Health equity research in obstetric anesthesia

Abstract

Purpose of review: Health equity is an important priority for obstetric anesthesia, but describing disparities in perinatal care process and health outcome is insufficient to achieve this goal. Conceptualizing and framing disparity is a prerequisite to pose meaningful research questions. We emphasize the need to hypothesize and test which mechanisms and drivers are instrumental for disparities in perinatal processes and outcomes, in order to target, test and refine effective countermeasures.

Recent findings: With an emphasis on methodology and measurement, we sketch how health systems and disparity research may advance maternal health equity by narrating, conceptualizing, and investigating social determinants of health as key drivers of perinatal disparity, by identifying the granular mechanism of this disparity, by making the economic case to address them, and by testing specific interventions to advance obstetric health equity.

Summary: Measuring social determinants of health and meaningful perinatal processes and outcomes precisely and accurately at the individual, family, community/neighborhood level is a prerequisite for healthcare disparity research. A focus on elucidating the precise mechanism driving disparity in processes of obstetric care would inform a more rational effort to promote health equity. Implementation scientists should rigorously investigate in prospective trials, which countermeasures are most efficient and effective in mitigating perinatal outcome disparities.

FIGURE 1:. NARRATIVE OF A MARGINALIZED PARTURIENT FOLLOWING A TIMELINE OF DISPARITY

This fictitious narrative of a marginalized minority immigrant parturient reflects a composite of patient experiences observed by the authors and described in the literature. The relevant key drivers of perinatal process and outcome disparities are explicated in Figure 2, and the timeline is detailed and explained in Supplemental Figure 1. The underlying social conditions should be considered as the fundamental causes of disease as illustrated in Supplemental Figure 2. Social determinants of health are explained in Supplemental Figure 3 as socially constructed mutable individual, family and community characteristics, pertaining to identity and socioeconomic status.

FIGURE 2:. KEY DRIVERS OF OBSTETRIC DISPARITIES

Certain mechanisms and pathways are key to perinatal and obstetric process and outcomes disparities. Various elements (characteristics of patient, healthcare system, or social structure) are enumerated in the leftmost column; they can be discerned from the parturient narrative (Figure 1). We organized them in domains in the second column and identified them as key drivers in the third column, with corresponding countermeasures (in the rightmost column) to overcome health access barriers, improve obstetric care quality and mitigate inferior perinatal outcomes. Some of the elements in the leftmost column are social determinants of health, which are further explained in Supplemental Figure 2 and Supplemental Figure 3 as fundamental causes of disease.