The current study aimed to develop and validate a questionnaire that measures a pregnant woman’s attitude towards labor pain relief. The LPRAQ-p was developed based on the outcome of focus group interviews. Subsequent validation analyses using EFA and CFA showed that the six-item LPRAQ-p has good psychometric properties: a two-factor structure with acceptable to good internal consistency and excellent model fit.
A Cronbach’s alpha between .60 and .70 indicates an acceptable level of reliability and a Cronbach’s alpha between .70 and .80 a good level (35). Both the women’s environment subscale and the total LPRAQ-p have good reliability scores (all above .75), while the social environment subscale has acceptable reliability scores (above .60). It must be noted that a recommended Cronbach’s alpha of ≥ .70 has been described as well (24). However, Cronbach’s alpha is very sensitive to the number of items and especially in an ultra-short scale this cut-off of .70 can be regarded as arbitrary (36).
Results showed that the LPRAQ-p consists of two subscales, including a women’s perception subscale. Two items of this subscale refer to beliefs a woman can have towards the outcome of receiving EA: the belief that she feels more self-confident during labor (item 9) and performs much better (item 10) with EA. Remarkably, the confidence women have in their ability to cope with labor is of major importance to how they perceive pain during labor (37, 38). This self-efficacy for labor has been related to decreased pain perception during labor (39, 40). This could imply that a woman’s belief of not being able to cope with labor without EA involves an enhanced pain perception during labor, which increases the willingness for request of EA even further. Indeed, confidence in the ability to cope with labor has been related to decreased pain medication use during labor (41). The third item of the women’s perception subscale comprises a general belief towards pain in labor (item 12), and addresses how women anticipate labor pain. Women can approach labor as a medical event with risks or as a normal and natural process (42). When viewing labor as a medical event, it is more likely that women wish to eradicate the pain with EA. However, when women view labor as a natural process they are more willing to embrace the pain, which enhances the coping ability (43-45). An interesting paradox in these women is that despite its challenging nature, they need the pain because it facilitates birth and therefore the joy and happiness of meeting their baby (46).
The second subscale of the LPRAQ-p is the social environment subscale, containing two partner items and one item concerning family and friends. Item 8 involves the influence of the anticipated partner’s needs during labor. For a partner, the major challenge during labor is to see his loved one suffering from pain (47), which can make the partner feel frustrated and helpless (48). However, being helpful is what a woman in labor needs most from her partner (49). Receiving EA has been associated with decreased partner anxiety and stress and an increased partner support and helpfulness during labor (50). This implies that a woman may have greater willingness for request of pain relief medication during labor for both her partner’s wellbeing and her own need of support. The other two items of the social environment subscale refer to influences of the attitudes towards labor pain relief of respectively the partner (item 11), and family and friends (item 13). Interestingly, a previous study found that a partner’s preference for EA was related to receiving EA, while a partner’s preference for labor without EA had no effect (16). In addition, being encouraged by family and friends to ask for EA was reported as a reason that pregnant women had greater willingness for request of pain relief medication during labor (16). Moreover, family members and friends with children can influence childbirth expectations by providing stories about their own childbirth experiences (42, 51). Especially the stories regarding bad experiences may enhance a woman’s willingness for request of pain relief medication during labor (42).
With regard to concurrent validity, the LPRAQ-p and its subscales were significantly correlated with symptoms of depression, pregnancy-specific distress and worries about delivery. Moreover, regarding construct validity all our hypotheses were confirmed. Women with elevated levels of depression and pregnancy-specific distress symptoms showed significantly higher scores on the LPRAQ-p. Our multiple linear regression analysis showed that pregnancy-specific distress symptoms predicted greater willingness for request of pain relief medication during labor, controlled for depression symptoms, age, level of education and parity. These findings correspond to previous studies reporting an association between antenatal fear of childbirth and request for labor pain relief (12-14). Fear of childbirth has been related to fear of pain (52) and lower childbirth self-efficacy (53), and both seem to be important factors in a woman’s attitude towards labor pain relief. This also applies to negative experiences provided by others, which has been related to fear of childbirth as well (54). Furthermore, a link between fear of childbirth and negative mood has been reported (54), which may explain our results regarding depression symptoms. Moreover, depression has been related to expectations for negative outcomes in general (18, 19). It could be speculated that women with depression symptoms are more likely to approach labor as a medical event with risks, with greater willingness to suppress the pain. However, our findings with regard to multiple linear regression showed that depression symptoms were no longer associated with greater willingness for request of pain relief medication during labor when pregnancy-specific distress symptoms were entered in the model. This could be explained by the high correlation between depression symptoms and pregnancy-specific distress symptoms (r = .51, p < .001, large effect size, see Table 5), suggesting that pregnancy-specific distress symptoms are more important in predicting a woman’s willingness for request of pain relief medication during labor. It should be noted that the TPDS-NA measures worry symptoms about pregnancy and delivery, with examples of items concerning worries about delivery being: “I worry about the delivery”, “I am afraid I will lose self-control during delivery” and “The delivery is troubling me”. It seems reasonable to believe that scores on the TPDS-NA are more predictive of a pregnant woman’s willingness for request of pain relief medication during labor than scores on a general depression questionnaire such as the EDS.
Furthermore, with regard to construct validity, we found at both a univariate and multivariate level, that nulliparous women had greater willingness for request of pain relief medication during labor, which was also reported in previous studies (10, 17). It is likely that multiparous women have more confidence in their ability to cope with labor, because they succeeded in giving birth before. Indeed, a recent study found that multiparous women reported higher childbirth self-efficacy scores compared to nulliparous women (53). Multiparous women with a history of complications during a previous delivery had greater willingness for request of pain relief medication during labor. These women can have expectations that something similar will happen during the next delivery (42). This may contribute to an enhanced childbirth fear (55) and likelihood of approaching labor as a medical event (42), and could therefore increase the preference for a pain free delivery.
Finally, our linear regression model predicted only a small percentage of the variance in scores on the LPRAQ-p, which should be taken into account when interpreting the results. Besides pregnancy-specific distress symptoms and nulliparity, a higher age was significantly associated with greater willingness for request of pain relief medication during labor and a high education level with lower willingness for request of pain relief medication during labor. Previous studies found different results regarding the association of age and education level with the request for EA during labor. Some studies found no significant association for both age and education level (56, 57). Other studies reported a similar relation between age and receiving EA (16, 17), but an opposite relation between education level and receiving EA (16, 58, 59).
A major strength of the current study is that the development of the LPRAQ-p was based on direct input from pregnant women, new mothers and obstetric caregivers using focus group interviews. Other strengths include the large sample size and the performance of both EFA and CFA in different samples to validate the questionnaire. A limitation of the current study is that the participants were white Dutch women, while in the Netherlands up to 25% of the women have a migration background (11% Western and 14% non-Western) (60). Since cultural background influences a woman’s attitude towards labor pain relief (4, 9), it is important to re-evaluate the psychometric properties of the LPRAQ-p in women of other ethnic groups. Also, the number of highly educated women was slightly higher in the current study compared to the national figures (65% versus 55%) (61), which may limit the generalizability of the results. With regard to the t-tests, mostly small effect sizes were found, which suggests that possible differences should be interpreted with caution.
The concept of the developed LPRAQ-p seems to be clinically relevant. It is important to have knowledge of a pregnant woman’s attitude towards labor pain relief, since EA can have detrimental effects on a woman in labor. Receiving EA has been related to an extended first and second stage of labor, increased need for additional oxytocin, hypotension, motor blockade, fever and urinary retention (20), and length of exposure to EA has been associated with non-spontaneous deliveries (21). During the antenatal period, women often already plan to ask for EA during labor (9, 10). Up until this point, there was no validated measure to obtain a pregnant woman’s attitude towards labor pain relief. The LPRAQ-p could be a valuable screening instrument to identify pregnant women with greater willingness for request of pain relief medication during labor. Because high scores can reflect poor self-efficacy for labor, and pregnancy-specific distress symptoms were significantly and independently related to high scores, these women may benefit from extra help and support during pregnancy and labor. During the focus group interviews, it was identified that self-efficacy for labor seems to be an important part of attitude towards labor pain relief as reflected in several final items of the LPRAQ-p. Moreover, our results suggest that pregnant women with elevated levels of pregnancy-specific distress symptoms have greater willingness for request of pain relief medication during labor. This means that strategies to help women with higher scores on the LPRAQ-p should address both self-efficacy and pregnancy-specific distress, especially since fear of childbirth has been associated with lower childbirth self-efficacy (53). Strategies could particularly be useful for nulliparous women and multiparous women with a history of complications during a previous delivery, who both showed to have higher scores on the LPRAQ-p, and have previously been described to have lower childbirth self-efficacy (53) and enhanced fear of childbirth (55).
During pregnancy, an obstetric caregiver could advise women with higher scores on the LPRAQ-p to participate in a childbirth education course in order to strengthen their self-efficacy and to reduce pregnancy-specific distress symptoms. Childbirth self-efficacy has indeed been related to knowledge of labor and practical coping skills (62). Several studies have examined the effectiveness of a childbirth education program during pregnancy on childbirth self-efficacy and fear of childbirth. A recent study examined the effectiveness of a companion-integrated childbirth preparation, designed to educate and support pregnant women and their birth companions, and found promising effects on fear of childbirth and childbirth self-efficacy (63). Two randomized controlled trials on a childbirth psychoeducational program showed a reduction in fear of childbirth in the intervention group (64, 65). One of these trials addressed self-efficacy as well, and reported a significant improvement (65). A randomized controlled trial on a short mindfulness-based childbirth preparation course for pregnant women and their partners showed an improvement in childbirth-efficacy in the intervention group (66). Moreover, a pilot study on a Mindfulness-Based Childbirth Education (MBCE) program found improvements in childbirth self-efficacy and fear for childbirth (67). Future research should investigate which childbirth education programs are most suitable for women with greater willingness for request of pain relief medication during labor, and whether these programs are effective in reducing EA rates.
Knowing which pregnant women have higher scores on the LPRAQ-p could also help obstetric caregivers to decide upon offering continuous support during labor. Lack of partner or social support during pregnancy has been associated with lower childbirth self-efficacy (53) and fear of childbirth (68). Therefore, it seems likely that support by a companion during labor has a beneficial effect on women with greater willingness for request of pain relief medication during labor. Continuous support during labor involves the constant presence of a companion during labor and delivery, who provides emotional and informational support, advices about coping techniques and comfort measures, and advocates on behalf of the woman in labor (69). The companion could be a doula, the partner, a family member or a friend (69). Continuous support is most helpful when it is provided by someone who is calm and trusted, with an accepting attitude and the ability to give a positive meaning to the pain (70). According to a recent Cochrane review, women who had continuous support during labor were less likely to receive EA (69).
Interestingly, while one may expect that receiving pain relief medication during labor could enhance the childbirth experience, a prospective study found that women who wanted to avoid labor pain relief medication were more satisfied after the birth than women who received labor pain relief medication (71). This study related fear of labor pain to a lower satisfaction with the childbirth experience (71). Moreover, two systematic reviews reported that receiving labor pain relief medication had no effect on the childbirth experience (72, 73). Instead, birth preparedness and continuous support were described to be important strategies to improve the experience of childbirth (72, 73). This could imply that antenatal childbirth education and continuous support during labor could both reduce EA rates and enhance the childbirth experience.