Race, Ethnicity, and Insurance as Determinants of Epidural Use: Analysis of a National Sample Survey

Martin J. Atherton, DRPH, MPH; Veronica Decarolis Feeg, PhD, RN, FAAN; Azza Fouad El-Adham, MSN


Nurs Econ. 2004;22(1) 

In This Article

Literature Review

Lowe (2002) defined childbirth pain as a natural phenomenon that occurs due to subjective, multidimensional responses to sensory stimuli during labor and delivery. It has a significant physiologic component and is mediated by the conditions of the mother and child, and the psychosocial context of the delivery. The woman's personal characteristics include medical and obstetrical conditions, combined with their situations to determine their responses to the pain and requests for anesthesia. Several variables correlate with severity of labor pain including parity, maternal age, and socio-economic status (Melzack, Taenzer, Feldman, & Kinch, 1981; Melzack et al., 1984).

Use of epidural anesthesia derives from a complex dynamic that exists between mother, obstetrician, and anesthesia provider. Although epidural is superior to other medical interventions in several aspects, the choice to use epidural still remains a matter between patient and doctor preference. Even in a study where mothers were well prepared for delivery through childbirth training, 81% still requested and received epidural anesthesia, which should be viewed as a compatible, complementary procedure (Melzack et al., 1981).

Epidural Use

There have been numerous studies on epidural use but few that focused specifically on factors that are person based, such as race or ethnicity, and economically based, such as insurance. Use of epidural analgesia for pain relief during labor and delivery is comparable to its use for relief of pain during surgical operations, because of the severity of childbirth pain. Epidural anesthesia is more recommended during childbirth, because it provides better pain relief than other medications such as intravenous analgesia, and has fewer unfavorable side effects. This improvement is estimated to be 40 mm on a 100 mm pain scale during the first stage of labor in a meta-analysis (Huang & Macario, 2002). Epidural provides significantly better pain relief in labor than meperidine (Ramin et al., 1995), and provides a sensory block of the pain experience that is more effective (Huang & Macario, 2002). Epidural anaesthesia is associated with a high degree of satisfaction among patients because it does not cause impairment of balance and can give the woman more mobility than other methods of childbirth pain medications (Comparative Obstetric Mobile Epidural Trial Study Group, 2002).

Race, Insurance, and Pain Management

Evidence of health disparities in the United States has prompted interest in crosscultural research to compare minority and nonminority groups on variables related to access and service. The variables of race and ethnicity are used to compare person characteristics that affect medical treatments or conditions to suggest interactive or discriminatory situations such as health care access (IOM , 2002), or to delineate fundamental biological explanations for physiologic outcomes such as in drug studies (Levy & Hawks, 1999).

Culture has been a known influence in the expression and perception of pain and a mediator in the inference of pain to others (Edwards & Fillingim, 1999). Because pain is a subjective experience, social scientists and clinical researchers have reported relationships of culture with a variety of pain responses and behaviors (Weber, 1996). Early studies demonstrating that pain threshold related to radiant heat techniques differed for African-Americans prompted a study by Reid (1992), where she analyzed pain, personality, and ethnicity measuring responses to immersion of an extremity in a cold-water bath. She found a significant racial difference in pain tolerance, with whites showing a higher pain tolerance than African-Americans.

Ethnicity and culture may be important in determining how the impact of pain is treated. Davitz and Davitz (1981) analyzed nurses' perception of their patients' pain. The researchers found that nurses from different cultures differed in their inferences of patients' physical pain and psychological distress. Among racial and ethnic minorities, variability in pain management may be a result of the provider perception of the pain and response to his or her estimate of the pain severity (Todd, Lee, & Hoffman, 1994). Studies also suggest that pain is relatively undertreated in racially and ethnically diverse populations (Cleeland et al., 1994; Cleeland, Gonin, Baez, Loehrer, & Pandya, 1997; Green, Baker, Sato, Washington, & Smith, 2002).

Childbirth pain takes on additional considerations in the dynamic of the person experiencing it and provider interpreting it. "Pain in labor and childbirth is expected by some women in all societies but may be interpreted, perceived and responded to differently" (Kay, 1982, p. 17). The dramatic rise in the use of epidural analgesia has come from women's requests or physician choice because it is the most effective method of pain relief (Thorp et al., 1993). Physician choice to use epidurals takes into account the clinical indication and potential known complications, or simply the belief that "maternal request is a sufficient justification for pain relief during labor" (Thorp & Breedlove, 1996, p. 81). However, cost is likely to play a role in the decision in a managed care environment.

In the study by Obst et al. (2001), health insurance and the likelihood of receiving epidural procedures among a large sample of singleton live births suggested that although there were differences by race, the strongest determinant of anesthesia remained insurance type. The study analyzed records of 121,351 births in New York during 1992, controlling for ethnicity, educational status, and facility-specific factors. The study found that African-American women had more than a 44.6% probability of receiving no anesthesia for vaginal birth compared with 23.5% of Caucasian women. Considerable variability, however, was noted in the use of either no anesthesia or epidural anesthesia depending on the type of maternal health insurance. While 8.9% of mothers with Medicaid coverage and 8.2% of mothers categorized as self-pay received an epidural, 18.1% and 21.3%, respectively, of mothers with HMO and private coverage received this pain control technique. Mothers enrolled in Medicaid were generally younger, less educated, and more likely to be African American than mothers covered by other sources of insurance.

In a survey by Johnson and Rosenfeld (1995), the authors stated that the introduction of Medicaid service in Tennessee resulted in an immediate and significant decrease in the epidural anesthesia rate in the population. Since most parturients describe their pain as severe and intolerable and request analgesia in labor, it is inappropriate that financing issues should play a role in providing pain relief.

Whether racial or ethnic characteristics influence preference of physician use or interact with insurance coverage is still unknown. Recent reports suggest that epidural block is being denied to women with Medicaid coverage. In some instances, patients have been denied epidural anesthesia for lack of prepayment. In other situations, Medicaid patients have been required to pay in advance for this pain technique (Pear, 1999). These allegations have not been substantiated, but remain a potential source of policy and practice concerns for health care providers and patients.

In this study the contributions of race, ethnicity, and economic factors were measured in the model as potential determinants of epidural use during delivery. The data source provides a large population-based sample that can be refined to measure race and insurance variables while controlling for extraneous, potentially confounding conditions of mother, child, and/or place of delivery.