Abstract Objective. To test the hypothesis that the decision to use epidural analgesia during labor is influenced not only by the woman and her background but also by the local cultural practice in the delivery unit. Design. Population-based cohort study. Setting. All delivery units in Sweden. Population. A nationwide sample of 2,529 women. Methods. Data were collected by questionnaires in early pregnancy and two months after birth, and from the Swedish Medical Birth Register. Logistic regression analysis was conducted, adjusted for gestational age, induction of labor and infant birthweight. Main outcome measures. Epidural analgesia during labor. Results. The odds of having an epidural analgesia were more than twice as high in the Stockholm region (odds ratio (OR) 2.4; 95% confidence interval (CI) 1.7-3.4) and three times higher in middle-north Sweden (OR 3.0; 95% CI 1.7-5.3) compared with the south of Sweden. Of the maternal factors, nulliparity was the strongest predictor (OR 6.3; 95% CI 5.1-7.9), followed by a prenatal belief that epidural analgesia would be needed (OR 3.5; 95% CI 2.8-4.4). Conclusion. The hypothesis of the study was confirmed. The woman and her background as well as the local cultural practice in the delivery unit matter with regard to the use of epidural analgesia.
The Department of Woman and Child Health, Reproductive and Perinatal Health Division, Karolinska Institutet, Campus Solna, Retzius väg 13 A, 4 tr, 171 77 Stockholm, Sweden.
OBJECTIVES: to investigate women's experiences of postnatal hospital care in relation to four different aspects: (1) interpersonal care; (2) time spent on physical check-ups; (3) time spent on information and support; and (4) time spent on assistance with breast feeding. More specifically, we aimed to establish whether typical clusters of women could be identified, and if so, whether these clusters could be related to specific outcomes of care, to the way in which care is organised, and to the individual's psychological health and socio-demographic background. DESIGN: longitudinal population-based survey, including three questionnaires completed in early pregnancy, at 2 months and 1 year after birth. SETTING: all postnatal wards in Sweden. PARTICIPANTS: women (n=2338) recruited at their first booking visit at 593 antenatal clinics, who responded to questions relating to postnatal hospital care 2 months after birth. FINDINGS: eight cluster profiles defined by the four aspects of postnatal care were identified. About half of the women were found in clusters that were satisfied with most aspects of care, and half in clusters that were dissatisfied with one aspect or more. Only 32% were very satisfied with all four dimensions. Specific groups of women, such as first-time mothers, migrants, young mothers and those with a short length of stay, were dissatisfied with different assessments of postnatal care. Psychological health in early pregnancy was associated with high ratings of all aspects of care, whereas emergency caesarean section and instrumental vaginal delivery was associated with dissatisfaction with breast feeding support and time spent on health check-ups. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: women's individual appraisal of specific aspects of hospital postnatal care could be grouped into response patterns that were shared by smaller or larger groups. These patterns were related to maternal characteristics, labour outcomes and the way in which care was organised. The multi-faceted approach used in this study provided details about who was dissatisfied with what, and showed that women are not necessarily either satisfied or dissatisfied with care in a general sense. In order to provide individualised care, the carer needs to be aware of these differences.
Department of Woman and Child Health, Division of Reproductive and Perinatal Health Care, Karolinska Institutet, Retzius väg 13 a-b, 171 77 Stockholm, Sweden.
This paper was presented at a Health Conference in March 2007, celebrating the 150th birthday of the Royal Women's Hospital in Melbourne. It discusses the definition of "normal childbirth", and the pros and cons of three medical technologies(a): caesarean section, epidural analgesia during labour and routine ultrasound screening during pregnancy, and whether clinical practices, in Australia and Sweden (author is Swedish), in relation to these methods are evidence based. It also discusses the impact of non-scientific reasons, such as anxiety, on clinical decision making.
