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The numbers are irrefutable — Black women are three times more likely than white, Asian and Hispanic women to die during or immediately after pregnancy, according to the CDC. The California Department of Public Health reports Black mothers account for only 5 percent of pregnancies in the state but make up 21 percent of pregnancy-related deaths. Investigations determine that more than half of these deaths are preventable.
The status quo is unacceptable — overall maternal mortality consistently ranks among the top causes of death among women ages 20 to 44 in the United States, and the rate has steadily increased since the 1990s. The specialty of anesthesiology has been working to reduce maternal morbidity and mortality through best practices and use of quality metrics. In April, we recognized Black Maternal Health Week, a week of awareness, activism and community-building aimed at improving the perinatal health of Black women. It is important to highlight that the health care community must continue to prioritize reducing Black maternal mortality and adopt real strategies for improvement.
Anesthesiologists are integral to the safe provision of modern obstetric care, delivery of anesthesia, and labor and delivery-related surgeries. As such, we are following strategies for obstetric anesthesia that include quality metrics aimed at improving the quality and safety of care for all patients, regardless of race.
When looking specifically at reducing mortality and morbidity, the first strategy is to use epidurals (neuraxial anesthesia) for pain relief during labor and especially in higher risk laboring women to help avoid general anesthesia, when possible, especially during cesarean delivery. That’s because there is a higher risk of complications after general anesthesia. But research shows that more Black women were administered general anesthesia for cesarean procedures than their white counterparts, furthering the racial equity divide in maternal health. We need to continue the campaign to educate patients that epidurals are safe and effective, as some minority communities have higher rates of misinformation or reluctance to use epidurals.
The second strategy is to use prophylactic medication to try to prevent low blood pressure during cesarean procedures. Studies show that Black women are more likely to have comorbidities like hypertension that increase the likelihood of cesarean deliveries, so extra precautions are vital to safe delivery for mother and child.
It’s also important to look at pain management through the lens of the opioid epidemic. Studies show that 1 in 300 women become addicted to opioids post-delivery. This is preventable through better pain management during delivery and C-sections, and through education of both providers and patients regarding optimal opioid prescribing practices. Reducing in-hospital opioid use and the amount of opioids prescribed after discharge following childbirth is a key strategy for optimal care of mothers and breastfeeding infants.
Use of standardized best practices known as “enhanced recovery” which utilizes a mix of medications that include acetaminophen and an anti-inflammatory like ibuprofen after a C-section can help reduce pain and opioid requirements.
Another strategy sounds simple: responsiveness and attention to a patient’s needs. Black women across the country have reported medical mistrust and the feeling of not being heard or having their pain taken seriously by medical providers. Managing pain safely and effectively is central to quality of care, including checking on the quality of pain relief and being prepared for labor epidural replacements. Replacing an inadequate labor epidural is an important quality metric since a dysfunctional epidural catheter is associated with higher pain scores, lower maternal satisfaction, and greater use of general anesthesia for cesarean delivery. Tailoring care to a patient’s needs and having a flexible approach to anesthesia will not only improve satisfaction, but also will demonstrate to patients, especially patients of color, that the practitioner is being responsive to their health and care experience.
Another key strategy to improving Black maternal health outcomes is using a system to monitor and track the emergence of headaches following anesthesia. The cause is often a complication known as an unintentional dural puncture, which occurs when the membrane that surrounds the spinal cord is punctured by the epidural needle. Skilled health care practitioners can reduce this risk by using certain techniques while administering the anesthesia, and by tracking any headache symptoms and treating with an epidural blood patch if needed.
Anesthesiologists, and all medical professionals, should approach all aspects of patient care with compassion, knowledge and skill. We must recognize the inequities that persist in the health care system and use quality metrics and purposeful actions to improve Black maternal health. The current status quo of maternal morbidity and mortality rates for the Black community is unacceptable. Practitioners must continue working towards quality improvements for better patient health. Anesthesiologists are taking a proactive role in this mission.
Dr. Mark Zakowski has worked as an obstetric anesthesiologist at Cedars-Sinai Medical Center in Los Angeles and is chair of the American Society of Anesthesiologists Committee on Obstetric Anesthesia.