Factors Affecting Opinion of Women Regarding the Use of Epidural Anesthesia During Labor in the Eastern Region of Saudi Arabia

Objectives Epidural anesthesia (EA) is one of the most popular and efficient techniques for labor pain relief. Women’s preferences and awareness about EA have been investigated worldwide through various studies. The level of awareness varies from region to region in Saudi Arabia. Consequently, the aim of this study is to understand the views of women regarding EA in the eastern region of Saudi Arabia and how this affects decision-making with regard to EA. Methods This cross-sectional study was conducted in the eastern region of Saudi Arabia from July-September, 2021, through a self-administered online questionnaire. The study included Saudi females aged 18 years and older living in the eastern region of Saudi Arabia. Data were analyzed using IBM SPSS Statistics for Windows, Version 25.0 (Released 2017; IBM Corp., Armonk, New York, United States). A p-value less than 0.05 was considered statistically significant. Results A total of 499 participants were included in the study. Nearly half of them were between the age of 25-35 years (46.9%, n = 234). The mean of the awareness score was 3.66 with SD = 1.491. It was observed that age was related to awareness. Women older than 45 years of age were found to be less aware. Additionally, the number of children these women had further affected their awareness; those who had four children or more tended to be less aware. The effect of regular antenatal care visits was clear, as pregnant women who maintained regular antenatal care visits showed more awareness. As for income, there was a notable increase in awareness with an increase in income. Participants who had had a previous delivery with EA were found to be more aware. Likewise, educational status also impacted their awareness. Women with a high school certificate or below were found to be less aware. Lastly, it was observed that a majority of the participants chose not to request an EA upon their next delivery (60.5%, n = 302). Conclusion The results demonstrated that awareness of EA in the study area is acceptable. The most important predictors for awareness about EA were age, educational status, income, number of children, regular antenatal visits, and previous delivery with EA. It was concluded that women who were aware were more likely to take EA.


Introduction
Labor is a physiological process defined as spontaneous painful uterine contractions that are responsible for expelling the fetus from the uterus [1][2]. Labor pain is considered the worst pain for pregnant women [1]. However, labor pain is subjective and differs among women [3]. There are several methods for labor pain relief; one of them is epidural anesthesia (EA). EA is widely used and is considered to be one of the most common and effective labor pain-relieving methods [4]. EA works by numbing sensory nerves as they enter the spinal cord. The anesthetic is injected into an area of the spine known as the epidural space. Once the medication has worn off, the sensation in the affected area returns [5]. EA can effectively decrease labor pain by nearly 95% [6]. Good pain management during labor requires cooperation between obstetricians, anesthesiologists, and pregnant women.
Several studies have been conducted globally to determine the preference and awareness of women toward EA. These studies show how culture and other factors affect women's opinions about EA. In Ethiopia, awareness about EA is low. This is because it was believed that labor pain is natural and that taking anesthesia for labor pain would be against the will of God [1]. On the other hand, EA is considered the most effective method in the United States and Canada [7]. In the Arabic region, EA is most commonly used by Palestinian [8] and Lebanese women [9].
Based on our findings, there are five studies to date regarding this topic in Saudi Arabia. In a study conducted in Khamis Mushait in 2020, results showed a low level of awareness toward EA [6]. Furthermore, in a study conducted in Najran in 2019, a lack of awareness about EA was found to exist. One of the reasons for the same was attributed to the fact that the information women had about EA stemmed from their family and friends, and not from a healthcare worker [2]. Conversely, in a study conducted in AlKhobar in 2021, with 209 participants from King Fahad University Hospital, findings revealed that most women were aware of EA for labor pain relief [10].
Saudi Arabia is a huge country, and each region's awareness level differs. For this reason, the primary aim of this study is to understand women's opinions regarding EA in the eastern region of Saudi Arabia and to elucidate the factors affecting decision-making about the same

Materials And Methods
This cross-sectional study was conducted in the eastern region of Saudi Arabia from July to September, 2021, through a self-administered online questionnaire taken from Ali Alahmari [6] and Naithani [3] studies with some modifications. Approximately two minutes were needed to fulfill the questionnaire. It was translated into Arabic and divided into five sections. The first section pertained to socio-demographic data, such as age, educational status, occupation, income, marital status, pregnancy, maternity, and antenatal care. The second section focused on the labor pain experienced by women who had delivered before. The third and fourth sections explored awareness about labor pain-relieving methods and EA. The last section contained a concluding question to assess the willingness of the participants to take an EA in the next delivery. Sociodemographic data were considered predictors, while awareness level and willingness to take EA were considered as outcomes.
The sample size was determined to be 385, calculated with a margin error of 5% and a confidence level of 95%. The inclusion criteria were all Saudi females aged 18 years and above, living in the eastern region of Saudi Arabia. The exclusion criteria were females aged less than 18, or females from other areas. Additionally, those who did not complete the questionnaire were excluded from the study.
The data were analyzed using IBM SPSS Statistics for Windows, Version 25.0 (Released 2017; IBM Corp., Armonk, New York, United States). A p-value less than 0.05 was considered statistically significant. Chisquare test was used. For the purpose of knowledge interpretation, each question was assigned a score of one point. Anyone who scored less than or equal to 3 out of 6 was considered to have insufficient knowledge. Anyone who scored above 3 was considered to have enough knowledge.
Consent was obtained from all participants before they were involved in the study. All data were kept confidential, and no subject was identified by name. The study was conducted under the approval of the Institutional Review Board Committee of King Fahad Hospital, Hofuf, Saudi Arabia (approval number: 19-EP-2021).

Results
A total of 499 participants completed the questionnaire. The study included women who were between 18 and 45 years of age. Nearly half were between 25 and 35 years of age (46.9%, n = 234). Table 1 shows the sociodemographic data of the participants.  Regarding the awareness score, 4.01% of participants scored 0 out of 6, only 8.62% scored 6 out of 6, about 29.66% scored 4, and 22.65% scored 5. Nearly 61% scored 4 and above, which was generally considered to be a good score. The mean of the awareness score was 3.66, with a median = 4.00 and SD = 1.491 ( Figure 1). Table 2 shows the relationships between demographic data and awareness about the EA effect. It was found that age was related to awareness (p-value of 0.008) as those older than 45 years of age were less aware. Likewise, educational status also impacted awareness (p-value of 0.002). Women with a high school certificate or below were found to be less aware. On the contrary, those with bachelor's degrees or above were found to be more aware. According to the data, the number of children also affected awareness (p-value of 0.05) as those who had four children or more were found to be less aware, and those who had one to three children were found to be more aware. The effect of regular antenatal care visits was apparent (p-value of 0.005). Pregnant women who maintained regular antenatal care visits showed a higher level of awareness.

FIGURE 1: Awareness Score
Additionally, the study also demonstrated a significant relationship between awareness and previous delivery with EA (p-value <0.0001). It was observed that those who had tried EA before were more aware. As for income, there was a notable increase in awareness and salary. Women who had income less than 5000SR were found to be less aware. On the other hand, those who earned 10000SR or more were found to be more aware.

2: Relationship between sociodemographic data and awareness
Participants were asked whether they were willing to request EA upon their next delivery or not. It was found that age difference substantially impacted the participants' decisions to request EA.; women between 25-35 years of age turned out to be more likely to accept EA, whereas the likelihood of refusal increased with an increase in age (p-value of 0.002). Similarly, women with four and more children tended to reject taking EA, while those with one to three children were more likely to accept EA (p-value of 0.002). Income significantly influenced the probability of taking EA. Among participants who earned less than 5000SR, about two-thirds refused to take EA, whereas over half of those who earned more than 15000SR accepted taking EA (p-value of 0.001). Women who had a previous delivery with EA had a positive attitude towards retaking it (p-value of <0.0001). Furthermore, pregnancy status failed to show any significant difference (p-value of 0.597).

Sociodemographic data
In my next delivery I will request an EA:  There was a significant statistical relationship between awareness and the probability of taking EA (p-value of <0.0001) by Chi-square test (Figure 2).

Discussion
This study aimed to assess the awareness and preference of Saudi women toward EA. The mean awareness score was 3.66, which was related to age, educational status, income, the number of children, pregnancy, antenatal care, and previous delivery with EA. Regarding preference, the data suggested a relationship between age, income, number of children, and previous delivery with EA and the probability of taking EA.
Regarding the awareness score, more than half of the participants scored four and above (60.93%), which was considered to be a good score. This result is similar to the results of previous Saudi studies [10][11]. However, some other Saudi studies have shown a lack of awareness about EA [2,4,6]. Furthermore, in this study, it was observed that there was a significant relationship between awareness and the probability of taking EA. Those who were unaware were more likely to refuse EA in the next delivery, while those who were aware were more likely to request it. This finding is in line with the AlKhobar study [10].
An initial objective of the study was to identify the relationship between demographic data and awareness. Consequently, the study found that those older than 45 years of age were less aware. However, this result contradicts a study conducted in Nigeria, which reported that awareness was more common in older women [12]. Further, through the current study, it was found that those with a high school educational certificate or less were less aware, and those with a bachelor's degree or higher were more aware. These results match those that have been observed in earlier studies conducted in France, Najran and Khamis Mushait in Saudi Arabia, and Nigeria [13,2,6,12]. However, they differ from some published studies, which found no relationship between education level and awareness [1,14].
Additionally, the results of this study showed that low-income women were less aware of EA. This finding is consistent with the results of Ali Alahmari, where a positive relationship between income and awareness was found to exist [6]. Regarding the relationship between awareness and the number of children, those with four or more children were found to be less aware, while those with one to three children were found to be more aware. This relation was also noticed in Nigeria [12] and can be attributed to the fact that multiparous women are less likely to take EA and, consequently, it may not be interesting for them to read about the same. Moreover, it was observed that pregnant women who maintain regular antenatal care visits showed more awareness scores. This finding is concurrent with previous studies conducted [1,6,14]. A possible explanation for this result is the education imparted by the health workers during such antenatal visits. Surprisingly, the results of this study did not show a significant difference between the group of women who had children and those who did not. However, this finding is not supported by the previous research conducted by Workie et al. in 2020, which showed a significant association between awareness of labor analgesia and parous women in comparison to nulliparous women [1].
Regarding preference, many factors affected women's opinions toward EA. The first factor was age; women aged 25-35 were more likely to accept taking EA. This matched the results of a recent study in Alkhobar, wherein it was found that age played a role in the preference for EA; women aged 30-35 were more likely to prefer EA [10]. Furthermore, a study in Jeddah demonstrated the same result wherein women aged less than 20 or more than 35 were found less likely to prefer EA [4]. The second factor was income; those with an income of less than 5000SR were more likely to refuse to take EA, which was also significantly noticed in a previous study conducted in Lebanon [9]. Surprisingly, in the Alkhobar study, women with low income preferred EA [10]. The third factor was parity; a study in Paris reported an inverse relationship between parity and preference for EA, i.e., women with more children were less likely to choose to deliver with EA [13]. This finding was similar to the results of this study, where the number of children impacted women's decisions to take EA, as those with four children or more were more likely to refuse to take EA. The possible explanation for this is the positive experience encountered in the previous delivery without EA and, additionally, the shorter labor time in multiparous women [13]. Moreover, in some cultures, labor pain is considered natural and medication is not prescribed to manage it [1,15], or women may want to experience a natural delivery without any analgesic methods [16]. The most significant factor examined in this study was previous experience with EA; this finding is in line with a previous study wherein it was found that women who have had a previous delivery using EA without complications had more preference toward EA [10].

Strength and limitations
The study was solely about EA. It does not apply to all types of analgesia, and it only applies to the eastern region of Saudi Arabia. Thus, it cannot be generalized to other areas. Data collection was conducted through social media. Consequently, those who do not use social media did not receive the survey.

Conclusions
This study aimed to determine women's awareness of EA in the eastern region of Saudi Arabia. The findings show that awareness about EA is relatively high in the study area. Age, educational status, income, pregnancy, number of children, regular antenatal visits, and previous delivery with EA were found to be the most important predictors of EA awareness. Furthermore, it was found that there was a significant relationship between awareness and the probability of taking EA i.e., women who were aware were more likely to take EA. Several factors affected their opinion and preferences to take it, such as age, income, parity, and previous delivery with EA. However, as this study was restricted to the eastern region of Saudi Arabia, it cannot be generalized. More research is needed in each region for a better understanding of attitudes toward EA, and for identifying the reasons behind the choices.

Additional Information
Disclosures