Mixed-methods systematic review: Childbearing women's views, experiences, and decision-making related to epidural analgesia in labour

Getting it right with discrete choice experiments: Are we hot or cold?

Discrete Choice Experiments (DCEs) are widely employed survey-based methods to assess preferences for healthcare services and products. While they offer an experimental way to represent health-related decisions, the stylized representation of scenarios in DCEs may overlook contextual factors that could influence decision-making. The aim of this paper was to evaluate the predictive validity of preferences elicited through a DCE in decisions likely influenced by a hot-cold empathy gap, and compare it to another commonly used method, a direct-elicitation question. We focused on preferences for pain-relief modalities, especially for an epidural during childbirth - a context where direct-elicitation questions have shown a preference for or intention to have a natural birth (representing the "cold" state), yet individuals often opt for an epidural during labor (representing the "hot" state). Leveraging a unique dataset collected from 248 individuals, we incorporated both the stated preferences collected through a survey administered upon hospital admission for childbirth and the actual pain-relief modality usage data documented in medical records. The DCE allowed for the evaluation of scenarios outside of those expected by respondents to simulate decision-making during childbirth. When we compared the predicted epidural use with the actual epidural use during labor, we observed a choice concordance of 71-60%, depending on the model specification. The concordance rate between the predicted and actual choices increased to 77-76% when accounting for the initial use of other ineffective modalities. In contrast, the direct-elicitation choices, relying solely on respondents' baseline expectations, yielded a lower concordance rate of 58% with actual epidural use. These findings highlight the flexibility of the DCE method in simulating complex decision contexts, including those involving hot-cold empathy gaps. The DCE proves valuable in assessing nuanced preferences, providing a more accurate representation of the decision-making processes in healthcare scenarios.

Effects of combined spinal-epidural anesthesia on anxiety, labor analgesia and motor blocks in women during natural delivery

BACKGROUND

The background of this study was analgesia in natural delivery. The combined spinal-epidural anesthesia has obvious analgesic effect on the parturients in natural labor, and combined spinal-epidural anesthesia has been widely used in anesthesia for various diseases.

AIM

To study the effects of combined spinal-epidural anesthesia on anxiety, labor analgesia, and motor blocks in parturients during natural delivery.

METHODS

A total of 120 women who gave birth at Changning District Maternal and Child Health Hospital between December 2021 to December 2022 were included; a random number table approach was employed to divide the women into a control group and a joint group, with each group consisting of 60 women. The control group was given epidural anesthesia, while the joint group was given combined spinal-epidural anesthesia. The visual analog scale (VAS) was used to evaluate the degree of maternal pain. Comparisons were made between the two groups’ conditions of childbirth and the duration of labor. Apgar scores were used to evaluate the status of the newborns at birth; Self-rating Anxiety Scale (SAS) and General Self-Efficacy Scale (GSES) scores, umbilical artery blood gas analysis indices and stress indices were compared between the two groups; and the frequencies of motor block and postpartum complications were analyzed.

RESULTS

In comparison to the control group, in the joint group, the VAS scores for the first, second, and third stages of labor were lower (P < 0.05). The rates of conversion to cesarean section and postpartum blood loss in the joint group were lower than those in the control group (P < 0.05). No significant differences were observed in the Apgar score, the duration of the first stage of labor, or the total duration of labor between the two groups (P > 0.05). The second and third stages of labor in the joint group were shorter than those in the control group (P < 0.05). When compared to the control group, the postpartum SAS score of the joint group was lower, while the GSES score was greater (P < 0.05). Between the control group and the joint group, the differences observed in pH, arterial carbon dioxide partial pressure, arterial oxygen partial pressure, or arterial hydrogen ion concentration were not significant (P > 0.05). Nitric oxide, cortisol, and adrenaline levels were lower in the joint group than in the control group (P < 0.05). There were no substantial differences in Bromage grade or rate of complications between the two groups (P > 0.05).

CONCLUSION

For parturients during natural delivery, combined spinal-epidural anesthesia can reduce anxiety, provide labor analgesia, shorten labor time, and reduce postoperative stress levels but did not result in a motor block.

Women's expectations about birth, requests for pain relief in labor and the subsequent development of birth dissonance and trauma

BACKGROUND

Birth is a significant event in women's lives. As Mansfield notes (2008) many women aim for a birth that avoids pharmacological pain relief because they are advised it is better for them and their baby. For women having their first baby, this may not be realistic as 3/4 of primiparous women in Australia will use pharmacological pain relief. This study examines the expectations that a group of women had regarding pain relief, how these expectations developed and what happened to requests for pain relief in labour.

METHODS

A longitudinal prospective study design was used to recruit 15 women who were having their first baby. Women having low risk pregnancies, hoping for a 'natural birth' (vaginal, no/minimal pharmacological pain relief) were eligible. A semi-structured interview tool was used across all three interviews that asked women about their expectations, then actual labour experience, pain management requests and how these were responded to by carers. Fifteen women were interviewed - at 36 weeks gestation; as soon after delivery of their baby as possible, then six months post-delivery (N = 43 interviews). Interviews were recorded and transcribed and coded by ES using NVivo software with hierarchical thematic analysis used.

RESULTS

The study found that women appear to experience a mismatch between expectations they had developed pre-birth, versus actual experience. This appears to cause a specific form of dissonance - which we have termed 'birth dissonance' leaving them feeling traumatised post birth. This is because what women expected to happen in birth was often not realised. In particular, some women requested pain relief in birth and felt that their request was not responded to as hoped, and also seemed to develop post-birth trauma. We proposed that this may have resulted from dissonance arising from their expectations about being able to birth without significant pain relief. Interventions and technology may also contribute to this sense of mismatch and post-birth trauma.

CONCLUSIONS

Low risk birthing women birthing in a hospital may have to engage with higher levels of technology, intervention and pain relief than that which they expected pre-birth. This could possibly be avoided with four simple changes. Firstly, better pre-birth education for women about how painful labor is likely to be. Secondly, pre-birth education which includes a detailed explanation of the utility of pharmacological and non-pharmacological pain relief. Thirdly, more egalitarian decision-making during labour and finally delivering upon women's requests for pain relief in labor, at the time that they ask for it. Further research is required to determine the extent of birth dissonance and how women making the transition to motherhood can avoid it.

Experiences of decisional conflict related to epidural labour analgesia among women during late pregnancy in a tertiary hospital in China: a mixed methods study

BACKGROUND

Research has indicated some women were in a state of uncertainty about pharmacological pain management decisions, which may lead to maternal anxiety and decisional regret. However, little is known about decisional conflict in the choice of epidural labour analgesia amongst Chinese women.

AIM

This study aimed to investigate the level of and reasons underlying decisional conflict in Chinese women during their late pregnancy when making a decision on the use of epidural analgesia in labour.

METHODS

A convergent parallel mixed methods study was undertaken, that included a quantitative survey (n = 323) and qualitative interviews (n = 17) with women recruited from a tertiary general hospital in Hangzhou, China. The quantitative survey assessed the level of and its influencing factors of women's decisional conflict, while the qualitative interview further explored experiences of and reasons underlying the conflict.

FINDINGS

Participants reported a high level of decisional conflict (mean±SD, 39.59±15.92), which related to decision delay and/or negative perceptions about the decision. Multiple stepwise linear regression analysis identified that highest level of education and knowledge of epidural were negatively associated with decisional conflict (p<0.05). Four decision-making styles (rational, dependant, intuitive and avoidant decision-making) associated with different levels of decisional conflict, and four underlying reasons (personal characteristics, informational provision, emotional support and participation in decision-making) of the conflict were thematized.

CONCLUSION

Decisional conflict related to epidural labour analgesia is a noteworthy issue amongst women during their late pregnancy. This study suggests a need for provision of family-centred shared decision-making practice about the use of epidural analgesia in labour.

Pregnant persons and birth partners' experiences of shared decision-making during pregnancy and childbirth: An umbrella review

OBJECTIVES

This umbrella review aimed to summarize evidence on pregnant persons and/or their birth partners' experiences and expectations of SDM during pregnancy and childbirth.

METHODS

We searched eight databases from 2011 to 2023. Quantitative, qualitative and mixed methods systematic reviews were included in this review.

RESULTS

We have identified 26 reviews that report on 622 primary studies involving over 213,000 pregnant persons and 22,000 birth partners, examining a broad range of decision-making scenarios in maternity care. The three-talk model was used to categorise the themes which include communication, weighing options, and making a decision. Multiple reviews have reported that pregnant persons and birth partners have mixed experiences in several decision-making scenarios, with insufficient information and inadequate consideration or answers to their questions being common issues. Pregnant persons and birth partners prefer clear explanations, simple communication, and involvement in decision-making. Exclusion from the decision-making during pregnancy and childbirth may lead to negative experiences, whilst involvement improves satisfaction, reduces distress and fosters empowerment.

CONCLUSIONS

The review highlights the importance of promoting SDM in maternity care, as it is fundamental to promoting maternal, newborn, and family well-being.

PRACTICE IMPLICATIONS

Health systems should redesign antenatal classes and train healthcare providers to enhance communication skills and encourage informed decision-making by pregnant persons and birth partners.

Intrapartum Analgesia-Have Women's Preferences Changed over the Last Decade?

Background: Global access to social media has supposedly changed women’s awareness about the pharmacological and alternative methods of pain relief during vaginal delivery. The purpose of the study was to analyze changes in women’s preference and opinion about different forms of labor analgesia over the past decade. Materials and methods: The study was designed as an anonymous survey with questions about women’s knowledge and preference of different forms of pain relief in labor. The survey was conducted in 2010 and 2020, with data collected from 1175 women in 2010 and 1033 in 2020. Results: There were no differences between 2010 and 2020 in the proportion of women who wanted to receive analgesia in labor, at, respectively 67.9% of women in 2010 and 73.9% in 2020. About 50% of women chose epidural analgesia as the only efficacious method of pain relief in labor both in 2010 and 2020. There were no differences between the two time-points in the distribution of chosen methods of pain relief. In total, 92.3% of women in 2010 and 94.9% in 2020 thought that they should have the possibility of independent choice of analgesia method before the delivery (p < 0.04). Conclusions: A high proportion of Polish women choose EDA over other pharmacological and nonpharmacological methods of pain relief in labor, and this preference has not changed over the last decade. Increasing women’s knowledge about different methods of intrapartum pain relief may lead to wider use of nonpharmacological methods of pain relief.

Parturients' Stated Preferences for Labor Analgesia: A Discrete Choice Experiment

OBJECTIVE

The objective was to investigate the extent to which treatment benefits, risks and costs affected parturients' preferences for labor analgesia.

METHODS

We recruited 248 healthy parturients prior to labor at an antenatal ward and administered a discrete choice experiment survey. Parturients were asked to choose among four hypothetical forms of labor analgesia: epidural analgesia, pethidine, Entonox and no analgesia, which were defined by: pain score, duration of second stage of labor, risks of instrumental delivery, back pain and permanent nerve injury, and out-of-pocket cost. We used mixed logit model to calculate the relative importance of each attribute (out of 100).

RESULTS

Parturients preferred receiving labor analgesia over not receiving analgesia and those who had positive past experience with epidural preferred epidural over other modalities. Out-of-pocket cost (28%), duration of second stage of labor (26%) and pain score following treatment (18%) were the most important attributes.

CONCLUSION

Out-of-pocket cost was a major concern. Parturients prioritized having lower pain and shorter labor experience over risks associated with epidural analgesia. Parturients should be presented with realistic range of risks of side-effects so that they can decide how to balance risks against benefits and costs associated with child labor.

Birth plan presentation to hospitals and its relation to obstetric outcomes and selected pain relief methods during childbirth

Background

The information on birth plan (BP) usage in Spanish hospitals is scant.

Aim

To identify the percentage of pregnant women presenting a BP at five hospitals in Spain, the reasons why some women failed to do so and how BP presentation relates to obstetric outcomes and selected pain relief methods.

Methods

In this descriptive, multi-centre study, data were retrospectively collected. During the postpartum visits at primary healthcare centres in various health districts in Barcelona (Catalonia, Spain), a data collection sheet about obstetric outcomes and analgesia was administered to 432 mothers who had completed a BP during their pregnancies. The main outcome was the rate of BP presentation to the hospital. The sociodemographic and obstetric characteristics and pain relief measures were compared to identify any differences between mothers who presented a BP and those who did not.

Results

A total of 422 (99.7%) women were studied; 51.2% of women (95% confidence interval (CI): 46.4–55.9) had presented a BP. The main reason for not presenting a BP was because the hospital midwives did not request them (61.2%). No differences were observed in BP presentation according to age, the country of origin, education, employment or hospital. Mothers who presented a BP were more likely to start breastfeeding in the birthing room (82.4% vs. 73.3%; p = 0.024). Epidural analgesia was the most common method used for pain relief (88.9%), and women who presented a BP attempted to use concomitant non-pharmacological methods more often (50.5% vs. 38.8%; p = 0.012).

Conclusion

Almost half of the mothers failed to present a BP, usually because midwives did not request it.