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Labour pain is among the most severe pain that a women experience in their lifetime. Since abolition of labour pain has always been surrounded by myths and controversies, providing effective and safe analgesia in labour remained a challenge. Objective: The Objective of this survey was to find out awareness, attitude and willingness to receive Labour Analgesia among pregnant women attending maternity hospitals and providing health education regarding labour analgesia to the participants and attendants encountered during study.
Method
This cross-sectional survey was conducted from January to March 2022 among pregnant women attending obstetrics & gynaecology department of BRD Medical College, Gorakhpur using semi structured, pretested questionnaire. Personal interview of participants was done to collect data.
Result
A total 204 valid responses were obtained out of 225 participants contacted (response rate 90.6%). Age of the participants were 20–35 years (mean 25.18, standard deviation 3.2). We found very little awareness regarding labour analgesia among participants attending to antenatal clinics but after providing information majority were willing to avail the facility of labour analgesia.
Conclusion
Awareness about labour analgesia was found limited but majority had positive attitude towards it. This demand supply gap can be filled by appropriate health education and increasing awareness about availability of these services.
Pain is described as an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage (International Association for the Study of Pain, IASP). Labour can be defined as spontaneous painful repetitive uterine contractions associated with the effacement and dilatation of the cervix and the descent of the foetus. Labour is reported to be one of the most painful experiences in a woman's life.
Knowledge, attitude, practice and barriers to educational implementation of nonpharmacological pain management during labor in Selected Hospitals, Kenya.
Labour pain, apart from physical component, also has emotional and cognitive elements. Labour has various effects on parturient and the foetus, some of them may be deleterious to one or both. Unaddressed labour pain can lead to certain morbidities and complications. Severe pain in the first stage of labour can make the parturient to bear down prematurely against an undilated/partially dilated cervix leading to tears and subsequent postpartum haemorrhage which is an important cause of maternal death in our environment. Uterine rupture and neuropsychological consequences can also happen in some patients. If such pain is unattended to, it can also signal an underlying problem such as obstructed labour.
in: DeChernrney A.H. Nathan L. Goodwin T.M. Laufer N. Current Diagnosis and Treatment in Obstetrics and Gynaecology. tenth ed. McGraw Hill Companies,
USA2007: 441-460
Analgesia for labour and delivery is at times controversial. Lack of knowledge regarding birth process can influence a woman's attitude to pain relief. A knowledgeable woman may understand labour pains, and positively view her pain as a sign of progress. Pain, a sense of accomplishment, and enjoyment are all experienced during labour, as a result some women may refuse pain relief.
Analgesia refers to the relief of pain without the loss of consciousness. Modalities of analgesia during childbirth include regional analgesia, systemic opioid analgesia, continuous labour support, pudendal blocks, immersion in water during the first stage of labour, sterile water injections in the lumbosacral spine, hypnosis, and acupuncture.
Labour analgesia has various beneficial effect to both parturient and foetus. ACOG and ASA stated “in the absence of a medical contraindication, maternal request is a sufficient medical indication for pain relief.” Pain management during labour has undergone various advancement since 1847, when Simpson found that chloroform could help relieve the pain a women felt during labour. His findings were not received favourably on religious and medical grounds.
The delivery of the infant in to the arm of a conscious and pain free mother is one of the most exciting and rewarding moments in medicine. (Donald D. Moir; father of labour analgesia). A study in India showed that 50% of caesarean delivery was a result of maternal request due to their previous bad experiences with labour pain.
It is now well recognized that the only consistently effective method of pain relief during labour is lumber epidural analgesia. In low-income countries epidural analgesia is a relatively new concept being available in few hospitals. Even when the option of epidural analgesia is provided to parturients, refusal rate is high. The reasons include the lack of demand by patients, obstetricians and anaesthesiologists who are not keen to routinely practice it, lack of equipment/devices and low awareness among pregnant women.
Most of the parturient still suffer from the agony of labour pains due to lack of awareness, lack of availability or knowledge of labour analgesia services.
The awareness level needs to be improved. With advancement in modern obstetrics and new trends coming up, mothers are keen to know about them. The decision to use epidural analgesia during labour is affected by many factors such as the culture and background of the women, their knowledge, financial status, and educational level.
Women's awareness regarding the use of epidural has increased in affluent countries. A study conducted in Finland showed that 66.5% of women with first vaginal delivery of singleton pregnancies had requested epidural analgesia for labour pain relief.
In Brazil, women who requested epidural analgesia were satisfied with their experience and 97% of them would consider going through the same procedure at future deliveries.
Combined spinal-epidural anesthesia and non-pharmacological methods of pain relief during normal childbirth and maternal satisfaction: a randomized clinical trial.
Most of the studies conducted in the field of labour analgesia have focused on drug trials which have evaluated the efficacy of various drugs that are used in epidural analgesia.
Very few studies have been conducted focusing on the pregnant women's views regarding labour analgesia in general and epidural analgesia in particular. Therefore, this study aims to assess the awareness, attitude and Willingness to receive Labour Analgesia among pregnant women attending maternity hospital at a tertiary care centre in Eastern U.P. We also provided health education to pregnant women and their accompanied persons regarding labour analgesia.
2. Materials and method
Study population: Pregnant women attending maternity hospital.
Study Design: Cross sectional survey using pretested questionnaire.
Study Unit: A pregnant woman above age 18 years of any gravida and parity attending obstetrics & gynaecology department of BRD Medical College Gorakhpur.
Sample size: Sample size of 204 patients was calculated based on a previous study (Hussain SS, Maheshwari P, 2017) where only 14% of the patients were aware about labour analgesia and using the formula z2 pq/d2. Where p is proportion of aware patients (14%), q is 100-p and d is absolute precision or alpha error of 5%. Applying an attrition rate of 10% (19) gave a sample size of 204.
Inclusion Criteria: Any pregnant woman above age 18 years who give consent to participate in the survey.
2.1 Exclusion criteria
i)
Parturients in active labour.
ii)
Patient who doesn't understand either of English, Hindi, Urdu and Bhojpuri.
iii)
Those who attended antenatal clinic for termination of pregnancy.
iv)
Those pregnant women who has already participated in the survey in last visit.
v)
Any pregnant women having contraindications for vaginal delivery.
vi)
Any pregnant woman not willing to participate in study and/or not giving consent.
3. Operational definition
Gravida: Primigravida women who had not become pregnant before were considered, and women who had become pregnant at least once before were considered multigravida.
Pain: Pain was graded using NRS (Numerical Rating scale). Participants were asked to rate their pain on a scale from 0 to 10 where “0” indicates absence of pain and “10” represents worst imaginable pain. This scale was categorised for analysis as:
Tabled
1Table-A Numerical Rating Scale (NRS) used for pain grading.
Had awareness: Women who said yes when asked if they had prior information about labour analgesia.
Had good attitude: Women who said yes when asked if labour pain should be treated.
Willingness: Women who said yes when asked if they would opt labour analgesia for their forthcoming delivery.
Study tools: Questionnaire was designed at the Department of Community Medicine, BRD Medical College in consultation with the principal investigator & co investigator to find out awareness about Labor Analgesia and attitude towards acceptance among pregnant women attending maternity hospital.
Sampling method: Multi stage random sampling was done to recruit study participants. In the first stage of sampling two days per week was decided randomly by rolling a 6-sided dice. This process was repeated till the data collection days for all 12 weeks (from January 2022 to March 2022) of data collection period was selected. By doing it we prepared a date wise list of 24 OPD days for data collection. Total duration of OPD day was divided in to four quarter (08:00 a.m. to 10:00 a.m., 10:00 a.m. to 12:00 p.m., 12 p.m. to 02:00 p.m., 2:00 p.m. to 4:00 p.m.) for purpose of data collection. On every morning of data collection day, decision for data collection timing was made by lottery method. Data collection has been done during this selected 2 h duration of OPD. 8–10 pregnant ladies per data collection day were recruited. Decision to include pregnant women in study was done by flipping a coin. If heads lady was asked to participate in study and if tails she was ignored.
Data collection and statistical analysis: Survey was conducted through personal interview among the pregnant women attending obstetrics & gynaecology department of BRD Medical College Gorakhpur using a semi-structured questionnaire to obtain information on awareness, attitude and willingness of pregnant women about Labour Analgesia. The questionnaire was framed to collect information on demography, medical history and obstetric history. A pilot study was undertaken to validate study protocol with a sample of 25 participants to know the average time required for completing the questionnaire through personal interview and to ensure that it is appropriate and understandable to participants. Pilot population was not part of the final study. The questionnaire was re-framed after making necessary amendments to make it simple and easy to understand. Aim and modality of study was explained to all the participants and were explained to mark questionnaires as per instructions. Women were requested to complete the survey through personal interview after obtaining their informed consent. After documenting sociodemographic and awareness related information participants were given a brief information about labour analgesia and then rest questionnaire completed. If the participant were not in favour of accepting labour analgesia, the reasons for the non-willingness were asked and noted. Each interview took about 8–10 min. Filled questionnaires were checked for completeness. Data collectors adhered to strict COVID-19 protocols. After data collection we asked participants regarding any queries regarding labour analgesia and addressed them. All participants were advised to continue their rest/next antenatal visits as per schedule. We collected data from various participants and analysed data by using Statistical Package for Social Sciences (SPSS) version 21.
3.1 Ethical clearance statement
Study was approved by Institutional Human Ethics Comittee of BRD Medical College Gorakhpur.
4. Results
Two hundred and twenty-five pregnant women were approached for the survey at obstetrics & gynaecology department of BRD Medical College Gorakhpur. Among them 212 consented and participated in the study, 8 of them left the survey incomplete, finally data from 204 (response rate 90.6%) participants were collected and analysed.
Data of 204 participants were analysed. Their sociodemographic attributes are compiled in Table 1. Majority of participants (48.5%) were in age group 25–30 year, 25% participants were having done graduation and 95.5% participants were unemployed or homemaker.
Out of the 204 participants 111 (54.4%) were primigravida and 93 (45.6%) were multigravida. They were at different stages of gestation. Among 93 multiparous women 79 had previous normal delivery,7 participants had delivery at home. Two-third (67.1%) of pregnant women who had at least one occasion of labour pain described it as severe and 31.8% rated it as moderate. More than half (52.9%) among previously normally delivered women had not offered any sort of labour analgesia. Six parturients requested and consented for caesarean section due to severe labour pain. Labour epidural analgesia was utilized by only 7.1% among previously normally delivered participants (Table 2).
Table 2Obstetric characteristics and previous labour analgesia exposure.
Obstetric characteristics
No. (%)
Gravida (N = 204)
Primigravida
111 (54.4)
Multigravida
93 (45.6)
Gestational period (N = 204)
First trimester
28 (13.7)
Second trimester
55 (27)
Third trimester
121 (59.3)
Mode of previous delivery (N = 93)
Normal
75 (80.6)
Caesarean
14 (15)
both
4 (4.4)
Place of previous delivery (N = 93)
At home
7 (7.5)
Peripheral health centre
24 (25.8)
Govt referral hospital
35 (37.6)
Private hospital
27 (29.1)
Expected mode of delivery in current pregnancy (N = 204)
Normal
121 (59.3)
Caesarean
22 (10.8)
Can't say
61 (29.9)
Previous normal delivery count (N = 79)
One
59 (74.7)
Multiple
20 (25.3)
Labour pain during Previous delivery (N = 85)
Mild
1 (1.1)
Moderate
27 (31.8)
Severe
57 (67.1)
Any method of labour analgesia used in previous normal delivery (N = 85)
No
45 (52.9)
Yes
40 (47.1)
Labour epidural analgesia used in previous delivery (N = 85)
Only 37.7% participants had an idea that normal delivery can be accomplished without suffering from labour pain (Table 3). Major source of information about labour analgesia were from treating doctors (25%) followed by social media (16.2%%) and relative and friends (10.8%).
Table 3Awareness about labour analgesia (N = 204).
Awareness about labour analgesia
Number (%)
Do you know vaginal delivery is possible without pain
Yes
77 (37.7)
No
110 (53.9)
Not sure
17 (8.3)
Source of information about labour pain relief (multiple options)
Doctor
51 (25)
Social media
33 (16.2)
Relatives/friends
22 (10.8)
Nurse/ASHA
9 (4.4)
Previous delivery
2 (1)
Labour pain relief methods known (multiple options)
Inhaled
17 (8.3)
intravenous injection
75 (36.8)
intramuscular injection
66 (32.4)
injection in lower back
10 (4.9)
Non pharmacological
35 (17.2)
Person providing labour pain relief
Obstetrician
16 (7.8)
Nurse/compounder
33 (16.2)
Anaesthesiologist
39 (19.1)
Don't know
116 (56.9)
Do you know availability of labour analgesia in your attending hospital
Yes
11 (5.4)
No
106 (52)
No idea
87 (42.6)
Any of your relative/friend used labour pain relief
Majority of the participants expressed positive attitude when they have given a brief information about labour analgesia. More than half (55.9%) participants opined that labour pain should be relieved. Only 34.8% participants were ready to bear extra cost for labour analgesia (Table 4). About two third (67.6%) participants expressed their willingness to utilise the service in their current/future delivery. Most participants cited their doctor's advice about the method of labour analgesia to be used.
Table 4Attitude about labour analgesia.
Attitude about labour analgesia
Yes
No
Can't say
Number (%)
In your opinion should labour pain be relieved
114 (55.9)
35 (17.2)
55 (27)
Do you have any fear regarding labour analgesia?
125 (61.3)
25 (12.3)
54 (26.5)
Are you ready to bear cost of labour analgesia?
71 (34.8)
36 (17.6)
97 (47.5)
Do you wish to opt labour analgesia in your current/future pregnancy?
138 (67.6)
28 (13.7)
38 (18.6)
Would you recommend labour analgesia to your family and friends?
100 (49)
15 (7.4)
89 (43.6)
Do you think that labour analgesia is not suitable in Indian setup?
10 (4.9)
27 (13.2)
167 (81.9)
Which method will you choose to relive pain of labour if offered?
Most common cited (71.4%) reason for showing willingness was the desire of pain relief during labour.(Table 5) Some (10%) were afraid of severe painful experience during previous delivery, another 10% wanted to opt labour analgesia because of fear of operative delivery. Four participants (2.9%) chose labour analgesia because they wanted delivery through vaginal route only. Regarding reluctance to utilise labour analgesia about one-third (31.3%) among non-willing participants thought that it may interfere with progress of labour. Thirteen participants (20.3%) believed that reducing labour pain may be harmful to them and/or foetus. Guardians of some (18.7%) participants refused to use labour analgesia in their patients. One participant experienced only mild pain in her last delivery and felt no need of any external manipulation of labour in the form of labour analgesia.
Table 5Reasons cited in favour and against of labour analgesia.
Reasons why wanted to opt labour analgesia (N = 140)
Number
%
Because it is better than painful labour
100
71.4
Traumatic experience in previous delivery
14
10
Fear of operations
14
10
Because it better than LSCS
8
5.7
Patient wanted vaginal delivery
4
2.9
Reasons why not desirous to utilise labour analgesia (N = 64)
McGill pain questionnaire comparing pain scores for women in labour and other painful conditions, shows that labour pain is more severe than cancer pain and it is almost close to the pain experienced due to amputation of digit.
The American College of Obstetricians and Gynaecologists (ACOG) rightly observed that labour is associated with severe pain for many women and that under no circumstance should a woman be allowed to bear pain which is amenable to safe intervention while under the care of a physician. So, in the absence of any contraindication, pain relief should be provided in labour on maternal request.
Pain – free labour is nearly universal in high income countries. However, in low – income countries where women are mostly burdened with high pregnancy rates and short interpregnancy intervals, pain relief in labour remains a distant reality.
In the present study 52.9% of the previously normally delivered participants were not utilized any method of pain relief during labour. Epidural analgesia is widely recognized and used as an effective method of pain relief in labour.
The use of epidural analgesia for relief of labour pain has increased globally in recent time. This is in sharp contrast to what is obtained in low-income countries with only between 1.3% and 12% of parturients benefitting from epidural analgesia.
In the present study only 7.1% participants used labour epidural analgesia in previous delivery. Participants had less awareness of labour pain and methods used for labour analgesia. The data from various low-income countries show similar result, India (10.2%)
Many women (53.9%) in present study still do not know that pain of labour can be relieved. In a study conducted by Sadawarte and Bhure primigravida women in a rural hospital in India had less knowledge and poorly prepared for the experience of labour.
A number of pregnant women report antenatal clinics during advance pregnancy. They lack adequate knowledge regarding childbirth. Some of them has attitude that pain of labour is a normal process to which every pregnant must experience to become a mother. Pain in labour is usually considered a positive feature of labour and the idea of relieving it is often opposed in developing countries. This reflects traditional values, according to which pain during labour denotes successful bonding with the baby. A girl child who is sensitized to such values during her growing period learns to accept and endure the pain of childbirth.
It has been observed that healthcare providers in developing countries are either ignorant or consider educating women on pain relief methods during labour as a low priority issue.
This study also found that only 60 out of 204 got some information regarding labour analgesia from their treating doctor and paramedical staff. Young women in some cultures believed that labour pain is natural and inevitable and that the ability to accept and endure it is a sign of womanhood.
In this study 3.7% of the participants were not opting labour analgesia because they wanted to experience natural birth. The most significant reason for refusal of labour analgesia in some studies was the desire to experience natural childbirth.
Issues in high-income countries are focused on the choice of methods and complications, while in low-income countries major issues are awareness and acceptability of analgesia for labour. Antenatal visits are the best time to impart this information. This is backed up by a study, which states the information provided about pain relief during antenatal periods are the most useful.
We conclude that there is little awareness about labour analgesia among pregnant women in Uttar Pradesh. Despite their lack of prior knowledge, majority want to have labour analgesia for their next delivery after educating then about labour analgesia. Among most significant reasons for refusal was harmful effect of labour analgesia, reluctance by guardian, insufficient knowledge and desire to experience natural childbirth. Most women were concerned about the extra cost incurred in using labour analgesia and provision of painless delivery. Parturient women in this study had poor knowledge about epidural analgesia, and this necessitates the role of doctors and other healthcare workers in disseminating appropriate and accurate knowledge regarding epidural analgesia and eliminating the fears and misconceptions of parturients to increase its utilization.
Recommendation
It is recommended that information about painless labour should be given by the antenatal physician, obstetrician or nurses in collaboration with anaesthesiologists to inform pregnant women about benefits, modalities and limitations of painless labour. There should be mass media campaign for proving information about labour analgesia, to increase awareness and acceptance of labour analgesia. Home visits by village health guides may be utilized for providing information about labour analgesia. Leaflets containing details on labour analgesia during antenatal visits can be another option for reducing the burden of counselling.
Financial support and sponsorship
Nil.
Declaration of competing interest
There are no conflicts of interest.
References
Ramasamy P.
Knowledge, attitude, practice and barriers to educational implementation of nonpharmacological pain management during labor in Selected Hospitals, Kenya.
in: DeChernrney A.H. Nathan L. Goodwin T.M. Laufer N. Current Diagnosis and Treatment in Obstetrics and Gynaecology. tenth ed. McGraw Hill Companies,
USA2007: 441-460
Combined spinal-epidural anesthesia and non-pharmacological methods of pain relief during normal childbirth and maternal satisfaction: a randomized clinical trial.
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