Medical records show that women of color may experience unequal treatment for pain relief after cesarean childbirth, according to a new retrospective study from researchers at UNC-Chapel Hill.

Johnson

The results highlight the need for continued efforts to undo biases in medical care. Many such efforts – including standardized pain management procedures adopted in 2016 for all patients undergoing a cesarean section – have been put in place at the UNC Medical Center, the UNC School of Medicine, as well as initiatives across the UNC Health Care system.

An analysis of data collected from records of women undergoing cesarean section at N.C. Women’s Hospital between 2014 and 2016 shows that, even though black and Hispanic women reported higher pain scores than white and Asian women, they received fewer pain assessments and lower doses of all pain medication, including both NSAIDs and opiates.

Jasmine Johnson, MD, a fellow in the Division of Maternal-Fetal Medicine at UNC’s Department of Obstetrics and Gynecology, is lead author of “Racial and Ethnic Inequities in Postpartum Pain Evaluation and Management,” which was published online Nov. 6, 2019, in Obstetrics and Gynecology.

Stuebe

Though research shows that differences in pain treatment among black and white patients are widely reported in healthcare settings, few have examined the disparity in women following childbirth.

“This study is one of the first to look at pain management disparities in the postpartum population,” Johnson said. “Although it can be uncomfortable to discuss at times, in order to combat implicit bias, we have to first acknowledge that it exists.”

The researchers note that the data they reviewed did not account for details such as patient beliefs about expression of pain, patient preferences on pain medication or any beliefs and potential biases among health care providers.

“In the context of racial inequities in severe maternal morbidity and mortality, these results are especially concerning,” said co-author Alison Stuebe, MD, MSc, professor of obstetrics and gynecology at the UNC School of Medicine. “Because we were relying on medical records, we don’t know whether our results reflect differences in the patients’ requests for assistance or any differences in how staff responded to requests.”

Despite this limitation, the researchers found it concerning that black women had the highest pain scores and experienced fewer pain assessments and less pain medication. Stuebe said that unpacking these nuances will be a central part of a recently funded project to reengineer postnatal unit care.

Researchers analyzed data from 1,701 women who had a cesarean section between July 1, 2014, and June 30, 2016 at N.C. Women’s Hospital. During two different 24-hour periods, severe pain (noted as between 7 and 10 or greater on the pain scale) was more common among black (28%) and Hispanic (22%) women than among women who identified as white (20%) or Asian (15%).

These differences could not be explained by clinical factors associated with postoperative pain control – such as advanced age, weight or surgical complications – suggesting that how providers treat women from different races may contribute to inequities in postpartum care.

“We all have biases – and our biases are necessary to function in the world,” said Johnson, who co-chairs the Diversity Task Force for the OB-GYN department. “We need to acknowledge these biases and take proactive steps to undo systemic racism.”

Racial disparities in health outcomes for pregnant women, including higher rates of maternal morbidity and mortality among black women and infants, are well documented. These differences in health outcomes persist even in studies that are adjusted for sociodemographic

factors such as insurance coverage, income and education. The persistence of such health disparities suggests that systemic racism, through which patients of different races receive different health care services, contributes to inequitable outcomes for patients of color.

The OB-GYN department currently includes a diversity and inclusion training requirement for residents and faculty, which can be fulfilled by completing a number of workshops on unconscious bias, equity in teaching, Safe Zone Training (concerning sexual orientation, gender identity and gender expression) and other related events. UNC Hospitals has also asked all employees to participate in at least one activity related to creating an equitable and inclusive environment for employees, patients and visitors in the current academic year.

In 2016, the hospital also standardized pain management procedures for all patients undergoing a cesarean section, with the anesthesiologist making a standing order for NSAIDs and Tylenol, and oxycodone for breakthrough pain.

Johnson said she is hopeful about the solutions she sees taking place as UNC’s School of Medicine works to promote a culture that celebrates diversity and inclusion. The researchers are currently engaged in a follow-up project is underway to assess the extent to which these changes have eliminated the inequities seen in the current study.

“In the years since this data was collected, we have standardized our pain management for postpartum patients, and our department and the wider hospital system have made steps forward in prioritizing implicit bias education and training for its providers and staff,” Johnson said.