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Ethnic differences in the use of intrapartum epidural analgesia
© Jimenez-Puente et al.; licensee BioMed Central Ltd. 2012
Received: 10 October 2011
Accepted: 20 July 2012
Published: 20 July 2012
Obstetric epidural analgesia (EA) is widely applied, but studies have reported that its use may be less extensive among immigrant women or those from minority ethnic groups. Our aim was to examine whether this was the case in our geographic area, which contains an important immigrant population, and if so, to describe the different components of this phenomenon.
Cross-sectional observational study. Setting: general acute care hospital, located in Marbella, southern Spain. Analysis of computer records of deliveries performed from 2004 to 2010. Comparison of characteristics of deliveries according to the mothers’ geographic origins and of vaginal deliveries noting whether EA was received, using univariate and bivariate statistical analysis and multiple logistic regression (MLR).
A total of 21,034 deliveries were recorded, and 37.4% of these corresponded to immigrant women. EA was provided to 61.1% of the Spanish women and to 51.5% of the immigrants, with important variations according to geographic origin: over 52% of women from other European countries and South America received EA, compared with around 45% of the African women and 37% of the Asian women. These differences persisted in the MLR model after adjusting for the mother's age, type of labor initiation, the weight of the neonate and for single or multiple gestation. With the Spanish patients as the reference category, all the other countries of origin presented lower probabilities of EA use. This was particularly apparent for the patients from Asia (OR 0.38; 95%CI 0.31-0.46), Morocco (OR 0.49; 95%CI 0.43-0.54) and other Africa (OR 0.55; 95%CI 0.37-0.81).
We observed a different use of EA in vaginal deliveries, according to the geographic origin of the women. The explanation for this involves a complex set of factors, depending both on the patient and on the healthcare staff.
Obstetric epidural analgesia (EA) has been shown to be the most effective method for relieving pain in labor. It enables women to better tolerate pain during labor and delivery, without affecting neonatal results, although there seems to be an association between epidural analgesia and instrumental vaginal delivery [1–4].
Relatively few studies have focused on the characteristics of women receiving obstetric EA [5–13]. One significant factor has been identified as that of greater demand for EA by women with a higher socio-economic and/or educational level [5, 8, 13, 14]. Studies carried out in the USA [5, 9, 11], Canada , Israel  and Western Europe [15–17] generally agree that EA is less commonly received by immigrant women and by those from minority ethnic groups. Other studies have examined the association between racial origin and various obstetric results, but without focusing on the use of EA [14–17].
Our catchment area, on the Spanish Mediterranean coast, has undergone considerable economic development in recent decades, mainly based on tourism. Over 30% of the resident population is of immigrant origin, from two main sources: the United Kingdom and other Western European countries, with a socio-economic level similar to or higher than that of the Spanish population; and other areas – Africa (fundamentally, Morocco), South America, Eastern Europe and Asia – with a lower socio-economic level than that of the native Spanish population.
Our aim was to describe the use of EA in deliveries performed at a hospital where the patients are from widely varying geographic areas. A secondary aim was to observe other characteristics of the perinatal assistance received by different ethnic groups, which might influence the use of EA.
This cross-sectional observational study was carried out at the Costa del Sol Hospital (Marbella, southern Spain), which is part of the Spanish public healthcare system and caters for a population of almost 400,000, of whom over 30% are registered foreign residents. Over 70% of the births in this area take place within the hospital. The Costa del Sol Research Ethics Committee approved the study.
We analyzed the computer records of all deliveries performed at the hospital between May 2004 and September 2010 for which data were available on the mother's age, place of residence and country of birth, the gestational age, neonatal birth weight, delivery mode and labor type, and the use or otherwise of EA. The database consulted did not provide reliable information about other variables of interest such as fetal position, parity, the mother’s obstetric background or socio-economic level. The women's countries of origin were grouped into 8 large geographic zones: Spain, United Kingdom, other Western Europe, Eastern Europe, Morocco, other Africa, Central and South America and Asia.
A descriptive analysis was made of all the deliveries recorded, with mean and standard deviation for quantitative variables, and of frequency distribution for the categorical ones. A study was then performed of the relation between the use of EA in vaginal deliveries (excluding cesarean sections) and the mother’s geographic origin, her age (with two cut-off points, at 20 and 35 years), neonatal birth weight (as a quantitative variable) and of single or multiple gestation, using the Student t test for continuous variables and the chi square test for categorical ones. The same analysis was also performed using multiple logistic regression (MLR) with the forced inclusion of the variables.
The level of statistical significance was set at 0.05 and 95% confidence intervals (CI) were calculated for the Odds Ratios (OR). The database was constructed using the dbase IV program and analyzed using R statistical software .
A total of 21,034 deliveries were studied. The mothers’ mean age was 31 years, with a standard deviation (SD) of 5.5 years. 3.4% were aged under 20 years, and 16.9% were aged over 35 years. Mean neonatal weight was 3272 g (SD 522 g), 18.5% of deliveries were induced and 1.6% corresponded to multiple gestations.
Characteristics of deliveries performed, by geographic origin of the mother
Characteristics of the mothers and neonates, by use of intrapartum epidural analgesia in vaginal deliveries
No use of epidural n
Use of epidural n
Bivariate P value
MLR Odds Ratios (95% CI)
Number of deliveries
Birth weight (SD)
Our study highlights the relation between the women's geographic origin and a series of characteristics related to the delivery: percentage of cesarean sections, high risk ages, neonatal birth weight and single/multiple gestation. We also describe the relation between the women's geographic origin and the use of EA in vaginal deliveries, this being more common among the Spanish women than among those from elsewhere, especially Africa and Asia.
Forty two percent of the women gave birth without EA and this percentage rose to 48.5% among women from abroad and to over 50% and 60% among those from Africa and Asia, respectively. Some studies have focused on women's preferences for EA [5–7, 9, 12], others on its recommendation by healthcare staff , while the majority, including our own, on the real use of EA [5, 8, 9, 11, 15–17]. Note that the use of EA depends on the interaction among three groups of factors: the women's preferences and knowledge, the recommendations made to them and the real availability of EA at the moment in question. For example, a study carried out in France reported that the most common reason for not receiving EA was that the delivery took place too quickly (44%), while only in 37% of the cases was this due to the woman's own decision  and another study performed in Canada reported a lower use of EA in women living further away from the hospital .
Our results largely concur with those reported by another study carried out in Spain, in a geographic area where immigration is motivated fundamentally by economic concerns, which described the use of EA in 75% of deliveries to Spanish women, in 68% of those to Latin American women, in 49% of those to women from Eastern Europe and in 52% of those to women from Morocco .
Other studies have identified a greater demand for EA from women with a higher socio-economic or educational background [5, 8, 12–14]. Less information is available about the influence of parity [10, 12–14], residence in rural or urban environments , the woman’s age , labor type , a more traditional mentality [6, 12], concern about the secondary effects of EA  or the couple's preferences . On the other hand, opinions are unanimous that EA is less commonly used among immigrant women and those from minority ethnic groups [8, 9, 11, 12, 15–17].
Less demand for EA by immigrant women.
Healthcare staff are less likely to offer EA to immigrant women:
Reports have described interracial physiological differences in the course of labor and delivery, with shorter durations for black than for white women, and for white than for Asian women . Inter-ethnic differences in pain perception have also been described . The different rate of cesarean sections observed among the different nationalities might provoke selection bias in the application of EA, as our study of the ethnic component was limited to vaginal deliveries. Finally, if immigrant women attend hospital at more advanced phases of labor, this could also discourage the use of EA.
Among other limitations, our study was a cross-sectional one, the design of which did not allow causal relations to be determined between the explanatory and the outcome variables. Moreover, we lacked some adjustment variables that could have been important, such as parity. In this respect, it is well known that primiparous women are more likely to require EA [10, 12, 14] and first generation immigrants are perhaps more likely to be multiparous. The deliveries resolved by cesarean section were excluded from our analysis as it was not possible to distinguish whether a given delivery aided with EA concluded in the performance of a cesarean section or whether on the contrary the cesarean section was performed using EA. We took the patients’ country of birth as an approximation of their ethnic origin, but recognise that some misclassification may have occurred. Finally, the geographic origins of the women were classified into large groups, within each of which there may have been significant heterogeneity.
Studies carried out in different countries generally agree that intrapartum epidural analgesia is less commonly received by immigrant women and by those from minority ethnic groups. In our catchment area, on the Spanish Mediterranean coast, with an important percentage of population of immigrant origin, we too have observed a lower use of epidural analgesia by immigrant women in vaginal deliveries.
Our results highlight the importance of the communication factor, as women from Western European countries with a socioeconomic status similar to that prevailing in Spain have lower rates of use. There also appears to be a socioeconomic component, as women from South America, who speak Spanish, present a lower degree of epidural use although significantly higher than that observed for women from areas that are less economically developed, like Africa and Asia. Specific interventions would be necessary to ensure that the mother’s geographic origin is not a barrier to access to epidural analgesia during labor.
AJP, M.D., Ph.D. is Responsible of the Evaluation Unit in the Costa del Sol Hospital (Marbella, Spain) and researcher of the CIBER Epidemiología y Salud Pública (CIBERESP), Spain. JDS, M.D. is a Resident Physician of the Department of Preventive Medicine in the Virgen de la Victoria Hospital (Málaga, Spain); NBP, B.Math. and FRR, D.Sc. are members of the Research Support Unit of the Hospital Costa del Sol (Marbella, Spain) and researchers of the CIBER Epidemiología y Salud Pública (CIBERESP), Spain; CML, M.D. is Director of the Obstetrics and Gynecology Area of the Costa del Sol Hospital (Marbella, Spain).
We thank Glenn Harding (Alhambra Traducciones) for the professional translation of the paper.
- Anim-Somuah M, Smyth R, Howell C: Epidural versus non-epidural or no analgesia in labor. Cochrane Database Syst Rev. 2005, 4: CD000331.PubMedGoogle Scholar
- Ohel G, Gonen R, Vaida S, Barak S, Gaitini L: Early versus late initiation of epidural analgesia in labor: does it increase the risk of cesarean section? A randomized trial. Am J Obstet Gynecol. 2006, 194: 600-605. 10.1016/j.ajog.2005.10.821.View ArticlePubMedGoogle Scholar
- Eltzschig HK, Lieberman ES, Camann WR: Regional Anesthesia and Analgesia for Labor and Delivery. N Engl J Med. 2003, 348: 319-332. 10.1056/NEJMra021276.View ArticlePubMedGoogle Scholar
- Leighton BL, Halpern SH: The effects of epidural analgesia on labor, maternal, and neonatal outcomes: a systematic review. Am J Obstet Gynecol. 2002, 186 (5 Suppl Nature): S69-S77.PubMedGoogle Scholar
- Toledo P, Sun J, Grobman WA, Wong CA, Feinglass J, Hasnain-Wynia R: Racial and ethnic disparities in neuraxial labor analgesia. Anesth Analg. 2012, 114: 172-178. 10.1213/ANE.0b013e318239dc7c.View ArticlePubMedGoogle Scholar
- Biedma Velazquez L, García de Diego JM, Serrano del Rosal R: Análisis de la no elección de la analgesia epidural durante el trabajo de parto en las mujeres andaluzas: “la buena sufridora”. Rev Soc Esp Dolor. 2010, 17: 3-15.View ArticleGoogle Scholar
- Harkins J, Carvalho B, Evers A, Mehta S, Riley ET: Survey of the Factors Associated with a Woman’s Choice to Have an Epidural for Labor Analgesia. Anesthesiol Res Pract. 2010, pii356789-10.1155/2010/356789.Google Scholar
- Liu N, Wen SW, Manual DG, Katherine W, Bottomley J, Walker MC: Social disparity and the use of intrapartum epidural analgesia in a publicly funded health care system. Am J Obstet Gynecol. 2010, 202: 273.e1-273.e8. 10.1016/j.ajog.2009.10.871.View ArticleGoogle Scholar
- Glance LG, Wissler R, Glantz C, Osler TM, Mukamel DB, Dick AW: Racial differences in the use of epidural analgesia for labor. Anesthesiology. 2007, 106: 19-25. 10.1097/00000542-200701000-00008.View ArticlePubMedGoogle Scholar
- Van den Bussche E, Crombez G, Eccleston C, Sullivan MJ: Why women prefer epidural analgesia during childbirth: the role of beliefs about epidural analgesia and pain catastrophizing. Eur J Pain. 2007, 11: 275-282. 10.1016/j.ejpain.2006.03.002.View ArticlePubMedGoogle Scholar
- Rust G, Nembhard WN, Nichols M, Omole F, Minor P, Barosso G, et al: Racial and ethnic disparities in the provision of epidural analgesia to Georgia Medicaid beneficiaries during labor and delivery. Am J Obstet Gynecol. 2004, 191: 456-462. 10.1016/j.ajog.2004.03.005.View ArticlePubMedGoogle Scholar
- Sheiner E, Sheiner EK, Shoham-Vardi I, Gurman GM, Press F, Mazor M, et al: Predictors of recommendation and acceptance of intrapartum epidural analgesia. Anesth Analg. 2000, 90: 109-113. 10.1097/00000539-200001000-00024.View ArticlePubMedGoogle Scholar
- Stark MA: Exploring Women's Preferences for Labor Epidural Analgesia. J Perinat Educ. 2003, 12: 16-21.PubMedPubMed CentralGoogle Scholar
- Le Ray C, Goffinet F, Palot M, Garel M, Blondel B: Factors associated with the choice of delivery without epidural analgesia in women at low risk in France. Birth. 2008, 35: 171-178. 10.1111/j.1523-536X.2008.00237.x.View ArticlePubMedGoogle Scholar
- García-García J, Pardo-Serrano C, Hernández-Martínez A, Lorenzo-Díaz M, Gil-González D: Diferencias obstétricas y neonatales entre mujeres autóctonas e inmigrantes. Prog Obstet Ginecol. 2008, 51: 53-62.View ArticleGoogle Scholar
- Manzanares Galán S, López Gallego MF, Gómez Hernández T, MartínezGarcía N, Montoya Ventoso F: Resultados del mal control del embarazo en la población inmigrante. Prog Obstet Ginecol. 2008, 51: 215-223. 10.1016/S0304-5013(08)71079-3.View ArticleGoogle Scholar
- David M, Pachaly J, Vetter K: Perinatal outcome in Berlin (Germany) among immigrants from Turkey. Arch Gynecol Obstet. 2006, 274: 271-278. 10.1007/s00404-006-0182-7.View ArticlePubMedGoogle Scholar
- R Development Core Team: R: A language and environment for statistical computing. 2010, R Foundation for Statistical Computing, Vienna, Austria, http://www.R-project.org/.Google Scholar
- Grzybowski S, Stroll K, Komelsen J: Distance matters: a population based study examining access to maternity services for rural women. BMC Health Serv Res. 2011, 11: 147-10.1186/1472-6963-11-147.View ArticlePubMedPubMed CentralGoogle Scholar
- Kirby JB, Taliaferro G, Zuvekas SH: Explaining racial and ethnic disparities in health care. Med Care. 2006, 44 (5 Suppl): I64-I72.PubMedGoogle Scholar
- Manly J: Deconstructing race and ethnicity: implications for measurement of health outcomes. Med Care. 2006, 44 (Suppl 3): S10-S16. 10.1097/01.mlr.0000245427.22788.be.View ArticlePubMedGoogle Scholar
- Garrido-Cumbrera M, Borrell C, Palència L, Espelt A, Rodríguez-Sanz M, Pasarín MI, et al: Social class inequalities in the utilization of health care and preventive services in Spain, a country with a national health system. Int J Health Serv. 2010, 40: 525-542. 10.2190/HS.40.3.h.View ArticlePubMedGoogle Scholar
- Scotland GS, McNamee P, Cheyne H, Hundley V, Barnett C: Women's preferences for aspects of labor management: results from a discrete choice experiment. Birth. 2011, 38: 36-46. 10.1111/j.1523-536X.2010.00447.x.View ArticlePubMedGoogle Scholar
- Christiaens W, Van De Velde S, Bracke P: Pain acceptance and personal control in pain relief in two maternity care models: a cross-national comparison of Belgium and the Netherlands. BMC Health Serv Res. 2010, 10: 268-10.1186/1472-6963-10-268.View ArticlePubMedPubMed CentralGoogle Scholar
- Wennberg J: Time to Tackle Unwarranted Variations in Practice. BMJ. 2011, 342: d1513-10.1136/bmj.d1513.View ArticleGoogle Scholar
- Eisenberg JM: The State of Research About Physicians´ Practice Patterns. Med Care. 2002, 40: 1016-1035. 10.1097/00005650-200211000-00004.View ArticlePubMedGoogle Scholar
- Wennberg J, Gittelsohn A: Small area variations in health care delivery. Science. 1973, 182: 1102-1108. 10.1126/science.182.4117.1102.View ArticlePubMedGoogle Scholar
- Snipes SA, Sellers SL, Tafawa AO, Cooper LA, Fields JC, BonhamIs VL: Is Race Medically Relevant? A Qualitative Study of Physicians' Attitudes about the Role of Race in Treatment Decision-Making. BMC Health Serv Res. 2011, 11: 183-10.1186/1472-6963-11-183.View ArticlePubMedPubMed CentralGoogle Scholar
- Strumpf EC: Racial/Ethnic Disparities in Primary Care. The Role of Physician-Patient Concordance. Med Care. 2011, 49: 496-503. 10.1097/MLR.0b013e31820fbee4.View ArticlePubMedGoogle Scholar
- Green CR, Anderson KO, Baker TA, Campbell LC, Decker S, Fillingim RB, et al: The unequal burden of pain: confronting racial and ethnic disparities in pain. Pain Med. 2003, 4: 277-294. 10.1046/j.1526-4637.2003.03034.x.View ArticlePubMedGoogle Scholar
- Weisse CS, Sorum PC, Sanders KN, Syat BL: Do gender and race affect decisions about pain management?. J Gen Intern Med. 2001, 16: 211-217. 10.1046/j.1525-1497.2001.016004211.x.View ArticlePubMedPubMed CentralGoogle Scholar
- Greenberg MB, Cheng YW, Hopkins LM, et al: Are there ethnic differences in the length of labor?. Am J Obstet Gynecol. 2006, 195: 743-748. 10.1016/j.ajog.2006.06.016.View ArticlePubMedGoogle Scholar
- The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6963/12/207/prepub
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