|Year : 2021 | Volume
| Issue : 2 | Page : 78-82
Knowledge and awareness of labor analgesia services available in our tertiary hospital among the pregnant women: A prospective study
Mahesh Madhugiri Chandrashekaraiah1, Lena Koshy1, Samah Haidar Hakema1, Sadiya S Ahmed2, Shakeel B Mahammad1, Nusiba Ibrahim2
1 Department of Anesthesia and Pain Medicine, King Hamad University Hospital, Muharraq, Bahrain
2 Department of Obstetrics and Gynecology, King Hamad University Hospital, Muharraq, Bahrain
|Date of Submission||22-Sep-2020|
|Date of Decision||14-Dec-2020|
|Date of Acceptance||15-Dec-2020|
|Date of Web Publication||16-Apr-2021|
Dr. Mahesh Madhugiri Chandrashekaraiah
Department of Anesthesia, King Hamad University Hospital, Muharraq
Source of Support: None, Conflict of Interest: None
Background: Knowledge regarding labor analgesia is poor among the pregnant women. This hinders them from utilizing the services in centers where it is available. In this study, we tried to analyze the awareness and knowledge of the antenatal women and their beliefs regarding labor analgesia. Patients and Methods: This prospective, observational study done in antenatal clinic for 1 month. Antenatal women who attended the clinic voluntarily filled the semi-structured questionnaire after the written and informed consent. Results: A total of 170 women filled the questionnaire out of 1099 antenatal visits. 68.8% were multipara and 50.58% had previous vaginal delivery. 63.3% study population had prior information of labor analgesia; while only 42.6% had information that labor analgesia services are available in our hospital (P = 0.002). Age, education, and parity were considered as predictors; however, parity is the only predictor for knowledge of labor analgesia odds ratio = 2.368 (95% CI–1.24, 4.51; P = 0.009). Majority (60.23%) of the study sample believe that there is no effective method of pain relief during labor. Binary logistic regression and Chi-square test used for the statistical analysis. Conclusion: Antenatal women still believe that there is no effective method of labor analgesia. Women prefer obstetrician advice for getting information regarding labor analgesia. In our study, the level of education has no impact on awareness of labor analgesia. Only parity is a predictive factor for knowledge of labor analgesia.
Keywords: Antenatal women, education, labor analgesia, parity
|How to cite this article:|
Chandrashekaraiah MM, Koshy L, Hakema SH, Ahmed SS, Mahammad SB, Ibrahim N. Knowledge and awareness of labor analgesia services available in our tertiary hospital among the pregnant women: A prospective study. Bali J Anaesthesiol 2021;5:78-82
|How to cite this URL:|
Chandrashekaraiah MM, Koshy L, Hakema SH, Ahmed SS, Mahammad SB, Ibrahim N. Knowledge and awareness of labor analgesia services available in our tertiary hospital among the pregnant women: A prospective study. Bali J Anaesthesiol [serial online] 2021 [cited 2021 Jun 23];5:78-82. Available from: https://www.bjoaonline.com/text.asp?2021/5/2/78/313884
| Introduction|| |
The patient acceptance for epidural labor analgesia in our hospital was comparatively lower than internationally documented rates. We have adequate provision of the services that include the 24/7 availability of an Anesthesia Registrar and supervising Consultant. The majority of the hospitals providing obstetric services including ours provide either entonox inhalation (50% N2O + 50% O2) with infrequent opioid injections or epidural labor analgesia for pain relief.
Several studies have shown that comfort level and pain relief are superior with epidural labor analgesia.,,,, Studies done earlier identified equivocally that pregnant women awareness regarding labor analgesia, different techniques, and the associated side effects are poor., The poor knowledge has been correlated to the education and parity., Our hospital has excellent facilities as explained above, yet the rate of epidural labor analgesia acceptance is too low in comparison to other health-care set up that work similar to our practice.
An earlier study also demonstrated that poor information led to the underutilization of the available labor analgesia services. We hypothesize that this low acceptance rate in our hospital is probably due to the lack of knowledge, awareness, and preexisting false belief regarding side effects regarding the labor analgesia services among the pregnant women. In this study, we tried to find the factors related to this poor utilization of the services. Questions were also framed to understand the most effective way to communicate with the women to increase their awareness and acceptance of labor analgesia services.
| Patients and Methods|| |
This prospective cross-sectional study received ethical approval from the Institutional Review Board (registry number KHUH/Research/No. 160/2017 on February 9, 2017). The semi-structured questionnaire was derived from earlier studies of similar kind., The questionnaire was tailored according to the local needs of our patients, and mainly directed to analyze to what extent they understand labor analgesia. The questions were also framed further to elaborate the information about labor epidural analgesia and their preexisting belief. Participant women signed the written and informed consent.
The target study group included women attending the antenatal clinic (ANC). The study was conducted in our hospital ANC for 1 month starting from July 25 to August 24, 2019. The exclusion criteria include repeat ANC visit for the same month. Convenient sampling was used for this study. The sample size was computed using earlier study assumptions. Considering the average ANC visit per month in our hospital about 1000 women and hypothesized frequency of knowledge regarding labor analgesia 40% ± 10%, confidence interval (CI) 99%, and design effect 1.0, the required sample size was calculated to be 138 (openepi.com). We achieved a total sample size of 170 out of 1099 ANC visits [Figure 1].
The available data compiled and matched against total number of ANC visits in that month; duplication avoided by maintaining a record of participants. Data on age and parity were reported in frequency and percentage. The association between knowledge about the available pain relief methods and possible sociodemographic risk factors (age, parity, and education) studied by computing adjusted odds ratios (OR) using binary logistic regression models. Other appropriate statistical tests such as Chi-square test applied wherever it deemed necessary. SPSS software (IBM Corp. Released 2017. IBM SPSS Statistics for Windows, version 25.0. Armonk, NY: IBM Corp.) was used for the analysis.
| Results|| |
During the study period, a total of 1099 antenatal women visited the ANC, 757 were eligible, amongst them 170 (18.68%) women voluntarily participated in the study. As shown in [Table 1], 106 (62.35%) respondents were <30 year old. One hundred and seventeen (68.8%) were multiparous. Fifty (29.41%) respondents were primipara. Eighty-six (50.58%) women had normal vaginal delivery.
[Table 2] illustrates the relationship between the level of education and the knowledge regarding labor analgesia. There is no impact of education on knowledge of labor analgesia (Chi-square test, P = 0.70). Furthermore, out of the 107 (63.31%) participants who have the information regarding labor analgesia, only 72 (42.6%) were aware that this service is available in our hospital (P = 0.002).
[Table 3] demonstrates the six questions. Among them the first, patient knowledge regarding different pain relief techniques available for labor analgesia. The respondents were mostly aware of gas inhalation (34.7%) followed by intramuscular injection (23.5%) and epidural labor analgesia (20.2%). Nearly 23% were not aware of any techniques for pain control. Second, when asked the information about the most effective labor analgesia technique among the available options given, majority of the respondents (60.29%) were of the opinion that there was no effective means of pain relief; however, those who knew methods of pain relief answered epidural analgesia (19.54%) as the most effective method. Third question related to the complications of epidural labor analgesia. 39.76% of participants were not aware of risk and complications associated with the procedure, 21.63% answered headache, and 14.03% paralysis of lower limb. Fourth question represents the mode through which women got the information regarding labor analgesia. Most women came to know about pain control methods for normal vaginal delivery from friends and relatives (39%). Media/internet/newspapers were the second source of knowledge acquisition. Brochures in ANC only informed 4% of the sample population.
The fifth question illustrates the preferred way to gain information regarding pain relief methods during labor. The majority of women (34.89%) opted for obstetric sessions. While 26.84% of them had the opinion that special sessions by anesthetists will be helpful in providing information. 18.79% opted for an ANC visit talk by nurses, whereas 14.09% collectively preferred pamphlets and videos.
The sixth question represents the personal beliefs that influence the decision making of the participants not to opt for epidural analgesia during labor. One hundred and fifty-three out of a total of 170 women answered this question. Headache found to be the leading reason followed by fear for undergoing cesarean section (C-section), and adverse advice by friends and relatives
[Table 4] shows the relation between parity and labor analgesia knowledge. Accordingly, multipara patients have significantly more knowledge about labor analgesia than primipara patients (Chi-square P = 0.009). There is a positive correlation between parity and knowledge about analgesia (r = 0.205, P = 0.008). Age (groups), parity, and education were deemed as predictors for knowledge of labor analgesia. Binary logistics regression analysis implies that parity is the only predictor for knowledge of labor analgesia among women with OR = 2.368 (95% CI – 1.24, 4.51; P = 0.009). The other two variables were not significant predictors and were not included in the model.
| Discussion|| |
Our study showed that parity is the only predictor for knowledge of labor analgesia among the women who participated (P = 0.009). Multiparty and knowledge had positive correlation (r = 0.205, P = 0.008). A total of 169 participants answered the question regarding level of education. One hundred and four women were highly educated (university graduate and above). Interestingly, 64.4% educated women and 61.5% women who were not graduates knew about labor analgesia making the level of education an insignificant factor (P = 0.70). Contrary to our findings, in a study done by Naithani et al. involving 200 antenatal women, they found that the level of education influence the acceptance to opt for labor analgesia, but the awareness of labor analgesia was low. Furthermore, in another study performed by Okojie and Isah, they found a statistically significant correlation between the level of education and previous labor experience with awareness as well as acceptance of labor epidural analgesia.
When we enquired about the availability of these services in our hospital, only 42.6% had information about our labor analgesia services in comparison to 63.31% women who knew about labor analgesia (P = 0.002). Our finding reflects Karn et al. recent review that despite many of the hospitals equipped with labor analgesic services, women still prefer to go through painful labor due to the lack of information. In a study done by Oladokun et al., although 80.5% had understanding of labor pain, only 19.5% had information regarding epidural labor analgesia. Delwatta et al. in their study noted that 41.9% knew about labor analgesia and among them only 6.4% had knowledge of epidural labor analgesia. A study done by Endalew et al. revealed that even in health-care personnel (midwifery) the awareness regarding labor analgesia was < 50%. Hussain and Maheswari also found similar findings that knowledge of labor analgesia was low in antenatal women as well as in medical students.
Our study revealed the source of information regarding labor analgesia for women was mainly from friends and relatives (39%) followed by media/internet (29%). ANC talks comprised of only 16% and 4% from hospital brochures. Harkins et al. in their research within 24 h of delivery found that the obstetrician, family and friends, childbirth classes, books, and previous birthing experience were important sources of information; however, in their study, the only factor that influenced in decision making of the parturient was previous epidural experience.
Edwards and Ansari in their study among middle eastern women concluded that women were not aware of labor epidural analgesia technique and also low acceptance rate was due to fear of side effects. In our study, 23% of pregnant women selected the option “none” when asked about available techniques for labor analgesia, but 34% of pregnant women knew about Entonox inhalation, 23% about intramuscular injection, and only 20% about epidural technique. Hazarika et al. depicted that only 14% in their study had knowledge of epidural labor analgesia. In a study by Ali et al., participants were mostly not aware of labor analgesia.
There were multiple responses when participants were asked about the most effective technique for labor analgesia. 60.29% said do not know (no effective technique) and 19.4% said epidural labor analgesia. This finding is similar to a survey done by Hasan et al. that was conducted in an Iraqi hospital, in which 59.9% of women were under the impression that labor pains cannot be controlled and only 5.9% were aware of painless labor.
Regarding the participant belief about the complications of epidural labor analgesia, we received multiple responses, the majority being unaware of risks and complications (34.34%). Fröhlich et al. conducted an Irish hospital survey and found that < 30% of patients had information regarding the potential complications that was variable and inaccurate. Ogboli-Nwasor and Adaji concluded the low knowledge among the women regarding side effects of epidural analgesia and fear of side effects led to underutilization of labor analgesia service; although, there was high awareness regarding labor analgesia among the study population.
The participants in our study preferred mostly the obstetrician (33%), followed by an anesthetist (22%), friends and relatives, for the information about labor analgesia. Nabukenya et al. concluded similar opinions. Gari et al. recommended special session by obstetrician or anesthetists followed by brochures in ANC. Anozie et al. in their study concluded that obstetrician should educate women in ANC regarding labor analgesia. Kamakshi et al. in their study noted the lack of knowledge among women and recommended more proactive steps to be taken by doctors in promoting labor epidural analgesia service. Thakur et al. recommended that knowledge and information has to be given in ANC visits to increase the awareness regarding labor analgesia services. Ali Alahmari et al. also noted similar findings and recommended to share information regarding labor epidural analgesia in ANC. Fawaz and Malas and Alakeely et al. in their studies emphasized the ANC visit consultation to impart the knowledge and allay fear of labor pains.
A specific question regarding reasons for not opting epidural labor analgesia technique revealed their concerns in the decreasing order of frequency: headache, fear of cesarean section, adverse advice from relatives and friends, and belief of paralysis. Ponnusamy et al. noted fear of backache, effect on the baby, and financial considerations that prevented the parturient from opting for labor epidural analgesia
There are few limitations in doing this kind of study. All participants might not interpret questions in similar way. Women may answer multiple choices that complicate the analysis. Duplication of the data is possible; however, to avoid this, we kept a register of the participants in the outpatient and also women were verbally told not to participate in the study more than once.
| Conclusion|| |
There is a gap between the availability of labor analgesia services and its utilization. The main source of information regarding labor analgesia was from friends and relatives. However, women expect more involvement by the obstetrician in discussing available pain relief methods during labor. The parity status of patients independently predicts the knowledge of labor analgesia. Surprisingly, level of education is not a predictive factor. The majority of women in our study have the preconception that there is no effective method for pain relief during labor.
- Dr Priya Das Phd., Scientific Researcher. Research and Education, King Hamad University Hospital Bahrain.
- Dr. Dhafir Al Khudairi MBCHB, FFARCSI Head, Anesthesia and Pain Medicine King Hamad University Hospital, Bahrain.
- Prof. Hosni Malas FRCOG ( London), Head, Obstetrics and Gynecology, King Hamad University Hospital, Bahrain.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Le Ray C, Goffinet F, Palot M, Garel M, Blondel B. Factors associated with the choice of delivery without epidural analgesia in women at low risk in France. Birth 2008;35:171-8.
Anim-Somuah M, Smyth RM, Cyna AM, Cuthbert A. Epidural versus non-epidural or no analgesia for pain management in labour. Cochrane Database Syst Rev 2018;5:CD000331.
Gupta S, Partani S. Neuraxial techniques of labour analgesia. Indian J Anaesth 2018;62:658-66.
] [Full text]
Van den Bosch AA, Goossens M, Bonouvrié K, Winkens B, Nijhuis JG, Roumen FJ, et al
. Maternal quality of life in routine labor epidural analgesia versus labor analgesia on request: Results of a randomized trial. Qual Life Res 2018;27:2027-33.
Stark MA. Exploring women's preferences for labor epidural analgesia. J Perinat Educ 2003;12:16-21.
Silva M, Halpern SH. Epidural analgesia for labor: Current techniques. Local Reg Anesth 2010;3:143-53.
To WW, Quality Assurance Subcommittee in Obstetrics and Gynaecology, Hospital Authority, Hong Kong. A questionnaire survey on patients' attitudes towards epidural analgesia in labour. Hong Kong Med J 2007;13:208-15.
Oladokun A, Eyelade O, Morhason-Bello I, Fadare O, Akinyemi J, Adedokun B. Awareness and desirability of labor epidural analgesia: A survey of Nigerian women. Int J Obstet Anesth 2009;1:38-42.
Naithani U, Bharwal P, Chauhan SS, Kumar D, Gupta S, Kirti. Knowledge, attitude and acceptance of antenatal women toward labor analgesia and caesarean section in a medical college hospital in India. J Obstet Anaesth Crit Care 2011;1:13-20. [Full text]
Okojie NQ, Isah EC. Perception of epidural analgesia for labour among pregnant women in a Nigerian tertiary hospital setting. J West Afr Coll Surg 2014;4:142-62.
Karn S, Yu H, Karna S, Chen L, Qiao D. Women's awareness and attitudes towards labor analgesia influencing practice between developed and developing countries. Adv Reprod Sci 2016:4;46-52.
Delwatta SL, Kaushalya PD, Shehan AK, Pilimatalawwe C, Prathapan S. Is knowledge and attitude on epidural analgesia during labor satisfactory among pregnant women attending antenatal clinics in Colombo district? Sri Lankan J Anaesthesiol 2019;27:21-7.
Endalew NS, Tawuye HY, Melesse DY. Knowledge and attitude towards pain relief in labor among final year midwifery students: A cross-sectional study. Int J Surg Open 2020;1:38-42.
Hussain SS, Maheswari P. Barriers for labour analgesia in South India – Knowledge and attitude of relevant stakeholders: A hospital-based cross-sectional study. Indian J Anaesth 2017;61:170-3.
] [Full text]
Harkins J, Carvalho B, Evers A, Mehta S, Riley ET. Survey of the factors associated with a woman's choice to have an epidural for labor analgesia. Anesthesiology research and practice 2010 Jan 1;2010.
Edwards G, Ansari T. A survey of women's views of epidural analgesia in the Middle East. J Asian Midwives 2015;2:34-41.
Hazarika R, Rajkhowa T, Parua S. Awareness of epidural labor analgesia among postpartum women at Guwahati Medical College: A cross-sectional study. Int J Adv Health Sci 2016;2:1-5.
Ali M, Sultan SF, Kumar A, Ghouri N. Knowledge, attitude and practices of labor analgesia amongst healthcare workers and patients: A single center cross sectional study. Pak J Med Sci 2020;36:S4-8.
Hasan MS, Alsaadi ZA, Abbas MA, Algoraby JM. Awareness and attitude of pregnant women towards labor analgesia in Babil province. Med J Babylon 2016;13:1.
Fröhlich S, Tan T, Walsh A, Carey M. Epidural analgesia for labour: Maternal knowledge, preferences and informed consent. Ir Med J 2011;104:300-2.
Ogboli-Nwasor EO, Adaji SE. Between pain and pleasure: Pregnant women's knowledge and preferences for pain relief in labor, a pilot study from Zaria, Northern Nigeria. Saudi J Anaesth 2014;8:S20-4.
Nabukenya MT, Kintu A, Wabule A, Muyingo MT, Kwizera A. Knowledge, attitudes and use of labour analgesia among women at a low-income country antenatal clinic. BMC Anesthesiol 2015;15:98.
Gari A, Aziz A, ALSaleh N, Hamour Y, Abdelal H, Ahmed RS. Awareness of epidural analgesia among pregnant women in Jeddah, Saudi Arabia. Electron Physician 2017;9:4274-80.
Anozie OB, Lawani LO, Mamah JE, Esike CO, Ezeonu OP, Eze JN, et al
. Epidural analgesia for management of labour pain: Determinants and deterrents among obstetricians in Nigeria. Int J Women's Health Reprod Sci 2018;4:410-4.
Kamakshi G, Anju G, Tania S, Priyanka G, Kamya B, Gegal P, et al
. Epidural analgesia during labor: Attitudes among expectant mothers and their care providers. Anesth Essays Res 2018;12:501-5.
] [Full text]
Thakur M, Sagar N, Tandon P. Knowledge and attitude regarding epidural analgesia among expectant mothers. Int J Reprod Contracept Obstet Gynecol 2017;6:1929-31.
Ali Alahmari SS, ALmetrek M, Alzillaee AY, Hassan WJ, Ali Alamry SM. Knowledge, attitude, and practice of childbearing women toward epidural anesthesia during normal vaginal delivery in alsanayeah primary health care in Khamis Mushait. J Family Med Prim Care 2020;9:99-104.
Fawaz M, Malas S. Lebanese women's awareness and attitude toward epidural anesthesia during labo. Data Brief 2018;19:530-4.
Alakeely MH, Almutari AK, Alhekail GA, Abuoliat ZA, Althubaiti A, AboItai LA, et al
. The effect of epidural education on primigravid women's decision to request epidural analgesia: A cross-sectional study. BMC Pregnancy Childbirth 2018;18:124.
Ponnusamy R, Reddy HK, Murugesan R. Awareness, knowledge and attitude about labor analgesia among providers and parturients; a survey based study. Anaesth Pain Intensive Care 2018;22:73-80.
[Table 1], [Table 2], [Table 3], [Table 4]