To the Editor,

The use of epidural analgesia during labour has steadily increased over the last two decades.1 To better counsel patients, we conducted a scoping review of patient-reported barriers and facilitators regarding epidural use in labour. We systematically searched seven databases (Medline-OVID, EMBASE, CINAHL, Cochrane Library, Web of Science, Scopus and PsycInfo) from inception until 21 December 2020 according to Preferred Reporting Items for Systematic Reviews extension for scoping reviews (PRISMA-ScR) guidelines.2 All screening and extraction were completed in duplicate.

After screening 2,690 citations, we included 42 studies encompassing 14,803 female patients. Agreement between reviewers was substantial, with a calculated kappa of 0.81 for abstract screening and 0.70 for final full-text review. Of the 42 studies, 17 studies were retrospective questionnaires in the postpartum period, eight studies included labouring patients, while the remainder (n = 17) were completed during antenatal visits. Four studies focussed exclusively on primiparous individuals. The included studies were diverse in country of origin, across North America (n = 10), Europe (n = 5), Africa (n = 8), Australasia (n = 5) and Asia (n = 18). Details of the 42 studies are available upon request.

Fifteen studies reported patient concerns for the safety of epidural analgesia, including maternal side effects (n = 13 studies) and foetal concerns (n = 15 studies). A frequent concern was prolonged labour, which was patient-reported in 14 studies. In addition, two studies reported the fear of maternal paralysis or permanent inability to walk following epidural. Several studies reported the belief that epidural use would negatively impact the delivery experience. Specifically, 19 studies reported that participants preferred to avoid epidurals because they believed that labour pain is natural. A further nine studies described the belief that motherhood required pain and the pain should not be treated. Five studies noted that participants had confidence in their pain tolerance to avoid analgesia. Two studies reported the preference to preserve mobility during labour. Four studies noted the belief that mother–baby bonding is improved through labour pain and therefore would be affected by an epidural. There were no geographic trends in whether safety concerns were reported by patients.

Fourteen studies noted institutional-level barriers or influences to requesting an epidural during labour, rather than personal beliefs. For example, eight studies noted that cost was a barrier to epidural request, which was predominantly reported by patients in low-income countries or countries without universal healthcare. Six studies noted that nurses, obstetricians, midwives, or anesthesiologists had explicitly discouraged the use of epidurals. Eleven studies noted that their partners or family members had influenced their decision-making. Three studies conducted in North America noted a lack of trust in the healthcare system, including fears of human error. Six studies described those participants had previously received an epidural in a prior pregnancy and had negative experiences with a medicated delivery, such as pruritus and the lack of sensation.

Seven studies across geographic areas noted that positive information related to epidural use, including information from friends or family members, was a strong facilitator in obtaining epidural analgesia. For example, a study noted that a mother had previously overestimated the risk of paralysis with epidural and was reassured following a long conversation with a physician. One study noted that partner support was a facilitator in decision to use epidural analgesia. Seven studies noted that positive attitudes of caregivers regarding epidural analgesia were a facilitator in requesting analgesia. Nevertheless, one study noted that patients felt pressured into receiving epidural analgesia or coerced with the threat of a Cesarean delivery.

Ultimately, our scoping review highlights the complex decision-making process behind epidural requests in labour. Across geographic regions, concerns about maternal and foetal safety were a unifying barrier while social support and patient counselling were a unifying facilitator. From the included studies, it is clear the decision to have an epidural can be highly influenced by social circles (e.g. partners, family members), healthcare workers and previous experiences with the medical system. As such, we recommend a multifaceted approach in patient counselling. Patient counselling should include safety information for both the labouring patient and the foetus, as well as a discussion of the patients’ past healthcare experiences and delivery preferences. Providers can offer to answer questions from partners or other social support members. Finally, future studies should evaluate whether specific interventions, such as outpatient education initiatives or intrapartum counselling checklists, can improve patient knowledge and empower decision-making regarding epidural use in labour.