Knowledge Perception and Utilisation of Labour Analgesia Among Antenatal Clinic Attendees in a Tertiary Centre in Makurdi, North-Central Nigeria

Abstract

Background:

Labour pain management forms an integral part of modern obstetric practice. Despite the availability of various forms of obstetric analgesia in Nigeria, reports indicate poor knowledge, awareness, and utilisation of labour analgesia among the obstetric population.

Objective:

To determine the knowledge, perception, utilisation, and factors affecting utilisation of labour analgesia among antenatal clinic attendees at the Federal Medical Centre (FMC), Makurdi.

Materials and Methods:

This was an analytical cross-sectional study conducted among 421 consecutively consenting antenatal patients in the Department of Obstetrics and Gynaecology at the FMC, Makurdi, between March 1 to July 31, 2023. Data were collected using an interviewer-guided questionnaire, analysed using Statistical Package for Social Sciences (SPSS) version 20.0, and results were presented in textual form and tables.

Results:

About 47% (199) of the study participants perceived labour pain as the worst possible pain. Only 18.3% (77) of the study participants were knowledgeable about labour analgesia, while just 6.4% (27) of the study participants had ever used it. On multiple logistics regression, the knowledge of labour pain relief (adjusted odd’s ratio [aOR] 0.090, CI = 0.038−0.215, P < 0.001) and mode of previous delivery (aOR 0.292, CI = 0.114−0.750, P < 0.011) were the factors affecting the utilisation of labour analgesia among study participants.

Conclusion:

There is poor knowledge and utilisation of labour analgesia among antenatal patients. Incorporation of labour analgesia into existing protocols and enhancing health education on labour analgesia as part of antenatal health talks can create awareness of labour analgesia among antenatal patients.

Introduction

Although childbirth is what all women desire to experience in their reproductive years, labour pains remain the most dreaded encounter.[1,2] Labour pain is a physiological process that results from ischaemia of the uterus during contraction, effacement, dilatation of the cervix, stretching of the vagina, perineum, and compression of the pelvic structures, which is mediated by the spinal segments of T10–L1 in the first stage and T12–L1, S2–S4 in the second stage of labour.[2,3,4,5] The perception of labour pain varies considerably among pregnant women, depending on their pain thresholds and responses. Some parturient perceive labour pain as severe, while others perceive it as either moderate or mild.[4,6,7] About 60%–70% and 35%–40% of nulliparous and multiparous women, respectively, experience severe labour pain.[2]

In contrast to first-world countries where painless labour is widely available, in developing countries, there are high birth rates and short inter-pregnancy intervals, the use of pain relief during labour remains elusive.[8] Many women in third-world countries hold cultural beliefs that labour pain is an unavoidable natural process and womanhood is determined by the ability of every woman to accept and endure it.[1,8]

Labour pain management forms an integral part of modern obstetrics practice.[9,10] It involves the use of pharmacological and non-pharmacological methods to relieve labour pain.[11,12] The pharmacological options of labour analgesia include the use of parenteral opioids, regional analgesia, and inhalational agents such as Entonox.[9,13] The non-pharmacological techniques include breathing exercises, labour support, transcutaneous electrical nerve stimulation, acupuncture, hypnosis, hydrotherapy, sterile water injection, relaxation techniques, and massage.[9,14] Epidural analgesia is the gold standard and recommended ideal labour analgesia.[9,13]

Despite the availability of various forms of obstetric analgesia, several studies have reported poor knowledge, awareness, and utilisation of labour analgesia among the obstetric population, especially in developing countries.[15,16,17,18,19] Therefore, there is a need for more studies to determine the factors responsible for the poor knowledge, awareness, and use of obstetric analgesia, particularly in developing countries such as Nigeria, to enable stakeholders in the health sector to provide solution to this healthcare problem of underutilisation of labour analgesia. The aim of this study was to determine the knowledge, perception, utilisation, and factors affecting utilisation of labour analgesia among antenatal clinic attendees at the Federal Medical Centre (FMC), Makurdi.

Subjects and Methods

Study design

This was an analytical cross-sectional study conducted in the Department of Obstetrics and Gynaecology at the FMC, Makurdi, from March 1 to July 31, 2023.

Study setting

The study was conducted in the antenatal clinic of the Department of Obstetrics and Gynaecology of the FMC, Makurdi, Benue State. This hospital provides services to inhabitants of Benue State and serves as a referral centre for hospitals in Benue State and neighbouring states.

Study population

Inclusion criteria

This includes all consenting pregnant women who had at least one parous experience and labour, irrespective of the mode of delivery, attending antenatal care at the FMC, Makurdi.

Exclusion criteria

• All primigravida

• Women who had delivered through caesarean section electively without labour experience.

• Women who declined to provide consent.

Sample size determination

The sample size was determined using the sample size formula for a prevalence study:[20]

here

n = Minimum sample size

Z = Standard normal variate (at 5% type I error, P < 0.05) = 1.96

P = Level of awareness of labour analgesia (56% reported from a previous study by Ekweani et al. in Zaria, Kaduna State, Nigeria[1]

1−P = 1−0.56 = 0.44

d = Precision = 0.05

Therefore, n = 1.96² × 0.56 × 0.44/ (0.05)² = 377

Using a non-response rate of 10%, N = 421.

Study protocol/enrolment

Data collection

Data were collected using an interviewer-guided questionnaire by the researchers to obtain information from all consenting participants who fulfilled the inclusion criteria. These questionnaires were administered during health talks and antenatal clinic consultations under the guidance of the researchers.

Data analysis

The data were analysed using the Statistical Package for Social Sciences (SPSS) version 20.0 for Windows (IBM SPSS Inc, Chicago, IL, USA). Categorical variables were analysed using the Chi-Square (χ²) test and Fisher’s exact test. Bivariate analysis was used to test the association of factors that determine the utilisation of labour analgesia, while logistic regression analysis was used to determine the strength of these associations. A P-value < 0.05 was considered statistically significant.

Ethical clearance

Ethical clearance was obtained from the Health Research Ethics Committee (HREC) of the FMC, Makurdi (FMH/FMC/HREC/108/VOL.1).

Results

Table 1 shows the sociodemographic characteristics of study participants. The majority of the study participants were within the age category of 30–34, 168 (39.9%). More than half, 229 (54.4%), of the study participants belonged to the Tiv ethnic group. Three hundred and eighty (90.3%) of the study participants were Christians. Most of the study participants had a tertiary level of education; 207 (49.2%) and 155 (36.8%) were traders. The majority of the study participants’ partners had a tertiary level of education; 286 (69.7%) and 155 (36.8%) worked as civil servants.

Table 1.

The sociodemographic characteristics of study participants

Variable	Frequency	Percent
Age (years)
<25	34	8.1
25–29	120	28.5
30–34	168	39.9
35–39	78	18.5
40–44	21	5.0
Tribe
Tiv	229	54.4
Idoma	76	18.1
Igbo	40	9.5
Others	76	18.1
Religion
Christianity	380	90.3
Islam	38	9.0
Others	3	0.7
Level of education
No formal education	6	1.4
Primary	51	12.1
Secondary	157	37.3
Tertiary	207	49.2
Occupation
Unemployed	99	23.5
Trading	155	36.8
Civil servant	53	12.6
Farming	29	6.9
Others	85	20.2
Partner’s level of education
No formal education	1	0.2
Primary	34	8.1
Secondary	100	23.8
Tertiary	286	67.9
Partner’s occupation
Unemployed	21	5.0
Trading	126	29.9
Civil servant	155	36.8
Farming	23	5.5

Table 2 shows the clinical characteristics of the study participants. The majority of study participants, 318 (75.5%), had <5 total number of pregnancies (gravidity) and were mostly multipara, 235 (55.8%). One hundred and eighty-six (44.2%) of the study participants booked their index pregnancies in the third trimester, and the majority, 391 (92.9%), of the study participants had hospital delivery in their previous pregnancies. Most, 359 (85.3%), of the study participants delivered through the vaginal route in their previous pregnancies.

Table 2.

The clinical characteristics of study participants

Variable	Frequency	Percentage
Gravidity
< 5	318	75.5
≥ 5	103	24.5
Parity
Primipara	162	38.5
Multipara	235	55.8
Grand multipara	24	5.7
Gestational age at booking
First trimester	43	10.2
Second trimester	181	43.0
Third trimester	186	44.2
Post date	11	2.6
Previous place of delivery
Home	30	7.1
Hospital	391	92.9
Mode of previous delivery
Vaginal delivery	359	85.3
Caesarean section	62	14.7

Table 3 shows the labour pain perception among the study participants. Most of the study participants perceived labour pain as the worst possible pain, 199 (47.3%), and severe pain, 128 (30.4%), whereas only a small proportion of the study participants, 3 (0.7%), perceived labour pain as not painful.

Table 3.

The perception of labour pain among study participants

Perception of labour pain	Frequency	Percent
No pain	3	.7
Mild pain	13	3.1
Moderate pain	78	18.5
Severe pain	128	30.4
Worst possible pain	199	47.3

Table 4 shows the knowledge of labour analgesia among the study participants. Only 77(18.3%) of the study participants were knowledgeable about labour analgesia. Out of the 77 study participants who had knowledge of labour analgesia, the majority, 30(39%), obtained their knowledge from health workers. Most, 322 (76.5%), of the study participants did not know the type of labour pain relief, and 324 (77.0%) of the study participants did not know the health personnel who administer labour analgesia. The majority, 327 (77.7%), of the study participants had no knowledge of their relative ever used labour analgesia.

Table 4.

The knowledge of labour analgesia among the study participants

Variables	Frequency	Percent
Knowledge of labour analgesia
Yes	77	18.3
No	344	81.7
How did you know about labour analgesia (n = 77)
Family and friends	27	35.0
Health workers	30	39.0
Fellow patients	1	1.3
Media	8	10.4
Antenatal health talk	5	6.5
Internet	6	7.8
Knowledge of labour pain relief
Inhalational	2	.5
Injection	45	10.7
Epidural/lower back injection	23	5.5
Non-pharmacological	26	6.2
Do not know	322	76.5
Others	3	.7
Who administers labour analgesia
Obstetrician	23	5.5
Nurses	34	8.1
Anaesthesiologist	40	9.5
Do not know	324	77.0
Relative ever used labour analgesia
Yes	38	9.0
No	327	77.7
Not sure	56	13.3

Table 5 shows the utilisation of labour analgesia among study participants. Only 27(6.4%) of the study participants had ever used labour analgesia. Of the 27 study participants who ever used labour analgesia, 23 (85.2%) used injectable analgesia. Three hundred and three (72%) of the study participants agreed that women have labour analgesia, and 290 (68.9%) desired to use analgesia in their next labour. The majority, 258 (61.3%), of the study participants were not afraid to use labour analgesia, 135 (32.1%) were afraid of labour analgesia, and 28 (6.7%) were not sure if they were afraid of labour analgesia. Of the 135 study participants who expressed fears about labour analgesia, 112 (83%) of them gave side effects as the reason for their fears of utilisation of labour analgesia. Most, 270 (64.1%), of the study participants will recommend analgesia in labour. Of the 270 study participants who will recommend labour analgesia, the majority, 168 (62.2%), do not know the method of labour analgesia to recommend.

Table 5.

The utilisation of labour analgesia among the study participants

Variable	Frequency	Percent
Ever used labour analgesia?
Yes	27	6.4
No	394	93.6
If yes, what type? n (27)
Inhalational	1	3.7
Injection (IM/IV)	23	85.2
Epidural/lower back injections	3	11.1
Should women have labour analgesia?
Yes	303	72.0
No	90	21.4
Do not know	28	6.7
Afraid of labour analgesia
Yes	135	32.1
No	258	61.3
Not sure	28	6.7
If yes, what are your fears? (n = 135)
Do not know	23	17.0
Side effect	112	83.0
Do you desire to use analgesia in next labour?
Yes	290	68.9
No	115	27.3
Do not know	16	3.8
Will you recommend analgesia in labour
Yes	270	64.1
No	119	28.3
Do not know	32	7.6
If yes, what method (n = 270)
Inhalational	11	4.1
Injection (IM/IV)	68	25.2
Epidural/lower back injection	20	7.4
Non-pharmacological	3	1.1
Do not know	168	62.2

Table 6 shows the reasons for not using analgesia during labour among the study participants. Three hundred and thirty-three (79.1%) of the study participants agreed with the lack of information on labour analgesia as the reason for not using analgesia in labour.

Table 6.

Reasons for not using analgesia during labour among the study participants

Reason for not using labour analgesia	Yes Freq (%)	No Freq (%)	Not sure Freq (%)
Lack of information on labour analgesia	333 (79.1)	56 (13.3)	32 (7.6)
Labour analgesia not available in the hospital	159 (37.8)	194 (46.1)	68 (16.2)
It is expensive	153 (36.3)	182 (43.2)	86 (20.4)
Wish and desire to feel natural labour pain	131(31.1)	256 (60.8)	34 (8.1)
Side effects of labour analgesia	182(43.2)	190 (45.1)	49 (11.6)
Cultural and social beliefs support experiencing labour pain	106 (25.2)	254 (60.3)	61(14.5)
Labour analgesia can affect the unborn baby	155 (36.8)	234 (55.6)	32 (7.6)
It can cause paralysis	93 (22.1)	290 (68.9)	38 (9.0)

The bivariate analysis was performed to determine the factors affecting the utilisation of pain relief in labour. This was performed using the sociodemographic and clinical characteristics, perception of labour pain, and knowledge of pain relief in labour as factors affecting the utilisation of labour analgesia. Of all these factors, it was the mode of delivery, perception of labour pains, and knowledge of pain relief in labour that were statistically significant with a P-value < 0.05. These statistically significant factors were further analysed using multiple logistic regression.

Table 7 shows the logistics regression analysis of factors affecting the utilisation of labour analgesia among the study participants. On further analysis using multiple logistic regression, the knowledge of labour pain relief (aOR 0.090, CI = 0.038−0.215, P < 0.001) and mode of previous delivery (aOR 0.292, CI = 0.114−0.750, P < 0.011) were statistically associated with the utilisation of labour analgesia.

Table 7.

Multiple logistics regression analysis of factors affecting the utilisation of labour analgesia among the study participants

Variable	P-value	Adjusted odd’s ratio	95% confidence interval
Knowledge of labour pain relief
No	<0.001	0.090	0.038–0.215
Yes	Ref
Perception of labour pain
Severe	0.210	0.563	0.230–1.381
Moderate or less	Ref
Mode of previous delivery
SVD	0.011	0.292	0.114–0.750
Caesarean section	Ref

Discussion

A larger proportion of the respondents perceived labour pain as the worst possible pain, some others as severe pain, while only a few members of the study group perceived it as painless. This finding corroborates with that of several studies where respondents similarly perceived labour pain as excruciating, unbearable, or severe.[2,3,7,8,16,17,19,21] This fact buttresses the need for labour analgesia among all parturients in labour.

The participants demonstrated poor knowledge of labour analgesia, consistent with findings from other studies.[2,3,8,16,17,18,19] This poor knowledge may be attributed to the cultural belief held by women in third-world countries that labour pain is a natural process and a woman’s worth is determined by her ability to endure it.[1,8] This contrasts with the Zaria study, where the majority of respondents had moderate knowledge.[1] This difference may be due to differences in the study location and the level of enlightenment among the study participants. Of the 77 study participants who knew of labour analgesia, most of them obtained their knowledge from health workers. This was similar to several studies that similarly observed a majority of their respondents obtaining knowledge of labour analgesia from health workers.[1,2,3,16] This was in contrast to other studies, which observed that the majority of their study participants acquired their knowledge from the internet, media, friends, and relatives.[8,17,18,19] More than three-quarters of the study participants do not know the types of labour analgesia and the health personnel who administer it, respectively, unlike previous studies where the majority of respondents had knowledge of the various types of analgesia and identified those who administer it as health workers.[1,2,8,16,18,22] This may be attributable to the poor knowledge and uptake of labour analgesia among antenatal patients in the study centre. Also, majority of the respondents had no knowledge if their relatives had ever used labour analgesia. This was similar to the study conducted in India where most of the study participants were not aware if their relatives ever used pain relief during labour.[16]

Only a small proportion of the study participants have ever used labour analgesia, and injectables were the most employed labour analgesia. This shows poor utilisation of pain relief among antenatal patients in our health facility. This finding was equally comparable to that observed by similar studies that found a poor level of utilisation of labour analgesia among their respondents.[1,2,3] Conversely, some studies found moderate utilisation of labour analgesia among their respondents.[16,17,21]The majority of participants agreed that women should have labour analgesia, and over two-thirds of them desired to use analgesia in their next delivery. This is consistent with several studies in which a majority of the respondents desire analgesia during labour.[2,3,16,19,21] This was at variance with a study in India where the majority of the study participants were not desirous of analgesia in their next delivery. Some reasons advanced for non-use of labour included the desire to experience natural birth, concerns about the harm to the baby, and religious beliefs against the will of God.[8] Fear of side effects was the most frequent concern expressed by respondents against the utilisation of labour analgesia. Although a majority of the respondents desire to recommend labour analgesia, most of them do not know the methods of labour analgesia to recommend. This finding was similar to that reported in India, where the majority of the respondents agreed to recommend labour analgesia to family and friends.[16] Most of the study participants agreed that the lack of information was the reason for not using analgesia during labour. This finding further buttresses the need to intensify health talks on labour analgesia during antenatal clinics to improve knowledge and utilisation of pain relief in labour among antenatal patients.

The knowledge of labour pain relief and mode of previous delivery were the factors affecting the utilisation of labour analgesia among study participants. However, this differs from the study by Workie et al., who found ages 25–31 to be significantly associated with the desire to utilise labour analgesia.[2] This current finding has further verifies the need for more education and awareness creation of labour analgesia in antenatal clinics across the country to improve knowledge and utilisation of pain relief during labour.

The strength of this study is both cross-sectional and analytical, and the limitation was the subjective method of assessing the perception of labour pain by the respondents.

Conclusion

Most survey participants considered labour pain as the most unbearable pain. However, only a small percentage of them knew about labour analgesia, and even fewer had ever used it. Healthcare professionals were the primary source of information for those who had any understanding of labour analgesia. Therefore, to enhance awareness and utilisation of labour analgesia among pregnant women, it is recommended to incorporate and intensify discussions about it during antenatal clinic health talks. In addition, all stakeholders in the health sector at various levels must enact policies to ensure the availability and accessibility of pain relief in labour to all pregnant women in various hospitals across the country.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.