Table shows that the age of participating women ranged from 19 to 44 years with a mean age of 31.2 years; 30 for Belgian women and 32 for Dutch women. Those having their first baby made up 55.7% of all respondents; in Belgium 50.0% (n = 68) were having their first baby, in the Netherlands, 60.9% (n = 62). More Belgian (71.9%; n = 97) than Dutch (45.9%; n = 68) women completed higher education. Belgian women reported longer labours, with an average of almost 10 hours, compared to the Dutch with an average of 8.5 hours (t = 2.14, p = 0.03) (Table ).
Among Belgian women, 47.8% (n = 65) made use of pharmacological pain relief during labour or delivery, compared to 14.5% (n = 22) of the Dutch respondents. In both countries primiparous women are almost twice as likely to receive pain relief than multiparous women (Belgium: 57.9% versus 30.%; the Netherlands: 31.2% versus 17.3%). Dutch women expect about the same level of labour pain (mean = 61.84) as Belgian women (mean = 63.76). Dutch and Belgian women show the same average acceptance of labour pain (B: mean = 3.72; Nl: mean = 3.75; t = -.39; p = 0.694), but the Belgians report higher average scores on personal control in pain relief than the Dutch (B: mean = 7.07; Nl: mean = 5.54; t = 7.95; p < 0.001) (Table ). Parity, length of labour and educational level especially may confound the comparison between Belgium and the Netherlands. Therefore these variables together with expected pain intensity and age were controlled for in the logistic regression model.
Logistic regression model
Tables shows the odds ratios and confidence intervals (CI) for the logistic regression models corresponding to the first and second research question, table presents the same logistic regression model ran for Dutch and Belgian women separately, in order to answer the third research question.
Logistic regression models with individual and country level predictors of pain medication use1 (N = 327)
Logistic regression models with individual level predictors of pain medication use1 for the Netherlands and Belgium separately
In model 1 (table ) the impact of labour pain acceptance and personal control on labour pain medication use is addressed (RQ1). What concerns the control variables, we find that longer labours (OR = 1.115 [1.065,1.167]) and younger age (OR = 0.912 [0.851,0.997]) rendered pain relief more likely. Expected pain intensity, level of education, and parity did not reach the 95% significance level. In line with our hypothesis, the interaction term 'pain acceptance*personal control' indicates that the likelihood of pain medication use is smallest if women have positive pain attitudes during pregnancy and report high personal control in pain relief after birth (OR = 0.613 [0.485,0.776]). In addition, the OR's of personal control in pain relief reveal that personal control in pain relief has no influence if women have average pain attitudes. Moreover, pain acceptance is the most important determinant of pain medication use during birth (OR = 0.439 [0.305,0.634]. This is also shown in the main effects model (no table) including only pain acceptance and personal control in labour pain, in addition to the control variables. In this main effect model only pain acceptance has a significant influence on pain medication use (pain acceptance: OR = 0.444[0.311,0.634]; personal control: OR = 1.187[0.997-1.413]).
In model 2 and 3 (table ), conform the second research question, care context is introduced by adding the country variable to the analysis. First of all, we find that the use of labour pain medication is more likely among Belgian women (OR model 2 = 0.134 [0.071,0.252]; ORmodel 3 = 0.085 [0.038,0.190]). Secondly, in model 3 (table ) it is shown that pain acceptance (OR = 0.435 [0.292,0.647]) and personal control in pain relief (OR = 0.721 [0.583-0.892]) reduce the likelihood of pain medication use, especially when they occur together (OR = 0.602 [0.468,0.775]. Thus, personal control in pain relief becomes a significant determinant of pain medication use, once the care context is introduced. This means that the country difference in pain medication use can be partially explained by differences in personal control in pain relief. We know from the descriptives that Dutch and Belgian women reported the same level of pain acceptance, while Belgians scored significantly higher than the Dutch on personal control in pain relief. This finding becomes more explicit in the results of the regression analyses for Belgium and the Netherlands separately.
In table , a similar regression model has been estimated for Belgian and Dutch women separately in order to answer the third research question: does the relative impact of labour pain acceptance and personal control in pain relief diverge between the Belgian and Dutch care context?
In Belgium, the likelihood of using pain relief is seriously reduced for women accepting labour pain (OR = 0.260 [0.138,0.487]). Personal control in pain relief, on the contrary, is of little importance (OR = 0.845 [0.633,1.129])). Also the co-occurrence of pain acceptance and personal control (OR = 0.684 [0.427,1,096] has no additional value.
For Dutch women a different picture arises from our results. The main determinant of pain relief shifts from labour pain acceptance towards personal control in pain relief. In table two differences are important when comparing the country specific findings. First, for the Dutch women, the interaction term 'pain acceptance*personal control in pain relief' is significant. Second, for Dutch women not pain acceptance but personal control in pain relief is important in predicting pain medication use. This means that for Dutch women, especially personal control in pain relief (OR = 0.642 [0.460,0.895] has a significant reducing effect on medication use, even more so when co-occurring with pain acceptance (OR = 0.660 [0.449,0.970]).
In Figure we show the predicted likelihood of labour pain medication use estimated with the country specific model in table . This graph illustrates that, among the women who report low pain acceptance and personal control in pain relief (i.e., mean - 1SD), Belgians have a 71% chance of having their labour pain relieved, versus a likelihood of 11% for the Dutch. This could be an indication of an under-met need for pain relief on the part of the Dutch women with negative pain attitudes and little control over medication use. For the group with high labour pain acceptance and a lot of control over medication use (i.e., mean + 1SD), Belgian and Dutch women's chances of receiving pain medication are 12% and 2%, respectively. Thus, on both ends of the continua (pain acceptance and control over pain relief), Dutch women are about six times less likely than Belgians to receive pain medication. Belgian women accepting labour pain (with a normal vaginal birth) and controlling pain medication use, still have a 12% chance to get pain medication, which could indicate an over-met need.
Predicted likelihood of pain medication use for Belgium and the Netherlands.