Structural Racism and Use of Labor Neuraxial Analgesia Among Non-Hispanic Black Birthing People

Abstract

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.

In Reply:

“…We thank Dr. Mihalek for her comment on our study in the April 2024 issue. 1 We agree with Dr. Mihalek that parturient expectancy and obstetric anesthesia service availability in the delivery hospital are important determinants of labor neuraxial analgesia use. They are not included in our study because of the lack of data.…”

Structural Racism and Use of Labor Neuraxial Analgesia Among Non-Hispanic Black Birthing People

“…I have some concerns related to the article by Guglielminotti et al 1 in the April 2024 issue. The Introduction states that reasons for reduced use of epidurals in labor may include, “…patient preference, insufficient prenatal education…and reduced access,” but also that, “…racism could be a significant contributor…” However, in the remainder of the article, there is no mention of any possible contributing factor other than structural racism.…”