Socioeconomic Deprivation and Utilization of Anesthetic Care During Pregnancy and Delivery

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

Socio-economic deprivation is associated with adverse maternal and childhood outcomes. Epidural analgesia, the gold standard for labour analgesia, may improve maternal well-being. We assessed the association of socio-economic status with utilisation of epidural analgesia and whether this differed when epidural analgesia was advisable for maternal safety. This was a population-based study of NHS data for all women in labour in Scotland between 1 January 2007 and 23 October 2020, excluding elective caesarean sections. Socio-economic status deciles were defined using the Scottish Index of Multiple Deprivation. Medical conditions for which epidural analgesia is advisable for maternal safety (medical indications) and contraindications were defined according to national guidelines. Of 593,230 patients in labour, 131,521 (22.2%) received epidural analgesia. Those from the most deprived areas were 16% less likely to receive epidural analgesia than the most affluent (relative risk 0.84 [95%CI 0.82-0.85]), with the inter-decile mean change in receiving epidural analgesia estimated at -2% ([95%CI -2.2% to -1.7%]). Among the 21,219 deliveries with a documented medical indication for epidural analgesia, the socio-economic gradient persisted (relative risk 0.79 [95%CI 0.75-0.84], inter-decile mean change in receiving epidural analgesia -2.5% [95%CI -3.1% to -2.0%]). Women in the most deprived areas with a medical indication for epidural analgesia were still less likely (absolute risk 0.23 [95%CI 0.22-0.24]) to receive epidural analgesia than women from the most advantaged decile without a medical indication (absolute risk 0.25 [95%CI 0.24-0.25]). Socio-economic deprivation is associated with lower utilisation of epidural analgesia, even when epidural analgesia is advisable for maternal safety. Ensuring equitable access to an intervention that alleviates pain and potentially reduces adverse outcomes is crucial.

No pain management for labour: individual and organisational determinants: A secondary analysis of the 2016 French National Perinatal Survey

BACKGROUND

Disparities in access to pain management have been identified in several care settings, such as emergency departments and intensive care units, but with regard to labour analgesia, it remains poorly explored.

OBJECTIVES

To determine the proportion of women without pain management during labour and its individual and organisational determinants.

DESIGN

Secondary analysis of a nationwide cross-sectional population-based study, the 2016 French National Perinatal Survey.

SETTINGS

All maternity units in France.

PARTICIPANTS

Ten thousand and eleven women who attempted vaginal delivery with a labour duration at least 15 min.

MAIN OUTCOME MEASURE

Absence of pain management, defined as absence of any pharmacological or nonpharmacological analgesic method during labour.

RESULTS

Among the 10 011 women included, 542 (5.4%) had no labour pain management: 318 (3.7%) of the 8526 women who initially preferred to use neuraxial analgesia and 222 (15.8%) of the 1402 who did not. Using generalised estimating equations stratified according to the maternal antenatal preference for neuraxial analgesia, the common determinants of no labour pain management in both groups were no attendance at childbirth education classes and admission to a delivery unit during the night. Among women who initially preferred to use neuraxial analgesia, those who delivered in units with <1500 annual deliveries compared with units with 2000 to 3499 annual deliveries, were more likely to do without pain management [adjusted odds ratio (OR) = 1.96; 95% confidence interval (CI), 1.39 to 2.78]; among those who did not prefer to use it, women born abroad were more likely to do without labour pain management (adjusted OR = 1.64; 95% CI, 1.12 to 2.40).

CONCLUSION

In France, 1 : 20 women had no labour pain management, and this proportion was three times higher among women who preferred not to use neuraxial analgesia. Enhancing maternal information on labour pain and its management, especially nonpharmacological methods, and rethinking care organisation, could improve access to analgesia of any kind.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Variance estimators for weighted and stratified linear dose-response function estimators using generalized propensity score

Propensity score methods are widely used in observational studies for evaluating marginal treatment effects. The generalized propensity score (GPS) is an extension of the propensity score framework, historically developed in the case of binary exposures, for use with quantitative or continuous exposures. In this paper, we proposed variance estimators for treatment effect estimators on continuous outcomes. Dose-response functions (DRFs) were estimated through weighting on the inverse of the GPS, or using stratification. Variance estimators were evaluated using Monte Carlo simulations. Despite the use of stabilized weights, the variability of the weighted estimator of the DRF was particularly high, and none of the variance estimators (a bootstrap-based estimator, a closed-form estimator especially developed to take into account the estimation step of the GPS, and a sandwich estimator) were able to adequately capture this variability, resulting in coverages below the nominal value, particularly when the proportion of the variation in the quantitative exposure explained by the covariates was large. The stratified estimator was more stable, and variance estimators (a bootstrap-based estimator, a pooled linearized estimator, and a pooled model-based estimator) more efficient at capturing the empirical variability of the parameters of the DRF. The pooled variance estimators tended to overestimate the variance, whereas the bootstrap estimator, which intrinsically takes into account the estimation step of the GPS, resulted in correct variance estimations and coverage rates. These methods were applied to a real data set with the aim of assessing the effect of maternal body mass index on newborn birth weight.

Towards a better understanding of risk selection in maternal and newborn care: A systematic scoping review

Globally, millions of women and their children suffer due to preventable morbidity and mortality, associated with both underuse and overuse of maternal and newborn care. An effective system of risk selection that differentiates between what care should be provided and who should provide it is a global necessity to ensure women and children receive appropriate care, at the right place and the right time. Poor conceptualization of risk selection impedes evaluation and comparison of models of risk selection across various settings, which is necessary to improve maternal and newborn care. We conducted a scoping review to enhance the understanding of risk selection in maternal and newborn care. We included 210 papers, published over the past four decades, originating from 24 countries. Using inductive thematic analysis, we identified three main dimensions of risk selection: (1) risk selection as an organisational measure to optimally align women's and children's needs and resources, (2) risk selection as a practice to detect and assess risk and to make decisions about the delivery of care, and (3) risk selection as a tool to ensure safe care. We found that these three dimensions have three themes in common: risk selection (1) is viewed as both requiring and providing regulation, (2) has a provider centred focus and (3) aims to avoid underuse of care. Due to the methodological challenges of contextual diversity, the concept of risk selection needs clear indicators that capture the complexity of care to make cross-setting evaluation and comparison of risk selection possible. Moreover, a comprehensive understanding of risk selection needs to consider access disparity, women's needs, and unnecessary medicalization.

[Maternity professionals working with pregnant and homeless migrant women]

Maternity professionals are sometimes required to provide care to migrant women in precarious circumstances. Decisions regarding the future and the social and medical support provided to these mothers and their babies must be made quickly and be efficient and effective, despite having to contend with a lack of resources. A qualitative study focused on professionals' emotional reactions in these contexts combining pregnancy, vulnerability, migration and perinatal care. It enabled an original research protocol to be established favouring professionals' reflexivity.

Analgesia during Labor and Vaginal Birth among Women with Severe Maternal Morbidity: Secondary Analysis from the WHO Multicountry Survey on Maternal and Newborn Health

Aim

To evaluate the use of analgesia for vaginal birth, in women with and without severe maternal morbidity (SMM) and to describe sociodemographic, clinical, and obstetric characteristics and maternal and perinatal outcomes associated with labor analgesia.

Methods

Secondary analysis of the WHO Multicountry Survey on Maternal and Newborn Health (WHO-MCS), a global cross-sectional study performed between May 2010 and December 2011 in 29 countries. Women who delivered vaginally and had an SMM were included in this analysis and were then divided into two groups: those who received and those who did not receive analgesia for labor/delivery. We further compared maternal characteristics and maternal and perinatal outcomes between these two groups.

Results

From 314,623 women originally included in WHO-MCS, 9,788 developed SMM and delivered vaginally, 601 (6.1%) with analgesia and 9,187 (93.9%) without analgesia. Women with SMM were more likely to receive analgesia than those who did not experience SMM. Global distribution of SMM was similar; however, the use of analgesia was less prevalent in Africa. Higher maternal education, previous cesarean section, and nulliparity were factors associated with analgesia use. Analgesia was not an independent factor associated with an increase of severe maternal outcome (Maternal Near Miss + Maternal Death).

Conclusions

The overall use of analgesia for vaginal delivery is low but women with SMM are more likely to receive analgesia during labor. Social conditions are closely linked with the likelihood of having analgesia during delivery and such a procedure is not associated with increased adverse maternal outcomes. Expanding the availability of analgesia in different levels of care should be a concern worldwide.