The pain of childbirth: perceptions of culturally diverse women

Women's and maternity care providers' perceptions of pain management during childbirth in hospitals in Southern Tanzania

BACKGROUND

The majority of women experience pain during childbirth. Offering and supporting women to use different methods for coping with pain is an essential competency for maternity care providers globally. Research suggests a gap between what women desire for pain management and what is available and provided in many low-and middle-income settings. The study aimed to understand how pain management is perceived by those involved: women experiencing childbirth and maternity care providers.

METHODS

Individual semi-structured interviews with women (n = 23), maternity care providers (n = 17) and focus group discussions (n = 4) with both providers and women were conducted in two hospitals in Southern Tanzania in 2021. Transcribed interviews were analysed using reflexive thematic analysis. Coding and analysis were supported by the software MAXQDA.

RESULTS

Three main themes were generated from the data. The first, 'pain management is multifaceted', describes how some providers and women perceived pain management as entailing various methods to manage pain. Providers perceived themselves as having a role in utilization of pain management to varying degree. The second theme 'pain management is primarily a woman's task' highlights a perception of pain management as unnecessary, which appeared to link with some providers' perceptions of pain as natural and necessary for successful childbirth. Few women explicitly shared this perception. The third theme 'practice of pain management can be improved' illustrates how women and maternity care providers perceived current practices of pain management as suboptimal. According to providers, this is primarily due to contextual factors such as shortage of staff and poor ward infrastructure.

CONCLUSION

Women's and maternity care providers' perceptions ranged from perceiving pain management as involving a combination of physiological, psychological and social aspects to perceive it as related with limited to no pain relief and/or support. While some women and providers had similar perceptions about pain management, other women also reported a dissonance between what they experienced and what they would have preferred. Efforts should be made to increase women's access to respectful pain management in Tanzania.

Tools for assessing labour pain: a comprehensive review of research literature

ABSTRACT

The experience of pain associated with labour is complex and challenging to assess. A range of pain measurement tools are reported in the literature. This review aimed to identify current tools used in research to assess labour pain across the past decade and to evaluate their implementation and adequacy when used in the context of labour pain. A literature search was conducted in databases MEDLINE and Cumulative Index of Nursing and Allied Health Literature, using search terms relating to labour, pain, and measurement. A total of 363 articles were selected for inclusion. Most studies (89.9%) assessed pain as a unidimensional experience, with the most common tool being the Visual Analogue Scale, followed by the Numerical Rating Scale. Where studies assessed pain as a multidimensional experience, the most common measurement tool was the McGill Pain Questionnaire. Only 4 studies that used multidimensional tools selected a tool that was capable of capturing positive affective states. Numerous variations in the implementation of scales were noted. This included 35 variations found in the wording of the upper and lower anchors of the Visual Analogue Scale, some assessment tools not allowing an option for "no pain," and instances where only sections of validated tools were used. It is clear that development of a standardised pain assessment strategy, which evaluates the multidimensions of labour pain efficiently and effectively and allows for both positive and negative experiences of pain to be reported, is needed.

Spiritual Experiences of Portuguese Women Who had a Water Birth

This study aimed to understand the significance of spirituality to Portuguese women who had a water birth. In-depth interviews, using a semi-structured questionnaire, were conducted with 24 women who experienced water birth at the hospital or home. Results were analyzed from a narrative interpretation perspective. Three spirituality-related categories emerged: (1) Beliefs and connections with the body; (2) Spirituality: integration of being a woman and transformation during birth; and (3) Spirituality as wisdom, intuition, or the sixth sense. Spirituality was perceived in women's faith and beliefs in a superior being that helped them manage the unpredictability and uncontrollability of giving birth.

Pain Intensity, coping and maternal satisfaction in Low-Risk labouring Women: A prospective descriptive correlational study

OBJECTIVES

The primary aim of the study was to explore pain intensity (PI) and pain coping (PC) scores and the relationship between them. The secondary aim was to explore the correlation between PI and PC scores with labour progress, parity, labour acceleration, labour augmentation and maternal satisfaction.

METHODS

A prospective descriptive correlational study was conducted in a maternity hospital in Northern Italy. The sample included 54 low-risk women in active labour at term of pregnancy. A data record sheet was used to collect the relevant variables and the Italian Birth Satisfaction Scale Revised (I-BSS-R) was administered to participants at least 24 h after birth.

RESULTS

In the first labour stage, the average PI score was 6.99 (SD = 1.95) and the average PC score was 6.5 (SD = 2.22). During the second labour stage, the average PI score was 7.75 (SD = 1.74) and the average PC score was 4.97 (SD = 2.76). The average PI score trend increased with labour progress. The average PC score improved between 4 and 7 cm of cervical dilatation. A significant positive correlation between PI scores and oxytocin augmentation (p < 0.001) and labour progression (p < 0.001) was noted. A significant positive correlation between PC scores and oxytocin augmentation (p = 0.02) was also observed. No significant differences were found for maternal satisfaction in regard to PI and PC scores.

CONCLUSION

coping in labour do not solely depend on PI but also on labour progress and oxytocin augmentation. Additional support to empower women to cope with pain may be required in case of labour augmentation.

Cultural influence on the expression of labour-associated pain

Background

Every woman expresses pain differently during birth since it depends on a multitude of predictive factors. The medical care received, companionship during birth, cultural background and language barriers of the women in labour can influence on the expression of pain. This study aims to evaluate the expression of pain during birth and its associated factors in women treated in a Spanish border town.

Methods

The study included 246 women in labour. The expression of pain during labour was evaluated using the validated ESVADOPA scale. A descriptive analysis and association study were performed between cultural identity and dimensions of the scale. Multiple linear regression models were performed to assess the association between cultural identity, origin, language barrier, and companionship during labour.

Results

The women included in the study comprised 68.7% Berbers, 71.5% Muslims and 82.1% were accompanied during labour. An association between cultural identity and greater body expression of pain (p = 0.020; Cramer’s V = 0.163) in addition to its verbal expression was found during the latent phase of labour, (p = 0.028; Cramer’s V = 0.159). During the active phase of labour, cultural identity was associated with pain expression through greater body response, verbal expression, expression of the facial muscles, anxiety, inability to relax and vegetative symptoms. The different factors studied that had a predictive value were companionship (p = 0.027) during the latent phase of labour and Berber origin (p = 0.000), language barrier (p = 0.014) and companionship (p = 0.005) during the active phase of labour. The models designed predict pain expression in the latent phase by companionship and type of companionship (β = 1.483; 95%CI = 0.459–2.506, β = 0.238; 95%CI = 0.029–0. 448, respectively), and in the active phase by background, language barrier and companionship (β = 0.728; 95%CI = 0.258–1.198, β = 0.738; 95%CI = 0.150–1.326, β = 1.888; 95%CI = 0.984–2.791, respectively).

Conclusion

Culture, origin, language barrier and companionship during labour influences the manner in which women in labour express their pain. An understanding of this may help midwives correctly interpret the signs of pain expression and be able to offer the appropriate assistance depending on a woman's particular characteristics. There is a clear need for new models of maternity care that will take the cultural and language characteristics of women in labour into consideration.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-05173-1.

Barriers to adequate pain control among women with cervical cancer: exploring unmet pain control needs in Ghana

BACKGROUND

Pain because of cervical cancer is a significant health issue globally, especially in women with advanced disease. However, little is known about unmet needs for pain control in low-resource settings where the burden of cervical cancer is the greatest.

OBJECTIVE

This study aimed to quantify the level of pain that women with cervical cancer in Ghana experience, explore attitudes toward pain and pain medications, and determine the barriers to adequate pain control.

STUDY DESIGN

A cross-sectional survey was conducted on 100 adult women with a histopathologic diagnosis of cervical cancer presenting for care at Komfo Anokye Teaching Hospital in Ghana. In addition, a descriptive analysis was conducted among all participants and the subgroup of women who reported pain but did not report pain medication use.

RESULTS

Among 100 participants with cervical cancer, the mean age was 59.5 years, and the median parity was 6.0 (interquartile range, 5.0–6.0); moreover, most participants presented with inoperable stage II or greater cervical cancer (99 of 100 [99%]). Of 100 participants, 80 (80%) had pain caused by their cervical cancer, with more than half (51 of 100 [51%]) rating their pain as a 3, 4, or 5 on a 5-point scale. Most participants reported pain significant enough to impact their sleep (58 of 99 [58.6%]) and their ability to carry out daily activities (54 of 100 [54%]). Furthermore, 55 of 100 participants (55%) took pain medications in the last week; however, only 5 of 54 participants (9.3%) reported complete improvement in their pain, and most participants (30 of 54 [55.6%]) felt they needed a stronger pain medication. Barriers to adequate pain control included the healthcare provider's focus on pain, with 14.1% of women reporting that their healthcare providers never asked about their pain (14 of 99 [14.1%]). In addition, participants’ attitudes toward pain control demonstrated that 34 of 95 participants (35.8%) believed that they should be able to tolerate their cervical cancer pain without medication. Among participants who ever took pain medication, 16 of 58 (27.6%) were bothered that they took pain medication, and 19 of 58 (32.7%) were concerned that they used too much medication. Most participants were able to afford (51 of 58 [88%]) and access (56 of 58 [96.6%]) pain medications and did not worry their supply would run out (56 of 58 [96.6%]).

CONCLUSION

Most patients had significant pain because of cervical cancer, and many of them endorsed needing more pain medications than what they were prescribed. The etiologies of the unmet need for pain control included missed opportunities to discuss pain control at clinic visits and patients’ attitudes toward pain management. Financial and access barriers to obtaining pain medications were minimal.

Contribution of maternal cardiometabolic risk factors to racial-ethnicity disparities in preterm birth subtypes

BACKGROUND

There are recognized racial-ethnic disparities in preterm birth and in maternal cardiometabolic risk factors likely linked to systemic racism. However, it is unclear the extent to which cardiometabolic risk factors contribute to the higher rates of preterm birth among minoritized populations.

OBJECTIVE

This study aimed to evaluate racial-ethnic disparities in preterm birth subtypes and the role of maternal cardiometabolic risk factors as mediators of the association between maternal race-ethnicity and preterm birth subtypes.

STUDY DESIGN

This was a retrospective cohort study of 295,210 singleton live births from 2011 to 2018. Preterm birth subtypes were defined as medically indicated and spontaneous preterm birth. Poisson regression with robust standard errors were used to provide estimates of the relative risks and 95% confidence intervals for preterm birth subtypes. Causal mediation analysis used logistic regression models to estimate the natural direct and natural indirect (mediated) effects of maternal cardiometabolic risk factors.

RESULTS

Compared with White individuals, Black, Asian, and Hispanic individuals were at increased risk for having both medically indicated preterm birth (1.45, 1.30-1.61; 1.21, 1.12-1.31; and 1.13, 1.05-1.22, respectively) (risk ratios, 95% confidence intervals, respectively) and spontaneous preterm birth (1.20, 1.08-1.34; 1.34, 1.26-1.43; and 1.16, (1.08-1.23), independent of established risk factors. The extent to which cardiometabolic risk factors mediated the associations between race-ethnicity (each group vs White in separate analyses) and preterm birth subtypes varied by race-ethnicity. Hypertensive disorders mediated 30.1% of the association between Black race-ethnicity and medically indicated preterm birth, but it did not mediate the association for other racial-ethnic groups or for spontaneous preterm birth. Any glucose disorder in pregnancy was a mediator of medically indicated preterm birth and spontaneous preterm birth for Asian (65.8% and 13.9%, respectively) and Hispanic (17.3% and 11.9%) race-ethnicity but not for Black race-ethnicity. Overweight or obesity mediated the association between race-ethnicity and medically indicated preterm birth (15.5% among Black individuals and 25.1% among Hispanic individuals) and spontaneous preterm birth (10.7% among Hispanic individuals) but was not a mediator among Asian individuals.

CONCLUSION

Black, Asian, and Hispanic individuals are at increased risk for preterm birth. Maternal cardiometabolic risk factors partially mediate the associations between race-ethnicity and preterm birth subtypes but the extent varies by race-ethnicity. These findings suggest that strategies that improve and diminish differences in cardiometabolic health between race-ethnicity populations may diminish disparities in preterm birth.

A longitudinal study exploring the evolution of pain during pregnancy and after delivery: does worry matter?

The aim of this study is to evaluate the evolution of pain through pregnancy until after delivery, as well as to explore the mediating role of pregnancy worries in this evolution of pain. We conducted a longitudinal cohort study. The convenience sample was evaluated on four separate occasions: in the first trimester of pregnancy (pain), during the third trimester (pain and worry), during labor (pain), and after birth (< 24 h; pain). The final sample included 120 pregnant women with a mean age of 31.29 years (SD = 4.9; range = [22, 42 years]). The results evidenced changes in pain over time (F = 13.31, p < .001). Pain severity increased in the third trimester compared to the first trimester (t =  - 4.60; 95% CI = [- 1.31, - 0.52]; p < .001), while pain during the third trimester and pain after delivery were comparable (t =  - 0.94; 95% CI = [- 1.02, 0.36]; p = .35). Pain during labor was uncorrelated with all other pain measures, so it was not included in the model. The results of the mediation analyses indicated a total effect of pain during pregnancy (first and third trimester) and worry on pain severity after delivery (B = 0.35; SE = 0.14; t = 2.43; 95% CI = [0.06, 0.65]; p = .017). Pregnancy worries (B = 0.14; SE = 0.07; 95% CI = [0.06, 0.29]), but not pain during the third trimester (B = 0.03; SE = 0.12; 95% CI = [- 0.17, 0.31]) mediated the relationship between pain during the first trimester and pain after delivery. These results support the need to reduce worry in pregnant mothers, especially when pain during the first trimester is high, to reduce the risk of pain after delivery.

Efficacy and safety of non-pharmacological interventions for labour pain management: A systematic review and Bayesian network meta-analysis

AIMS AND OBJECTIVES

To compare and rank the efficacy and safety of non-pharmacological interventions in the management of labour pain.

BACKGROUND

Recently, various non-pharmacological interventions have been applied to manage labour pain and have shown positive effects. However, evidence identifying which type of non-pharmacological intervention is more efficient and safer is limited.

DESIGN

Systematic review and Bayesian network meta-analysis based on PRISMA-NMA.

METHODS

Seven databases were searched from database inception-March 2020. Two reviewers independently performed study selection, quality appraisal and data extraction. Conventional meta-analysis was conducted using either fixed-effects model or random-effects model according to statistical heterogeneity. The Bayesian network meta-analysis was conducted using the consistency model.

RESULTS

43 studies involving nine non-pharmacological interventions were included. The Bayesian network meta-analysis showed that acupressure (SMD = -2.00, 95% CrI -3.09 to -0.94), aromatherapy (SMD = -2.01, 95% CrI -3.70 to -0.35) and massage therapy (SMD = -1.26, 95% CrI -2.26 to -0.30) had significant positive effects on alleviating labour pain, with aromatherapy being the most effective. The results also revealed that yoga (SMD = -130.85, 95% CrI -212.01 to -59.32) and acupressure (SMD = -10.14, 95% CrI -20.24 to -0.41) were the most effective interventions for shortening the first stage and the second stage of labour, respectively. There were no significant differences between non-pharmacological interventions and usual care or placebo control on the use of pharmacological methods and neonatal 5-min Apgar score.

CONCLUSIONS

The evidence in this network meta-analysis illustrates that non-pharmacological interventions are effective and safe for labour pain management in low-risk pregnant women. In the future, well-designed studies are needed to validate the conclusion of this network meta-analysis.

RELEVANCE TO CLINICAL PRACTICE

The results support the use of non-pharmacological interventions, especially aromatherapy and acupressure, to relieve labour pain in low-risk pregnant women. Non-pharmacological interventions for labour pain management are recommended to apply according to maternal women's preference and values.

Pain Relief During Childbirth in the Context of 50 Years of Social and Technological Change

Pain relief during childbirth continues to stimulate controversy as new treatments emerge and continuing interventions in the birth process invoke concerns about safety, technologic imperatives, and informed consent. In this historical commentary, I identify a complex dissonance between scientific advances and women's needs and expectations regarding childbirth. Evidence-based practice became the standard during the last 50 years and has reinforced a more conservative and parsimonious use of technology to respond to women's needs for pain relief. In reviewing this history, it is apparent that pain relief during labor is inextricably linked to interventions. Nurses can advance evidence-based practice and facilitate robust informed consent as they support women during childbirth.

Group Differences Between Countries and Between Languages in Pain-Related Beliefs, Coping, and Catastrophizing in Chronic Pain: A Systematic Review

Objective

To evaluate the extent to which pain-related beliefs, appraisals, coping, and catastrophizing differ between countries, language groups, and country economy.

Design

Systematic review.

Methods

Two independent reviewers searched 15 databases without restriction for date or language of publication. Studies comparing pain beliefs/appraisals, coping, or catastrophizing across two or more countries or language groups in adults with chronic pain (pain for longer than three months) were included. Two independent reviewers extracted data and performed the quality appraisal. Study quality was rated as low, moderate, or high using a 10-item modified STROBE checklist. Effect sizes were reported as small (0.20–0.49), medium (0.50–0.79), or large (≥0.80).

Results

We retrieved 1,365 articles, read 42 potential full texts, and included 10 (four moderate-quality, six low-quality) studies. A total of 6,797 adults with chronic pain (33% with chronic low back pain) were included from 16 countries. Meta-analysis was not performed because of heterogeneity in the studies. A total of 103 effect sizes were computed for individual studies, some of which indicated between-country differences in pain beliefs, coping, and catastrophizing. Of these, the majority of effect sizes for pain beliefs/appraisal (60%; eight large, eight medium, and eight small), for coping (60%; seven large, 11 medium, and 16 small), and for catastrophizing (50%; two medium, one small) evidenced statistically significant between-country differences, although study quality was low to moderate.

Conclusions

In 50% or more of the studies, mean scores in the measures of pain beliefs and appraisals, coping responses, and catastrophizing were significantly different between people from different countries.

Mediating Effects of Cardiometabolic Risk Factors on the Association Between Maternal Race-Ethnicity and Cesarean Delivery Among Low-Risk Women

Background: While racial-ethnic disparities in cesarean delivery rates among nulliparous women delivering a term singleton in the vertex position (NTSV) exist, it remains unclear the extent to which potentially modifiable maternal cardiometabolic risk factors (obesity, maternal hyperglycemia and hypertensive disorders) underlie these disparities. We examined race-ethnicity and risk of NTSV cesarean deliveries and whether the associations were mediated by maternal cardiometabolic risk factors. Materials and Methods: A cohort study of 62,048 NTSV deliveries in Kaiser Permanente Northern California. The outcome was cesarean delivery. Results: Black, Asian, and Hispanic women were at increased risk of having a NTSV cesarean delivery compared with White women (relative risks and 95% confidence intervals: 1.37 [1.28-1.45]; 1.11 [1.07-1.16]; 1.12 [1.07-1.16], respectively), independent of established risk factors and prenatal care utilization. The extent to which cardiometabolic risk factors mediated the associations between race-ethnicity (each group vs. White, in separate analyses) and NTSV cesarean delivery varied by race-ethnicity. Maternal overweight/obesity (body mass index ≥25.0) mediated the association between Black and Hispanic race-ethnicity and NTSV cesarean delivery (21.1% [15.8-26.4] and 24.7% [14.6-34.8, respectively), but not for Asian race. Maternal hyperglycemia (gestational diabetes mellitus or preexisting diabetes) mediated the association between Asian and Hispanic race and NTSV cesarean delivery (18.5% [9.8-27.2] and 9.8% [5.0-14.7], respectively), but not for Black race. Hypertensive disorders mediated 3.2% (0.70-5.8) of the association between Black race and cesarean delivery, but not for other race-ethnicities. Conclusion: Black, Asian, and Hispanic women are at increased risk for NTSV cesarean deliveries. Maternal cardiometabolic risk factors only partially mediate the associations between race-ethnicity and NSTV cesarean deliveries.

Postpartum infection, pain and experiences with care among women treated for postpartum hemorrhage in three African countries: A cohort study of women managed with and without condom-catheter uterine balloon tamponade

Objective

We aimed to determine the risk of postpartum infection and increased pain associated with use of condom-catheter uterine balloon tamponade (UBT) among women diagnosed with postpartum hemorrhage (PPH) in three low- and middle-income countries (LMICs). We also sought women’s opinions on their overall experience of PPH care.

Methods

This prospective cohort study compared women diagnosed with PPH who received and did not receive UBT (UBT group and no-UBT group, respectively) at 18 secondary level hospitals in Uganda, Egypt, and Senegal that participated in a stepped wedge, cluster-randomized trial assessing UBT introduction. Key outcomes were reported pain (on a scale 0–10) in the immediate postpartum period and receipt of antibiotics within four weeks postpartum (a proxy for postpartum infection). Outcomes related to satisfaction with care and aspects women liked most and least about PPH care were also reported.

Results

Among women diagnosed with PPH, 58 were in the UBT group and 2188 in the no-UBT group. Self-reported, post-discharge antibiotic use within four weeks postpartum was similar in the UBT (3/58, 5.6%) and no-UBT groups (100/2188, 4.6%, risk ratio = 1.22, 95% confidence interval [CI]: 0.45–3.35). A high postpartum pain score of 8–10 was more common among women in the UBT group (17/46, 37.0%) than in the no-UBT group (360/1805, 19.9%, relative risk ratio = 3.64, 95% CI:1.30–10.16). Most women were satisfied with their care (1935/2325, 83.2%). When asked what they liked least about care, the most common responses were that medications (580/1511, 38.4%) and medical supplies (503/1511, 33.3%) were unavailable.

Conclusion

UBT did not increase the risk of postpartum infection among this population. Women who receive UBT may experience higher degrees of pain compared to women who do not receive UBT. Women’s satisfaction with their care and stockouts of medications and other supplies deserve greater attention when introducing new technologies like UBT.

Neuraxial Analgesia in Pregnant Hispanic Women: An Assessment of Their Beliefs and Expectations

Background

The presence of racial/ethnic disparities in the use of neuraxial labor analgesia for childbirth has been previously described. The purpose of this study was to assess the childbirth pain management beliefs among a small sample of pregnant Hispanic women and to evaluate the Spanish translation accuracy of the Childbirth Pain Scale (CPBS).

Methods

To collect data, we interviewed 20 pregnant Spanish-speaking women using an interview guide, a demographic datasheet, and the CPBS a 15-item survey. Interviews were transcribed verbatim, translated, and uploaded to ethnograph v6. Descriptive statistics and thematic analysis were used to analyze the data.

Results

Most of the participants were from Mexico (n=16) and Central America (n=4), mean age was 28.3, and all (n=20) spoke Spanish as their primary language. In this sample, 80% of nulliparous and 100% of multiparous women saw pain as having a positive role in delivery. Four major themes emerged from the data: Theme 1: Normalcy of childbirth pain (pain is good), Theme 2: Availability and role of pain medication, Theme 3: Naturalistic strategies to endure pain, and Theme 4: Fear of the unknown/childbirth process. In this sample, 18 of 20 women stated they did not want epidural analgesia unless medically indicated. During labor and delivery 100% of nulliparous and 25% of multiparas chose to receive epidural analgesia. No changes were requested by the participants regarding the translation of the CPBS.

Conclusion

Childbirth pain was seen as a valuable component of the birthing process. The majority of participants believed pain medication should be avoided unless medically necessary. These results suggest that racial/ethnic disparities in the use of epidural analgesia may partially reflect patient beliefs and preferences. It is crucial to be aware of these differences to optimize shared decision-making for women in this vulnerable patient population.

Epidural analgesia for labour pain in nulliparous women in Norway in relation to maternal country of birth and migration related factors

OBJECTIVE

To investigate associations between maternal country of birth and other migration related factors (length of residence, reason for migration, paternal origin) and epidural analgesia for labour pain in nulliparous women in Norway.

DESIGN

Population-based register study including nulliparous migrant women (n = 75,922) and non-migrant women (n = 444,496) with spontaneous or induced labour. Data were retrieved from the Medical Birth Registry and Statistics Norway, 1990-2013. Odds ratios (OR) with 95% confidence intervals (CI) were estimated by logistic regression, and adjusted for maternal age, marital status, maternal education, gross income, birth year, hospital size and health region.

MAIN OUTCOME

Epidural analgesia for labour pain.

RESULTS

Epidural analgesia was administered to 38% of migrant women and 31% of non-migrant women. Compared with non-migrants, the odds of having epidural analgesia were lowest in women from Vietnam (adjOR 0.54; CI 0.50-0.59) and Somalia (adjOR 0.63; CI 0.58-0.68) and highest in women from Iran (adjOR 1.32; CI 1.19-1.46) and India (adjOR 1.19; CI 1.06-1.33). Refugees (adjOR 0.83; CI 0.79-0.87) and newly arrived migrants (adjOR 0.92; CI 0.89-0.94) had lower odds of epidural analgesia. Migrant women with a non-migrant partner (adjOR 1.14; CI 1.11-1.17) and those with length of residence ≥10 years (adjOR 1.06; CI 1.02-1.10) had higher odds.

CONCLUSION

The use of epidural analgesia varied by maternal country of birth, reason for migration, paternal origin and length of residence. Midwives and obstetricians should pay extra attention to the provision of adequate information about pain relief options for refugees and newly arrived migrants, who had the lowest use.

Cultural conceptions of Women's labor pain and labor pain management: A mixed-method analysis

AIM

We assess American cultural beliefs about labor pain and labor pain management, including stereotypical and disparate beliefs about labor pain of women from different racial groups.

RATIONALE

Understanding cultural beliefs about labor pain is critical as these beliefs influence experience, interpretation, and treatment of labor pain.

METHOD

We used an online survey with quantitative and qualitative questions about American labor pain beliefs. Participants were recruited and compensated using TurkPrime's Panels during the first week in August 2017 and the last week in May 2018. The completion rate was 76.86 percent (n = 214). After screening using quality control items, the final sample included 200 respondents.

RESULTS

Qualitative results indicate that 56.5 percent (n = 113) of respondents have an accurate understanding of nociceptive/sensory drivers of labor pain, and 55.8 percent (n = 63) of those respondents focused on the second stage of labor. However, only two respondents (1%) mentioned non-sensory (i.e., psychological) causes of labor pain - reflecting a lack of cultural knowledge of the biopsychosocial nature of pain. Categorical responses indicate almost all respondents (95%; n = 190) believe women have a right to labor pain relief, and the majority believe labor pain has value (68%; n = 136) and should be treated medically (87%; n = 174). Quantitative results document stereotypical beliefs that women of color experience less labor pain than white women. Belief that there is value in experiencing labor pain and that pain should not be treated medically were both associated with greater racial disparities in beliefs about labor pain severity. Beliefs were not related to respondent sociodemographic identity, suggesting they are American cultural constructs.

CONCLUSION

Future consideration of the influence of dominant American cultural beliefs about labor pain - including misunderstanding of the nature of labor pain and racial bias in expectations of labor pain - on individuals, norms, and structures is expected to improve quality of patient care.

Primiparous women's experiences of normal vaginal delivery in Iran: a qualitative study

BACKGROUND

Childbirth is considered as the most challenging psychological event in a woman's life. It has a major effect on women's lives with long-term positive or negative impacts. Cultural, religious, and socioeconomic differences can affect women's perception about normal vaginal delivery (NVD) experience. Therefore, it is necessary to explore the primiparous women's perception about it.

METHODS

This qualitative study, with a descriptive content analysis approach, was conducted in Kashan, a city in the center of Iran. Purposive sampling was used to recruit the participants of the current study. Data was gathered by semi-structured interviews during 24 h after normal vaginal birth among primiparous women. The sampling started from June to October in 2016. Interviews continued until data saturation which was achieved in the 14th interview but for assurance, it continued until the 17th one.

RESULTS

The following three main themes were extracted "immersion in stress", "pain, the essence of NVD" and "strategies for situation management". Furthermore, seven subthemes were obtained including 'loss threat', 'stressful context', temporary impairment in physiologic harmony, paradoxical emotions, self-management, emotional support, and spiritual support.

CONCLUSIONS

This study showed that stress and pain were two highlighted issues in NVD process. Increasing women's awareness about NVD process, familiarizing the primiparous women with the simulated delivery room, accompanying these women for emotional support, and providing spiritual support can be effective in situation management to make the child delivery a pleasant and satisfying experience.

Comparison of the effect of educational software and booklet on anxiety and pain during labour: a randomised controlled clinical trial

This randomised clinical trial was conducted on 153 pregnant women. Participants were assigned into two intervention groups including educational software and an educational booklet and a control group through block randomisation. A training session was implemented for the intervention groups at 30-36 weeks and they were taught how to use the educational methods. Participants were followed-up until the childbirth time and the severity of pain was measured at four stage of cervical dilatation (4, 6, 8 and 10 cm) by Visual Analogue Scale (VAS). Spielberger State-Trait Anxiety Inventory was completed at 4-5 cm cervical dilatation. There was no significant difference between groups in terms of the labour pain intensity (p > .05). After intervention, mean (SD) of state anxiety score was 38.7 (2.6) in educational software group, 44.3 (7.4) in educational booklet group and 63.3 (8.2) in control group. Also, mean (SD) of trait anxiety score was 47.4 (2.7) in educational software group, 47.2 (2.4) in educational booklet group and 61.8 (3.9) in control group. The mean state and trait anxiety scores in both intervention groups were significantly lower than control group (p < .001). Both intervention groups were effective in reducing anxiety. Thus, these educational methods should be recommended for pregnant women in clinical practices.IMPACT STATEMENTWhat is already known on this subject? Childbirth is one of the most important crises in women's life, in which stress and other forms of emotional distress such as anxiety are likely to occur during it. Safe practices and effective interventions can be offered to pregnant women to tolerate the labour pain and reduce anxiety during labour.What do the results of this study add? There was no statistically significant difference between two intervention groups (educational software and educational booklet groups) and control group in terms of the pain intensity at the cervical dilatation of 4, 6, 8 and 10 cm. But the state and trait anxiety in both groups (educational software and educational booklet groups) was significantly less than the control group. Also, the anxiety level was significantly lower in the educational software group than the educational booklet group.What are the implications of these findings for clinical practice and/or future research? Educational software and booklet with educational content about position modification during pregnancy, stretching exercises, breathing techniques and exercises, relaxation and lower back massage for reducing anxiety should be recommended for pregnant women in clinical practices.

Opioid Utilization and Perception of Pain Control in Hospitalized Patients: A Cross-Sectional Study of 11 Sites in 8 Countries

BACKGROUND

Hospitalized patients are frequently treated with opioids for pain control, and receipt of opioids at hospital discharge may increase the risk of future chronic opioid use.

OBJECTIVE

To compare inpatient analgesic prescribing patterns and patients' perception of pain control in the United States and non-US hospitals.

DESIGN

Cross-sectional observational study.

SETTING

Four hospitals in the US and seven in seven other countries.

PARTICIPANTS

Medical inpatients reporting pain.

MEASUREMENTS

Opioid analgesics dispensed during the first 24-36 hours of hospitalization and at discharge; assessments and beliefs about pain.

RESULTS

We acquired completed surveys for 981 patients, 503 of 719 patients in the US and 478 of 590 patients in other countries. After adjusting for confounding factors, we found that more US patients were given opioids during their hospitalization compared with patients in other countries, regardless of whether they did or did not report taking opioids prior to admission (92% vs 70% and 71% vs 41%, respectively; P < .05), and similar trends were seen for opioids prescribed at discharge. Patient satisfaction, beliefs, and expectations about pain control differed between patients in the US and other sites.

LIMITATIONS

Limited number of sites and patients/country.

CONCLUSIONS

In the hospitals we sampled, our data suggest that physicians in the US may prescribe opioids more frequently during patients' hospitalizations and at discharge than their colleagues in other countries, and patients have different beliefs and expectations about pain control. Efforts to curb the opioid epidemic likely need to include addressing inpatient analgesic prescribing practices and patients' expectations regarding pain control.

The childbirth experience: obstetric and psychological predictors in Italian primiparous women

BACKGROUND

The experience of childbirth crucially impacts a mother's psychological well-being and the mother-infant relationship. It is recognised that negative births can be linked to different forms of discomfort, both for the mother as well as for the infant. This prospective longitudinal study aimed to study the effect of obstetric and psychological variables on women's subjective experience of childbirth.

METHODS

111 primiparous Italian women completed a set of questionnaires at 38-40 weeks of pregnancy (Time 1) and 1-5 days after childbirth (Time 2). Sociodemographic and obstetric information were collected. Data about the childbirth were obtained from the mother's ward birth records. Women completed the Wijma Delivery Expectancy/Experience Questionnaire both before and after childbirth.

RESULTS

The subjective experience of birth was significantly predicted by the duration of the expulsive phase (β = .26; p < .05), the use of epidural analgesia (β = .21;  p< .05) and by fear of birth (β = .21; p < .05). The effect of mode of birth and duration of the dilatation phase on women's birth experience was not found.

CONCLUSIONS

In our study, neither instrumental childbirth nor caesarean section have a significant effect on women's birth experience. Instead, both a longer expulsion phase and epidural analgesia contribute to the negative experience. Moreover, the higher the fear of birth, the worse the women's emotional experience. These findings confirmed the role of obstetric and psychological variables on birth experience. More investigation about this topic could be useful to develop specific interventions to prepare women for birth.

Women's experiences of pharmacological and non-pharmacological pain relief methods for labour and childbirth: a qualitative systematic review

BACKGROUND

Many women use pharmacological or non-pharmacological pain relief during childbirth. Evidence from Cochrane reviews shows that effective pain relief is not always associated with high maternal satisfaction scores. However, understanding women's views is important for good quality maternity care provision. We undertook a qualitative evidence synthesis of women's views and experiences of pharmacological (epidural, opioid analgesia) and non-pharmacological (relaxation, massage techniques) pain relief options, to understand what affects women's decisions and choices and to inform guidelines, policy, and practice.

METHODS

We searched seven electronic databases (MEDLINE, CINAHL, PsycINFO, AMED, EMBASE, Global Index Medicus, AJOL), tracked citations and checked references. We used thematic and meta-ethnographic techniques for analysis purposes, and GRADE-CERQual tool to assess confidence in review findings. We developed review findings for each method. We then re-analysed the review findings thematically to highlight similarities and differences in women's accounts of different pain relief methods.

RESULTS

From 11,782 hits, we screened full 58 papers. Twenty-four studies provided findings for the synthesis: epidural (n = 12), opioids (n = 3), relaxation (n = 8) and massage (n = 4) - all conducted in upper-middle and high-income countries (HMICs). Re-analysis of the review findings produced five key themes. 'Desires for pain relief' illuminates different reasons for using pharmacological or non-pharmacological pain relief. 'Impact on pain' describes varying levels of effectiveness of the methods used. 'Influence and experience of support' highlights women's positive or negative experiences of support from professionals and/or birth companions. 'Influence on focus and capabilities' illustrates that all pain relief methods can facilitate maternal control, but some found non-pharmacological techniques less effective than anticipated, and others reported complications associated with medication use. Finally, 'impact on wellbeing and health' reports that whilst some women were satisfied with their pain relief method, medication was associated with negative self-reprisals, whereas women taught relaxation techniques often continued to use these methods with beneficial outcomes.

CONCLUSION

Women report mixed experiences of different pain relief methods. Pharmacological methods can reduce pain but have negative side-effects. Non-pharmacological methods may not reduce labour pain but can facilitate bonding with professionals and birth supporters. Women need information on risks and benefits of all available pain relief methods.

"There is no time for knowing each other": Quality of care during childbirth in a low resource setting

OBJECTIVE

To explore women's and healthcare provider's perspectives of what quality of care during childbirth means to them and how this can be improved.

DESIGN

14 Focus Group Discussions (FGD) with women and 27 Key Informant Interviews (KII) with healthcare providers. Thematic framework analysis was used.

SETTING

14 public healthcare facilities across two districts in Malawi. Mothers who had given birth at a healthcare facility within the last 7-42 days and healthcare providers who were directly involved in maternity care.

FINDINGS

Perceptions of what constitutes good quality of care differed substantially. For healthcare providers, the most important characteristics of good quality care included structural aspects of care such as availability of materials, and sufficient human resources. For women, patient-centred care including a positive relationship and experience was prioritised. However, both groups had similar views on what constitutes poor quality of care; unwelcoming reception on admission, non-consented care, physical and verbal abuse were described as examples of poor care. Shortage of staff, poor labour room design and a non-functional referral system were key barriers identified.

KEY CONCLUSIONS

Women as well as healthcare providers want good quality, professional care at birth and are disappointed if this is not in place.

IMPLICATION FOR PRACTICE

There is a need to incorporate women as well as healthcare provider's views when designing, implementing, monitoring and evaluating maternal health programmes. For a positive birth experience, a healthcare facility needs to have an enabling environment and good communication between healthcare providers and women should be actively promoted.

Investigating determinants for patient satisfaction in women receiving epidural analgesia for labour pain: a retrospective cohort study

BACKGROUND

Epidural analgesia is a popular choice for labour pain relief. Patient satisfaction is an important patient-centric outcome because it can significantly influence both mother and child. However, there is limited evidence in the correlations between clinical determinants and patient satisfaction. We aim to investigate clinical covariates that are associated with low patient satisfaction in parturients receiving labour neuraxial analgesia.

METHODS

After institutional ethics approval was obtained, we conducted a retrospective cohort study using electronic and corresponding hardcopy records from 10,170 parturients receiving neuraxial analgesia between the periods of January 2012 to December 2013 in KK Women's and Children's Hospital in Singapore. Demographic, obstetric and anesthetic data were collected. The patient satisfaction scores on the neuraxial labour analgesia was reported by the parturient at 24 to 48 h post-delivery during the post-epidural round conducted by the resident and pain nurse. Parturients were stratified into one of three categories based on their satisfaction scores. Ordinal logistic regression models were used to identify potential covariates of patient dissatisfaction.

RESULTS

10,146 parturients were included into the study, of which 3230 (31.8%) were 'not satisfied', 3646 (35.9%) were 'satisfied', and 3270 (32.2%) were 'very satisfied'. Multivariable ordinal logistic regression analysis showed that instrument-assisted vaginal delivery (p = 0.0007), higher post-epidural pain score (p = 0.0016), receiving epidural catheter resiting (p <  0.0001), receiving neuraxial analgesia at a more advanced cervical dilation (p = 0.0443), multiparity (p = 0.0039), and post-procedure complications headache (p = 0.0006), backache (p <  0.0001), urinary retention (p = 0.0002) and neural deficit (p = 0.0297) were associated with patient dissatisfaction. Chinese, compared with other ethnicities (p = 0.0104), were more likely to be dissatisfied.

CONCLUSIONS

Our study has identified several clinical determinants that were independent associated factors for low patient satisfaction. These covariates could be useful in developing a predictive model to detect at-risk parturients and undertake time-sensitive precautionary measures for better patient satisfaction.

Service Evaluation of Relaxation Workshops for Pregnant Women

This article reports a service evaluation of "antenatal education on physiology of childbirth and relaxation." A service evaluation was carried out during group class discussion, immediately after the workshops, and following birth. Identified themes in the collected data were (a) my own relaxation, (b) confident, and not afraid, (c) proud of myself, (d) unexpected and feeling in control, and (e) support. Overall, women creatively customized the learned skills and reported feelings of pride and confidence. They reported feeling able to apply relaxation techniques when unexpected situations arise. Support and encouragement from partners and midwives were also valued by women. The evaluation demonstrates the efficacy of designing antenatal education that includes education on physiology of normal birth and relaxation training.

Correlation of different parity and school education with acceptance of labor analgesia among antenatal women: A questionnaire-based study

Background and Aim:

Pain relief is nearly regarded as the right of patients in modern day health care. Women undergo excruciating pain during normal vaginal delivery (NVD). However, the acceptance of labor analgesia (LA) has remained very poor. The present study was aimed to assess the correlation of previous exposure to such pain (parity) and school education with LA acceptance.

Methods:

The present comparative study was conducted with a total 400 consented participants. A questionnaire was used to collect sociodemographic variables, acceptance/nonacceptance of LA, and the reasons for not opting for LA in upcoming delivery were noted. Participants were divided into primiparous, multiparous, and nulliparous (control). They were also grouped as per school education and compared taking illiterates as controls. Data are presented in absolute number. Fisher's exact test is used for comparison; P < 0.05 was considered statistically significant.

Results:

Seventy (17.5%) multiparous and 38% primiparous participants were compared with 44.5% nulliparous women. Only 2.75% participants were illiterate. 69.50% were rural inhabitant and 81.50% believed in Hinduism. 87.14% multiparous, 84.21% primiparous, and 88.76% nulliparous women declined LA (P > 0.05). The desire to experience NVD without LA as a reason for nonacceptance was significantly less among primiparous and multiparous as compared to nulliparous (P < 0.0001), but not among literate and illiterate participants (P > 0.295 in all).

Conclusion:

Previous labor pain significantly reduces the desire to experience NVD without LA, but still more than 80% parturients of any parity do not want LA due to one or more reasons. School education has no impact on LA acceptance.

The communication and emotional support needs to improve women's experience of childbirth care in health facilities in Southwest Nigeria: A qualitative study

OBJECTIVE

To improve women's childbirth experiences in health facilities, their psychosocial and communication needs have to be met. However, what constitutes these specific needs is poorly understood, particularly in Sub-Saharan Africa. This paper explores women's needs for communication and emotional support during facility-based childbirth.

METHODS

Qualitative research was conducted in a large referral maternity hospital and its catchment communities in Akure, Nigeria. In-depth interviews (IDIs) and focus group discussions (FGDs) were conducted among women of reproductive age, midwives, doctors, and facility administrators. Thematic analysis was used to synthesize findings, and then interpreted within the context of this study and existing quality of care framework.

RESULTS

Forty-two IDIs and 10 FGDs are included in this analysis. Participants reported such needs as communication in simple words in local language by healthcare staff, having their husbands as birth companions, spiritual support, and prayers from family members and healthcare providers.

CONCLUSION

To increase, improve, and sustain facility-based childbirth in Nigeria, health systems should appreciate the uniqueness and importance of each woman's needs during childbirth. Practical and sustainable actions should be taken to meet these needs, within the confines of the acceptable sociocultural norms.

Variation in Vaginal Birth After Cesarean by Maternal Race and Detailed Ethnicity

Objective Our objective was to examine the likelihood of vaginal birth after cesarean (VBAC) for women in Massachusetts. Methods We used birth certificate data among term, singleton, vertex presentation births by repeat cesarean or VBAC to conduct logistic regression models to examine the likelihood of VBAC for women categorized into standard classifications of race and ethnicity and into 31 detailed ethnicities. Data were analyzed for the entire study period (1996-2010, N = 119,752) and for the last 5 years (2006-2010, N = 46,081). Results The adjusted odds of VBAC were lowest for non-Hispanic Black mothers (0.91, CI [0.85, 0.98]) and highest for Asian/Pacific Islander mothers (1.41, CI [1.31, 1.53]) relative to non-Hispanic White women. VBAC rates ranged from 5.8 % among Brazilians to 29.3 % among Cambodians. The adjusted odds of VBAC were lower for 7 of the 30 ethnic groups (range of AORs 0.40-0.89) and higher for 8 of the 30 ethnic groups (range of AORs 1.18-2.11) relative to self-identified American mothers. For the last 5 years, Asian/Pacific Islander mothers had a higher adjusted VBAC rate (1.39, CI [1.21, 1.60]), as did 9 of the 30 ethnic groups (range of 1.25-1.84). Only Brazilian mothers had lower rates (0.37, CI [0.27, 0.50]), relative to self-identified American mothers. Conclusions Detailed maternal ethnicity explains the variation in VBAC rates more precisely than broad race/ethnicity categories. Improvements in our public health data infrastructure to capture detailed ethnicity are recommended to identify and address disparities and improve the quality of maternity care.

An ethnography on perceptions of pain in Dutch "Natural" childbirth

OBJECTIVE

this study offers insight into how women perceive childbirth pain and how they make decisions about whether to use an epidural during childbirth in the low technology context of the Netherlands maternity care system.

DESIGN

ethnographic research consisting of participant observation at births and prenatal and postnatal appointments; semi-structured interviews with a sample of recently post-partum women; coding and triangulation of data to determine key themes in the interviews.

SETTING AND PARTICIPANTS

the study was carried out with participants in thirteen urban cities around the Netherlands. The 40 post-partum women had lived in the Netherlands for at least 10 years prior to participation in the study, spoke English proficiently, and had a vaginal birth within the past 18 months. Additionally, participant observation occurred in midwifery practices.

FINDINGS

analysis of the interviews revealed three key themes: first, participants perceive childbirth pain as "natural" and positive, and approach its management through non-medical birth methods; second, participants prioritize autonomy in childbirth which they see as something they can "do on [their] own" without pain medication; and third, participants' decisions about using an epidural was supported by professional advice and social connections, such as friends and family members.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

women's conception of pain is central to decisions about childbirth in the Netherlands. This ethnographic research illustrates how perceptions and attitudes toward childbirth pain are affected by definitions of a "natural" birth, women's capacity to give birth, and the presence of professional and social support for non-medical births.

Patient-controlled analgesia with remifentanil versus alternative parenteral methods for pain management in labour

BACKGROUND

Multiple analgesic strategies for pain relief during labour are available. Recently remifentanil, a short-acting opioid, has recently been used as an alternative analgesic due to its unique pharmacological properties.

OBJECTIVES

To systematically assess the effectiveness of remifentanil intravenous patient-controlled analgesia (PCA) for labour pain, along with any potential harms to the mother and the newborn.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (9 December 2015), ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP), handsearched congress abstracts (November 2015), and reference lists of retrieved studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs) and cluster-randomised trials comparing remifentanil (PCA) with another opioid (intravenous (IV)/intramuscular (IM)), or with another opioid (PCA), or with epidural analgesia, or with remifentanil (continuous IV), or with remifentanil (PCA, different regimen), or with inhalational analgesia, or with placebo/no treatment in all women in labour including high-risk groups with planned vaginal delivery.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion, extracted data, and appraised study quality.We contacted study authors for additional information other than incomplete outcome data. We performed random-effects meta-analysis.To reduce the risk of random error in meta-analysis we performed trial sequential analysis. We included total zero event trials and used a constant continuity correction of 0.01 (ccc 0.01) for meta-analysis. We applied the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) approach to assess the quality of evidence.

MAIN RESULTS

Twenty RCTs with 3569 women were included. Of those, 10 trials (2983 participants) compared remifentanil (PCA) to an epidural, four trials (216 participants) to another opioid (IV/IM), three trials (215 participants) to another opioid (PCA), two trials (135 participants) to remifentanil (continuous IV), and one trial (20 participants) to remifentanil (PCA, different regimen). No trials were identified for the remaining comparisons.Methodological quality of studies was moderate to poor. We assessed risk of bias as high for blinding issues and incomplete outcome data in 65% and 45% of the included studies, respectively.There is evidence of effect that women in the remifentanil (PCA) group were more satisfied with pain relief than women in the other opioids (IV/IM) group (standardised mean difference (SMD) 2.11, 95% confidence interval (CI) 0.72 to 3.49, four trials, very low-quality evidence), and that women were less satisfied compared to women in the epidural group (SMD -0.22, 95% CI -0.40 to -0.04, seven trials, very low-quality evidence).There is evidence of effect that remifentanil (PCA) provided stronger pain relief at one hour than other opioids administered IV/IM (SMD -1.58, 95% CI -2.69 to -0.48, three trials, very low-quality evidence) or via PCA (SMD -0.51, 95% CI -1.01 to -0.00, three trials, very low-quality evidence). Pain intensity was higher in the remifentanil (PCA) group compared to the epidural group (SMD 0.57, 95% CI 0.31 to 0.84, six trials, low-quality evidence).Data were limited on safety aspects for both the women and the newborns. Only one study analysed maternal apnoea in a comparison of remifentanil (PCA) versus epidural and reported that half of the women in the remifentanil and none in the epidural group had an apnoea (very low-quality evidence). There is no evidence of effect that remifentanil (PCA) was associated with an increased risk for maternal respiratory depression when compared to epidural analgesia (RR 0.91, 95% CI 0.51 to 1.62, ccc 0.01, three trials, low-quality evidence) and no reliable conclusion might be reached compared to remifentanil (continuous IV) (all study arms included zero events, two trials, low-quality evidence). In one trial of remifentanil (PCA) versus another opioid (IM) three out of 18 women in the remifentanil and none out of 18 in the control group had a respiratory depression (very low-quality evidence).There is no evidence of effect that remifentanil (PCA) was associated with an increased risk for newborns with Apgar scores less than seven at five minutes compared to epidural analgesia (RR 1.26, 95% CI 0.62 to 2.57, ccc 0.01, five trials, low-quality evidence) and no reliable conclusion might be reached compared to another opioid (IV) and compared to remifentanil (PCA, different regimen) both with zero events in all study arms (one trial, very-low quality evidence). In one trial of remifentanil (PCA) versus another opioid (PCA) none out of nine newborns in the remifentanil and three out of eight in the opioid (PCA) group had Apgar scores less than seven (very-low quality evidence).There is evidence that remifentanil (PCA) was associated with a lower risk for the requirement of additional analgesia when compared to other opioids (IV/IM) (RR 0.57, 95% CI 0.40 to 0.81, three trials, moderate-quality evidence) and that it was associated with a higher risk compared to epidural analgesia (RR 9.27, 95% CI 3.73 to 23.03, ccc 0.01, six trials, moderate-quality evidence). There is no evidence of effect that remifentanil (PCA) reduced the requirement for additional analgesia compared to other opioids (PCA) (RR 0.76, 95% CI 0.45 to 1.28, three trials, low-quality evidence).There is evidence that there was no difference in the risk for caesarean delivery between remifentanil (PCA) and other opioids (IV/IM) (RR 0.63, 95% CI 0.30 to 1.32, ccc 0.01, four trials, low-quality evidence) and epidural analgesia (RR 1.0, 95% CI 0.82 to 1.22, ccc 0.01, nine trials, moderate-quality evidence), respectively. Pooled meta-analysis revealed an increased risk for caesarean section under remifentanil (PCA) compared to other opioids (PCA) (RR 2.78, 95% CI 0.99 to 7.82, two trials, very low-quality evidence). However, a wide range of clinically relevant and non-relevant treatment effects is compatible with this result.

AUTHORS' CONCLUSIONS

Based on the current systematic review, there is mostly low-quality evidence to inform practice and future research may significantly alter the current situation. The quality of evidence is mainly limited by poor quality of the studies, inconsistency, and imprecision. More research is needed on maternal and neonatal safety outcomes (maternal apnoea and respiratory depression, Apgar score) and on the optimal mode and regimen of remifentanil administration to provide highest efficacy with reasonable adverse effects for mothers and their newborns.

Labour pain experiences and perceptions: a qualitative study among post-partum women in Ghana

Background

Women have experienced severe labour pain over the years and various attempts have been made to effectively manage labour pain. However, there is paucity of literature on the labour pain experience and perceptions about labour pain with the contemporary Ghanaian health system. Therefore this study sought to gain an in-depth understanding on labour pain experiences and perceptions of post-partum women.

Methods

The study adopted an exploratory descriptive qualitative approach and collected data through individual interviews. Informed consent was obtained from all the participants who were purposively sampled. After transcription of interviews, the data were analyzed inductively using content analysis techniques.

Results

Women in this study experienced pain during labour rated as mild, moderate and severe and the pain was felt at the waist area, vagina, lower abdomen and the general body. The women expressed labour pain through crying, screaming and shouting. They prayed to God to help reduce the severe pain. Some women endured the pain, cried inwardly and others showed no sign of pain. Some women believed that crying during labour is a sign of weakness. Pain reliefs such as pethidine (Meperidine) was occasionally given. Non-pharmacologic measures employed included walking around, deep breathing, side-lying, waist holding, squatting, taking a shower and chewing gum. The individuality of pain experience and expression was emphasized and the socio-cultural orientation of women made some of them stoic.

Conclusion

We concluded that it is necessary for all health professionals to manage labour pain effectively taking the socio-cultural context into consideration.

Requests for cesarean deliveries: The politics of labor pain and pain relief in Shanghai, China

Cesarean section rates have risen dramatically in China within the past 25 years, particularly driven by non-medical factors and maternal requests. One major reason women request cesareans is the fear of labor pain, in a country where a minority of women are given any form of pain relief during labor. Drawing upon ethnographic fieldwork and in-depth interviews with 26 postpartum women and 8 providers at a Shanghai district hospital in June and July of 2015, this article elucidates how perceptions of labor pain and the environment of pain relief constructs the cesarean on maternal request. In particular, many women feared labor pain and, in a context without effective pharmacological pain relief or social support during labor, they came to view cesarean sections as a way to negotiate their labor pain. In some cases, women would request cesarean sections during labor as an expression of their pain and a call for a response to their suffering. However, physicians, under recent state policy, deny such requests, particularly as they do not view pain as a reasonable indication for a cesarean birth. This disconnect leads to a mismatch in goals for the experience of birth. To reduce unnecessary C-sections, policy makers should instead address the lack of pain relief during childbirth and develop other means of improving the childbirth experience that may relieve maternal anxiety, such as allowing family members to support the laboring woman and integrating a midwifery model for low-risk births within China's maternal-services system.

Differences in the Frequency of Use of Epidural Analgesia between Immigrant Women of Turkish Origin and Non-Immigrant Women in Germany - Explanatory Approaches and Conclusions of a Qualitative Study

Introduction: The starting point of this study was the considerably lower rate of epidural analgesia use among women of Turkish origin in Germany compared to non-immigrant women in the German Research Foundation (DFG)-funded study entitled "Perinatal Health and Migration Berlin". The study aimed to identify possible differences in the women's attitudes towards epidural analgesia. Methods: Exploratory study with semi-structured interviews, interviews lasting 17 minutes on average were conducted with 19 women of Turkish origin and 11 non-immigrant women at a Berlin hospital. The interviews were subjected to a qualitative content analysis. Results: Immigrant women of Turkish origin in Germany more frequently ascribe meaning to the pain associated with vaginal delivery. They more frequently categorically reject the use of epidural analgesia, 1) for fear of long-term complications such as paralysis and back pain and 2) based on the view that vaginal delivery with epidural analgesia is not natural. Information on epidural analgesia is frequently obtained from a variety of sources from their social setting, in particular, by word of mouth. The women in both groups stated that they would take the decision to use epidural analgesia independent of their partner's opinion. Discussion: The differences in epidural analgesia use rates observed correspond to the women's attitudes. For the immigrant women of Turkish origin in Germany, the attitude towards using epidural analgesia is based in part on misinformation. In order to enable the women to make an informed decision, epidural analgesia could receive a stronger focus during childbirth courses.

Methods of Coping With Labor Pain Used by Jordanian Women

The purpose of this study is to explore labor pain coping methods among Jordanian parturients. Descriptive statistics and content analysis were used to analyze data on demographics and coping methods from 100 low-risk parturients who were recruited from the postpartum unit in a major hospital in Jordan: Four labor pain-coping methods that included physiological, psychological, spiritual, and cognitive coping were reported. This study confirms previous findings regarding coping methods and adds new knowledge on coping with labor pain among Jordanian parturients: The significance of childbirth education as a means to inform Jordanian women about coping with labor pain is emphasized. This study also highlighted the important roles that nurses and midwives can play as educators and supporters during pregnancy and labor.

The Turkish version of perceived support and control in birth scale

OBJECTIVE

This is a methodological study carried out to evaluate the validity and reliability of the Turkish version of the Support and Control in Birth Scale (SCIB).

METHODS

This study included 339 post-partum women. The validity of the Turkish version of the scale was assessed in terms of content and construct validity. Reliability was evaluated using the internal consistency coefficient, the test-retest correlation coefficient and the item correlation between the subscales.

RESULTS

The internal consistency coefficient of the scale was 0.84 (p < 0.01). There were significant correlations between sub-scales (rho = 0.122, 0.129, 0.263, p < 0.05), and the test-retest correlation coefficient of the scale was also significant (rho = 0.86, α = 0.000). As in the original scale, a three-factor structure was examined, which explained 42.85% of the total variance. The model was verified by a confirmatory factor analysis.

CONCLUSION

The Turkish version of the SCIB is a reliable and valid instrument for measuring the perceived support and control during birth among Turkish women.

Perceptions of labour pain management of Dutch primary care midwives: a focus group study

BACKGROUND

Labour pain is a major concern for women, their partners and maternity health care professionals. However, little is known about Dutch midwives' perceptions of working with women experiencing labour pain. The aim of this study was to explore midwives' perceptions of supporting women in dealing with pain during labour.

METHODS

We conducted a qualitative focus group study with four focus groups, including a total of 23 midwives from 23 midwifery practices across the country. Purposive sampling was used to select the practices. The constant comparison method of Glaser and Straus (1967, ren. 1995) was used to gain an understanding of midwives' perceptions regarding labour pain management.

RESULTS

We found two main themes. The first theme concerned the midwives' experienced professional role conflict, which was reflected in their approach of labour pain management along a spectrum from "working with pain" to a "pain relief" approach. The second theme identified situational factors, including time constraints; discontinuity of care; role of the partner; and various cultural influences, that altered the context in which care was provided and how midwives saw their professional role.

CONCLUSION

Midwives felt challenged by the need to balance their professional attitude towards normal birth and labour pain, which favours working with pain, with the shift in society towards a wider acceptance of pharmacological pain management during labour. This shift compelled them to redefine their professional identity.

The Development and Psychometric Analysis of the Women’s Experience in Childbirth Survey

Background and Purpose: A woman’s perception of the childbirth experience has not been adequately measured. The purpose of the Women’s Experience in Childbirth Survey (WECS) is to provide a comprehensive measure of the experience for women having a vaginal birth. Methods: A cross-sectional design with 302 postpartum women analyzed the psychometric properties of the WECS. Validity was assessed using exploratory factor analysis and correlation to a self-rating of the overall experience. Results: Exploratory factor analysis identified four subscales consistent with the organizing framework. WECS scores and self-rated experience were significantly correlated r = .51, p < .01. Internal consistency α = .86 and temporal stability (r = .88, p < .001) are adequate. Conclusion: Initial analysis indicates sufficient reliability and validity for further development and testing.

In wealthier countries, patients perceive worse impact of the disease although they have lower objectively assessed disease activity: results from the cross-sectional COMORA study

Objectives

To investigate patterns in patient-reported and physician-reported disease outcomes in patients with rheumatoid arthritis (RA) from countries with different level of socioeconomic development.

Methods

Data from a cross-sectional multinational study (COMOrbidities in RA) were used. Contribution of socioeconomic welfare (gross domestic product (GDP); low vs high) of country of residence to physician-reported (tender joint count, swollen joint count (SJC), erythrocyte sedimentation rate, disease activity score based on 28 joints assessment (DAS28)-3v based on these three components and physician global assessment) and patient-reported (modified Health Assessment Questionnaire (mHAQ), patient global assessment and fatigue) disease outcomes was explored in linear regressions, adjusting for relevant confounders.

Results

In total, 3920 patients with RA from 17 countries (30 to 411 patients per country) were included, with mean age of 56 years (SD13) and 82% women. Mean SJC varied between 6.7 (Morocco) and 0.9 (The Netherlands), mean mHAQ ranged between 0.7 (Taiwan) and 1.5 (The Netherlands). Venezuela had the lowest (1.7) and the Netherlands the highest score on fatigue (5.0). In fully adjusted models, lower GDP was associated with worse physician-reported outcomes (1.85 and 2.84 more swollen and tender joints, respectively, and 1.0 point higher DAS28-3v), but only slightly worse performance-based patient-reported outcome (0.15 higher mHAQ), and with better evaluation-based patient-reported outcomes (0.43 and 0.97 points lower on patient global assessment and fatigue, respectively).

Conclusions

In patients with RA, important differences in physician-reported and patient-reported outcomes across countries were seen, with overall a paradox of worse physician-reported outcomes but better patient-reported outcomes in low-income countries, while results indicate that these outcomes in multinational studies should be interpreted with caution. Research on explanatory factors of this paradox should include non-disease driven cultural factors influencing health.

The quality of childbirth care in China: women's voices: a qualitative study

BACKGROUND

In the context of improved utilisation of health care and outcomes, rapid socio-economic development and health system reform in China, it is timely to consider the quality of services. Data on quality of maternal health care as experienced by women is limited. This study explores women's expectations and experiences of the quality of childbirth care in rural China.

METHODS

Thirty five semi-structured interviews and five focus group discussions were conducted with 69 women who had delivered in the past 12 months in hospitals in a rural County in Anhui Province. Data were transcribed, translated and analysed using the framework approach.

RESULTS

Hospital delivery was preferred because it was considered safe. Home delivery was uncommon and unsupported by the health system. Expectations such as having skilled providers and privacy during childbirth were met. However, most women reported lack of cleanliness, companionship during labour, pain relief, and opportunity to participate in decision making as poor aspects of care. Absence of pain relief is one reason why women may opt for a caesarean section.

CONCLUSIONS

These findings illustrate that to improve quality of care it is crucial to build accountability and communication between providers, women and their families. Ensuring women's participation in decision making needs to be addressed.

Women's experiences of coping with pain during childbirth: a critical review of qualitative research

OBJECTIVE

to identify and analyse qualitative literature exploring women's experiences of coping with pain during childbirth.

DESIGN

critical review of qualitative research.

FINDINGS

ten studies were included, conducted in Australia, England, Finland, Iceland, Indonesia, Iran and Sweden. Eight of the studies employed a phenomenological perspective with the remaining two without a specific qualitative methodological perspective. Thematic analysis was used as the approach for synthesising the data in this review. Two main themes emerged as the most significant influences upon a woman's ability to cope with pain: (i) the importance of individualised, continuous support and (ii) an acceptance of pain during childbirth. This review found that women felt vulnerable during childbirth and valued the relationships they had with health professionals. Many of the women perceived childbirth pain as challenging, however, they described the inherent paradox for the need for pain to birth their child. This allowed them to embrace the pain subsequently enhancing their coping ability.

KEY CONCLUSIONS

women's experience of coping with pain during childbirth is complex and multifaceted. Many women felt the need for effective support throughout childbirth and described the potential implications where this support failed to be provided. Feeling safe through the concept of continuous support was a key element of care to enhance the coping ability and avoid feelings of loneliness and fear. A positive outlook and acceptance of pain was acknowledged by many of the women, demonstrating the beneficial implications for coping ability. These findings were consistent despite the socio-economic, cultural and contextual differences observed within the studies suggesting that experiences of coping with pain during childbirth are universal.

IMPLICATIONS FOR PRACTICE

the findings suggest there is a dissonance between what women want in order to enhance their ability to cope with pain and the reality of clinical practice. This review found women would like health professionals to maintain a continuous presence throughout childbirth and support a social model of care that promotes continuity of care and an increasing acceptance of pain as part of normal childbirth. It is suggested future research regarding the role of antenatal provision for instilling such a viewpoint in preparation of birth be undertaken to inform policy makers. The need for a shift in societal norms is also suggested to disseminate expectations and positive or negative views of what the role of pain during childbirth should be to empower women to cope with childbirth and embrace this transition to motherhood as part of a normal process.

Acute symptoms associated with chemical exposures and safe work practices among hospital and campus cleaning workers: a pilot study

BACKGROUND

Cleaning workers are regularly exposed to cleaning products containing hazardous chemicals. This study investigated acute symptoms associated with chemical exposures among cleaning workers and their safe work practices.

METHODS

This cross-sectional study included 183 cleaning workers employed in an academic medical center and affiliated health sciences campuses in Northern California. Data on respiratory, eye, skin, neurological, and gastrointestinal symptoms and occupational factors were collected by in-person interviews or self-administered questionnaires.

RESULTS

Chemical-related symptoms (several times monthly or more often) were more common among workers who performed patient area cleaning (44%) than hospital custodians (36%) or campus custodians (28%). After controlling for age, sex, and job title, symptoms were associated with exposure to carpet cleaners (OR = 2.98, 95% CI 1.28-6.92), spray products (OR = 2.82, 95% CI 1.16-6.82), solvents (OR = 2.71, 95% CI 1.20-6.15), and multi-purpose cleaners (OR = 2.58, 935% CI 1.13-6.92). Except for gloves, regular use of personal protective equipment was infrequent.

CONCLUSIONS

Study findings suggest a need for additional interventions such as use of less toxic products to reduce health risks among cleaning workers.

The influence of detailed maternal ethnicity on cesarean delivery: findings from the U.S. birth certificate in the State of Massachusetts

BACKGROUND

Our objective was to examine the likelihood of primary cesarean delivery for women at low risk for the procedure in Massachusetts.

METHODS

Birth certificate data for all births from 1996 to 2010 that were nulliparous, term, singleton, and vertex (NTSV; N = 427,393) were used to conduct logistic regression models to assess the likelihood of a cesarean delivery for each of the 31 ethnic groups relative to self-identified "American" mothers. The results were compared with broad classifications of race/ethnicity more commonly employed in research.

RESULTS

While 23.3 percent of American women had primary cesarean deliveries, cesarean delivery rates varied from 12.9 percent for Cambodian to 32.4 percent for Nigerian women. Women from 21 of 30 ethnic groups had higher odds of a primary cesarean (range of adjusted odds ratios [AORs] 1.09-1.77), while only Chinese, Cambodian, and Japanese women had lower odds (range of AORs 0.66-0.92), compared with self-identified "Americans." Using broad race/ethnicity categories, Non-Hispanic black, Hispanic, and "Other" women had higher odds of cesarean delivery relative to Non-Hispanic white women (range of AORs 1.12-1.47), while there were no differences for Asian or Pacific Islander women.

CONCLUSIONS

Detailed maternal ethnicity explains the variation in NTSV cesarean delivery rates better than broad race/ethnicity categories. Different patterns of cesarean delivery between ethnic groups suggest cultural specificity related to birth culture.