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\begin{document}

\title{Investigating determinants for woman's choice to accept an epidural for
labour analgesia at the delivery unit of the Tamale Teaching Hospital.}



\author[1]{Thomas Anabah}%
\author[2]{Sylvanus Kampo}%
\author[3]{Aglais  Falagán}%
\affil[1]{Habana Medical Service, Tamale, Ghana}%
\affil[2]{C. K. Tedam University of Teachnology and Applied Sciences}%
\affil[3]{University for Development Studies, Tamale, Ghana}%


\vspace{-1em}



  
  \date{June 04, 2024}


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\selectlanguage{english}
\begin{abstract}
Abstract Objective: This study aimed to assess factors that influence
epidural labour analgesia acceptance or refusal at the maternity unit of
the Tamale Teaching Hospital. Design: Prospective cross-sectional
survey, Setting: This study was carried out at the maternity unit of the
Tamale Teaching Hospital Population or Sampling: We recruited 540
parturients at the maternity unit of the Tamale Teaching Hospital.
Methods: A structured questionnaire was administered to each recruited
parturients after childbirth. Main Outcome Measures: The primary
outcomes measured were awareness and factors that affected epidural
labour analgesia acceptance at the delivery unit of the Tamale Teaching
Hospital Results: The data showed that 525 (97.2 \%) of the participants
were aware of epidural labour analgesia, out of which 503 (93.1 \%)
refused to accept the epidural for labour analgesia. Age, educational
background, cultural or religious beliefs, attitudes of midwives and the
cost of the epidural labour analgesia service were observed to be some
determinants of the epidural labour analgesia use at the delivery unit
of the Tamale Teaching Hospital.%
\end{abstract}%



\sloppy


\textbf{INTRODUCTION}

However, fulfilling as it may be, childbirth is a painful experience for
many parturients {[}1, 2, 3, 4{]}. Among the various forms of labour
pain management, epidural labour analgesia is by far the gold standard
technique {[}4, 5{]}. This suggests that epidural labour analgesia is
worthwhile since it effectively relieves labour pain. Despite the many
advantages of epidural labour analgesia, it has not been fully accepted
and is not routinely practised in health facilities in developing
countries {[}6{]}. The low patronage of epidural labour analgesia
services could partially be attributed to lack of awareness, limited
resources or lack of equipment such as patient monitors, local
anaesthetics or analgesics and overwhelming patient numbers {[}6, 7{]}.

Labour analgesia is the most effective method for restoring normal
uterine activity {[}8{]}. Relieving pain during childbirth decreases
blood stress hormone release and thereby increase tissue perfusion in
healthy parturient {[}7{]}. Multiple randomized controlled trials
comparing epidural analgesia with other forms of labour pain management
have demonstrated adequate maternal pain relief and higher maternal
satisfaction among the epidural group {[}9{]}. Developed countries are
challenged with the choice and complications of epidural labour
analgesia, whereas in developing countries, the issue revolves around
awareness, acceptability, and availability of epidural labour analgesia
service {[}10{]}. In Ghana, epidural labour analgesia services are not
readily available at the maternity units. Recently, teams of medical
volunteers from the USA found problems related to understanding and the
appropriate use of pain control during childbirth at one of Ghana's
largest obstetric units. At the delivery unit of the Tamale Teaching
Hospital, we recently introduced epidural labour analgesia service and
observed very low patronage. Many parturients in Ghana go through
childbirth without labour pain control. Severe labour pain can have
deleterious effects on both the mother and the fetus {[}11{]}.
Availability and high patronage of epidural labour analgesia at the
maternity units in Ghana may help reduce maternal related complications.
This study aimed to investigate determinants of woman's choice for
epidural labour analgesia use at the delivery unit of the Tamale
Teaching Hospital.

\textbf{METHODS}

This prospective cross-sectional survey was carried out at the delivery
unit of the Tamale Teaching Hospital from June 2016 to December 2020.
The research committee of the Tamale Teaching Hospital approved the
study protocol on May 17, 2016 for the data collection. Written informed
consent was obtained from the individual woman after providing them with
adequate explanations regarding the aims of the study.

The study recruited women who came to the maternity unit of the Tamale
Teaching Hospital for childbirth. All recruited women consented to be
part of this study. We excluded women who suffered post-delivery
complications, those who were scheduled for cesarean section and all
eligible women who declined to participate in this study. A convenience
sampling technique was used to randomly select the study participants.
After obtaining written informed consent from each qualified
participant, they were asked to randomly pick confidentially prepared
slips that had either `YES' or `NO' inscribed on them. Only eligible
respondents who happened to pick slips with the inscription `YES' were
enrolled for the study. The participants were required to complete a
structured questionnaire which was developed and validated by the
authors for this study. The questionnaire was prepared in English and
had it translated and explained to respondents in their local language
where necessary. The primary outcomes measured were awareness and
factors that affected epidural labour analgesia acceptance at the
delivery unit of the Tamale Teaching Hospital.

Statistical Analysis

The sample size for this study was calculated using the equation
{[}12{]}.

\emph{Necessary Sample Size = (Z-score) \textsuperscript{2} *
StdDev*(1-StdDev) / (margin of error) \textsuperscript{2}}

95\% confidence interval (Z-score = 1.96), Standard Deviation
(\emph{StdDev = 0.5)} and margin of error = \selectlanguage{ngerman}± 3.8 or 5 \%. Therefore,
our sample size adjustment was between 400 and 700 respondents.

All statistical analyses were carried out using the Statistical Package
for Social Sciences Software (SPSS) version 20.01 (IBM Corporation,
Armonk, NY, USA). The results were presented as means, frequencies and
tables. The confidence interval was 95\% and considered statistically
significant at P \textless{} 0.05. Statistical analysis was performed
for age, educational background, occupation, religion, gestational age,
awareness and acceptance of epidural labour analgesia and reasons for
unwillingness to accept epidural labour analgesia using one-way ANOVA,
multiple comparisons by Tukey's test and logistic regression. The
student's t-test was used for statistical comparisons between two
groups.

\textbf{RESULTS}

Demographic characteristics of respondents

A total of 543 respondents were recruited for this study. Data for three
were excluded from the analysis because they later refused to
participate in this study. Therefore, data for 540 respondents were
included in the analysis.

The data analysed showed that 477 (88.3 \%) of the respondents that were
recruited for this study were within the age range of 25-34 years old,
27 (5.0 \%) were within the age bracket of 15-24, whereas 36 (6.7 \%)
were within 35-45 years old \textbf{(Table 1)} .~ We assessed the
educational background of the respondents and realized that 37 (6.9 \%)
attained tertiary education, 205 (37.9 \%) had high school education,
101 (18.7 \%) had primary school education, whereas 197 (36.5 \%) had no
formal education \textbf{(Table 1)} . The data also showed that 477
(88.3 \%) of the respondents had their gestational age between 36-40
weeks old and 63 (11.7 \%) were above 40 weeks of gestation
\textbf{(Table 1).~}

Awareness of epidural labour analgesia service at the delivery unit of
the Tamale Teaching Hospital.

To investigate the causes of low patronage of the epidural labour
analgesia service at the delivery unit of the Tamale Teaching Hospital,
we first assessed respondent's awareness of the epidural labour
analgesia service available at the delivery unit of the Tamale Teaching
Hospital. We asked the respondents to know if they were aware that
labour pain could be managed during childbirth. The data showed that 339
(62.8\%) of the respondents were not aware that labour pain could be
managed during childbirth, 108 (20.0 \%) of them indicated that labour
pain could not be managed, and 93 (17.2 \%) of them said labour pain
could be managed (\textbf{Table 2)} . We again assessed respondent's
awareness of the various options of labour analgesia services available
at the delivery unit of the Tamale Teaching Hospital. We observed that 2
(0.4 \%) of the respondents were informed of IV/IM injections
(analgesic), 527 (97.6 \%) were informed of epidural labour analgesia
services, 1 (0.2 \%) was informed of deep breathing exercise, while 7
(1.3 \%) were informed of all the options available at the delivery unit
of the Tamale Teaching Hospital \textbf{(Table 2)} . The data also
revealed that only 1 (0.2 \%) of the respondents have ever received
epidural labour analgesia service for childbirth \textbf{(Table 2).}

Determinants of epidural labour analgesia acceptance at the delivery
unit of the Tamale Teaching Hospital during childbirth.

To investigate whether labour pain intensity influences the decision of
women to accept labour analgesia or not, we first assessed pain
experienced during childbirth. It was revealed that 172 (38.1 \%)
suffered severe pain, 359 (66.5 \%) experienced excruciating pain, while
9 (1.7 \%) reported moderate pain \textbf{(Table 3)} . Fear of labour
pain was assessed. We observed that 456 (84.4 \%) expressed very much
fear for pain, 66 (12.2 \%) expressed much fear for pain, 17 (3.2 \%)
indicated moderate fear for pain and only 1 (0.2\%) expressed mild fear
for pain \textbf{(Table 3)} .~Respondents were asked if they would like
to deliver babies without experiencing much pain. 503 (91.5 \%)
indicated that they would very much like to deliver babies without
suffering from severe labour pain\textbf{(Table 3)} .

We assessed the individual respondents to know if age or educational
background could influence epidural labour analgesia use. We observed
that 233 (43.1 \%), 210 (38.9 \%) and 35 (6.5 \%) of the respondents
within the age range of 25-34 and 35-45years old who experienced severe
or excruciating labour pain respectively refused to consider epidural
labour analgesia services at the delivery unit \textbf{(Table 4)} .
Conversely, 11 (2.0 \%) and 15 (2.8 \%) of the respondents within the
age range of 25-34 and 35-45 years old who experienced severe or
excruciating labour pain respectively would like to receive the epidural
labour analgesia service during childbirth \textbf{(Table 4)} . The data
suggested that 167 (30.9 \%) and 29 (5.4 \%) who had no formal education
and experienced severe or excruciating labour pain respectively refused
to accept epidural labour analgesia for childbirth. Also, 79 (14.6 \%)
and 18 (3.3 \%) who had primary school education and experienced severe
or excruciating labour pain respectively refused to receive an epidural
for labour analgesia, whereas 8 (1.5 \%) and 188 (34.8 \%) who had high
school education and complained of severe or excruciating pain
respectively also refused to accept epidural labour analgesia
\textbf{(Table 4)} .

The univariate ordinal logistic regression model is presented in Table 5
to reflect the associations between potential covariates and labour pain
level. The data showed that age, educational background, and religion
were not associated factors to predict labour pain experienced by a
patient (categories: `Moderate pain', `Severe pain' `Excruciating
pain').

We asked respondents to know why they would not accept epidural for
labour analgesia during childbirth. 63 (11.7 \%) of the respondents
indicated that they were been advised by their midwives not to accept
the epidural labour analgesia, whereas 112 (20.7 \%) of them refused to
accept epidural labour analgesia to be identified as a true mother and
have much love for their babies (\textbf{Table 6)} .

\textbf{DISCUSSION~~~~}

Main findings

This study aimed to test the hypothesis that fear, misconceptions and
lack of awareness lead to refusal of epidural for labour analgesia. The
following principal observations emerged; parturient who reported at the
maternity unit of the Tamale Teaching Hospital showed awareness of
epidural labour analgesia services, however, many refused to receive an
epidural for labour analgesia on our labour and delivery service. The
educational background, age, cultural or religious beliefs and attitude
of some midwives were observed to be factors that influenced the refusal
of epidural for labour analgesia.

Strengths and limitations

In brief, the results from this study and related literature reviewed
consistently showed that there is generally very low patronage of
epidural labour analgesia among parturients in developing countries with
age, educational background, cultural or religious beliefs, cost of
service and attitude of some midwives arguably being the most predictive
of acceptance or refusal of the epidural for labour analgesia. Language
barrier and failure to explore some effects of socio-economic background
on the awareness and acceptance of labour analgesia services were the
limitations encountered during this study. There is a need for
healthcare providers to initiate education on the epidural for labour
analgesia to reduce fear and misconceptions to increase patronage.

Interpretation

Studies have demonstrated that parturients who accept to receive an
epidural for labour analgesia are more likely to have attended
ante-natal care or read some reference books {[}13{]}. Also, factors
within parturients may influence whether they receive an epidural for
labour analgesia. Other reasons such as anaesthesia care providers not
accessible in a timely fashion, friends and family members discouraging
the parturient, and previous experiences may impact future choices
{[}14{]}. Policies guiding practice at the various hospitals may also
prevent a parturient from receiving an epidural for labour analgesia.

Childbirth experience in Ghana ranges from agony to ecstasy. It is
described as a multidimensional experience that includes intense
physical, emotional, psychological, developmental, social, cultural and
spiritual components. It differs in meaning and quality for each
labouring woman and changes as labour progresses. Labour pain is ranked
among the most intense pains recorded {[}1{]}. Many women in Ghana rate
labour pain as severe, while a few reports little or no pain {[}2{]}.
Each woman's labour pain is unique to her. The amount of labour pain one
woman may feel will differ from that felt by another woman. It depends
on factors such as level of pain tolerance, the size, and position of
the baby, the strength of uterine contractions and prior birth
experiences {[}3{]}. The findings of this study suggested that many
parturients experience severe or excruciating pain in Ghana during
childbirth and may need pain relief \textbf{(Table 3)} .~ Satisfaction
with childbirth experience is closely related to less pain during
labour. Numerous strategies, both pharmacologic and non-pharmacologic,
have been used as a treatment for labour pain relief {[}4{]}. Shidhaye
et al reported that many pregnant women in developing countries are
mostly not aware of labour analgesia services in their hospital. Lack of
awareness or the availability of labour analgesia services in many
hospitals of poor resource countries may be the prime cause of low
patronage {[}15{]}. Olayemi \emph{et al} {[}11{]} attributed low
awareness of epidural for labour analgesia to the fact that healthcare
providers themselves are either ignorant of pain relief in labour or
consider it a less priority in educating women. Conversely, the present
study showed awareness of epidural for labour analgesia among
parturients at the maternity unit of the Tamale Teaching Hospital. A
survey demonstrated that out of 76 \% of pregnant women who showed some
awareness of epidural labour analgesia service, only 19 \% of them
patronized it during childbirth, while the majority refused to accept it
due to fears and misconceptions {[}16{]}. Another literature showed a
disparity of epidural use that existed along ethnic and racial lines,
with Africa American less likely than whites to receive an epidural for
labour analgesia. Fear, naturalism and family influence were some
reasons that led to the refusal of epidural for labour analgesia by the
Africa Americans {[}17, 18{]}. Similarly, the findings of this study
showed that despite the high awareness of epidural labour analgesia
service among parturients at the delivery unit, many still refused for
it to be administered to them.~ Age, educational background, cultural or
religious beliefs, cost of service, and some attitudes of midwives among
others were factors that led to the refusal of the epidural for labour
analgesia at the delivery unit of the Tamale Teaching Hospital. Hanem et
al. and Minhas et al. {[}19, 15{]} reported a correlation between
educational background and knowledge on labour analgesia acceptance.
Although our current study did not evaluate the socioeconomic background
of respondents, we observed that women with non-formal education were
less likely to accept epidural for labour analgesia. They have bound to
the cultural or religious beliefs that labour is a natural process and
does not need any intervention in the form of pain management and that
husbands are the heads of the family and therefore should give their
consent before they accept labour analgesia. These findings were not out
of place, more so in a setting where traditional and religious practices
are prevalent.~This may have a great influence on the decision to refuse
epidural labour analgesia.~An in-depth understanding of these factors
observed may better enable healthcare providers to assist parturients in
the decision-making process at the delivery unit regarding epidural for
labour analgesia.

\textbf{CONCLUSION}

Our survey echoes that a significant number of parturients at the
delivery unit of the Tamale Teaching Hospital were well informed of
epidural labour analgesia service. Surprisingly, very few showed
interested in the epidural labour analgesia service. We identified age,
educational background, cultural or religious beliefs, cost of the
epidural labour analgesia service and attitude of some midwives to
influence the patronage. The findings of this study have concepts for
obstetric and anaesthesia education and practice. Healthcare providers
have the responsibility to publicize comprehensive and evidence-based
data to the public. Parturients, family members, friends and spouses
should be educated on the benefits and risks of epidural for labour
analgesia before admission to the delivery unit. An in-depth
understanding of the factors observed in this study may well qualify
healthcare workers to help in the decision-making process.

\textbf{DECLARATION}

Author contributions

All authors contributed to the study conception and design. Material
preparation, data collection, and analysis were performed by Thomas
Winsum Anabah, Sylvanus Kampo, Aglais Arredondo Falagán. The first draft
of the manuscript was written by Thomas Winsum Anabah and all authors
commented on previous versions of the manuscript. All authors read and
approved the final manuscript.

Funding

No funding was obtained for this study

Acknowledgements

We thank the Chief Executive Officer (CEO) of the Tamale Teaching
Hospital for the support he gave us during this study. We also wish to
thank all the staff of the department of obstetrics and Gynecology for
making available all the necessary materials needed for this study.

Ethics approval

The research committee of the Tamale Teaching Hospital approved the
study protocol on May 17, 2016 for the data collection\textbf{.}

Availability of data and materials

The datasets generated and/or analyzed during the current study are not
publicly available due to patient confidentiality but are available from
the corresponding author on reasonable request.

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\textbf{Table Legends}

Table 1. Demographic characteristics of respondents

Table 2. Distribution of respondents on the bases of awareness of labour
analgesia service at the delivery unit of the Tamale Teaching Hospital

Table 3. Responses to questions on labour pain experienced

Table 4. Distribution of respondents based on labour pain experienced,
age, educational background and religion regarding the refusal of
epidural for labour analgesia. Data were statistically significant at P
\textless{} 0.05

Table 5. Univariate ordinal logistic regression to predict pain level of
patient regarding age, educational background and religion. Data were
statistically significant at P \textless{} 0.05

Table 6. Responses to the question, why wouldn't you consider epidural
for labour analgesia?

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