Introduction
Quality of life (QOL) is a multidimensional process that involves physical as well as mental aspects of life, influenced by subjective positive and negative evaluations [
1‐
3]. Health-related quality of life has become a valid indicator of a population’s well-being. It is a measure to assess the effects of treatment on physical, mental, emotional, and social functioning. Routine QOL questions about perceived physical and mental health and functioning became an important component of health surveillance, and are generally considered valid indicators of service needs as well as intervention outcomes [
3]. Childbirth is an important critical aspect of life that can influence a women’s QOL. It has been shown that women’s subjective evaluation of childbirth has a major impact on maternal QOL after delivery [
4,
5]. Women with an uncomplicated pregnancy and childbirth have the highest QOL scores compared to women who have a complicated pregnancy and/or delivery [
6]. Women with a negative childbirth experience have a harder time bonding with their child postpartum [
7]. A negative childbirth experience may even result in a posttraumatic stress disorder, occurring in 2–6% of all deliveries [
8‐
10].
Women’s childbirth experience in turn is influenced by many factors, including socio-economic and demographic characteristics, pregnancy complications, labor characteristics, mode of delivery, neonatal outcome, and social support [
5,
11‐
13]. One of these factors is the experience of labor pain [
14]. Labor pain experience is subjective and multifactorial. Not having had a choice in pain relief, and not being satisfied in coping with pain during labor were associated with a negative birth experience [
15]. Labor pain incidentally results in posttraumatic stress symptoms [
9] or depressive symptoms, even more so when it results in persistent postpartum pain [
16]. For many pregnant women, the fear of labor pain is also of major concern, resulting in severe fear of childbirth in 6–10% [
17]. This fear of pain can even result in a request for an elective cesarean section [
18].
As the experience of labor pain contributes to the childbirth experience of women, optimal pain relief is an important issue. Maternal QOL during and after childbirth may be improved, if the health care professionals discuss labor pain and its management with the pregnant woman antepartum [
19]. Epidural analgesia (EA) has been shown to be the most effective method of pharmacological pain relief during labor, as compared with other methods of labor analgesia [
20‐
22]. A reduced risk of postpartum depression was demonstrated in women who received epidural analgesia, compared to no analgesia [
23]. Non-inferiority of routine EA with regard to the risk of operative delivery could not be demonstrated in this trial. No important differences in labor and neonatal outcomes were found between both groups. However, routine EA use was likely to lead to more operative deliveries and more maternal adverse effects, including hypotension and motor blockade [
24].
Because EA seems to affect not only a women’s delivery but also her puerperium, we were interested to find out whether there would be a difference in QOL postpartum, in routine labor EA as compared with analgesia on request. We hypothesized that women who receive routine EA will have a greater change in QOL postpartum, as they might have a more positive childbirth experience because of EA during labor. The purpose of this study, therefore, was to evaluate the changes in QOL of women who received routine labor EA, as compared to women who were given pain relief on request only (control group), with special attention paid to the women who requested no pain relief at all.
Discussion
In this study, the maternal QOL was evaluated and compared between women who received routine EA during labor, and those who were given pain relief on request only. Women in both groups showed comparable changes in QOL from antepartum to 6 weeks postpartum, which is in line with other studies [
1,
12]. Our hypothesis, that routine labor EA would result in a significant improvement of QOL after delivery as compared with analgesia on request, could not be confirmed.
We used the SF-36 in this study to measure quality of life. The SF-36 is a generic tool to measure a person’s quality of life and to compare this with other people’s QOL. It has been used internationally and in cost-effectiveness studies (which was de primary intent of the TREAT-study). During pregnancy, a difference in both the routine EA group as well as the control group was observed, when compared to a general non-pregnant population studies ad described by van der Zee [
25]. When comparing the SF-36 scores of our pregnant population with this general population, pregnant women scored lower on 5 out of the 9 subscales: physical functioning, social functioning, role limitations due to physical problems, emotional well-being, and bodily pain. This is in line with previous studies that showed an overall reduced QOL in women during pregnancy and the postpartum period [
1,
29]. This seems to imply that routinely given pain relief does not influence women’s health-related QOL.
As women participating in the TREAT trial were well informed about the possibilities of labor pain relief, this might have resulted in a decrease of fear of pain as well as pain experience during delivery in these women. In turn this may have had a positive effect on their birth experience.
In the control group, nearly 24% of women delivered without request for any kind of analgesia. Compared with women who received analgesia in the control group, there were a few statistical significant differences. Women who received analgesia in the control group were older, more often multiparous, higher educated and had a lower BMI. Also, mode of delivery was more often spontaneously and less had an unplanned cesarean section. The fact that multiparous women less often choose EA during labor can be explained by positive previous delivery experiences which may also play a role in increased confidence resulting in decreased fear of pain in multiparous women [
30]. It is likely that women who choose not to request analgesia are more confident in their own ability to handle pain and their physical functioning than women who do not have this confidence. The higher maternal age in this group can probably be linked to this multiparity. Other studies also showed a positive relationship between a higher BMI (> 25 kg/m
2) and request for EA analgesia, but showed a negative relationship between higher education and EA request [
31,
32]. However, these differences in characteristics did not result in a significant change of QOL after delivery, as compared with the women who did receive analgesia on request. Nevertheless, we found a nearly significant difference in the dimension physical functioning in favor of the women who delivered without any pain medication (
p = 0.054). Significance could presumably have been demonstrated if the number of women who delivered without any pain medication (now,
n = 61) had been comparable in size with the number of women who received pain medication on request (now,
n = 194).
The strength of this study is that it is the first randomized controlled trial, evaluating the effect of routine labor EA on maternal QOL, 6 weeks postpartum. The SF-36 questionnaire used in this study is a standard and well-known non-specific health-related QOL questionnaire, which has been validated for the evaluation of QOL after delivery [
12,
13,
27,
33].
The study also has some limitations. Firstly, we cannot exclude selection bias of the women participating in the TREAT-trial, and thus also in the QOL study, as it is likely that these women favored EA for labor pain treatment more than those women who refused participation.
Secondly, our follow-up period of 6 weeks is relatively short. Not all women will have recovered completely in 6 weeks. Delivery-related problems like urinary incontinence, perineal pain, and chronic exhaustion may have an effect on the QOL when these women return to their daily activities after their maternity period is completed [
34]. However, the mode of delivery (spontaneous, vaginal instrumental or unplanned cesarean section) would only have a small impact on these results, as these labor characteristics were not significantly different between both groups. Besides, during the routine postpartum check-up at 6 weeks, no women reported adverse effects of EA such as hypotension or motor blockade. Postpartum depression is most common between 6 and 12 weeks postpartum, and can have a major effect on the maternal QOL [
34,
35]. Previous studies compared the QOL at 6 weeks and 6 months postpartum [
34,
36,
37], and even at 2 years after delivery [
16]. They evaluated the effect of earlier induction on QOL [
36,
37] or the relationship between physical and emotional health problems [
34]. Even though these studies did not have the same intervention, they showed higher QOL scores 6 months postpartum compared to 6 weeks. Evaluation at longer periods after childbirth might give a better insight into the long-term effect of pregnancy and labor on women’s QOL.
Thirdly, the TREAT-trial did not have quality of life as a primary outcome. The study was powered to show non-inferiority of routine use of epidural analgesia, and therefore, it is possible that this study was underpowered to show a statistical significant difference in QOL between the two groups. We conclude that the routine administration of EA during labor and pain relief on request are associated with comparable changes of women’s QOL antepartum to 6 weeks postpartum, whereas women in the routine EA group had more adverse events related to EA. Based on the changes in women’s QOL, no preference can be given to routine labor EA, as compared with labor analgesia on request. Future studies may focus on the long-term effect of routine EA on the postpartum QOL.