Commentary — November 2016
By Estevan A. Apodaca, MD, and Swati B. Avashia, MD
Tex Med. 2016;112(11):17-18.
During my time on labor and delivery, I noticed a concerning trend: Most English-speaking patients received epidural anesthesia while most Spanish-speaking patients did not. This was not due to a lack of resources, staff, or ability to pay since epidural anesthesia is accessible for all laboring patients. It was due to a lack of effort to educate a patient population on the risks and benefits of this commonly used pain control method and an underlying belief that not doing so is acceptable practice.
My concerns began when I admitted a Spanish-speaking patient in labor. She had never had an epidural in her previous deliveries, but after I explained the risks and benefits to her in Spanish, she concluded that she wanted an epidural. I counseled her to tell her nurse when she was ready for the epidural based on her pain level. Hours later when the patient was ready to push, she asked if the epidural was coming. I asked the nurse what happened, and she said the patient had not needed an epidural in the past and assumed she did not want one now. I was dismayed that the patient would suffer avoidable labor pain.
Through this experience, I realized many of our pregnant Spanish-speaking patients are enduring avoidable labor pain due to inadequate information. This disparity, although not life-threatening, is part of our long history in health care of providing inferior care to minority and marginalized patients.
It is well-established in the literature that ethnic disparities exist in labor pain management. A 2004 study published in the American Journal of Obstetrics and Gynecology cites reasons that include insurance status, education, cultural differences in pain perception during childbirth, mistrust of health care professionals, and over-exaggerated rates of side effects from epidural anesthesia. However, the study shows ethnicity remains a significant predictor of epidural anesthesia use, independent of other factors. A 2014 study published in the International Journal of Obstetric Anesthesia found Hispanic patients who speak Spanish as their preferred language and who lack a high school education had lower rates of epidural anesthesia.
Many myths prevail in patients declining epidural anesthesia, particularly the risk of chronic back pain, paralysis, and neonatal effects, even though research consistently demonstrates epidurals are safe for mothers and newborns. These findings are consistent with the research showing lower education attainment and speaking a foreign language decrease epidural acceptance. The increased understanding by English-speaking patients of the risks and benefits of epidural anesthesia may be contributing to acceptance and use.
At this time, there are little data on whether physicians, health care providers, and institutions recognize disparities in epidural anesthesia use as a concern or have a process to ensure adequate patient education about epidurals in Spanish-speaking populations. Furthermore, the impact of culturally appropriate epidural anesthesia education among Spanish-speaking populations hasn't been well studied. At this point, we know the disparity in pain management in labor exists, but we haven't taken the next step to do something to address it.
Several steps can be taken to improve what is likely a disparity in information rather than a disparity due to cultural preferences. First, medical establishments should have a process to measure disparities in epidural use and assess barriers to education regarding epidural anesthesia. Second, training institutions should teach students and residents about health care disparities and raise awareness about root causes, such as language and cultural stereotypes. Third, we need to expand the use of evidence-based educational materials that improve informed consent with regard to epidural anesthesia in Spanish-speaking patients. These materials should be implemented in a consistent way to provide adequate time to address and answer questions regarding pain management during labor.
The goal is not to increase the rates of epidural use, only to ensure Spanish-speaking patients have the same opportunity as English-speaking patients to make an informed decision when it comes to controlling their labor pain.
Estevan A. Apodaca, MD, is a family medicine resident at The University of Texas at Austin Dell Medical School.
Swati B. Avashia, MD, is an assistant professor of medicine in the family medicine residency program at Dell Medical School.
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