Exploring Obstetric Analgesia in Labor Management: Assessing Knowledge and Usage Among Midwives in North-Central Nigeria

Background of the Study

Labor pain has been described to be excruciating and one of the most painful experiences a woman has to endure during parturition.^[1] In many developed countries, labor pain management during childbirth is considered a routine part of intrapartum care and all laboring women have access to the method of pain relief that they choose.^[2] However, in developing countries, including Nigeria, options for labor pain alleviation are very limited. Adequate labor pain management during childbirth is a way of promoting a satisfactory birth experience and a healthy reproductive outcome for women.^[3] However, inadequate labor pain management negatively impacts maternal and fetal well-being, as well as the progress of labor.^[4] It may further lead mothers to postpartum depression, post-traumatic stress disorder, negative experiences and dissatisfaction after childbirth, and fear of childbirth, which increases maternal request for cesarean section.^[5] Prolonged, unrelieved labor pain can also cause hypertension, hyperglycemia, constipation, and maternal and fetal distress.^[6] Thus, obstetric care providers like midwives have to attain painless labor by utilizing safe and optimal analgesia.^[5]

The American College of Obstetricians and Gynecologists states that laboring women should be offered pain management when desired.^[7] Additionally, the World Health Organization (WHO) stated that a woman’s preferences should be taken into consideration when prescribing pain relief during labor, and the WHO analgesic ladder should be followed.^[8] Midwives are in a key position to help women in labor understand their options and make informed choices.^[9]

Labor pain management involves a series of activities that include pain assessment as well as pain control or abolition.^[5] Thus, obstetric care providers have to utilize safe and optimal interventions to attain painless labor.^[2,5] Labor pain relief methods are categorized into pharmacological (inhalation anesthesia, regional anesthesia, opioids such as pethidine) and nonpharmacological (hypnosis, laboring in water, acupuncture, massage) methods.^[8,10] Labor pain management with the use of pharmacological agents or non-pharmacologic means has become an integral component of labor management.^[7]

The important role played by midwives in providing compassionate support during the process of labor cannot be underestimated, especially in instances of positive interaction with women in labor, by showing care and encouragement to those women enduring labor pain.^[11] Although labor pain management is accepted and implemented in many countries in the world, it is not a common practice in most developing countries like Nigeria. Despite their knowledge, obstetricians routinely prescribed and utilized very little obstetric analgesia according to the studies done in Nigeria.^[12,13] Thus, a substantial unmet need for labor pain management exists among women in labor. This might be a result of several factors, which include a lack of drugs, healthcare delivery systems, and limited knowledge and abilities of the healthcare provider to administer labor analgesia.^[1,14] On the other hand, myths about long-term back pain, injury to the infant, breastfeeding difficulties, increased risk of cesarean sections, slow progress of labor, and long-term health issues, cultural and religious issues are some factors that influence the use of labor analgesia in clients.^[15]

Several scholars have conducted studies on knowledge, attitudes, and perceptions of the usage of pain relief methods during labor among other healthcare providers and obstetricians in Nigeria but there is a gap in knowledge and utilization of pain relief methods among midwives who are the main caregivers for women in labor.^[12−14] Moreover, anecdotal reports also revealed that there is poor knowledge and utilization of obstetric analgesia among midwives in the north-central region of Nigeria. Thus, this study was carried out to assess knowledge and utilization of obstetric analgesia as well as factors influencing the choice of obstetric analgesia among midwives in the north-central region of Nigeria.

Research Hypothesis

Hypothesis 1 (Ho): We hypothesize that there is no significant association between knowledge and utilization of obstetric analgesia in labor among midwives working in the north-central region of Nigeria.

Hypothesis 2 (Ho): We hypothesize that there is no significant relationship between sociodemographic variables of Midwives and utilization of obstetric analgesia in labor.

Study Design/Study Population

This is an institution-based cross-sectional descriptive study conducted among midwives in the north-central region of Nigeria to accomplish the study’s aim. The population for the study was all midwives in Ilorin, Kwara State. The sample size for this study was calculated using Andrew Fisher’s formula (1922): $n=\frac{z^{2}pq}{d^2}$ where ‘n’ is the required sample size; ‘Z’ is the standard normal deviation corresponding to the 95% coefficient interval (equivalent to 1.96); ‘P’ is the prevalence of the attribute being studied and was estimated at 0.3; ‘q’ is 1 − p and ‘d’ is the margin of error or the desired level of precision which was set at 5% (0.05). We calculated the minimum required sample size to be 112 using the formula and to account for potential loss of questionnaires, and non-responses of filled questionnaires, an additional 10% of the sample size was added as a precaution. Thus, a final sample size of 123 respondents was used for the study, and the purposive sampling technique was used to select the 123 midwives who were willing to participate and have worked in the maternity ward of the selected healthcare facilities in the past 12 months.

Instrument for Data Collection

The instrument used for data collection instrument was a self-constructed questionnaire which consists of both open and closed-ended questions. The questionnaire consists of three sections; section A was designed to elicit information on socio-demographic characteristics; section B was designed to assess the knowledge of obstetric analgesia; and section C was designed to assess the utilization of obstetric analgesia. The face and content validity of the instrument was done by experts in the field of psychology, maternal and child health nursing research, and statistics. The reliability of the instrument was determined using a test-retest method which involved the administration of the 12 copies questionnaire (10% of the sample size) to midwives from a different health facility with similar characteristics at two-week intervals. The reliability of the instrument was measured using Cronbach’s Alpha and a Cronbach Alpha coefficient of 0.85 was obtained which confirmed the reliability of the instrument. The questionnaires were designed in English language and were distributed by the researchers. The respondents were first told about the purpose of the research study and consent was taken from each participant before questionnaires were administered. The questionnaires were retrieved back on the spot after completion by the respondents to avoid loss. A total of 123 questionnaires were administered and the same were retrieved. Thus, the response rate for the study was 100%. The midwives were met in their various wards. Data were collected from May 9 to June 26, 2023. The process of data collection lasted over a period of 7 weeks.

Statistical Analysis

The collected data were analyzed using IBM SPSS version 25 (Armonk, NY), and the results were presented using both descriptive and inferential statistics. Descriptive statistics such as frequencies and percentages were used to summarize categorical variables. Inferential statistics in the form of chi-square was used to test the association between the independent variables (sociodemographic variables and knowledge) and dependent variables (utilization, of obstetric analgesia) at a 0.05 level of significance.

Ethical Considerations

All related ethical issues were addressed during the conduct of this study. Ethical clearance and approval to carry out the study was obtained from the General Hospital Ilorin Ethics Review Committee. Information about the research was discussed in detail with participants and consent forms were duly signed by them. Confidentiality and anonymity were ensured as names were not required on questionnaires and could not be linked to the participants.

Sociodemographic Characteristics

The study elicited responses from a total of 123 midwives, and the findings, as presented in Table 1, show that more than half of the respondents 65 (52.8%) were between the age of 30–40 and were married 69 (56.1%). The majority of the respondents 97 (78.9%) were Yoruba by tribe and more than half of them 73 (59.3%) were Christians and a higher proportion of them 57 (46.3%) had 11–20 years of work experience. The majority 78 (63/4%) were Bachelor of Nursing Science (BNSc) certificate holders and less than half 41(33/3%) were Nursing Officer 1.

Knowledge of Obstetric Analgesia Among Midwives

Table 2 shows that the majority 118 (95.9%) of the respondents had heard of obstetric analgesia before and knew that obstetric analgesia is pain relief in labor. The majority of them 89 (72.4%) opined that pain is a subjective phenomenon. The majority 107 (87.0%) of the respondents stated that they knew about pain assessment tools, yet only 21 (17.1%) knew that the pain assessment scale rating is not 0–6. More than half of them 71 (57.7%) said they had heard of the WHO pain ladder and 98 (79.7%) also stated that they knew about the methods of obstetric analgesia in labor. Ninety-two (74.8%) of the respondents stated that the pharmacological method of obstetric analgesia offers a better birth experience. More than half of the respondents 69 (56.1%) said that the right time to give obstetric analgesia is during the first stage of labor. Eighty-one (65.9%) and 80 (65.0%) of the respondents had good knowledge about the pharmacological and non-pharmacological methods of obstetric analgesia in labor respectively.

Utilization of Obstetric Analgesia Among Midwives

Table 3 shows that more than half of the respondents 73 (59.3%) have used pain assessment tools during labor, while the majority 103 (83.7%) have used obstetric analgesia in the management of women during labor. A high proportion of the respondents 47 (38.2%) said that they have previously used both methods of obstetric analgesia (pharmacological and non-pharmacological) in the management of women during labor. The major reasons for non-utilization of obstetric analgesia by midwives were: no equipment 49 (39.8%), hospital policy 48 (39.0%), and lack of knowledge 12 (9.8%).

Association Between Utilization of Obstetric Analgesia in Labor and Sociodemographic Variables

Findings from Table 4 revealed that there was a statistically significant association between utilization of obstetric analgesia in labor and knowledge (χ² = 16.582, p < 0.001) as well as years of experience (χ² = 17.280, p < 0.015) and Nursing Rank (χ² = 36.579, p < 0.000); since the p-value < 0.05 significance value, the null hypothesis was rejected and the alternative hypothesis was accepted.

Strengths and Limitations

Strengthening our study was the data collection from the participants, who were midwives, who had worked in maternity wards in the past year. The study had some limitations, firstly, it was conducted in a general government hospital which has a high patient inflow and workload. As a result, some of the midwives were unable to participate because of stress, workload, or lack of time. Secondly, the study was carried out in a single secondary hospital using a cross-sectional survey. This removes the possibility of generalization of the findings to other settings.

Key Messages

• Overall knowledge of the midwives on obstetric analgesia was adequate, and more than half of them have utilized obstetric analgesia in labor pain management.

• A high proportion of midwives frequently utilize the non-pharmacological method compared to the pharmacologic method of obstetric analgesia.

• It is necessary to motivate midwives to utilize obstetric analgesia more proactively in order to enhance the birth experience and outcome, as well as prevent the negative effects associated with severe labor pain.