Nonpharmacological pain relief for labour pain: knowledge, attitude, and barriers among obstetric care providers

Introduction

Pain is defined by the International Association for the Study of Pain as an unpleasant sensory and emotional experience associated with actual or potential tissue damage (Raja et al., 2020). Labour pain is a complex human experience and is greatly affected by numerous factors which make it a unique experience for each woman. However, labour pain is rated as severe by the majority of women; 90% of them reported satisfaction with the experience three months postpartum. This may be due to the positive labour outcomes and the effective pain management during labour (Labor & Maguire, 2008). The anatomical and physiological explanation of labour pain illustrated that it has two main components, visceral and somatic, and the process of cervical dilation has a contributing role in the two components. Visceral pain starts in the early first stage and continues during the second stage of labour due to pressure created by the uterine contraction on the cervix and lower uterine segment, leading to stretching and distension and activating excitatory nociceptive afferents. Alongside the visceral pain, somatic pain occurs in the late first and second stages of labour. Somatic pain results from the severe stretching and ischemia generated by fetal descent in the cervix, vaginal, perineum, and pelvic floor (Gonzalez et al., 2016; Labor & Maguire, 2008).

Numerous physical and psychological factors can contribute to the severity of labour pain. Physical factors include frequency, duration, and intensity of contraction. Psychological factors include stress, anxiety, and fear (Siyoum & Mekonnen, 2019). Inadequately controlled labor pain leads to negative or upsetting childbirth experiences. labour pain management is critical to improve the birth experience and decrease the incidence of postpartum depression (Mo et al., 2022).

Nonpharmacological pain relief (NPPR) methods can be utilized to reduce pain, alleviate suffering and enhance women’s well-being during labour (Heim & Makuch, 2022). NPPR methods are recommended by the World Health Organization (WHO), among other sources of pain relief, to provide a positive birth experience (WHO, 2018). These methods are safe for both mother and fetus, have no side effects, do not affect labour progress, are cost-effective, and delay the use of pharmacological pain relief. NPPR helps women tolerate pain and have a more positive birth experience (Smith et al., 2018; Boaviagem et al., 2017). Furthermore, NPPR reduces negative outcomes associated with pharmacological pain relief methods and improves obstetric outcomes (Gallo et al., 2018). Many women prefer NPPR methods such as music and massage therapy, heat applications, deep breathing exercises, position change, aromatherapies, acupressure, relaxation, acupunctures, transcutaneous electrical nerve stimulation (TENS), and hydrotherapy (Adams et al., 2015; Boaviagem et al., 2017; Benfield, Heitkemper & Newton, 2018).

Research indicates that the majority of women report being able to manage labor pain using NPPR methods and reported high satisfaction with this approach (Czech et al., 2018). Therefore, obstetric care providers (OCPs) play a crucial role in managing pain, promoting patient comfort, and aiding in the recovery of patients during their hospital stay. However, studies have shown that many hospitalized patients do not receive nonpharmacological interventions for pain relief (Rantala, Hakala & Pölkki, 2022), which can negatively affect their physical, emotional, and spiritual well-being as well as increase postpartum complications and healthcare costs (Karabulut, Gurcayir & Aktas, 2016).

The knowledge and attitude of nurses and other OCPs greatly influence the utilization of NPPR methods. Unfortunately, evidence has found that approximately two-thirds of OCPs have inadequate knowledge (66.9%) and unfavorable attitudes (65.5%) toward NPPR (Kheshti et al., 2016; Eyeberu et al., 2022), resulting in the underutilization of these methods (30.4%) (Bishaw, Sendo & Abebe, 2020) Several barriers prevent OCPs from implementing NPPR methods (Bradfield et al., 2019). Many OCPs doubt the effectiveness of NPPR compared to pharmacological options (Boateng, Kumi & Diji, 2019). Moreover, OCPs view NPPR methods as time-consuming and impractical due to their heavy workload, inadequate staffing, and limited clinical time (Klomp et al., 2016). In addition to limited knowledge, negative attitudes toward nonpharmacological pain relief and choice of obstetric care providers and patients can negatively affect the NPPR application. Among the aforementioned barriers, the knowledge and attitude of the obstetric care providers are the most vital (Bishaw, Sendo & Abebe, 2020). Literature suggests further research on the barriers that prevent obstetric care providers from offering nonpharmacological pain relief in maternity care (Boateng, Kumi & Diji, 2019). Nonpharmacological pain relief is considered suitable to make labor pain more controllable and tolerable. The first and most important step in nonpharmacological pain relief application is to evaluate the current situation. In Saudi Arabia, there are scarce studies, and there is a gap between the obstetric care provider’s knowledge and attitude regarding nonpharmacological labour pain relief and its application in a real situation; therefore, it is very important to explore the barriers to nonpharmacological labour pain relief application which varies by culture, policies, and places. Due to this lack of information, the current study aims to evaluate nonpharmacological pain relief-related knowledge, attitudes, and barriers among obstetric care providers in Najran, Saudi Arabia.

Materials & Methods

Sampling

The Epi Info free sample size calculator (https://www.openepi.com/SampleSize/SSCohort.htm) was used to calculate the sample size. The total number of obstetric care providers working in the delivery room, emergency department, and inpatient maternity departments was 245, according to the data obtained from the MCH administration. The parameters used for sample size calculation were 99.9% CI, 5% margin error, and a power of 99%; the prevalence of adequate NPPR-related knowledge was 54.2% % from the prior study (Bishaw, Sendo & Abebe, 2020). The calculated sample size was 179, and we added 10% for the estimated nonresponse rate and the incomplete information. Thus, the required sample size was 197. In case of the selected OCPs refused participation, they were replaced by another. The self-reported questionnaire was distributed to all OCPs (n = 245), and 205 questionnaires were pooled. Then, 19 questionnaires were excluded due to incomplete and inconsistent information, so 186 questionnaires were analyzed. The participants in the current study were 19 physicians, 144 nurses, and 23 midwives (Fig. 1).

Results

Barriers to offering NPPR methods among OCPs

OCPs acknowledged that patient belief, lack of time, and workload were the strongest barriers to offering NPPR methods in labour pain management 67.7%, 64.5%, and 61.3%, respectively. At the same time, the lowest barriers related to insufficient motivation (6.5%) and lack of equipment (16.1%) (Fig. 2).

Discussion

Labor is a unique experience where contradictory emotions are present. Pain is an inseparable part of the labor process, and it should probably be managed without side effects for the mother, the progress of labor, and the infant. NPPR is considered suitable to make labor pain more controllable and tolerable. The first and most important step in NPPR application is to evaluate the current situation. In Saudi Arabia, there are no available studies in the international database to evaluate the knowledge, attitude, and barriers to NPPR application for labor pain; therefore, it’s the first Saudi study performed for this aim. In the present study, over three-quarters of the OCPs had adequate knowledge about NPPR definition, benefits, main types, and physiological background.

In the same line, Eyeberu et al. (2022) found that 82.7% of the OCPs had adequate knowledge regarding NPPR, and only 12.5% only knew all types of NPPR. The most known NPPR type among their participants was psychotherapy and massaging (Eyeberu et al., 2022). Besides, (Emelonye et al. (2017) illustrated that most of the midwives who participated in the study acknowledged the husband’s presence and support during labor as an important NPPR method, but only one-quarter of them applied it in real practice. In addition, Boateng, Kumi & Diji (2019) explored the midwives and nurses’ experience of NPPR utilization in a qualitative study. They illustrated that the majority of their participants have good knowledge about NPPR but demonstrated low knowledge regarding many types of it. Furthermore, Bishaw, Sendo & Abebe (2020) reported that 54.2% of their OCPs had satisfactory knowledge regarding NPPR methods. The participants reported that psychotherapy, ambulation, massage, patient education, and allow companionship were the most popular and known nonpharmacological pain methods. In addition, Jira et al. (2020) investigated the nurses’ knowledge and attitude regarding NPPR and its associated factors. They found that more than half of their participants had adequate knowledge regarding NPPR benefits, while 38.3% did not know its types. The possible explanation for the satisfactory knowledge about NPPR among the OCPs is that the majority of them had Bachelor’s degrees or postgraduate education. In addition, the minimum educational requirement to work as a health care provider all over the world is a high diploma. Therefore, it is expected that most OCPs will have satisfactory knowledge regarding different aspects of patient care, including NPPR. Even if the OCP had limited information about any aspect of patient care, he could access it smoothly through the open database.

On the other hand, a recent Iranian study found that 73.6% of their healthcare providers had limited knowledge regarding complementary and alternative therapy modalities (Jafari et al., 2021). The differences between the current study and the Iranian one related to knowledge score may be related to the type of knowledge evaluated. The current study evaluated knowledge regarding definition, modalities, benefits, and physiological background, while the Iranian one evaluated only complementary and alternative therapy modalities.

The present study showed that most of the participants had a positive attitude toward NPPR methods in labour pain management, with the mean scores ranging from 3.55- 4.23 for all items. Labour and childbirth are considered normal physiologic processes by OCPs; therefore, a large proportion of them thought that the use of pharmacological pain relief methods was unnecessary. However, 87.6% of them perceive labour pain as severe and should be managed properly to enhance a positive birth experience without using pharmacological pain relief methods, which may delay labor and cause fetal distress. Consequently, a positive attitude toward NPPR is common among midwives, obstetricians, and nurses (Bishaw, Sendo & Abebe, 2020). Furthermore, an Egyptian study illustrated that 69.0% to 89.7% of the OCPs had a positive attitude toward NPPR utilization during the first stage of labor but reported little benefit from it during the second stage (Mousa et al., 2018). A recent Iranian study found that 79% of healthcare providers had a positive attitude toward the utilization of NPPR, and they thought that both mind and body should be managed equally and in a synchronized manner (Jafari et al., 2021). Besides, Jira et al. (2020) reported that around half of the maternity nurses in their study have a positive attitude toward NPPR regardless of their ability to apply it in clinical practice. They further added that NPPR is very effective for mild to moderate pain and has little effect on severe pain.

On the contrary, Eyeberu et al. (2022) studied obstetricians’ utilization and attitude toward NPPR for Ethiopian women. They illustrated that although a high percentage of their participant utilized NPPR methods, 65.5% of them had an unfavorable attitude toward it. Disparities between the Ethiopian study and the current one may be due to participant sex, where 43.1% of their participants were male compared to only 10.5% in the current study

Concerning barriers to offering NPPR methods, OCPs acknowledged that patient belief, lack of time, and workload were the strongest barriers to providing NPPR methods during labour. At the same time, the lowest barriers are related to insufficient motivation and lack of equipment. Most NPPR methods require adequate training, time, and relaxation from the healthcare providers; therefore, the current study reported a lack of time and high workload as the most significant barriers to NPPR utilization. Along the same line, an Ethiopian study reported that lack of adequate training, high patient flow, and high workload were the most important barriers to NPPR utilization (Bishaw, Sendo & Abebe, 2020). Furthermore, the nurse should have a strong belief and commitment to NPPR to overcome other obstacles to its implementation. The qualitative study conducted by Boateng, Kumi & Diji (2019) reported that the most important barrier among their participants was the strong belief in pharmacological pain relief compared with NPPR. They elaborated that most midwives reported that NPPR might induce relaxation, but it does not take the pain away. In fact, pain is an inseparable part of the normal labor experience because of physiological reasons, and it has an important role in the labor process; therefore, it needs to be tolerable and controllable but rarely relived using NPPR. NPPR can delay the use of pharmacological analgesia, decreasing the dose required and consequently decreasing the expected side effects (Gallo et al., 2018; Bonapace et al., 2018). Mwakawanga et al. (2022) reported that the limited number of healthcare providers and high workload discourage them from applying NPPR or continuing its utilization, especially for some methods that require the continuous presence of the OCPs. In the same line with the current study, the lack of facilities to apply some NPPR methods and client beliefs regarding it were also reported barriers (Bonapace et al., 2018). Other studies reported that many women were not ready to utilize NPPR and preferred pharmacological methods (Anarado et al., 2015; Thomson et al., 2019). In addition, Mousa et al. (2018) reported that the most common barriers among their participants were hospital-related factors such as lack of facilities, policies and guidelines, and high workload. They further added that clinician-related factors, such as their knowledge and attitude toward NPPR, were important barriers to its utilization.

In binary logistic regression analysis, the training related to NPPR and years of work experience were significantly associated with OCPs’ knowledge and attitudes regarding NPPR. However, educational level was found to be associated only with knowledge. Moreover, those participants who participated in in-service training regarding NPPR were more likely to have adequate knowledge and positive attitudes than those who didn’t participate. In addition, a one-year increase in work experiences increased the OCPs’ probability of having adequate knowledge and positive attitudes by 1.7 times.

Most undergraduate health education programs did not give much attention to complementary and alternative medicine. However, higher education may contain complete courses related to complementary medicine, including NPPR methods. The current study showed that a master’s degree qualification increased the probability of having adequate knowledge by 3.3 times compared with a high diploma. Bishaw, Sendo & Abebe (2020) found that higher education increased the care provider’s probability of practicing NPPR by 3.45 times. Besides, Jira et al. (2020) reported that nurses with postgraduate education reported a 12.2 times higher probability of having adequate knowledge regarding NPPR methods compared to diploma nurses. They further added that nurses with higher experience had a higher probability of having adequate knowledge when compared with nurses who reported less than one year of experience. They further added that nurses who received NPPR training had a 7.5 times higher probability of having higher knowledge and a 4.6 times higher probability of a positive attitude than nurses who never received training. The results of the current study highlighted that although most participants had good knowledge and positive attitudes regarding NPPR, they had numerous barriers related to its application in the practical setting. These barriers need to be considered and solved to enhance NPPR application and, consequently, provide a more positive birth experience.

Conclusions

Most OCPs had adequate knowledge and a positive attitude regarding NPPR during labour. OCPs acknowledged that patient belief, lack of time, and workload were the strongest barriers to offering NPPR for labour pain management. At the same time, the lowest barriers are related to insufficient motivation and lack of equipment. Binary logistic regression showed that training related to NPPR and years of work experience were significantly associated with OCP’s knowledge and attitudes regarding NPPR. However, educational level was associated only with NPPR knowledge.

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