2026/02/16 by Mathew Lyons · 1 voice · 1 citation
Medicine · #Anesthesia and Pain Management #Maternal and Perinatal Health Interventions #Pelvic floor disorders treatments
paper · pdf · doi:10.1111/anae.70177
openalex publication_date 2026/02/16 · openalex created_date 2026/02/17 · openalex updated_date 2026/07/27
Macgregor et al. provide valuable evidence on ethnic disparities in epidural use in New Zealand, adding important international context to recent findings [1, 2]. They acknowledge not including caesarean births in analysis, noting that caesarean rates were comparable between Māori and non-Māori populations, and suggest this exclusion is unlikely to affect findings. However, emergency caesarean rates varied substantially across ethnic groups, ranging from 18% in the Māori population to 32% in the Middle Eastern/Latin American/African population. While Māori and European emergency caesarean rates were similar, dismissing selection concerns based on this single comparison overlooks the substantial variation across other groups. Women receive epidurals during labour before anyone knows how they will give birth. Many who labour with epidurals go on to require emergency caesarean birth. Without knowing epidural rates among women who progressed to caesarean birth, it is not possible to assess whether the exclusion masked disparities in other ethnic groups. While overall caesarean rates may appear similar between some groups, Pacific and Māori women had a greater median BMI than European women yet lower caesarean rates. This would suggest that obesity predicts surgical birth differently across ethnic groups, perhaps reflecting differences in anthropometrics [3]. Even when overall rates appear comparable, if risk-outcome relationships differ across ethnicities, selecting only vaginal births creates groups that differ in unmeasured ways, making ethnic comparisons more challenging. If ethnicity affects which provider a woman sees and providers have different practices for women of different ethnicities, the provider could be a mediator rather than a confounder on the causal pathway from ethnicity to epidural access. If certain providers systematically discourage epidurals in specific ethnic groups, adjusting for provider identifies where the disparity operates but may inadvertently make it appear explained or resolved. The unadjusted ethnic disparity represents the actual inequity experienced by women. Provider-stratified analyses could help identify whether inequitable care is concentrated with providers, while mediation analysis could quantify the proportion of ethnic disparity operating through provider selection vs. within-provider differences in care. The methods describe splitting data 80/20 for training and testing with area under the curve calculations and model development, yet the results section presents no validation metrics, area under the curve values, predictive models or test set performance. It remains unclear whether the reported models represent training set, test set or full dataset results. Clarification of the model validation approach and presentation of the corresponding performance metrics would strengthen confidence in the findings. These considerations matter, because effective labour analgesia is important for maternal wellbeing and safety [4]. Ensuring equitable access requires understanding where barriers operate and how epidural timing intersects with ethnicity and outcomes. Studies examining complete birthing populations, including women progressing to surgical birth, alongside qualitative research exploring decision-making and system factors, are required. The authors' identification of this disparity provides important impetus for such research.