Since the 1970s, the frequency and use of pain relief during childbirth – and most especially the use of epidural analgesia during labor – has increased dramatically. Reports on epidural rates range from 47 percent to as high as 76 percent of vaginal births, while between 39 percent and 56 percent of women use narcotic analgesics – including drugs like Fentanyl – via IV for managing labor and delivery pain. Only about 14 percent of women, the literature reveals, use no pharmacologic method to relieve childbirth pain.
Hispanic women, however, are another story. New research from the University of Virginia School of Nursing, conducted by doctoral candidate Juliane Milburn, finds that Hispanic women were 53 percent less likely than all other races to have an epidural and 41 percent less likely to use a combination of epidural and IV medications during labor than all other races.
"One of the most unique features of childbirth pain is that it is one of the few situations in health care where acute pain may be left untreated as part of care management," Milburn said, "and for some women, the ability to make that choice is more important than medical interventions."
Sifting through more than 7,000 medical records over six years from U.Va. Medical Center archives, Milburn found some unusual patterns in pain relief for childbirth by race. Her dissertation qualified and quantified – the first American study to do both – just why so many Hispanic women opt out of pain relief during childbirth when compared to women of other races.
"Juliane's interest in this topic came out of her own clinical practice of working in labor and delivery caring for such women, her travels to Spanish-speaking countries, fluency in Spanish and also as a labor and delivery nurse in a local primary care clinic for migrants," said Milburn's adviser, Linda Bullock, associate dean for research in the Nursing School. "Her research fills a real gap in our understanding of why these patterns in pain relief exist. Nurses, being there at the bedside, are patients' best advocate and often serve as primary navigators during their hospital stay, so understanding certain groups' propensities to have (or refuse) pain relief is part of culturally competent care."
With explosive growth in Hispanic and Latino populations in the U.S., Milburn explained, it's critical for nurses to learn that in some cultures, pain during childbirth is viewed as a necessary and natural rite of passage for which no relief is sought.
Also, "a woman's experience during the childbirth and hospitalization can shape future health care practices for the entire family," she said, "and a significant facet of that experience is pain control, making the nurses' understanding of birthing practices and pain management for this population crucial."
While previous studies have revealed disparities in the utilization of pain relief in general – whites tend to receive the most pain relief in emergency rooms, compared to people of other races and ethnicities, research has shown – Hispanic women, Milburn found, often go medication-free during childbirth quite by choice. That determination, she found during 17 interviews with a group of Hispanic mothers nationwide? within two years of giving birth, was based on a number of culturally based belief systems, including ideal birth standards, religion, their mothers' and grandmothers' stories as well as misconceptions about possible side-effects drugs might have on their infants and themselves.
Milburn's interviews revealed a number of themes about Hispanic women's belief systems around childbirth, including:
- The belief that labor and childbirth are battles to be overcome;
- That the pain of that battle is an integral part of the process, as well as something that is better for babies;
- That a mother's role is akin to the Virgin Mary's – one of sacrifice and denying one's own needs for those of the child;
- Enduring the pain of labor, and being strong throughout the process, is valued by the culture;
- A pervasive belief that epidurals will cause permanent back problems.
Slightly more than 16 percent of women who gave birth at U.Va. Medical Center over the past six years chose no pharmacologic method of pain control during labor. Nearly 43 percent opted for intravenous drugs to relieve childbirth pain, while nearly 71 percent chose regional anesthesia (a spinal epidural) during childbirth. Of those last two groups, nearly 30 percent chose both intravenous and regional anesthesia combined.
By comparison, 22.4 percent of Hispanic women opted for no pain relief during childbirth at all, compared to 14 percent for all other races. Nearly 45 percent of Hispanic women refused an epidural, compared to 26 percent of women from all other races.
In all pain control method categories, Asians, African-Americans and whites made similar choices, with the exception that Asians used epidurals with greater frequency than other groups.
"The literature describes the lower rate of epidural use by Hispanic women as a disparity," Milburn said. "But is it truly? Or is the true disparity the lack of cultural understanding by U.S. health care providers and the inability for Hispanic women to communicate their desires secondary to language and cultural differences, and or the propensity to undermine these client's wishes by asserting our own values?"
Nationally, Hispanics make up a huge and growing proportion of the overall U.S. population: At the 2010 Census, they numbered 50.5 million, and currently account for at least 16 percent of the total population (a 43 percent increase since the 2000 Census). In Virginia, the Hispanic population rose from 4.7 percent in the 2000 Census to 7.9 percent in the 2010 census, representing an increase of 91.7 percent.
Research like Milburn's not only reveals how differently women from a variety of racial and ethnic backgrounds cope with and experience something as profound as childbirth, it illustrates the levels of cultural competence that today's nursing professionals must have, she said.
"For nurses, the ability to understand the cultural beliefs and practices of ethnic and racial minorities and immigrant women regarding the birth process would help to improve the overall health of the mother and her family," she said. "It can also assist in alleviating the stress of unfamiliarity during a critical time in a woman's life.
"With Hispanics now the largest minority group in the U.S., attention to their culture and health care needs is needed to prevent further disparities."