Non-English Speakers Get Less Care for C-Section Pain

Pain assessments and medications received after a cesarean delivery were lower among women whose first language was not English, according to a retrospective study.

While these women had similar oxycodone therapeutic equivalent (OTE) doses within 24 hours of a C-section compared to women whose first language was English, OTEs at 24 to 48 hours were significantly lower (2 vs 4, respectively; P=0.03), reported Alison Wiles, MD, of Mount Sinai South Nassau Hospital in Oceanside, New York.

And nonsteroidal anti-inflammatory drug (NSAID) administration was lower compared with patients whose first language was English, during both time periods:

• 0-24 hours: 1 vs 2 doses, respectively (P=0.03)
• 24-48 hours: 2 vs 3 doses (P=0.03)

Additionally, Black women received the least amount of NSAID doses between 24 and 48 hours after delivery, but the highest amount of OTEs, Wiles said in a presentation at the American College of Obstetricians and Gynecologists (ACOG) virtual meeting.

"Non-English speaking patients received fewer pain assessments, as well as fewer NSAID and OTE doses, which may indicate language as a barrier for equitable pain management in the postpartum period," Wiles stated. She added that the reduction of NSAIDs administered to Black women was significant, as there was not a clinically meaningful difference in pain scores across racial and ethnic groups.

Wiles noted that scheduled pain assessments and around-the-clock non-opioid medications may reduce disparities.

Ashanda Saint Jean, MD, chair of ob/gyn at Health Alliance Hospitals in Kingston, New York, said that it was concerning to see that women who did not speak English had the least amount of pain assessments and medications.

"For me, that represents an impaired ability for self-advocacy," Saint Jean said in an interview. "If you can't properly communicate with a patient, how will you know if they are in pain?"

Saint Jean, who was not involved in the study, added that looking at pain assessments as a vital sign, and further standardizing evaluations, could reduce the potential for unconscious biases to impact care and allow clinicians to provide adequate pain relief.

While this data did show racial disparities in post-operative pain management for C-sections, Saint Jean added that significant patient information was missing, such as repeat C-section and presence of uterine fibroids or endometriosis, that may have impacted the amount of pain medication given.

Wiles and colleagues conducted a retrospective cohort study to determine if pain management for C-section births differed by racial and ethnic group or primary language. They analyzed women who had a C-section delivery between January and June 2018 at Mount Sinai South Nassau Hospital. They tracked pain scores and the administration of NSAIDs and OTEs across racial and ethnic groups.

Wiles's group excluded women who underwent C-section hysterectomy, received general anesthesia or pain control via patient-controlled analgesia, had allergies to opiates, or had a history of drug use.

The researchers included 327 mothers in the analysis. The mean maternal age was 32, and gestational age was an average of 39 weeks. Around 75% of the study participants spoke English as their primary language.

The number of pain assessments given was lower in Hispanic women compared to non-Hispanic women (10 vs 11, P=0.02), and in women whose primary language was not English compared to English-speaking women (10 vs 11, P=0.01).

Black women received the lowest number of NSAID doses (1 dose) between 24-48 hours postpartum (P=0.0009). This group received three doses of OTEs, which was higher than other racial groups, but the difference was not significant (P=0.32).

Wiles and colleagues stated that studies with larger sample sizes may demonstrate further disparities in pain score assessments and opioids administered.

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