During an emergency cesarean delivery, communication, clinical expertise, and collaboration are imperative for the multidisciplinary team. In that moment, there is nothing more crucial to the well-being of the patient than the dyad of an obstetrician and anesthesiologist. Being tasked with the surgical and anesthetic responsibility to ensure the health and safety of the mother and the fetus is a stressful, critically important phenomenon that happens in ORs every day. In the obstetrical domain, we have witnessed some highly distressing inequities in health care delivery. This is a pressing issue, but one must realize that inequities are not unique to the birthing process, nor do the solutions lie in this environment. Maternal and child health care gaps are broad and encompass disparities in access, quality, and outcomes of health care services. This leads to unequal treatment and poorer prognosis in certain populations. We aim to explore the efforts made to understand and address inequity in health care delivery, with a specific focus on the field of maternity care. By examining the existing plans and initiatives, we gain insight into the progress made and the challenges that lie ahead in achieving equity in obstetric health care delivery.
What we know
In 2021, non-Hispanic Black women had a maternal mortality rate that was 2.6 times the rate for non-Hispanic White women – 69.9 deaths versus 26.6 deaths per 100,000 live births (asamonitor.pub/3FvbfeD). There is an alarming disparity in the rate of preterm birth as well; one large review found that Black women have a twofold increased risk over White women (Am J Perinatol 2013;30:433-50). For many years, underlying factors such as genetics and epigenetics, environmental exposures, and individual microbiome differences were purported to contribute to these differences. However, it has become increasingly apparent that maternal and infant health disparities reflect broader underlying social and economic inequities, often rooted in the stressors of racism and discrimination (Am J Public Health 2006;96:826-33; Am J Perinatol 2013;30:433-50). Of note, the weathering hypothesis states that “chronic exposure to social and economic disadvantage leads to accelerated decline in physical health outcomes and could partially explain racial disparities in a wide array of health conditions” (Ann Epidemiol 2019;33:1-18.e3).
There is a complex interplay of social, economic, and systemic factors that contribute to the racial disparities in maternal and infant health in the U.S. Socioeconomic status, race, ethnicity, gender, geographic location, and cultural beliefs significantly impact access to health care services and the quality of care received. Understanding these disparities is crucial to developing effective strategies for achieving equity in health care. Factors such as inadequate access to prenatal care, limited availability of obstetric services in underserved areas, and implicit biases in health care providers are exacerbating. Similarly, in anesthesiology, access to pain management and anesthesia services may be unequal due to socioeconomic factors, racial biases, and geographic disparities. It is through the interplay of these two specialties that we can see the culmination of population-based health care inequity at the vulnerable time of childbirth. From the anesthetic standpoint, we know that both racial and ethnic minority parturients experience lower use of neuraxial analgesia for labor pain management, higher use of general anesthesia for cesarean delivery, and lower quality of peripartum pain management compared with non-Hispanic White women counterparts (Ann Epidemiol 2019;33:1-18.e3).
Given the urgency of addressing inequity in obstetric care, various initiatives have been implemented to improve access and outcomes. One notable effort is the expansion of Medicaid eligibility, which has increased access to prenatal care for low-income women. This is a significant advancement as many women across the U.S. use this method of insurance coverage. For example, as of 2021 in Florida, 45.5% of all pregnant women used Medicaid services (asamonitor.pub/3F3V0Es). One study showed Medicaid expansion was associated with lowering maternal mortality by 7.01 maternal deaths per 100,000 live births relative to states that did not have Medicaid expansion (Womens Health Issues 2020;30:147-52). Most maternal mortality occurs during the postpartum period. Therefore, extending coverage beyond the initial six- to eight-week postpartum period could be life-saving.
Additionally, programs like the Maternal Mortality Review Committees (MMRCs) have been established to investigate maternal deaths and identify opportunities for improvement. These state-based committees help identify disparities in care, leading to targeted interventions and policy changes through guidance and governance from state health departments and the Centers for Disease Control and Prevention (CDC). Through rigorous review and timely, constructive, personalized feedback, better adherence to national standards of care and enhanced information dissemination can be achieved.
In addition, the implementation of culturally competent care models has shown promise in reducing disparities in obstetric outcomes. These models involve understanding and respecting diverse cultural beliefs and practices, offer language services, and provide patient-centered care to improve patient-provider communication and trust. The level of engagement extends past the obstetrician and the anesthesiologist, however, since every interaction a pregnant patient receives throughout her antepartum, intrapartum, and postpartum care can play a vital role in her safety. As we consider the implications of implicit bias and racism in our delivery of care during this crucial encounter, it is imperative that, rather than reducing it to individualism, we focus on all the very purposeful and structural norms that can create a racist or biased interaction.
Inequity in anesthesiology care of the parturient
Inequity in anesthesiology care has gained attention with an emphasis on reducing disparities in pain management and access to anesthesia services in obstetric patients. Research has highlighted disparities in pain assessment and treatment, with racial and ethnic minorities often receiving suboptimal pain management. Recognizing these facts, efforts have been made to increase awareness among health care providers about biases and to provide education on culturally sensitive pain management.
Physician prejudice toward patients and the notion that racism could interfere with health care delivery and lead to inferior treatment of pain, while profoundly distressing, has been extensively documented – “a rhetoric of exculpation can only be counterproductive” (Ann Epidemiol 2019;33:1-18.e3).
Moreover, initiatives such as enhancing diversity in the anesthesiology workforce have been pursued to mitigate disparities. Increasing the number of underrepresented minorities in the medical field can help bridge cultural and linguistic gaps, improve patient-provider communication, and foster trust.
Efforts to remove “the color line” as a barrier to equitable care continue
Several plans and policies have been developed to achieve equity in health care delivery. The Affordable Care Act (ACA) in the U.S. aimed to increase access to health care services, reduce disparities, and improve quality of care. Specifically, it expanded insurance coverage, prohibited insurance discrimination based on preexisting conditions, and emphasized preventive care.
In addition, health care institutions have implemented quality improvement initiatives focused on reducing disparities. These initiatives involve data collection, analysis, and direct feedback to physicians. By monitoring and benchmarking performance, institutions can develop targeted interventions to improve outcomes. One initiative in our state is the Florida Perinatal Quality Collaborative Postpartum Access & Continuity of Care Initiative. This program’s purpose is to “work with providers, hospitals, and other stakeholders to improve maternal health through hospital facilitated continuum of postpartum care by arranging and providing timely, and risk-appropriate, coordinated care and services” (asamonitor.pub/3tseKPq).
Efforts to understand and address inequity in health care delivery, specifically in obstetrics and obstetric anesthesia care, have gained momentum in recent years. Policies, programs, and initiatives have been developed to increase access, improve quality, and reduce disparities. However, challenges such as implicit biases, socioeconomic factors, and geographic disparities persist. Continued research, advocacy, and collaboration among health care providers, policymakers, and communities are essential to achieving equity in health care and ensuring that every individual receives high-quality care regardless of their background.