Pain acceptance and personal control in pain relief in two maternity care models: a cross-national comparison of Belgium and the Netherlands

Pain acceptance and personal control in pain relief

The first research question (RQ1) addressed in this paper is whether acceptance of labour pain and personal control in pain relief determine the way childbearing women cope with labour pain. Pain acceptance, or the willingness to experience pain [21], has emerged as an important condition that reduces the suffering that often accompanies the experience of pain [22–25]. For example Waldenstrom et al. [26] reported that women with negative pain attitudes experienced more pain and were more anxious during labour. Fear is commonly found to be associated with increased labour pain [27–30]. The non-acceptance of pain is associated with the need for pain reduction, while acceptance results in lower emotional distress [25]. Heinze and Sleigh [11] found that women who laboured with an epidural had a lot of fear about childbirth, an external locus of control for childbirth, and a desire to remain passive in the childbirth process. Positive pain attitudes or confidence, as opposed to fear, have been shown to decrease pain perception and pain medication use [31, 32]. In line with these findings, it is our hypothesis that the acceptance of labour pain will result in less need for pain medication during childbirth.

In general, personal control is one of the main determinants of maternal satisfaction with childbirth [33–40] When narrowed down to labour pain, personal control is about women's active role in the decision to have or refrain from having pain relief during labour [41]. Based on women's perceptions of control as described in the literature and on their own experience in midwifery, McCrea and Wright [4] define personal control as 'a) the women's feeling of being in control as opposed to staff being in control; b) their input into decision-making governing pain medication; and c) use of personal coping resources to cope with labour pain'. Only a few investigations have been done with regard to personal control in pain relief. In addition to the psycho-social determinants of personal control in pain relief [42], its impact on satisfaction with pain relief during labour has been investigated [4]. However, our research question--is personal control in pain relief associated with pain medication use during childbirth--has not yet been addressed. We expect that personal control in pain relief as such will not be predictive of pain medication use, but will interact with pain acceptance. It will reduce pain medication use in women with positive pain attitudes and increase it in women with negative attitudes towards labour pain. This hypothesis is in accordance with Heinze and Sleigh's argument [11] that women's preferences and beliefs may have more influence on the management of labour pain than situational factors, such as personal control in pain relief. In fact, we assume that personal control in pain relief will be bound more by context than pain acceptance since it is dependent on what the hospital staff allows for.

The role of the care context

The second and third research questions concern the role of the care context. While it is important to recognise individual characteristics (e.g., pain acceptance and personal control) when explaining the use of pain medication, it is equally important to consider the interplay of these factors with the social contexts in which pain medication is used [43]. As our second research question (RQ2) we want to assess the contribution of the Belgian and Dutch care context to 1) the pain acceptance and personal control in pain relief and 2) the medication use during labour. In a third step (RQ3), a cross-national comparison of Belgian and Dutch childbearing women allows us to gain insight into the relative importance of pain acceptance and personal control in pain relief in two maternity care models. The three research questions and variables included in this investigation are represented in figure 1.

Although they are neighbouring countries sharing the same language, political system and geography, Belgium and the Netherlands are characterised by a different organisation of health care, particularly in maternity care. In Belgium the medical risks of childbirth are emphasised but neutralised by a strong belief in the merits of the medical model [44, 45]. In line with the midwifery model of care, in the Netherlands childbirth is defined as a normal physiological process and family event [46].

These different approaches to childbirth are reflected in the organisation and utilisation of maternity care facilities. In the Netherlands, for example, home births are encouraged by directing women expecting a normal birth into primary care [47], resulting in a 21.5% home birth rate [48]. The option of a policlinical birth, or a 'home birth away from home', (11.3%) [48] provides women with the possibility of having a midwife-led hospital birth with a short stay after the baby is born [49]. In case of difficulties during pregnancy and labour, women are referred to specialist care [50]. The relatively high proportion of home births and the emphasis on normality result in low rates of obstetric interventions [51]. In contrast, in Belgium 97.9% of childbearing women prefer to have their babies in hospital, finding reassurance in the proximity of obstetric technology. Home births are most popular in Flanders with 1.4%, compared to Brussels with 0.4% and Wallonia with 0.3% [52]. Not surprisingly, Belgium has been characterised by higher obstetric intervention rates compared to the Netherlands. However, over time the obstetric intervention rates of both countries have been converging and even reversing. For example in 2003 the Flemish induction rate was 30% and the percentage of caesarean sections was 18.3% [53], versus 28.8% and 14.8%, respectively, in the Netherlands [54]. In 2007 caesarean section rates were 19% in Flanders and 15.4% in the Netherlands. In that year Dutch induction rates (33%) however, exceeded the Belgian induction rates (25.6%). The Flemish figures are comparable to the numbers in Brussels, where the section rate was 16.6% and the induction rate 27.8% in 2004 [55]. So far, these data are unavailable for Wallonia. The difference is especially large regarding the use of pain medication during labour. The Dutch organisation for perinatal epidemiology (SPRN) reports that the Netherlands stands out for its low use of pain relief during labour. In 2007, in 9.6% of all Dutch deliveries, an epidural had been administered [56]. In Belgium the use of epidural analgesia has doubled since 1991, from 32% to 66.6% in 2007[48, 57].

Some authors found indications of a specific pain culture in the Netherlands. Dutch women showed a greater acceptance of labour pain compared to Americans in Senden's study [18]: nearly two thirds of the Dutch women laboured without pain medication, compared to one-sixth of the Americans. Jordan [58] concluded from a comparison of childbearing women in Yucatan, Sweden, the Netherlands and the United States that the majority of Dutch women do not expect or receive pain medication during labour. The distinctive Dutch ideas about pain and discomfort, which are reflected in a low use of pain medication, is also mentioned by DeVries [46]: "Dutch ideas about pain and the value of medication (...) are reflected in their relatively low use of pain and other medications compared to other nations in the European Union." (p. 158). Belgian maternity care is characterised by the medical model in which pain is viewed as controllable and needless [59]. Consequently, we tend to believe that Belgian and Dutch women are socialised in different pain cultures as part of the dominant models of maternity care. In the women-centred approach, conform the mastery model [60] pain acceptance and personal control are believed to be valuable coping strategies [42]. Pain is perceived as an ally in the birth process. Pain serves a biological purpose and is seen as constructive [61–63]. In the pain management model [60] however pain is perceived as a needless inconvenience easily resolved by means of pain medication [59]. In addition, in the biomedical care ideology, personal control may conflict with the control of the staff health professionals. They might experience women's personal control as encroaching on their expertise and on their decision-making role. In conformity with this biomedical ideology and practice, we assume that Belgian women planning a hospital birth are more likely to reject labour pain, to try to avoid it and to rely on health professionals to control it. Therefore we expect them to score low on pain acceptance and low on personal control in pain relief. In the Netherlands we think the opposite is more likely because the midwifery model, which we assume also permeates into Dutch hospitals, defends the view that labour pain serves a biological purpose and that relieving it might disturb the natural birth process [64].

Selection of method

In a cross-national comparative investigation of Belgian and Dutch childbearing women we assessed how the organisation of maternity care was related to antenatal and postnatal outcomes, such as satisfaction with childbirth [39, 45, 65] and childbirth expectations and experiences [66]. In this paper we focus on the use of pain medication during labour. In order to be able to quantify the contribution of the maternity care system to women's childbirth experiences and to reach as many women as possible in a short period of time, two questionnaire surveys were carried out: one at 30 weeks of pregnancy and one within two weeks after childbirth. A 2 weeks postpartum time frame was chosen to minimise the effect of inaccurate recall on reports of the birth experience, following the approach used by Ayers and Pickering [67]. Women were invited to participate over a 3-month period. Five to 8 months elapsed from invitation to participate to completion of the last questionnaire. As data collection was not carried out simultaneously in each hospital or midwifery practice, 1 year was necessary to gather all the data (September 2004 - September 2005).

Measurement

Population and sample

The study concerns two comparable cities in the Belgian and Dutch regions, Ghent and Tilburg, respectively. Although we do not claim representativeness, we will refer to Belgium and the Netherlands, and the Belgian and the Dutch to enhance the readability of this paper. Since the total population of pregnant women could not be determined, we had to rely on a convenience sample. In Ghent there are four hospitals of which three agreed to participate. We have no reason to believe that the population of the missing hospital differs from the populations of the participating hospitals. In Tilburg both hospitals agreed to cooperate. At each hospital pain relief, more specifically epidural analgesia, was available on a 24-hour basis.

In addition, we contacted six midwifery practices in Tilburg to reach enough women planning a home birth. In Belgium, Ghent does not have enough midwifery practices to attain the same number of home births. Therefore, we went beyond the city borders of Ghent and contacted 21 midwifery practices across Flanders. Although women who had a home birth were excluded from our analyses, we want to emphasise that they were surveyed as part of the bigger project. We also ask the attention of the reader for the fact that women planning for a home birth, but who were referred to the hospital between their thirtieth week of pregnancy and the moment of birth (including labour), were included in our analysis. For Belgium this is the case for 16 respondents, for the Netherlands 89. This difference reflects the large number of referrals in the Netherlands (see e.g. [50]).

Sample size calculations based on a 0.95 confidence interval suggested we needed 600 study participants for a reliable statistical analysis. At 30 weeks of pregnancy, 827 women filled out the antenatal questionnaire; 611 of those women also participated in the study during the first 2 weeks after delivery and completed the second questionnaire.

Since we needed information about both time points for our analysis, our initial sample counted 611 respondents. After exclusion of home births (n = 179), Caesarean sections (n = 84) and the cases with missings on the variables educational level (n = 13), pain relief (n = 5) and place of delivery (n = 3), a working sample of 327 childbearing women consisting of 157 Belgian and 170 Dutch women remained. Because pharmacological pain relief is not available at home, only spontaneous vaginal deliveries in hospital settings were included. We excluded women with obstetric interventions, such as caesarean section or forceps delivery, because it was thought that in the case of an obstetric intervention women would not have been involved actively in decision-making regarding the use of pain relief. Also, the acceptance of labour pain seems irrelevant in such a situation.

Procedure

During prenatal visits, women were asked by their midwife or obstetrician to participate in the research project, in order to include both home and hospital births. Inclusion criteria were broad: both Belgian and Dutch women had to speak and understand Dutch and had to be 18 years or older. The antenatal questionnaire was handed out during an antenatal visit at 30 weeks of pregnancy together with an information sheet. It was returned to the obstetrician or midwife during one of the following antenatal visits. Within a few days after delivery, women received the postnatal questionnaire either from the medical staff in the case of a hospital birth, or from the midwife in the case of a home birth. Women who delivered in a hospital completed the postnatal questionnaire during their postpartum stay in the maternity ward. Women with a short stay or home birth, however, responded by direct mail instead. Antenatal and postnatal questionnaires were given a code to facilitate the merging of the antenatal and postnatal information from each respondent.

Women were recruited during prenatal visits to their obstetricians and midwives. Therefore, we had little control over the inclusion process and, consequentially, the response rate. Although we asked that women who refused to participate be registered, this was not systematically done by every hospital. As a result, we do not know the exact number of women invited to participate in this study. To calculate the response rate we used the number of provided questionnaires; that number is based on an estimate of eligible women made by midwives and obstetricians acting as proxy. The response rate was calculated by dividing the number of respondents by the number of provided questionnaires. This calculation resulted in an average response rate of 43% (n = 238) for all Belgian hospitals, 41% (n = 137) for Belgian midwifery practices, 42% (n = 208) for Dutch hospitals and 54% (n = 244) for Dutch midwifery practices. For hospitals the smallest response rate was 19%, the highest 68%. For the midwifery practices the response rate was 38% and 100%, respectively. However, we know that not all questionnaires were distributed, which means that our estimations of the response rates are in fact very conservative.

Ethical considerations

A written informed consent was required of all respondents. Anonymity was guaranteed, since the researchers have no information about the identity of the respondent. The Committee for Ethics of the University Hospital has approved the study. Ethical approval was gained in Ghent only. In the Netherlands, approval from a research Ethics committee is not required if no interventions take place during the research. It was explained to potential participants that they were free to participate and that their privacy was guaranteed.

Data analysis

After an exploration of the descriptives, a logistic regression analysis was performed using SPSS 15. The predictive value of the acceptance of labour pain and personal control in pain relief upon the actual use of pain relief was investigated. A logistic regression model has been constructed and the adjusted odds ratios (OR) calculated.

Descriptives

Among Belgian women, 47.8% (n = 65) made use of pharmacological pain relief during labour or delivery, compared to 14.5% (n = 22) of the Dutch respondents. In both countries primiparous women are almost twice as likely to receive pain relief than multiparous women (Belgium: 57.9% versus 30.%; the Netherlands: 31.2% versus 17.3%). Dutch women expect about the same level of labour pain (mean = 61.84) as Belgian women (mean = 63.76). Dutch and Belgian women show the same average acceptance of labour pain (B: mean = 3.72; Nl: mean = 3.75; t = -.39; p = 0.694), but the Belgians report higher average scores on personal control in pain relief than the Dutch (B: mean = 7.07; Nl: mean = 5.54; t = 7.95; p < 0.001) (Table 1). Parity, length of labour and educational level especially may confound the comparison between Belgium and the Netherlands. Therefore these variables together with expected pain intensity and age were controlled for in the logistic regression model.

Logistic regression model

In model 1 (table 2) the impact of labour pain acceptance and personal control on labour pain medication use is addressed (RQ1). What concerns the control variables, we find that longer labours (OR = 1.115 [1.065,1.167]) and younger age (OR = 0.912 [0.851,0.997]) rendered pain relief more likely. Expected pain intensity, level of education, and parity did not reach the 95% significance level. In line with our hypothesis, the interaction term 'pain acceptance*personal control' indicates that the likelihood of pain medication use is smallest if women have positive pain attitudes during pregnancy and report high personal control in pain relief after birth (OR = 0.613 [0.485,0.776]). In addition, the OR's of personal control in pain relief reveal that personal control in pain relief has no influence if women have average pain attitudes. Moreover, pain acceptance is the most important determinant of pain medication use during birth (OR = 0.439 [0.305,0.634]. This is also shown in the main effects model (no table) including only pain acceptance and personal control in labour pain, in addition to the control variables. In this main effect model only pain acceptance has a significant influence on pain medication use (pain acceptance: OR = 0.444[0.311,0.634]; personal control: OR = 1.187[0.997-1.413]).

In model 2 and 3 (table 2), conform the second research question, care context is introduced by adding the country variable to the analysis. First of all, we find that the use of labour pain medication is more likely among Belgian women (OR _{model 2} = 0.134 [0.071,0.252]; OR_{model 3} = 0.085 [0.038,0.190]). Secondly, in model 3 (table 2) it is shown that pain acceptance (OR = 0.435 [0.292,0.647]) and personal control in pain relief (OR = 0.721 [0.583-0.892]) reduce the likelihood of pain medication use, especially when they occur together (OR = 0.602 [0.468,0.775]. Thus, personal control in pain relief becomes a significant determinant of pain medication use, once the care context is introduced. This means that the country difference in pain medication use can be partially explained by differences in personal control in pain relief. We know from the descriptives that Dutch and Belgian women reported the same level of pain acceptance, while Belgians scored significantly higher than the Dutch on personal control in pain relief. This finding becomes more explicit in the results of the regression analyses for Belgium and the Netherlands separately.

In table 3, a similar regression model has been estimated for Belgian and Dutch women separately in order to answer the third research question: does the relative impact of labour pain acceptance and personal control in pain relief diverge between the Belgian and Dutch care context?

In Belgium, the likelihood of using pain relief is seriously reduced for women accepting labour pain (OR = 0.260 [0.138,0.487]). Personal control in pain relief, on the contrary, is of little importance (OR = 0.845 [0.633,1.129])). Also the co-occurrence of pain acceptance and personal control (OR = 0.684 [0.427,1,096] has no additional value.

For Dutch women a different picture arises from our results. The main determinant of pain relief shifts from labour pain acceptance towards personal control in pain relief. In table 3 two differences are important when comparing the country specific findings. First, for the Dutch women, the interaction term 'pain acceptance*personal control in pain relief' is significant. Second, for Dutch women not pain acceptance but personal control in pain relief is important in predicting pain medication use. This means that for Dutch women, especially personal control in pain relief (OR = 0.642 [0.460,0.895] has a significant reducing effect on medication use, even more so when co-occurring with pain acceptance (OR = 0.660 [0.449,0.970]).

In Figure 2 we show the predicted likelihood of labour pain medication use estimated with the country specific model in table 3. This graph illustrates that, among the women who report low pain acceptance and personal control in pain relief (i.e., mean - 1SD), Belgians have a 71% chance of having their labour pain relieved, versus a likelihood of 11% for the Dutch. This could be an indication of an under-met need for pain relief on the part of the Dutch women with negative pain attitudes and little control over medication use. For the group with high labour pain acceptance and a lot of control over medication use (i.e., mean + 1SD), Belgian and Dutch women's chances of receiving pain medication are 12% and 2%, respectively. Thus, on both ends of the continua (pain acceptance and control over pain relief), Dutch women are about six times less likely than Belgians to receive pain medication. Belgian women accepting labour pain (with a normal vaginal birth) and controlling pain medication use, still have a 12% chance to get pain medication, which could indicate an over-met need.