We have defined sociodemographic factors associated with the use of labor epidural pain relief at a tertiary center in Hanoi, Vietnam. Patients who predictably decline epidural analgesia in labor may benefit from increased educational outreach about risks and benefits.(5) Increased epidural utilization during labor has correlated with lower rates of general anesthesia for cesarean delivery, and a reduction in litigation related to aspiration morbidity and mortality in obstetric patients. (6–8) Increasing epidural utilization in developing countries may enhance the safety of obstetric anesthesia care.
Our finding that women with health insurance and higher education levels are more likely to request epidural analgesia during labor are consistent with a previous United States study.(9) A study of sociodemographic and obstetric factors associated with labor epidural analgesia use among 5,350 women in Canada revealed higher rates of epidural analgesia use in women with higher income and higher education, and lower rates in those who were of ethnic minority group, unemployed, or living in rural areas. (10)
In the current study, parturients in both groups, irrespective of epidural use, expressed concern about side effects of epidural analgesia during labor (64.7% vs 65.7% respectively). In Vietnam, there are misconceptions and fear about the epidural technique and complications including neurological injury, back pain, and headache, and ineffective pain relief. Similar misconceptions were reported among a Canadian cohort; 15.9% of women reported concern that epidural analgesia can result in paraplegia. (10) In addition, a large proportion of women surveyed in Pakistan, Karachi and Hong Kong expressed concern that epidural analgesia may result in permanent backache or cause muscle weakness in the lower extremities during labor. (11–13) Access to health education on the availability and benefits of epidural analgesia in labor increases utilization rate. (14) The current study adds to this body of literature suggesting that a lack of knowledge about the safety and anticipated side effects of the epidural technique itself plays a role in discouraging use of labor epidural analgesia. Women may benefit from focused educational outreach as part of their prenatal care, so that they can make an informed choice with the most accurate information about risks and benefits.
Through multiple logistic regression analysis, we have determined that patient factors associated with request for epidural pain relief were age greater than 35 years, multiparity, high income, high level of education, living in urban areas, and the profession of homemaker or office worker. These findings are consistent with previous reports; an analysis of labor epidural utilization among 8229 deliveries at five United States hospitals revealed an association with increased maternal age, Caucasian ethnicity and private insurance coverage. (15) Our finding that multiparity was also associated with epidural analgesia request may reflect prior delivery experience, with or without analgesia. We did not evaluate whether multiparous patients utilized epidural pain relief for previous deliveries.
Another factor associated with epidural analgesia use in our study was a graduate level of education. Women with higher levels of education requested epidural analgesia more frequently (odds ratio 4.02 for women with a college-level education compare to primary school only). This finding is consistent with prior reports. (9, 10, 15) A United States report on rate of labor epidural analgesia was 22.6% in women with < 8th -grade education compared to 48.1% among those who finished high school. (16) Furthermore, a study in Israel showed that the epidural request rate was only 4.9% in women with < 5 years of schooling, compared to w 84% of women who had higher levels of education. (17) Collectively, these data suggest that pregnant women with higher education levels may have either better comprehension of physiological mechanisms of labor pain, more access to acquire health information about the methods of pain relief during labor and its risks and benefits, or both. Education about labor epidural analgesia may promote better patient decision-making. (17) In addition, the role of the partner or spouse has been reported as a key factor affecting epidural use. (9) While we did not evaluate this potential influence in our study, prenatal courses to inform both patient and spouse may be beneficial.
Parturients with low income and living in rural sites requested labor epidural pain relief less frequently than high-income women from urban regions. A potential barrier to epidural utilization is lack of insurance coverage for this procedure. In our cohort, 31.4% of women who did not receive epidural analgesia during labor lacked insurance coverage, while 24.2% of women who requested epidurals lacked insurance coverage. Socioeconomic inequality and its impact on in health care delivery has been described, (18–21) and is a concern in Vietnam. (22) Under-utilization of labor epidural pain relief may not only serve as a marker for health care disparity but may also provide an outcome metric for targeted efforts to lower disparity. Vietnamese women may have a cultural perception that labor pain is natural, and a mindset that pain in childbirth should be tolerated rather than eliminated. Satisfaction in childbirth in the Vietnamese population has not been reported, but a European report suggests that a perception of personal control from labor pain relief may increase satisfaction. (23) There may be added benefit for visiting health providers and prenatal health course instructors to focus on patients who may predictably have a low rate of epidural utilization, to be sure there is appropriate access to health information that is tailored for patient understanding and access to care.
Our study is not without limitations. First, the postpartum survey was performed 24 hours after delivery, and some parturients may not have recalled the details related to their birthing experience. Second, because the research was conducted only at the Hanoi Obstetrics and Gynecology Hospital, which is the leading obstetric hospital in Hanoi and a teaching facility, the external validity may be limited and not representative of parturients who live further from a resourced center in Vietnam. For example, as has been reported that many Vietnamese women who delivery in non-university public hospitals or small maternity units forego epidural analgesia because there is no available anesthesiologist.
In summary, we have defined factors associated with parturient request for labor epidural analgesia at a tertiary teaching hospital in Hanoi, Vietnam. Increasing the rate of labor epidural analgesia is a way to enhance maternal safety through avoidance of general anesthesia and associated aspiration risk. Resources applied for educational outreach to encourage health literacy can be directed toward patients who are multiparous, older, less educated, have lower income and education, and are from rural areas.