title: Obstetric anaesthesia and socio-economic disparity
Creators: name: Halliday, Lucy Olivia Egan
Publisher: name: University of Glasgow
Year: 2024

description: Obstetric anaesthesia is one of the largest subspecialties of anaesthesia. Anaesthetists participate in over 60% of births in the UK, and this number is continuing to rise. Obstetric anaesthesia is concerned with the management of pain in labour, and of anaesthesia for caesarean birth, as well as the management of high-risk patients. Women of low socioeconomic position are at a higher risk during childbirth than the general population. They have higher rates of obesity and adverse health behaviours at baseline, and are at a greater risk of severe maternal morbidity and mortality. Maternity services in Scotland are run by the publicly funded National Health Service, which aims to provide equitable treatment that is free at the point of care.

A body of work on labour epidural analgesia and anaesthesia for caesarean birth is presented. The first part is concerned with labour epidural analgesia. A narrative review is undertaken in which all of current research relating to labour epidural analgesia is summarised. This is followed by a network meta-analysis of ultra-low, low and high concentration local anaesthetics for labour epidural analgesia. This demonstrated that ultra-low concentrations of local anaesthetic (&lt;0.08% bupivacaine or equivalent) are associated with at least as good outcomes as low concentration local anaesthetics and may be associated with some improved outcomes, including reduced overall local anaesthetic consumption and reduced incidence of motor block, whilst maintaining analgesic efficacy. A survey into current epidural practice in Scotland is then presented. This demonstrates that within Scotland there is considerable variability in labour epidural analgesia initiation and management, including choice of local anaesthetic, drug delivery systems and initial management of low block.

The final two chapters are concerned with socio-economic position and how it is associated with the provision of obstetric anaesthesia in Scotland’s National Health Service (NHS Scotland). Firstly I demonstrate that low socio-economic position is associated with reduced utilisation of labour epidural analgesia, and this disparity persists even in women who are identified as having a medical condition for which labour epidural analgesia is recommended. These results were similar in sensitivity analyses of primiparous women, and of women giving birth in one Scottish city with 24-hour uniform access to obstetric and anaesthetic care. The relationship is compounded in women of non-white ethnicity. In contrast I found that low socioeconomic position is associated with an increased utilisation of general anaesthesia for caesarean birth. To explore the robustness of these findings, I undertook a number of sensitivity analyses to investigate the observed discrepancy. These included, (1) the exclusion of women with relative contraindications to utilisation of neuraxial analgesia, (2) excluding women with previous caesarean birth, and (3) only include women delivering babies at term. The results of all of these sensitivity analyses were consistent with the main analysis, that low socio-economic position is associated with greater use of general anaesthesia at caesarean birth.

The aim of this body of work is to identify best possible practice in obstetric anaesthesia. This is achieved through a combination of narrative review, metaanalysis, survey and two population level analyses. I take advantage of the exponential growth in computational processing power of the last few years, by using specialised statistical computing software to analyse vast quantities of data relevant to obstetric anaesthesia and create graphics to communicate the results. These studies highlight areas for improvement to minimise harm and maximise benefits for all women in Scotland, and in particular those of low socio-economic position who are at a higher risk of adverse events during labour and delivery.