|Year : 2017 | Volume
| Issue : 2 | Page : 90-94
Epidural analgesia in hispanic parturients: A single-blinded prospective cohort study on the effects of an educational intervention on epidural analgesia utilization
Daniel A Hansen1, Reuel J Measom2, Barbara Scott2
1 Department of Anaesthesiology, Mayo Clinic, Phoenix, Arizona, USA
2 Department of Anaesthesiology, University of Nevada School of Medicine, Reno, Nevada, USA
|Date of Web Publication||7-Nov-2017|
Daniel A Hansen
Department of Anaesthesiology, Mayo Clinic, Phoenix, Arizona
Source of Support: None, Conflict of Interest: None
Introduction: Epidural analgesia for the management of labour pain in pregnant women is a common intervention. In the United States, Hispanic parturients underutilize epidural anaesthesia when compared to other ethnic groups. Data suggest that misinformation deters many women from epidural analgesia while in labour. We hypothesized that education regarding epidural analgesia provided during a prenatal visit would normalize the utilization rates of Hispanic women while in labour. Materials and Methods: We performed a prospective, single-blinded cohort study with participants of self-described Hispanic origin in the second or third trimester. Participants (n = 45) were randomly assigned to receive an educational pamphlet on epidural anaesthesia or a control pamphlet. Following completion of their pregnancy, medical records were reviewed and participants were contacted for subjective information regarding their birth experience. Results: 38.9% of the control group was compared with 34.8% of the epidural group that received epidurals for labour analgesia (P value = 0.83), with no statistically significant differences noted between the two groups. Collection of subjective comments was notable for repeated concerns regarding complications due to neuraxial analgesia. Conclusions: A passively delivered educational pamphlet on epidural analgesia is unlikely to significantly influence Hispanic parturients' utilization of epidural analgesia. Cultural differences and values should be considered when addressing epidural analgesia to Hispanic patients. Additionally, in this patient population preemptively addressing concerns of chronic back pain may help alleviate reservations regarding epidural use.
Keywords: Epidural anaesthesia, epidural analgesia, Hispanic, obstetric anaesthesia
|How to cite this article:|
Hansen DA, Measom RJ, Scott B. Epidural analgesia in hispanic parturients: A single-blinded prospective cohort study on the effects of an educational intervention on epidural analgesia utilization. J Obstet Anaesth Crit Care 2017;7:90-4
|How to cite this URL:|
Hansen DA, Measom RJ, Scott B. Epidural analgesia in hispanic parturients: A single-blinded prospective cohort study on the effects of an educational intervention on epidural analgesia utilization. J Obstet Anaesth Crit Care [serial online] 2017 [cited 2019 Dec 12];7:90-4. Available from: http://www.joacc.com/text.asp?2017/7/2/90/217771
| Introduction|| |
Childbirth can be an extremely painful experience for some women and throughout history societies have worked to minimize the mortality and pain associated with labour. Today, spinal anaesthesia is typically reserved for caesarean deliveries, while epidurals are generally the modality of choice for analgesia in the labouring patient. Epidural rates in the United States vary regionally, but are cited as 38–61% nationally., The National Vital Statistics Report, published by the Centre for Disease Control (CDC), reported an overall utilization of neuraxial analgesia in 27 states as 61%. Subgroup analysis demonstrates that whites have the highest neuraxial analgesia rates at 68.6% compared with Hispanic rates of 47.7%. While there are multiple modalities for pain management in the peripartum setting, epidurals, unless contraindicated, are the most commonly employed therapy.,,, Risks and benefits of epidural analgesia are beyond the scope of this study, but distinct utilization rates based on ethnicity suggest some sort of bias that should be investigated. Disparate rates of epidural utilization have many potential reasons, and a lack of information regarding epidural analgesia leads to underutilization.,, Furthermore, despite similar expectations for pain management during the labour experience, Spanish-speaking females are less likely to have epidurals.
We hypothesized that providing educational materials regarding epidurals to Hispanic parturients would lead to increased utilization of epidurals for pain management in the peripartum period.
| Materials and Methods|| |
To test our hypothesis, we designed a prospective, single-blinded cohort study with Hispanic parturients to assess if an educational intervention would increase their utilization of neuraxial analgesia. After an initial study design and approval from the local Institutional Review Board, we began enrolling participants of self-described Hispanic origin, at a single hospital. Enrolment occurred in two 6-month phases in the second half of 2012 and again in early 2016. The two phases and interval gap were determined by logistical restraints on the study authors in medical training. In addition to being of self-described Hispanic origin, participants had to be at least 18 years of age and should be in the second or third trimester of their pregnancy. No limits were placed on whether the mother was primiparous or multiparous. Potential participants were told that the study was regarding childbirth and their experience, but no further information was given regarding the specifics of the study. If interested in participating, the parturient was then consented, enrolled and basic demographic information was collected. Total number of potential participants versus enrolled participants was not recorded. Simple randomization was employed and participants were assigned to one of two groups. The experimental (epidural) group received a basic educational pamphlet on epidural analgesia and the control group received a stock educational brochure on bacterial vaginosis. All study materials and conversations were provided in Spanish or English based on the participant's preference. Furthermore, all translations were performed by a neutral-certified medical translation company. Totally, 45 participants were enrolled. Sample size was determined based on logistical limitations of continued enrolment extending past the prescribed time period for enrolment. At the time of enrolment and randomization, the participants in the epidural group were handed the standardized pamphlet and instructed to read it (provided in English and Spanish) and ask any questions to their provider. The pamphlet on epidural analgesia was created for the study after a literature review and using validated studies identifying key concerns of Hispanic women. Specifically, the pamphlet provided basic information on: (1) what is an epidural, (2) how it works, (3) benefits of epidurals, (4) risks of epidurals and (5) a common question portion that addressed risk of paralysis, chronic back pain, religious considerations (particularly Roman Catholic teachings given Hispanic ethnicity correlation with Roman Catholicism) and familial considerations. Furthermore, the pamphlet included a simple three-part cartoon depiction of the procedure, the anatomy and basic setup of a generic epidural catheter, tubing and continuous infusion pump for drug delivery. Following completion of each pregnancy, medical records were reviewed and participants were contacted via telephone for subjective information regarding their birth experience. A standardized set of questions was utilized in the conversation and responses were recorded [Table 1]. Data were finalized and then analysed. Statistical analysis was undertaken with Microsoft Excel and Chi-square testing. This manuscript adheres to applicable Equator and STROBE guidelines.
| Results|| |
Follow-up with the parturients involved a near equal rate of epidural utilization despite our educational pamphlet. The epidural group (n = 23) had an epidural rate of 34.8%, while the control group (n = 18) had a rate of 38.9%, resulting in a P value of 0.83 with similar group characteristics with regards to primiparous versus multiparous status (33% primiparous in control group, 39% in epidural group). Spinal anaesthesia was the primary modality for anaesthesia in 21.7% of the epidural group and in 16.7% of the control group (P-value = 0.72); all of which were for planned caesarean deliveries. 43.5% of the parturients in the epidural group and 44.4% of the control group did not prefer epidural analgesia for labour and the difference between the groups was not significant (P-value = 0.96). There were no statistically significant differences noted between the groups on any of the metrics measured. Furthermore, there was no significant morbidity or mortality associated with any of the participants or their infants. [Table 2] summarizes the data.
Follow-up with the participants was notable for several findings. First, it was difficult to contact many of the participants, with a significant number of phone numbers no longer associated with the participant. Of the 45 enrolled patients, four were completely lost to follow-up (8.8%), including medical records and telephone contact. Of the remaining 41 participants, 13 (31.7%) were successfully contacted for subjective commentary regarding their birth experience and reasoning for or against epidural use. A scripted conversation was utilized in the follow-up conversations and all follow-up was attempted within 4 months of delivery. Seven of those contacted (54.8%) voiced concerns regarding epidurals and perceived complications. One (7.6%) supported epidural use and the remaining five (38.6%) were neutral regarding epidural use following their birth experience (from both groups). Among the majority who expressed concern regarding epidural use, concerns of chronic back pain predominated (71.4%) with concerns for delayed labour and poor family experience, each representing a lesser portion (14.3% each). [Table 3] demonstrates comments regarding epidural use collected from the participants.
|Table 3: Selected comments from post-partum follow-up regarding epidural use|
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| Discussion|| |
Racial or ethnic disparities exist in the treatment of pain.,,,,, In the 21st century, multiple modalities are available for the treatment of pain in the peripartum setting and epidurals remain the predominant option for most labouring women.,,, Multiple studies have demonstrated that Hispanic women are less likely to plan on epidural use, despite the fact that epidurals are a safe, effective option for peripartum analgesia.,, We attempted to assess whether a passive educational tool would be sufficient to affect the existing disparity in epidural utilization between Hispanic parturients and non-Hispanic parturients. In our study, a passive intervention in the form of a bilingual pamphlet on epidural analgesia was not sufficient to significantly alter the utilization of epidurals among Hispanic parturients.
Despite the national disparity in epidural utilization by Hispanic women, there is evidence that suggests expectations for pain management during labour are similar in all women. Further studies suggest that overall healthcare literacy is an important factor in epidural understanding and utilization, as are general education levels.,, There is some evidence to suggest that race/ethnicity plays a small role in epidural analgesia requests and timing when requested; however, this is likely more impacted by a lack of prenatal education regarding analgesic options., Hispanic females who speak Spanish at home rather than English are less likely to request or receive epidurals. Another study found that severity of labour pain, low parity, higher educational levels, and more secular (compared to religious) patients were more likely to request epidural analgesia. Determining more precise geographic and regional differences with epidural use is exceptionally complex as citizenship status (e.g. legal immigrant versus illegal immigrant versus first-generation citizen), socioeconomic status, nation of origin, and other variables all interplay in the milieu of factors involved with decision-making in the peripartum period.
Undoubtedly, there are myriad reasons and factors why Hispanic women underutilize epidural analgesia compared to other groups. Fear of chronic back pain is a commonly cited reason for epidurals not requested by Hispanic parturients. This is not only true in the United States. In Mexico, the Annual Congress of Anaesthesiologists created a work group to investigate concerns regarding epidurals and noted that fear of back pain is the most commonly cited reason. Indeed, in our study, concerns regarding chronic back pain were the most common reason for the participants to refuse epidurals or regret in having them. Additionally, the idea that 'women should cope with labour pain' and the influence of family and friends are other factors listed among Hispanic women for not getting epidurals. Obviously, epidural placement is not without complications and potentially permanent sequelae; however, chronic back pain is not one of the associated complications. This has been validated in multiple studies.,,,,, Reviewing the medical literature, we were able to identify a single case report where neuraxial analgesia might be associated with chronic back pain. Interestingly, fear of chronic back pain is rarely reported as a concern among other ethnic groups. Other reasons cited for reticence regarding epidurals in other studies, in our study and anecdotally include cultural, religious and familial influences. Our educational pamphlet specifically addressed risks and benefits of epidural analgesia, how the procedure is performed, religious considerations (e.g. the position of the Roman Catholic Church), the personal nature of the decision-making process in the peripartum period (e.g. discussed the role of family and partner involvement but ultimately, as per U.S. and state law, decisions rest with the labouring mother) and a variety of other information points. All efforts were taken to ensure the pamphlet was neutral in tone so as to not encourage or discourage epidural requests, but merely to provide information.
In our study, there were a number of limitations. First, the sample size of 45 patients makes it challenging to extrapolate the data more generally and identify any subtle statistical differences. Logistical limitations prevented a more robust sample size and a priori power calculations to more definitively guide our study effects. In addition, the homogenous ethnic mixture of our patients (the vast majority were either Mexican or of Mexican origin) may not reflect the opinions and experiences of other Hispanic groups (e.g. Puerto Ricans, Bolivians, Costa Ricans, etc.). Furthermore, our single-centre study was performed in a pregnancy centre designed for those of lower socioeconomic station. This likely affects the decision-making process during labour in multiple ways. Lastly, we lost 8.8% of our initial participants to follow-up and were unable to assess their medical charts or establish contact following completion of their pregnancies. This is likely due to the nature of the recruitment centre, which offered free or minimal cost prenatal care with some patients delivering at different locations, despite plans for delivery within the associated hospital.
| Conclusion|| |
In conclusion, our study suggests that a passively delivered educational pamphlet on epidural analgesia is unlikely to significantly influence Hispanic parturients' utilization of epidural analgesia. Likely, there are myriad factors underlying the general trend towards under-utilization of epidural analgesia among Hispanic parturients, yet our study affirms previous studies identifying fear of back pain as a primary motivation for this population. Among Hispanic parturients, preemptively addressing concerns of neuraxial analgesia associated chronic back pain may help alleviate reservations, but further investigations towards this end are needed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]