PERCEPTION OF EPIDURAL ANALGESIA FOR LABOUR AMONG PREGNANT WOMEN IN A NIGERIAN TERTIARY HOSPITAL SETTING

Abstract

Background:

Epidural anaesthesia is the preferred technique and gold standard for labour analgesia. However this technique is poorly utilized in our setting .This study is therefore aimed to assess the perception of this technique for labour analgesia among pregnant women in a Nigerian tertiary hospital setting in order to suggest ways of improving the utilization of same.

Aim & Objectives

To assess the knowledge and percerption of women regarding epidural analgesia for labour in the antenatal clinics.

Setting

University of Benin Teaching Hospital, Benin, Southsouth Nigeria.

Methods

A total of 420 women attending the antenatal clinics of the University of Benin Teaching Hospital in South-south Nigeria were interviewed using semi-structured researcher-administered questionnaires. Respondents’ socio-demographic characteristics, knowledge of epidural analgesia and its acceptance were obtained, documented and analyzed.

Results

Four hundred and five (94.6%) out of 420 gave complete responses to the questions asked. A majority of the respondents 322(79.5%) were not aware of epidural analgesia. Of the 83(20.9%) who were aware, 22.9% knew it was used to relieve labour pain and 20(24.1%) had first knowledge about epidural analgesia from health workers. A majority of the respondents 310(76.5%) would accept epidural analgesia if offered to them. The level of education and previous labour experiences were statistically significantly associated with awareness and acceptance of epidural analgesia respectively (p = 0.000)

Conclusion

This study has shown that there is poor awareness and acceptance of epidural analgesia in labour in this environment which would be greatly improved by public enlightenment and counselling during ante-natal visits.

Introduction

Management of labour pain has remained a clinical issue and it is as old as mankind. Labour pain perception varies in onset, timing, duration and severity. Effective management of labour pain results in greater maternal satisfaction with the birth process1. More than two thirds of un-anaesthetized women described their pain intensity with terms such as "distressing," "horrible" or "excruciating" at some point during the first stage of labour2.

Many pharmacologic and non-pharmacologic treatments have been developed to treat labour pain. Pharmacologic methods include the use of parenteral opioids, regional techniques, and inhalational agents such as entonox3,4. Epidural analgesia is the preferred technique and gold standard for labour analgesia as it carries the advantage of an ‘awake’ mother who is able to participate in the delivery process, and foetal effects are minimal. The technique can also be extended for operative deliveries in the event of such occurrence. Its analgesic effect helps in the management of medical conditions coexisting with pregnancy such as preeclampsia by preventing further increases in the blood pressure as well as in the prevention of vaginal and cervical tears that may result from increased straining by the woman due to excessive pain resulting in life threatening haemorrhages. It is also beneficial in women with intracranial aneurysms which may rupture from increases in blood pressure brought about by the pain of labour5.

Despite its many advantages, this technique is not popular especially in developing countries. Consequently epidural analgesia is not available to many women during childbirth especially in rural areas, where the majority of the population reside, as there are inadequate resources and few trained practitioners to perform the technique. Most women are offered only intermittent opioid analgesia such as pethidine or pentazocine in early labour, usually at the birth attendant’s discretion and this is usually inadequate 6.

There is therefore a need to increase the awareness of epidural for labour analgesia in order to increase its demand which would encourage more availability and provision of the technique.

Patients & Methods

This was a cross-sectional study among 420 women attending the antenatal clinics of the University of Benin Teaching Hospital, Benin in South south Nigeria. They were selected by a systematic sampling method and interviewed using researcher-administered semi-structured questionnaires which were pretested in another hospital. This was done after ethical clearance was obtained from the Ethics and Research Committee of the University of Benin Teaching Hospital and informed verbal consent obtained from the respondents. The respondents’ socio-demographic characteristics, knowledge of pain relief methods, including epidural analgesia and its acceptance were obtained and recorded. The data obtained were analyzed using SPSS version 16. Tables, figures and charts were used to present descriptive data. Associations were tested using Chi square, and level of significance was set at <0.05.

Results

Four hundred and five (94.6%) out of 420 respondents gave complete responses to the questions asked. The mean age of the pregnant women was 31.23± 4.9 years with a range of 21-44 years. The age group of 25-30 years had the highest proportion (42.0%) while those 41-45 years had the least of 3.2%. Majority 270(66.7%) of the respondents had secondary education followed by those with tertiary education 83(20.5%), primary education 48(11.9%) and the respondents who had no formal education recording 1.0%. Civil servants and traders made up 36.0% and 26.2% respectively while artisans were 40(9.9%) as shown in Table1.

Table 2 shows that 83(20.5%) of the respondents were aware of epidural analgesia out of which 22.9% knew it could be used to relieve labour pain while 8 (9.6%) thought it was just an intramuscular injection. A majority of the respondents had first knowledge about epidural analgesia from health workers 20(24.1%). This was closely followed by information from the television and radio in 19.3% and 16.9% respectively as indicated in Table 2.

The awareness of epidural analgesia was affected by the level of education of the respondents. Most of the women who had tertiary level of education were aware of epidural analgesia compared to those with no education. This was statistically significant (P=0.000.) as shown in Table 3.

Figure 1 shows that a majority of the respondents 310(76.5%) would accept epidural analgesia if offered to them. In contrast, 54(13.3%) of the respondents would not accept epidural analgesia while 41(10.2%) respondents were indifferent. Of the 310 respondents that would accept epidural analgesia, 185(59.7%) would accept it to avoid the pain in labour while 51(16.5%) would accept it on their doctors’ advice 51 (Fig 2).

There was increased level of acceptance of epidural analgesia with increasing level of education: 64.6%, 76.3% and 83.1% for primary, secondary and tertiary education respectively (Table 4).

Respondents with a previous labour experience were more willing to accept epidural analgesia compared with those without prior experience. The association between epidural labour acceptance and a previous labour experience was statistically significant (p = 0.000) as shown in Table 5.

The reasons given by 46.3% of the respondents for non-acceptance of epidural analgesia included labour being a natural physiology and thus a good experience for women , not feeling the baby coming (9.3%), prolongation of labour (7.4%) and paralysis (3.7%) as indicated in Fig. 3.

Majority 394(97.2%) of respondents had not had epidural analgesia while 11(2.7%) had received epidural analgesia during their previous labour. A majority 9(81.8%) of those who had had epidural found it beneficial while 2(18.2%) could not ascertain its benefit.

Table 6 shows the reasons proffered by the respondents for poor utilisation of epidural analgesia in Nigeria. Low level of awareness (17.5%) was the major reason for its poor utilisation in our setting.

Discussion

Management of labour pains may be achieved with different methods however epidural analgesia remains the gold standard. A previous study noted the poor utilization of labour analgesia services as a result of poor pre-natal information6.

Concerning the awareness of epidural analgesia, about 21% of the respondents had prior knowledge of this method of labour pain relief and among them many had misconceptions of what an epidural was. This was similar to the work of Oladukun7 in 2008 in Western Nigeria which showed that 19.5% of the respondents had knowledge of epidural analgesia, but in contrast with the work of Olayemi7 and colleagues in the same hospital in 2003 where 10% had knowledge of epidural analgesia. This increase in knowledge was explained by the increase in the number of educated women in the period between the two studies. There is still a major gap in knowledge regarding epidural labour analgesia in the developing world since a study in Ireland9 found 41% of the pregnant women had planned to use an epidural for labour pain relief. Also in another study in Hongkong10, 47% of antenatal patients reported having been exposed to the concept of epidural analgesia in labour.In the current study, educational status played a significant role in the level of awareness. This showed the benefit of female education of women which not only enlightened but also empowered women in our environment.

A small percentage of the respondents in the index study knew that epidural analgesia could be used to relieve labour pains. Most of the respondents got their information from health workers and the mass media. This was similar to findings in an earlier study in Benin City, Nigeria where it was reported that most of the respondents got their information from health care providers6. This further emphasized the need for prenatal counselling by health care providers. Presenting prenatal choices for labour analgesia by health care providers in such facilities would go a long way in helping women make choices and give informed consent regarding their pain management in labour.

Majority of the respondents were willing to accept epidural analgesia during labour. The acceptance of epidural analgesia was also noted to be influenced by a previous experience of labour and this was found to be statistically significant.(p=0.000) Many of the respondents were willing to accept epidural if advised by a health personnel to do so and if it would reduce the pain of labour. Reasons for non-acceptance were “labour is natural” and some were of the opinion that epidural analgesia might lead to complications. This was a similar finding with a study in India, a developing country like Nigeria, where women in the antenatal clinics were reported to prefer epidural analgesia. Those who were not willing to accept this method of pain relief expressed concerns regarding effect on their babies and increased rates of vaginal instrumentation and caesarean deliveries.11 In another study among Latinos, where women in labour were interviewed regarding acceptance of epidural analgesia, 39% were willing to accept while the others did not accept and were of the opinion that women should cope with their pain while some believed that it might lead to backpain and other complications.12 The level of education of the respondent played a major role as those who had completed high school education accepted epidural analgesia in labour. This was further emphasized in the study in the United kingdom13 where more than 50% were willing to receive epidural analgesia in labour. It may therefore be observed that the acceptance of epidural analgesia for labour is related to both socio cultural factors and levels of education. This underscored the need for the attainment of the MDGs3 and 5 and to ensure every sector is developed.

It was also observed that a previous epidural and previous labour experience influenced the desirability of labour epidural among respondents. This was different from a another study in California USA, where it was observed that women who received epidural were nulliparas, those who had pitocin, had partners who preferred epidural analgesia and high school educational attainment.14 This may be as a result of improved awareness of, and fear of labour pains. In the index study women who had received epidural and those willing to accept labour epidural were of higher educational status.

Awareness may also result from exposure to mass media and internet facilities. The availability of trained medical personnel such as anaesthetists, obstetricians and midwives may also account for better availability and utilization of labour epidural services. There is the need for a well developed labour epidural service which will increase awareness and hence boost demand in order to close the gap that exists between the developing and developed countries.

Some of the respondents did not accept epidural analgesia due to poor knowledge and misconceptions regarding epidural analgesia as it might lead to complications. Epidurals are considered safe in trained hands and it has not been found to increase the incidence of prolonged labour, caesarean sections, or backpain15. A follow-up cohort study15 showed that one year after delivery, there were no differences in the numeric rating scores for back pain or level of interference with activities between women who had labour epidurals and those who did not.

Reasons proffered for the poor utilization of labour epidural services were lack of awareness, cost and underdevelopment. Financial constraint may be an issue in resource poor setting and hence there may be a need for government and management bodies to subsidize the rate and make it attractive for women in labour. Apart from free maternal and childhealth care offered by some state government, free epidurals may also be incorporated to increase its utilization. In the setting where this study was carried out, average cost of an epidural analgesia is $35 while in Harvard, women pay as high as $338.16 This however did not influence the demand for epidural analgesia in the developed countries as the women in these countries have access to health insurance compared to women in developing countries. It can therefore be deduced that low level of utilization in Nigeria results from a fundamental defect in the obstetric analgesia services as well as cost, since most women in the developing countries like Nigeria cannot afford to pay the average cost of $35 for this service.

Epidural analgesia still remains the gold standard for pain management in labour and thus its relevance in obstetric analgesia service could not be overemphasized. There is therefore a need to make this technique available in health institutions in Nigeria.

This study demonstrated the poor knowledge and utilization of labour epidurals. Many of the respondents were willing to accept labour epidurals if offered to them. This study also revealed misconceptions in the perception of epidural labour analgesia.

There is therefore need to raise awareness regarding epidural labour analgesia by policy makers and other stakeholders regarding the need to introduce an epidural analgesia service.

Antenatal clinic health education to enable women make choices regarding pain management during labour is advocated. There should be the establishment of a dedicated 24hr obstetric service by training and retraining of medical personnel in charge of provision of labour epidural service, increasing its awareness by means of mass media and provision of internet facilities by the government in schools, libraries, and hospitals and other public places of interest. Subsidizing epidural services by the government and other stakeholders by incorporating it into the free maternal and child health programs all over the country will increase its utilization.

Limitation

In some cases, we could not get the full attention of the respondents as they passed through the rigours of ante-natal clinic visits.

Conclusions

This study has shown that there is poor awareness and acceptance of epidural analgesia in labour in this environment which would be greatly improved by public enlightenment and counselling during ante-natal visits.

Table 1. Socio-demographic characteristics.

VARIABLE	FREQUENCY (N=405)	PERCENT (%)
Age
21-25	52	12.8
25-30	170	42.0
31-35	93	23.0
36-40	77	19.0
41-45	13	3.2
Mean age ± SD	31.23±4.9
Range	21-44
Religion
Christianity	388	95.8
Islam	11	2.7
ATR	6	1.5
Marital status
Single	16	4.0
Married	389	96.0
Education
None	4	1.0
Primary	48	11.9
Secondary	270	66.7
Tertiary	83	20.5
Occupation
Trader	106	26.2
Civil servant	146	36.0
Artisan	40	9.9
Applicant/unemployed	33	8.1
Teacher	21	5.2
Farmer	17	4.9
Student	16	4.0
Banker	15	3.7
Private secretary	6	1.5
Health worker	5	0.5

Table 2. Respondents’ awareness and first source of information on epidural analgesia .

	Frequency	Percent
Relatives	9	10.8
Friends	8	9.7
Printed Materials	10	12.0
Television	14	16.9
Internet	6	7.2
Health worker	20	24.1
Radio	16	19.3
Total	83	100.0
Awareness of epidural
General Pain reliever	39	46.9
Intramuscular Injection	8	9.6
Spinal injection	17	20.5
Labour pain reliever	19	22.9
Total	83	100

Table 3. Educational level and awareness of epidural analgesia.

Educational level	Awareness of labour epidural				Total
	Yes		No
	N	(%)	N	(%)	N	(%)
None	0	(0.0)	4	(100.0)	4	(0.9)
Primary	0	(0.0)	48	(100.0)	48	(11.9)
Secondary	12	(4.5)	256	(95.5)	268	(66.2)
Tertiary	71	(83.5)	9	(10.6)	85	(20.9)
Total	83	(20.5)	322	(79.5)	405	(100.0)
χ2= 23.549 Df = 2 P = 0.000

Table 4. Association between education and acceptance of epidural analgesia.

Educational level of respondents	Acceptance of epidural analgesia
	No idea		Yes		No		Total
	N	(%)	N	(%)	N	(%)	N	(%)
None	0	(0.0)	4	(100.0)	0	(0.0)	4	(100.0)
Primary	5	(10.4)	31	(64.6)	12	(25.0)	48	(100.0)
Secondary	33	(12.2)	206	(76.3)	31	(11.5)	270	(100.0)
Tertiary	3	(3.6)	69	(83.1)	11	(13.3)	83	(100.0)
Total	41	(10.1)	310	(76.5)	54	(13.3)	405	(100.0)

Table 5. Association between Respondents acceptance of epidural analgesia and previous experience.

Previous Labour experience	Acceptance of epidural analgesia
	Yes	(%)	No	(%)	Indifferent	(%)	Total	(%)
Yes	272	(77.5)	38	(10.8)	41	(11.7)	351	(86.7)
No	38	(70.4)	16	(29.6)	0	(0.0)	54	(13.3)
Total	310	(76.5)	54	(13.3)	41	(10.1)	405	(100.0)
X2=19.028 DF=2 P=0.000

Table 6. Reasons proffered by respondents for poor utilization of epidural in Nigeria.

	Frequency* N=405	percentage
No idea	292	70.8
Lack of awareness	71	17.5
Procedure is expensive	27	6.7
underdevelopment	12	2.9
Procedure not necessary	7	1.7
May be harmful	3	0.7
*multiple responses

Figure 1 . Respondents acceptance of epidural analgesia .

Figure 2. Reasons for acceptance of epidural analgesia .

Figure 3 . Reasons for non acceptance of epidural analgesia .