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Department of Family Practice, Faculty of Medicine, University of British Columbia, Vancouver, BCWomen's Health Research Institute, BC Women's and Children's Hospital, Vancouver, BC
School of Population and Public Health, Faculty of Medicine, University of British Columbia, Vancouver, BCBC Children's Hospital Research Institute, Vancouver, BC
School of Population and Public Health, Faculty of Medicine, University of British Columbia, Vancouver, BCBC Children's Hospital Research Institute, Vancouver, BC
This study sought to assess change in knowledge and preference for epidural use associated with use of an information pamphlet and to explore women's decision-making and information needs regarding pain relief in labour.
Methods
Six focus groups with women who were pregnant or had given birth during the past 12 months were conducted in three northern communities in British Columbia. Following completion of a 10-item knowledge pretest, women were randomly assigned to read either a short version or a detailed version of the pamphlet and then complete a post-test. After reading the alternate pamphlet they participated in a moderated discussion. Pretest and post-test knowledge scores were compared, and a thematic analysis of focus group data was conducted.
Results
Knowledge scores increased (2.12 points out of a possible total of 10; standard deviation 2.38; 95% CI 1.38 to 2.87). There was no difference in knowledge change or epidural preferences according to which version participants read first. Women preferred the detailed version and indicated that its information was more balanced. Four themes related to decision-making and information needs arose from the focus groups: making an informed choice, being open-minded, wanting comprehensive information, and experiencing pressure to have/not have an epidural.
Conclusion
An illustrated information pamphlet can significantly increase women's knowledge of benefits and risks of epidural analgesia, but it is not associated with change of preference. Women prefer to receive comprehensive information prenatally to support informed choices in labour.
Résumé
Objectif
La présente étude avait pour but d'évaluer le changement dans le niveau de connaissance sur la péridurale et le choix d'y recourir à la suite de la lecture d'un dépliant d'information, et d'étudier le processus décisionnel sous-jacent et les besoins en information concernant l'analgésie pendant le travail.
Méthodologie
Six séances de discussion entre des femmes qui étaient enceintes ou avaient accouché dans les 12 mois précédents ont eu lieu dans trois localités du Nord de la Colombie-Britannique. Après avoir répondu à un test de connaissances de dix questions, les participantes ont lu la version courte ou la version détaillée d'un dépliant, selon une répartition aléatoire. Elles ont ensuite répondu une nouvelle fois au test, puis ont pris part à une discussion animée. Les résultats du pré-test et du post-test ont été comparés, et les données issues des séances de discussion ont fait l'objet d'une analyse thématique.
Résultats
Les résultats au test de connaissances ont augmenté (de 2,12 points sur un maximum de 10; écart-type : 2,38; IC à 95 % : 1,38 à 2,87) après la lecture. Le changement dans le niveau de connaissance et le choix de recourir à la péridurale était le même, peu importe la version du dépliant lue en premier. Les participantes ont préféré la version détaillée, précisant que son contenu était mieux équilibré. Enfin, les séances de discussion ont permis de dégager quatre thèmes en lien avec le processus décisionnel et les besoins en information : la prise de décision éclairée, l'ouverture d'esprit, le désir d'obtenir de l'information complète et la pression de recourir ou non à la péridurale.
Conclusion
La lecture d'un dépliant d'information illustré peut entraîner une hausse significative de la connaissance des avantages et des risques de la péridurale, mais n'est pas associée à un changement dans la décision d'y recourir ou non. Les femmes préfèrent obtenir de l'information complète sur le sujet pendant la grossesse afin d'être en mesure de faire un choix éclairé pendant le travail.
Epidural analgesia has become an increasingly popular method of pain relief during labour. A 2011 study reporting on birth certificate data for 27 US states indicated that 61% of labouring women used epidural analgesia for pain management during labour.
In Canada, epidural analgesia was used in 56.7% of labours ending in vaginal delivery in 2011, as reported by the Canadian Institute for Health Information.
A 2011 Cochrane systematic review of 38 randomized controlled trials concluded that epidural analgesia provided superior pain relief when compared against other pain relief methods.
Epidural analgesia is performed by injecting a local anaesthetic into the epidural space of the lower spine. The anaesthetic blocks sodium channels in the nerve fibres from conducting pain from the pelvis and thus blocks transmission to the central nervous system.
Potential side effects include itchiness, drowsiness, shivering, fever, maternal hypotension, urinary retention, and, less frequently, post–dural puncture headache. Epidural analgesia is associated with a prolonged second stage of labour and increased instrumental vaginal delivery.
highlighted the discrepancy between expectations and experiences of pain. Among women who planned not to use pharmacological pain relief, 52% actually used it.
The review concluded that knowledge about pain management helped women make informed choices and that consideration and evaluation of options also helped women cope physically and psychologically.
an epidural. Fear of adverse consequences of epidural analgesia are significant deterrents to its use, including fears of needles, paralysis, chronic back pain, or increased risk of caesarean.
illustrated that women often could not recall information regarding epidural analgesia given by anaesthetists during labour as part of the informed consent process.
To address gaps in women's knowledge about epidural analgesia, we developed and evaluated a pamphlet intended for review before the labour experience. We measured change in women's knowledge of risks and benefits of epidural analgesia in labour after reading the pamphlet and assessed their preference for a short version versus a more detailed version. We also explored women's decision-making and information needs regarding pain management strategies for labour.
Materials and Methods
Setting and Participants
We conducted six focus groups in three rural British Columbia communities purposely selected to reflect the ethnic, socioeconomic, and geographic diversity of childbearing women in the northern region of the province. The Northern Health Authority (NHA) is the largest health region in the province, covering over two thirds of British Columbia, and access to antenatal care and education is a significant issue for women in this rural region.
Participants included English-speaking women who were pregnant or had given birth in the past 12 months and who lived in the NHA. Recruitment strategies included the following: (1) third-party recruitment by public health nurses; (2) passive recruitment using study posters in community settings frequented by pregnant women and new mothers; and (3) passive recruitment through posting of recruitment posters to Facebook message boards on the subjects of childbirth, parenting, and community events. Ethics approval for the study was obtained from the behavioural research ethics boards of the University of British Columbia and the NHA [H14-03404]. All participants read and signed a study consent form. They received a $25 honorarium for their participation. Participants were also reimbursed for childcare costs and/or for travel expenses if they attended by transit or from an outlying community.
Development Process
We developed an epidural patient information pamphlet with the support of Optimal Birth BC (www.optimalbirthbc.ca), a multidisciplinary team consisting of academic and clinician researchers and specialists in health education who are funded in British Columbia to enhance informed decision making among parturient women and their families. The aim of the pamphlet is to increase women's knowledge of epidural analgesia to ensure that they have accurate knowledge of the risks, benefits, and alternatives for pain relief in labour. The pamphlet is intended to support discussions among women, their families, and their primary maternity care providers well in advance of labour and delivery.
Content for the pamphlet was developed from a review of the literature,
examination of existing provincial patient resources, and discussions with anaesthetists. We developed a long, detailed version of the pamphlet (1565 words) containing a reference list and numerical risk estimates for adverse outcomes and a short version (846 words) with summary information in narrative form. The multidisciplinary development team reviewed the two pamphlets and assessed their accuracy, plain language level, and layout. The readability of the pamphlet was further assessed using the SMOG Index,
and it was found to have a reading level higher than recommended for plain language materials. We edited the content to a grade 9 reading level by reformatting the pamphlets to have low keyword density and a simplified sentence structure. Both pamphlet versions were printed as four-panel, double-sided colour prototypes. The Figure presents the short version of the pamphlet prototype (Figure).
Participants completed a demographic questionnaire and a pretest consisting of the following: (1) 10 knowledge statements about outcomes related to epidural analgesia, each scored as “True,” “False,” or “Don't Know”; and (2) a single-item question, “For your next birth would you consider an epidural?” scored as “Yes,” “No,” and “Unsure.” The single item was followed by an open-ended prompt asking, “Why/Why not?” After the pretest, the participants were randomly assigned to review the short version or the detailed version of the pamphlet. Participants read the assigned pamphlet and then repeated the 10-item knowledge test and same single-item question. The post-test additionally included questions assessing the participant's perspective on the pamphlet length, amount of information, bias, usefulness in making a decision, impact on the ease or difficulty of making a decision, and impact on their ability to make an informed choice. Following completion of these tasks, each participant was asked to read whichever length of pamphlet she had not just evaluated to compare the two formats.
A research team member (S.M. or A.H.) with experience in focus group moderation guided a 30-minute discussion with participants about their impressions of the pamphlet. Open-ended questions explored the following issues: participants' information needs and preferences regarding epidural use for pain relief; the relevance of the pamphlet's content and its comprehensibility; the impact of the pamphlet on knowledge; the appearance of the font, colour scheme, layout, and tri-fold format; and preference for the short version or the long version and why. Each focus group discussion was audiotaped and transcribed verbatim.
Knowledge Pretest and Post-Test Analysis
Change in knowledge was measured by summing the number of correct answers for each respondent and then comparing scores using paired t tests, after tests of normality indicated that the answers were normally distributed. Sample size calculations were not undertaken before the study because we had no basis on which to estimate baseline knowledge scores. The influence of demographic characteristics, as well as test length, on post-test scores was evaluated using linear regression to test the significance of inclusion of predictor variables in the regression model. Changes in preference for an epidural at the next birth was documented in a five-point Likert scale and analyzed using the Wilcoxon signed ranks test for paired nonparametric data. A P- value of or below 0.05 was considered to be statistically significant. Attributes of the pamphlets measured on a five-point scale were compared between persons receiving short versions and long versions of the scale by using the chi-square statistic.
Analysis of Focus Group Discussions
Thematic analysis guided the focus group qualitative analysis.
Two research team members (E.G. and N.T.) independently coded a sample of the transcripts and compared their coding. They achieved a high level of congruence in coding, and any disagreements were resolved through discussion with a third member of the research team (S.M.). The two coders then each took one half of the transcripts and coded them independently. The coded transcripts were then entered into QSR NVivo qualitative data management software for organization (Mac version 10.1.3, QSR International., Melbourne, Australia). Key thematic findings were written into an explanatory narrative.
Results
Forty women were enrolled in the study (Table 1). Most were born in Canada, were between the ages of 20 to 29, and lived with a partner. Education was evenly distributed among categories of high school graduation, college or technical school, and university completion. Similarly, there was a wide range of income. All but three participants were multiparous, with about one half of the sample having one previous child. Most (75%) had given birth vaginally for their first birth. When asked where they had received information about epidurals to date, the most common responses, in order, were classes, books, friends, their family doctor, and the Internet. When asked where they would go for information the most frequent responses, in order of prevalence, were family doctors, the Internet, books, nurses, and classes (Table 2).
Knowledge scores increased significantly after reading the pamphlet (Table 3). The mean difference was 2.12 points on a possible total of 10 (standard deviation [SD] 2.38; 95% CI for the difference 1.38 – 2.87; P < 0.001). Changes in scores were significant for both the short version (mean difference 2.42 [SD 2.27]; 95% CI 1.33 – 3.51) and the long version (1.27 [SD 1.83]; 95% CI 0.25 – 2.28). Changes in scores between the long and short versions were not significantly different before or after adjusting for maternal age, parity, care provider, income, or education.
Table 3Knowledge test, before and after review of the pamphlet
Preference for epidural analgesia for the next birth did not change overall after reading the pamphlet or reading either the short version or the detailed version.
Attributes of the Pamphlet
Overall, respondents indicated that the length of the pamphlets was just right (67.5%); 15% indicated that the pamphlets were too short or somewhat short, and 17.1% indicated that they were too long. Although 31.3% of the group reading the detailed version first felt that it was too long, only 5.3% who read short version first felt that it was too long. With respect to the amount of information, overall 70% felt that it was just right. Among women who started with the short version, 36.8% felt that there was too little information, compared with 18.8% who read the long version first; there was no significant difference between groups. Significantly more women (75%) in the long version group felt that the information provided was balanced compared with those in the short version group (52.6%), where more women felt that the pamphlet was slanted towards having an epidural (36.8% vs. 12.6%). Eighty percent of women overall indicated that the pamphlet would be useful to assist them in making a decision about an epidural, with 12.5% being neutral. Differences between groups were not statistically significant. Sixty percent of women overall felt that enough information was included to enable an informed choice with 30% wanting more information, a finding similar across groups.
Attitudes Towards Short and Long Versions
In focus group discussions, participants perceived the content of both versions to be detailed, but overall they preferred the long version. The list of citations was perceived to be trustworthy and illustrated that the content was from published scientific sources and provincial data. Participants who were pregnant and had not received an epidural before felt the information in the pamphlets was novel and provided “a good foundation” of knowledge. All participants, regardless of previous experience with epidural use, described learning new information in the pamphlets relating to use of antibiotics, intravenous fluids, forceps and vacuum delivery, and the potential for slowing down labour progress.
Perceptions of the Pamphlet Appearance
Women recommended using a brighter, eye-catching colour scheme. They had positive remarks about the photographs, including one of a woman having an epidural catheter inserted. Although the photograph was alarming to some participants, it did not change their preferences for epidural use, and they expressed that it was more useful to have realistic expectations.
Comprehensibility of the Pamphlet
In discussion, participants expressed that the pamphlets were easy to read and the content easy to understand. However, two participants who had backgrounds in health promotion felt that the pamphlet was written for a “junior high” reading level and expressed concerns that they would be difficult to understand for women with low literacy. These two participants recommended the creation of a more simplified version where information is presented in bullet points.
Usability of the Pamphlet
Participants had mixed opinions on whether they would use a pamphlet if it was presented in a display in a doctor's office. They preferred to receive pamphlets directly from a trusted care provider and felt it was unlikely that they would pick it up on their own (“I think if it was something that was handed to you, it would work fantastically”) (Focus Group 5). Participants also expressed that they access most of their prenatal information on the Internet and suggested incorporating the pamphlet into existing online resources and adding a video illustrating what an epidural insertion looks like.
Thematic Analysis of Focus Group Discussions
Four core key themes emerged: (1) making an informed choice, (2) being open-minded, (3) wanting comprehensive information, and (4) experiencing pressure to have/not have an epidural.
Making an informed choice
Discussions revealed that choice of epidural analgesia is an important decision for women that requires good information and deliberation. However, participants who had discussed the option of epidural analgesia with a care provider during pregnancy typically felt that the decision was “downplayed,” as one described: “All the doctors and nurses seem to downplay the whole thing—‘Oh, it's just an epidural,’ you know” (Focus Group 6). Those women who had actually faced the intrapartum decision of whether or not to have an epidural recalled that it was challenging to understand the risks and make a decision. Having a clear understanding of their options in advance, they explained, would help women make more informed decisions, be less susceptible to pressure from their family and care team, and feel less frightened about the epidural itself. As one woman expressed, “It would have been nice to know kind of the whole process of when can you have one and when you can't, what to expect” (Focus Group 5).
Women perceived that, to make an informed choice, they had to behave as active and engaged patients. This behaviour included knowing what questions to ask, having prompts (eg, the pamphlet) to structure discussion with their care provider, and having enough time for discussion with care providers. As one participant described, “If you didn't ask specific questions, you didn't get the answers. You had to be reactive, there wasn't just general information when going to the doctor” (Focus Group 5).
Wanting comprehensive information
When asked what information they valued most, participants offered a diverse list that included information presented in the pamphlet, such as the effectiveness of epidurals for pain management, their impact on the risk of CS, their impact on the length of labour, and potential side effects for the baby. Participants also identified additional information that they would like to see included in the pamphlet (Table 4).
Table 4Participants' expressed information needs, in addition to pamphlet
Theme
Topic
Alternative pain management strategies
Breathing techniques, comparative risks and benefits of options
Indications for epidural
Pain relief in active labour, rest and sleep during prolonged labour, for CS only
Effect of epidural on labour
Effect on positions for labouring, effect on options for labouring in water
Effect of epidural on postpartum period
Dural headaches, when the catheter would be removed, when can I go home
Effect of epidural on baby
Alertness, ability to breastfeed, effect of antibiotics on baby
Feasibility of receiving an epidural
Potential delays and the reasons for them, not receiving it in a timely fashion
Many participants expressed that they did not have adequate knowledge about epidurals before their labour and delivery. These women had unresolved questions about their birth experience and described a sense of mystery around the process of receiving and recovering from delivery with an epidural, as one expressed: “Do you conclusively have to stay overnight after you have an epidural at the hospital? I did anyway at the hospital I gave birth in. It was the worst part of getting the epidural” (Focus Group 4). Others described not knowing what pain relief options were available at their local hospital: “I don't think they do the walking epidural here, the one where you can actually get out of the bed. So there's really no option” (Focus Group 2). Knowledge about the availability of accessing an epidural was perceived to be something that would increase women's realistic expectations and satisfaction with care. Participants also felt that it was important for women to understand in advance what an epidural looks like and feels like. Others expressed that seeing what an epidural looks like would help them feel connected to their body: “I made my husband take a picture of it in my back, to show me when it was going on! [Laughs]” (Focus Group 2). Finally, women wished to learn more about other pain relief options to make an informed choice among all available treatments.
Being open-minded
Most participants expressed a desire for a drug-free delivery but emphasized that they were “open-minded” to the option of epidural analgesia. Their decision making occurred at two time points; first, during the antenatal period, when they formed a preference; and then during labour, where they made an actual choice. Because of the uncertainty of labour and delivery, participants felt that their needs could not be predicted in advance. They described intrapartum decision making as a process of making trade-offs between their short-term needs (eg, pain relief) and long-term values (eg, medication-free birth): “I'm keeping it open-minded because I'm so… I guess people call it ‘granola.’ I don't want any medication or epidural, but if I'm in a lot of pain and I want to ‘off myself’ or something, I'm telling myself now that ‘if you want an epidural, you’re allowed to take it’” (Focus Group 2). All participants felt it was important to understand their options before labour to make an informed decision during labour.
Experiencing pressure to have/not have an epidural
Participants' narratives revealed that some experienced pressure to make a choice for epidural that reflected the preferences of their primary maternity care provider or significant other. This pressure undermined their sense of autonomy: “During prenatal appointments, one of the doctors said, ‘And what's your plan for pain meds?’ and I was like, ‘Oh my plan is none at all!’ And he kind of laughed and said, ‘Oh, you’ll change your tune when you're in the hospital!' and I said, ‘Oh, no. If it goes wrong, or if it's taking way longer, or if it's way more [painful], I’ll consider it, but that's not my plan!' And I kind of felt like I got a bit of an eye roll and an, ‘OK, we’ll see what happens'” (Focus Group 6). Others described experiencing pressure from their partner or friends to consider an epidural, a choice that was not consistent with their preferences. One reflected that pressure may come first from hospital staff and then be reinforced by a family member: “Someone [in the hospital] says ‘Well the anaesthesiologist is going to go home so do you want the epidural or not?’ … Like maybe your husband or your partner is there and they're like ‘Honey you’re already in a lot of pain, maybe we should just say yes and when they get here and you don’t want it we can say no’” (Focus Group 4). Participants perceived that in their rural, low-resource settings, epidurals may not be available on request, and anaesthetists may not respond to an on-call request for an epidural if there is no emergency. Thus, they felt pressured to consider the option while an anaesthetist was available and on site.
Discussion
Our evaluation demonstrated that one brief reading of an information pamphlet resulted in a significant increase in women's knowledge of risks and benefits of epidural analgesia in labour. The lack of demonstrated difference in change scores between the short version and the detailed version of the form undoubtedly reflects the presence of the answers to the questions in both versions. Nonetheless, participants preferred the detailed version. Our analysis of focus group discussions revealed that women strongly desired detailed knowledge of the attributes of pain relief in labour well in advance of intrapartum decision making. We observed several factors that may impede women's informed decision making for epidural analgesia: having care providers, family members, and friends who “downplay” the importance of the decision to women; lack of procedural information on the process and feasibility of receiving an epidural; and experiencing pressure to request an epidural within the time that an anaesthetist is available and on site. Limited access to the health service resources necessary for epidural analgesia impedes women's ability to make an informed choice.
Women expressed a preference for the longer, detailed version of the pamphlet and noted that the inclusion of incident rates for potential side effects and a reference list gave a more balanced view and a sense of trustworthiness. The finding that preference for use of epidural analgesia was not associated with change in knowledge scores was not unexpected, given prior work reporting the influence of external factors on preference, such as partner preference and previous experience with epidural analgesia,
In focus group discussions, women appeared more likely to voice their attitudes and experiences if they preferred to avoid an epidural (eg, to have an unmedicated delivery). This finding suggests that there may be social pressure to avoid pain relief medications.
Our qualitative findings were similar to those of other evaluations of paper-based information pamphlets on epidural pain relief. In a randomized controlled trial of the UK Obstetric Anaesthetists' Association patient information pamphlet, “Pain Relief in Labour,” Stewart et al.
observed that 70% of women in both usual care and intervention groups would have liked to discuss analgesia methods with an anaesthetist before delivery. Similarly, in our study, participants expressed a desire to receive verbal and/or paper-based information from a care provider before delivery in order to be adequately prepared to make a decision.
Previous qualitative studies have consistently found that women often have misinformed expectations of pain in childbirth and the experience of pain relief in labour.
Multiparous participants in this study had held similar misperceptions before labour and emphasized the importance of having procedural information on what having an epidural looks like and feels like, how long it takes from request to pain relief, and under what conditions they would have to wait for an epidural. Participants felt that having realistic expectations of the procedure would enhance their satisfaction with the birth experience.
Participants were mothers from rural and remote communities in northern British Columbia, where epidural analgesia is accessible and primary maternity care is provided largely by family physicians. Our findings thus may not be generalizable to the experience of women in urban health service settings.
Patient's preferences may change between healthcare experiences (such as birth intervals) as they gain information, reflect on their experience, and gain clarity on the attributes of healthcare they value most.
Thus, the availability of paper-based tools during the birth interval when women have less access to maternity care providers fills a gap. After pregnancy onset, these tools may serve to start and complement iterative discussions with caregivers, a necessary component of informed consent.
Participants' experiences of pressure or coercion to choose an epidural is concerning. The pamphlet may prepare women to participate more actively in shared decision making in the event that anaesthesia consultations are required to address complex pain management issues.
An illustrated information pamphlet can significantly increase women's knowledge of the benefits and risks of epidural analgesia. Comprehensive information during pregnancy supports informed choice during labour and may mitigate the influence of pressure or coercion from support persons and caregivers.
Do women have a choice? Care providers' and decision makers' perspectives on barriers to access of health services for birth after a previous caesarean.
Future research may incorporate additional information items and use larger sample sizes to evaluate knowledge change and other relevant patient-centred outcomes such as decisional conflict, satisfaction with the experience, and congruence between the woman's values and her pain relief treatment. Maternity care providers may use these evidence-based pamphlets in antenatal discussions about pain relief in labour. In these discussions, maternity care providers may ask women to express their fears about labour pain and their preferences regarding methods of pain relief so that their birth plans may incorporate both the clinical evidence and their values.
Acknowledgements
The authors wish to thank the funding agencies that provided generous support for this study. Patricia Janssen was supported by a Senior Scholar Salary award at the BC Children's Hospital Research Institute (formerly Child and Family Research Institute) in Vancouver. Sarah Munro was supported by a Canadian Institute of Health Research Frederick Banting and Charles Best scholarship (291083) and by University of British Columbia Graduate Fellowship and Public Scholar awards. This project was funded by a peer-reviewed Clinical Research Capacity Building Award from the Child and Family Research Institute.
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Do women have a choice? Care providers' and decision makers' perspectives on barriers to access of health services for birth after a previous caesarean.
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