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The disparity in neuraxial analgesia use for Black parturients: an integrative review
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The disparity in neuraxial analgesia use for Black parturients: an integrative review
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THE DISPARITY IN EPIDURAL ANALGESIA USE FOR BLACK PARTURIENTS
THE DISPARITY IN NEURAXIAL ANALGESIA USE FOR BLACK PARTURIENTS: AN
INTEGRATIVE REVIEW
By
Melanie Janson, Elena Martinez, Yan Zhu
A Doctoral Capstone Presented to the
FACULTY OF THE USC KECK SCHOOL OF MEDICINE
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the Requirements for the Degree
DOCTOR OF NURSE ANESTHESIA PRACTICE
May 2025
THE DISPARITY IN EPIDURAL ANALGESIA USE FOR BLACK PARTURIENTS ii
The following manuscript was contributed to in equal parts by Melanie Janson, Elena Martinez,
and Yan Zhu.
THE DISPARITY IN EPIDURAL ANALGESIA USE FOR BLACK PARTURIENTS iii
Dedication
Melanie Janson, RRNA, Elena Martinez, RRNA, and Yan Zhu, RRNA, dedicate this
project to the anesthesia profession caring for pregnant women. In an effort to achieve equity in
maternal health care, we aim to close the gap in knowledge by providing insights into the
socioeconomic factors that disadvantage women in obstetric analgesia and anesthesia.
THE DISPARITY IN EPIDURAL ANALGESIA USE FOR BLACK PARTURIENTS iv
Acknowledgments
We want to extend our heartfelt gratitude to the following people who participated in this
project:
Dr. Elizabeth Bamgbose, our committee chair, for her constructive feedback, invaluable
guidance, and academic advice.
Dr. Joshua Carr and Dr. Erica McCall, our committee advisors, for their clinical
expertise, valuable comments, and checking and editing of this project.
Reneé A. Rau, our librarian, for her time and assistance in article research.
The staff of the Keck School of Medicine Doctorate Nurse Anesthesia Program, for their
continual support and investment in the profession.
Our colleagues from the class of 2025, for their constant compassion and encouragement.
And those who were involved in this project but we did not name, we are eternally
grateful to you.
THE DISPARITY IN EPIDURAL ANALGESIA USE FOR BLACK PARTURIENTS v
Table of Contents
Distribution of Work .......................................................................................................................ii
Dedication ......................................................................................................................................iii
Acknowledgements.........................................................................................................................iv
Abstract ..........................................................................................................................................vi
Chapter One ....................................................................................................................................1
Introduction..........................................................................................................................1
Research Question and Specific Aims.................................................................................2
Background and Significance..............................................................................................3
Operational Definition ........................................................................................................5
Chapter Two ....................................................................................................................................7
Methodology........................................................................................................................7
Chapter Three ..................................................................................................................................8
Literature Review.................................................................................................................8
Economic Stability ..................................................................................................8
Education Access and Quality ..............................................................................10
Health Care Access and Quality ...........................................................................11
Neighborhood and Built Environment ..................................................................14
Social and Community Context ............................................................................16
Chapter Four .................................................................................................................................19
Results ...............................................................................................................................19
Chapter Five ..................................................................................................................................21
Discussion and Conclusion ...............................................................................................21
References......................................................................................................................................25
Appendix A: PRISMA Flow Diagram..........................................................................................33
THE DISPARITY IN EPIDURAL ANALGESIA USE FOR BLACK PARTURIENTS vi
Abstract
Adequate obstetric analgesia increases maternal satisfaction and improves birth
outcomes. Despite the popularity of epidural analgesia in labor pain management, in the United
States, significant disparities exist in epidural analgesia use among parturients, particularly
Blacks. Current literature has yet to identify key factors influencing this racial disparity
conclusively. This research study referenced the social determinants of health (SDOH), defined
by the U.S. Department of Health and Human Services, to identify the contributing factors to this
racial disparity in epidural analgesia use. Using PubMed, Clinical Key, Cochrane, NCBI
Bookshelf, and Google Scholar database, an integrative literature review was performed. A total
of 10 articles were initially selected, followed by snowball technique to obtain additional articles.
The literature review was structured into the five domains of SDOH: economic stability,
education access and quality, health care access and quality, neighborhood and built
environment, and social and community context. The results uncovered the impact of each
SDOH on the disparity of epidural analgesia use among Black parturients.
THE DISPARITY IN EPIDURAL ANALGESIA USE FOR BLACK PARTURIENTS 1
Chapter One
Introduction
Significant disparities in maternal care and outcomes linger in contemporary obstetric
medicine despite global advocacy for a woman-centered childbirth practice and a rigorous
national agenda consistent with cultural and diversity training of healthcare providers. The
American College of Obstetricians and Gynecologists (ACOG) has acknowledged differences in
the quality of reproductive care in historically marginalized populations – racial, ethnic,
religious, and gender minorities. Specifically, Black patients are consistently at a greater risk for
undertreatment of pain. Research has demonstrated Blacks are 22% less likely to receive any
analgesia when experiencing similar painful conditions when compared to White patients
(Meghani et al., 2012).
Neuraxial analgesia is considered the gold standard for labor pain management by the
World Health Organization (Halliday et al., 2022). This anesthetic technique has demonstrated
greater maternal awareness and better neonate Apgar scores when compared to other intrapartum
interventions such as opioids or nitrous oxide (Silva et al., 2010). In high-risk pregnancy
patients, the American Association of Nurse Anesthesiology (AANA) considers neuraxial
analgesia beneficial in controlling maternal blood pressure, improving placental flow, and
preparing for emergent delivery (AANA, 2022). Among neuraxial analgesia techniques, epidural
anesthesia is the predominant method of analgesia, with nearly 3 out of 5 United States (U.S.)
women receiving a labor epidural (Butwick et al., 2018). Childbirth may cause one of the most
severe incidents of pain a woman experiences in her lifetime (Lizuka, 2018). Inadequate pain
control in this setting is linked to increased childbirth-related post-traumatic stress disorder and
postpartum depression (Shnol et al., 2014). Additionally, high rates of elective cesarean section
THE DISPARITY IN EPIDURAL ANALGESIA USE FOR BLACK PARTURIENTS 2
in the United States have been attributed to increased reported fear surrounding labor pain.
(Amiri et al., 2019).
Pain relief is an essential component of intrapartum management desired by many
women (ACOG, 2019; WHO, 2018). However, there is a difference in the implementation of
neuraxial analgesia for labor among parturients of different races, with Black women less likely
to receive epidural analgesia for vaginal delivery and less likely to have neuraxial analgesia for
cesarean delivery (Arago et al., 2017; Tangel et al., 2020). As analgesic treatment disparities
persist among the Black population in obstetric care, it is critical for the trend of reproductive
injustice to be nationally recognized and for healthcare to gain a more profound understanding of
why these inequalities exist.
Research Question and Specific Aims
The research question guiding this study is: What social determinants of health (SDOH),
defined by the U.S. Department of Health and Human Services, contribute to the disparity in
epidural analgesia administration among Black parturients? The specific aims of this paper are as
follows:
1. Conduct an integrated literature review on the impact of social determinants of health on
patient outcomes and the disparity of epidural analgesia administration among Black
parturients.
2. Develop an executive summary of factors contributing to the disparity in epidural
analgesia administration among Black parturients in relation to the social determinants of
health.
3. Provide practice recommendations to address the disparity in epidural analgesia use for
Black parturients.
THE DISPARITY IN EPIDURAL ANALGESIA USE FOR BLACK PARTURIENTS 3
Background and Significance
Maternal Morbidity
Singh et al. (2017) examined life expectancy data in the United States between 1950 and
2015 from the National Vital Statistics System. In 1950, life expectancy for Whites was 69.1
years, while for Blacks, life expectancy was 60.8 years. In 2015, life expectancy for Whites was
79.2 years, while for Blacks, it was 76.2 years. Cardiovascular disease is one of the leading
causes of death in the United States; Singh et al. found Blacks have a greater associated mortality
rate. Blacks experienced cardiovascular-related death 28% more than all other racial and ethnic
groups. Cancer mortality rates are also 15% higher in Blacks than Whites.
In a report addressing maternal health, the United States Government Accountability
Office stated the United States averages more maternal deaths than other developed high-income
countries. Maternal mortality rates in the United States during 2018 were 17.4 per 100,000 live
births, while Canada was 8.6 per 100,000 live births, and the United Kingdom was 6.5 per
100,000 live births (United et al. Office, 2022). According to the Centers for Disease Control and
Prevention (CDC), in 2020, the maternal mortality rate in the United States was 23.8 per 100,000
live births. In non-Hispanic Black women, maternal mortality was 55.3 deaths per 100,000 live
births, compared to 19.1 deaths per 100,000 live births among non-Hispanic White women.
Maternal mortality rates in Hispanic and non-Hispanic Black women increased significantly
from 2019 to 2020 (p < 0.05) (Hoyert, 2022). In a study examining 6,879,332 inpatient records,
Black women were 38% more likely to experience severe maternal morbidity, 44% more likely
to undergo general anesthesia for cesarean deliveries, and 45% more likely to receive no
analgesia in vaginal delivery compared to White women (Tangel et al., 2020).
THE DISPARITY IN EPIDURAL ANALGESIA USE FOR BLACK PARTURIENTS 4
The most common severe maternal morbidity (SMM) indicators include blood
transfusion, pulmonary edema/acute heart failure, sepsis, adult respiratory distress syndrome, air
and thrombotic embolism, eclampsia, cerebrovascular disorders, and acute renal failure (CDC,
2021b). In 2014, the incidence of SMM was 144 per 10,000 delivery hospitalizations, almost a
200% increase from 1993. The CDC reported blood transfusions have increased, from 24.5 per
10,000 delivery hospitalizations in 1993 to 122.3 per 10,000 delivery hospitalizations in 2014
(CDC, 2021a). Black women insured under Medicaid are 1.7 times more likely to experience
SMM compared to White women (CDC, 2021b). Postpartum hemorrhage is one of the leading
causes of preventable SMM and maternal mortality (Say et al., 2014). A cross-sectional study by
Guglielminotti et al. examined the hospital discharge records of women undergoing their first
vaginal delivery and evaluated severe maternal morbidity and postpartum hemorrhage rates. The
records of over 575,524 women were analyzed; administration of neuraxial analgesia, either
epidural or combined spinal epidural, was compared to no intervention. The research team found
administering neuraxial analgesia in vaginal delivery may be protective, with a 14% reduction in
risk for SMM (Guglielminotti et al., 2022).
Anesthesia for Labor
A retrospective study of the New York State Perinatal Database examined epidural
analgesia for labor between 1998 and 2003. Among the 81,883 patient childbirth admission
records, 38.3% of women received an epidural for pain management during labor. The research
team adjusted for socioeconomic status, provider effects, and clinical risk factors and found
Black women were 22% (OR 0.78, 95% CI 0.74-0.83, p < 0.0001) less likely to receive epidural
analgesia compared to non-Hispanic Whites (Glance et al., 2007). A longitudinal study
conducted between 1999 and 2002 across 19 different obstetric centers in the U.S. found Black
THE DISPARITY IN EPIDURAL ANALGESIA USE FOR BLACK PARTURIENTS 5
women were more likely to receive general anesthesia compared to White women during a
cesarean section. After controlling for obstetric and non-obstetric covariates (i.e., age, insurance,
race, body mass index), Black women maintained higher odds of receiving general anesthesia
(OR 1.7, 95% CI 1.5 – 1.8, p < 0.001) (Butwick et al., 2016).
Operational Definitions
For the purposes of this paper, the following operational definitions are recognized:
Black: A person of the black racial group with African ancestral origins. This term was
published in 1997 by the Office of Management and Budget standards for the classification of
federal data on race and ethnicity and is the official term used by the U.S. Census Bureau
(Revisions to the Standards for the Classification of Federal Data on Race and Ethnicity, 1997).
Parturient: Women in active labor (having regular uterine contractions and cervical
dilation ≥ 3 cm) who meet the following criteria: healthy, singleton, term (after 38 weeks),
uncomplicated pregnancy, vaginal delivery, and without contraindications to neuraxial analgesia
(allergy, maternal hemorrhage, septicemia, infection at insertion site, coagulopathy) (AnimSomuah et al., 2018).
Health Disparity: In 2010, Healthy People 2020 defined a health disparity as differences
in health or healthcare between population groups that are closely related to economic, social, or
environmental disadvantages. Health disparities adversely affect groups of people who have
historically experienced greater social or economic discrimination or exclusion based on their
characteristics such as race, ethnicity, religion, status, gender, age, disability
(cognitive/sensory/physical), sexual orientation, or gender identity (Braveman, 2014).
Social Determinants of Health: The U.S. Department of Health and Human Services
published the Healthy (HHS) People 2030 objectives, emphasizing the social determinants of
THE DISPARITY IN EPIDURAL ANALGESIA USE FOR BLACK PARTURIENTS 6
health (SDOH). SDOH are nonmedical circumstances, such as the conditions in which people
are born, live, learn, work, play, worship, and age, that positively or negatively influences one’s
health, functioning, and quality-of-life outcomes and risks. (U.S. Department of Health and
Human Services). The five domains of the SDOH include economic stability, education access
and quality, health care access and quality, neighborhood and built environment, and social and
community context.
Neuraxial/Epidural Analgesia: Neuraxial technique provides adequate analgesia while
preserving motor function during labor (vaginal or cesarean delivery) through the administration
of local anesthetics with or without low-dose opioids. Neuraxial analgesia includes standard
epidural, spinal anesthesia, combined spinal epidural, and dural puncture epidural techniques
(AANA, 2022). It is the most effective modality in alleviating labor pain in modern obstetric
medicine (Aragao et al., 2019). Epidural is an intermittent or continuous infusion of analgesia
through an epidural catheter performed in the first stage of labor in either the sitting or flexed
lateral position. The epidural catheter lies near the T10 – L1 nerve roots, blocking the
transmission of pain signals from the body to the brain and providing analgesia for the lower part
of the body in the first and second stages of labor (AANA, 2022; Kocarve, 2017). In this review,
both neuraxial and epidural labor analgesia will be used interchangeably.
THE DISPARITY IN EPIDURAL ANALGESIA USE FOR BLACK PARTURIENTS 7
Chapter Two
Methodology
An extensive literature search of PubMed, Clinical Key, Cochrane, NCBI Bookshelf, and
Google Scholar was performed following the Preferred Reporting Items for Systematic Review
and Meta-Analyses (PRISMA) guidelines (See Appendix A for PRISMA flow diagram). The
search focused on capturing relevant articles covering disparity in obstetrics anesthetic
techniques and maternal health outcomes using the keywords “labor, obstetrics,” “neuraxial,”
“disparity,” and “social determinants of health.” The results yielded 107 abstracts; articles were
included if they (1) were published in a peer-reviewed journal, (2) were written in the English
language, (3) were published after 2012, and (4) included the obstetric population. Five articles
did not meet all inclusion criteria but were used to support background information. Articles
were excluded if they were (1) considered gray literature and (2) unavailable in electronic
format. After removing articles that did not meet inclusion and exclusion criteria, 22 articles
were reviewed, and 10 were included in the integrated review.
The snowball technique was utilized to obtain additional articles. Each additional article
was critically analyzed for relevance by the authors. In addition to the published scientific
articles, the authors sought out current obstetric analgesia and anesthesia practice guidelines and
ethical responsibility from professional trade organizations, including AANA, ASA, and ACOG.
The authors explored governmental sources (e.g., CDC, WHO, HHS) for definitions and
infographics of health disparities and SDOH. The data retrieved from the respective sites were
reviewed to gain a deeper understanding of the relationship between the two. Lastly, the authors
examined national objectives and key challenges to develop further research and practice
recommendations.
THE DISPARITY IN EPIDURAL ANALGESIA USE FOR BLACK PARTURIENTS 8
Chapter Three
Literature Review
To capture the essence of how social determinants of health directly contribute to a
disparity in epidural analgesia among Black parturients, the authors have structured the literature
review into five domains of SDOH (economic stability, education access and quality, health care
access and quality, neighborhood and built environment, and social and community context).
Economic Stability
Loggins et al. (2018) utilized data from 70,000 participants in the 2012 National Survey
on Drug Use and Health to explore racial disparities between White and Black women and
identify risk factors that may impact pregnancy outcomes. Results found Black parturients were
86% less likely to be married (p < 0.001) and were 1.82 times more likely to be younger (e.g.,
between the ages 12-17 and 18-25) (p = 0.021) in comparison to White parturients. Additionally,
Black parturients were 48% less likely to be employed (p <0.05) and 69% less likely to have
higher income (p < 0.001) versus White parturients.
Singh et al. (2017) examined the disparities in healthcare access among ethnicities,
family income levels, and employment status. The researchers conducted a series of statistical
analyses by extracting public data from databases, including the National Vital Statistics System,
National Health Interview Survey, National Survey of Children’s Health, American Community
Survey, and Behavioral Risk Factor Surveillance System. Statistics showed poverty,
unemployment, and uninsurance rates were 25.4%, 11.3%, and 11.0% in Black patients,
compared to 10.4%, 5.0%, and 6.3% among non-Hispanic Whites. Socioeconomic and
employment status played a role in the affordability of healthcare access. Approximately 17.2%
of individuals with income below 138% poverty level were uninsured compared to 3.3% of those
THE DISPARITY IN EPIDURAL ANALGESIA USE FOR BLACK PARTURIENTS 9
with income above 400% poverty level; 28% of unemployed individuals were uninsured
compared to 11% of employed individuals. Furthermore, families with an annual income of less
than $35,000 were 10.56 times (p<0.05) more likely not to receive medical care and 5.38 times
(p<0.05) more likely to delay seeking medical care due to cost compared to families with an
annual income of $100,000 or more. Unemployed individuals were 1.67 times (p<0.05) more
likely not to receive medical care and 1.78 times (p<0.05) more likely to delay seeking medical
care due to cost compared to individuals who worked full-time.
The impact of socioeconomic status on the use of epidural analgesia was evaluated by
Liu et al. (2010). Researchers analyzed information from the 2004-2006 Niday perinatal
database, a database with 82 hospitals and midwives practice groups comprising more than 95%
of births in Ontario, Canada. After excluding records with incomplete information, a total of
220,814 vaginal births were reviewed. Each subject was categorized into neighborhood family
income quintiles and education quintiles, with 1 being the poorest/lowest and 5 being the
richest/highest. Statistical analysis showed that as the neighborhood income increased, more
parturients delivered in teaching hospitals and fewer in small community hospitals. And
parturients from a higher education neighborhood were more likely to have prenatal care and
fewer obstetric complications. In comparison, parturients from a lower neighborhood income and
education level were “associated with a higher percentage of teenaged mothers, a lower
percentage of advanced maternal age, higher gravidity, or tobacco use during pregnancy;
preexisting health problem … or intrapartum complications.” There was also a disparity in the
use of epidural analgesia in parturients from different socioeconomic and educational
backgrounds. The use of epidural analgesia in teaching hospitals was 74.27%, compared to
32.28% and 61.94% in small and large community hospitals, respectively. Regardless of the
THE DISPARITY IN EPIDURAL ANALGESIA USE FOR BLACK PARTURIENTS 10
hospital, epidural analgesia use significantly decreased in parturients from neighborhoods of
lower income and education level. Parturients in low-income neighborhoods were 41% less
likely to receive epidural analgesia compared to those in high-income neighborhoods (OR 0.59,
95% CI 0.58-0.61).
Education Access and Quality
The reasons parturients refused neuraxial analgesia for pain management were examined
by Toledo et al. in 2013. The researchers conducted a quantitative and qualitative 21-question
survey with open-ended questions on 509 parturients during labor and before requesting labor
analgesia. The socio-demographic characteristics varied, with 63% White, 23% Hispanic, and
14% African American women participating in the study. While 95% of all participants
discussed neuraxial analgesia with their obstetricians, 39% (n=198) voiced concerns because of
fears, misunderstandings, and mistrust. For instance, participants had the following concerns:
“transfer of drugs to the baby,” “afraid of a needle in my spine,” “back pain,” “paralysis,”
“epidurals can slow down labor,” “it increases my risk of C-section,” “human error,” “sounds
shady.” Further analysis showed that 25% (n= 129) of participants refused neuraxial analgesia
with reasons from one of the four identified qualitative themes: desire for a natural laboring
process, concerns related to neuraxial analgesia, perceptions of self having a high pain threshold,
and influences of friends and family. When encountering parturients refusing neuraxial
analgesia, the researchers recommended providers continue to care and further investigate
concerns, clarify misunderstandings, and disseminate evidence-based literature to guide
parturients’ medical decisions.
Orejuela et al. (2012) conducted a prospective observational study on fifty parturients
admitted at the University of Texas Health Science Center in Houston for vaginal delivery in
THE DISPARITY IN EPIDURAL ANALGESIA USE FOR BLACK PARTURIENTS 11
July 2009. While 92% of the subjects received prenatal care, only 28% (n=14) discussed
analgesia options with their providers during the visits. The researchers created a 9-question
survey evaluating participants’ opinions on epidural analgesia upon their admission to the Labor
and Delivery unit. The participants then completed the same survey questionnaires after
receiving routine pain management counseling from obstetric physician residents. The analyzed
data showed there was no statistical significance in the incidence of receiving epidural analgesia
before and after pain management counseling (p=0.28). The most common reasons for refusing
epidural analgesia were fear of paralysis (76%) and fear of chronic back pain (54%). Logistic
regression analysis further revealed that higher than high school education was the only factor
influencing parturients’ inclination to request epidural analgesia (OR 4.94, 95% CI 1.6-15.1).
Wilson et al. (2014) conducted a prospective observational cohort study on 397
parturients presenting for vaginal delivery requesting neuraxial anesthesia. Of the 397 subjects,
161 subjects identified themselves as African American. Statistical analysis showed that 79% of
these African Americans had a high school or less education level (p<0.001). More African
Americans received information about neuraxial analgesia from their family and friends (45%)
as compared to medical professionals (16%), including anesthesia providers, nurses, and
obstetric providers. Nevertheless, the 161 African American parturients reported statistically
significant pain relief after neuraxial analgesia was placed, with a pain score ranging from 7.7 to
1.5 (P =0.020).
Health Care Access and Quality
Traynor et al. (2016) examined the use of neuraxial labor analgesia in the obstetric
anesthesia workforce by surveying the anesthesia providers from a stratified random sample of
1193 hospitals. The results showed neuraxial labor analgesia was continuously available only in
THE DISPARITY IN EPIDURAL ANALGESIA USE FOR BLACK PARTURIENTS 12
hospitals with greater than or equal to 1,500 annual births. In hospitals with less than 1500 yearly
births, in-house neuraxial analgesia availability varied from 15% to 41%, and on-call availability
ranged from 48% to 84%, resulting in limited access.
Extracting data from the National Center for Health Statistics, Way et al. (2021)
conducted a cohort study of 25,210,263 live births in the United States between 2010 and 2017,
investigating infant mortality rates stratified by birth settings and maternal residence.
Researchers categorized birth settings as one of the following: hospital, birth center, planned
home birth, and others. Maternal residence was categorized as rural or urban. Statistical analysis
revealed that 15.5% of the 25,210,263 (n=3,902,802) live births occurred in rural counties
compared to 84.5% (n=21,307,443) in urban counties. Of the rural births, 97.8% were born in
hospitals, while 0.5%, 1.5%, and 0.4% were born in birth centers, planned home births, and
others, respectively. Of the rural births, 8.4% of the parturients were Black, non-Hispanic
women. Subsequently, during 2010-2017 there were 25,928 infant deaths in rural counties
compared to 128,407 infant deaths in urban counties; 49.7% of the infant deaths in rural counties
occurred during the early neonatal period (< 7 days). The unadjusted infant mortality rate per
1,000 births in rural counties (6.61, 95% CI 6.53, 6.69) was higher than in urban counties overall
(6.04, 95% CI 6.00, 6.07).
In a qualitative study exploring racial/ethnic bias in obstetric care, 50 people were
interviewed, including 14 Black parturients, 3 fathers, midwives, doulas, reproductive justice
advocates, and medical professionals. (Davis, 2019). With both in-person and on-the-phone
interviews of the patients’ birth stories, the researcher examined how provider bias (e.g., explicit,
implicit, unconscious) leads to a myriad of discriminatory behaviors, such as neglect, disrespect,
dismissiveness, and lack of empathy toward Black patients. The presence of these biases among
THE DISPARITY IN EPIDURAL ANALGESIA USE FOR BLACK PARTURIENTS 13
healthcare providers contributed to misdiagnosis, maltreatment, and poor provider-patient
communication in the labor and delivery settings. Furthermore, the study showed a correlation
between the perception of discrimination and medical mistrust. The reproductive experiences
told by the Black women in the study illuminated the potential negative consequences associated
with medical mistrust, including poor maternal satisfaction, adverse birth outcomes, and
reluctance to seek medical care.
Sohn (2017) analyzed the 2008 Panel of the Survey of Income Program Participation (n=
114,345) to examine health insurance rates among racial groups before the Affordable Care Act.
The researcher created life tables to determine the age rates of loss and gain in coverage.
Compared to White, Hispanic, and Asian groups, African Americans were twice as likely to lose
their insurance coverage. While they may have regained health coverage faster than nonHispanic White individuals, their higher loss rates nullified the gain. Before age 65, Whites lived
less than eight years without insurance coverage, while African Americans lived more than
twelve years without coverage, on average.
Marchi et al. (2021) examined women’s health insurance coverage change after the
Affordable Care Act. Researchers extracted data from the 2011-2017 California Maternal and
Infant Health Assessment with a sample size of 47,487 subjects. Women’s baseline insurance
coverage was analyzed before the Affordable Care Act (2011-2013) and each year from 2014 to
2017. Before the implementation of the Affordable Care Act, 24.4% of women lacked health
insurance coverage before pregnancy and 1.8% during pregnancy. This prevalence ratio before
pregnancy decreased to 23.8%, 16.6%, 11.8%, and 10.1% from 2014 to 2017, respectively. After
adjusting for demographic characteristics, including maternal age, ethnicity, language, income,
education, material status, and the number of live births, in 2017, the percentage of women
THE DISPARITY IN EPIDURAL ANALGESIA USE FOR BLACK PARTURIENTS 14
without healthcare insurance before pregnancy had decreased by 53.6% compared to 2011-2013.
In comparison, the change in health insurance coverage during pregnancy was not statistically
significant, from 1.8% in 2011-2013 to 1.3% in 2017.
Neighborhood and Built Environment
According to the American Community Survey conducted by the Bureau of the Census
(2021), approximately 13.6% of the United States population were Black, with most residing in
the southeastern regions. The District of Columbia, Mississippi, Georgia, and Louisiana were the
top four states with the most Blacks, 45%, 38.0%, 33.0%, and 33.0% respectively. According to
1980, 1990, and 2000 decennial census data from the United States Department of Agriculture
and 5-year estimates for 2007-2011 and 2015-2019 from the American Community Survey
(2022), 310 U.S counties were identified as having high and persistent poverty levels in 2019. Of
these 310 counties, 267 were rural - nonmetropolitan, concentrated in the southern border
regions, Mississippi Delta, Appalachia, the Black Belt, and Federal Indian reservations. In 2018,
approximately 7.8% of the rural population and 13.1% of the urban population were identified as
Blacks. Furthermore, Blacks in both rural and urban areas in 2019 continued to have the highest
poverty rate among all ethnic groups, with a 30.7% poverty rate in rural and 20.4% in urban
areas, compared to 13.3% and 9.7%, respectively, in Whites.
Singh et al. (2017) also examined the impact of education and place of residence on
healthcare access. Approximately 20.2% of Blacks had a college degree compared with 34.2% of
non-Hispanic Whites. Only 3.9% of all individuals with a college degree or higher were
uninsured. In comparison, nearly 22.8% of individuals with lower than a high school educational
level was uninsured, and they were 2.90 times more likely not to receive medical care and 1.96
times more likely to delay seeking medical care due to cost compared to individuals with a
THE DISPARITY IN EPIDURAL ANALGESIA USE FOR BLACK PARTURIENTS 15
college degree. Examining the disparities geographically, college degree completion was lowest
in the Southeastern region of the United States. Disparities in seeking medical care also existed
based on the place of residence. Individuals living in non-metropolitan areas were 1.29 times
more likely not to receive medical care and 1.15 times more likely to delay seeking medical care
compared to those living in large metropolitan areas.
Butwick et al. (2018) hypothesized neuraxial labor analgesia varied across the U.S. in a
state-wise manner. The study looked retrospectively at birth certificates linked to 2,652,950 U.S.
women in 2015. Birth certificate data included demographic details and medical data such as
intrapartum analgesia. Data were analyzed via multilevel multivariable regression modeling with
a median odds ratio and intraclass correlation coefficient. Results demonstrated the state of
Maine had the lowest prevalence of women receiving neuraxial analgesia (36.6%; 95% CI,
33.2%-40.1%), while Nevada had the highest prevalence (80.1%; 95% CI, 78.3%-81.7%).
Theoretical modeling of the data indicated a 50% increase in receiving neuraxial analgesia if a
woman moved to a state with a higher usage prevalence. However, further modeling adjusting
for patient-related factors demonstrated that the state alone explained 5.4% of the variance.
Instead, patient-level factors, like late or no prenatal care (no prenatal care: OR 0.61 95% CI
0.59-0.62), race/ethnicity (Non-Hispanic Black: OR 0.86 95% CI 0.85-0.87), older maternal age,
education level of 12th grade or less (Grade < 8: OR 0.57 95% CI 0.56-0.58), and lack of private
insurance or no insurance at all had an inverse relationship on neuraxial analgesia use. In a
separate model, the research team sought to determine if neuraxial analgesia delivery varied
depending on the presence of physician anesthesiologists or certified registered nurse anesthetists
(CRNAs) in the state. After controlling for patient-related factors and the anesthesia workforce,
the state could explain only 4.3% of neuraxial analgesia use, compared to the previous model’s
THE DISPARITY IN EPIDURAL ANALGESIA USE FOR BLACK PARTURIENTS 16
result of 5.4%, indicating the anesthesia workforce accounts only for a small variation in
neuraxial analgesia use.
Social and Community Context
Roberson (2019) interviewed twelve primiparous Black parturients from a Level II
trauma center postpartum unit in the southeastern United States who were offered epidural
analgesia for pain management but refused or initially refused the treatment. The three themes
identified were fear, naturalism, and family influence. Seven of the twelve participants expressed
fear of back pain and paralysis associated with epidural analgesia. Other responses included
concerns regarding a slower postpartum recovery, back complications, and an inability to tolerate
the epidural placement. The women cited friends, family, and social media as their sources of
information regarding epidurals. The hospital offered a free prenatal class, which none of the
study participants attended. Six of the twelve participants desired a natural birth without pain
management interventions. One participant mentioned that in her native country, epidural
analgesia was not generally available; thus, this culture of naturalism influenced her to refuse
epidural analgesia for labor pain management. The researcher further identified family influence
as the third most common theme shaping Black parturients’ perceptions of epidural analgesia for
labor pain management. Three participants reported matriarchal influence leading them to refuse
epidural analgesia. Two participants identified their mothers and grandmothers as role models
and desired to mimic their epidural-free laboring experiences. In addition, when asked about
influences from African American culture, participants cited resiliency, lack of trust in the
medical establishment, and access to care issues.
Hollingshead et al. (2016) utilized The Race/Ethnicity Expectations of Pain
Questionnaire (REPQ) to assess stereotypical beliefs regarding pain in White and Black
THE DISPARITY IN EPIDURAL ANALGESIA USE FOR BLACK PARTURIENTS 17
individuals. Five hundred and fifty-one undergraduates at Indiana University-Purdue University
rated pain sensitivity on a visual analog scale for Asian, Hispanic, Black, and White people.
Researchers also inquired about the participants' pain and willingness to report the pain they
experienced. The research team only reported data for White and Black individuals in the final
analysis. The research team found participants indicated White individuals were more sensitive
to pain (p < 0.001) and were more willing to report it compared to Black individuals (p < 0.001).
When stratified by race, Black participants also rated White individuals as more sensitive to pain
(p < 0.01) and more willing to report pain compared to a Black individual (p < 0.001). Personal
perception of pain compared to the opposite racial group revealed that White individuals rated
themselves as more sensitive to pain (p < 0.001) and willing to report their pain compared to
Black individuals (p < 0.001). In contrast, Black participants rated themselves as less sensitive (p
< 0.05) and less likely to report compared to White individuals (p < 0.001).
Hoffman et al. (2016) examined medical students' and residents’ beliefs regarding
biological differences between White and Black individuals and their pain perception among the
two racial groups. Subsequent treatment plans aimed at pain management were analyzed for
efficacy. The research was conducted in two parts and published collectively. The initial study
documented White laypersons’ beliefs that false biological differences exist between Blacks and
Whites, and consequently, Black individuals experience less pain. In the subsequent study, two
hundred twenty-two medical students and residents (White, native English speakers, and born in
the United States) were enrolled. Mock medical cases were presented with White and Black
patients were used to analyze pain scoring and treatment recommendations. Participants
completed the same measure in Study 1 to determine their beliefs about biological differences
between Whites and Blacks. The research team found participants agreed with 11.55% of the
THE DISPARITY IN EPIDURAL ANALGESIA USE FOR BLACK PARTURIENTS 18
false biological beliefs. Ordinary least squares regression examined the relationship between
false beliefs, pain ratings, and treatment. The analysis indicated participants with firmer false
beliefs rated the pain of the Black patient as less compared to White patients (p = 0.026).
Treatment plans selected by these participants were less accurate for the Black patient versus the
White patient (p = 0.014). As medical students progressed in their training, they indicated both
patients felt more pain, and the accuracy of their treatment plans improved (p < 0.001).
THE DISPARITY IN EPIDURAL ANALGESIA USE FOR BLACK PARTURIENTS 19
Chapter Four
Results
After an extensive literature search, the research team summarized vital findings into an
executive summary identifying the disparities contributing to lower epidural use among Black
parturients. The disparities are discussed within the context of the Social Determinants of Health
(SDOH) to satisfy the primary aim. Based on the search, the research team identified strong
indicators that healthcare access and quality, education access and quality, and social and
community context play a role.
1. Economic stability: Compared to White women, Blacks have a lower socioeconomic
status in the United States, which is associated with higher unemployment and uninsured
rates, as well as less likelihood of seeking medical care or receiving epidural analgesia
(Singh et al., 2017; Liu et al., 2010).
2. Education access and quality: Inadequately informed of the evidence-based information,
some Black parturients refused neuraxial analgesia due to fears, mistrust, and
misunderstanding (Toledo et al., 2013; Orejuela et al., 2012; Wilson et al., 2014).
Statistics showed fewer Blacks with a college degree compared to non-Hispanic Whites,
and a lower education level was linked to a higher uninsured rate and the likelihood of
delaying seeking medical care (Singh et al., 2017).
3. Health care access and quality: Neuraxial analgesia was unavailable 24/7 in all hospitals,
limiting parturients’ access (Traynor et al., 2016). Black parturients were also more likely
to lose insurance coverage compared to other ethnicities, yet such disparity improved
after the Affordable Care Act (Sohn, 2017; Marchi et al., 2021). Provider bias (e.g.,
explicit, implicit, and unconscious) towards Black parturients can lead to poor medical
THE DISPARITY IN EPIDURAL ANALGESIA USE FOR BLACK PARTURIENTS 20
judgment, differential treatment, low patient satisfaction, delayed medical care, and
negative birth outcomes (Davis, 2019).
4. Neighborhood and built environment: Environmental inequalities in healthcare,
education, and employment persist within the Black community in the United States.
Analyses show Blacks are most populated in the southeastern region- areas in the nation
consisting of most rural counties, highest per capita poverty, and lowest rate of college
degree completion (Bureau of the Census, 2021; Singh et al., 2017). Recent studies have
consistently shown the disadvantages of Blacks in terms of education level, geographic
location, access to care, and employment status (Singh et al., 2017). A theoretical model
built using geographic barriers relating to obstetric care shows that neuraxial analgesia
use is associated with access to prenatal care, race/ethnicity, age, educational level, and
insurance coverage (Butwick et al., 2018).
5. Social and community context: Refusal of labor neuraxial analgesia in Black parturients
is found to be centered on fear of complications and adverse effects of neuraxial
analgesia, the feeling of empowerment from natural birth, and the family matriarchal
influence on the birth plan, ranking accordingly (Roberson, 2019). In addition, Black
patients are more likely to receive inadequate pain treatment compared to White patients
due to the racial bias of the providers (Hollingshead et al., 2016; Hoffman et al., 2016).
THE DISPARITY IN EPIDURAL ANALGESIA USE FOR BLACK PARTURIENTS 21
Chapter Five
Discussion and Conclusion
Existing research demonstrates Black women are less likely to receive adequate pain
management in healthcare. Inadequate analgesia is also an issue during labor and delivery, with
Black women receiving neuraxial analgesia less compared to White women. Previous studies
have cited the racial disparities between the groups but have not conclusively identified key
factors influencing this outcome. The Social Determinants of Health provides a framework to
identify nonmedical factors affecting individual health and well-being. Factors across all five
domains were found to impact the Black community and contribute to Black women’s ability to
receive and choose neuraxial analgesia.
Black parturients experience higher unemployment rates, earn less income, and are more
likely to be uninsured. Lower levels of education were identified among Black women, which
was closely associated with unemployment, lack of insurance, and delaying medical care. The
Black community is heavily concentrated in the Southeastern region of the United States. It
makes up 7.8% of the rural population and lives in counties with some of the highest poverty
levels. Lower rates of education achievement, high unemployment, and issues with healthcare
access were identified in these regions. Black women utilized friends and family as their sources
of information regarding neuraxial analgesia and commonly cited fear as the primary motivation
for deciding against receiving an epidural. Stories of racism and disrespect, as well as direct
experiences from providers, identified mistrust in the healthcare system as an issue.
This research project aligns with the American Association of Nurse Anesthesiology’s
Code of Ethics; it addresses the nurse anesthesiologists’ Responsibility to the Patient and
Responsibility to Society. Under the tenant Responsibility to the Patient, nurse anesthesiologists
THE DISPARITY IN EPIDURAL ANALGESIA USE FOR BLACK PARTURIENTS 22
vow to protect and respect our patient’s safety, comfort, and well-being. All individuals in labor
deserve equal access to safe, effective pain management. The authors’ effort is also consistent
with the U.S. Department of Health and Human Services Healthy People campaign in
establishing health equity and the World Health Organization’s (WHO) initiative for supporting
high-quality, evidence-based care for all pregnant women and their babies.
Research linking neuraxial analgesia and a reduction in severe maternal morbidity across
all racial and ethnic groups highlights the importance of access and healthcare delivery on patient
outcomes (Guglielminotti et al., 2022). Rural hospitals are struggling after the COVID-19
pandemic due to lost government relief funds, increasing costs, and reduced investments. As a
result, hospitals have closed altogether, particularly in areas in the South or closed specialty units
like obstetrics (Levinson et. al, 2023). With the Black community representing a large proportion
of the Southeastern rural community, black parturients may be losing critical access to neuraxial
analgesia when delivering. A direct link between rural anesthesia care and rates of neuraxial
anesthesia delivery is an important next step in research to identify this barrier.
Limitations
Several limitations exist regarding this integrative review. It is possible that not all
relevant studies were identified due to the restriction of analyzing literature available in the
English language. Valuable data regarding maternal health in the United States may have been
utilized and examined in the context of neuraxial analgesia and published in a foreign journal.
The United States varies widely geographically, racially, and financially. Identified disparities
considered to contribute to the disparities of Black women receiving neuraxial analgesia may not
be applicable across all communities. The research team identified several disparities in the
context of the SDOH that contribute to Black women not receiving neuraxial analgesia.
THE DISPARITY IN EPIDURAL ANALGESIA USE FOR BLACK PARTURIENTS 23
However, overall information regarding the topic is limited. Racial disparities in maternal
mortality and morbidity are well documented, but more research regarding neuraxial analgesia
and pain management for Black women in labor is needed.
Strengths
Through a thorough analysis of existing literature, the research team identified several
elements contributing to Black women being less likely to receive neuraxial analgesia while in
labor. To better understand the context of these elements, the team organized findings within the
five categories of the Social Determinants of Health. The SDOH is an existing framework
utilized by several important institutions, like the WHO, and is acknowledged to play an
essential role in our health and well-being. Organizing these conditions within the framework
identifies areas of need and provides a clear target to improve future health outcomes among
Black women.
Conclusion
This study aims to raise awareness of disparities in obstetrics neuraxial analgesia in our
health system and provide clinicians with essential socioeconomic backgrounds related to the
issue. From the extensive literature review, the authors of this study concluded the disparities in
the use of neuraxial analgesia are closely linked to the five domains of SDOH: Economic
Stability, Education Access and Quality, Healthcare Access and Quality, Neighborhood and
Built Environment, and Social and Community Context. The study findings may serve as a
framework for hospital and health system leaders in setting goals, developing protocols, and
implementing interventions to improve obstetric analgesia and anesthesia equity. This study
recommends disseminating the information through hospital-wide educational interventions to
THE DISPARITY IN EPIDURAL ANALGESIA USE FOR BLACK PARTURIENTS 24
increase providers’ knowledge of neuraxial disparities and their SDOH association in Black
parturients.
Recommendations for future research include the following:
1. Correlation between hospital location/type and neuraxial analgesia use in the U.S.
2. Correlation between obstetric workforce and neuraxial analgesia use in the U.S.
3. Correlation between institutional provider perinatal training and neuraxial
analgesia use.
4. Assessment in provider cultural competency and the maternal satisfaction in
neuraxial analgesia use.
5. Replication of the study with more recent data regarding using neuraxial analgesia
and pain management for Black parturient in labor.
6. Development of an educational infographic for healthcare provider diversity and
inclusion training.
THE DISPARITY IN EPIDURAL ANALGESIA USE FOR BLACK PARTURIENTS 25
References
Amiri P., Mirghafourvand M., Esmaeilpour K., Kamalifard M., & Ivanbagha R. (2019). The
effect of distraction techniques on pain and stress during labor: A randomized controlled
clinical trial. BMC Pregnancy Childbirth. 19(1), 534. doi: 10.1186/s12884-019-2683-y
Anim-Somuah M, Smyth RM, Cyna AM, Cuthbert A. Epidural versus non-epidural or no
analgesia for pain management in labour. Cochrane Database Syst Rev. 2018 May
21;5(5):CD000331. doi: 10.1002/14651858.CD000331.pub4. PMID: 29781504; PMCID:
PMC6494646
Aragão F.F., Aragão P.W., Martins C.A., Leal K.F.C.S., & Ferraz Tobias A. (2019). Analgesia
de parto no neuroeixo: uma revisão da literatura [Neuraxial labor analgesia: a literature
review]. Braz J Anesthesiol. 69(3), 291-298. doi: 10.1016/j.bjan.2018.12.001
Braveman P. What are health disparities and health equity? We need to be clear. Public Health
Rep. 2014 Jan-Feb;129 Suppl 2(Suppl 2):5-8. doi: 10.1177/00333549141291S203.
PMID: 24385658; PMCID: PMC3863701
Butwick A.J., Bentley J., Wong C.A., Snowden J.M., Sun E., & Guo N. (2018). United States
state-level variation in the use of neuraxial analgesia during labor for pregnant women.
JAMA Network Open. 1(8): e186567. doi:10.1001/jamanetworkopen.2018.6567
Butwick, A. J., Blumenfeld, Y. J., Brookfield, K. F., Nelson, L. M., & Weiniger, C. F. (2016).
Racial and ethnic disparities in mode of anesthesia for cesarean delivery. Anesthesia and
analgesia, 122(2), 472–479. doi: 10.1213/ANE.0000000000000679
Butwick A.J., Wong C.A., & Guo N. (2018). Maternal body mass index and use of labor
neuraxial analgesia: A population-based retrospective cohort study. Anesthesiology.
129(3):448-458. doi: 10.1097/ALN.0000000000002322
THE DISPARITY IN EPIDURAL ANALGESIA USE FOR BLACK PARTURIENTS 26
Centers for Disease Control and Prevention. (2021a, February 2). Severe maternal morbidity in
the United States. U.S. Department of Health & Human Services.
https://www.cdc.gov/reproductivehealth/maternalinfanthealth/severematernalmorbidity.ht
ml
Centers for Disease Control and Prevention. (2021b, December 16). Severe maternal morbidity
after delivery discharge among U.S. women, 2010-2014. U.S. Department of Health and
Human Services.
https://www.cdc.gov/reproductivehealth/maternalinfanthealth/smm/smm-after-deliverydischarge-among-us-women/index.htm
Davis D. A. (2019). Obstetric racism: The racial politics of pregnancy, labor, and birthing.
Medical anthropology, 38(7), 560–573. https://doiorg.libproxy2.usc.edu/10.1080/01459740.2018.1549389
Glance, L. G., Wissler, R., Glantz, C., Osler, T. M., Mukamel, D. B., & Dick, A. W. (2007).
Racial differences in the use of epidural analgesia for labor. Anesthesiology, 106(1), 19–
8. Retrieved from https://doi.org/10.1097/00000542-200701000-00008
Guglielminotti, J., Landau, R., Daw, J., Friedman, A. M., Chihuri, S., & Li, G. H. (2022). Use of
labor neuraxial analgesia for vaginal delivery and severe maternal morbidity. JAMA
Network Open, 5(2): e220137. Retrieved from
https://doi.org/10.1001/jamanetworkopen.2022.0137
Halliday, L., Nelson, S. M., & Kearns, R. J. (2022). Epidural analgesia in labor: A narrative
review. International journal of gynaecology and obstetrics: the official organ of the
International Federation of Gynaecology and Obstetrics, 159(2), 356–364.
https://doi.org/10.1002/ijgo.14175
THE DISPARITY IN EPIDURAL ANALGESIA USE FOR BLACK PARTURIENTS 27
Healthy People 2030. (n.d.) Social determinants of health. U.S. Department of Health and
Human Services, Office of Disease Prevention and Health Promotion. Retrieved
November 5, 2022, from https://health.gov/healthypeople/priority-areas/socialdeterminants-health
Hernandez D. (2016). Affording housing at the expense of health: Exploring the housing and
neighborhood strategies of poor families. Journal of Family Issues. 37(7):921-946.
Hoffman K.M., Trawalter S., Axt J.R., Oliver M.N. (2016). Racial bias in pain assessment and
treatment recommendations, and false beliefs about biological differences between blacks
and whites. Proc Natl Acad Sci USA.113(16), 4296-4301. doi: 10.1073/pnas.1516047113
Hollingshead, N. A., Meints, S. M., Miller, M. M., Robinson, M. E., & Hirsh, A. T. (2016). A
comparison of race-related pain stereotypes held by White and Black individuals. Journal
of Applied Social Psychology, 46(12), 718-723. Retrieved from
https://doi.org/10.1111/jasp.12415
Hoyert, D.L. (2022). Maternal mortality rates in the United States, 2020. NCHS Health E-Stats.
Retrieved from https://dx.doi.org/10.15620/cdc:113967
Howell E.A., Brown H., Brumley J., Bryant A.S., Caughey A.B., Cornell A.M., … Grobman
W.A. (2018). Reduction of peripartum racial and ethnic disparities: A conceptual
framework and maternal safety consensus bundle. Journal of Obstetric, gynecologic &
neonatal Nursing. 47(3), 275-289. doi: 10.1097/AOG.0000000000002475
Hueston WJ, McClaflin RR, Mansfield CJ, Rudy M. Factors associated with the use of
intrapartum epidural analgesia. Obstet Gynecol. 1994 Oct;84(4):579-82. PMID: 8090396
THE DISPARITY IN EPIDURAL ANALGESIA USE FOR BLACK PARTURIENTS 28
Lizuka Y, Masaoka N, Ohashi K. Pain in labor assessed from two discomfort aspects: Physical
pain intensity and psychological stress state. J Obstet Gynaecol Res. 2018
Jul;44(7):1243-1251. doi: 10.1111/jog.13660. PMID: 29978540.
Jiménez-Puente A., Benítez-Parejo N., Del Diego-Salas J., Rivas-Ruiz F., & Maañón-Di Leo C.
(2012). Ethnic differences in the use of intrapartum epidural analgesia. BMC Health
Services Research.12, 207. doi: 10.1186/1472-6963-12-207
Kocarev M, Khalid F, Khatoon F, Fernando R. Neuraxial labor analgesia: a focused narrative
review of the 2017 literature. Curr Opin Anaesthesiol. 2018 Jun;31(3):251-257. doi:
10.1097/ACO.0000000000000595. PMID: 29543614.
Lange E.M.S., Rao S., & Toledo P. (2017). Racial and ethnic disparities in obstetric anesthesia.
Seminars in Perinatology. 41(5), 293-298. doi: 10.1053/j.semperi.2017.04.006
Levinson, Z., Godwin, J., & Hulver, S. (2023, February 23). Rural hospitals face renewed
financial challenges, especially in states that have not expanded medicaid. KFF.
https://www.kff.org/health-costs/issue-brief/rural-hospitals-face-renewed-financialchallenges-especially-in-states-that-have-not-expanded-medicaid/
Liu, N., Wen, S. W., Manual, D. G., Katherine, W., Bottomley, J., & Walker, M. C. (2010).
Social disparity and the use of intrapartum epidural analgesia in a publicly funded health
care system. American journal of obstetrics and gynecology, 202(3), 273.e1–273.e2738.
https://doi-org.libproxy2.usc.edu/10.1016/j.ajog.2009.10.871
Loggins Clay, S., Griffin, M., & Averhart, W. (2018). Black/White disparities in pregnant
women in the United States: An examination of risk factors associated with Black/White
racial identity. Health & Social Care in the Community, 26(5), 654–663.
https://doi.org/10.1111/hsc.12565
THE DISPARITY IN EPIDURAL ANALGESIA USE FOR BLACK PARTURIENTS 29
Marchi, K. S., Dove, M. S., Heck, K. E., & Fan, C. (2021). The Affordable Care Act and
changes in women's health insurance coverage before, during, and after pregnancy in
California. Public health reports (Washington, D.C. : 1974), 136(1), 70–78. https://doiorg.libproxy2.usc.edu/10.1177/0033354920962798
Meghani S.H., Byun E., & Gallagher R.M. (2012). Time to take stock: A meta-analysis and
systematic review of analgesic treatment disparities for pain in the United States. Pain
Med. 13(2), 150-74. doi: 10.1111/j.1526-4637.2011.01310.x
Oladapo O.T., Tunçalp Ö., Bonet M., Lawrie T.A., Portela A., Downe S., & Gülmezoglu A.M.
(2018). WHO model of intrapartum care for a positive childbirth experience:
Transforming care of women and babies for improved health and wellbeing. BJOG.
125(8), 918-922. doi: 10.1111/1471-0528.15237
Orejuela, F. J., Garcia, T., Green, C., Kilpatrick, C., Guzman, S., & Blackwell, S. (2012).
Exploring factors influencing patient request for epidural analgesia on admission to labor
and delivery in a predominantly Latino population. Journal of immigrant and minority
health, 14(2), 287–291. https://doi-org.libproxy2.usc.edu/10.1007/s10903-011-9440-2
Roberson M.C. (2019). Refusal of epidural anesthesia for labor pain management by African
American parturients: An examination of factors. AANA Journal. 87(4), 299-304.
Rooks J.P. (2012). Labor pain management other than neuraxial: What do we know and where
do we go next? Birth. 39(4), 318-322. doi: 10.1111/birt.12009
Rust G., Nembhard W.N., Nichols M., Omole F., Minor P., Barosso G., & Mayberry R. (2004).
Racial and ethnic disparities in the provision of epidural analgesia to Georgia Medicaid
beneficiaries during labor and delivery. Am J Obstet Gynecol. 191(2), 456-462. doi:
10.1016/j.ajog.2004.03.005
THE DISPARITY IN EPIDURAL ANALGESIA USE FOR BLACK PARTURIENTS 30
Say, L., Chou, D., Gemmill, A., Tuncalp, O., Moller, A. B., Daniels, J., . . . & Alkema, L.
(2014). Global causes of maternal death: a WHO systematic analysis. Lancet Global
Health, 2(6), E323-E333. Retrieved from https://doi.org/10.1016/s2214-109x(14)70227-x
Semega, J., Kollar, M., Creamer, J., Mohanty, A. (2019). Income and Poverty in the United
States. United States Census Bureau. Retrieved from
https://www.census.gov/content/dam/Census/library/publications/2019/demo/p60-
266.pdf
Sheiner, Eyal MD*†; Sheiner, Einat K. MD†; Shoham-Vardi, Ilana PhD†‡; Gurman, Gabriel M.
MD†§; Press, Fernanda MD*†; Mazor, Moshe MD*†; Katz, Miriam MD*†. Predictors of
Recommendation and Acceptance of Intrapartum Epidural Analgesia. Anesthesia &
Analgesia 90(1):p 109-113, January 2000. | DOI: 10.1097/00000539-200001000-00024
Silva M., Halpern S.H. (2010). Epidural analgesia for labor: Current techniques. Local Reg
Anesth. 3, 143-153. doi: 10.2147/LRA.S10237
Singh G.K., Daus G.P., Allender M., Ramey C.T., Martin E.K., Perry C., ... & Vedamuthu I.P.
(2017). Social determinants of health in the United States: Addressing major health
inequality trends for the nation, 1935-2016. International Journal of MCH and AIDS.
6(2), 139-164. doi: 10.21106/ijma.236
Sohn H. (2017) Racial and ethnic disparities in health insurance coverage: Dynamics of gaining
and losing coverage over the life-course. Popul Res Policy Rev. 36(2), 181-201. doi:
10.1007/s11113-016-9416-y
Tangel, V. E., Matthews, K. C., Abramovitz, S. E., & White, R. S. (2020). Racial and ethnic
disparities in severe maternal morbidity and anesthetic techniques for obstetric deliveries:
THE DISPARITY IN EPIDURAL ANALGESIA USE FOR BLACK PARTURIENTS 31
A multi-state analysis, 2007-2014. Journal of clinical anesthesia, 65, 109821. Retrieved
from https://doi.org/10.1016/j.jclinane.2020.109821
Toledo P., Sun J., Grobman W.A., Wong C.A., Feinglass J., & Hasnain-Wynia R. (2012). Racial
and ethnic disparities in neuraxial labor analgesia. Anesthesia Analgesia. 114(1), 172-
178. doi: 10.1213/ANE.0b013e318239dc7c
Toledo P., Sun J., Peralta F., Grobman W.A., Wong C.A., Hasnain-Wynia R. (2013). A
qualitative analysis of parturients' perspectives on neuraxial labor analgesia. International
Journal of Obstetric Anesthesia. 22(2):119-23. doi: 10.1016/j.ijoa.2012.11.003
Traynor A.J., Aragon M., Ghosh D., Choi R.S., Dingmann C., Tran Z.V., & Bucklin B.A.
(2016). Obstetric anesthesia workforce survey: A 30-year update. Anesthesia Analgesia.
122(6):1939-46. doi: 10.1213/ANE.0000000000001204
United States Government Accountability Office. (2022, October 19). Maternal Health:
Outcomes Worsened and Disparities Persisted During the Pandemic.
https://www.gao.gov/assets/gao-23-105871.pdf
United States Census Bureau. (2021). QuickFacts.
https://www.census.gov/quickfacts/geo/chart/US/RHI225221
United States of Agriculture. (2022, March 09). ERS Charts of Note.
https://www.ers.usda.gov/data-products/charts-of-note/charts-of note/?topicId=4e8a0642-
e40d-4299-906e-906bbaaf9e4d
Way, E. A., Carwile, J. L., Ziller, E. C., & Ahrens, K. A. (2022). Out-of-hospital births and
infant mortality in the United States: Effect measure modification by rural maternal
residence. Paediatric and perinatal epidemiology, 36(3), 399–411.
THE DISPARITY IN EPIDURAL ANALGESIA USE FOR BLACK PARTURIENTS 32
Wilson, S. H., Elliott, M. P., Wolf, B. J., & Hebbar, L. (2014). A prospective observational study
of ethnic and racial differences in neuraxial labor analgesia request and pain relief.
Anesthesia and analgesia, 119(1), 105–109.
World Health Organization (2018). WHO recommendations: Intrapartum care for a positive
childbirth experience. Retrieved from
https://apps.who.int/iris/bitstream/handle/10665/260178/9789241550215-eng.pdf
THE DISPARITY IN EPIDURAL ANALGESIA USE FOR BLACK PARTURIENTS 33
Appendix A. PRISMA Flow Diagram
Abstract (if available)
Abstract
Adequate obstetric analgesia increases maternal satisfaction and improves birth outcomes. Despite the popularity of epidural analgesia in labor pain management, in the United States, significant disparities exist in epidural analgesia use among parturients, particularly Blacks. Current literature has yet to identify key factors influencing this racial disparity conclusively. This research study referenced the social determinants of health (SDOH), defined by the U.S. Department of Health and Human Services, to identify the contributing factors to this racial disparity in epidural analgesia use. Using PubMed, Clinical Key, Cochrane, NCBI Bookshelf, and Google Scholar database, an integrative literature review was performed. A total of 10 articles were initially selected, followed by snowball technique to obtain additional articles. The literature review was structured into the five domains of SDOH: economic stability, education access and quality, health care access and quality, neighborhood and built environment, and social and community context. The results uncovered the impact of each SDOH on the disparity of epidural analgesia use among Black parturients.
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Asset Metadata
Creator
Martinez, Elena
(author)
Core Title
The disparity in neuraxial analgesia use for Black parturients: an integrative review
School
Keck School of Medicine
Degree
Doctor of Nurse Anesthesia Practice
Degree Program
Nurse Anesthesiology
Degree Conferral Date
2025-05
Publication Date
11/25/2024
Defense Date
09/11/2024
Publisher
Los Angeles, California
(original),
University of Southern California
(original),
University of Southern California. Libraries
(digital)
Tag
disparity,labor,neuraxial,Obstetrics,social determinants of health
Format
theses
(aat)
Language
English
Contributor
Electronically uploaded by the author
(provenance)
Advisor
Bamgbose, Elizabeth (
committee chair
), Carr, Joshua (
committee member
), McCall, Erica (
committee member
)
Creator Email
eilee@usc.edu,jil9625@gmail.com
Unique identifier
UC11399E4G4
Identifier
etd-MartinezEl-13655.pdf (filename)
Legacy Identifier
etd-MartinezEl-13655
Document Type
Dissertation
Format
theses (aat)
Rights
Martinez, Elena
Internet Media Type
application/pdf
Type
texts
Source
20241202-usctheses-batch-1225
(batch),
University of Southern California
(contributing entity),
University of Southern California Dissertations and Theses
(collection)
Access Conditions
The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the author, as the original true and official version of the work, but does not grant the reader permission to use the work if the desired use is covered by copyright. It is the author, as rights holder, who must provide use permission if such use is covered by copyright.
Repository Name
University of Southern California Digital Library
Repository Location
USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA
Repository Email
cisadmin@lib.usc.edu
Tags
disparity
labor
neuraxial
social determinants of health