|Year : 2011 | Volume
| Issue : 1 | Page : 13-20
Knowledge, attitude and acceptance of antenatal women toward labor analgesia and caesarean section in a medical college hospital in India
Udita Naithani1, Prerna Bharwal1, Sandeeep Singh Chauhan1, Deepak Kumar1, Sunanda Gupta1, Kirti2
1 Department of Anaesthesiology and Critical Care, RNT Medical College and Associated Group of Hospitals, Udaipur, Rajasthan, India
2 Department of Community Medicine, RNT Medical College and Associated Group of Hospitals, Udaipur, Rajasthan, India
|Date of Web Publication||25-Aug-2011|
Department of Anaesthesiology and Critical Care, RNT Medical College and Associated Group of Hospitals, Udaipur, Rajasthan
Source of Support: None, Conflict of Interest: None
Background : The present audit was initiated to evaluate the knowledge, attitude, perception and acceptance of women toward labor analgesia and caesarean section, in a Medical College Hospital in Udaipur, India.
Materials and Methods : A semi-structured interview of 200 antenatal women was conducted, to assess the knowledge, attitude and perception regarding labor analgesia and caesarean section (CS) and to estimate the correlation of awareness and acceptability with demographic variables. The data were analyzed using Epi Info 6 and the Likert type scale (0 - 10), as also the chi square test, to calculate the statistical significance.
Results : Most of the patients (n = 181, 90.50%) were unaware of labor analgesia. When the option of labor analgesia was offered, only 23% (n = 46) accepted it and the most significant reason for refusal was to experience natural child birth (n = 114 / 154, 74.03%). An educational status of the graduate level had a positive impact on knowledge about labor analgesia (P = 0.0001). When the option for CS was offered, 73.50% women (n = 147; P = 0.008) refused and the most common reasons for refusal were fear of operation (53.06%, n = 78) and delay in resuming household work (46.26%, n = 68). Educational status up to the graduate level and previous surgical experience of CS had a positive correlation with preference for CS (P = 0.0092 and P = 0.0001, respectively).
Conclusions : Awareness and acceptance for labor analgesia was relatively low among the prospective parturients. A higher level of education had a significant impact on their decisions regarding delivery.
Keywords: Acceptance, awareness, caesarean section, knowledge, labor analgesia
|How to cite this article:|
Naithani U, Bharwal P, Chauhan SS, Kumar D, Gupta S, Kirti. Knowledge, attitude and acceptance of antenatal women toward labor analgesia and caesarean section in a medical college hospital in India. J Obstet Anaesth Crit Care 2011;1:13-20
|How to cite this URL:|
Naithani U, Bharwal P, Chauhan SS, Kumar D, Gupta S, Kirti. Knowledge, attitude and acceptance of antenatal women toward labor analgesia and caesarean section in a medical college hospital in India. J Obstet Anaesth Crit Care [serial online] 2011 [cited 2020 Jan 28];1:13-20. Available from: http://www.joacc.com/text.asp?2011/1/1/13/84250
| Introduction|| |
Natural labor is a painful process. Several methods of labor analgesia have evolved over the years, but pain relief in labor is still controversial.  In developed countries the issue is focused on the choice of methods and complications, while in developing countries, the issues revolve around awareness, acceptability and availability of labor analgesia. 
In addition to fear of child birth women may not be aware of the analgesic options for labor. ,, Culture, ethnic group, age and education may have a strong influence on the attitude toward pain relief in labor. 
Several studies have been conducted worldwide to determine the influence of socioeconomic and obstetric factors on the patient's knowledge and acceptance of labor analgesia, ,,, along with their attitude toward caesarean delivery, anaesthesia preferences and the outcome. ,,, There is a paucity of such data from the Indian subcontinent, as Indian women still have minimum participation in their pregnancy and healthcare decisions.
This study thus aims to assess the level of awareness, knowledge and acceptance of antenatal women to analgesia during labor and caesarean sections and to evaluate the effect of the demographic variables on these parameters.
| Materials and Methods|| |
This study was conducted at a women's hospital (average annual delivery rate: 17,000 deliveries) affiliated to a medical college in the southern region of Rajasthan, India, from 1 April, 2009 to 31 March, 2010. Following approval from the hospital Ethics Committee, informed consent was taken from antenatal patients for taking part in a semi-structured interview.
Sample size calculation
A power analysis to indicate the sample size was calculated by using Epi Info-6, for a descriptive study, taking the population size as 45,000, according to the parturients attending the antenatal clinic of our hospital in one year. Frequency of having knowledge regarding obstetric anaesthesia and analgesia (expected and worst acceptable frequency) ranged from 38.9% to 40% versus 20%, respectively, with a confidence level of 99.99%. The calculated sample size required was 91. However, this study was conducted in 200 prospective parturients, to increase the chances of accuracy.
This study was based on a semi-structured interview to assess the knowledge, attitude and acceptance toward labor analgesia and caesarean delivery, among antenatal women. A structured questionnaire (Appendix 1), assuring voluntary anonymous response, had three parts, including details of patient demographic characteristics, labor analgesia and caesarean section.
The data were entered and analyzed using Ep Info-6 on mean score, on a Likert-type scale, range (0 - 10). The chi-square test was used to calculate the statistical significance. P < 0.05 was considered as significant.
| Results|| |
a. Demographic characteristics: Two hundred antenatal women were subjected to a semi-structured interview having a mean age of 25.63 ± 4.35 years, with single parity in 86 (43%) and multiparity in 114 (57%) women. Most of the patients were Hindus (88%), homemakers or unemployed (82.50%). Their economic status was above the poverty line (92.50%) and they were in the third trimester of pregnancy (83%). The educational status of the study population showed an education up to graduation in only 15% (30). Sixteen percent (32) of the women had previous surgical experience of which 63.3% (19 / 30) had a previous CS. [Table 1]
b. Labor Analgesia (LA): Women were enquired about the cause and severity of any past experience of severe pain and asked to grade it using 0 - 10 visual analog scale (VAS), most of the women graded it as 2 (59.50%); 3 (16.50%) or 4 (21.50%). One hundred and five women (52.50%) had no past experience of labor pains, of which 86 were primiparous, 19 had previous caesarean deliveries; while the rest of the women graded previous labor pains as grade 4 (21.50%) or 3 (15.50%). Expected labor pain of the present pregnancy was graded by the majority as 4 (44.50%) or 3 (26%) [Table 2]. One hundred and eighty-one (90.50%) women were unaware about painless labor. Among 19 (9.50%) women who were aware about labor analgesia, ten (52.63%) knew that it was provided by injection in the lower back and two (10.52%) termed it as 'epidural' (one was a doctor and one was a graduate whose relative received painless labor); 68.43% (13 / 19) described the provider of LA as an anaesthesiologist and six (31.57%) as a doctor. [Table 3].
|Table 2: Distribution of cases on the basis of score given to past experience of severe pain, previous labor pain and expected labor pain using VAS (0 – 10)|
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|Table 3: Distribution of cases on the basis of knowledge, methods, source and provider of labor analgesia|
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When the option of pain alleviation during labor was offered, only 23% (46) accepted it. Among them preference of the method of LA was epidural in 20 (43.48%), analgesic injections in seven (15.22%), 15 (32.31%) preferred elective CS as the method for avoiding labor pain and four (8.70%) women preferred the treating doctor to take the decision regarding the pain alleviation method. Among 154 (77%) women who refused LA, the most common reason for refusal was to experience natural childbirth (74.03%; 114 / 154) [Figure 1].
|Figure 1: Distribution of cases according to reason for refusing labor analgesia (n = 154 / 200, 77% women refused labor analgesia)|
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c. Caesarean section (CS): When the option for a hypothetical caesarean section was offered, 147 patients (73.50%) refused and the main reasons for refusal were fear of operation (53.06%; 78 / 147) and the extra care required in the postoperative period, which would lead to delay in resuming household work (42.6%; 68 / 147). Among the parturients who preferred CS for the present pregnancy, 26.50% (53 / 200) gave the most common reason for opting for it, which was "advised by the treating doctor" (83.02%; 44 / 53) [Figure 2]. When knowledge of the study population was assessed regarding the caesarean section, a majority of the women (70%) did not know that anaesthesia would be required for CS, while 83% expressed ignorance about the provider of anaesthesia. When they were asked about the choice of anaesthesia, most of them left it to the 'doctor's advice' (65%), while 29.50% preferred regional and 5.50% preferred general anaesthesia. Most of them (71.50%) were not concerned about surgery and anaesthesia for CS, however, they cited extra care postoperatively and delay in resuming household work, as their major concern [Figure 3]. Forty-one percent (82 / 200) were aware that blood transfusion may be required for CS; among them 53.66% (44 / 82) stated that blood would be provided by the hospital, 12.20% (10 / 82) said relatives would provide the same, while 32.93% (27 / 82) did not know about the source of blood. Only one (0.50%) patient, who was a doctor, knew about the complications of blood transfusion.
|Figure 2: Distribution of cases according to reason for preferring caesarean section (n = 53 / 200, 26.50% women preferred caesarean section)|
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|Figure 3: Distribution of cases according to reason for refusing caesarean section (n = 147 / 200, 73.50% women refused caesarean section)|
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d. Effect of demographic factors on the knowledge and acceptance of labor analgesia: Women with an educational status of a graduate level had a positive impact on the awareness of painless labor (P = 0.0001). The women who were graduates, urban, or had a previous caesarean delivery were found to have a significantly better knowledge regarding 'injection in the lower back' as a method of labor analgesia (P = 0.0001, P = 0.006, P = 0.004, respectively) and knowledge that the provider of LA was called the 'anaesthesiologist or a doctor' (P = 0.0001, P = 0.008, P = 0.0002, respectively). A significant source of information for graduates regarding labor analgesia was friends and relatives (P = 0.0001) and urban women (P = 0.004). Women who had a previous experience of CS, significantly preferred elective CS as their choice of method for painless delivery, while others preferred epidural as their method of choice for LA (P = 0.009).
e. Effect of demographic factors on the knowledge and acceptance of the caesarean section: An educational status of the graduate level and a previous experience of CS had a significant positive correlation with preference for CS (P = 0.0092, P = 0.0001, respectively) as well as knowledge about requirement of anaesthesia for CS (P = 0.001; P = 0.0001, respectively), while only graduates knew that an anaesthesiologist or a doctor was a provider of anaesthesia (P = 0.001).
| Discussion|| |
It is generally considered that an interview is a superior method for in-depth data collection because a relationship develops with the subjects in the study and the researcher feels confident that they would respond openly and honestly, thus enhancing the quality of the data. Thus, we conducted a semi-structured interview in 200 antenatal women, to assess the awareness and acceptance of labor analgesia and caesarean section among the Indian population.
An increasing number of women worldwide are using epidural analgesia as a pain management strategy during labor, but in our study we found that only 9.5% of the women were aware of the availability of pain relief during labor; and when the option of painless labor was offered for their current pregnancy only 23% accepted it. The incidence of awareness and acceptance of labor analgesia from Nigeria (27 and 57.6%, respectively)  and Lagos (38.9 and 65.3%, respectively)  differ from Australia (98 and 80%, respectively).  This discrepancy in the level of awareness and acceptance could be attributed to the fact that child birth is still viewed as a physiological process in most of the developing countries, which is managed with as little interference as possible. Many women still do not know that pain of labor can be relieved. 
The experience of pain in labor is unique for each woman  and the attitude toward labor may also be influenced by a woman's uprising, culture, ethnic group, age and peer pressure.  In some studies the past experience and expected labor pain were graded as high as 8.4 and many women were afraid and scared of labor pain, , while in our study the past experience or expected labor pains were graded as low as 3 or 4; and most of the women were confident that they could cope with the labor pains. It has been observed that in developing countries like India and South Africa,  antenatal education may be of even greater importance, as women may be less educated than women from the industrialized world and therefore, have a poorer knowledge of human reproduction. Furthermore, their ability to seek and access information is limited, so women are dependent on the education provided by relatives, friends, , and health workers.  They identified tablets and IV / IM injections as methods to provide pain relief in labor, few were aware of epidural or breathing exercise as methods of painless labor. ,,
Use of intrapartum epidural analgesia is reported to vary considerably with the women's insurance status, race, parity, age and the specialty of the physician managing the labor. Race and lower socioeconomic status were seen as univariate predictors of refusal for epidural analgesia for labor; while full / part time employment, higher income, higher educational level, a prior educational program and knowledge about epidural were documented as univariate predictors of acceptance. , The degree of subjective pain, low parity and a high level of education were associated significantly with the acceptance of epidural labor analgesia. ,, In our study, except the graduate level of education, none of the demographic variables like age, religion, parity, occupation or background had improved awareness and acceptance of labor analgesia. This implicates a general, low level of knowledge in all strata of society.
Pain in labor is usually considered a positive feature of labor and the idea of relieving it is often opposed in developing countries. This reflects traditional values, according to which pain during labor denotes successful bonding with the baby. A girl child who is sensitized to such values during her growing period learns to accept and endure the pain of childbirth.  The educational level of our study population was very poor, only 15% of the women were graduates and had a significantly better knowledge about painless labor (P = 0.0001). This shows that women with better education can understand the birth process and have the ability to gather information about pain relief in labor and may gradually develop acceptance for it.
It has been highlighted that healthcare providers in developing countries are either ignorant or consider educating women on pain relief methods during labor as a low priority issue. This apparent neglect is emphasized further by the observation that even women who had prior antenatal visits with obstetric healthcare providers did not have increased awareness.  In contrast, a recent study in a tertiary obstetric hospital of Australia  revealed that almost all women accessed antenatal information regarding intrapartum pain management, usually from multiple and varied sources. The vast majority of women were well-informed regarding their pain management in labor. They were more concerned with the maternal side effects than the fetal effects when deciding against pain management and this may be due to a greater awareness in their population that fetal side effects of epidural analgesia in general, are small. More women in Australia received information from an anaesthetist / obstetrician, while women in the United Kingdom received it from the media. 
The other domain of our study was to know the attitude of Indian women toward caesarean delivery, as babies delivered by the caesarean section have increased steadily over the last few years. Several studies have appeared in the western literature, ,,, but none are available from the Indian subcontinent. When we offered CS for the current pregnancy only 4% (8 / 100) wanted elective CS to avoid labor pains and 22% (44 / 200) wanted to accept it only if advised by the treating doctor. In a similar study from Singapore  82.9% of the women left the decision on the treating doctor. Elective caesarean delivery was opted for by 3.7% of the women from Singapore,  4% from an Italian survey,  7% from a Scottish study,  and 13.2% in women using the public healthcare system in Brazil.  The most popular reason for choosing CS was the avoidance of labor pain and stress; ,, a psychological disorder arising from the unreasoned dread of childbirth has even been described as 'Tokophobia'.  In a Brazilian study 40% of the women expected to have a CS, as vaginal delivery was considered to be risky, with negative experience and CS presented as the best quality care. 
In some countries the popularity of elective CS was attributed to their role in preservation of sexual function and urinary continence,  but these were not major consideration in Asian countries.  In our study 73.50% women refused CS mainly because of the fear of operation (53.06%) and the extra care required postoperatively (46.20%).
Common reasons cited by other authors for refusal of CS were a wish to experience natural child birth, fast recovery and safer vaginal delivery. , Some women even thought that their child bearing capabilities were threatened by CS and their family size would have to be limited.  Higher education, higher maternal age, greater number of antenatal visits, primiparous, delivery in private hospitals and previous CS have been reported to have an association with high CS rates. 
In our study the women who were graduates and had previous CS showed significant preference for caesarean delivery (P = 0.0092 and P = 0.0001, respectively). Most of the women in our study did not know that anaesthesia was required for CS (70%), nor did they have any knowledge about the provider (83%) and 65% left the choice of anaesthesia on doctor's advice. This reflects that knowledge about anaesthesia and anaesthesiologists among patients is limited in India and improves with a higher education level, as reported earlier. ,
It is difficult to change the attitude and perception of the female population toward issues related to childbirth. Educational status does have a positive correlation with the acceptance of the methods for pain relief during childbirth. In the current scenario, even if pain relief during childbirth is offered, the poorly educated women are apprehensive and consequently refuse interventions. This reflects on our healthcare system, which is not geared up to provide sufficient cognitive and emotional preparation for childbirth. Considering the level of education in our population, dedicated childbirth educators could help in improving obstetric care, help in allowing women to make their own decisions regarding childbirth and also sensitize them to accessing analgesia in labor.
There were some limitations of this study as it was conducted at a single tertiary healthcare center attached to a medical college, thus, limiting the reliability of data, which could have been gained from basing it in multicentric institutions. Another potential limitation of this study was that the sample of parturients surveyed at our institution was a less-educated patient base and thus might not necessarily reflect national obstetric population preferences. We questioned the women only once in the antenatal period, so extrapolation of our findings to postnatal women may be inappropriate, as once these women had experienced labor their views could have been different. In spite of the above-mentioned limitations certain conclusions could be drawn.
| Conclusion|| |
We conclude that knowledge and acceptance of labor analgesia and caesarean section was significantly less in antenatal women, irrespective of age, parity, occupation or religion in our study group. The most significant reason for refusal of labor analgesia was the 'desire to experience natural childbirth'. Regarding the caesarean section women were mostly concerned about the extra care required in the postoperative period and the delay in resuming their household duties. A graduate level of education, an urban background or a previous surgical experience had a positive impact on the knowledge and acceptance of labor analgesia and the caesarean section.
The low literacy levels in the urban as well as rural population of India are responsible for the status of the low acceptance of labor analgesia. Her ignorance regarding availability of labor analgesia services, her inability to access information, her unawareness to stress for the right to receive these services are some of the reasons responsible for the, 'inadequate labor analgesia services' in different centers.
Future audits to validate the above-mentioned statements in different hospitals of the country, as well as audits on practice strategies among anaesthesiologists and obstetricians toward providing these services to the parturients, should be conducted. These audits will give us an overall view of the reasons behind the lack of awareness and acceptability of labor analgesia among antenatal women and help in planning future strategies to improve the situation.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3]