Midwives’ utilization of nonpharmacological pain relief measures for labor pain management: A descriptive cross-sectional study

Idang Neji OJONG, Alberta David NSEMO,Mathias AGBA

Department of Nursing Science, Faculty of Allied Medical Sciences, College of Medical Sciences, University of Calabar,Cross River State, Nigeria

ABSTRACT

Objectives:This study sought to examine midwives’ utilization of nonpharmacological pain relief measures in labor pain management and to test the relationship between midwives’ knowledge and utilization of nonpharmacological pain relief measures for labor pain management in secondary health facility in Calabar, Cross River State, Nigeria.

Materials and Methods:A descriptive cross-sectional design was used for the study.The study was rooted in Katherine Kolcaba’s Comfort theory.Totally, 67 participants were recruited for the study using the purposive sampling technique.A self-made structured questionnaire was used to obtain participants’ information on knowledge, utilization, and predictors of nonpharmacological pain relief measures.

Results:Although 41 (61.2%) of the participants had knowledge about nonpharmacological pain relief measures, few did not know some of the cognitive-behavioral and environmental measures in labor pain management.There was 35.8% (24/67) for utilization of cognitive-behavioral measures and 55.2% (37/67) for psychological/emotional measures for labor pain management by respondents, respectively.Fifty (74.6%) of respondents agreed that predictors such as lack of knowledge, lack of updates and training, work experience, best practice guidelines, and equipment were hindrances to utilization.There was statistically significance in relationship between the level of knowledge and utilization of nonpharmacological pain relief measures (r = 0.6, P ＜ 0.05).

Conclusion:The utilization of nonpharmacological measures for labor pain management is low, thus it is recommended that frequent education, training updates on effective labor pain management, provision of clinical guidelines on labor pain management, and enrichment of midwifery training curriculum are imperative to ensure quality labor pain management and positive health outcome.

Keywords: Labor pain management, midwives, Nigeria, nonpharmacological, pain relief, utilization

INTRODUCTION

Parturients experience labor pain of varying degrees,ranging from moderate to severe pain during the first and second stages of labor.The progression, intensity,characteristics, as well as the cause of first and second stages of labor pain varies greatly among women.[1]When pain during labor is severe, it may adversely affect parturient and fetus.Particularly, those parturients with cardiac comorbidity are at high risk.Therefore, effective pain relief in labor is not only humane but also has vast physiological and psychological benefits for both the mother and the baby.[2]nonpharmacological pain relief measures according to the study conducted by Gokhale and Gokhale,[3]has extensively been found to be effective in pain management.nonpharmacological pain relief measures are therapies and complimentary approaches used in relieving pain without the use of medications or drugs.[4]Literature classified nonpharmacological pain relief measures into four groups and types.These include: (i) Physical or comfort measures (positioning, immobilization, massage,use of heat and cold application, and trans-electrical nerve stimulation [TENS]), (ii) psychological or emotional support measures (meditation, presence, psychotherapy,reassurance, caring and comforting words), (iii) cognitive measures (distraction and relaxation techniques, therapeutic touch, music therapy, and imagery), and (iv) environmental measures (minimizing noise, comfortable beds and room temperature, dim light, and decoration).[5]According to Collins and Kaslow’s study,[6]midwives should possess a good knowledge of all the types of nonpharmacological pain relief measures and utilized these measures to adequately relieve pain in labor.

Documented evidence showed that the utilization of nonpharmacological pain relief measures is of great benefit as it reduces labor pain, anxiety, frequent prescription and administration of analgesic, and cost implication on patients.[6,7]The use of nonpharmacological pain relief measures is increasing.Literature revealed that the use of nonpharmacological pain relief measures and therapeutic touch in pain management is advocated by stakeholders of nursing.[8]

Nurses’ perspectives, views, and opinion play a crucial role in the utilization of nonpharmacological pain relief measures.Khalil[9]observed that, nurses’ perspectives on the importance, usefulness and effectiveness of nonpharmacological pain relief measures are significant to utilization.Globally, the perspectives and extent of utilization of nonpharmacological pain relief measures have been researched.[10,11]The North American Nurses Association (NANA) 2018, statistics revealed that 80%-90% of nurses viewed utilization of nonpharmacological pain relief measures as effective in reducing pain intensity in labor.In sub-Saharan Africa hospitals and Nigerian health-care facilities studies revealed that ＜40% of nurses rarely utilized nonpharmacological pain relief measures in labor pain management and postoperative pain management.[12,13]

In developed nations, pain-free labor has become the norm,and the majority of women deliver in hospital, while the story is different in most developing countries like Nigeria where only 35% of women deliver in hospital.Childbirth in Nigeria has been identified as unhappy event, and it is less satisfactory because there is an unmet need for pain relief during labor.[14]

Madenski[15]identified the factors that militate on utilization of nonpharmacological pain relief measures include the level of knowledge on nonpharmacological pain relief measures,education and training, years of experience, working conditions and organization policy.Several literature revealed that organizational factor such as availability of multimodal guidelines on pain management, sufficient manpower, nursepatient ratio, heavy workload, and level of preoperative education of patient on pain relief.[16-18]Literature highlighted factors related to health system include lack of support by the hospital system, mentoring and coaching on the utilization as prognosticators.[17]

In proffering solution to hindrances to nonutilization of nonpharmacological pain relief measures, Masumbokoet al.[18]advocated for increased awareness, of health-care providers to apply nonpharmacological pain relief measures,education, provision of standard protocol or guidelines on pain management, broad-based promotion of multimodal pain management.Institutional belief, commitment, and academic detailing for providers and education on the treatment modalities were needed.Coulling and Kaslow[7]report that pain management requires a multidimensional treatment that promotes patients’ optimal comfort and calls for a comprehensive examination of hindrances to pain management measures.

However, observation of practice of utilization of nonpharmacological measures in labor pain management in general hospital by researchers revealed haphazard utilization of nonpharmacological pain relief measure by midwives.[17]This practice has implication for labor outcome.This as a result has created an urgent need to fill the existing gap.Although researches have been conducted to address this concern in other health- care institutions both at the national and international level in an attempt to provide solution to the problems.From the literature reviewed, it was observed that none of these researches was conducted in the area of study.Hence, this study seeks to examine midwives’knowledge of nonpharmacological pain relief measures in labor pain management, to determine the proportion of midwives utilizing nonpharmacological pain relief measures in labor pain management and also identify the predictors of midwives’ utilization of nonpharmacological pain relief measures for labor pain management in secondary health facility in Calabar, Cross River State, Nigeria.

MATERIALS AND METHODS

Study design and setting

A descriptive cross-sectional design is considered suitable for this study because it allows for description of phenomenon based on a particular variable of interest such as participant characteristics, age, and level of education and years of working experience.It also permits the organization of data.The study was rooted in Katherine Kolcaba’s Comfort theory and was carried out in General Hospital Calabar because it is the best secondary health facility where maternal and child health services is carried out by skilled birth attendants.

Accessible population

The accessible population includes all the midwives working in the maternity units of General Hospital Calabar that were present during the time of data collection period.The sample size was 67.The purposive sampling technique was use for this study since the sample size was not enough for sampling hence the researcher decided to use the total accessible population.

Inclusion and exclusion criteria

The inclusion criteria were as follows (1) registered midwives with for more than 6 months working experience in maternity unit of the hospital; (2) participants who gave informed consent; and (3) participants who were willing to partake in the study and provide information for the study.The inclusion criteria were as follows: midwives who were not working in maternity unit, ＜6 months’ experience in maternity wards or were unwilling to participate.

Study tool and data collection procedure

The structured questionnaire including four sections and 27 items was used for serving as interview guide/schedule.Section A includes 5 items on demographic data of the respondents.Section B includes 8 items measuring midwives’knowledge on nonpharmacological pain relief measures in labor pain management.Section C includes 9 items measuring midwives’ utilization of nonpharmacological measures by midwives for labor pain management.Section D includes 5 items on predictors of midwives’ utilization of nonpharmacological measures for labor pain management.The response for each item on section B is “yes” and “no,”and interpreted as 1 and 2 in proportions.For the 8 items in Section B, scoring 9-16 points is rated as “good knowledge”while ＜9 points is rated as “poor knowledge.” Section C and D are rated using a 4-point scale from “1 = strongly agreed,” “2 = agreed,” “3 = disagreed,” to “4 = strongly disagreed.” Scoring 19-36 points is rated “good utilization”of nonpharmacological pain relief measures in labor management while ＜19 points indicates “poor utilization.”

Copies were presented to experts in measurement and evaluation to scrutinize.In order to test the reliability of the instrument, a pilot study was carried out on 7 midwives at University of Calabar Teaching Hospital.A test-retest reliability method was used in determining the reliability of the instrument.Here, the questionnaire was administered to the respondents, and after 1 week, it was administered to the same respondents, data generated from the two sets of the questionnaire were analyzed using Person product-moment correlation coefficient.The highest range result of reliability coefficient was 0.84.Reliability refers to the extent to which an assessment instrument measures or produces stable, consistent, accurate, and replicable result.A reliability between 0.8 and 0.9 was considered as good reliability.[19]

Statistical analysis

The quantitative data were analyzed using descriptive analysis and the relationship between midwives’ knowledge and utilization of nonpharmacological pain relief measures was tested using Pearson Product Moment Correlation analysis at 0.05 level of significance.AP＜ 0.05 indicated a significant relationship.The analysis was done with the aid of Statistical Package for Social Sciences version 23 (IBM SPSS,Armonk, NY, USA).[20]

Ethical considerations

Ethical approval was collected from Cross River State Health Research Ethics Committee with REC NO.CRSMOH/RP/REC/2021/566 dated August 22, 2021.The midwives were informed by the researchers that anonymity and confidentiality would be maintained in all the information given.Informed consent was obtained and participation was voluntary.

RESULTS

The socio-demographic characteristics of the respondents are shown in Table 1.management.The findings as regarding midwives’ knowledge revealed that although more than half of the participants claimed to be knowledgeable about nonpharmacological pain relief measures, majority did not have knowledge about all the types of nonpharmacological pain relief measures such as physical comfort, psychological-emotional,cognitive-behavioral and environmental measures used in relieving pains in labor.The reason for their knowledge about nonpharmacological pain relief could be attributed to the basic foundation knowledge from curriculum contents they had in school, while lack of adequate knowledge on all the types of nonpharmacological pain relief measures may be due to a lack of specific and frequent educational updates and seminars on various types and contemporary types of nonpharmacological pain relief measures to midwives.

Table 1: Sociodemographic variables of the respondents (n=67)

Findings of this study are in agreement with Aliet al.,[12]in Nigeria who observed that majority of the midwives had knowledge about nonpharmacological pain relief measures but did not know all the types used in pain management.However, the finding of this study was contrary to Boatenget al.,[21]who found out that in Ghana midwives had very good knowledge about nonpharmacological pain relief measures and majority of the midwives used cognitive-behavior, physical,psychological and environmental interventions to relieve labor pains.This may be attributed to frequent education,training, and updates on the use of nonpharmacological pain relief measures alongside with pharmacological measure and availability of standardized best practice guidelines to ensure quality pain management by nurses.This implies

Table 2 shows the distribution of respondents’ level of knowledge on nonpharmacological pain relief measures in labor pain management.The summary responses of the participants on midwives’ level of knowledge on nonpharmacological pain relief measures in labor pain management showed that 41 (61.2%) had good knowledge while 26 (38.8%) had poor knowledge.

Table 2: Midwives’ knowledge on nonpharmacological painrelief measures in labour pain management (n=67)

Table 3 shows the respondents’ responses on utilization of cognitive-behavioral measures and psychological and emotional measures in labor pain management.The total rate of the respondents answering “strongly agreed” and “agreed” to utilization of cognitive-behavioral measures was 35.8% (24/67), which meant only 35.8% midwives had good utilization on cognitive-behavioral measures in labor pain management while 64.2% (43/67) who answered “disagreed”and strongly disagreed” had poor utilization.In the same way, totally, 37 (55.2%) had good utilization of psychological and emotional measures in labor pain management while 30 (44.8%) had poor utilization.

Table 3: Midwives’ utilization of nonpharmacological pain relief measures in labour pain management (n=67)

Table 4 shows predictors of utilization of nonpharmacological pain relief measures in labor pain management.The total rate of the respondents answering “strongly agreed”and “agreed” was 74.6% (50/67), which indicated 74.6% of respondents agreed that predictors such as lack of knowledge, lack of belief in effectiveness, lack of training and education, lack of availability of clinical guidelines and lack of equipment and materials were hindrances to utilization of nonpharmacological pain relief measures.

Table 4: Predictors of utilization of nonpharmacological pain relief measures in labour (n=67)

The Pearson product-moment correlation implied that the level of knowledge was significantly related with utilization of nonpharmacological pain relief measures in labor pain management [Table 5].

Table 5: The relationship between midwives’ knowledge andutilization of nonpharmacological pain relief measures in labour pain management

DISCUSSION

Knowledge of nonpharmacological pain relief measures in labor pain management

The importance of knowledge of nonpharmacological pain relief measures in effective labor pain management cannot be overemphasized.Knowledge of midwives needs to be assessed to establish utilization of these measures in labor pain that if regular training, education, seminar, and best practice guidelines on nonpharmacological pain relief measures are provided, midwives in the selected settings will improve their knowledge on nonpharmacological pain relief measures.

Proportion of utilization of nonpharmacological pain relief measures

The utilization of nonpharmacological pain relief measures depends on the number or population of midwives that utilizes these measures.The quantitative findings in four domains of nonpharmacological pain relief measures indicated that majority of the participants only utilized some physical measures such as positioning and immobilization while majority did not use massage, hot and cold application including TENS to relieve postoperative pain of patients.On psychological measures, half of the participants utilized reassurance, meditation, and emotional support from family members while majority also did not use presence, spent time to communicate (psychotherapy).Majority of the participants indicating very low proportion did not utilize almost all the cognitive-behavioral measures such as diversional therapy,relaxation and breathing technique, therapeutic touch,imagery, music therapy, and preoperative pain education to relieve labor pain.

The reason for low utilization of all the types of nonpharmacological pain relief measures by participants could be as a result of inadequate knowledge, training,updates, seminar, and lack inadequate number of nurses in the shift.In addition, the lack of experts in the field of pain management to provide teaching, coaching, and mentoring on the use of these measures may also constitute to low utilization.

Findings of this study result were in line with the research conducted by Well and McCaffery,[22]which revealed that majority of the midwives did not utilize all forms of nonpharmacological pain relief approaches in pain management.It was recommended that midwives should avoid overdependent on pharmacological management to pain and should utilize various types of nonpharmacological strategies to manage postoperative pains.

Contrary to this finding, Celebioghi[23]study showed that most participants demonstrated a high level of utilization on all the physical, psychological-emotional, emotional, and cognitive behavior nonpharmacological pain relief measures such as the use of distraction, diversional therapies - music,imagery mostly used by nurses, especially by the chief nursing officers, who frequently utilized all types of nonpharmacological pain relief measures in labor pain management.Most frequently used nonpharmacological pain relief methods were calming voice, information, and deep breathing.

The reason for the high utilization of nonpharmacological pain relief measures in the study might be linked to the premium paid on building capacities and competencies of midwives through constant education, training, update on effective pain management strategies through the use of nonpharmacological pain relief measures in advance country.Moreover, it may be due to the enrichment of pain management educational curriculum contents, peer training,mentoring, institutional support, and human and material resources available in pain management.

Predictors of utilization of nonpharmacological pain relief measures

Effective management of postoperative pain requires that all the factors hindering utilization of pain management strategies need to be identified and proffer necessary solution.The findings showed that majority of the participants agreed that lack of knowledge, lack of belief in effectiveness, lack of training and education, lack of availability of clinical guidelines, and lack of equipment and materials hinders utilization of nonpharmacological pain relief measures in labor pain management.The findings revealed that there was a serious gap in knowledge, training,and education of midwives on nonpharmacological pain relief measures which had an effect on utilization of these measures.In line with this study, Williamset al.[24]observed that most of the poor application of nonpharmacological measures in pain management was related to inadequate knowledge of midwives in each shift, lack of time, heavy workload and lack of frequent training.Findings agrees with Boateng[21]who noticed that factors such as lack of time,skills, guidelines, lack of resources, lack of experience in using nonpharmacological methods, insufficient knowledge of nonpharmacological pain relief, personal beliefs and cultural values regarding pain and relief methods, belief of nurses, primarily role in the administration of pain medication and heavy workload of midwives as hindrances to midwives’use of nonpharmacological pain relief measures in labor patients.Contrary to these findings, a study conducted by Celebioghi[23]revealed that practicing midwives utilized all the types of nonpharmacological pain relief measures to reduce labor pains.Good utilization level was attributed to adequate ratio of midwives’ workforce in the shift,availabilities of nonpharmacological equipment, and best practice guidelines for the management of pain.The study findings also revealed that the provision of continuing development education was offered to midwives as strategies on pain management.Curriculum was enriched to include the current types of nonpharmacological pain relief measures and clinical monitoring supervision.This implies that midwives in well-developed countries pay more attention on capacity building to develop skills in nonpharmacological measures in labor pain management.

From the statistical analysis, the results confirmed that the level of knowledge was significantly related with the utilization of nonpharmacological pain relief measures in labor pain management.This implied that the more knowledgeable the midwife is, the better the utilization of non-pharmacological pain relief measures in labor pain management.The result was in line with the views of Konlanet al.,[25]who indicated that adequate knowledge and awareness of nonpharmacological pain relief measures are implicated for effective utilization.The knowledge of midwives on concept of pain, effect of nonpharmacological pain relief measures, complications and physiology of pain helped in labor pain assessment and choice of nonpharmacological pain relief measures to be used.

Implication of findings to midwifery practice

The study revealed inadequate knowledge on all the types of nonpharmacological pain relief measures, low utilization,and hindrances to the use of nonpharmacological pain relief measures in labor pain management among midwives.The findings of the study have significant implication for effective labor pain management.It, therefore, implies that if the respondents receive training and education on nonpharmacological pain relief measures in labor they will gain adequate knowledge to ensure higher utilization.Furthermore, addressing the hindrances to the use of nonpharmacological pain relief measures will improve utilization.

Limitation of the study

This study was limited to only 67 midwives working in maternity units of General Hospital Calabar, the sample size may not be a true representation of midwives in Cross River State as a whole for generalization of the findings.The researchers suggest similar study to be conducted in a tertiary health facility in the state, also a larger sample size should be used for comparison.

CONCLUSION

Based on the findings of the study, the following conclusions were made that: level of knowledge has a positive significant relationship on utilization of nonpharmacological pain relief measures.It can also be deduced from the above findings that predictors (lack of knowledge, lack of belief in effectiveness, lack of training and education, lack of availability of clinical guidelines, and lack of equipment and materials) significantly influence midwives’ utilization of nonpharmacological pain relief measures in parturient patients.Thus, it was recommended that frequent education,training update on effective pain management, provision of clinical guidelines on pain management, and enrichment of midwifery training curriculum content was imperative to ensure high-quality labor pain management and positive health outcome.

Acknowledgments

There authors are grateful and also acknowledged all the midwives who participated in this study despite their tight schedule of duties and also acknowledged all the authors whose articles were used to support this study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.