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.

Association between perinatal pain and postpartum depression: A systematic review and meta-analysis.

INTRODUCTION: In recent years, clinical studies have shown that perinatal pain could increase the risk of postpartum depression, while such a conclusion appears controversial. Therefore, we conducted this systematic review and meta-analysis to explore the association between perinatal pain and postpartum depression, and to evaluate the effectiveness of epidural labor analgesia in reducing the risk of postpartum depression. METHODS: PubMed, Web of Science, Embase and Cochrane Library were searched from inception to Jan 30th, 2022. The effect size of the meta-analysis was calculated using odds ratio and 95 % confidence interval. Statistical analysis was performed using Stata 15.0 software. RESULTS: There were 19 studies included with a total of 96,378 patients. Among the included studies, 10 investigated the association between perinatal pain and the risk of postpartum depression, and 9 reported that between labor analgesia and the risk of postpartum depression. The results of meta-analysis showed that perinatal pain increased the risk of postpartum depression [OR = 1.43, 95% CI (1.23, 1.67), p<0.05], and epidural analgesia could reduce the risk of postpartum depression [OR = 0.42, 95% CI (0.33, 0.55), p < 0.05]. LIMITATIONS: Source of heterogeneity in the association between perinatal pain and PPD could not be identified due to the limitations of the original studies. There were mainly cohort studies included in the assessment for effectiveness of epidural analgesia in reducing the incidence of postpartum pain. Therefore, we look forward to more RCTs to confirm our results. CONCLUSION: Perinatal pain is one of the risk factors for postpartum depression, and epidural analgesia could reduce the risk of PPD. This result might provide guidance for clinical practice. However, psychological health counseling should be combined with epidural analgesia for perinatal pain to reduce the risk of PPD.

Interventions for fear of childbirth including tocophobia.

BACKGROUND: Many women experience fear of childbirth (FOC). While fears about childbirth may be normal during pregnancy, some women experience high to severe FOC. At the extreme end of the fear spectrum is tocophobia, which is considered a specific condition that may cause distress, affect well-being during pregnancy and impede the transition to parenthood. Various interventions have been trialled, which support women to reduce and manage high to severe FOC, including tocophobia. OBJECTIVES: To investigate the effectiveness of non-pharmacological interventions for reducing fear of childbirth (FOC) compared with standard maternity care in pregnant women with high to severe FOC, including tocophobia. SEARCH METHODS: In July 2020, we searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP), and reference lists of retrieved studies. We contacted researchers of trials which were registered and appeared to be ongoing. SELECTION CRITERIA: We included randomised clinical trials which recruited pregnant women with high or severe FOC (as defined by the individual trial), for treatment intended to reduce FOC. Two review authors independently screened and selected titles and abstracts for inclusion. We excluded quasi-randomised and cross-over trials. DATA COLLECTION AND ANALYSIS: We used standard methodological approaches as recommended by Cochrane. Two review authors independently extracted data and assessed the studies for risk of bias. A third review author checked the data analysis for accuracy. We used GRADE to assess the certainty of the evidence. The primary outcome was a reduction in FOC. Secondary outcomes were caesarean section, depression, birth preference for caesarean section or spontaneous vaginal delivery, and epidural use. MAIN RESULTS: We included seven trials with a total of 1357 participants. The interventions included psychoeducation, cognitive behavioural therapy, group discussion, peer education and art therapy. We judged four studies as high or unclear risk of bias in terms of allocation concealment; we judged three studies as high risk in terms of incomplete outcome data; and in all studies, there was a high risk of bias due to lack of blinding. We downgraded the certainty of the evidence due to concerns about risk of bias, imprecision and inconsistency. None of the studies reported data about women's anxiety. Participating in non-pharmacological interventions may reduce levels of fear of childbirth, as measured by the Wijma Delivery Expectancy Questionnaire (W-DEQ), but the reduction may not be clinically meaningful (mean difference (MD) -7.08, 95% confidence interval (CI) -12.19 to -1.97; 7 studies, 828 women; low-certainty evidence). The W-DEQ tool is scored from 0 to 165 (higher score = greater fear). Non-pharmacological interventions probably reduce the number of women having a caesarean section (RR 0.70, 95% CI 0.55 to 0.89; 5 studies, 557 women; moderate-certainty evidence). There may be little to no difference between non-pharmacological interventions and usual care in depression scores measured with the Edinburgh Postnatal Depression Scale (EPDS) (MD 0.09, 95% CI -1.23 to 1.40; 2 studies, 399 women; low-certainty evidence). The EPDS tool is scored from 0 to 30 (higher score = greater depression). Non-pharmacological interventions probably lead to fewer women preferring a caesarean section (RR 0.37, 95% CI 0.15 to 0.89; 3 studies, 276 women; moderate-certainty evidence).  Non-pharmacological interventions may increase epidural use compared with usual care, but the 95% CI includes the possibility of a slight reduction in epidural use (RR 1.21, 95% CI 0.98 to 1.48; 2 studies, 380 women; low-certainty evidence). AUTHORS' CONCLUSIONS: The effect of non-pharmacological interventions for women with high to severe fear of childbirth in terms of reducing fear is uncertain. Fear of childbirth, as measured by W-DEQ, may be reduced but it is not certain if this represents a meaningful clinical reduction of fear. There may be little or no difference in depression, but there may be a reduction in caesarean section delivery. Future trials should recruit adequate numbers of women and measure birth satisfaction and anxiety.

Relationship between delivery with anesthesia and postpartum depression: The Japan Environment and Children's Study (JECS).

BACKGROUND: Postpartum depression is one of the most commonly experienced psychological disorders for women after childbirth, usually occurring within one year. This study aimed to clarify whether women with delivery with anesthesia, including epidural analgesia, spinal-epidural analgesia, and paracervical block, had a decreased risk of postpartum depression after giving birth in Japan. METHODS: The Japan Environment and Children's Study (JECS) was a prospective cohort study that enrolled registered fetal records (n = 104,065) in 15 regions nationwide in Japan. Binomial logistic regression analyses were performed to calculate the adjusted odd ratios (aORs) for the association between mode of delivery with or without anesthesia and postpartum depression at one-, six- and twelve-months after childbirth. RESULTS: At six months after childbirth, vaginal delivery with anesthesia was associated with a higher risk of postpartum depression (aOR: 1.233, 95% confidence interval: 1.079-1.409), compared with vaginal delivery without analgesia. Nevertheless, the risk dropped off one year after delivery. Among the pregnant women who requested delivery with anesthesia, 5.1% had a positive Kessler-6 scale (K6) score for depression before the first trimester (p < 0.001), which was significantly higher than the proportions in the vaginal delivery without analgesia (3.5%). CONCLUSIONS: Our data suggested that the risk of postpartum depression at six months after childbirth tended to be increased after vaginal delivery with anesthesia, compared with vaginal delivery without analgesia. Requests for delivery with anesthesia continue to be relatively uncommon in Japan, and women who make such requests might be more likely to experience postpartum depressive symptoms because of underlying maternal environmental statuses.

Satisfaction in parturients receiving epidural analgesia after prenatal shared decision-making intervention: a prospective, before-and-after cohort study.

BACKGROUND: The explanation of epidural analgesia by anesthesiologist would often begin after the parturient is admitted to the hospital. Because of labor pain, the decision of receiving epidural analgesia would often be made by the family members, instead of the parturient herself. We aimed to test whether earlier prenatal shared decision-making (SDM) interventions increase parturient's comprehension and satisfaction of epidural labor analgesia, compared to conventional explanation after labor pain begun. METHODS: During the 28th week of gestation, we provided the SDM parturient health education as well as a leaflet with quick response codes. Scanning the code would link to education videoclips which explained what epidural analgesia is and its advantages and disadvantages. Original routine practice group parturients received explanation of analgesia after admission for delivery. To measure the satisfaction of labor pain service, the accessibility of information, and the communication with medical staff, we designed a questionnaire with reference to (1) Pregnancy and Maternity Care Patients' Experiences Questionnaire (PreMaPEQ), (2) Preterm Birth Experience and Satisfaction Scale (P-BESS), and (3) Women's Views of Birth Labor Satisfaction Questionnaire (WOMBLSQ). The questionnaire was amended after a pretest involving 30 parturients who had received epidural analgesia. Scree test analysis and exploratory factor analysis were performed; then, the questionnaire was revised again. A total of 200 valid questionnaires were collected-100 each from the original routine practice group and the SDM group. RESULTS: The SDM group reported significantly higher satisfaction with and understanding of epidural analgesia, and a significantly higher satisfaction with the information received, and the quality of pain relief. After SDM intervention, significant increasement of the average satisfaction scores in question "my epidural is effective" (9.10%; mean difference: 0.38; 95% confidence interval, 0.17 ~ 0.59; p < 0.001) and "The effect of epidural is just as what I have expected" (10.41%; mean difference: 0.41; 95% confidence interval, 0.18 ~ 0.64; p < 0.001) was demonstrated. CONCLUSIONS: An earlier prenatal SDM intervention with sufficient information through videoclips increased parturients' comprehensions and satisfaction of epidural analgesia service. TRIAL REGISTRATION: ISRCTN registry, 14,256,563. Registered April 1st, 2020 ( https://doi.org/10.1186/ISRCTN14256563 ).

Women's epidural decision-making in labour: A Townsville perspective.

BACKGROUND: Despite being an efficacious means of pain relief, there is a broad range of usage rates of epidural analgesia among countries worldwide. Australia sits between common usage in North America and more conservative usage in the UK. The reason for this is unclear, raising the question of whether there is a difference between Australia and other Western countries in pregnant women's attitudes toward epidural use, or the hospital context. AIM: To explore predictors for epidural analgesia request among pregnant women in Townsville, Australia. MATERIALS AND METHODS: A three-phase mixed methods exploratory study design, with Phase One involving 12 one-on-one interviews with pregnant and post-partum women regarding attitudes toward labour analgesia decision-making and epidural preferences. Interview data were analysed thematically to develop a survey distributed to 265 third-trimester women in Phase Two. Phase Three involved a chart review of survey participants to record delivery mode, epidural request and indication. Bivariate and logistic regression analysis of Phases Two and Three data were used to develop predictive models for epidural decision-making. RESULTS: Interviews revealed several themes influencing analgesia preferences in Townsville women: concerns regarding personal safety, trust in health professionals, and previous experiences with labour. The logistic regression identified epidural request in labour to be predicted by: primiparity, epidural experience, induction or augmentation of labour, and perceived sense of control associated with epidural use. CONCLUSIONS: This study suggests that the most significant influencers on Townsville women's epidural decision-making were parity, induction or augmentation of labour, previous experience of epidurals and attitude toward epidurals.

Psychological factors and maternal-fetal attachment in relation to epidural choice.

INTRODUCTION: A woman's first childbirth is an event of great importance to her life, involving her transition to parenthood. Many studies have analyzed the roles of depression, anxiety and fear of childbirth linked to childbirth expectations and the consequent choice of an epidural to avoid pain. Few studies have investigated the predictor role of maternal-fetal attachment on the choice of epidural. OBJECTIVE: Explore, in a sample of low-risk pregnant nulliparous women, differences regarding the preference, or not, of epidural for vaginal childbirth. DESIGN AND SETTING: 87 nulliparous women, aged 24 to 44 years of age, were recruited in the maternity ward of a public hospital of the metropolitan area of Tuscany (Italy) during the 3rd trimester of gestation. Participants were asked to complete the Pregnancy Related Anxiety Questionnaire-R, Wijma Delivery Expectancy Questionnaire, Centrality of Events Scale, and Prenatal Attachment Inventory. FINDINGS: Multivariate analyses of variance showed that women who chose delivery without epidural reported lower levels of fear of childbirth and anxiety, and higher levels of centrality of pregnancy and prenatal attachment to unborn child, than women who chose epidural. KEY CONCLUSIONS: Our data highlight the importance that medical staff focus on the maternal bond, to help future mothers have the best possible childbirth experience.

The association between labor epidural analgesia and postpartum depression: a systematic review and meta-analysis.

BACKGROUND: Previous studies have demonstrated that appropriate treatment for postoperative pain can lead to improvement in depressive symptoms, however the association between adequate intrapartum pain control and the development of postpartum depression is not clear. The purpose of the study was to examine the effects of labor epidural analgesia and postpartum depression. METHODS: We performed a quantitative systematic review in compliance with the PRISMA statement. We conducted a search of PubMed, Embase, the Cochrane Database of Systematic Reviews and Google Scholar databases. The primary outcome was a positive screen of postpartum depression among women who received labor epidural analgesia up to 3 months into the postpartum period. Meta-analysis was performed using the random effect model. RESULTS: Of the 148 studies available, 9 studies with 4442 patients were included in the analysis. The use of labor analgesia on positive depression screen compared to control revealed no significant effect, OR (95% CI) of 1.02 (0.62 to 1.66, P = 0.94). CONCLUSION: Based on current literature, the use of epidural analgesia for pain relief during labor doesn't appear to affect the likelihood of postpartum depression. Future studies are warranted to further investigate these findings and identity other possible preventative interventions that reduce postpartum depression.

Management of the second stage of labour in women with epidural analgesia: A qualitative study exploring Midwives' experiences in Northern Italy.

OBJECTIVE: To explore midwives' experiences of the management of the second stage of labour in women with epidural analgesia. DESIGN: Descriptive qualitative study using semi-structured face-to-face interviews. PARTICIPANTS: Purposive sample of twelve midwives working in three Obstetric Units. Among them six were senior midwives with more than five years' experience on labour ward and six were junior midwives with less than five years' experience on labour ward. FINDINGS: The findings included four themes: a) timing of second stage of labour and maternal pushing; b) maternal positions and mobility; c) perspectives on epidural boluses; d) midwifery presence and support. The time 'allowed' by midwives for the passive phase of the second stage of labour ranged from zero to two hours, with some of them avoiding vaginal examinations to delay the recorded starting time of active pushing. The semi-sitting and the lithotomy positions were the most used respectively in labour and at birth. Some midwives encouraged the kneeling position or the lateral position. Regarding the management of the epidural bolus during the second stage of labour, the interviewees' opinions were divided between favourable and unfavourable to the administration of analgesic boluses after the full cervical dilatation. Midwives reported their experiences of providing different care to women with epidural analgesia when compared to women without epidural, mainly due to a more medicalised approach and the midwives' sense of 'usefulness' when caring for women not experiencing labour pain. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: To our knowledge, this was the first study on this topic conducted in an Italian setting. Despite the consistent body of evidence on the effects of epidural analgesia in the second stage on birth outcomes, the lack of clear guidelines, the presence of different hospital protocols and Obstetricians' opinion, introduce uncertainty in midwifery practice and lead midwives with feelings of 'uselessness'. Across the four themes, midwives frequently had to negotiate a space for their professional autonomy with other healthcare professionals, whilst adhering to the Obstetric Units' protocols. An influencing factor on the care provided to women with epidural was the years of midwife's experience on labour ward. Further research and the development of comprehensive midwifery care guidelines on the management of the second stage of labour in women with an epidural analgesia appears essential.

Effect of companion presence on maternal satisfaction during neuraxial catheter placement for labor analgesia: a randomized clinical trial.

BACKGROUND: Neuraxial labor analgesia is frequently achieved after placing an epidural catheter under sterile conditions. There is no consensus on the risk versus benefit of allowing a parturient's companion to remain during the procedure. We sought to assess the effect of the presence of a companion on maternal satisfaction and anxiety during neuraxial catheter placement for labor analgesia. METHODS: Healthy nulliparous parturients planning to receive neuraxial labor analgesia after admission to labor, and who had a companion with them at the time of interview, were randomized to having a companion present or not present in the labor and delivery room during neuraxial catheter placement. Participants completed questionnaires to assess maternal anxiety, pain catastrophizing and health literacy. Satisfaction was scored on 5-point Likert scale (1- highly dissatisfied, 2- dissatisfied, 3- neutral, 4- satisfied, 5- highly satisfied). RESULTS: A total of 143 participants completed the study. The Wilcoxon-Mann-Whitney odds ratio for a random pair of satisfaction scores for a woman with her companion present compared with companion not present was 1.93 (95% CI 1.30 to 2.81, P=0.001). Anxiety scores were decreased following the procedure (P=0.39) in both groups. Eighty-nine percent of women randomized to companion not present would have preferred to have a companion present (P <0.001) compared with only one with their companion present who would have preferred her companion to be not present (P=0.99). CONCLUSION: Maternal satisfaction can be improved with the presence of a companion in the labor and delivery room at the time of neuraxial catheter placement for labor analgesia.

Pain management and medical interventions during childbirth among perinatal distressed women and women dissatisfied in their partner relationship: A prospective cohort study.

OBJECTIVE: The purpose of this study was to investigate possible associations between distress in pregnant women and their use of pain management and medical interventions. Furthermore, we assessed the effects of reported dissatisfaction in relationship with their partner, or weak social support. DESIGN: This was a prospective cohort study. SETTING: Women were invited to participate while attending prenatal care at participating Icelandic health care centres. Birth outcome data were obtained from the hospitals where these women gave birth. PARTICIPANTS: Women in this study participated in a research project where 2523 women were screened three times during pregnancy for anxiety and depression. Women who had positive results at screening were invited to a semi-structured interview during pregnancy as well as every fourth woman who had negative results. Five hundred and sixty-two women participated in the interviews and the final sample was 442 women. MEASUREMENTS: Distress was defined as symptoms of anxiety, stress and depression. The Edinburgh Postpartum Depression Scale (EPDS) and the Depression, Anxiety and Stress Scales (DASS) were used for screening purposes. During the interview, the women answered the Dyadic Adjustment Scale (DAS), the Multidimensional Scale of Perceived Social Support (MSPSS), and the Adverse Experienced Interview (AEI). The main outcome variables that were obtained from the women's childbirth records were: (1) use of pain management, categorized as: epidural analgesia, non-pharmacological pain management, nitrous oxide, pharmacological medication, or no pain management; (2) medical interventions categorized as: induction, stimulation, and episiotomy; and (3) mode of childbirth. A logistic regression analysis, adjusted for significant covariates, was conducted. FINDINGS: A significant association was found between perinatal distress at 16 weeks gestation and use of epidural as single pain management. Overall, distressed women were 2.6 times more likely than non-distressed women to use epidural as a single pain management. They were also less likely to go through childbirth without use of any pain management method. Women who were dissatisfied in their relationship were significantly more likely to undergo induction of childbirth, an episiotomy and/or a vacuum extraction than those who were satisfied in their relationship, regardless if they were distressed or not. No association was found between social support and the outcome variables. KEY CONCLUSIONS: Women with perinatal distress were more likely to use an epidural than non-distressed women. The use of an epidural might help them manage pain and uncertainties related to childbirth. Women who were dissatisfied in their partner relationship may be more likely to undergo induction of childbirth, episiotomy and/or vacuum extraction. IMPLICATION FOR PRACTICE: Midwives need to acknowledge the possible association of distress and use of an epidural during childbirth and screen for distress early in pregnancy. It is important to offer counselling and help during pregnancy for expectant parents who are distressed or dissatisfied in their relationship.

[Universalization, parity and evolution of the demand of epidural analgesia in labor in Andalusia (Spain)]. / Universalización, paridad y evolución de la demanda de anestesia epidural durante el parto en Andalucía.

OBJECTIVE: Assess whether the universalization of epidural analgesia supplied in hospitals of the Andalusia Public Health Service (SSPA) has ended up with the inequalities shown in previous studies regarding to their demand: the percentage of women who rejected epidural analgesia was higher among the users having low educational level, lower income and working as housekeeper. METHOD: The data are based on satisfaction surveys conducted by the Institute for Advanced Social Studies amongst of SSPA users. This survey includes a section aimed at women attended in labor (N = 21,300). The hierarchical segmentation analysis shows which variables are the ones that discriminate most in the usage of epidural analgesia. Subsequently, through a model of binary logistic regression we analyze which socio-demographic variables are significant (2012) and how its impact is on the choice of epidural analgesia in childbirth. RESULTS: Overall, the socio-demographic variables of the users are statistically significant in the demand or not of epidural analgesia during labor. However, the detailed analysis of the last year (2012) shows that none of the socio-demographic variables introduced in the model has a significant effect on the decision of using epidural analgesia. CONCLUSIONS: The process of universalization of epidural anesthesia in childbirth has ended with social inequalities in their use, that is, with those differences that are not due to a real choice but are induced by socio-cultural characteristics of women.

Can women in labor give informed consent to epidural analgesia?

There are reasons to believe that decision-making capacity (mental competence) of women in labor may be compromised in relation to giving informed consent to epidural analgesia. Not only severe labor pain, but also stress, anxiety, and premedication of analgesics such as opioids, may influence women's decisional capacity. Decision-making capacity is a complex construct involving cognitive and emotional components which cannot be reduced to 'understanding' alone. A systematic literature search identified a total of 20 empirical studies focused on women's decision-making about epidural analgesia for labor pain. Our review of these studies suggests that empirical evidence to date is insufficient to determine whether women undergoing labor are capable of consenting to epidural analgesia. Given such uncertainties, sufficient information about pain management should be provided as part of prenatal education and the consent process must be carefully conducted to enhance women's autonomy. To fill in the significant gap in clinical knowledge about laboring women's decision-making capacity, well-designed prospective and retrospective studies may be required.

[Remifentanil during labour; has its place in pain relief during labour been decided?] / Remifentanil tijdens de bevalling.

Patient-controlled analgesia using remifentanil (remifentanil PCA) has been used as a new form of pain relief during labour since soon after its release on the market. Reduction in pain scores lasts for 1 to 2 hours, and the analgesia is inferior to that of an epidural. Remifentanil PCA can be an alternative for epidural analgesia in cases where the woman cannot or does not want to receive epidural anaesthesia. In some hospitals in the Netherlands remifentanil PCA is being used on a large scale, possibly because of its less invasive character and for logistical reasons. The Netherlands RAVEL study comparing remifentanil with epidural analgesia showed greater satisfaction with pain relief in the epidural group. There is a high risk of hypoventilation during remifentanil PCA use, leading to desaturation; since desaturation can be a late consequence of hypoventilation, adequate monitoring of the woman is essential. It would be ideal to monitor the frequency and depth of ventilation along with peripheral saturation, and one-on-one care of the woman is advised.

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.

The Relationship Between Women's Intention to Request a Labor Epidural Analgesia, Actually Delivering With Labor Epidural Analgesia, and Postpartum Depression at 6 Weeks: A Prospective Observational Study.

BACKGROUND: Postpartum depression (PPD) is associated with pain during and after delivery, with studies showing reduced rates among women delivering with labor epidural analgesia (LEA). We hypothesized that women who intend to deliver with LEA but do not receive it are at higher risk for PPD at 6 weeks due to the combined experience of untreated labor pain and unmatched expectations during labor, and evaluated the interaction between labor plans related to LEA, satisfaction with pain control when actually delivering with LEA, and PPD at 6 weeks after delivery. METHODS: A total of 1497 women with a vaginal delivery were enrolled into this prospective longitudinal study. Women's initial intention to deliver with or without LEA, how they subsequently delivered, and satisfaction with pain relief were recorded on postpartum day 1. Primary aim was selected as PPD at 6 weeks among women intending to deliver with but subsequently delivering without LEA compared with the rest of the cohort. Primary outcome was PPD at 6 weeks using the Edinburgh Postnatal Depression Scale; PPD was defined with a score ≥10 (scale from 0 to 30). Demographic and obstetric data were recorded. Fisher exact test was used for comparisons between groups. The interaction between intention and actual delivery with regard to LEA and PPD was tested. RESULTS: Overall, 87 of 1326 women completing the study at 6 weeks had PPD (6.6%). For the primary aim, 439 (29.3%) delivered without LEA, of which 193 (12.9%) had intended to deliver with LEA; the PPD rate among these women was 8.1%, which was not statistically different from the rest of the cohort (6.3%; odds ratio [OR], 1.30; 95% confidence interval [CI], 0.72-2.38; P = .41). A total of 1058 women (70.7%) delivered with LEA and 439 (29.3%) delivered without; therefore, 1169 (78.1%) delivered as intended and 328 (21.9%) did not (unmatched expectations). Evaluating the interaction between effects, there was a strong negative additive interaction between intending to deliver without LEA and actually delivering with LEA (risk difference = -8.6%, 95% CI, 16.2%-1.6%; P = .014) suggesting that unmatched intention effect is significantly associated with negative outcome. In multiple regression analysis, while intending to deliver with LEA (OR, 1.06; 95% CI, 1.01-1.11; P = .029) and actually delivering with LEA (OR, 1.07; 95% CI, 1.01-1.13; P = .018) both increased the odds for PPD, the multiplicative interaction was protective (OR, 0.92; 95% CI, 0.86-0.99; P = .022), after adjusting for cofactors. CONCLUSIONS: Our study results did not demonstrate a significant increase in the odds for PPD at 6 weeks among women who intended to deliver with LEA but subsequently delivered without. However, we identified a protective interaction between intended LEA use and actual use on the incidence of PPD. Our data suggest an increased risk when women do not deliver as intended, particularly when not initially intending to deliver with LEA. The relationship between unplanned LEA and PPD may be mediated by a physically difficult delivery rather than or in addition to negative emotions related to unmet expectations or a sense of personal failure; therefore, counseling women after delivery to address any negative perceptions may be useful.

Labor Analgesia as a Predictor for Reduced Postpartum Depression Scores: A Retrospective Observational Study.

BACKGROUND: Using labor, epidural analgesia has been linked to a reduced risk of postpartum depression, but the role of labor pain relief in this association remains unclear. The goal of this study was to test the hypothesis that effective epidural analgesia during labor is associated with reduced postpartum depression symptomatology. METHODS: A single, institutional, retrospective, observational cohort design was chosen. The primary outcome was Edinburgh postnatal depression scale (EPDS) score, measured at the 6-week postpartum visit. Subjects included in the final analysis had (1) received labor epidural analgesia; (2) pain assessed during labor both before and during initiation of labor epidural analgesia by 0-10 numeric rating scores; and (3) depression risk assessed by the EPDS and documented at their 6-week postpartum visit. Simple and multiple linear regression was used to identify the best model for assessing the association between pain improvement, defined as percent improvement in pain (PIP), and depression, after adjusting for a history of anxiety or depression, other psychiatric history, abuse, trauma, mode of delivery, and other maternal or fetal comorbid diseases. RESULTS: Two hundred one patients were included in the final analysis. Women with higher improvements in pain were associated with lower EPDS scores (r = 0.025; P = .002). Variables known to be associated with depression (body mass index, anxiety and/or depression, third- and fourth-degree perineal lacerations, and anemia) were significantly correlated with EPDS score and included in the final model. After we adjusted for these covariates, PIP remained a significant predictor of EPDS score (r = 0.49; P = .008), accounting for 6.6% of the variability in postpartum depression scores. The full model including pain, body mass index, anxiety and/or depression, perineal lacerations, and anemia explained 24% of the variability in postpartum depression scores. CONCLUSIONS: Although the extent of labor pain relief by epidural analgesia predicts lower postpartum depression scores, the relative contribution of PIP to risk for postpartum depression symptoms may be less than other established risk factors for depression. These data support that the clinical significance of labor analgesia in the development of postpartum depression needs to be more clearly defined.

Obstetric and psychological characteristics of women choosing epidural analgesia during labour: A cohort study.

OBJECTIVES: To investigate the obstetric and psychological characteristics of women who opt to use epidural analgesia (EDA) during labour and the impact of participating in labour preparation courses on women's decisions to use EDA. DESIGN: Longitudinal cohort study. SETTING: Akershus University Hospital, Norway. POPULATION: 2596 women with singleton pregnancies and intended vaginal delivery. METHODS: Data were collected using two self-completed questionnaires at pregnancy weeks 17 and 32. Fear of childbirth was assessed by the Wijma Delivery Expectancy Questionnaire (W-DEQ). Symptoms of anxiety were measured by the Hopkins Symptom Check List (SCL-25) and depression by the Edinburgh Postnatal Depression Scale (EPDS). Obstetric and socio-demographic information was retrieved from birth records at the maternity ward. MAIN OUTCOME MEASURE: Preference for EDA was indicated by the questionnaire item "I would prefer an epidural regardless" on a 4-point scale (1 = highly agree, 4 = highly disagree) at pregnancy week 32. RESULTS: Twenty-one percent of the women (540/2596) answered that they would choose EDA as the only alternative method of analgesia during labour. Counselling for fear of childbirth [OR 3.23 (95%CI 2.12; 4.92)] and W-DEQ sum score ≥ 85 [OR 2.95 (95%CI 2.06; 4.23)] were significantly (p<0.001) associated with choice of EDA. Participation in labour preparation courses was significantly (p = 0.008) associated with a reduction of intended use of EDA during labour [OR 0.67 (95%CI 0.49; 0.90)]. CONCLUSION: Fear of childbirth is significantly associated with women's choice of EDA during labour. On the other hand, women that participate in labour preparation courses would rather consider other methods of analgesia during labour.

Paradox of the institution: findings from a hospital labour ward ethnography.

BACKGROUND: Interest in the influence of culture on birth practices is on the rise, and with it comes a sense of urgency to implement practices that aid the normalisation and humanisation of birth. This groundswell is occurring despite a broader cultural milieu of escalating technology-use and medicalisation of birth across the globe. Against this background, rates of epidural analgesia use by women in labour are increasing, despite the risk of side effects. Socio-cultural norms and beliefs are likely to influence pain relief choices but there is currently scant research on this topic. METHODS: This study was undertaken to gain insight into the personal, social, cultural and institutional influences on women in deciding whether or not to use epidural analgesia in labour. The study had an ethnographic approach within a theoretical framework of Critical Medical Anthropology (CMA), Foucauldian and feminist theory. Given the nature of ethnographic research, it was assumed that using the subject of epidural analgesia to gain insight into Western birth practices could illuminate broader cultural ideals and that the epidural itself may not remain the focus of the research. RESULTS: Findings from the study showed how institutional surveillance, symbolised by the Journey Board led to an institutional momentum that in its attempt to keep women safe actually introduced new areas of risk, a situation which we named the Paradox of the institution. CONCLUSIONS: These findings, showing a risk/safety paradox at the centre of institutionalised birth, add a qualitative dimension to the growing number of quantitative studies asserting that acute medical settings can be detrimental to normal birth practices and outcomes.

Pain, Anxiety, and Fatigue During Labor: A Prospective, Repeated Measures Study.

BACKGROUND: Pain, anxiety, and fatigue are known to significantly influence labor; however, the interacting relationships among the three symptoms have not been empirically shown. PURPOSE: The aim of this study was to investigate the interrelationships among intrapartum pain, anxiety, and fatigue relative to the mode of delivery, with or without epidural analgesia (EDA). METHODS: A prospective, repeated measures design was adopted, and women with uncomplicated pregnancies at term (N = 186) were enrolled. Self-reported visual analog scales were used to assess pain, anxiety, and fatigue during the four phases of labor, as determined by cervical dilation (e.g., Phase 1 = 2-4 cm, Phase 2 = 4-6 cm, Phase 3 =10 cm, and Phase 4 = immediately after delivery of the placenta). Of the 186 participants, 48 received EDA when their cervical dilation was 3-4 cm. RESULTS: Throughout the process of labor, pain, anxiety, and fatigue were significantly correlated, no matter whether participants had received EDA, especially during Phases 1 and 3. For the participants undergoing EDA, the level of fatigue decreased more slowly than the levels of pain and anxiety. The participants who received EDA had significantly greater pain and fatigue in Phase 1 of labor than those who did not receive EDA. Mode of delivery was correlated with age, parity, and pain level in Phase 2 of labor and anxiety level in Phase 2 of labor. CONCLUSIONS/IMPLICATIONS FOR PRACTICE: Intrapartum pain, anxiety, and fatigue were strongly interrelated. Intrapartum pain management (EDA) led to a significant decline in anxiety and fatigue. Furthermore, fatigue accumulated during the course of labor and was not easily diminished. These findings provide a reference for maternity nurses to develop strategies for managing multiple symptoms.