Key words
birth - pregnancy - delivery - pain - labour - labour pain
Schlüsselwörter
Geburt - Schwangerschaft - Entbindung - Schmerz - Wehen - Geburtsschmerz
Introduction
Epidural analgesia is the gold standard for pain management during childbirth. Regional
analgesic procedures are used in around 20 to 30 % of all births in Germany today
[1]). In the process of tissue damage, pain perception and pain expression, psychological
processes are activated that are influenced by cognitive and emotional elements. Biological,
social and cultural-ethnic factors contribute to further modification of this “pain
cascade”. Pain perception and response to pain vary interculturally [2]. The fact that pregnant immigrants undergo epidural analgesia significantly less
often than non-immigrants has also been reported in the United States [3], [4], [5]), Canada [6] and Spain [7]. Studies focusing particularly on the use of epidural analgesia by immigrant women
with a Turkish background were conducted in Sweden [8], Austria [9] and Germany [10]. There are a variety of explanations for this. One study conducted in the United
States, which investigated the lower rate of epidural analgesia use in Hispanic women
demonstrated a correlation with the womenʼs linguistic proficiency [11]. This result could point to a language barrier when the patient requests epidural
analgesia or to communication gaps when presenting information or during patient consent.
A qualitative study from the United States concluded that Hispanic womenʼs decision
not to use epidural analgesia was primarily due to misconceptions about the intervention
and its risks [12]. Furthermore, in addition to the already mentioned sociocultural differences in
pain perception [13], the partnerʼs attitude [14], the attitude of the medical personnel towards immigrant women [15], the womenʼs educational level [3], [6] and religious background (secular vs. religious) [16] have also been discussed as influencing factors.
In Germanyʼs currently largest study on perinatal health and migration, significant
differences were also observed in the use of epidural analgesia and combined spinal-epidural
anaesthesia (together referred to as “epidural analgesia” below) among immigrant women
of Turkish origin and non-immigrant women. In the group of women with vaginal delivery,
epidural analgesia was used in 28.2 % of immigrant women of Turkish origin and in
44.4 % of German women (p < 0.001) [17]. There are no indications, either in clinical routine or in the published literature,
that women of Turkish origin present to the labour ward at a too advanced stage of
labour so that the use of epidural analgesia is precluded.
Based on the available research results, it is only possible to speculate about the
reasons for the significant differences in the rate of epidural analgesia use among
pregnant women of Turkish origin and non-immigrant women. The study presented here
aimed to identify possible reasons on the part of the women for the different epidural
analgesia rates. To this end, the following questions were raised: Do attitudes towards
epidural analgesia differ between women of Turkish origin and non-immigrant women?
Which factors influence the attitudes towards epidural analgesia?
Methods
Since quantitative studies have not provided any answers to this question to date,
we elected to use an explorative-qualitative approach that allows attitudes and their
logical framework to be elucidated.
Inclusion and exclusion criteria
The inclusion criteria were as follows: pregnant women at least 18 years old who consented
to complete an interview during antenatal care, at the admissions area of the delivery
room and on an obstetrics ward. The exclusion criteria were as follows: women in an
advanced stage of labour or those assessed by the personnel as being in a physically
or emotionally difficult situation.
Interviews
The interviews aimed to ascertain whether the observed differences in the epidural
rates of the immigrant women of Turkish origin and those of non-immigrant women were
based on differences in attitude. To this end, after their consent was obtained, the
women were interviewed at a Berlin hospital. The interviews were designed as focused
(semi-structured) interviews and were tested in a pretest and subsequently modified
slightly [18]. Additionally, a brief questionnaire was used to obtain data on the pregnancy and
on sociodemographic and immigration background. In the interviews, the women were
asked to describe their attitudes towards epidural analgesia during childbirth as
well as about the causal framework underlying the attitude. All of the documents used
were translated into Turkish by qualified translators. An interpreter was used as
needed to simultaneously interpret the interview. The interviews were recorded on
a dictaphone. The field notes on the interview context (setting, brief description
of the interviewee, rapport, highlights, difficult moments, surprises) were written
up in condensed form. All of the interviews were conducted by 1 person (I. P.). After
transferring the audio file from the dictaphone to a digital text document, the audio
file was deleted from the dictaphone. The data was then pseudonymised. The interviews
were transcribed according to the recommendations of Kuckartz et al. (2008) [19] and qualitative content analysis was performed based on the design proposed by Mayring
(2002) [20]. Categorisation was undertaken inductively, i.e. using the material provided by
the interviews. Within the group of women of Turkish origin the comparison was broken
down in more detail with regard to immigrant generation (first vs. second/third),
educational level (none/primary vs. secondary/university degree) and parity (nulliparous
vs. all others) when appropriate. Due to the high correlation between immigrant generation
and German proficiency, no comparisons were undertaken between women with various
levels of German proficiency.
The interviews were conducted on 12 days from June to August 2015. Among the women
of Turkish origin, 9 were interviewed with an interpreter because they preferred the
interview in Turkish. Care was taken to ensure that the interviews did not prolong
waiting time or delay planned examinations or consultations. The interviewees were
selected randomly. Only 25 % of the women who were approached did not agree to be
interviewed.
When planning the study, it was assumed that around 50 interviews per group would
be required to obtain sufficient information. However, among the non-immigrant women,
a content-related “saturation” was achieved after 10 interviews, so that interviews
of this subgroup were discontinued after the 11th interview. In the interviews with
the immigrant women of Turkish origin, content-related “saturation” was achieved after
19 interviews.
Due to the interpreting required in some cases, the interviews with the women of Turkish
origin took longer than the interviews with the non-immigrant women (average 21 minutes
compared to 13 minutes, respectively).
Statistics and vote of the Ethics Committee
The descriptive statistical analysis of the brief questionnaire was undertaken using
the SPSS statistics software (Version 23.0, IBM). A positive vote of the Ethics Committee
is in place for the overall project, the German Research Council (DFG)-funded study
“Perinatal Health and Migration in Berlin” (FKZ EA1/235/08). The project presented
here was separately approved by the Charité Data Protection Officer.
Results
In total, after the interviews 552 minutes of audio material was available, with transcription
of the material requiring around 64 hours altogether.
The interviewees were 30 pregnant women, 19 of them women of Turkish origin and 11
non-immigrant women. The sociodemographic data are presented in [Table 1].
Table 1 Sociodemographic data on the interviewees (n = 30).
|
|
All (n = 30)
|
Immigrant women of Turkish origin (n = 19)
|
Non-immigrant women (n = 11)
|
|
Age (years)
|
|
|
|
|
|
29 (21–41)
|
29 (21–41)
|
29 (25–37)
|
|
Gestational age (weeks)
|
|
|
|
|
|
34.7 (25–41)
|
34.1 (25–41)
|
35.8 (30–40)
|
|
Parity
|
|
|
|
|
|
33.2 (9)
|
42 (8)
|
9.1 (1)
|
|
|
66.8 (21)
|
58.0 (11)
|
90.9 (10)
|
|
Secondary school completion
|
|
|
|
|
|
20 (6)
|
31.6 (6)
|
0
|
|
|
6.7 (2)
|
10.5 (2)
|
0
|
|
|
30 (9)
|
26.3 (5)
|
36.4 (4)
|
|
|
43.3 (13)
|
31.6 (6)
|
63.7 (7)
|
|
German proficiency (self-assessment)
|
|
|
|
|
|
|
52.6 (10)
|
|
|
|
|
15.8 (3)
|
|
|
|
|
5.3 (1)
|
|
|
|
|
26.3 (5)
|
|
|
Resident in Germany
|
|
|
|
|
|
|
52.6 (10)
|
|
|
|
|
55.6 (5)
|
|
|
|
|
44.4 (4)
|
|
|
Partner
|
|
|
|
|
|
93.3 (28)
|
100 (19)
|
81.8 (9)
|
|
|
6.7 (2)
|
0
|
18.2 (2)
|
|
Religion
|
|
|
|
|
|
26.6 (8)
|
5.3 (1)
|
63.6 (7)
|
|
|
60 (18)
|
94.7 (18)
|
0
|
|
|
13.3 (4)
|
0
|
36.4 (4)
|
The content analysis encompassed 18 interviews of immigrant women of Turkish origin
and 10 interviews of non-immigrant women.
In the brief questionnaire, the interviewees were asked to name the most important
people for them in the event of questions on pregnancy and childbirth. For the women
of Turkish origin, this was the obstetrician, followed by the midwife and the womanʼs
mother. For the non-immigrant women, the most important people were the obstetrician,
the midwife and the partner.
In the section below, the results of the interviews with respect to labour pain (feelings
and meaning), attitudes towards and sources of information on epidural analgesia and
the role of the partner are presented.
Labour pain
Feelings arising at the thought of labour pain included a) fear, b) fear mixed with
confidence, c) serenity and d) other (e.g. uncertainty). These items were mentioned
equally often in both groups. The women were also asked, “Do you think labour pain is meaningful?” Non-immigrant women responded more frequently that they did not think that labour
pain is meaningful (5 out of 9 vs. 1 out of 12). However, they were often of the opinion
that “childbirth without pain is not possible” or that pain belongs to childbirth as a “necessary evil”. Immigrant women of Turkish origin more frequently said that the pain was meaningful
or had explanatory models for it (11 out of 12), such as the separation or detachment
of the child: “Yes, itʼs natural for it to be that way, because a child becomes detached from the
woman. Thatʼs way it has to be (…) connected with pain. A part becomes separated from
the body”. (Inter. 28, Turkish origin) and “Labour pain as a signal”. In this respect there
were no differences between the immigrant generations.
Attitudes towards epidural analgesia
The responses to the question “What is your position regarding epidural analgesia?” were categorised into a) agreement, b) agreement if necessary – defined as both the
necessity from the perspective of the personnel and the necessity from the perspective
of the pregnant woman – and 3) rejection. There were significant differences in the
acceptance of epidural analgesia from the beginning. Non-immigrant women had a much
more positive attitude towards epidural analgesia, which is reflected by the following
statement: “To be honest, if itʼs possible to have something like that, why not use it?” (Inter. 22, non-immigrant). Women of Turkish origin expressed rejection more often:
“Even if itʼs unbearable, I wouldnʼt have the injection”. (Inter. 27, Turkish origin) The results were the same for women of different parity.
Multiparous women rejected the use of epidural analgesia as often as nulliparous women
(4 out of 9 vs. 3 out of 8). However, there were differences in the attitudes towards
epidural analgesia with respect to immigrant generations. First-generation immigrant
women more frequently categorically rejected epidural analgesia (6 out of 8 vs. 1
out of 9), while second-generation immigrant women more frequently considered epidural
analgesia to be an option (“if needed”) (6 out of 9 vs. 0 out of 8).
The immigrant women of Turkish origin frequently justified their (negative) attitudes
with their concerns about the placement of the epidural analgesia (4 out of 16 vs.
1 out of 9) and about complications (8 out of 16 vs. 1 out of 9): “Iʼm afraid of it, because I have friends who have had back pain ever since they had
the epidural”. (Inter. 29, Turkish origin). Both women with lower education levels (secondary school
not completed, primary school) and those with higher education levels (Realschule,
school-leaving exam [Abitur], university studies) had these concerns (3 out of 6 vs.
5 out of 10). The information and consent consultation, the scope of the information
and consent sheet and the requirement for a signature all contributed to fears with
respect to the risks of epidural analgesia: “But then I wonder why you have to give your signature while you are in labour. […].
Three or four pages, Iʼve heard. You donʼt have to give your signature for other pain
relievers, like laughing gas or whatever”. (Inter. 17, Turkish origin)
The opinion that vaginal delivery with epidural analgesia no longer constitutes natural
childbirth was expressed only by pregnant women of Turkish origin (5 out of 16 vs.
0 out of 9): “For me, when it comes down to it, natural childbirth means doing it without an epidural”. (Inter. 17, Turkish origin).
Sources of information on epidural analgesia
Equal numbers of immigrant and non-immigrant women stated that their sources of information
on epidural analgesia were books/internet and a previous childbirth. However, differences
were also observed: Immigrant women of Turkish origin obtained their information on
epidural analgesia more frequently from their social environment (5 out of 14 vs.
0 out of 7) and from friends and relatives (4 out of 14 vs. 0 out of 7): “In our community, they say that youʼll have back pain later or permanent damage or
[…] you even have the risk that you […] will be paralysed …” (Inter. 13, Turkish origin). In the group of pregnant women of Turkish origin, this
was especially true for nulliparous women compared to multiparous women (6 out of
6 vs. 3 out of 8). As expected, the latter group obtained information on epidural
analgesia frequently through a previous childbirth. Non-immigrant women more frequently
used other sources to obtain information on epidural analgesia: obstetrician, antenatal
course, job-related health care setting, television (6 out of 7 vs. 2 out of 14).
Role of the partner
The interviewees were asked about the partnerʼs attitude towards epidural analgesia
and the role of his opinion in electing to use epidural analgesia or not. The majority
of both groups of women reported that they took this decision themselves, as reflected
by the following statements: “He respects my decision. He says he will adjust to it”. (Inter. 6, Turkish origin) and “He supports me in the way I decide and wouldnʼt have much chance to disagree”. (Inter. 16, non-immigrant)
[Table 2] presents a summary of the pregnant womenʼs attitudes and opinions and presents differences
and commonalities between the 2 surveyed groups.
Table 2 Summary and overview of the interview statements.
|
Immigrants of Turkish origin
|
Non-immigrant women
|
|
Commonalities
|
-
There are no differences among the groups with respect to feelings at the thought
of labour pain.
-
The pregnant women in both groups reported with equal frequency that they obtained
information on epidural analgesia from the internet/books or from a previous childbirth,
if applicable.
-
The majority of the women take the decision for or against epidural analgesia without
regard for their partnerʼs attitude.
|
|
Differences
|
|
Significance of labour pain
|
|
|
|
|
Attitudes towards epidural analgesia
|
|
|
|
|
Reasons for rejecting epidural analgesia
|
-
There are more often concerns about the procedure and the complications (paralysis,
back pain).
-
For one-third of the women, a vaginal delivery with epidural analgesia is no longer
a natural childbirth.
|
|
|
Sources of information on epidural analgesia
|
|
|
|
Discussion
In principle, all women should have all options for pain management during labour
available to them after they have received adequate information. There should be no
discrepancies in pain relief provision either on the part of the hospital or due to
the patientʼs social or insurance status. Considering that adequate options are available
for pain-free childbirth, the question arises as to why some women elect to use these
options while other women choose to tolerate the labour pain. The interview-based
qualitative study presented here aimed to identify factors behind the womenʼs decision
to agree to epidural analgesia or reject it. A qualitative study is particularly well-suited
for investigating this question.
There were significant differences in the attitudes of the 2 interviewed groups of
women towards epidural analgesia. In contrast to the non-immigrant women, the majority
of the pregnant women of Turkish origin categorically rejected the use of epidural
analgesia. The study identified 3 main reasons for this:
-
concerns regarding the direct placement of epidural analgesia
-
concerns regarding long-term sequelae (back pain, paralysis) and
-
the desire for natural childbirth.
Identical concerns were expressed by Hispanic women in a study performed in the United
States [12]. In another study conducted in the United States, 54 % of the women surveyed stated
that they rejected the use of epidural analgesia due to their concern about possible
risks to their own health. In this population, Hispanic women constituted the largest
ethnicity and also constituted the largest group that did not use epidural analgesia
[14].
The desire to experience an unmedicated birth as grounds for rejecting epidural analgesia
has also been reported in other studies [14], [21], [22]. The pregnant women of Turkish origin surveyed obtained information about epidural
analgesia from their social environment (relatives, neighbours, friends, acquaintances)
more frequently than non-immigrants. While the women were not asked about their current
state of knowledge about epidural analgesia, similar to a study performed in the United
States, statements such as “Thatʼs what I heard” or “Thatʼs what they say” suggest that the rejection of epidural analgesia is not based on an informed decision
and may actually be based on misunderstandings [12]. Another study performed in the United States described a similarly diverse range
of sources of information about epidural analgesia. However, there was no correlation
between the source of information and the actual use of epidural analgesia [14].
Strengths of the study
-
This study offers approaches for explaining the lower rate of use of epidural analgesia
among immigrant women of Turkish origin compared to non-immigrants, as they were documented
both in an analysis of data from the 1990s [23] and of current data [17] in Berlin. The results can most likely also be transferred to pregnant women of
Turkish origin in Austria, where a lower rate of use of epidural analgesia has also
been reported [9].
-
The explorative-qualitative methodology allows to identify differences in the attitudes
of the 2 groups of women.
-
Using an interpreter allowed to include and evaluate the attitudes of women with limited
German proficiency.
-
The study was conducted with 1 method, at 1 location and by 1 (female) interviewer.
Therefore there is no interobserver bias.
Limitations
This study considered only the womenʼs perspective. Other possible reasons, such as
the attitude of the obstetric personnel towards the two groups of women or towards
the intervention were not investigated.
Conclusions
-
Based on the results of this study, it can be concluded that the attitudes towards
epidural analgesia among pregnant women of Turkish origin are based on misconception
and fear of complications. Since obstetricians and midwives are among the most important
persons for women of Turkish origin, members of these 2 professions could make an
effort during their antenatal care to mitigate existing fears of long-term sequelae
due to epidural analgesia. For women whose German proficiency is insufficient, it
would be a good idea to offer printed materials in Turkish on the subject. For illiterate
patients, providing a professional interpreter and/or care by German- and Turkish-speaking
obstetricians and midwives during antenatal care would be desirable. Women making
an informed decision can also elect not to have epidural analgesia, for example, if
they wish to experience an unmedicated birth. This decision should be respected whether
or not the woman is an immigrant.
-
For non-immigrant women, the study results show that the higher rate of epidural analgesia
use corresponds with their attitudes and desires.
