Race , in the historical context, was used to describe ancestry and people with shared physical traits. Ethnicity is also related to a shared ancestry, but denotes a shared culture (e.g., language, traditions, values). Race and ethnicity are social constructs; yet, to understand disparities within groups and develop targeted interventions, patients must be grouped by race and ethnicity. It is important to understand that misuse of race as a biologic construct may cause harm, and may actually magnify disparities. Genetic determinism is the belief that genes determine all phenotypic differences between the socially defined races, and that differences in allelic frequency drive disparities. However, in the United States, and worldwide, there is significant admixture among racial groups; genetic variability within racial groups is greater than variability between groups. Therefore, self-identified race may serve as a proxy for exposures, but is not a reliable proxy for genetic differences.

The US Office of Management and Budget “Race and Ethnic Standards for Federal Statistics and Administrative Reporting” classifies people into racial groups to facilitate comparing federal data. In 1997, the race categories were updated ; in this chapter, the following racial and ethnic categories are used: American Indian and Alaska Native, Asian, Black or African American, Native Hawaiian or Other Pacific Islander, White, and Hispanic. Nearly 3.6 million children were born in the United States in 2023, and more than 30% of the US population self-identifies as a racial or ethnic minority.

Multiple definitions for disparities exist, but the US Agency for Healthcare Research and Quality, which produces the annual National Disparities Report , defines disparity as a difference between two groups, where the absolute difference is statistically significant, and the relative difference is at least 10% worse for the nonreferent group. The National Institute on Minority Health and Health Disparities (NIMHD) defines a health disparity as a health difference that adversely affects disadvantaged populations. Currently designated health disparity populations include racial and ethnic minority groups, populations of less privileged socioeconomic status, underserved rural populations, sexual and gender minority groups, and people with disabilities.

The root causes of disparities are complex; in healthcare, one conceptual model organizes the causes of disparities into patient factors, provider factors, and healthcare systems factors, which all interact with each other ( Fig. 14.1 ). Clinical care alone accounts for a small proportion of health outcomes, whereas the social determinants of health account for as much as 50%. The social determinants of health are defined by the World Health Organization as the nonmedical factors that influence health outcomes. These factors include income, education, employment, housing, transportation, food insecurity, social inclusion, and nondiscrimination, as well as access to health services. The NIMHD Minority Health and Health Disparities Research Framework incorporates the domains that influence health (e.g., biologic, behavioral, built environment, sociocultural environment, healthcare systems) and the levels of influence within those domains (e.g., individual, interpersonal, community, societal) in a matrix which expands on previous models to reflect the intersectionality of factors on both individual and population health ( Fig. 14.2 ).

Origins of Healthcare Disparities.

Adapted from Kilbourne AM, Switzer G, Hyman K, et al. Advancing health disparities research within the health care system: a conceptual framework. Am J Public Health . 2006;96:2113–2121.

National Institute on Minority Health and Health Disparities Research Framework.

Adapted from National Institute on Minority Health and Health Disparities. NIMHD research framework. Available at: https://www.nimhd.nih.gov/about/overview/research-framework/nimhd-framework.html . Accessed 19 January 2025.

Prenatal care, when established early and delivered with adequate quality, has been shown to improve pregnancy-related outcomes. In 2022, the rates of late (defined as initiation of care in the third trimester) or no prenatal care were higher for Black, Hispanic, American Indian and Alaskan Native, and Native Hawaiian and Pacific Islander women compared to non-Hispanic White women (10.0%, 9.1%, 12.6%, 22.4%, versus 4.7%, respectively). The barriers to access to prenatal care are likely multifactorial, but lack of appointment availability and long wait times disproportionately affect minority women compared to non-Hispanic White women using the same clinics. Past experiences of racism may also pose a barrier to women initiating prenatal care. In one study, Black and Hispanic women were three times more likely to report having experienced discrimination due to race, language, or culture than non-Hispanic White women. Many of the conditions associated with severe maternal morbidity and mortality, such as obesity, hypertensive disorders of pregnancy, diabetes mellitus, and other chronic illnesses are more prevalent among minority women; therefore, increasing the access to prenatal care for medical optimization may improve health outcomes. Studies have shown that public health department prenatal care programming is associated with improved Black maternal mortality rates.

Neuraxial labor analgesia, such as epidural analgesia or combined spinal-epidural analgesia, is the most effective treatment for the pain associated with childbirth. Both the American College of Obstetricians and Gynecologists and the American Society of Anesthesiologists have promoted the use of neuraxial analgesia due to its efficacy and minimal effects on the neonate. Yet, despite 73% of delivering women using neuraxial labor analgesia for pain control in the United States, Black and Hispanic women are less likely to use this modality of pain control in labor compared to non-Hispanic White women (adjusted odds ratio [aOR], 0.86 and 0.75, respectively).

Studies documenting racial and ethnic disparities in use of neuraxial labor analgesia date back at least 20 years. In 2004, using the Georgia Medical Claims database, Rust et al. compared neuraxial labor analgesia use by race and ethnicity. Fifty-three percent of the 29,833 women in the cohort used neuraxial analgesia, but differences existed by race and ethnicity. While 60% of non-Hispanic White women used neuraxial labor analgesia, only 50% of Black women and 35% of Hispanic women used it. These disparities persisted even after controlling for patient age, metropolitan status, and the availability of anesthesiologists in the area. More contemporary studies have also documented racial and ethnic differences in the use of neuraxial analgesia for labor pain. Differences in use may be driven by the anticipated desire for neuraxial labor analgesia. In one study, women who were Hispanic and non-Hispanic Black were less likely to anticipate neuraxial labor analgesia use than non-Hispanic White women (51%, 61%, and 83%, respectively, P <.001) at the time of admission to the hospital for childbirth. Anticipated and actual use of neuraxial labor analgesia among Spanish-speaking Hispanic women were lower than among Hispanic women who speak English as their primary language. Even after adjusting for age, marital status, income, obstetric provider type (obstetrician/midwife), and labor type, Spanish-speaking women were significantly less likely to anticipate (aOR, 0.70; 97.5% confidence interval [CI], 0.53 to 0.92) and use (aOR, 0.88; 97.5% CI, 0.78 to 0.99) neuraxial labor analgesia compared to English-speaking Hispanic women.

Knowledge and familiarity with neuraxial labor analgesia may differ by race and ethnicity. Misconceptions and fears have been shown to be important drivers in a patient’s decision-making. In one survey, the rationale for avoiding neuraxial analgesia included fears of paralysis due to the procedure (76%), concerns about chronic back pain after the procedure (54%), and advice from friends and family against the use of neuraxial labor analgesia (36%). After analgesic counseling, the anticipated use rate increased from a baseline of 14% to 38%. In a randomized controlled trial, 200 patients were randomized to a formalized language-concordant education program regarding labor neuraxial analgesia (consisting of a video, informational pamphlet, and in-person counseling) versus standard care. The Hispanic women who participated in the education program had an increased likelihood of using neuraxial labor analgesia compared with those who received standard care (risk ratio, 1.33; 95% CI, 1.02 to 1.74).

A patient’s obstetric provider, and her provider’s preferences, may also contribute to differences in the rates of neuraxial labor analgesia use as the provider may discuss analgesic options with the patient in the antepartum period. The rate of neuraxial anesthesia use is lower among patients who deliver with nonobstetricians (e.g., midwives). While midwives historically cared for a smaller proportion of non-Hispanic White women than obstetricians, a study published in 2014 indicated there were no longer significant differences in maternal race or ethnicity between patients cared for by the two types of providers.

Racism may also contribute to disparities in neuraxial labor analgesia use. Several types of racism exist, including interpersonal, institutional, and structural. Institutional and structural racism are forms of racism that are embedded in systems, codified through laws or unwritten policies and established beliefs, which perpetuate unfair treatment to minority populations. Structural racism has been identified as one of the key drivers of the social determinants of health for marginalized populations ( Fig. 14.3 ). A commonly cited example is redlining, a now outlawed practice, in which the government sanctioned certain geographical areas as Black neighborhoods, and deemed these areas hazardous for monetary lending by banks. This practice led to generational economic disadvantage.

Conceptual Map of Structural Racism in Healthcare.

Adapted from Furtado K, Verdeflor A, Waidmann T. A conceptual map of structural racism in health care; 2023.

Click to access A%20Conceptual%20Map%20of%20Structural%20Racism%20in%20Health%20Care.pdf

. Accessed 19 January 2025.

A cross-sectional study used 2017 US natality data to evaluate the association between structural racism and neuraxial analgesia use. Structural racism was operationalized as an index of three Black-White inequity ratios (ratios for lower education, unemployment, and incarceration in jails) measured in the county of the delivery hospital. The index was stratified into terciles, with the third tercile corresponding to the highest level of structural racism. For Black women, after adjustment for sociodemographic and clinical characteristics, the adjusted odds of neuraxial labor analgesia use for women in the third tercile compared to the first tercile was reduced by 28.3% (95% CI, 26.9% to 29.6%). For White women, this difference was 15.6% (95% CI, 14.7% to 16.5%). Given these differential effects observed in population-level data with multivariable risk adjustment, clinicians working in communities with substantial structural racism may not perceive any differences in the use of neuraxial analgesia.

Disparities in the use of neuraxial labor analgesia may impact disparities in the use of general anesthesia for cesarean delivery. While both neuraxial and general anesthesia are safe for cesarean delivery anesthesia, neuraxial anesthesia is preferred due to the numerous maternal and fetal benefits (see Chapter 26 ). In two studies using data from the Maternal-Fetal Medicine Units Network cesarean delivery registry, non-Hispanic Black and Hispanic patients had the highest odds of undergoing general anesthesia for cesarean delivery compared with non-Hispanic White patients. It is possible that the differential use of epidural labor analgesia among minority women contributed to the increased use of general anesthesia for cesarean delivery. In a retrospective analysis of 35,117 cesarean deliveries performed at a single academic institution between 2007 and 2018, 1147 cases (3.3%) were performed under general anesthesia. The rates of general anesthesia were 5.0% for Black patients, 3.7% for Hispanic patients, 2.6% for Asian patients, and 2.8% for non-Hispanic White patients ( P <.001). Among the patients who were in labor at the time of their cesarean delivery, 82.0% had neuraxial labor analgesia in situ . There were no racial or ethnic differences in the rates of general anesthesia use among those who had an epidural catheter in situ ( P =.16). These findings suggest that the extension of epidural analgesia to epidural surgical anesthesia may be one strategy for mitigating disparities in avoidable use of general anesthesia.

Disparities in postpartum pain management have also been reported. In a retrospective cohort study of 1701 cesarean deliveries, severe pain after delivery (pain score ≥ 7/10) was more common among women identifying as Black (28%) or Hispanic (22%) compared to those who identified as non-Hispanic White (20%) or Asian (15%). Black and Hispanic women also had fewer pain assessments and received less opioid pain medication than non-Hispanic White women in the first 24 hours after delivery. Other studies have shown that Black and Hispanic women have greater odds of a pain score > 5/10, but receive less inpatient pain medication (fewer morphine equivalents) than non-Hispanic White women, as well as fewer prescriptions for discharge opioid prescriptions.

Multiple definitions for severe maternal morbidity (SMM) exist. The US Centers for Disease Control and Prevention (CDC) define SMM as a composite of 21 indicators that can be extracted from administrative data. The American College of Obstetrics and Gynecology and the Society for Maternal-Fetal Medicine define SMM as unintended outcomes in the birthing process that may have significant short- and long-term consequences to a woman’s heath. In the United States, the prevalence of SMM increased from 146.8 per 10,000 discharges in 2008 to 179.8 per 10,000 discharges in 2021. The rates increased for all racial and ethnic groups; however, even after adjustment for demographics and hospital and visit characteristics, SMM rates were higher for all groups compared with non-Hispanic White women (aOR: Hispanic, 1.22; Asian, 1.33; Black, 1.39; American Indian, 1.41; Pacific Islander, 1.53).

Other studies have similarly found that adjustment for socioeconomic status does not eliminate disparities. A study with 588,232 matched hospital deliveries in New York City found that racial disparities in SMM persisted in even the highest income and educational groups ; nevertheless, living in the poorest neighborhoods exacerbated SMM risk among both Hispanic women and non-Hispanic Black women. The patient’s site of care, in particular, and delivery hospital type, may further contribute to disparities in SMM. Using the Nationwide Inpatient Sample data for 2010 and 2011, hospitals were stratified by the proportion of Black deliveries. Seventy-four percent of Black deliveries occurred in medium and high Black-serving hospitals, and these hospitals had a higher rate of SMM than low Black-serving hospitals (18.8 versus 13.3 per 1000 deliveries). Black women who delivered at high Black-serving hospitals had the highest rates of SMM (20.5 per 1000 deliveries). The clustering of minoritized and under- and uninsured people in low-quality health systems is an example of structural racism.

Disparities occur in many SMM conditions. Hemorrhage is a major contributor to SMM, and the incidence of postpartum hemorrhage (PPH) has been increasing (see Chapter 37 ). The majority of hemorrhages are secondary to uterine atony, and Hispanic ethnicity has been shown to be an independent risk factor for uterine atony requiring pharmacologic treatment. Black women are 53% more likely to receive a blood transfusion than non-Hispanic White women. Whether hemorrhage disparities are related to minority women experiencing more atony, having more underlying anemia, or a combination of other factors is not completely understood.

Black women are at higher risk for developing peripartum cardiomyopathy, are more likely to have severe disease at the time of diagnosis, and have worse recovery than non-Hispanic White women.

Maternal mortality is discussed in detail in Chapter 39 . Historically, in the United States, Black women are three to four times more likely to suffer peripartum death than non-Hispanic White women, and disparities exist for American Indian and Alaska Native women as well. Using data from the National Vital Statistics for 2021, the maternal mortality rate for non-Hispanic Black women was 2.6 times the rate for non-Hispanic White women. Maternal mortality risk increases with increasing age among all racial groups; however, Black women over 40 years of age are three and a half times more likely to die of pregnancy-related complications compared to White women of the same age. The substantial difference in maternal mortality among different racial and ethnic groups is not unique to the United States. Disparities in maternal mortality have also been found in the United Kingdom, Spain, and other countries.

In the United States, differences in four conditions accounted for 59% of the maternal mortality disparity gap using 2016 to 2017 vital statistics data: preeclampsia/eclampsia, postpartum cardiomyopathy, embolic disorders, and hemorrhage. Data from a report from nine states’ Maternal Mortality Review Committees (MMRC) found differences in pregnancy-related mortality by race and ethnicity. Among Black women, the most common causes of pregnancy-related deaths were cardiomyopathy, cardiovascular conditions, preeclampsia and eclampsia, hemorrhage, and embolism. Hypertensive disease was the leading cause of maternal death among Hispanic women.

Excess mortality has been noted for Black and Hispanic women who experience SMM compared to non-Hispanic White women. Among women with hypertensive disorders of pregnancy, Black women are 10 times more likely to die than non-Hispanic White women, and Hispanic women are eight times more likely to die than non-Hispanic White women. Disparities persist even after adjusting for confounders (e.g., age, marital status, and residence). Similarly, other studies have found that Black women who experience preeclampsia, eclampsia, abruption, placenta previa, and PPH have a higher case fatality rate than non-Hispanic White women.

Maternal geography, or site of care, may also contribute to disparities. States with a greater proportion of Black women in the population have higher rates of pregnancy-related deaths while states with fewer Black women have lower rates of pregnancy-related deaths. It has been posited that population-based disparities may be a result of poverty, immigration, or rural location, but Black women in Georgia are more likely to die in metropolitan, nonrural locations than rural locations. Adjustment for access to care does not eliminate disparities. A study of pregnancy-associated deaths in the state of Louisiana from 2016 to 2017 found increased maternal mortality for women residing in maternity care deserts; however, even after adjustment for geographic access, the racial and ethnic disparities persisted.

Given that healthcare disparities are multifactorial, interventions at multiple levels will be required to reduce or eliminate them. In 2018, the National Partnership for Maternal Safety within the Council for Patient Safety in Women’s Healthcare developed the Reduction of Peripartum Racial and Ethnic Disparities Bundle . The bundle’s recommendations were organized into four Rs (Readiness, Recognition and Prevention, Response, and Reporting and Systems Learnings), which are used in the other maternal safety bundles. The recommendations were organized into five themes: (1) measurement of disparities, (2) recognition of disparities at the personal and systems levels, (3) awareness of the magnitude of disparities, (4) communication barriers, and (5) differences in the structure of care. In 2021, the American Society of Anesthesiologists Committee on Obstetric Anesthesia released a Statement on Reducing Maternal Peripartum Racial and Ethnic Disparities in Anesthesia Care . Actionable strategies for anesthesiologists are summarized in Box 14.1 .

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  Healthcare disparities are a global issue and affect many vulnerable populations, including women who belong to racial and ethnic minority groups, immigrants, nonnative speakers, asylum seekers, and residents of rural communities.

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  Social determinants of health are the nonmedical factors that influence health outcomes, including income, education, employment, housing, transportation, food security, social inclusion, and nondiscrimination, as well as access to health services. These factors play an important role in health outcomes.

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  Racial and ethnic disparities exist for the use of neuraxial labor analgesia and for neuraxial versus general anesthesia for cesarean deliveries. For women who are in labor, the extension of epidural analgesia to epidural anesthesia may be one strategy to mitigate disparities in avoidable use of general anesthesia for cesarean delivery.

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  Racial and ethnic disparities in maternal mortality have been documented in the United States and worldwide. In the United States, the rate of maternal mortality has been three to four times higher for Black women compared to non-Hispanic White women.

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  Multiple strategies have been suggested for reducing racial and ethnic disparities, including accurate measurement of race, ethnicity, and primary spoken language; use of dashboards to track disparities in outcome metrics; provider education about disparities and their root causes; reducing provider-patient communication barriers by shared decision-making; and engagement in programs to reduce workforce racial and ethnic disparities and increase workforce diversity.

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  Protocols such as enhanced recovery protocols and patient safety bundles should be implemented when possible, as these may help reduce variations in care, decrease implicit bias, and reduce disparities.