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 Table of Contents  
Year : 2022  |  Volume : 24  |  Issue : 3  |  Page : 73-78

Knowledge, attitude, and practice of labor analgesia in antenatal women in India: An observational study

1 Department of Anaesthesiology and Critical Care, Armed Forces Medical College, Pune, Maharashtra, India
2 Department of Anaesthesiology and Critical Care, UNIFIL Level 1+ Hospital, Naqoura, Lebanon
3 Department of Anaesthesiology and Critical Care, Command Hospital Air Force, Bengaluru, Karnataka, India
4 Department of Anaesthesiology and Critical Care, 6 Air Force Hospital, Coimbatore, Tamil Nadu, India
5 Department of Anaesthesiology and Critical Care, Military Hospital, Kirkee, Pune, Maharashtra, India

Date of Submission24-Dec-2020
Date of Decision11-Feb-2021
Date of Acceptance01-Mar-2021
Date of Web Publication01-Apr-2022

Correspondence Address:
Lt Col (Dr) Nipun Gupta
Department of Anaesthesiology and Critical Care, UNIFIL Level 1+ Hospital, Naqoura
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jmms.jmms_192_20

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Background: The concept of labor analgesia is widely unknown to the antenatal women and parturients in the Indian medical setup. Aims: The aim of this study was to assess the knowledge, attitude, and practice of labor analgesia in antenatal women visiting the antenatal clinic in a tertiary care hospital. Methodology: One hundred twenty women in the antenatal period between the age group of 18 and 40 years attending the antenatal clinic were included in the study. A Google form-based questionnaire was used to collect data. Statistical Analysis: Ordinal and nominal data were presented as numbers and percentages. Bar diagrams and pie charts were used for graphical representation. Results: Twenty-one (17.5%) respondents, out of 120, were aware of labor analgesia. Among the rest 99, 13 participants did not have knowledge nor they wanted to gather information further. Out of 86 unaware respondents, 62 (72.1%) were interested in acquiring the knowledge of labor analgesia and rather would be comfortable if the treating obstetrician imparts the information; 46 (53.5%) of them wanted the information to be imparted during the obstetric consultation sessions and 10 (11.6%) respondents considered the best time for gathering awareness for labor analgesia at, or after the onset of labor pain. The major concerns of the respondents for labor analgesia were the safety of their health and the effect on the baby. Conclusions: Awareness of labor analgesia in Indian antenatal women is low. The treating obstetrician should impart knowledge regarding labor analgesia in the pre- and antenatal period which should be supplemented with more emphasis during the prelabor period.

Keywords: Analysis, awareness, obstetrical analgesia, pregnant women

How to cite this article:
Paul D, Gupta N, Patra AK, Saurav, Prasad G V. Knowledge, attitude, and practice of labor analgesia in antenatal women in India: An observational study. J Mar Med Soc 2022;24, Suppl S1:73-8

How to cite this URL:
Paul D, Gupta N, Patra AK, Saurav, Prasad G V. Knowledge, attitude, and practice of labor analgesia in antenatal women in India: An observational study. J Mar Med Soc [serial online] 2022 [cited 2022 Aug 14];24, Suppl S1:73-8. Available from: https://www.marinemedicalsociety.in/text.asp?2022/24/3/73/342380

  Introduction Top

Labor pain is one of the severe painful conditions known to humans. Medical literature shows that pain perception in labor varies in onset, timing, duration, and severity based on sociodemographic and biological variables such as age, parity, race, religious affiliation, and ethnicity.[1] The variability of labor pain perception is evident by the fact that in a study, only 52% of parturients considered labor pain as severe.[2] Over the centuries women have accepted labor pain as a part of natural phenomenon to achieve the motherhood, till 1847 when James Simpson introduced inhalational analgesia for labor pain.[3] Since then, the technique of labor analgesia has evolved rapidly till today's time in which a parturient has a plethora of safe and effective options available for labor analgesia to choose from. The growing popularity and clinical application of labor analgesia can be made from the fact that number of cases opting for labor epidural analgesia has tripled in the United States of America between 1981 and 2001.[4] Despite this, the lack of awareness regarding labor analgesia techniques persists since, the 50% of parturients perceive labor pain as an indication for cesarean delivery.[5]

In high-income nations, labor analgesia is widely opted for, but not in the case of developing countries.[6] In high-income nations, the focus areas are the type of technique and complications, in contrast to developing counties where the primary focus revolves around knowledge, attitude, and availability of labor analgesia.[7] This has been substantiated in the Indian population by one study revealing that more than 70% of participants were unaware about the concept of painless delivery.[8] High maternal and neonatal mortality are the prime focus areas for medical professionals in developing nations, leading to neglect of labor analgesia for antenatal women.

The provision and acceptance of labor analgesia are multifactorial and involve a lot of stakeholders including administration of medical setup, treating obstetrician, anesthesiologist, and the parturient herself. An administrative attitude toward labor analgesia is one side of the coin. The other side consists of the knowledge and attitude of health-care providers and parturient toward labor analgesia. A study conducted in Indian setup revealed that the acceptance for labor analgesia is 11%.[9] In the Indian setup, despite the availability of various methods of labor analgesia, most of the parturient attending tertiary care hospitals are still hesitant to ask for labor analgesia. Studies have shown that creating awareness by imparting appropriate information about labor analgesia to parturient can surely improve its acceptance level.[8]

We planned a study to evaluate the factors regarding labor analgesia specific to parturient, thus negating the administrative factors and factors associated with treating obstetricians and anesthesiologists, of which few data are available concerning the Indian setup.

The aim of this observational study was to assess the knowledge, attitude, and practice of labor analgesia in women visiting the antenatal clinic in a tertiary care hospital. The main objectives were to assess the awareness of labor analgesia in antenatal women, assessment of the barriers for nonacceptance of labor analgesia, and to ascertain appropriate person, means, and time for imparting information regarding labor analgesia to women in the reproductive age group.

  Methodology Top

After obtaining institutional ethical committee approval (IEC No. 2020/77), this observational cross-sectional study was carried out in a tertiary care hospital from May 2020 to July 2020. Antenatal women between the age group of 18 and 40 years attending antenatal clinics were included in the study. Patients not consenting for the study, scheduled for elective cesarean section, decided not to answer a question, found the questions nonanswerable, or lost interest in the survey were excluded from the study.

The sample size of 120 was calculated based on the prevalence of awareness regarding labor analgesia of 8.5 [10], confidence interval of 95%, and allowable margin of error of 5%.

A structured Google form-based questionnaire was prepared after discussion among the authors and also referring with the previous studies. The Google form-based questionnaire can be assessed through this link https://forms.gle/YAqaJmFamSseohY37. A pilot study was done on 20 antenatal patients attending the antenatal clinic, and the questionnaire justified our aim and objectives, hence validated.

The questionnaire had two sections. In the first section, demographic data were recorded, such as age, education level, occupation, parity, and previous normal or cesarean delivery.

The second section consisted of questions to assess the knowledge and perception of labor analgesia. Patients were asked about the pain they expected in the present pregnancy and incase of multigravida, we also enquired about their previous experience. However, if the patient had little or no knowledge about labor analgesia, we educated patients regarding labor analgesia. After imparting the facts and clarifying their doubts, patients were questioned if they would prefer labor analgesia during the present pregnancy. If patients were reluctant, we enquired the reason for hindrance.

Single interviewer, with previous experience in community surveys, collected the data in the local language. To avoid the interviewer's bias, the interviewer recorded the answers as provided by the respondent. To reduce the subject bias, the interviewer assured respect to the views and beliefs of participants; data confidentiality, and the complete anonymity of the participants.

Statistical analysis

Data were collected from all the 120 patients and analyzed based on the type of data. Microsoft Office Excel 2016 was used to analyze the data. Ordinal and nominal data were presented as numbers and percentages. Bar diagrams and pie charts were used for graphical representation.

  Results Top

Using a consecutive sampling technique, 120 antenatal women attending an antenatal clinic and fulfilling inclusion and exclusion criteria were included in the study [Figure 1].
Figure 1: Participant flow diagram

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Eighty-eight (73.3%) out of 120, were between the age group of 20 and 30 years. The majority of participants were Hindus, graduate or above, homemaker by occupation, and belonged to urban areas. The demographic profile of the study population is summarized in [Table 1].
Table 1: Demographic characters of the participants

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Out of 21 (17.5%) of total respondents who had knowledge of labor analgesia [Figure 2], 13 (61.9%) of them obtained the information from family, friends, or social media [Figure 3]. Ninety-nine (82.5%) respondents did not have awareness about labor analgesia, out of which 86 (86.9% of women who had no awareness) respondents were interested in obtaining information regarding labor analgesia.
Figure 2: Summary of awareness for labor analgesia

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Figure 3: Source of information for labor analgesia

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Sixty-two (72.1%), out of a total of 86 unaware respondents who were interested in information regarding labor analgesia were comfortable with their treating obstetrician imparting them the information [Figure 4].
Figure 4: Choice for the resource of knowledge

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Forty-six (53.5%) out of these 86, wanted the information to be imparted to them during the obstetric consultation sessions itself and 21 (24.4%) of these 86 respondents, wanted the information in audiovisual format [Figure 5].
Figure 5: Choice for the mode of dissemination of awareness

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Regarding the timing of imparting the information, 10 (11.6% of total unaware interested respondents) subjects considered the best timing would be at or after the onset of labor pain during the childbirth [Figure 6].
Figure 6: Choice of appropriate timing to impart information for labor analgesia

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Out of 21 respondents who had awareness about labor analgesia, 7 respondents did not want to opt for labor analgesia during present delivery. Out of 99 respondents who did not had awareness about labor analgesia, 13 respondents did not want to have additional information regarding the same. Twenty respondents (16.7% of total respondents) were either not interested in information despite being unaware about labor analgesia or who in spite of being aware of labor analgesia did not want to opt for the same during the present upcoming delivery. The reasons cited by these 20 respondents were obtained [Figure 7].
Figure 7: Summary of concerns regarding labor analgesia

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  Discussion Top

Labor is a natural process and it is assumed that labor pain is well tolerated and pain relief is not an important part of intrapartum care.[11] The American College of Obstetricians and Gynecologists noted that there is no other situation than a labor room, where even a physician accepts pain experienced by the patients.[12] However, over the years with the understanding of the neurophysiology, pain during labor has been acknowledged. The severity of the labor pain was earlier assumed to be mainly related to the cervical dilatation, but studies have shown it to be multifactorial.[13]

Labor analgesia has been marred with myths and misbelieves since the time of its inception, making its provision to antenatal women a challenge. However, the World Health Organization presently recommends epidural analgesia (A type of labor analgesia technique) for healthy pregnant women requesting pain relief during labor.[14] Awareness regarding labor analgesia among antenatal women is the basic requirement for them to place a request for the same. In India, awareness regarding labor analgesia among parturient is low which has been brought out in various studies revealing an awareness level of <10%.[8],[15],[16] The present study shows that 82.5% of parturients were not aware regarding labor analgesia which is less than previously published studies. This difference can be due to our study being conducted in an urban setup, which is supported by the fact that urban areas contribute more than 99% of the Indian labor analgesia services.[17] This is reverse of the situation in developed countries where the awareness is 80%.[18]

In the present study, 61.9% of respondents with previous knowledge about labor analgesia obtained the information from either friends/family members or respondents own experience during previous childbirth. Contribution from social media and family doctors was negligible. Furthermore, out of six respondents who had awareness regarding labor analgesia were multipara. Out of these six, three had opted for labor analgesia in the last childbirth, two obtained knowledge from friends and family members, and one obtained the knowledge from anesthesiologists during the last childbirth. The striking absence of obstetricians as information provider reflects on limited training and knowledge of obstetricians in the field of labor analgesia which has also been reported by previous studies.[17] A study by Shidhaye et al. clearly elicits that lack of obstetric analgesia teaching, low level of practical exposure, and the prevailing confusion/ignorance regarding the maternal and neonatal benefits of epidural analgesia, as the major obstacle in implementing labor analgesia.[8]

Women planning a pregnancy or women in the antenatal period revealed three important things to be considered for imparting any type of information. The three important things were, the right person imparting the information, the timing, and means of imparting information appropriately.[19] In the present study, 72.1% of respondents who were currently unaware but interested in obtaining information regarding labor analgesia were comfortable with their treating obstetrician imparting them the information. Regarding means of imparting the information in case of respondents who were currently unaware but interested in information, 53.5% of respondents opined it to be imparted during consultation sessions by the treating obstetrician and 24.4% of respondents opined it to be in an audiovisual format.

Improved acceptance for epidural analgesia for labor in antenatal women has been seen if prior information is imparted in the antenatal period using videos and demonstrations.[20] The finding of this study also emphasizes the important role of the treating obstetrician. Obstetricians have vital responsibility for the successful implementation of labor analgesia program by imparting adequate information to the parturient. A study conducted in Indian setup revealed, 82% of the obstetrician while providing antenatal care do not discuss labor analgesia with their patients.[21]

With no prior knowledge about labor analgesia among majority of antenatal women in Indian setup, the first exposure for them to this knowledge is usually at or after the onset of labor, if at all the labor analgesia is planned. The treating obstetrician or anesthesiologist concerned normally explains the same to the parturient. The appropriateness of the timing of imparting new information to a woman in acute pain, who is the decision maker for a procedure under informed consent, is questionable. Some researches advocate for imparting information about labor analgesia in the first antenatal visit.[22] In the present study, respondents were equally divided, regarding the best timing of imparting information of labor analgesia. Opinions were divided between the options of before conceiving, during the antenatal period, and at term. Only 1.2% of respondents who were currently unaware but interested in obtaining information agreed to have such knowledge at or after the onset of labor. To impart knowledge of labor analgesia thus requires a concerted and planned effort on the part of treating obstetrician for effective implementation of labor analgesia program in their setup.

Studies have shown that ineffective labor analgesia services in India are due to the financial constraints of the patients and or budgetary constraints of the hospital administration.[8],[17] As reported in the literature, 52% of the antenatal population considered extra-financial burden as an important factor for not opting for labor analgesia.[13] Monetary factors for patients should not be a limiting factor when considering the labor analgesia program in a government medical setup. The present study tried to find areas of concern relating to both patient and administration other than monetary factors, acting as a barrier in the acceptance of labor analgesia. In the present study, 20 parturients were not interested to accept such services regardless of having the facility. Analyzing the reasons cited by them, this study found that the major concern among the respondents was that the technique of labor analgesia might adversely affect their health. However, the popular belief of religious viewpoint of inability to participate in the process of labor due to labor analgesia was not a concern for more than 50% of respondents in this study. This finding is contrary to observations where the majority of ladies wanted to feel the natural childbirth in a previous study.[7] This study showed that concern like personal beliefs or misconceptions, as reported by respondents, can be easily addressed by imparting adequate knowledge to the target population and has no socioreligious association.

The present study analyzed the antenatal women's perspective of the factors related to labor analgesia. The low level of awareness as reported in this study and literature is the key limiting factor for implementation and acceptance of labor analgesia in the Indian setup. Treating obstetrician has a pivotal role to play in creating awareness as they develop a rapport with the women at an early stage in the process of childbirth and can help to achieve the intended goal. This, in turn, requires adequate knowledge and practical nuances for labor analgesia on part of treating obstetricians.

Imparting adequate knowledge of labor analgesia to the antenatal women or women, planning for pregnancy will atleast help to negate the factors distinct to a financial burden to the patient (not a concern in government setup), the hospital administration, and socioreligious factors. This will lead to an environment conducive for the labor analgesia program to gain pace and cover a wider population. As Keynes' Law in economics states “Demand creates its supply”, so in this case once antenatal women will start demanding the service of labor analgesia, the administrative and socio-religious hindrances will give way.

The present study is an observational study that has limitations inherent to the design of the study. It has focused only on parturient for the labor analgesia service, not addressing the availability of equipment and infrastructure, monitoring facility, and obstetrician-anesthesiologist coordination which have a major role in the implementation of such services.

  Conclusions Top

In spite of lack of awareness among antenatal women regarding labor analgesia, majority were fervent to obtain information regarding the same and accept pain relief for their upcoming delivery. However, considerable number of respondents were either not interested in information despite being unaware about labor analgesia or who in spite of being aware of labor analgesia did not want to opt for the same during the present upcoming delivery. The reasons cited by them for nonacceptance of labor analgesia can easily be overcome if information regarding labor analgesia is imparted to, antenatal women and women who are planning pregnancy, by treating obstetricians with support from the anesthesiologist from an early antenatal period rather than at or after the onset of labor pain.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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