Investigating disparity in labor epidural analgesia management in black vs. white women: a retrospective case-control study (2018-2022)

Background: Disparities in labor epidural analgesia (LEA) management could reduce maternal satisfaction and increase risk. We compared times from the first administration of breakthrough pain medication (top-up) to LEA replacement to evaluate disparities across race. Methods: In this retrospective cohort study (01-01-2018 to 12-31-2022), all patients with LEA and maternal race/ ethnicity of non-Hispanic White or Black were eligible. Patients with a scheduled cesarean delivery, previous back instrumentation, or maternal age < 18 were excluded. We used a Cox Proportional Hazards model to evaluate our primary outcome. Predefined top-up medications given >= 60 minutes from initial LEA placement and before replacement were valid. Any replacement >= 60 minutes from the initial LEA was valid. We also studied secondary outcomes incidence of epidural replacement and postoperative patient satisfaction. Results: There were 11,168 total patients receiving LEA, with 479 (5.5%) replacements in White patients and 127 (5.0%) in Black patients. There were 387 (3.5%) LEAs with a top-up followed by replacement within 24 hours. After adjusting for confounders, no association was detected between race and LEA management (Hazard Ratio 0.82; 95% CI 0.63, 1.06; P = 0.13). We failed to detect an association between patient race and the incidence of replacement (P = 0.23). We found that race (P = 0.02) and LEA replacement (P < 0.001) were associated with increased odds of lower postpartum satisfaction. Conclusions: We didn't detect disparity in treatment at our institution with standardized LEA management protocols. However, Black women and those with LEA replacements were less satisfied. Future studies should evaluate the generalizability and explore interventions that improve patient satisfaction.