Association Between Limited English Proficiency and Operative Vaginal Birth

Objectives: Limited English proficiency (LEP) is a risk factor for adverse health care outcomes and may contribute to disparities in obstetrical care. Prior research has shown an association between LEP and obstetric anal sphincter injuries (OASIS); however, the underlying causes remain uncertain. For patients with LEP, language barriers may affect the process of obtaining consent and conducting shared decision-making for obstetrical operative instrumentation (ie, vacuum and forceps), the most significant risk factor for OASIS. The objective of this study was to evaluate if LEP is associated with increased risk of operative vaginal delivery in a cohort in which prior analysis has shown an association between LEP and increased risk of OASIS.

Methods: A secondary analysis of a prior retrospective study investigating the association between LEP and OASIS was performed. All patients who underwent term vaginal cephalic births between January 2016 and July 2023 at a single hospital center were included. The following variables were extracted from the electronic medical record: preferred language, OASIS injury, age, height, pre-gravid BMI, race, ethnicity, insurance type, parity, gestational age at birth, oxytocin use, epidural analgesia receipt, length of second stage of labor, any forceps or vacuum assistance, fetal position, birth weight, and maternal blood loss. Patients with LEP were defined as those with a non-English primary language. Binary logistic regression was used assess odds of operative versus spontaneous vaginal birth, adjusting for LEP, age, pre-gravid BMI, parity, and birth weight of fetus. Statistical analysis was performed in SPSS.

Results: A total of 15,736 patients were included in the study, of which 13,977 patients were English speaking and 1759 patients had LEP. There was no difference in odds of operative vaginal birth between patients with LEP and their English speaking counterparts (aOR 1.10, 95% CI 0.85-1.42). Prior parity (aOR 0.20, 95% CI 0.17-0.24) and increased pre-gravid BMI (aOR: 0.98, 95% CI 0.97-0.995) were significantly associated with decreased risk of operative vaginal delivery. Age (aOR: 1.07, 95% CI 1.06-1.09) was significantly associated with increased risk of operative delivery. The adjusted logistic regression model predicted an overall 94.0% of outcomes and explained 8.8% (Nagelkerke R2) of the variance in operative vaginal delivery, with the Hosmer-Lemeshow test calculating goodness-of-fit at 0.344.

Conclusions: Among patients with term vaginal deliveries, patients with LEP had a similar likelihood of undergoing operative vaginal birth compared to their English-speaking counterparts. However, in a previous analysis of this cohort, patients with LEP were more likely to sustain OASIS. Further research is needed to understand the association between of language barriers and OASIS, including any potential adverse impacts arising from impaired communication between healthcare providers and patients during labor.