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
Table 1Characteristics of study participants
Table 2Participants' sources of information about epidural analgesia
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.
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
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.
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.