Disparities in headache management for obstetric patients

Significant racial and ethnic disparities exist in the management of postdural puncture headache with an epidural blood patch among obstetric patients, according to a New York State study published in JAMA Network Open.¹

Compared to White patients, Hispanic, Black and patients of other race and ethnicity were significantly less likely to be treated with an epidural blood patch (EBP), and the timing of the EBP after hospital admission was significantly longer. Both the lack of an EBP and delayed treatment may be linked to long-term adverse effects.

“Although we were aware of the well-documented racial and ethnic disparities in maternal health outcomes, there has been limited research on disparities specifically related to obstetric anesthesia care,” said principal investigator Allison Lee, an associate professor of anesthesiology at Columbia University Irving Medical Center in New York City.

In contrast to non-Hispanic White women, minority women have lower labor epidural rates—despite it being the most effective modality for pain relief—according to Lee, along with higher rates of general anesthesia for cesarean deliveries, which is associated with greater risks and complications for the mother.

“Worse management of pain after cesarean delivery also occurs in minority women,” Lee told Contemporary OB/GYN®.

Due to the importance of effective management of postdural puncture headache and growing evidence of complications if untreated, “we hypothesized that similar patterns of inferior management for this type of headache in minority women would be observed,” Lee said.

The cross-sectional study used New York state hospital discharge records from January 1998 to December 2016. Of the 8921 mothers, aged 15 to 49 (mean age 30), with a postdural puncture headache after neuraxial analgesia or anesthesia for childbirth, 55.6% were White, 14.6% Hispanic, 11.5% Black and 15.2% other race and ethnicity.

Of the cohort, 47.0% were managed with an EBP: 53.4% of White patients vs. 41.7% of Hispanic patients, 35.7% Black patients and 35.2% of patients of another race and ethnicity.

In addition, timing of EBP was a median 2 days after hospital admission for White patients compared to 3 days for Hispanic patients, Black patients and patients of another race and ethnicity (P < 0.001).

“Our hypothesis was proven,” Lee said. “However, we were encouraged that after adjusting for patient and hospital characteristics, there was no difference in the EBP rate among Hispanic patients compared to White patients. But the EBP rate was 20% lower for Black patients and 15% lower for patients of other races and ethnicities.”

Lee noted that anesthesia providers must systematically assess for headache postpartum and intervene quickly. Similarly, other peripartum care providers, including obs and nurses, should be trained for the signs and symptoms of postdural puncture headache and promptly communicate any concerns to the anesthesia providers.

“We encourage all institutions to provide training in implicit bias to clinicians; to review their anesthesia-related outcomes based on race and ethnicity, including perhaps implementing ‘disparities dashboards’; and to provide high-quality information in patients’ preferred language,” said Lee, an officer of diversity, equity and inclusion for the Department of Anesthesiology at Columbia University Irving Medical Center.

Researchers should also evaluate interventions that address disparities, to determine the most effective solutions.

“To better understand these issues, we need more anesthesia-related outcomes collected on a national level to better quantify disparities and initiate corrective measures,” Lee said.

Reference

1. Lee A, Guglielminotti J, Janvier A-S, et al.Racial and ethnic disparities in the management of postdural puncture headache with epidural blood patch for obstetric patients in New York State. JAMA Netw Open. Published online April 21, 2022. doi:10.1001/jamanetworkopen.2022.8520