This study was conducted as the first step in the development of a multidimensional tool to measure the quality of neuraxial labour analgesia achieved in clinical trials. We explored parturient perspectives and experiences to help ensure that the instrument, which ultimately will be developed, will reflect all of the important dimensions that constitute quality analgesia for childbearing women. Significant differences have been shown to exist between patient and health provider ratings regarding the value of a given health state, and as a general rule, research supports use of tools that reflect patient perspectives.19
Multidimensional instruments have been developed and validated for use in many areas of health research, but they are not commonly available in obstetrical anesthesia.19-22
These types of tools permit assessment of various dimensions of health (physical, mental, emotional) in various forms (health profiles, health indices). By generating a summation of the scores for each dimension of quality into a global score (index of the quality achieved), a health index can be used to compare directly the overall quality of health (or analgesia) achieved in a given treatment arm. By integrating patient-perceived benefits and harms into a single score, global measures, such as the overall quality of analgesia achieved over a given time interval, are likely to provide the best means of assessing the overall importance of subtle and/or complex combinations of findings in neuraxial labour analgesia trials.19,23
Participants in this study provided valuable insights into the dimensions that should be measured to capture quality neuraxial labour analgesia as a research outcome. While women described quality neuraxial labour analgesia as pain relief without side effects, their responses indicated the need to capture information broadly as it relates to cognitive, emotional, and physical dimensions of this outcome. Responses also suggested an important relationship between these dimensions and perceptions of control.
Within the physical dimension, participants affirmed the importance of traditionally measured attributes, i.e., pain/pain relief and minimization of motor and sensory block and pruritus. Responses suggested that the methods currently used to measure these outcomes require modification, e.g., the language used for description and the perspective of assessment, to capture information that reflects women’s experiences more meaningfully. Women’s discussions further suggested specific attributes relating to control that should be measured within this dimension. These attributes included pain control/ prevention of breakthrough pain, participation in pain control, mobility, and the degree to which analgesia regimens permit preservation of the bodily sensations of labour progress, including those that permit participation in the birth without pain.
Similarly, participants’ responses suggested the need to capture information relating to cognitive and emotional dimensions of quality neuraxial analgesia as well as regarding a relationship between these dimensions and perceptions of control. The latter was demonstrated by responses suggesting that pain control improved women’s abilities to function in the cognitive dimension, i.e., to focus, process, and respond appropriately to information and to cope with less control in the physical dimension, e.g., immobility. Conversely, women’s experiences of poor quality analgesia were associated with loss of control in both emotional, e.g., fear and anxiety, and cognitive dimensions.
These findings, as well as other work, support the need for more direct capture of information related to women’s perceptions of participation and control during labour and delivery.24,25
Our findings and those of others2,26
further suggest that this information is necessary to allow neuraxial labour analgesia research to demonstrate the many advances that currently are evident only at the clinical level. Capture of this information is also needed to guide interpretation of the overall importance of the findings in modern labour analgesia trials and clinical care. It should not be assumed, however, that these are the only issues that exist with measurement in labour analgesia trials. Additional issues include the need to standardize outcomes between studies, the need to optimize the methods used to scale responses, the need for validated tools to measure outcomes in some dimensions, e.g., mobility, as well as the need to modify tools used in other dimensions, e.g., labour pain.9,24
These issues must also be addressed to provide a solid foundation for evidence-based practice in labour and delivery analgesia.
Lastly, this qualitative study provides important additional insights into the perspectives of women who have either made the decision to receive neuraxial labour analgesia a priori
or describe themselves as open to having it if they feel the need during childbirth. Previous work has suggested that pain relief by itself does not guarantee satisfaction with the childbirth experience and that satisfaction in this context is multi-dimensional, relating more to maternal expectations, their supports (including the quality of the relationship between women and their caregivers), and perceived control.9,25-28
These findings were interpreted to suggest that women do not value pain relief during labour and delivery and that they do not have expectations related to it.29,30
The latter interpretation is not supported by our findings. The majority of women in this study shared that they valued pain relief highly and described that pain relief had improved their abilities to cope and to focus on the birth experience. Participants in this study also related that they valued quality relationships with caregivers and had expectations related to pain relief. They shared that a supportive childbirth environment was one that also supported them in their choices related to pain relief. Multiparas, in particular, described expectations and fears related to the accessibility and timely availability of epidural pain relief as well as the importance of being able to freely choose it without health care providers and others making them feel as if they had “wimped out” or had “given up some prize”. Fear of pain and previous experiences with inadequate pain control during labour and delivery have been associated with fear of childbirth and the decision to undergo elective Cesarean delivery.31
Overall, our study findings provide valuable insights into childbearing women’s perspectives regarding the characteristics that constitute quality neuraxial labour analgesia, suggesting the dimensions and specific attributes that must be measured in order to capture this outcome in research. Further work is needed to explore and validate these findings. In addition, this study provides important information related to the perspectives of women who desire or are open to neuraxial labour analgesia, including their expectations and fears surrounding pain relief. These findings have implications for interpretation of existing research as well as antenatal education.
A strength of this study includes using women, who recently delivered with neuraxial labour analgesia, as authorities whose experiences and perspectives could provide insight into the characteristics that constitute quality neuraxial labour analgesia. Women were interviewed shortly after delivery when their experiences were still fresh in their memories. In addition, the participants represented women who had experienced different methods of childbirth and who had both positive and negative experiences with epidural analgesia. Other strengths of this study are the steps undertaken to promote precise and exacting standards. The research team included individuals from different disciplinary backgrounds in order to minimize potential bias ensuing from a single disciplinary perspective. Inter-rater reliability checks were undertaken to ensure consistency in coding. The development of codes and themes were derived inductively from the data, and an extensive audit trail was maintained to document key methods and decisions and the rationale for these.
Limitations are also present. Although not all women were native English speakers, participation required fluency in English. Non-English speaking women might have had different expectations and experiences. Participants delivered in hospitals in a large urban centre where epidural services are readily available. The experiences of women receiving neuraxial analgesia in smaller community hospitals might be different. Notably, some women in our study who resided in small towns shared that they had opted for care in a teaching hospital because of limited access to such resources. Most participants had attended university or a community college and might have different expectations than women who were less educated. Women who were too tired to participate in the study may also have had different experiences and perspectives than the participants. Finally, a second interview with the women, particularly those who had operative deliveries, may have allowed for more in-depth insights into their experiences to emerge.