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OBSTETRIC ANESTHESIA

Predictors of Recommendation and Acceptance of Intrapartum Epidural Analgesia

Eyal Sheiner, MD^*,, Einat K. Sheiner, MD, Ilana Shoham-Vardi, PhD^,, Gabriel M. Gurman, MD^,§, Fernanda Press, MD^*,, Moshe Mazor, MD^*,, and Miriam Katz, MD^*,

*Department of Obstetrics and Gynecology, Faculty of Health Sciences, Epidemiology and Health Services Evaluation Department, and §Division of Anesthesiology, Soroka Medical Center, Ben Gurion University of the Negev, Beer-Sheva, Israel

Address correspondence and reprint requests to Eyal Sheiner, MD, Department of Obstetrics and Gynecology, Soroka Medical Center, PO Box 151, Beer-Sheva 84101, Israel.

	Abstract

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We conducted this prospective study to characterize the obstetric and sociodemographic variables that predict physicians’ recommendations and patients’ acceptance of intrapartum epidural analgesia. The study population consisted of 447 consecutive, low-risk parturients in early active labor. Epidural analgesia was recommended to 393 patients (87.9%), however only 164 (41.7%) consented to receive it. A multiple logistic regression analysis demonstrated that the severity of pain, as assessed by the medical staff (odds ratio [OR] = 1.5, 95% confidence interval [CI] 1.13, 1.93), low parity (OR = 0.57, 95% CI 0.44, 0.74), and low maternal age (OR = 0.89, 95% CI 0.79, 0.99) were significant factors affecting recommendations of epidural analgesia. In a multivariate analysis, severity of subjective pain (OR = 1.39, 95% CI 1.16, 1.68), low parity (OR = 0.80, 95% CI 0.73, 0.99), high education (OR = 90.09, 95% CI 27.02,257.06), and the patients’ being secular compared with religious (OR = 2.14, 95% CI 1.08,4.21) were found to be independent predictors of acceptance of epidural analgesia. There are differences between patients offered and those not offered epidural analgesia and between parturients who accept and those who do not accept this analgesia. Implications: We studied the factors that influence the recommendation of epidural analgesia by obstetricians, as well as its acceptance by the laboring patients at a university hospital in Israel. Epidural analgesia was recommended more often to low parity, younger women exhibiting more pain. Parturients who perceived greater pain were more secular, had low parity, and had a higher level of education were more likely to accept it.

	Introduction

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An important factor in the care of pregnant women is analgesia during labor. The use of epidural analgesia has increased greatly in the last decade. Most studies have shown that epidural analgesia provides better pain relief than other methods (1–5).

There is a large disparity in the use of epidural analgesia among hospitals. Some departments use it for most women [approximately 80% in France (6)], while others hardly use it [6%–23% reported in five hospitals in the US (7) and 4.6% in a rural hospital in Canada (8)]. Recently, the number of patients given epidural analgesia during labor was reported to be more than 50% in many institutions in the US (9).

Little information is available about socioeconomic and obstetric factors that influence parturients’ decisions to accept or reject recommendations to use intrapartum epidural analgesia and concerning patients who are offered this mode of analgesia. Huston et al. (7) reviewed 8229 deliveries at five hospitals in the US in order to characterize women who used epidural analgesia during labor. They found epidural analgesia to be associated with nulliparity, higher maternal age, Caucasian ethnicity, and those who have private insurance. Thompson et al. (10) found that women receiving epidural analgesia were more likely to be Caucasian and to be receiving care from an attending physician.

In the present study, we aimed to define the obstetric and sociodemographic factors characterizing parturients who were offered and who accepted epidural analgesia. In addition, we attempted to assess if the severity of pain, as exhibited by patients and their subjective perception of it, predicts physicians’ recommendations and patients’ acceptance of intrapartum epidural analgesia.

	Methods

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The study population consisted of 447 consecutive, low-risk laboring women in early active labor (i.e., 4–5 cm cervical dilation with regular contractions). All parturients were at term (38- to 42-wk gestation), with a singleton fetus in cephalic presentation who had begun to deliver during the day shifts. Patients were excluded from the study on the basis of the following criteria: clinical evidence of cephalopelvic disproportion, placental insufficiency, scarred uterus, or advanced labor. The deliveries took place in the delivery room of the Soroka University Medical Center between May 1, 1997, and November 30, 1997. Women were interviewed before the administration of any type of analgesia.

Data were collected prospectively by one of the authors (ES). Information was obtained regarding ethnic origin (i.e., Jewish or Bedouin Arab), maternal age, number of pregnancies and deliveries, marital status (i.e., married, separated, or divorced), degree of religious practice (religious, traditional, or secular), level of education, and participation in antenatal childbirth preparation classes. In addition, the presence of a husband or any significant other during labor was noted. All parturients were asked if the option of epidural analgesia was offered to them after admission to the delivery ward and if they wanted to use this mode of analgesia. In addition, they were asked about the degree of pain by using a visual analog scale (VAS). The VAS is easy to use and is a sensitive, reliable method for pain measurement (11,12). One obstetrician and the midwife attending the birth estimated the degree of pain experienced by the parturients, using the same scale. When two different scores were given (by the obstetrician and midwife), the mean score was calculated.

During the study period, there were six obstetricians practicing in this delivery room. The epidural analgesia was offered to the laboring women by the obstetric team during rounds, which were performed every hour. Individual provider bias in offering epidural analgesia was not likely to occur because a team approach was fostered. The patients were given an explanation regarding the two options of analgesics available in our medical center, epidural analgesia or IV opioids. A written form explaining the technique of epidural was provided to those who were interested in receiving epidural analgesia, and an anesthesiologist was called when further information was required. It is noteworthy that patients attending antenatal classes are made aware of the risks and benefits of the two available analgesic techniques. In our study population, we found that only primiparas had participated in the antenatal classes. The study was approved by the ethics committee of the hospital.

Statistical analyses were performed with the SPSS package (SPSS, Chicago, IL). ² or Fisher’s exact test for comparison of proportions and Student’s t-test for comparison of means were used. P < 0.05 was considered statistically significant. Logistic regression was used to investigate the multivariate regression relationship of patients’ sociodemographic characteristics or pain perception, and physicians’ offer of intrapartum epidural analgesia, as well as its use during labor. Odds ratios (OR) with 95% confidence intervals (CI) were calculated from the regression coefficients.

	Results

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Of the 447 parturients interviewed, epidural analgesia was offered to 393 patients (87.9%). One hundred sixty-four patients consented, but it was administered to only 131. Twenty patients did not receive epidural analgesia because of the unavailability of an anesthesiologist to administer it, while the other 13 were not given epidural analgesia because of technical and medical reasons.

Table 1 compares the characteristics of the 393 women who were offered an intrapartum epidural analgesia with the 54 women who were not. Patients who were offered epidural analgesia compared with those who were not were significantly younger (26.5 vs 32.8 yr, repectively, P < 0.001), were of Jewish ethnicity (63.4% and 11.1%, respectively, P < 0.001), and had fewer pregnancies and deliveries (2.7 vs 7.8 pregnancies, respectively, P < 0.001; 2.3 vs 7.1 deliveries, respectively, P < 0.001). In addition, they were better educated than parturients who were not offered epidural analgesia (none of the latter group had more than 12 yr of schooling), were more likely to have participated in a childbirth preparation course (none of the latter group had participated), tended to be more secular (45.8% vs 3.7%, respectively, P < 0.001), and were more likely to have a close relative present during labor (61.8% vs 14.8%, respectively, P < 0.001). The degree of pain exhibited was found to be significantly higher in those parturients who were offered epidural analgesia (mean VAS score = 8.11) as compared with those who were not (mean VAS score 5.72, P < 0.001).

	Discussion

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In Israel, the basic health services are equally available to all patients, regardless of ethnicity or any sociodemographic factor, and epidural analgesia, as well as most other procedures in childbirth, are fully covered by the National Health Insurance. Despite this, epidural analgesia was not equally offered to all parturients. Actually, the univariate analysis demonstrated a large disparity between parturients who were offered this analgesia and those who were not, including ethnicity, as was found by Todd et al. (14). It is not clear whether the impact of ethnicity on the offer of epidural analgesia is the "chicken or egg," i.e., because Bedouin women were much less likely to accept epidural analgesia, providers lacked enthusiasm to suggest it. However, caution is required in interpreting those results because many of those variables are interrelated. Indeed, a multiple logistic analysis taking into account all the statistically significant univariate variables, showed only the degree of pain, parity, and maternal age to be independent factors responsible for this difference.

In a further analysis of our data, we compared patients’ perception of their pain with that estimated by the healthcare provider. The caregiver tended to underestimate the pain of the Bedouin and the grandmultiparous women who tended to suffer stoically (15). Although the means of the self-assessments of pain intensity levels of Jewish and Bedouin parturients were similar (8.55 and 8.53, respectively, P = 0.25), the caregiver interpreted Bedouin women to experience less pain than the Jewish patients (6.89 vs 8.52, P < 0.001). Thus, it is important for the clinician to be aware of the wide spectrum of factors that might influence pain expression and interpretation.

The obstetricians might have assumed that older parturients with high birth order are candidates for shorter and, thus, less painful delivery as compared with those with low birth order. Although it was shown that the major independent determinant of labor pain is parity and that parity is negatively associated with the level of pain (16), Ranta et al. (17) examined the intensity of labor pain in grandmultiparas and found that a significant number felt that they had received insufficient pain relief during labor. None of those patients had received epidural analgesia. Thus, the option of epidural analgesia should be provided to grandmultiparous women as well. Low birth order was found to be an independent predictor of the offer and the acceptance of epidural. Almost all studies concerning epidural analgesia found nulliparity independently associated with this mode of analgesia (1,7,18) This trend may be a result of the higher rates of recommendation by the medical staff probably because of the knowledge that primiparous women tend to suffer more pain than multiparas (16,19) and maybe because of the exposure to this type of analgesia during participation in antenatal childbirth classes. Women who do not express pain during labor are more likely to undergo painful deliveries, because the staff is less attuned to their needs and, therefore, may be less likely to offer epidural analgesia to them.

Religious women are less likely to use epidural analgesia for various reasons. They might be less informed with regard to the benefits and the risks of this analgesia, and they might lack the support from their religious leaders to use it. The association between the level of education and the use of epidural is probably a result of the patients’ being better informed about the benefits and risks of it; therefore, they might be less fearful of this type of analgesia. Finally, the degree of pain certainly influences parturients’ acceptance of intrapartum epidural analgesia. It seems that patients who suffer extreme pain will accept intrapartum epidural analgesia regardless of their level of education.

This study was conducted in a delivery room that has approximately 1000 deliveries a month, with a relative shortage of anesthesiologists, although this service is available 24 hours a day. The fact that a particular patient may ultimately not receive epidural analgesia because of logistics did not affect the obstetrician’s recommendation rate. At this institution, the obstetricians expect that the anesthesiologist will be available at all times. The 12% of the patients who consented to epidural analgesia but could not receive it are the exception and were offered an alternative method of analgesic, i.e., parenteral opioids. Because of the results of our study, the Division of Anesthesiology has improved the availability of the on-call anesthesiologists in order to provide the option of epidural analgesia to more laboring women.

This study demonstrates that there are differences between patients offered and those not offered epidural analgesia, and between parturients who accept and those who do not accept it. We believe that the options available to provide labor analgesia should be discussed with all patients, regardless of age, parity, socioeconomic, ethnic, or religious backgrounds.

	Acknowledgments

 
The authors want to thank the midwives Sue Shachar, Leslie Tannenbaum, and Adrienne Neta, and Hadar Spivack, MD, for their help and valuable remarks on the paper.

	References

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Similar articles in Web of Science Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Web of Science (12) Citing Articles via Google Scholar Google Scholar Articles by Sheiner, E. Articles by Katz, M. Search for Related Content PubMed PubMed Citation Articles by Sheiner, E. Articles by Katz, M.