship between antepartum depressive symptoms and postpartum opioid use is particularly relevant.

OBJECTIVE

This study evaluated the association between antepartum depressive symptoms and significant postpartum opioid use during birth hospitalization.

STUDY DESIGN

This retrospective cohort study at an urban academic medical center from 2017 to 2019 included patients who received prenatal care at the medical center and linked pharmacy and billing data with electronic medical records. The exposure was antepartum depressive symptoms, defined as Edinburgh Postnatal Depression Scale ≥10 during the antepartum period. The outcome was significant opioid use, defined as: (1) any opioid use following vaginal birth and (2) the top quartile of total opioid use following cesarean delivery. Postpartum opioid use was quantified using standard conversions for opioids dispensed on postpartum days 1 to 4 to calculate morphine milligram equivalents. Poisson regression was used to calculate risk ratios and 95% confidence intervals, stratified by mode of delivery and adjusted for suspected confounders. Mean postpartum pain score was a secondary outcome.

RESULTS

The cohort included 6094 births; 2351 births (38.6%) had an antepartum Edinburgh Postnatal Depression Scale score. Of these, 11.5% had a maximum score ≥10. Significant opioid use was observed in 10.6% of births. We found that individuals with antepartum depressive symptoms were more likely to have significant postpartum opioid use, with an adjusted risk ratio of 1.5 (95% confidence interval, 1.1-2.0). When stratified by mode of delivery, this association was more pronounced for cesarean births, with an adjusted risk ratio of 1.8 (95% confidence interval, 1.1-2.7), and was no longer significant for vaginal births. Mean pain scores after cesarean delivery were significantly higher in parturients with antepartum depressive symptoms.

CONCLUSION

Antepartum depressive symptoms were associated with significant postpartum inpatient opioid use, especially following cesarean delivery. Whether identifying and treating depressive symptoms in pregnancy may impact the pain experience and opioid use postpartum warrants further investigation.

Disparities in emergency department and urgent care opioid prescribing before and after randomized clinician feedback interventions

OBJECTIVES

Racial and ethnic minorities receive opioid prescriptions at lower rates and dosages than White patients. Though opioid stewardship interventions can improve or exacerbate these disparities, there is little evidence about these effects. We conducted a secondary analysis of a cluster-randomized controlled trial conducted among 438 clinicians from 21 emergency departments and 27 urgent care clinics. Our objective was to determine whether randomly allocated opioid stewardship clinician feedback interventions that were designed to reduce opioid prescriptions had unintended effects on disparities in prescribing by patient race and ethnicity.

METHODS

The primary outcome was likelihood of receiving a low-pill prescription (low ≤10 pills, medium 11-19 pills, high ≥20 pills). Generalized mixed-effects models were used to determine patient characteristics associated with low-pill prescriptions during the baseline period. These models were then used to determine whether receipt of a low-pill prescription varied by patient race or ethnicity during the intervention period between usual care and three opioid stewardship interventions: (1) individual audit feedback, (2) peer comparison feedback, and (3) combined (individual audit + peer comparison) feedback.

RESULTS

Compared with White patients, Black patients were more likely to receive a low-pill prescription during the baseline (adjusted odds ratio [OR] 1.18, 95% confidence interval [CI] 1.06-1.31, p = 0.002) and intervention (adjusted OR 1.43, 95% CI 1.07-1.91, p = 0.015). While combined feedback was associated with an overall increase in low-pill prescriptions as intended (adjusted OR 1.89, 95% CI 1.28-2.78, p = 0.001), there were no significant differences in treatment effects of any of the interventions by patient race and ethnicity.

CONCLUSIONS

Combined individual audit and peer comparison feedback was associated with fewer opioid pills per prescription equally by patient race and ethnicity. However, the intervention did not significantly close the baseline disparity in prescribing by race.