Initial Preference for Labor Without Neuraxial Analgesia and Actual Use: Results from a National Survey in France Laure Kpéa, RM, MPH,*† Marie-Pierre Bonnet, MD, PhD,*†‡ Camille Le Ray, MD, PhD,*†§ Caroline Prunet, MPH,*† Anne-Sophie Ducloy-Bouthors, MD,∥ and Béatrice Blondel, PhD*† BACKGROUND: The rate of neuraxial analgesia during labor in France is one of the highest among high-income countries: 77% of vaginal deliveries in 2010. In this context, the question of how women’s preferences for delivering without neuraxial analgesia relate to actual use is of interest. Our objective was to study the factors associated with women’s initial preference for labor without neuraxial analgesia and those associated with its use in women who initially preferred not to have it. METHODS: We used data from the 2010 French National Perinatal Survey, a cross-sectional study of a representative sample of all births in France. Data were collected from interviews with mothers in the postpartum ward and from medical records. Our sample included 7123 women who had vaginal deliveries and were at low risk for cesarean delivery. The factors analyzed were maternal sociodemographic characteristics, prenatal care, childbirth class attendance, labor management, and organization of maternity units. Multilevel Poisson regression models were used to study factors associated with women’s initial preference in the overall population and to study factors associated with actual use of neuraxial analgesia in the group of women who initially preferred not to have it. RESULTS: Initially, 26% of our population (n = 1835) preferred to deliver without neuraxial analgesia; this preference was associated with high parity, unfavorable social conditions, and delivery in a public maternity unit. Among these women, 52% (n = 961) delivered with neuraxial analgesia. This discrepancy between initial preference and actual use was significantly associated with nulliparity (adjusted relative risk [aRR] = 1.4; 95% confidence interval [CI], 1.3–1.6), oxytocin augmentation of labor (aRR = 2.4; 95% CI, 2.1–2.7), presence of an anesthesiologist in the unit 24/7 (aRR = 1.4; 95% CI, 1.2–1.6; compared with delivery in hospitals without an anesthesiologist on site 24/7), and high midwife workload (aRR = 1.1; 95% CI, 1.0–1.2). There was no clear association with maternal educational level. CONCLUSIONS: Our results suggest that parity, the management of labor, and availability of anesthesiologists play a major role in the intrapartum decision to use neuraxial analgesia for women who initially preferred not to have it. Further research is necessary in the clinical circumstances leading to this decision and the role of women’s demands and medical staff attitudes throughout labor. (Anesth Analg 2015;121:759–66)
N
euraxial analgesia is the most effective method for pain relief during labor.1 Its use in France is very high: a rate of 77% of vaginal deliveries was recorded in 2010.2 In comparison, neuraxial analgesia was used in 65% of vaginal deliveries in Finland in 2012,3 61% in the United States in 2008,4 and 57% in Canada in 2006.5 From the *INSERM (U1153), Obstetrical, Perinatal and Pediatric Epidemiology Research Team, Center for Epidemiology and Biostatistics, Paris, France; †DHU Risks in Pregnancy, Paris-Descartes University, Paris, France; ‡Service d’Anesthésie-Réanimation Chirurgicale, Hôpital Cochin, Hôpitaux Universitaires Paris Centre, Assistance Publique Hôpitaux de Paris, Paris, France; §Maternité Port Royal, Hôpital Cochin Saint-Vincent-de-Paul, Assistance Publique Hôpitaux de Paris, Paris, France; and ∥Pôle Anesthésie Réanimation, Maternité Jeanne de Flandre, CHRU Lille, Lille, France. Accepted for publication March 25, 2015.
Funding: The 2010 National Perinatal Survey was funded by the French Ministry of Health. The authors declare no conflicts of interest. Reprints will not be available from the authors. Address correspondence to Béatrice Blondel, PhD, INSERM U 1153, Obstetrical Perinatal and Pediatric Epidemiology Research Team, Port Royal Maternity Unit, 53 avenue de l’Observatoire, 75014 Paris, France. Address e-mail to [email protected]. Copyright © 2015 International Anesthesia Research Society DOI: 10.1213/ANE.0000000000000832
September 2015 • Volume 121 • Number 3
Neuraxial analgesia may be indicated when the risk of cesarean delivery or of obstetric maneuvers is high, or in the setting of uterine scars, breech presentation, or multiple pregnancy, to avoid the need for general anesthesia. Beyond these situations, in principle, its use should depend only on the woman’s choice.6,7 Previous studies have shown that both preference for neuraxial analgesia and its actual use during labor are more frequent in nulliparas, women with a high educational level or high socioeconomic status, and non-Hispanic white women.8–13 Actual use also is more frequent for women with induction of labor, instrumental vaginal deliveries, or giving birth in large public or teaching hospitals.9,10,14 Few studies have specifically examined the association between women’s initial preference to not use neuraxial analgesia and its final use.15,16 This subject is nonetheless important because it helps us to understand how women’s preferences change during labor and how the medical team in the labor room takes into consideration both women’s requests and the particular circumstances of their delivery. Our first objective was to estimate the proportion of women with a low risk of cesarean delivery who initially preferred to give birth without neuraxial analgesia and to www.anesthesia-analgesia.org
759
Copyright © 2015 International Anesthesia Research Society. Unauthorized reproduction of this article is prohibited.
Initial Preference for Labor Without Epidural and Actual Use
study the factors associated with this preference. Our second objective was to estimate the proportion of women who did not initially prefer—but finally used—neuraxial analgesia during labor and to investigate the maternal, medical, and organizational factors associated with receiving neuraxial labor analgesia when they did not prefer it initially. This study analyzed data from a representative sample of births in France in 2010.
METHODS
The 2010 French National Perinatal Survey was approved by the National Council on Statistical Information (Comité du label) and the French Commission on Information Technology and Liberties (registration number 909003). The approval covers use of this survey by its coordinating team in our research unit at the National Institute of Health and Medical Research. All women provided oral informed consent to the interview, and the Commission did not require written consent. The investigation of women’s preferences for analgesia during delivery was one of the study objectives.
Study Population
The National Perinatal Surveys are regular cross-sectional surveys that include all women with live births and stillbirths in France, at 22 gestational weeks or more, or weighing at least 500 g, during a 1-week period in all French maternity units.2 Data come from 3 sources: the medical records; interviews of the women about their social and demographic characteristics, prenatal care, and pain management during labor; and a questionnaire about maternity unit organization, completed by the head of each unit. Midwives interviewed the women according to a standardized questionnaire, 1 to 4 days after delivery, when the women were hospitalized in the postpartum ward. The 2010 sample included 14,681 women in 535 maternity units.2 Comparisons of this database with data from birth certificates and hospital discharge statistics show that the sample was representative of all births in France in 2010.2,17
We excluded all fetal deaths (because their mothers were not interviewed) and all cesarean deliveries (Fig. 1). We also excluded women who might have received a neuraxial analgesia because of being at high risk of cesarean delivery during labor (previous cesarean, multiple pregnancy, noncephalic presentation, and delivery before 37 weeks’ gestation). Finally, we excluded women who had induced labor before or after rupture of membranes because they often have very painful contractions. All the women in this study started labor spontaneously.
Outcome Measures and Variables
Women’s initial preference was known from the following question: “Before your delivery, did you want an epidural for pain relief?” The precoded answers were yes or no. Information about the use of neuraxial analgesia during labor was extracted from the medical records. The term “neuraxial analgesia” was used for all neuraxial techniques used for labor pain relief, including epidural, spinal, and combined spinal-epidural analgesia. The characteristics of mothers that we studied were age, parity, educational level, nationality, and family situation (living with partner or not). We defined 3 separate binary variables to take women’s health status and medical conditions into account: adverse obstetrical history (previous stillbirth, neonatal death, fetal growth restriction, preterm birth), chronic medical conditions (mainly hypertension and obesity [body mass index ≥35 kg/m2]), and medical disorders or unfavorable conditions during the current pregnancy (mainly gestational diabetes, hypertension, hospital admission for preterm labor). Care during pregnancy included adequacy of prenatal care and attendance at prenatal classes. Prenatal care was defined as adequate when women had at least 1 visit per month and 3 ultrasound examinations, as recommended in France for full-term pregnancies. Characteristics of labor and delivery were gestational age, oxytocin augmentation of labor, and mode of vaginal delivery (spontaneous or operative vaginal delivery). Characteristics of maternity unit organization were status (public or private), availability
Figure 1. Flow chart of the study population.
760 www.anesthesia-analgesia.org
anesthesia & analgesia
Copyright © 2015 International Anesthesia Research Society. Unauthorized reproduction of this article is prohibited.
of anesthesiologist (always present in the maternity unit, always present in the hospital, or not always present), and midwives’ workload in the labor ward. Workload was estimated in each unit by calculating the ratio of the number of midwives per shift in the labor ward to the number of annual deliveries; workload was considered high in the quartile with the lowest ratio, that is, in the 25% of maternity units with the fewest midwives per annual deliveries.
Statistical Analysis
We first estimated the proportion of women who initially preferred to give birth without neuraxial analgesia and its 95% confidence interval (CI), in the overall sample of women at low risk of cesarean delivery, and by characteristics of women, prenatal care, and maternity units. We tested the associations between the preference for labor without neuraxial analgesia (versus preference for labor with neuraxial analgesia) and the studied characteristics, using univariate and multivariate analyses. Second, among the women who initially preferred to deliver without neuraxial analgesia, we estimated the proportion (and 95% CI) of those who finally used neuraxial analgesia during labor in the overall group and by characteristics of women, prenatal care, labor, delivery, and maternity units. We studied the associations between the actual use of neuraxial analgesia (versus nonuse of neuraxial analgesia) and the studied characteristics, using univariate and multivariate analyses. Univariate associations were tested with χ2 tests. We used multilevel Poisson regression models with robust error variance for the multivariable analyses. We included all factors associated in the univariate analyses described earlier (P < 0.20) and the medical conditions (adverse obstetrical history, chronic medical conditions, and medical disorders during the current pregnancy). These models included a random effect for the maternity unit based on our hierarchical data. We included interaction terms in the models, to test whether there were interactions between parity and each studied characteristic, because there could be variations in labor experience and obstetrical management between nulliparous and parous women. Adjusted relative risks (aRRs) and their 95% CIs were estimated, and Wald tests were performed. A threshold of 5% was used to define statistical significance. Women with missing data were excluded from multivariable analyses, and thus, the number of women was slightly lower than the total number of women. Data were analyzed with SAS 9.3 (SAS Institute Inc., Cary, NC) and Stata SE13.0 (StataCorp LP, College Station, TX).
RESULTS
The sample included 7653 women at low risk of cesarean delivery (Fig. 1). Because information about initial preference for or final use of neuraxial analgesia was unknown for 530 women (6.9%), we analyzed data from 7123 women. In this sample, 25.8% (95% CI, 24.8–26.8) of women initially preferred to deliver without neuraxial analgesia (Fig. 1). The proportions of women who preferred no neuraxial analgesia by maternal characteristics, prenatal care, and hospital status are presented in Table 1. When we took into account the maternal, medical, and organizational
September 2015 • Volume 121 • Number 3
characteristics in the multivariable analysis, the aRR of preference for labor without neuraxial analgesia was greater than one in women younger than 25 years (compared with age 25–29 years), multiparas (compared with primiparas), women with a low educational level, non-French nationality, and single women. The aRR was lower than one in private maternity units. The association between women’s preferences and prenatal classes differed according to parity (significant interaction, P = 0.002); attendance at prenatal classes was significantly associated with a preference for labor without neuraxial analgesia for parous women only (primiparas: aRR = 1.3 [95% CI, 1.1–1.6], multiparas: aRR = 1.4 [95% CI, 1.1–1.6]). The interactions between parity and the other variables were not significant (all P > 0.20). Among the women who initially preferred to give birth without neuraxial analgesia (n = 1835), 52.4% (95% CI, 50.1– 54.7) used neuraxial analgesia during labor. Table 2 presents maternal, care, and hospital characteristics associated with neuraxial analgesia use in this group. The relative risk of neuraxial analgesia was greater for nulliparity, gestational age ≥41 weeks, oxytocin augmentation of labor, anesthesiologist’s presence 24/7, and high midwife workload. Oxytocin augmentation of labor had a stronger impact on the use of neuraxial analgesia for parous women (significant interaction with parity, P < 0.001; nulliparas: aRR = 1.8 [95% CI, 1.6–2.1], primiparas: aRR = 3.2 [95% CI, 2.4–4.1]; multiparas: aRR = 3.6 [95% CI, 2.7–4.8]). There was no significant interaction between the other studied characteristics and parity (all P > 0.10).
DISCUSSION
A quarter of the women at low risk of cesarean delivery in France initially preferred to give birth without neuraxial analgesia; however, about half of them ultimately used it. The main factors associated with use among these women were nulliparity, oxytocin augmentation of labor, and the availability 24/7 of an anesthesiologist in the obstetric department. Taking into account women’s preferences not to have neuraxial analgesia is an important issue in France because the organization of care and the management of labor and delivery contribute in numerous ways to the widespread use of neuraxial analgesia during labor. Consultation with an anesthesiologist is mandatory during the third trimester of pregnancy. Accordingly, every woman knows the labor pain relief options available in the maternity unit and should, therefore, be able to make an informed decision. The national health insurance fund provides universal coverage for maternity care and reimburses the anesthesiology consultation and analgesia administration in both public and private maternity units. An anesthesiologist must always be present (24 hours per day, 7 days a week) on site in the obstetric department or in another department in hospitals with 1500 to 2000 deliveries a year, and on site in the obstetric department in larger units; midwives monitor parturients with neuraxial analgesia and are authorized to reinject epidural analgesic solutions ordered by the anesthesiologist (top-up doses). In addition, each midwife often is responsible for several laboring women at the same time, which can prevent her from providing the additional emotional support needed by many women who choose to give birth without neuraxial analgesia.
www.anesthesia-analgesia.org
761
Copyright © 2015 International Anesthesia Research Society. Unauthorized reproduction of this article is prohibited.
Initial Preference for Labor Without Epidural and Actual Use
Table 1. Initial Preference for Delivery Without Neuraxial Analgesia by Characteristics of Mothers, Pregnancies, and Maternity Units: Percentages of Women and Adjusted Relative Risks Total Maternal age (y)
N
euraxial analgesia is the most effective method for pain relief during labor.1 Its use in France is very high: a rate of 77% of vaginal deliveries was recorded in 2010.2 In comparison, neuraxial analgesia was used in 65% of vaginal deliveries in Finland in 2012,3 61% in the United States in 2008,4 and 57% in Canada in 2006.5 From the *INSERM (U1153), Obstetrical, Perinatal and Pediatric Epidemiology Research Team, Center for Epidemiology and Biostatistics, Paris, France; †DHU Risks in Pregnancy, Paris-Descartes University, Paris, France; ‡Service d’Anesthésie-Réanimation Chirurgicale, Hôpital Cochin, Hôpitaux Universitaires Paris Centre, Assistance Publique Hôpitaux de Paris, Paris, France; §Maternité Port Royal, Hôpital Cochin Saint-Vincent-de-Paul, Assistance Publique Hôpitaux de Paris, Paris, France; and ∥Pôle Anesthésie Réanimation, Maternité Jeanne de Flandre, CHRU Lille, Lille, France. Accepted for publication March 25, 2015.
Funding: The 2010 National Perinatal Survey was funded by the French Ministry of Health. The authors declare no conflicts of interest. Reprints will not be available from the authors. Address correspondence to Béatrice Blondel, PhD, INSERM U 1153, Obstetrical Perinatal and Pediatric Epidemiology Research Team, Port Royal Maternity Unit, 53 avenue de l’Observatoire, 75014 Paris, France. Address e-mail to [email protected]. Copyright © 2015 International Anesthesia Research Society DOI: 10.1213/ANE.0000000000000832
September 2015 • Volume 121 • Number 3
Neuraxial analgesia may be indicated when the risk of cesarean delivery or of obstetric maneuvers is high, or in the setting of uterine scars, breech presentation, or multiple pregnancy, to avoid the need for general anesthesia. Beyond these situations, in principle, its use should depend only on the woman’s choice.6,7 Previous studies have shown that both preference for neuraxial analgesia and its actual use during labor are more frequent in nulliparas, women with a high educational level or high socioeconomic status, and non-Hispanic white women.8–13 Actual use also is more frequent for women with induction of labor, instrumental vaginal deliveries, or giving birth in large public or teaching hospitals.9,10,14 Few studies have specifically examined the association between women’s initial preference to not use neuraxial analgesia and its final use.15,16 This subject is nonetheless important because it helps us to understand how women’s preferences change during labor and how the medical team in the labor room takes into consideration both women’s requests and the particular circumstances of their delivery. Our first objective was to estimate the proportion of women with a low risk of cesarean delivery who initially preferred to give birth without neuraxial analgesia and to www.anesthesia-analgesia.org
759
Copyright © 2015 International Anesthesia Research Society. Unauthorized reproduction of this article is prohibited.
Initial Preference for Labor Without Epidural and Actual Use
study the factors associated with this preference. Our second objective was to estimate the proportion of women who did not initially prefer—but finally used—neuraxial analgesia during labor and to investigate the maternal, medical, and organizational factors associated with receiving neuraxial labor analgesia when they did not prefer it initially. This study analyzed data from a representative sample of births in France in 2010.
METHODS
The 2010 French National Perinatal Survey was approved by the National Council on Statistical Information (Comité du label) and the French Commission on Information Technology and Liberties (registration number 909003). The approval covers use of this survey by its coordinating team in our research unit at the National Institute of Health and Medical Research. All women provided oral informed consent to the interview, and the Commission did not require written consent. The investigation of women’s preferences for analgesia during delivery was one of the study objectives.
Study Population
The National Perinatal Surveys are regular cross-sectional surveys that include all women with live births and stillbirths in France, at 22 gestational weeks or more, or weighing at least 500 g, during a 1-week period in all French maternity units.2 Data come from 3 sources: the medical records; interviews of the women about their social and demographic characteristics, prenatal care, and pain management during labor; and a questionnaire about maternity unit organization, completed by the head of each unit. Midwives interviewed the women according to a standardized questionnaire, 1 to 4 days after delivery, when the women were hospitalized in the postpartum ward. The 2010 sample included 14,681 women in 535 maternity units.2 Comparisons of this database with data from birth certificates and hospital discharge statistics show that the sample was representative of all births in France in 2010.2,17
We excluded all fetal deaths (because their mothers were not interviewed) and all cesarean deliveries (Fig. 1). We also excluded women who might have received a neuraxial analgesia because of being at high risk of cesarean delivery during labor (previous cesarean, multiple pregnancy, noncephalic presentation, and delivery before 37 weeks’ gestation). Finally, we excluded women who had induced labor before or after rupture of membranes because they often have very painful contractions. All the women in this study started labor spontaneously.
Outcome Measures and Variables
Women’s initial preference was known from the following question: “Before your delivery, did you want an epidural for pain relief?” The precoded answers were yes or no. Information about the use of neuraxial analgesia during labor was extracted from the medical records. The term “neuraxial analgesia” was used for all neuraxial techniques used for labor pain relief, including epidural, spinal, and combined spinal-epidural analgesia. The characteristics of mothers that we studied were age, parity, educational level, nationality, and family situation (living with partner or not). We defined 3 separate binary variables to take women’s health status and medical conditions into account: adverse obstetrical history (previous stillbirth, neonatal death, fetal growth restriction, preterm birth), chronic medical conditions (mainly hypertension and obesity [body mass index ≥35 kg/m2]), and medical disorders or unfavorable conditions during the current pregnancy (mainly gestational diabetes, hypertension, hospital admission for preterm labor). Care during pregnancy included adequacy of prenatal care and attendance at prenatal classes. Prenatal care was defined as adequate when women had at least 1 visit per month and 3 ultrasound examinations, as recommended in France for full-term pregnancies. Characteristics of labor and delivery were gestational age, oxytocin augmentation of labor, and mode of vaginal delivery (spontaneous or operative vaginal delivery). Characteristics of maternity unit organization were status (public or private), availability
Figure 1. Flow chart of the study population.
760 www.anesthesia-analgesia.org
anesthesia & analgesia
Copyright © 2015 International Anesthesia Research Society. Unauthorized reproduction of this article is prohibited.
of anesthesiologist (always present in the maternity unit, always present in the hospital, or not always present), and midwives’ workload in the labor ward. Workload was estimated in each unit by calculating the ratio of the number of midwives per shift in the labor ward to the number of annual deliveries; workload was considered high in the quartile with the lowest ratio, that is, in the 25% of maternity units with the fewest midwives per annual deliveries.
Statistical Analysis
We first estimated the proportion of women who initially preferred to give birth without neuraxial analgesia and its 95% confidence interval (CI), in the overall sample of women at low risk of cesarean delivery, and by characteristics of women, prenatal care, and maternity units. We tested the associations between the preference for labor without neuraxial analgesia (versus preference for labor with neuraxial analgesia) and the studied characteristics, using univariate and multivariate analyses. Second, among the women who initially preferred to deliver without neuraxial analgesia, we estimated the proportion (and 95% CI) of those who finally used neuraxial analgesia during labor in the overall group and by characteristics of women, prenatal care, labor, delivery, and maternity units. We studied the associations between the actual use of neuraxial analgesia (versus nonuse of neuraxial analgesia) and the studied characteristics, using univariate and multivariate analyses. Univariate associations were tested with χ2 tests. We used multilevel Poisson regression models with robust error variance for the multivariable analyses. We included all factors associated in the univariate analyses described earlier (P < 0.20) and the medical conditions (adverse obstetrical history, chronic medical conditions, and medical disorders during the current pregnancy). These models included a random effect for the maternity unit based on our hierarchical data. We included interaction terms in the models, to test whether there were interactions between parity and each studied characteristic, because there could be variations in labor experience and obstetrical management between nulliparous and parous women. Adjusted relative risks (aRRs) and their 95% CIs were estimated, and Wald tests were performed. A threshold of 5% was used to define statistical significance. Women with missing data were excluded from multivariable analyses, and thus, the number of women was slightly lower than the total number of women. Data were analyzed with SAS 9.3 (SAS Institute Inc., Cary, NC) and Stata SE13.0 (StataCorp LP, College Station, TX).
RESULTS
The sample included 7653 women at low risk of cesarean delivery (Fig. 1). Because information about initial preference for or final use of neuraxial analgesia was unknown for 530 women (6.9%), we analyzed data from 7123 women. In this sample, 25.8% (95% CI, 24.8–26.8) of women initially preferred to deliver without neuraxial analgesia (Fig. 1). The proportions of women who preferred no neuraxial analgesia by maternal characteristics, prenatal care, and hospital status are presented in Table 1. When we took into account the maternal, medical, and organizational
September 2015 • Volume 121 • Number 3
characteristics in the multivariable analysis, the aRR of preference for labor without neuraxial analgesia was greater than one in women younger than 25 years (compared with age 25–29 years), multiparas (compared with primiparas), women with a low educational level, non-French nationality, and single women. The aRR was lower than one in private maternity units. The association between women’s preferences and prenatal classes differed according to parity (significant interaction, P = 0.002); attendance at prenatal classes was significantly associated with a preference for labor without neuraxial analgesia for parous women only (primiparas: aRR = 1.3 [95% CI, 1.1–1.6], multiparas: aRR = 1.4 [95% CI, 1.1–1.6]). The interactions between parity and the other variables were not significant (all P > 0.20). Among the women who initially preferred to give birth without neuraxial analgesia (n = 1835), 52.4% (95% CI, 50.1– 54.7) used neuraxial analgesia during labor. Table 2 presents maternal, care, and hospital characteristics associated with neuraxial analgesia use in this group. The relative risk of neuraxial analgesia was greater for nulliparity, gestational age ≥41 weeks, oxytocin augmentation of labor, anesthesiologist’s presence 24/7, and high midwife workload. Oxytocin augmentation of labor had a stronger impact on the use of neuraxial analgesia for parous women (significant interaction with parity, P < 0.001; nulliparas: aRR = 1.8 [95% CI, 1.6–2.1], primiparas: aRR = 3.2 [95% CI, 2.4–4.1]; multiparas: aRR = 3.6 [95% CI, 2.7–4.8]). There was no significant interaction between the other studied characteristics and parity (all P > 0.10).
DISCUSSION
A quarter of the women at low risk of cesarean delivery in France initially preferred to give birth without neuraxial analgesia; however, about half of them ultimately used it. The main factors associated with use among these women were nulliparity, oxytocin augmentation of labor, and the availability 24/7 of an anesthesiologist in the obstetric department. Taking into account women’s preferences not to have neuraxial analgesia is an important issue in France because the organization of care and the management of labor and delivery contribute in numerous ways to the widespread use of neuraxial analgesia during labor. Consultation with an anesthesiologist is mandatory during the third trimester of pregnancy. Accordingly, every woman knows the labor pain relief options available in the maternity unit and should, therefore, be able to make an informed decision. The national health insurance fund provides universal coverage for maternity care and reimburses the anesthesiology consultation and analgesia administration in both public and private maternity units. An anesthesiologist must always be present (24 hours per day, 7 days a week) on site in the obstetric department or in another department in hospitals with 1500 to 2000 deliveries a year, and on site in the obstetric department in larger units; midwives monitor parturients with neuraxial analgesia and are authorized to reinject epidural analgesic solutions ordered by the anesthesiologist (top-up doses). In addition, each midwife often is responsible for several laboring women at the same time, which can prevent her from providing the additional emotional support needed by many women who choose to give birth without neuraxial analgesia.
www.anesthesia-analgesia.org
761
Copyright © 2015 International Anesthesia Research Society. Unauthorized reproduction of this article is prohibited.
Initial Preference for Labor Without Epidural and Actual Use
Table 1. Initial Preference for Delivery Without Neuraxial Analgesia by Characteristics of Mothers, Pregnancies, and Maternity Units: Percentages of Women and Adjusted Relative Risks Total Maternal age (y)
