DISCUSSION    
Main findings
This study aimed to test the hypothesis that fear, misconceptions and lack of awareness lead to refusal of epidural for labour analgesia. The following principal observations emerged; parturient who reported at the maternity unit of the Tamale Teaching Hospital showed awareness of epidural labour analgesia services, however, many refused to receive an epidural for labour analgesia on our labour and delivery service. The educational background, age, cultural or religious beliefs and attitude of some midwives were observed to be factors that influenced the refusal of epidural for labour analgesia.
Strengths and limitations
In brief, the results from this study and related literature reviewed consistently showed that there is generally very low patronage of epidural labour analgesia among parturients in developing countries with age, educational background, cultural or religious beliefs, cost of service and attitude of some midwives arguably being the most predictive of acceptance or refusal of the epidural for labour analgesia. Language barrier and failure to explore some effects of socio-economic background on the awareness and acceptance of labour analgesia services were the limitations encountered during this study. There is a need for healthcare providers to initiate education on the epidural for labour analgesia to reduce fear and misconceptions to increase patronage.
Interpretation
Studies have demonstrated that parturients who accept to receive an epidural for labour analgesia are more likely to have attended ante-natal care or read some reference books [13]. Also, factors within parturients may influence whether they receive an epidural for labour analgesia. Other reasons such as anaesthesia care providers not accessible in a timely fashion, friends and family members discouraging the parturient, and previous experiences may impact future choices [14]. Policies guiding practice at the various hospitals may also prevent a parturient from receiving an epidural for labour analgesia.
Childbirth experience in Ghana ranges from agony to ecstasy. It is described as a multidimensional experience that includes intense physical, emotional, psychological, developmental, social, cultural and spiritual components. It differs in meaning and quality for each labouring woman and changes as labour progresses. Labour pain is ranked among the most intense pains recorded [1]. Many women in Ghana rate labour pain as severe, while a few reports little or no pain [2]. Each woman’s labour pain is unique to her. The amount of labour pain one woman may feel will differ from that felt by another woman. It depends on factors such as level of pain tolerance, the size, and position of the baby, the strength of uterine contractions and prior birth experiences [3]. The findings of this study suggested that many parturients experience severe or excruciating pain in Ghana during childbirth and may need pain relief (Table 3) .  Satisfaction with childbirth experience is closely related to less pain during labour. Numerous strategies, both pharmacologic and non-pharmacologic, have been used as a treatment for labour pain relief [4]. Shidhaye et al reported that many pregnant women in developing countries are mostly not aware of labour analgesia services in their hospital. Lack of awareness or the availability of labour analgesia services in many hospitals of poor resource countries may be the prime cause of low patronage [15]. Olayemi et al [11] attributed low awareness of epidural for labour analgesia to the fact that healthcare providers themselves are either ignorant of pain relief in labour or consider it a less priority in educating women. Conversely, the present study showed awareness of epidural for labour analgesia among parturients at the maternity unit of the Tamale Teaching Hospital. A survey demonstrated that out of 76 % of pregnant women who showed some awareness of epidural labour analgesia service, only 19 % of them patronized it during childbirth, while the majority refused to accept it due to fears and misconceptions [16]. Another literature showed a disparity of epidural use that existed along ethnic and racial lines, with Africa American less likely than whites to receive an epidural for labour analgesia. Fear, naturalism and family influence were some reasons that led to the refusal of epidural for labour analgesia by the Africa Americans [17, 18]. Similarly, the findings of this study showed that despite the high awareness of epidural labour analgesia service among parturients at the delivery unit, many still refused for it to be administered to them.  Age, educational background, cultural or religious beliefs, cost of service, and some attitudes of midwives among others were factors that led to the refusal of the epidural for labour analgesia at the delivery unit of the Tamale Teaching Hospital. Hanem et al. and Minhas et al. [19, 15] reported a correlation between educational background and knowledge on labour analgesia acceptance. Although our current study did not evaluate the socioeconomic background of respondents, we observed that women with non-formal education were less likely to accept epidural for labour analgesia. They have bound to the cultural or religious beliefs that labour is a natural process and does not need any intervention in the form of pain management and that husbands are the heads of the family and therefore should give their consent before they accept labour analgesia. These findings were not out of place, more so in a setting where traditional and religious practices are prevalent. This may have a great influence on the decision to refuse epidural labour analgesia. An in-depth understanding of these factors observed may better enable healthcare providers to assist parturients in the decision-making process at the delivery unit regarding epidural for labour analgesia.