Assessing quality with qualitative research

Epidural analgesia is currently the most effective method available to control pain in labour and has become a popular choice for labouring women in North America. In Canada, epidural analgesia was used in nearly half (45.7%) of all vaginal deliveries in 2001-2002. In the United States, a sample from seven states suggests that 68% of women received neuraxial labour analgesia in 2003. Ideally, labour analgesia should be tailored to the individual patient’s labour, medical condition, preferences, and goals. To this end, current literature most clearly addresses interactions between neuraxial labour analgesia and the progress of labour, mode of delivery, complication rates, and a number of medical conditions. In comparison, less evidence is available to measure the effectiveness of various analgesic techniques in addressing women’s preferences and goals for analgesia during labour and delivery. Maternal satisfaction with pain relief is a common measure used in quantitative trials of various analgesic techniques in order to capture effectiveness in meeting women’s expectations, preferences, and goals. However, satisfaction is a multidimensional construct influenced by analgesic experience, delivery outcomes and complications, human interactions, and other factors. As a result, a global measure of satisfaction with analgesia may or may not discriminate successfully between a high-quality and a low-quality analgesic experience. The limitation of relying on global satisfaction to signal high-quality analgesia is apparent when considering the group of randomized controlled trials that compared epidural analgesia with non-epidural analgesia or no analgesia. Five of these trials included a measure of satisfaction with analgesia among the outcomes, and metaanalysis suggests no significant difference between groups (relative risk 1.18, 95% confidence interval 0.92 to 1.50; n = 1,940 women). In pursuit of a more robust method to evaluate the factors that determine high-quality neuraxial analgesia from women’s perspectives, Dr. Pamela Angle and her colleagues have initiated an ambitious program of mixedmethods research. Published in the current issue of the Journal, their article describes a series of interviews and focus groups that aimed to identify themes relevant to the experience of childbirth pain and epidural analgesia. The purpose of this qualitative study was to define the specific factors that may be important for an overall measure of high-quality analgesia. Participants were women of mixed parity who had received epidural labour analgesia and who had met with the investigators to discuss their experience of epidural labour analgesia within 72 hr following delivery. The major themes that emerged suggest women are concerned primarily that effective analgesia should be readily available, free of effects on labour progress, and established without complications. If trade-offs become necessary, rather than avoidance of other side effects, such as pruritis, continuous pain control is most important, followed by preserved motor strength and mobility. Beyond this, a high-quality analgesic experience should: 1) restore a feeling of internal control and the ability to focus; 2) enable decision-making and give back (external) control; 3) preserve desirable bodily sensations of labour progress; 4) preserve mobility and strength; and 5) improve a woman’s overall labour and delivery experience. J. M. Mhyre, MD (&) Department of Anesthesiology, University of Michigan Health System, Room L3622 Women’s Hospital, 1500 East Medical Center Drive, Ann Arbor, MI 48109-5278, USA e-mail: jmmhyre@umich.edu; jmmhyre@med.umich.edu