Research Proposal
Identifying characteristics of birthing women regarding receiving pharmacological pain management: a correlational survey.
What are the characteristics of birthing women who receive pharmacological pain management compared to birthing women who do not receive pharmacological pain management in a Dutch low-risk population?
Module: Advanced Research Methods
Module leader: Mechthild Gross
Student: Joke Hilhorst
Matriculation number 169863
Date of submission: 17th of July 2016
Word count:
Content
Abstract
Like the abstract of a research paper, the project summary, should be no more than 300 words and at the most a page long (font size 12, single spacing). Provided preferably on a separate page, it should summarize all the central elements of the protocol, for example the rationale, objectives, methods, populations, time frame, and expected outcomes. It should stand on its own, and not refer the reader to points in the project description.
Introduction
Literature review
Aim & research question
Methodology and design
Methods
Access, Ethical and Legal Issues
Timetable
Budget & Funding Sources
Dissemination
Introduction
Childbirth has become increasingly medicalised in developed countries (Luce et al , 2016). This is also reflected in the percentages of pharmacological pain management (PPM) used by women in labour, mostly administered as epidural anaesthesia (EDA) (Jeschke et al, 2012). In 2008, in 27 of the United States of America, 61% of women who had a singleton birth by a vaginal delivery received epidural or spinal anaesthesia (Osterman, 2011). In France, in 2010, this percentage was even higher: 77% of birthing women received EDA (INSERM, 2015), whilst in their neighbour land Spain the percentage was 57.5 between 2004 and 2010 (Jimenez, 2012). In NHS hospitals in England, in the period 2013-2014, 34.8% of birthing women received epidural or caudal and spinal anaesthesia (HSIC, 2014). Although Dutch birthing women have a tradition of birthing without PPM, and still prefer prenatally not to use PPM (Klomp, 2013), the number of them receiving pharmacological pain relief has been rising over the past decade and the use of EDA increased from 5,4% in 2003 to 17,9% in 2012 (PRN, 2013). In the Netherlands, between 1988 and 2004, the rising demand for PPM accounted for 25% of the increase in referrals from midwives to obstetricians (Amelink, 2009).
PPM is associated with unintended side-effects, that will be elucidated here. EDA has an increased risk on maternal hypotension and severe headache, maternal fever, motor blockade, urinary retention. Furthermore on oxytocin administration for augmentation, longer second stage, assisted vaginal births, Caesarean Sections (CS) because of foetal distress (Anim, 2011) and neonates being evaluated and treated in the hospital for suspected sepsis (Lieberman, 2002). Epidurals also may increase the risk of a less positive birth experience in the long term, which has a enduring impact on the family’s future health (Maimburg, 2016). Conversely, opioids like pethidine and remifentanil (both used in the Netherlands), give more maternal and foetal/neonatal sedation than EDA (Ullman, 2010). With remifentanil, also having the potential to cause, life-threatening respiratory depression can occur (Stienstra, 2008).
Furthermore, in community-based maternity care systems like the Dutch system, childbearing women have to be referred to obstetrician-led care (OLC) for medical interventions such as electronic foetal monitoring and augmentation of labour and PPM. This deprives women of the possibility to give birth at home (Klomp, 2013). In the Netherlands approximately 85% of all pregnancies start in midwife-led care (MLC) (PRN, 2013). Low-risk women in MLC may choose to give birth at home, in a birth centre or in hospital. If risk factors or complications arise, women are referred to OLC.
The rise in the usage of PPM has probably been influenced by several factors. Not only by Dutch and international media, women’s friends and family (Amelink-Verburg et al., 2009), but also by new guidelines on the use of PPM introduced in the Netherlands which state that women's request is a sufficient medical indication for PPM during labour and that epidural analgesia is the method of choice for the elimination of labour pain (Quality Institute for Healthcare (Kwaliteitsinstituut voor de Gezondheidszorg CBO, 2008).
The above mentioned issues indicate the need to know more about the characteristics of women who do and do not (ask for and) receive PPM and to develop interventions to empower women to give birth without PPM and thus reduce this aspect of medicalization, with it’s already known and to be discovered unwanted side-effects.Herzien AP Therefore, the literature will be searched to discover characteristics of birthing women who do and who do not receive medical pain management in Western cultures. Western cultures are chosen, as these come the closest to the Dutch culture.
Literature review
Aim
Explore the topic, discover what is already known and what needs to be discovered, is essential previous to determine the need for research and to formulate a research question (Rees, 2003 p 26). Therefore a structured literature review will be performed to achieve this.
Literature search, selection and appraisal
A structured literature review was performed to search for evidence about the characteristics of birthing women who receive PPM compared with birthing women who do not receive pharmacological pain management in Western cultures. In June 2016, four electronic databases were searched to answer the question: “What are the characteristics of birthing women who do and who do not receive medical pain management in Western cultures”. PubMed, CINAHL AP (via EBSCOhost) and Psychology and Behavioral Sciences Collection (PBSC via EBSCOhost) were searched for published full text primary research articles with date (2006-2016), language (only English and French) and continent/country (Europe, North America, Australia and New Zealand) restrictions, using advanced search. Rough internet searches revealed the following (combinations of) key words/key terms: belief* OR factor* OR preference OR characteristi* OR expertise OR experien* OR approach) AND ("labour pain" OR "labor pain" OR "labour-pain" OR "labor-pain" ) AND ( management OR relief OR coping OR pharmacological OR epidural OR pethidine OR remifentanyl OR non-pharmacological. Reference lists and suggestions of online databases were searched. Finally, after excluding duplicates, 11 articles were chosen based on their relevance to the topic. Within this context, relevance is defined as related to items that are registered in every first line midwifery record. First line midwifery care as provided in the Netherlands, is care supplied by midwives to low-risk women during pregnancy, birth and puerperium in private midwifery practices. The process of searching and selecting the articles is displayed in appendix 1.
The quality of the articles was assessed based on three tools: the Strobe checklist for observational studies as this tool is advocated by outstanding medical journals (BJOG, 2013), the Critical Appraisal Skils Programme (CASP, 2013) for the systematic review since this is a relatively comprehensive tool and outstanding books about qualitative research (Patton, 2002; Meyer, 2015) (appendix 3). Details of these assessments are displayed in appendix 2.
Findings
Characteristics related to the use of PPM, as identified in the literature mostly relate to epidural use. They can be subdivided in aspects that are whether or not related to pregnancy and childbirth. The latter comprise age and level of education. The former encompass parity, a previous instrumental delivery, attended antenatal class, received continuous support during labour, the professional who was the responsible caregiver during labour, and the (planned) place of birth. All characteristics will be discussed in the following paragraphs. For the purpose of this paper all different shapes of PPM like EDA, pethidine or remifentanyl are all treated as PPM, as they all cover the essence of this paper.
Maternal age
Regarding maternal age, various results were found in the studies. Veringa et al (2011), in a prospective cohort study in the Netherlands in 177 nulliparous women, found that the crude odd of using PPM was identical (cOR 0.98 95% CI 0.92–1.06). This was confirmed by the findings of Jeschke et al in 2012, in a German survey in 193 women (aOR 1.004, 95% CI 0.930 – 1.084 for EDA). However, Räisänen (2014), in a Swedish population-based case–control study in 521179 women, saw a higher probability for EDA use in younger primigravid women (aOR 1.37, 95%CI 1.26 – 1.50) and in women older than 40 who gave birth to more than one child (aOR 1.25, 95%CI 1.19 – 1.31). The reason for these different findings is unknown, but could be affected by the use of PPM or EDA and by differences in sample sizes.
Educational level
Educational level is a subject of contradistinctions in literature. It was found to affect the request for PPM by Veringa et al (2011): nulliparous women who were lower educated were more likely to request PPM (cOR 1.97, 95% CI 1.006–3.85). Contrariwise, Koteless et al (2012) in a survey (5350 women) performed in Cananda, detected a higher probability to use EDA in women with higher education levels (OR 1.12, 95% CI 1.07–1.18). Steel et al (2013) however, in a cross-sectional survey (n=2445) in Australia, found no difference with respect to educational level and the use of EDA, but did with respect to pethidine: this was less used in women with university level. These considerable deviate findings cannot be explained yet.
Parity
For parity, the literature seems to be conclusive: they all found a lower probability for multiparous women to choose and/or use EDA/PPM, or a higher probability for nulliparous to actually choose and/or use it. Schytt et al (2010) reported in a population-based cohort study (n=2529) in Sweden nulliparity to be the strongest prognosticator for EDA use (OR 6.3; 95% CI 5.1– 7.9). Jenschke found a lower chance for EDA use in multiparae (aOR 0.05; 95%CI: 0.01–0.22). Klomp et al (2013) observed in a prospective multi-centre cohort study (n=1511) that primipae who announced a desire to use PPM relief had a higher chance to use it than multiparae with the same intention (OR 4.60 CI 2.27 to 9.13). Séjourné (2013), in survey (n=114), noticed multiparae less often to express the whish for EDA during labour. Further, Steel also observed primiparae to be more prone to use EDA (OR 2.1). Finally, in the study of Räisänen, EDA use was inversely correlated with parity. Despite these unambiguous results, the evidence still is disputable, seen the (to some extend severe) shortcomings of the studies.
Antenatal class
The influence of the attendance of antenatal class (which is not further specified in the literature) on PPM usage is not univocal the selected studies. In de study of Veringa et al nulliparous women who did attend antenatal class were more likely to not ask for PPM (cOR 0.42, 95% CI 0.21–0.86). On the other hand, Jeschke et al found no difference for women who attended antenatal class compared to women who did not (aOR 1.045 95% CI 0.361 – 3.021). The studies took place in different midwifery cultures, which could make the difference.
Continuous support
Three different designs of studies brought forth inconclusive results regarding continuous support during labour (CSDL). In a qualitative study (n=10) Leap (2010) found that women who received midwife-led continuity of care (two midwives through pregnancy, labour, birth, and the first few weeks postpartum) were less prone to use PPM during labour. This is a higher level of CSDL than in the two following studies, where CSDL was only during labour. Veringa in nulliparous women found no difference between CSDL and no CSDL by midwives/doulas (cOR 0.92, 95% 0.49–1.70), whereas Hodnett et al in a large systematic review (2013) saw that women who received CSDL had a lower risk to receive PPM (RR 0.90, 95% CI 0.84 to 0.96). The different results of the former two studies could possibly be due to the different countries; the latter worldwide systematic review however eliminates this possible explanation.
Primary professional providing care during labour
The caring professional during birth possibly can make the difference, according to the results of Koteless: the probability for EDA use if cared for by a midwife was lower compared to an obstetrician (OR 0.12 95% CI 0.10–0.1). Gibson confirmed this in a qualitative study (n=80) (2014): he found that all women cared for by an obstetrician received PPM, compared to 50% in de midwives group.
The (planned) place of birth
The actual place of birth, but possibly also the planned place of birth could influence the EDA usage, as seen in two studies. Both Klomp and Gibson observed that women who planned to birth in a hospital were more likely to use PPM. Klomp found an OR of 2.14 (95% CI 1.04 to 4.39) and Gibson took note of a 100% EDA use, even if women whished to birth naturally. Gibson also found that women once entering the hospital were persuaded to use PPM.
Previous instrumental delivery
One study (Steel) observed a higher probability for EDA usage in women with a previous instrumental delivery (OR = 2.21).
Discussion and conclusion
The above described characteristics of women (whether or not) using EDA can be disputed seen in the light of the different designs and the (to some extend severe) shortcomings, of the studies, which are displayed in appendix 2. Further, only two studies are performed in the Netherlands and did not investigate all characteristics. As this is the country of residence and thus interest of the author, the gap in the literature as discovered by this literature review is the characteristics birthing women in a Dutch low-risk population who either receive PPM or not receive PPM.
Aim & research question
The gap in the literature led to the aim of the study: to detect the characteristics of birthing women in a Dutch low-risk population who either receive PPM or not receive PPM. This leads to the following research question: “What are the characteristics of birthing women who receive pharmacological pain management compared to birthing women who do not receive pharmacological pain management in a Dutch low-risk population?”. Sub-questions to be answered are:
• Is the midwifery practice that is responsible for the care during pregnancy, labour and puerperium related to whether or not use PPM for a Dutch low-risk birthing woman?
• Is the level of education of a pregnant woman related to whether or not use PPM for a Dutch low-risk birthing woman?
• Is the age of a pregnant woman related to whether or not use PPM for a Dutch low-risk birthing woman?
• Is the parity of a pregnant woman related to whether or not use PPM for a Dutch low-risk birthing woman?
• Is a previous instrumental delivery of a pregnant woman related to whether or not use PPM for a Dutch low-risk birthing woman?
• Is antenatal class of a pregnant woman related to whether or not use PPM for a Dutch low-risk birthing woman?
• Is the intended place of birth of a pregnant woman related to whether or not use PPM for a Dutch low-risk birthing woman?
• Is the professional who attends birth related to whether or not use PPM for a Dutch low-risk birthing woman?
• Is continuous support offered during labour related to whether or not use PPM for a Dutch low-risk birthing woman?
• Is the actual place of birth related to whether or not use PPM for a Dutch low-risk birthing woman?
In these questions, some concepts need to be defined. To be investigated characteristics are items that emerged from the literature are detectable during pregnancy and are included in every midwifery record, in order to allow easy detection for midwives. Birthing women are women who give birth. Pharmacological pain management is one of the following administered pharmacological pain relief options that are used in the Netherlands: epidural analgesia, remifentanil intravenous patient controlled analgesia (PCA) and pethidine intramuscular. The different possible medicines that can be administered via epidural catheters and the different possible dosages of all medicines are not mentioned, as they do not interrelate with the research question. Dutch means giving birth in the Netherlands. Low-risk means not having a medical reason to give birth in a hospital (VIL). Level of education … . Antenatal class relates to every way of preparation for giving birth, which can be for example antenatal class, yoga or mindfulness. The (intended) place of birth can be at home, in a hospital or on a birth centre. The professional can be a midwife or an obstetrician (in training). Continuous support means a midwife providing support during all stage of labour.
Methodology and design
To answer the research question(s), a quantitative positivism AP study is chosen as this
A correlational survey is assumed to be an adequate choice, as this methodology is competent if the research question is a level two question (elemental information is known about two or more aspects, Rees, 2003, p 13) thus if a relationship between variables is backed by literature (Brink & Wood, 1998, p 161). The literature review in this paper suggests a relationship between characteristics of birthing women and their use of PPM.
https://books.google.nl/books?id=D9htBgAAQBAJ&printsec=frontcover&dq=methodology+in+research&hl=nl&sa=X&redir_esc=y#v=onepage&q=methodology%20in%20research&f=false
You need to be able to describe, critique and justify the choice of your underlying methodology (qualitative or quantitative) and the design within that methodology.
This will direct all other parts of the study and the methods you use so stay faithful to the methodology and design.
Any good research textbook/ research literature will give detail and critique of methodology.
Me: Angela, please advice that students may reference primary sources of methodology. A textbook such as Polit and Hungler is a bit to general and is only considered as secondary ressource.
Methods
Population & Sample
Population, sample type & sampling process
The population being studied ideally would be (the group of) all pregnant women, living in the Netherlands, who during their first antenatal visit do not have an indication for antenatal visits by an obstetrician in a hospital. This could be done using the data of Perined (Perined) in which almost all births (both under responsibility of midwives and obstetricians) in the Netherlands have been registered. However, it is generally known that these data often have been filled in without high precision, which decreases validity. Therefore, a database (AVM-VeCaS, which will be described in the next paragraph) of exclusively low-risk women has been chosen as sample (details will later be given). In this database consensus and communication has been taking place about how to fill in the different data fields. The most
A)sample+is)“a)smaller)(but)hopefully)representative)) collection)of)units)from)a)population)used)to)determine) truths)about)that)population”)(Field,)2005)
Data from women that gave birth:
Theoretical population: Dutch low-risk birthing women
Study population: low-risk birthing women in 25 Dutch midwifery practices
Sampling frame: VeCaS database (assessment of errors) (for data for internal and external characteristics)
Sample: women meeting inclusion criteria (gave birth, …)
VeCaS is a Midwifery Case Registration System (Verloskundig Casusregistratie Systeem) of the University of Midwifery Education & Studies (AVM) in Maastricht. It started in 2008 to collect all data from midwifery records of low-risk clients in midwifery practices. The main aim is quality improvement of first line midwifery care. Sub-aims are to provide more insight in first line midwifery care in the Netherlands, create research possibilities for lecturers and students of the AVM, academisation of the midwifery practice and create possibilities to transfer research projects to midwifery practices that participate in AVM-VeCaS. The promoter for AVM-VeCaS is the chairperson of the Research Centre for Midwifery Science of the AVM. Data from midwifery records are registered in a standardized way, which is communicated with all 25 participating midwifery practices. The data are sent automatically to the AVM- VeCaS-database twice every year. The VeCaS-project has been dealt with the Medical Ethical Committee (Medisch-Ethische ToetsingsCommissie, METC) Maastricht under MEC-nr. 09-4-061 and registered with the Commission Protection Personal Data (College Bescherming Persoonsgegevens) under number m1489634.
https://kb.icts.maastrichtuniversity.nl/display/ISM/Manual+File+Service+-+Mapping+UM+network+drives+in+Mac+OS+X
Selection process
Women meeting inclusion criteria (gave birth, …)
Sample size (numbers and rationale)
http://www.openepi.com/SampleSize/SSCohort.htm ?
Inclusion/exclusion criteria
See selection process??
Data
Data Collection
Data collection from existing database
problem with existing data being valid and reliable AP
Independent variables:
Draft 27/6:
Midwifery practice : may say something about the way midwives…
Level of education
Age
Parity
Previous instrumental delivery
Antenatal class
Intended place of birth
Professional attending birth
Continuous support
Place of birth
Data Analysis
(Draft 27/6 )
Descriptive statistics:
Descriptive statistics is used to evaluate and describe the variables. Frequencies and percentages will be calculated for nominal and dichotomous variables. Sample means (normally distributed metric variables), medians (skewed distributed metric variable) and standard deviations (…) will be calculated if applicable.
Inferential statistics:
To analyse if the AVM-VeCaS variables are independent predictors for PPM during labour, they will be put in a … multivariate logistic regression analysis.
Issues of Rigour
Internal and external validity will be described. For internal validity possible bias in the study design and even so confounding variables will be traced, described (Cluett and Bluff, 2000). As the data cannot be measured whilst eliminating for confounders, the statistical analysis will adjust for them. External validity will be described, based on the extent to which the results can be generalised to other populations and situations (ref). A consideration of the reliability will be made by evaluating the chance of being able to obtain the same results in a retest by other researchers. AP Also, the Cronbach’s alpha score will be calculated to evaluate the internal consistency reliability (ref).
Access, Ethical and Legal Issues
Access:
???
Ethical issues:
Database: informed consent already provided by women
Questionnaire for midwifery practices: informed consent by form (after providing information by a letter).
No risk for women, or midwifery practices, or researcher.
Ethical approval will be requested to Zuyd (Maastricht) and MHH.
Legal issues:
???
Authonomy, non-maleficence, beneficence and justice(Beauchamp 2001).
Autonomy – The right for an individual to make his or her own choice.
• Beneficence – The principle of acting with the best interest of the other in mind.
• Non-maleficence – The principle that “above all, do no harm,” as stated in the Hippocratic Oath.
• Justice – A concept that emphasizes fairness and equality among individuals.
Timetable
In order to adequately plan all needed activities to perform the intended research, a timetable (table 1) is made, based on the estimated time needed for every part of the process. Improvement of this research proposal by the feedback received after submission will be used to improve this proposal in August. Then, September and October will be used to ask for ethical approval, and to perform the extensive structured literature review. Hereafter, in November, December and January the Analysis of the data will be done, whereupon in January February and March the thesis will be written.
Table 1 GANTT chart
Aug Sept Oct Nov Dec Jan Feb Mar
Refine proposal
Ethical approval
Review literature
Analysis data
Write thesis
Budget & Funding Sources
In table 2, the estimated study costs for this research project, that requires funding, are displayed. The fees for the MHH constitute of the winter semester fee and the fee for the thesis module. The fees will be paid from the teacher scholarship.
Table 2 Estimated study cots for this research project.
MHH fees € 2800
Unpaid leave for two weeks
€ 900
Thesis printing & binding
€ 200
Travel to Hannover for the defense
€ 100
not required by hannover AP
Dissemination
The results of this study will be disseminated amongst the author’s professional colleagues of the research platform of Midwifery Science of the University of Midwifery Education & Studies in Maastricht, AVM-VeCaS midwifery practices and the colleague students of the European MSc in Midwifery. Furthermore, possibilities for publication will be explored.
Reference List
Appendices
Appendix 1: Literature search and selection process
* used search terms: belief* OR factor* OR preference OR characteristi* OR expertise OR experien* OR approach) AND ("labour pain" OR "labor pain" OR "labour-pain" OR "labor-pain" ) AND ( management OR relief OR coping OR pharmacological OR epidural OR pethidine OR remifentanyl OR non-pharmacological
Flow-chart: Display of searching and selecting relevant literature: numbers
Table 3 Selected articles per database/other sources
Database ==> Pubmed (1261) CINAHL (307) Psychology and Behavioral Sciences Collection (13) Reference lists/screens popping up via databases (1) Country
Filters ⇓==> 316 15 9
Relevance 1 12 2 3
Relevance 2 8 1 1 2
Duplicates excluded 8 1 0 2
Article finally selected ⇓==>
Leap 2010
Schytt 2010 Swe
Veringa 2011 Veringa 2011 NL
Jeschke 2012 G
Koteless 2012 Canada
Hodnett 2013 all
Klomp 2013 NL
Séjourné 2013 F
Steel 2013 Australia
Gibson 2014 USA
Räisänen 2014 Swe
Relevance 1: based on title and abstract
Relevance 2: based on full text
Duplicates in red
Appendix 2: Information about selected articles
Table 4 General data and appraisal of articles used for literature review
Author(s),year, country Aim Study design/sample Results Appraisal
Leap et al, 2010, Australia To explore women’s views of labour pain and continuity of carer.
Qualitative study/ 10 Women with continuous support during labour and having one midwife with the woman during labour facilitating a process of building confidence in their ability to give birth were less likely to require PPM. Meyer (2015)/Patton (2002):
Approach fitting to research question +
First voice –
Openness +/-
Appropriate circumstances +
Transparency of data collection +
>1 data collection method –
Transparency of methodological descisions –
Quotations used +
Transparency of researcher’s skills –
Transparency of data analysis (ie themes) +
Analysis by >1 researcher +
Potential sources of bias and error reported –
Schytt&
Walden-ström, 2010. Sweden To test the hypothesis that the decision for EDA use during labour is influenced by both the woman and her background and the regional cultural practice in the delivery unit.
Population-based cohort study/ 2529
Higher probability for EDA use during labour: nulliparity, prenatal belief that EDA would be wished. Regions in Sweden differ significantly in EDA usage.
Strobe (appendix 3):
1+
2 very scarce
3 +
4 +
5 +
6 in earlier study
7 –
8 –
9 –
10 –
11 +
12a +
12b –
12c –
13a +
14a characteristics+ confounders –
14b –
14c NA
15 +
16 a +, no unadjusted
17 –
18 –
19 +, insufficiently critical (ie no bias mentioned)
20 insufficiant
21 –
22 –
Veringa et al, 2011, Netherlands To examine if pain cognitions forecast the demand for pain relief during the first stage of labour and which pain cognition is the strongest forecaster of a demand for pain relief. Prospective cohort study/ 177 low-risk nulliparous pregnant women.
Women not requesting pain relief scored higher on internal pain control.
Women requesting pain relief during the first stage of labor had higher external pain and catastrophizing scores, experienced more pain, had a lower educational level, not attended antenatal class and a longer first stage of labour. Strobe (appendix 3):
1a +/- 1b +
2 short
3 +
4 +
5 +
6 +
7 +, no effect modifier
8 +
9 +
10 –
11 +
12 +
13 +
14a+ 14b – 14c _
15 +
16a + 16b NA 16c –
17 –
18 +
19 +, no direction or magnitude
20 +
21+
22 +
Jeschke et al. 2012, Germany To identify predictors associated EDA usage. Survey/193 The probability of EDA use was equal in women with regard to attendance of antenatal classes, age, reports of positive experiences with EDA and attitudes towards labour with EDA; was higher in women who had previous EDA and preferred painless labour and lower in multiparae.
Strobe (appendix 3):
1 +
2 short
3 +
4 +
5+
6 +/-
7 +, confounders unclear, effect modifiers –
8 +
9 –
10 –
11 +
12a + 12b – 12c –
13 +
14a +, confounders – 14b – 14c –
15 –
16a +, no unadjusted, confounders not specified 16b – 16c –
17 –
18 +
19 +
20 +
21 +
22 +
Koteles et al, 2012, Cananda To determine characteristics and satisfaction related to EDA use for labour pain relief in Canadian women. Survey/5350. Higher probability for EDA use during labour: higher education and income levels. Lower probability for EDA use during labour: First Nations, unemployed, homemaker, living in rural area, seeing a midwife, family physician or nurse in pregnancy and labour. Strobe (appendix 3):
1 +
2 +
3 +
4 +
5 +
6 +
7 only outcomes and exposures
8 –
9 not in methods, in discusiion
10 weighted sampl; not how
11 –
12 +; confounders not mentioned
13 NA
14a + not confounders
14b –
14c NA
15 +
16a –OR and 95% CI, no adjustments
16b +
16c NA
17 –
18 +
19 + bias mentioned, direct./mang. –
20 +
21 +, not critically considered
22 +
Hodnett et al, 2013, Cochrane review To assess the effects of continuous, one-to-one support during labour compared with usual care. Systematic review/Twenty-two trials, 15,288 women
Women allotted to continuous support were less likely to have analgesia during labour (RR 0.90, 95% CI 0.84 to 0.96).
CASP (appendix 3):
1 +
2 +
3 +
4 +
5 ?
6 +
7 +
8 ?
9 +
10 +
Klomp et al, 2013, Netherlands To examine the associations with low risk pregnant women’s characteristics and their preferences and actual use of in labour PPM.
Prospective multi-centre cohort study/ 1511.
Higher probability for PPM preference in pregnancy: non-Dutch ethnic background and planned hospital birth. Higher probability for actual use of preferred PPM: primiparae and planned hospital birth.
Strob (appendix 3)e:
1 +
2 +
3 +
4 +
5 +
6 +
7 only outcomes and exposures
8 +
9 –
10 –
11 +
12a +
12b –
12c –
13 NA
14a participants+ rest marginal
14b +
!4c NA
15 +
16+, no unadjusted
17-
18 +
19 +
20 +
21 –
22-
Séjourné & Callahan, 2013, France To investigate women about their reasons for birthing with/without EDA and perceptions of labour (pain). Survey (not mentioned)/ 114. Lower probability for EDA use during labour: multiparty, pain evaluation ?), labour description as not very horrible and natural, woman feeling strong during birth. Strobe (appendix 3):
1a-; 1b insufficiant
2 scarce
3 +
4 –
5 +
6 –
7 –
8 –
9 –
10 –
11 –
12 –
13 –
14 –participants: restricted, rest –
15 +
16 (un)adjusted estimates and CI-
17 –
18 –
19 +, no direction or magnitude
20 +
21 –
22 +
Steel et al, 2013, Australia To explore the determinants related to women’s use of PPM.
Cross-sectional survey/1835
Higher probability for non-PPM use during labour: married women, higher consultation rates with midwives, massage during pregnancy, yoga/meditation class, women prepared for labour. Lower probability for non-PPM use during labour: multiparity, higher obstetric consultation rates, previous low birth weight. Higher probability for EDA use during labour: previous caesarean section or instrumental delivery,
Lower probability for EDA use during labour: use of herbal tea, birthing in community/birth centre settings, women who feel safer if they know an obstetrician. Lower probability for pethidine use during labour: birthing in community/birth centre settings, university qualification Strobe (appendix 3):
1 +
2 +
3 +
4 –
5 +
6+
7 only outcomes and exposures
8 +
9 not here, in discussion
10 –
11 +
12a +/-
12b +
12c –
13 NA
14 participants +, rest-
15+
16a OR without 95% CI 16b + 16c –
17 –
18 unclear
19 + no direction or magnitude
20 +
21 +
22 +
Gibson, 2014, USA To determine differences in the preparation for and experiences with labour pain by women electing midwives versus obstetricians.
Qualitative study/
80 Higher probability for EDA use during labour: women receiving care from an obstetrician, giving birth in hospital Meyer (2015)/Patton (2002):
Approach fitting to research question
First voice +
Openness
Appropriate circumstances
Transparency of data collection
>1 data collection method
Transparency of methodological descisions
Quotations used
Transparency of researcher’s skills
Transparency of data analysis (ie themes)
Analysis by >1 researcher
Potential sources of bias and error reported
Räisänen et al, 2014, Sweden To evaluate if socioeconomic status influences EDA use for labour pain relief in publicly funded health care. Population-based case–control study/ 521179
Higher probability for EDA use during labour: multiparity, induction of labour, higher birthweight,. G1: youg maternal age, single marital status, smoking, post-term pregnancy, pre-eclampsia, gestational diabetes, maternal diabetes mellitus, depression, fear of childbirth and prior terminations. P>1: maternal age> 40. Strobe (appendix 3):
1 +
2 +
3 +
4 +
5 +
6 +
7 +
8 +
9 +
10 NA whole population
11 +
12 +
13 NA
14 +
15 +
16 only adjusted, confounders not further commented
17 +
18 +
19 + not magnitude
20 +
21-
22 +
NA: not applicable
Appendix 3: Checklists used for appraisal