Fatigue in Pregnancy: The validity and reliability of the Farsi Multidimensional Assessment of Fatigue scale.

OBJECTIVES: Fatigue is a common discomfort experienced during pregnancy and may contribute to severe labour pain and postpartum depression. This study aimed to translate the Multidimensional Assessment of Fatigue (MAF) scale into Farsi and validate it in a sample of pregnant Irani women. METHODS: This cross-sectional questionnaire study was conducted between January and June 2016 at eight healthcare centres in Sabzevar, Iran. The English version of the MAF scale was translated into Farsi and assessed for content validity. Participants completed the Farsi MAF scale and the Farsi World Health Organization-5 Well-being index (WHO-5). Construct validity was assessed through exploratory factor analysis (EFA). Cronbach's alpha coefficient and the intraclass correlation coefficient (ICC) were used to determine the internal consistency and stability of the Farsi MAF scale. RESULTS: A total of 582 women met the inclusion criteria, of which 541 completed the MAF scale (response rate: 93%). The EFA of the 15 items confirmed the previously proposed one-factor structure with a Cronbach's alpha coefficient of 0.957 for the Farsi MAF scale. Stability was confirmed by the ICC value (0.702) for the Global Fatigue Index (GFI) and the mean GFI was 20.33 ± 12.71. Concurrent validity was confirmed by a moderate negative correlation (r = -0.35; P <0.001) between the scores of the Farsi MAF scale and the Farsi WHO-5. Women who received a high level of support from their husbands, who were satisfied with the quality of their marital relationship and with a well-being score of >50 reported a lower level of fatigue than the other groups (P ≤0.012). CONCLUSION: The Farsi MAF scale is a reliable and valid questionnaire to investigate fatigue in pregnant Irani women. Interventions to promote marital satisfaction and women's well-being are recommended.

Perceptions and experiences of labour companionship: a qualitative evidence synthesis.

BACKGROUND: Labour companionship refers to support provided to a woman during labour and childbirth, and may be provided by a partner, family member, friend, doula or healthcare professional. A Cochrane systematic review of interventions by Bohren and colleagues, concluded that having a labour companion improves outcomes for women and babies. The presence of a labour companion is therefore regarded as an important aspect of improving quality of care during labour and childbirth; however implementation of the intervention is not universal. Implementation of labour companionship may be hampered by limited understanding of factors affecting successful implementation across contexts. OBJECTIVES: The objectives of the review were to describe and explore the perceptions and experiences of women, partners, community members, healthcare providers and administrators, and other key stakeholders regarding labour companionship; to identify factors affecting successful implementation and sustainability of labour companionship; and to explore how the findings of this review can enhance understanding of the related Cochrane systematic review of interventions. SEARCH METHODS: We searched MEDLINE, CINAHL, and POPLINE K4Health databases for eligible studies from inception to 9 September 2018. There were no language, date or geographic restrictions. SELECTION CRITERIA: We included studies that used qualitative methods for data collection and analysis; focused on women's, partners', family members', doulas', providers', or other relevant stakeholders' perceptions and experiences of labour companionship; and were from any type of health facility in any setting globally. DATA COLLECTION AND ANALYSIS: We used a thematic analysis approach for data extraction and synthesis, and assessed the confidence in the findings using the GRADE-CERQual approach. We used two approaches to integrate qualitative findings with the intervention review findings. We used a logic model to theorise links between elements of the intervention and health and well-being outcomes. We also used a matrix model to compare features of labour companionship identified as important in the qualitative evidence synthesis with the interventions included in the intervention review. MAIN RESULTS: We found 51 studies (52 papers), mostly from high-income countries and mostly describing women's perspectives. We assessed our level of confidence in each finding using the GRADE-CERQual approach. We had high or moderate confidence in many of our findings. Where we only had low or very low confidence in a finding, we have indicated this.Labour companions supported women in four different ways. Companions gave informational support by providing information about childbirth, bridging communication gaps between health workers and women, and facilitating non-pharmacological pain relief. Companions were advocates, which means they spoke up in support of the woman. Companions provided practical support, including encouraging women to move around, providing massage, and holding her hand. Finally, companions gave emotional support, using praise and reassurance to help women feel in control and confident, and providing a continuous physical presence.Women who wanted a companion present during labour and childbirth needed this person to be compassionate and trustworthy. Companionship helped women to have a positive birth experience. Women without a companion could perceive this as a negative birth experience. Women had mixed perspectives about wanting to have a male partner present (low confidence). Generally, men who were labour companions felt that their presence made a positive impact on both themselves (low confidence) and on the relationship with their partner and baby (low confidence), although some felt anxious witnessing labour pain (low confidence). Some male partners felt that they were not well integrated into the care team or decision-making.Doulas often met with women before birth to build rapport and manage expectations. Women could develop close bonds with their doulas (low confidence). Foreign-born women in high-income settings may appreciate support from community-based doulas to receive culturally-competent care (low confidence).Factors affecting implementation included health workers and women not recognising the benefits of companionship, lack of space and privacy, and fearing increased risk of infection (low confidence). Changing policies to allow companionship and addressing gaps between policy and practice were thought to be important (low confidence). Some providers were resistant to or not well trained on how to use companions, and this could lead to conflict. Lay companions were often not integrated into antenatal care, which may cause frustration (low confidence).We compared our findings from this synthesis to the companionship programmes/approaches assessed in Bohren's review of effectiveness. We found that most of these programmes did not appear to address these key features of labour companionship. AUTHORS' CONCLUSIONS: We have high or moderate confidence in the evidence contributing to several of these review findings. Further research, especially in low- and middle-income settings and with different cadres of healthcare providers, could strengthen the evidence for low- or very low-confidence findings. Ahead of implementation of labour companionship, researchers and programmers should consider factors that may affect implementation, including training content and timing for providers, women and companions; physical structure of the labour ward; specifying clear roles for companions and providers; integration of companions; and measuring the impact of companionship on women's experiences of care. Implementation research or studies conducted on labour companionship should include a qualitative component to evaluate the process and context of implementation, in order to better interpret results and share findings across contexts.

Does the Coping Assessment for Laboring Moms (CALM) Scale Enhance Perception of Nursing Presence?

Traditional 0-to-10 pain assessment may be inadequate during labor. The Coping Assessment for Laboring Moms (CALM) scale was developed to focus on facial, behavioral, psychosocial, vocalization, and verbal expressions to aid holistic nursing support during childbirth. Using a comparative design, the 0-to-10 pain and CALM scales were evaluated to determine differences in women's perceptions of nursing presence using the Positive Presence Index during labor at a community hospital in the Pacific Northwest. Positive Presence Index scores for knowing what would work best for me, comforting touch, taking care of everything so I could concentrate, and understanding what I was saying were significantly higher among women when nurses used the CALM tool to guide labor support. The CALM scale needs further testing with a larger, more diverse population.

Assessment of pain associated with childbirth: Women's perspectives, preferences and solutions.

OBJECTIVE: to develop an understanding of women's experiences of pain associated with childbirth and the assessment of labour pain. This exploratory study, informed by modern pain science, sought to explore women's retrospective reports of their pain experience during labour and to ascertain what pain assessment strategies might be acceptable in maternity care or future research. DESIGN: a qualitative study was performed using phenomenology as the theoretical framework. Data were collected from semistructured telephone interviews. Thematic analysis of transcripts was performed. SETTING: Melbourne, Australia. PARTICIPANTS: 19 women - both primiparous and multiparous - who gave birth in a large maternity hospital, either in a midwife-led birth centre or with standard hospital birth suite care were interviewed in the month following labour and birth. FINDINGS: two themes were identified in post-birth interviews that related to pain assessment. The first theme is the acceptability of pain assessment and reflects the interview structure, drawing on responses from a set question that asked what pain assessment strategies would be acceptable. The second theme emerged from women's comments about measurement accuracy, including the limitations of using a scale with a static upper limit and the changing nature of labour pain. KEY CONCLUSIONS: a woman-centred approach demands pain assessment that matches each woman's preference for mode and timing and captures the multiple dimensions of pain. Women describe the need for an expanding scale to accommodate the progressive modifications of their conception of what is extreme pain. IMPLICATIONS FOR PRACTICE: whenever a series of pain ratings is required, researchers and health professionals need to find ways to adjust for the fluctuations in pain scale interpretation.

Prospective longitudinal cohort questionnaire assessment of labouring women's preference both pre- and post-delivery for either reduced pain intensity for a longer duration or greater pain intensity for a shorter duration.

BACKGROUND: Assessments of labour pain focus on pain intensity, not on duration. We aimed to assess the importance labouring women apply to pain intensity and duration before labour and post-delivery. METHODS: Forty healthy women scheduled for labour induction were enrolled in this institutional review board-approved, prospective cohort study. Participants completed a pain preference questionnaire before active labour and within 24-h of delivery. The questionnaire consisted of seven stem questions that evaluated preference for pain intensity or duration. The pain preference ratio was determined by dividing the percentage of women who preferred reduced pain intensity for longer duration by that of those who preferred greater pain intensity for shorter duration (estimate of the odds). The overall hypothetical pain burden was determined by multiplying intensity by time. All questions presented the same overall hypothetical pain burden. RESULTS: Pain preference questionnaire scores demonstrated preference for low intensity pain for a longer duration rather than higher intensity for a shorter duration, both pre-labour (P<0.001) and post-delivery (P<0.001): the null median imputed as 3 of 6 (i.e. no preference for pain intensity over pain duration). This preference for pain duration over intensity was greater post-delivery compared with before labour (P=0.03). There was a significant correlation (r=0.83; P=0.04) between the pain preference ratio vs overall hypothetical pain burden before labour but not after delivery (r=0.28; P=0.59). CONCLUSIONS: In this preliminary labour assessment, women preferred lower pain intensity at the cost of longer pain duration. This suggests that pain intensity is the primary driver of hypothetical pain burden-a preference reinforced post-delivery.

Preferences for mode of delivery in nulliparous Argentinean women: a qualitative study.

BACKGROUND: Over the last three decades, cesarean section (CS) rates have been rising around the world despite no associated improvement in maternal and perinatal mortality and morbidity. The role of women's preferences for mode of delivery in contributing to the high CS rate remains controversial; however these preferences are difficult to assess, as they are influenced by culture, knowledge of risk and benefits, and personal and social factors. In this qualitative study, our objective was to understand women's preferences and motivational factors for mode of delivery. This information will inform the development and design of an assessment aimed at understanding the role of the women's preferences for mode of delivery. METHODS: We conducted 4 focus group discussions (FGDs) and 12 in-depth interviews with pregnant women in Buenos Aires, Argentina in 4 large non-public and public hospitals. Our sample included 29 nulliparous pregnant women aged 18-35 years old, with single pregnancies over 32 weeks of gestational age, without pregnancies resulting from assisted fertility, without known pre-existing medical illness or diseases diagnosed during pregnancy, without an indication of elective cesarean section, and who are not health professionals. FGDs and interviews followed a pre-designed guide based on the health belief model and social cognitive theory of health decisions and behaviors. RESULTS: Most of the women preferred vaginal delivery (VD) due to cultural, personal, and social factors. VD was viewed as normal, healthy, and a natural rite of passage from womanhood to motherhood. Pain associated with vaginal delivery was viewed positively. In contrast, women viewed CS as a medical decision and often deferred decisions to medical staff in the presence of medical indication. CONCLUSIONS: These findings converge with quantitative and qualitative studies showing that women prefer towards VD for various cultural, personal and social reasons. Actual CS rates appear to diverge from women's preferences and reasons are discussed.

Obstetric complications and psychological well-being: experiences of Bangladeshi women during pregnancy and childbirth.

Women in developing countries experience postnatal depression at rates that are comparable with or higher than those in developed countries. However, their personal experiences during pregnancy and childbirth have received little attention in relation to postnatal depression. In particular, the contribution of obstetric complications to their emotional well-being during the postpartum period is still not clearly understood. This study aimed to (a) describe the pregnancy and childbirth experiences among women in Bangladesh during normal childbirth or obstetric complications and (b) examine the relationship between these experiences and their psychological well-being during the postpartum period. Two groups of women--one group with obstetric complications (n=173) and the other with no obstetric complications (n=373)--were selected from a sample of women enrolled in a community-based study in Matlab, Bangladesh. The experiences during pregnancy and childbirth were assessed in terms of a five-point rating scale from 'severely uncomfortable=1' to 'not uncomfortable at all=5'. The psychological status of the women was assessed using a validated local version of the Edinburgh Postnatal Depression Scale (EPDS) at six weeks postpartum. Categorical data were analyzed using the chi-square test and continuous data by analysis of variance. Women with obstetric complications reported significantly more negative experiences during their recent childbirth [95% confidence interval (CI) 1.36-1.61, p<0.001] compared to those with normal childbirth. There was a significant main effect on emotional well-being due to experiences of pregnancy [F (4,536)=4.96, p=0.001] and experiences of childbirth [F (4,536)=3.29, p=0.01]. The EPDS mean scores for women reporting severe uncomfortable pregnancy and childbirth experiences were significantly higher than those reporting no such problems. After controlling for the background characteristics, postpartum depression was significantly associated with women reporting a negative childbirth experience. Childbirth experiences of women can provide important information on possible cases of postnatal depression.

The utility of BDI-II in assessment of pre- and postpartum depression symptoms and their relation to labor pain.

BACKGROUND: It is argued that the total Beck Depression Inventory II (BDI-II) score likely overestimates depression in pregnant women given the overlap between depressive and somatic symptoms during pregnancy. The aim of this study was to explore the structure and the intensity of depression symptoms during pregnancy and two months postpartum. In populations with high incidence of somatic complaints (i.e. chronic pain sufferers) depression is also often related to higher pain intensity. Therefore, the relationships between depression symptoms and expected, perceived and recalled labor pain were also examined. SUBJECTS AND METHODS: 60 healthy primiparas enrolled the study. BDI-II as measure of depression was completed during the late stage of pregnancy and two months postpartum. Assessments of maximum and average labor pain were completed in three different time periods (before - expected labor pain, during/immediately after labor - perceived labor pain, and one month postpartum - recalled labor pain). RESULTS: Depression symptoms measured two months postpartum were significantly lower than the ones measured during the late stage of pregnancy (t=8.377, df=49, p<0.01). During the late stage of pregnancy, BDI-II items with highest mean scores were those measuring somatic symptoms of depression. Depression measured during the late stage of pregnancy correlated significantly with maximum labor pain expectancies (r=0.41, p<0.01). CONCLUSION: The use of standardized questionnaires with a high rate of somatic items such as BDI-II may not be the best solution when screening for mood disorders in pregnant women. Levels of depression share a significant relationship with maximum labor pain expectancies only.

A survey of attitudes of expectant first-time fathers and mothers toward epidural analgesia for labor.

OBJECTIVE: To evaluate the attitude of expectant fathers to the use of epidural analgesia during labor and to compare it to the attitude of their partner. METHODS: The study group consisted of consecutive expectant, first-time parents who presented at the delivery room of a major medical center over a 3-month period. Only those with a single, term fetus in cephalic presentation were included. Both partners were asked to complete a questionnaire on desire to receive epidural analgesia firstly on admission and again later during labor at first discussion of the use of epidural analgesia with medical staff. Findings were compared between partners, between the two time points and with the actual use of epidural analgesia in labor. The effect of various socio-demographic variables on this decision was analyzed. RESULTS: One hundred fifty couples completed the study. On admission, 64.1% of the expectant fathers and 78.6% of the expectant mothers expressed a preference for epidural analgesia (P=0.01). Later in labor, the corresponding rates were 77.9% and 87.4%. In total 95.3% of the women received epidural analgesia. There was no effect of age, level of education, salary, or attendance in a birth preparatory course on the decision to use epidural analgesia by either partner. CONCLUSION: The decision to use epidural analgesia differs between partners, changes during the course of labor and is unrelated to socio-demographic factors.

Assessment of social psychological determinants of satisfaction with childbirth in a cross-national perspective.

BACKGROUND: The fulfilment of expectations, labour pain, personal control and self-efficacy determine the postpartum evaluation of birth. However, researchers have seldom considered the multiple determinants in one analysis. To explore to what extent the results can be generalised between countries, we analyse data of Belgian and Dutch women. Although Belgium and the Netherlands share the same language, geography and political system and have a common history, their health care systems diverge. The Belgian maternity care system corresponds to the ideal type of the medical model, whereas the Dutch system approaches the midwifery model. In this paper we examine multiple determinants, the fulfilment of expectations, labour pain, personal control and self-efficacy, for their association with satisfaction with childbirth in a cross-national perspective. METHODS: Two questionnaires were filled out by 605 women, one at 30 weeks of pregnancy and one within the first 2 weeks after childbirth either at home or in a hospital. Of these, 560 questionnaires were usable for analysis. Women were invited to participate in the study by independent midwives and obstetricians during antenatal visits in 2004-2005. Satisfaction with childbirth was measured by the Mackey Satisfaction with Childbirth Rating Scale, which takes into account the multidimensional nature of the concept. Labour pain was rated retrospectively using Visual Analogue Scales. Personal control was assessed with the Wijma Delivery Expectancy/Experience Questionnaire and Pearlin and Schooler's mastery scale. A hierarchical linear analysis was performed. RESULTS: Satisfaction with childbirth benefited most consistently from the fulfilment of expectations. In addition, the experience of personal control buffered the lowering impact of labour pain. Women with high self-efficacy showed more satisfaction with self-, midwife- and physician-related aspects of the birth experience. CONCLUSION: Our findings focus the attention toward personal control, self-efficacy and expectations about childbirth. This study confirms the multidimensionality of childbirth satisfaction and demonstrates that different factors predict the various dimensions of satisfaction. The model applies to both Belgian and Dutch women. Cross-national comparative research should further assess the dependence of the determinants of childbirth satisfaction on the organisation of maternity care.

[Anxiety assessment in parturients requesting epidural analgesia for pain relief]. / Ocena leku u rodzacych zdecydowanych na analgezje zewnatrzoponowa.

OBJECTIVES: Neuraxial methods provide the most effective labor pain relief. This study aimed at assessing anxiety level in parturients requesting epidural analgesia (EA). MATERIAL AND METHODS: Forty five women in spontaneous, active labor were enrolled, both primiparas (n=36) and multiparas (n=9). Anxiety was assessed by means of Spielberger State and Trait Anxiety Inventory (STAI) before administration of EA, and pain was measured by visual-analog scale (VAS) before and after analgesia. RESULTS: In all the studied parturients state anxiety was strikingly higher than the trait (53.9 +/- 11.8 vs. 39.3 +/- 8.4; P < 0.0001); the difference appeared insignificant in multiparas only. State anxiety was comparable independently of parity, labor outcome and systemic opioid administration. No association between anxiety level and labor pain intensity preceding analgesia, the duration of labor stages and demographic parameters could be found. However, a negative correlation between state anxiety and pain intensity reported after EA administration was noted (R = -0.315, p = 0.040), and, in cases of physiological labor, a negative association between state anxiety and the neonate Apgar score at the 1st minute after birth could be observed (R = -0.337, p = 0.047, Spearman rank test). CONCLUSIONS: In parturients requesting EA, state anxiety level is increased and not connected with the trait. Furthermore, in these women, anxiety appears not to be associated with labor pain but may influence the analgesic effect of the blockade. Anxiety does not determine labor duration and outcome; however, it may be connected with the well-being of the neonate immediately after birth.

A questionnaire survey on patients' attitudes towards epidural analgesia in labour.

OBJECTIVES: To evaluate patient attitudes about epidural services in labour and correlate them with patient options and actual usage of epidural analgesia. DESIGN: Questionnaire survey. SETTING: Eight Hospital Authority obstetrics units. PARTICIPANTS: A cohort of new antenatal patients and a cohort of postnatal in-patients over 1 calendar month. MAIN OUTCOME MEASURES: Antenatal patient awareness of epidural services and attitudes towards epidural analgesia during labour; the actual usage of such analgesia and the reported experience of postnatal patients. RESULTS: A total of 2109 and 2851 patients completed the antenatal and postnatal survey, respectively. The former revealed that only 47% of patients had been exposed to the concept of epidural analgesia in labour, and only 13% opted for such analgesia. In the postnatal cohort, the overall epidural analgesia rate was 10%, although 19% had actually requested it. Patients who received epidural analgesia in labour were more likely to consider their experience as favourable (85%) compared to those who went through labour without such analgesia (26%) [P<0.001]. There was no significant improvement in knowledge about epidural analgesia among postnatal as compared to antenatal patients. The main reasons generally ascribed by patients for not being able to obtain an epidural service despite it being requested, were related to limited resources. CONCLUSION: The results showed poor general awareness of pregnant women about the proper role of epidural analgesia in labour, leading to a low patient demand for such services. Despite the low prevailing request rate for epidural analgesia in labour, there appears to be a lack of adequate resources to meet the demand.

How to implement complementary therapies for laboring women.

Complementary therapies have been a part of nursing practice for centuries and are supported today as a part of nursing practice by many state boards of nursing. Some of these modalities can be used by nurses as a part of their comprehensive plan of labor support for women during the childbirth experience. This article describes five complementary therapies (aromatherapy, massage, use of birth balls, music therapy, and hydrotherapy), and how one large Midwestern hospital system implemented an educational program for nurses that helped them integrate complementary therapies into their nursing care for laboring women.

Re-significando a dor e superando a solidão: experiências do parto entre adolescentes de classes populares atendidas em uma maternidade pública de Salvador, Bahia, Brasil / Re-signifying pain, overcoming loneliness: childbirth experiences among working-class adolescents in a public maternity hospital in Salvador, Bahia, Brazil

Este artigo examina o parto em uma maternidade pública de Salvador, Bahia, Brasil, com base na perspectiva de mulheres jovens e adolescentes, a maioria das quais negras e de classes populares. O estudo, de caráter antropológico, baseia-se na análise de entrevistas e na etnografia do hospital, particularmente do centro obstétrico. As mulheres descrevem o trabalho de parto como dominado pelo medo, solidão e dor, sensações que se transformam em amor com o nascimento da criança. Enfocando o parto como um processo biossocial, o trabalho mostra como as jovens produzem significados durante o processo de parturição, enquanto se encontram envolvidas nas interações sociais próprias ao parto hospitalar, particularmente com os profissionais de saúde. Do ponto de vista simbólico, as parturientes experienciam o parto como um rito de passagem que legitima a maternidade, em um contexto social e institucional que, ao contrário, deslegitima a reprodução sexual de mulheres negras, jovens e de baixa renda e estigmatiza a maternidade na adolescência.

[Re-signifying pain, overcoming loneliness: childbirth experiences among working-class adolescents in a public maternity hospital in Salvador, Bahia, Brazil]. / Re-significando a dor e superando a solidão: experiências do parto entre adolescentes de classes populares atendidas em uma maternidade pública de Salvador, Bahia, Brasil.

This article examines childbirth in a public maternity hospital in Salvador, Bahia, Brazil, from the perspective of young and adolescent women, mostly black and working-class. As an anthropological study, it is based on the analysis of birth narratives and hospital ethnography, especially in the obstetric ward. The women describe labor as dominated by fear, loneliness, and pain. These feelings are transformed into love with the birth of the child. Viewing childbirth as a biosocial process, the authors show how the young women construct meanings during the birth; meanwhile, social interactions specific to hospital birth develop, particularly with healthcare professionals. Symbolically, women construct birth as a rite of passage legitimating motherhood, against the institution's effective de-legitimization of sexual reproduction in low-income black mothers and stigmatization of adolescent motherhood.

[Retrospective assessment of epidural analgesia during labor according to parturients]. / Retrospektywna ocena znieczulenia zewnatrzoponowego porodu przez rodzace.

AIM: The aim of the study was to find out parturients' evaluation of epidural analgesia (EA) during labor and factors influencing their opinion. MATERIALS AND METHODS: 100 women, aged 26-42, who gave birth at I Department of Obstetrics and Gynaecology in Warsaw, filled in a specially prepared inquiry. Primiparas contributed to 87% of the study group. The results were analyzed according to analgesia evaluation as: very good (group A-64%), good (group B-30%) and insufficient (group C-6%). RESULTS: Patients evaluated their pain according to Visual Analog Scale before and after EA was applied in the I and II stage of labor, respectively. Significant differences regarding the pain level in the II stage were observed--among patients from group C it was even higher than before EA was applied. That group more often notified perineum pain during the II stage of labor. Feeling uterine contractions, tenesmus and drugs' side effects had no influence on women's opinion. The way of grading EA depended on parity and education--patients from group C were all well-educated primiparas. The time of making a decision about willing to give birth with EA also depended on parity--multiparas decided earlier than primiparas. Women's main source of information about labor EA were press and books (56%), than labor school (26%), other women (24%) and only for 20% their gynaecologist. In spite of the differences in their answers, the majority of women would decide on labor EA again (95%) and recommend it to others (98%). CONCLUSIONS: The majority of patients gives labor EA very positive opinion. Insufficient pain control in the II stage of labor and perineum pain are the main factors lowering EA evaluation--it seems important to pay more attention to that fact in the future. Time of making a decision about EA and women's opinion depend on parity. As press is the main source of information for patients, the wider promotion of EA by medical staff seems necessary.