Pharm World Sci (2010) 32:206211 DOI 10.

1007/s11096-010-9371-3

RESEARCH ARTICLE

Post natal use of analgesics: comparisons between conventional postnatal wards and a maternity hotel
Hedvig Nordeng Anne Eskild Britt-Ingjerd Nesheim

Received: 26 October 2009 / Accepted: 21 January 2010 / Published online: 10 February 2010 Springer Science+Business Media B.V. 2010

Abstract Aim To investigate factors related to analgesic use after delivery, and especially whether rates of analgesic use were different in a midwife-managed maternity hotel as compared to conventional postnatal wards. Setting One maternity hotel and two conventional postnatal wards at l University Hospital in Oslo, Norway. Method Data Ulleva were obtained from hospital records for 804 women with vaginal deliveries. Main outcome measure Postnatal analgesic use. Results Overall, approximately half the women used analgesics after vaginal delivery in both conventional postnatal wards and maternity hotel. The factors that were signicantly associated with use of analgesics postnatally in multivariate analysis were multiparity, having a nonWestern ethnicity, smoking in pregnancy, younger age, instrumental delivery, analgesic use during labour, maternal complications post partum, and duration of postnatal

stay 4 days or more. Conclusion The use of analgesics is determined by socio-demographic and obstetric factors rather than the organisation of the ward. Keywords Analgesics Drug utilisation Maternity care Maternity hotel Norway Organisation postnatal ward

Impact of ndings on practice Health care professionals should be attentive to the need for analgesics among women with vaginal delivery, and acknowledge that there are both cultural and obstetric factors related to the womans need for pharmacological pain relief. Organisational factors in itself should have little inuence on the use of analgesics after birth.

Introduction
H. Nordeng (&) Department of Pharmacy, School of Pharmacy, University of Oslo, P.O. Box 1068, Blindern, 0318 Oslo, Norway e-mail: h.m.e.nordeng@farmasi.uio.no H. Nordeng A. Eskild Department of Psychosomatics and Health Behavior, Division of Mental Health, Norwegian Institute of Public Health, Oslo, Norway A. Eskild Department of Gynecology and Obstetrics, Akershus University Hospital and University of Oslo, Oslo, Norway B.-I. Nesheim l University Hospital, Oslo, Department of Obstetrics, Ulleva Norway

The majority of studies on drug use after delivery have been conducted in the 1980s or earlier. These studies report that approximately 80% of all women use drugs, mostly analgesics, during their stay in conventional postnatal wards (Table 1). As a response to the increasing use of drugs and medical interventions during childbirth, delivery wards in many parts of the world have undergone changes from conventional hospital wards to midwife-managed delivery wards and maternity hotels, driven by a wish to de-medicalize childbirth. Randomised studies have shown signicant differences in intrapartum care and delivery between midwife-managed delivery wards and conventional delivery wards [69]. A meta-analysis including

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almost 9,000 low-risk women found that women giving birth in home-like delivery wards were less likely to use analgesics during labour than were women in conventional delivery wards [10]. It has been suggested that the lower use of analgesics during labour in home-like delivery wards may be the result of more support from caregivers during labour and limited availability of pharmacological analgesics [10]. It is not known if this analogy can be applied to postnatal use of analgesics. To date, no study has investigated whether women in midwife-managed maternity hotels are less likely to use analgesics after delivery as compared to conventional postnatal wards. There are many factors, both medical and socio-demographic, that might contribute to the use of analgesics after delivery. To our knowledge, only one earlier study has assessed factors associated with postnatal drug use [3]. This study reports a signicantly higher overall use of drugs among rst time mothers, women with operative delivery, women who used analgesics during labour and among women who experienced perineal tearing at delivery. Their data analyses, however, were not performed for specic drug groups and no adjustment was made for potential confounding factors. As it is likely that different factors are related to the use of different drugs (i.e. analgesics and antibiotics), the results of drug specic analyses would possibly have been more informative. Furthermore, the impact of the organisation of the postnatal care was not addressed in that study.

postnatal wards. An additional aim was to investigate the associations between socio-demographic and obstetric factors and use of analgesics after vaginal delivery.

Methods Study population and design The study was retrospective and based on patients hospital records. The study population included women who were randomly selected among all women with a vaginal l University Hospital in Oslo, Norway in delivery at Ulleva the years 1998 and 2001. The years of study sampling were chosen since the midwife-managed maternity hotel was established in 1999 and we wanted data also from before this establishment. The ideology behind the maternity hotel is to provide a safe, home-like environment. The criteria for admission to the maternity hotel were a healthy child at term and a healthy mother. The maternity hotel offered the same duration of stay (4 days) for uncomplicated deliveries as the conventional postnatal wards. The conventional l University Hospital is organised postnatal ward at Ulleva as a any hospital ward, staffed with both midwifes, childrens nurses and obstetricians. A minimum sample of 370 patients was required from each year to obtain a 95% condence interval of 5% around an estimated prevalence of analgesics use of 40%. The selected women were classied into three groups: Postnatal stay conventional postnatal ward in 1998 (n = 415), post natal stay in the maternity hotel in 2001 (n = 181) and post natal stay in conventional postnatal ward in 2001 (n = 208). Hence, the study sample included a total of 804 women, representing 23.9% of all women

Aim of the study The main aim of this study was to compare use of analgesics after vaginal delivery among women in a midwifemanaged maternity hotel with women in conventional

Table 1 Overview of studies of on drug use in hospital wards after delivery Country Study Study period population Women at maternity wards in 148 hospitals Study Data collection size 9,593 Interview in hospital after delivery Women using analgesics (%) 21 Comment 3540% caesarean deliveries in ve hospitals. 12 countries reported caesarean section rates 915% The proportion of women with caesarean section ranged between 9 and 13% Mode of delivery not stated Mode of delivery not stated Reference [1]

Hospitals in 1987 22 countries

Norway

1980

Ireland Ireland

1982 1979

Women at wards in hospital Women at wards in

maternity ve university

970 Hospital records 82

[2]

maternity 2,004 Hospital records 80 three hospitals 232 Interview in hospital after delivery 51

[3] [4]

Women at one maternity hospital ward

USA

1974 Women at one obstetric 76 hospital ward

168 Hospital records 62

Only women with vaginal deliveries

[5]

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l University Hospital in with a vaginal delivery at Ulleva 1998 and 11.9% in 2001. Data collection Data were obtained from obstetric hospital records. The obstetric records included a standardised antenatal health record with information on the womans socio-demographic characteristics, the partograph with information on the delivery, and standardised records for drug use after delivery and postnatal complications. The outcome measure was use of analgesics (one unit or more) from after delivery until discharge from hospital, coded yes or no. One unit of analgesic was dened as use of any analgesic drug at one occasion, regardless of administration or dosage. The denition was decided on due to practical reasons as some analgesics exist in different strengths (naproxen 250 and 500 mg) and some in combination (for example paracetamol 500 mg and codeine 30 mg). In a subanalysis the outcome measure was use of more than 5 units of analgesics. The main explanatory variable was type of postnatal ward, classied as maternity hotel (in 2001) or postnatal ward in 1998 or in 2001. The reference category was maternity hotel. As a result of the criteria for admission to the maternity hotel, women with complications during and after delivery are over-represented in the postnatal ward. These factors could be associated with use of analgesics. Hence, the following potentially confounding variables were included in the analyses: (1) Maternal characteristics: parity, ethnicity, age at delivery, smoking during pregnancy, highest completed education and chronic maternal illness. The largest non-Western ethnic group came from Pakistan. (2) Obstetric variables: Pregnancy duration, mode of delivery, duration of labour, use of analgesics during labour, perineal tearing at delivery (grade 3 or 4, or episiotomy), maternal complications after delivery, and duration of postnatal stay. Maternal complications after delivery included haemoglobin levels B 10 g/dl, blood loss C 1,000 ml, blood pressure C 140/90, fever C 38C or infections. Variables were categorised as presented in Table 2. Information on smoking during pregnancy or on the duration of labour was not available for 12 and 13% of the women, respectively. For these variables a separate missing information category was included in the analyses. Statistical methods

other covariables on the use of analgesics were estimated as crude (cOR) and adjusted odds ratios (aOR) with 95% condence intervals (CI) in univariate and multivariate logistic regression analyses. Also stratied analyses for each postnatal ward were conducted. Only variables signicant in the univariate data analyses were included in the logistic regression models. The HosmerLemenshow goodness-of-t statistic was performed to ensure robustness of the logistic regression models [11]. The statistical analyses were performed using the Statistical Package for Social Sciences (SPSS), version 11.0.

Results After delivery, 48.4% of the women with vaginal delivery used analgesics during their postnatal stay. The most frequently used analgesics were paracetamol and non-steroid anti-inammatory drugs (NSAIDs), followed by codeine and paracetamol in combination. The mean number of units of analgesics used was 3.8 (SD: 3.2, range: 131). A total of 88 women (10.9%) used more than 5 units of analgesics postnatally. The analgesics were with few exceptions administered orally. There was no signicant difference in the proportion of women who used analgesics according to type of postnatal ward: 49.7% received analgesics at the maternity hotel, 52.9% at the postnatal ward in 2001 and 45.5% at the postnatal ward in 1998 (P = 0.183, chi-square test). Also, there was no signicant difference between the different postnatal wards in the mean number of analgesic units (mean standard deviation: 3.8 2.5 at the maternity hotel, 3.9 2.8 at the postnatal ward in 2001 and 3.8 3.7 at the postnatal ward in 1998). The proportion of women using [5 units of analgesics during their postnatal stay was 11.0% at the maternity hotel, 13.0% at the postnatal ward in 2001 and 9.9% at the postnatal ward in 1998 (P = 0.504, chi-square test). Mean birth weight of the children was 3,509 g (SD 596 g) and 7.1% were premature (mean gestational length 39.5, SD 2 weeks). In all, 72.4% of the deliveries started spontaneously. The duration of labour was less than 4 h for 23.6% of the women, between 4 and 8 h for 36.9% of the women and over 8 h for 33.1% of the women. In all, 13.2% of the women reported chronic illness during pregnancy, mostly asthma and allergy (5.5%) Information about other socio-demographic and obstetric variables is presented in Table 2. Factors related to postnatal analgesic use

Chi-square tests were used to analyse differences in the distribution of categorical variables according to type of postnatal ward. The impacts of the postnatal ward and

Type of postnatal ward was not signicantly associated with analgesic use in univariable nor in multivariable

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Pharm World Sci (2010) 32:206211 Table 2 Univariate and multivariate analysis of factors associated with use of analgesics after vaginal delivery Variable Postnatal stay Maternity hotel 2001 Postnatal ward 2001 Postnatal ward 1998 Parity 1st child 2nd child [2nd child Ethnicity Nordic Non-Nordic, western Non-Western Age at delivery (years) \25 2529 3034 3539 C40 Smoking during pregnancy Education University or similar High-school Primary school Other Mode of delivery Spontaneous vaginal Forceps or vacuum at delivery Analgesics during labour None Nitrous oxide or local analgesics Pethidine Epidural anaesthetic Tearing at delivery None Small tears Episiotomy or large tears Maternal complications after deliverya Duration of postnatal stay (days) \2 3 4 [4 88/147 (59.9) 214/501 (42.7) 87/156 (55.8) 104/175 (59.4) 48/102 (47.1) 65/135 (48.1) 206/450 (45.8) 70/117 (59.8) 1.0 0.5 (0.30.7) 0.9 (0.51.3) 1.8 (1.32.5) 1.0 1.1 (0.61.8) 1.0 (0.61.5) 1.7 (1.02.9) 1.0 82/186 (44.1) 141/301 (46.8) 43/88 (48.9) 123/229 (53.7) 1.0 1.1 (0.81.6) 1.2 (0.72.0) 1.5 (1.02.2) 1.0 328/704 (46.6) 61/100 (61.0) 1.0 1.8 (1.22.8) 1.0 172/406 (42.4) 98/205 (47.8) 55/86 (64.0) 64/107 (59.8) 1.0 1.3 (0.91.8) 2.4 (1.53.9) 2.0 (1.33.1) 1.0 50/92 (54.3) 126/259 (48.6) 144/303 (47.5) 52/119 (43.7) 17/31 (54.8) 61/111 (55.0) 1.0 0.8 (0.51.3) 0.8 (0.51.2) 0.7 (0.41.1) 1.0 (0.52.3) 1.4 (0.92.1) 1.0 231/553 (41.8) 20/50 (40.0) 138/200 (69.0) 1.0 0.9 (0.51.7) 3.1 (2.24.4) 1.0 155/382 (40.6) 134/278 (48.2) 100/143 (69.9) 1.0 1.4 (1.01.9) 3.4 (2.35.1) 1.0 90/181 (49.7) 110/208 (52.9) 189/415 (45.5) 1.0 1.1 (0.81.7) 0.9 (0.61.2) 1.0 Number of women using analgesics/total (%) cOR (95% CI)

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aOR (95% CI)

1.0 (0.61.5) 0.8 (0.51.1)

2.6 (1.73.8) 6.8 (3.812.1)

0.9 (0.51.8) 2.8 (1.84.4)

0.8 (0.51.4) 0.6 (0.31.1) 0.5 (0.20.9) 0.4 (0.10.9) 1.8 (1.12.8)

0.9 (0.61.3) 1.2 (0.72.1) 0.8 (0.51.5)

1.8 (1.13.0)

1.6 (1.02.4) 1.8 (1.03.3) 2.3 (1.53.9)

0.7 (0.41.1) 1.2 (0.72.1) 1.6 (1.12.3) 1.0 1.5 (0.92.7) 1.8 (1.13.0) 2.9 (1.55.5)

cOR crude odds ratio, aOR adjusted odds ratio, 95% CI 95% condence interval The multivariate logistic regression included all variables shown in the table
a

Maternal complications after delivery included haemoglobin levels B 10 g/dl, blood loss C 1,000 ml, blood pressure C 140/90, fever C 38C or infections

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logistic regression analyses (Table 2). Other factors were, however, signicantly associated with analgesics use in multivariable data analyses: multiparity, non-Western ethnicity, being \35 years at delivery, smoking during pregnancy, use of forceps or vacuum at delivery, use of analgesics during labour, maternal complications after delivery and postnatal stay C4 days (Table 2). Factors not signicantly associated with postnatal use of analgesics in multivariate analyses were: birth weight, pregnancy duration, chronic maternal illness and duration of labour. In stratied analyses for each postnatal ward, we found a stronger impact of parity and mode of delivery for women at the maternity hotel. For women with 2 or more children at the maternity hotel the aOR of postnatal analgesic use was 25.9 (95% CI: 5.5122.8) and the aOR of was 5.7 (95% CI: 1.522.3) for women with a forceps or vacuum assisted delivery. The other estimates of associations were similar between the three postnatal wards. When use of [5 units of analgesics was used as the outcome measure, no signicant impact of postnatal wards was found. The adjusted odds ratio (aOR) for use of [5 units of analgesics was 0.8 (95% CI: 0.41.5) for postnatal ward in 2001, and 0.6 (95% CI: 0.31.1) for the postnatal ward in 1998 as compared with the maternity hotel. Non-Western ethnicity (aOR = 3.3; 95% CI: 1.76.3), use of forceps or vacuum assisted delivery (aOR = 2.1; 95% CI: 1.14.1), episiotomy or large tears (aOR = 3.1; 95% CI: 1.37.3) and maternal complications (aOR = 2.0; 95% CI: 1.23.5) were associated with use of [5 units of analgesics postnatally. Age, smoking during pregnancy or duration of stay was not associated with use of [5 units of analgesics. The HosmerLemeshow goodness-of-t statistic supported that the nal multiple regression models tted (P [ 0.05).

Discussion Use of analgesics postnatally should be determined by medical needs and not by organisational factors. This study did not identify any signicant impact of organisation of the postnatal ward on analgesic use. Even though the maternity hotel is more home-like, our results suggest that the accessibility to analgesics is similar to the conventional postnatal wards. The prevalence of analgesic use after delivery in our study was lower than in three of the four previous published studies (Table 1). Earlier studies have shown that analgesics are the most frequently used drugs after delivery, used from 21 to 84% of the women (Table 1). The lower use of analgesics found in this study could be a result of the efforts to de-medicalise childbirth. In addition, the Baby-Friendly Hospital Initiative launched

by United Nations International Childrens Emergency Fund (UNICEF) and World Health Organization (WHO) in l University hospital participates) set 1991 (in which Ulleva further focus on childbirth as a normal and in most cases healthy state of being [12]. Another explanation might be that only women with vaginal deliveries were included in our study. Previous studies have included between 0 and 40% women with a caesarean delivery (Table 1). During the stay in hospital and maternity hotel analgesics are supplied free of charge, thus insurance issues or ability to pay will not impact her postnatal use of analgesics. Post-labour pain tends to increase with increasing parity. This may explain the higher use of analgesics among women with previous deliveries. Also, the womans own perception of pain, general attitude towards drugs and knowledge of drugs, may inuence use of analgesics. Culture plays a signicant role in the attitude toward pain at childbirth, perception of pain, and ways of coping with pain in relation to childbirth [13]. It seems likely that this could also be true for drug use after delivery. Personal and professional support may modify the womens responses to pain at childbirth [14, 15]. Women who feel that they have emotional and medical support are more condant and report less pain [14, 15]. In this study, communication problems among women with non-Western ethnicity may have created emotional stress, and increased the use of analgesics after delivery. Being younger than 35 years of age at delivery was an independent explanatory factor associated with postnatal use of analgesics. One explanation could be that women feel more experienced, secure, and cope better with pain with increasing age. However, this association was not maintained when more than ve units of analgesics was used as the dependent variable in the analyses. Previous studies have shown that women who smoke during pregnancy are more likely to use drugs [1518]. Smoking in pregnancy may be a characteristic of women who are less restrictive to use of drugs in general. It is not surprising that labour-related factors inuenced the postnatal use of analgesics [16]. Women with use of forceps or vacuum at delivery or complications after delivery may have pain and require analgesics. Higher postnatal use of analgesics among women who used analgesics during labour may reect a difcult delivery, low tolerance of pain or willingness to treat pain pharmacologically. Higher likelihood of analgesic use among women with a postnatal stay of C4 days may indirectly reect difculties during labour, but also a longer duration of drug accessibility. The data used in our study were obtained from obstetric hospital records. Underreporting or incomplete recording could lead to an underestimation of postnatal drug use. Discrepancy between recorded analgesic use (distributed

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drugs) and analgesics actually ingested may have occurred. Analgesic use in our study may have been overestimated if the women did not ingest the drug distributed. On the other hand, analgesic use may have been underestimated if the women ingested self-provided drugs. In our study, we controlled for potential confounding factors related to the delivery and to the womans background. However, there may still be insufcient control for factors not measured in our study. For example, we did not take use of drugs during pregnancy into account, though women used to using medication may have a different approach to analgesic use than women with no medication use during pregnancy. Also, we did not have information about socio-psychological factors like extent of support during and after labour and on the personal experience or preference of analgesics of the health care personnel in care for the mother, though these factors may have an impact on the use of analgesics after labour. Qualitative studies among both health care personnel and mothers may reviel attitudes, knowledge and reasons for use of analgesics postnatally.

References
1. Collaborative Group on Drug Use in Pregnancy (CGDUP). Medication during pregnancy: an intercontinental cooperative study. Int J Gynaecol Obstet. 1992;39:18596. 2. Passmore CM, McElnay JC, DArcy PF. Drugs taken my mothers in the puerperium: inpatients survey in Northern Ireland. BMJ. 1984;289:15936. 3. Matheson I. Drugs for the mother and infant in the maternity ward. A study of 5 Norwegian university hospitals (in Norwegian with English abstract). Medikamenter til mor og barn i barselavdelinger. En kartlegging ved fem norske sykehus. Tidsskr Nor Laegeforen. 1989;109:211822. 4. Treacy V, McDonald D. Drug utilization in antenatal and postnatal wards. Ir Med J. 1982;74:15960. 5. Doering PL, Stewart RB. The extent and character of drug consumption during pregnancy. JAMA. 1978;239:8436. 6. MacVicar J, Dobbie G, Owen-Johnstone L, Jagger C, Hopkins M, Kennedy J. Simulated home delivery in hospital: a randomised controlled trial. Br J Obstet Gynaecol. 1993;100:31623. 7. Hundley VA, Cruickshank FM, Lang GD, et al. Midwife managed delivery unit: a randomised controlled comparison with consultant led care. BMJ. 1994;309:14003. 8. Waldenstrom U, Nilsson CA. A randomized controlled study of birth center care versus standard maternity care: effects on womens health. Birth. 1997;24:1726. 9. Byrne JP, Crowther CA, Moss JR. A randomised controlled trial comparing birthing centre care with delivery suite care in Adelaide, Australia. Aust NZ J Obstet Gynaecol. 2000;40:26874. 10. Hodnett ED. Home-like versus conventional institutional settings for birth (Cochrane Review). In: The Cochrane Library, Issue 1. Chichester, UK: Wiley; 2004. 11. Hosmer DW, Lemenshow S. Applied logistic regression. 2nd ed. New York: Wiley; 2000. pp. 14756. ISBN:0-471-35632-8. 12. Baby-Friendly Hospital Initiative. In: World Health Organization/UNICEF. Protecting, promoting and supporting breastfeeding: the special role of maternity services. Geneva: WHO; 1989. ISBN: 92-4-156130-0. 13. Callister LC, Khalaf I, Semenic S, Kartchner R, VehvilainenJulkunen K. The pain of childbirth: perceptions of culturally diverse women. Pain Manag Nurs. 2003;4:14554. 14. Corbett CA, Callister LC. Nursing support during labor. Clin Nurs Res. 2000;9:7083. 15. Hodnett ED. Pain and womens satisfaction with the experience of childbirth: a systematic review. Am J Obstet Gynecol. 2002; 186:S16072. 16. Buitendijk S, Bracken MB. Medication in early pregnancy: prevalence of use and relationship to maternal characteristics. Am J Obstet Gynecol. 1991;165:3340. 17. Bonassi S, Magnani M, Calvi A, Repetto E, Puglisi P, Pantarotto F, et al. Factors related to drug consumption during pregnancy. Acta Obstet Gynecol Scand. 1994;73:53540. 18. Larivaara P, Hartikainen AL, Rantakallio P. Use of psychotropic drugs and pregnancy outcome. J Clin Epidemiol. 1996;49:130913.

Conclusion Nearly half the women in this study used analgesics during their hospital stay after vaginal delivery. Staying in a midwife-managed maternity hotel rather than in conventional postnatal wards did not inuence the use of analgesics. Factors related to delivery, but also to the womans sociodemographic characteristics, were signicantly associated with postnatal use of analgesics among women with vaginal delivery. These factors were multiparity, having a nonWestern ethnicity, smoking in pregnancy, younger age, instrumental delivery, analgesic use during labour, maternal complications post partum, and duration of postnatal stay C4 days.
l Acknowledgment We would like to thank the staff at Ulleva University Hospital for recording of data. Funding We would like to thank The Norwegian Womens Public Health Association for funding the study. Conict of interest statement None.

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