Year : 2023 | Volume
| Issue : 1 | Page : 45-57
Awareness, preconception, and fear of epidural analgesia among childbearing women in Saudi Arabia: An observational cross-sectional study
Fatma Aldammas1, Abdulrhman A Alshihri2, Rayan K Alhowaish2, Basheer M Alotaibi2, Abdullah F Alhamdi2, Faisal F Algharbi2, Hamad Y Alhassoun2, Mohammed H Alhamad2, Abdullah A Alhaddab3
1 Department of Anesthesia, College of Medicine, King Saud University, King Khalid University Hospital, Riyadh, Saudi Arabia
2 Department of Intern, College of Medicine, King Saud University, King Khalid University Hospital, Riyadh, Saudi Arabia
3 Department of Student, College of Medicine, King Saud University, King Khalid University Hospital, Riyadh, Saudi Arabia
Assistant Professor and Consultant, Department of Anesthesia, College of Medicine, King Saud University, Riyadh
Source of Support: None, Conflict of Interest: None
|Date of Submission||02-Nov-2022|
|Date of Decision||07-Nov-2022|
|Date of Acceptance||07-Nov-2022|
|Date of Web Publication||02-Jan-2023|
Background: Labor pain is one of the most excruciatingly painful sensations a woman can have. A woman's attitude toward childbirth might be influenced by her lack of understanding of the birth process and the pain she experiences throughout labor and delivery. The control of pain is an important aspect of appropriate obstetrical care. Our study aims to measure the level of awareness, preconception, and fear of epidural analgesia (EDA) among childbearing women.
Methods: An observational cross-sectional, hospital-based study was conducted using a self-administered questionnaire. The study included all pregnant women who were attending an obstetrical clinic for routine antenatal follow-up at King Khalid university hospital in Riyadh, Saudi Arabia, during the month of August 2022. They were asked about five main parts that tapped their awareness, preconception, and fear of EDA. Data were analyzed by SPSS version 26 using descriptive methods, including mean, frequency, and percentage, and also Pearson's correlation coefficient for regression analysis to find the correlation between socio-demographics and awareness and between awareness and fear.
Results: Participants in our study included 202 childbearing women. Most women, about 113 (55.9%), participating in the study were aged between 25 and 34 years old. The majority of the participants of this study were Saudi, about 196 (97.0%). In terms of education, 120 (59.4%) of the participants graduated from university. One hundred and forty two (70.3%) of the participants had a monthly income of less than 10000. When it comes to parity, the majority of participants, about 102 (50.5%), have had more than two pregnancies. The average percentage of awareness among the participants showed 45.9%, with an insignificant very moderate correlation between parity and awareness (r = -0.088, P = 0.107); women's knowledge, income, and age were also insignificantly related to awareness. Also, the result showed a moderate level of fear with an average percentage of 44.6% among the participants, with a moderate correlation between awareness and fear with a value of (r = 0.184, P = 0.004).
Conclusion: This study results demonstrate a good level of desirability toward using EDA for labor pain, yet there is a limited level of preconceptions and a low level of awareness and knowledge about EDA. In addition, the results showed that the average percentage of fear is 44.6%. Therefore, we suggest that more awareness, knowledge, and guidance about EDA should be provided to pregnant women through antenatal clinics. Furthermore, educational campaigns should be made to dispel misconceptions and fears about EDA.
Keywords: Anesthesia, awareness, epidural analgesia, fear, labor pain, preconception
|How to cite this article:|
Aldammas F, Alshihri AA, Alhowaish RK, Alotaibi BM, Alhamdi AF, Algharbi FF, Alhassoun HY, Alhamad MH, Alhaddab AA. Awareness, preconception, and fear of epidural analgesia among childbearing women in Saudi Arabia: An observational cross-sectional study. Saudi J Anaesth 2023;17:45-57
|How to cite this URL:|
Aldammas F, Alshihri AA, Alhowaish RK, Alotaibi BM, Alhamdi AF, Algharbi FF, Alhassoun HY, Alhamad MH, Alhaddab AA. Awareness, preconception, and fear of epidural analgesia among childbearing women in Saudi Arabia: An observational cross-sectional study. Saudi J Anaesth [serial online] 2023 [cited 2023 Feb 3];17:45-57. Available from: https://www.saudija.org/text.asp?2023/17/1/45/364882
| Introduction|| |
Labor pain is a common issue experienced by pregnant women. For the majority of women, labor is a painful experience. But there are multiple pharmacological methods for reducing labor pain, including opioids and epidural analgesia (EDA). EDA is the most effective and prevalent method for the treatment of pain during vaginal delivery, especially in Western countries, and it is used to save anesthetic time when cesarean delivery is needed., During EDA, a combination of local anesthetic and opioid analgesic is injected into the lumbar epidural space. The mechanism of EDA involves numbing the nerves that are responsible for pain delivery in the anatomical region via the spinal cord. EDA blocks action potential transmission in the nerves, thus inhibiting the perception of pain, and the type of medication and volume used affects the degree of numbing.,
The lack of knowledge and awareness among women regarding pain relief options for labor, especially in low- and middle-income countries, is a pertinent issue. Studies have shown that women obtain information about EDA mainly from friends and relatives, who may not be well informed regarding how EDA works, its safety, or its effectiveness. Additionally, the correct or incorrect information received from friends and relatives often significantly overshadows the information gained from the media, and literature. Informed consent for EDA is required from pregnant women to carry out the procedure, but due to limited knowledge of EDA, some women may reject the procedure and thus, not receive the benefits from it.
Multiple studies have been conducted regarding EDA use in labor among pregnant women in Saudi. One study in Khamis Mushait showed that the majority of women of childbearing age had limited knowledge concerning the benefits and complications associated with EDA. Another study conducted in Jeddah showed that women experienced fears associated with EDA; specifically, half of the women were uncertain about whether EDA causes paraplegia, with more than a third believing this to be incorrect and 15.9% believing this to be true. This study also reported fears regarding the pain of needle insertion. Furthermore, research carried out in Riyadh showed that 42% of women knew about EDA from friends and relatives, whereas only 8% knew about EDA from brochures at antenatal clinics. Based on all these previous studies, it can be concluded that there is a need for proper education regarding EDA during labor for women in Saudi.
Our study aims to measure the level of awareness, preconceptions, and level of fear regarding EDA among childbearing women in King Khalid University Hospital (KKUH) in Riyadh, Saudi Arabia. As our objective is to follow up on previous studies, especially the population of Riyadh, to cover fear as, to our knowledge, no previous studies have included fear assessment as one of their objectives.
| Patients and Methods|| |
This research was designed as a hospital-based observational cross-sectional study conducted at KKUH, using a self-administered questionnaire that was based on previous research,, and approved by Institutional Review Board at King Saud University, College of Medicine, Riyadh, Saudi Arabia on August 2022 (Ref. No. 22/0592/IRB), Clinical Trials Identifier: NCT05596604. The sample included pregnant women attending an obstetrical clinic for routine antenatal follow-up, and the data collection was conducted during the months of August to October 2022. The questionnaire included five parts (socio-demographic, preconception, awareness, fear, and desirability). A total of 26 questions were provided with multiple choice answers. The sample size was determined using the Comrey and Lee criterion; Comrey and Lee stated that a 200-sample size is acceptable. The questionnaire was completed by 202 participants who met the inclusion criteria that is being a pregnant woman and completing the survey, and the exclusion criteria were non-pregnant women and an incomplete survey. The data collectors made it clear to the participants that taking part in the study was completely optional, and the participants signed an anonymous consent form. The data were analyzed by SPSS version IBM SPSS Statistics for Windows, Version 26.0 (Released 2019, IBM Corp, Armonk, New York). 26 using descriptive methods, including mean, frequency, and percentage, and also Pearson's correlation coefficient for regression analysis to find the correlation between socio-demographics and awareness and between awareness and fear.
| Results|| |
In this study, we surveyed 202 childbearing women after excluding 14 participants for not completing the survey as per our exclusion criteria. The demographic profile of the participants in this study is illustrated in [Table 1].
In the Preconception we aim to know their thoughts and experiences about EDA [Table 2].
In the Awareness section the questions are meant to Assess the participant's knowledge and awareness regarding EDA [Table 3]. Calculating the average percentage of awareness among the participants showed 45.9% as a level of awareness, which means 54.1% of the participants, showed a lack of knowledge.
In the fear section we aim to assess participant's fear of EDA [Table 4]. When it comes to fear the average percentage of fear among the participants is 44.6%, only those who chose (I agree) as an answer.
Correlation among demographics and awareness
Results of this study revealed an insignificant very moderate correlation between parity and awareness (r = -0.088, P = 0.107); women's knowledge, income, and age were also insignificantly related to awareness [Table 5]. As presented in [Table 6], regression analysis was used to check the relation. Awareness was entered into the equation as a dependent variable and education, age, parity, and income as independent variables. Results showed that all the variables together explained 12.0% of the variance in awareness toward EDA. The model was insignificant (F = 0.718, P = 0.581) and awareness was mostly predicted by age (B = -0.298, P = 0.472).
Regression analysis was conducted for checking the relationship between awareness and fear. Awareness and fear were moderately correlated with a correlation value of r = 0.184, P = 0.004. The correlation is reported in [Table 7].
|Table 7: Correlation between awareness and demographics, and awareness and fear|
Click here to view
In this section of the survey, we wanted to sense the needs and attitudes towards EDA in the future and if there is a place for improvement [Table 8].
| Discussion|| |
This study aimed to assess women's awareness, preconceptions, and fear regarding EDA for labor. We divided and organized the questionnaire items into five sections (demographics, preconceptions, awareness, fear, and desirability), and each section comprised a certain set of questions. The goal of this work is to help improve pregnant women's decision-making and quality of care by identifying misconceptions and fears concerning EDA.
Among the women who participated in our study, 94.1% had heard about EDA; however, only 17.8% had heard about EDA from doctors, whereas the majority of these women, that is 56.8%, had heard about it from family and friends. Similarly, in previous studies, the most common source of information in Riyadh (42%) and Khobar (34%) was found to be family and friends.,
Surprisingly, in our study, only 28.7% had an experience of EDA, which is a lower proportion than that found in Khobar, Jeddah, and Khamis Mushait, where approximately 32% had the experience of EDA. However, the proportion who had experienced EDA in this study was higher than previously found in Riyadh with a proportion of 13%.,,, This finding shows a positive improvement of approximately 15% in the proportion of women with experience of EDA in Riyadh in comparison with 2013. Overall, of women who had experienced EDA, 86.2% were satisfied, and only 29.3% developed complications and side effects.
Conversely, in this study, 52.5% chose not to have EDA, and the two most common reasons were that EDA was not presented and explained to them by a doctor and the fear of side effects, as indicated by 31.1% and 30.1% of the women, respectively. Similarly, the fear of side effects was found to be the most common reason for preventing EDA in Khobar (40%).
This confirms the importance of addressing awareness and fear of EDA through assessment and improvement.
One of the main goals of our study was to assess the awareness of EDA since previous studies showed differences in public awareness and knowledge about EDA. Specifically, positive public awareness and knowledge were reported in Riyadh and Jeddah, the first two studies about EDA in Saudi Arabia, and negative awareness and knowledge were demonstrated in recent studies in Khobar and Khamis Mushait.,,, In the awareness section of our survey, we used six questions to assess the respondents' knowledge and awareness levels regarding EDA. The average percentage of awareness was found to be 45.9%, which reflects a low level of knowledge and awareness, and this result is in line with the findings of other recent studies in Saudi Arabia. Moreover, the average percentage of participants who were unsure about their answers to the questions was approximately 41.5%, which also indicates a significant lack of knowledge.
Across the awareness section, we found the most common misconception to be “contractions become weak or stop entirely after the administration of EDA” (30.7%). This was also the most common misconception in Riyadh, Jeddah, and Khamis Mushait, but in Khobar, EDA causing paraplegia was the most frequent misconception, indicating variation between populations.,,,
Previous studies have shown variation in the correlation between awareness and demographic variables; for example, in Khamis Mushait, a significant correlation was found between age and awareness. However, in Khobar, no correlation was found between these variables, and, in Riyadh, knowledge and parity were found to have a significant moderate correlation.,
Relatedly, in our study, we found an insignificant, moderate correlation between parity and awareness. Specifically, women who had multiple pregnancies had slightly better awareness of EDA. Age, education level, and income were also insignificantly related to awareness. We hypothesize that the easy access to information through the internet and social media, regardless of its scientific accuracy, may have affected the demographic differences between participants. For instance, individuals may not have to have higher education or more experience to know significantly more than other demographic groups.
Throughout previous research, we found fear to be a preventive reason for EDA, such as the fear of side effects in Khobar.
Regarding the importance of fear, through our study, we aimed to discover more about fear. Inspired by the literature, we developed a set of questions and designated a section of the survey to examine fear. Through our assessment, we found that “the possibility of EDA complication” is feared the most, with 62.9% reporting this fear. The average percentage of participants reporting fear was 44.6%, which is a moderate level of fear, and approximately 25.2% of the participants were unsure about their feelings toward EDA.
Additionally, in this study, we attempted to examine the relationship between awareness and fear. Surprisingly, the results showed a moderate correlation between awareness and fear, which may be the result of individuals having poor sources of information, which was the case for the majority of the participants in our study.
To improve people's awareness of EDA and relieve their fear, 83.2% of the participants agreed with the need for an EDA awareness campaign. In addition, 88.6% of the women reported a preference for EDA being presented and explained to them by a physician during their antenatal clinic visits.
At the end of the survey, 57.9% reported feeling positive about considering EDA, 8.9% reported that they would not consider it, and 33.2% of the women were unsure. We assume that the latter 33.2% of women are in need of consultation and clarification to make a clear decision.
Limitation of this study
The limitation of this study includes keeping up with the high flow of patients attending their antenatal appointments in a short window of time. This issue affected the number of questions in the survey, and the amount of detail we could obtain from each patient.
| Conclusion|| |
In conclusion, this study aimed to measure the level of awareness, preconceptions, and level of fear regarding EDA among childbearing women. Although our study results demonstrated a good level of desirability toward using EDA for labor pain, the women showed a limited level of preconceptions and a low level of awareness and knowledge about EDA. Moreover, we identified a moderate level of fear of EDA among the participants. Therefore, we suggest that more awareness, knowledge, and guidance about EDA should be provided to pregnant women through antenatal clinics. Furthermore, educational campaigns should be made to dispel misconceptions and fears about EDA.
We give special thanks to the Department of Obstetrics and Gynecology at King Khalid University Hospital for their much-appreciated cooperation. Also, we gratefully acknowledge all the medical student's participation as data collectors in the study.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
James JN, Prakash KS, Ponniah M. Awareness and attitudes towards labour pain and labour pain relief of urban women attending a private antenatal clinic in Chennai, India. Indian J Anaesth 2012;56:195-8.
] [Full text]
Dehghanpisheh L, Sabetian G, Faghirzade Z, Sahmeddini MA. Knowledge and attitude of Iranian parturient women towards painless labor: A qualitative survey. Prof Med J 2015;22:966-72.
Lurie S, Priscu V. Update on epidural analgesia during labor and delivery. Eur J Obstet Gynecol Reprod Biol 1993;49:147-53.
Morishima HO. Labor analgesia in the US and Japan. Masui 2007;56:1040-3.
Karn S, Yu H, Karna S, Chen L, Qiao D. Women's awareness and attitudes towards labor analgesia influencing practice between developed and developing countries. Adv Reprod Sci 2016;4:46-52.
Wong CA. Advances in labor analgesia. Int J Womens Health 2009;1:139-54.
Minhas MR, Kamal R, Afshan G, Raheel H. Knowledge, attitude and practice of parturients regarding epidural analgesia for labour in a university hospital in Karachi. J Pak Med Assoc 2005;55:63.
Jathar D, Shinde VS, Patel RD, Naik LD. A study of patients' perception about knowledge of anaesthesia & anaesthesiologist. Indian J Anaesth 2002;46:26-30. [Full text]
Alahmari SS, ALmetrek M, Alzillaee AY, Hassan WJ, Alamry SM. Knowledge, attitude, and practice of childbearing women toward epidural anesthesia during normal vaginal delivery in Alsanayeah Primary Health Care in Khamis Mushait. J Fam Med Prim Care 2020;9:99-104.
Gari A, Aziz A, ALSaleh N, Hamour Y, Abdelal H, Ahmed RS. Awareness of epidural analgesia among pregnant women in Jeddah, Saudi Arabia. Electron Physician 2017;9:4274-80.
Mohamed HF, Alqahtani J, Almobaya N, Aldosary M, Alnajay H. Women's awareness and attitude toward epidural analgesia. J Biol Agric Healthc 2013;3:46-52.
Al Sulmi ES, Al Yousef MM, Almuslim JA, Al Muslim RA, Amailo ZA, Alabbad FA. Awareness, perceptions, and desirability of epidural analgesia among pregnant women in King Fahad University Hospital, Al Khobar. Cureus 2021;13;e20146.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]