COVID-19 pandemic and racial disparities in neuraxial labor analgesia

W e read with great interest the recent article by Torres and colleagues regarding the effect of the COVID-19 pandemic on racial disparities in neuraxial labor analgesia. We congratulate the authors on this important research to identify disparities in neuraxial labor analgesia and the need to understand the drivers of these disparities to better address them. We would like to highlight several points in response. Though the study found that Hispanic and Black or African American patients were less likely to receive labor epidural analgesia compared to White or Caucasian patients, they did not find that the COVID-19 pandemic exacerbated these racial disparities. This is of great interest given that COVID-19 exacerbation of many disparities has been well speculated and documented. Chmielewska et al found that both global maternal and fetal outcomes worsened during the pandemic, with increases in maternal deaths, stillbirths, ruptured ectopic pregnancies, and maternal depression. Of note, there was substantial variation in outcomes between high-income and low-income settings. Though Torres et al evaluated labor epidural utilization rates stratified by race and ethnicity, severe maternal morbidity and maternal mortality are not discussed. Studies have found that racial disparities in severe maternal morbidity are present across categories of anesthetic and analgesic techniques. Additionally, Black women are more likely to receive no analgesia for vaginal deliveries when compared to White women. An evaluation of the pandemic’s impact on severe maternal morbidity and mortality may elucidate exacerbations in racial disparities not reflected by epidural utilization rates alone. It is also important for future studies to include both highand low-income settings to understand how income levels may influence disparities regarding the COVID-19 pandemic. Racial disparities in neuraxial labor analgesia are well documented, and many potential contributory factors have been discussed in the literature. As discussed by Torres et al, personal and cultural differences may influence perceptions and expectations of labor epidural anesthesia. Patient knowledge about neuraxial labor analgesia, including inadequate prenatal education, lack of exposure to educational materials, and lower health literacy, could contribute directly to racial and ethnic disparities in its use. Given the decrease in prenatal care visits during the pandemic, prenatal education and access to educational materials were likely strained. Provider-level factors also likely contribute, including differential assessment of pain, provider bias, and differences in obstetricianvs midwife-led delivery. For example, minority women are more likely to deliver with midwives than nonminority White women, and lower rates of neuraxial analgesia use are seen with nonobstetrician delivery providers. A 2022 qualitative study of community midwives from the greater Seattle area found an increased interest in midwifery services during the COVID-19 pandemic. An increase in the use of midwifery services and avoidance of hospital settings during the pandemic may have exacerbated racial disparities in neuraxial analgesia use, and larger studies are needed to evaluate any potential associated impact. The influence of these patient and provider-level contributory factors along with the effects of systemic racism on health disparities is complex and warrants further attention. A recent systematic review found that nearly 85% of systematic reviews and meta-analyses related to maternal and pregnancy outcomes during the COVID-19 pandemic did not include equity items to account for racial or geographic disparities, and 95% of the studies did not report race at all. The exclusion of racial and geographic disparity considerations from research contributes to widening health disparities nationwide and further exacerbates these issues. Identifying the existence and severity of racial and ethnic disparities in anesthesia care is a key step in beginning to combat them. National studies are needed to investigate the impact of the COVID-19 pandemic on neuraxial anesthesia disparities, with attention to severe maternal morbidity and maternal mortality.