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State variation in neuraxial use during labor in the United States
Abstract Number: O2-3
Abstract Type: Original Research
Introduction: Neuraxial labor analgesia (NA) is the most effective method of providing pain relief to women undergoing labor.(1) In 2008, 61% US women who delivered vaginally received NA.(2) Less clear is whether variation exists in the prevalence of NA use across US states.
Methods: Using US natality data, we obtained data from 2,867,559 women who delivered in 49 states in 2015. Random-effects logistic regression was used to examine the variation in rates of NA use across US states, adjusting for demographic, obstetric, and intrapartum covariates (see Figure legend). State-level NA rates and 95% CIs were calculated by converting the random-effect for each state to a relative risk and multiplying by the national rate. We also calculated the median odds ratio to estimate the odds of NA that would occur if a patient moved from a state with a low odds of NA to a state with a high odds of NA, after case-mix adjustment.
Results: Among women undergoing labor, 2,080,591 (72.6%) women received NA. The national NA rate for the adjusted model was 73.1%. The distribution of adjusted rates of NA use across US states are presented geographically in Figure 1 and by rank order in Figure 2. In 2015, the median NA rate across states was 73.3% (IQR=65.9%-77.7%). Maine had the lowest NA rate (37%; 95% CI=34%-41%) and Utah the highest (80%; 95% CI=79%-81%). The median odds ratio was 1.19 (95% CI=1.11-1.28) suggesting that variation exists across states after accounting for case-mix.
Discussion: Our findings indicate that wide variability exists in the rate of NA use across US states, variation that has not been documented to date. Variability in state-level NA use could not be fully explained by patient-level factors. Therefore, there is a pressing need to better understand reasons for the extent of state-level variation in NA rates across the US, such as clinical decision-making, patient education/preferences, and access to anesthesia providers. Further, whether this divergent NA practice is associated with obstetric outcomes must also be determined.
References: (1) Cochrane Database Syst Rev. 2012 Mar 14;(3):CD009234.(2) NVSS 2011; 59:no.5