Awareness and Attitude Toward Epidural Analgesia During Labor Among Pregnant Women in Taif City: A Hospital-Based Study

Objectives This study aimed to investigate the awareness and attitudes towards epidural analgesia (EA) among pregnant women in Taif City, Saudi Arabia. The rationale was to identify potential barriers to the acceptance and use of EA, which is an effective pain management option during labor. Methods We conducted a cross-sectional survey at a single healthcare center in Taif City. The participants, pregnant women visiting the center, were recruited using a convenience sampling method. Data collection was facilitated by a questionnaire distributed through a quick response (QR) code. The questionnaire assessed demographic information, awareness levels, previous exposure to EA, and personal attitudes toward its use during labor. Data analysis focused on quantifying the levels of awareness and identifying patterns in attitudes. Results The results revealed a low level of awareness about EA among the participants, with a significant proportion having never been exposed to it before the survey. Attitudes towards EA were varied, with some expressing openness to its use and others displaying apprehension or resistance, which appeared to be influenced by cultural perceptions and a lack of information. Conclusions The study highlighted a substantial lack of awareness and varied attitudes towards EA among pregnant women in Taif City. Educational interventions are necessary to increase awareness and address cultural misconceptions. The study’s limited scope and potential sample bias suggest the need for broader culturally tailored research to inform strategies for improving the acceptance and utilization of labor analgesia.


Introduction
Labor pain is among the most intense pains encountered by humans.Yet its recollection fades over time.Unlike other types of pain, labor pain is a profoundly personal and subjective experience that is challenging but also emotional and significant.Cognitive, social, and environmental factors are the pivotal elements shaping the perception of labor pain.Notably, even with the intense nature of labor pain, the administration of labor analgesia during childbirth is not a standard practice.Multiple studies have underestimated the role of labor analgesia in contributing to childbirth satisfaction, as it is perceived to play a minor part.However, if a woman maintains the belief that her pain is both purposeful (i.e., her body's effort to deliver her baby)

Sample population
We estimated a sample size of 478 pregnant women using the Raosoft Sample Size Calculator (Raosoft, Inc., Seattle, WA) for the six-month data collection period, aiming for a confidence level above 97% and a margin of error below 5%.Participation was contingent upon informed consent, granted after participants were briefed on the study's aims and methods.We included pregnant women attending routine antenatal care who agreed to participate and excluded those unable to scan the questionnaire's quick response (QR) code with their mobile phones.

Data collection
Data were gathered through a self-administered questionnaire, distributed in Arabic, and accessible via a QR code scanned by the participant's mobile phone.Participants were allowed only one attempt to complete the questionnaire to avoid duplicate responses.Before the main study, the questionnaire was pretested and validated on a pilot group of 50 pregnant women, who were subsequently excluded from the primary analysis.The data collection occurred from February 1, 2023, to July 31, 2023.
The questionnaire comprised three sections, starting with a consent statement.The first section collected demographic information, including age, nationality, education level, employment status, and monthly income.The second section focused on medical and obstetric history, querying participants about medical comorbidities such as diabetes, gestational diabetes (GD), hypertension (HTN), preeclampsia, cardiac disease, asthma, hypothyroidism, the number of prior births, and previous C/S.The third section assessed specific knowledge about EA, including history of EA use in previous pregnancies, willingness to consider EA in the current pregnancy or recommend it to others, understanding of EA's mechanisms (e.g., whether it affects uterine contractions or the ability to push, leading to C/S, or if lower limb paralysis is a complication), and preferred methods for acquiring further information about EA (e.g., no further education, videos, brochures, consultations with an obstetrician during antenatal visits, or teaching sessions by an anesthetist).The most favored method of education was through regular consultations with obstetricians during antenatal visits (49.1%), followed by video presentations (15.7%), written materials such as pamphlets, brochures, and flyers (11.6%), and special sessions led by an anesthetist (10.9%; Figure 1).

FIGURE 1: Preferred method of future education about epidural analgesia
We further analyzed participant characteristics based on prior receipt of the EA.Those who had received EA were significantly more likely to have a higher monthly income (20.8% in the >15,000 SAR category, 10.0% in the >10,000 to 15,000 SAR category, and 3.2% in the 5,000 to 10,000 SAR category; p = 0.002).The prevalence of EA use was also higher among participants who had a previous C/S than those who had not (9.3% vs. 3.6%, respectively; p = 0.012;   When considering the inclination towards EA during labor, younger participants were more likely to consider it (61.1% under 30, 51.1% aged 31 to 40, and 29.7% over 40; p < 0.001).The likelihood of considering EA was also significantly associated with the level of education; those with a university degree were more inclined (63.7%) than those with secondary (46.2%) or primary education (31.5%; p < 0.001).Furthermore, participants with HTN or preeclampsia were less likely to consider EA (36.8%) than those without these conditions (54.0%; p = 0.037).Parity also showed a significant association; women who had given birth once or twice were more likely to consider EA (61.9%) compared to those who had never given birth (57.1%) and those who had given birth more than twice (42.7%; p < 0.001; Table 4).

Demographic data
Responses

Discussion
Saudi Arabia is a vast country with myriad geographic and cultural characteristics [9].This hospital-based study conducted in Taif City, located in the western region of Saudi Arabia, aimed to explore pregnant women's awareness and attitudes toward EA during labor in comparison with other regions of the Kingdom.Our sample's demographics align with those from similar studies across the country [10][11][12][13][14][15][16][17][18].Interestingly, only employment status -specifically being employed in the medical field -was a significant predictor of awareness about EA, diverging from another study in the same region that implicated age, education, history of C/S, and previous EA experiences as influential factors [11].Using multivariable logistic regression, our analysis determined that employment status was the primary determinant.Awareness of EA among the women in our study was low at 6.7%, notably less than percentages reported from other Saudi regions, where the figures ranged from 16.2% to 85.6% [10][11][12][13][14][15][16][17][18].This disparity could be due to Taif's predominantly rural population, where traditional views may prioritize natural over medical approaches, impacting knowledge acquisition about EA.A clear link between knowledge of EA and its utilization has been established [10,11,13,[16][17][18].Moreover, only 5.3% of our study participants had previously been exposed to EA, the lowest rate compared to other Saudi regions where exposure rates ranged from 20.1% to 38.6% [10][11][12][13]15,16,18].Moreover, only 5.3% of our study participants had previously been exposed to EA, the lowest rate compared to other Saudi regions where exposure rates ranged from 20.1% to 38.6% [10][11][12][13]15,16,18].This may reflect the limited availability of EA in local healthcare centers and underscore the need for enhanced awareness.We noted a significant correlation between a higher monthly income (over 15,000 SAR) and a previous receipt of EA.However, unlike findings from a study in Jazan that showed a correlation between EA exposure and women aged 30 to 40 living in urban areas with higher educational levels [12], we did not find a significant correlation with other demographic variables.This suggests that economic factors may influence the accessibility of EA.
Contrary to existing evidence suggesting that EA does not increase the C/S delivery rate [3], our study revealed a notable association between the C/S rate and prior exposure to EA.This unexpected discovery highlights the need for further research to confirm these findings and to re-evaluate our practices in Taif City.
The C/S rate in our study was 29.5%, situated between rates found in other regional studies [11,15].It has been suggested that increasing awareness of labor analgesia, specifically EA, might reduce the rate of elective C/S deliveries, which is fueled by the fear of labor pain [19].Regarding preferences for EA, 53.3% of participants were considering it for their current pregnancy.This desirability rate for EA indicates some acceptance of the method in Taif, albeit lower than in some regions but higher than in others [10,12,13].
Younger women, those with fewer children, and university graduates showed a higher likelihood of choosing EA, contrasting with findings from Al Khobar [10].
Medical conditions in our participants did not seem to influence awareness or previous use of EA.However, women with HTN or preeclampsia were less inclined to desire EA, contrary to our initial assumption that medical advice would increase awareness in such cases.The implications of the EA for patients with specific medical conditions warrant further investigation.
Educating pregnant women is pivotal in navigating labor analgesia choices.Inclusion of early education on labor analgesia in antenatal care, delivered by anesthetists and obstetricians, is recommended [10][11][12].Our findings revealed that the preferred source of education about EA was obstetricians, which highlights the importance of direct physician-patient interaction.Following this study, we initiated integrated lectures by anesthetists and obstetricians as part of the antenatal care visits to educate about EA.Additionally, we have developed a simplified educational video on EA for dissemination on social media and recommended the inclusion of EA teaching modules in university curricula and premarital education programs.
This study had several important limitations.Its cross-sectional design captures only a snapshot in time and does not account for changes in perceptions or educational interventions that may occur throughout the pregnancy.Being a single-center study, the findings may not be generalizable across different regions or healthcare settings within Saudi Arabia or elsewhere.The reliance on self-reported data may introduce response bias, as participants might provide socially desirable answers or their recollections might be affected by their current circumstances.Additionally, excluding women who could not use the QR code technology could introduce a selection bias, potentially skewing the sample towards a more technologically savvy and possibly younger demographic.This study also does not explore the reasons behind the low rates of awareness and previous exposure to EA, which could be influenced by cultural, socioeconomic, or educational factors not accounted for in the analysis.Furthermore, the interpretation of the data is limited by the lack of qualitative insights that could provide a deeper understanding of personal beliefs and societal norms affecting attitudes toward labor analgesia.

Conclusions
The awareness of epidural analgesia among pregnant women in Taif City is generally low, except for those working in medical professions.A correlation between previous EA exposure and C/S rates was observed.
The preferred method of EA education was direct communication with obstetricians.Therefore, it is essential to enhance awareness about EA and other labor analgesia methods through comprehensive health education.This will empower women to make informed decisions regarding pain management during labor, leading to improved delivery experiences and maternal satisfaction.

FIGURE 2 :
FIGURE 2: Previous trial of epidural analgesia across different monthly income groups (A) and with or without a history of C/S (B)C/S, cesarian section; SAR, Saudi Riyals.
animal subjects or tissue.Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work.Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work.Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.

TABLE 2 : Responses to questions assessing specific knowledge of EA
C/S, cesarean section; EA, epidural analgesia.

TABLE 4 : Association of participant demographic data with consideration of epidural analgesia during labor
Significant at p<0.05 using the chi-square test and the exact test.

TABLE 5 : Univariate logistic regression analysis of factors affecting epidural analgesia knowledge
CI, confidence interval; OR, odds ratio; C/S, cesarean section; GD, gestational diabetes mellitus; HTN, hypertension; NA, not applicable; SAR, Saudi Riyals.*Significant at p<0.05 using chi-square test and exact test.

TABLE 6 : Multivariable logistic regression analysis of factors affecting epidural analgesia knowledge
CI, confidence interval; OR, odds ratio; C/S, cesarean section; NA, not applicable.*Significant at p<0.05 using using chi-square test and exact test.