Of the 120 maternal health care providers approached, 117 responded, representing a 97.5% response rate. Table 1 demonstrates the socio-demographic characteristics of the participants. The participant’s age ranged from 27-60 years, with a mean age (±standard deviation) of 38.44 (± 7.41) years. Most of the participants (71.8%) were aged between 31 to 40 years. Among them, 50.2% were males and 49.6% females. The study included 48 (41.0%) midwives, 53 (45.3%) obstetricians and 16 (13.7%) anesthesiologists. The participants’ mean duration of practice (±standard deviation) was 9.54 (±4.94) years. A majority of the participants (66.9%) had been in practice for 10 years or less.
Table 1
Socio-demographic characteristics of the respondents, N=117.
Socio-demographic characteristics
|
|
Frequency
|
|
Percentage (%)
|
Sex
|
|
|
|
|
Male
|
|
58
|
|
49.6
|
Female
|
|
59
|
|
50.4
|
Age (years)
|
|
|
|
|
≤30
|
|
7
|
|
6
|
31 – 40
|
|
84
|
|
71.8
|
41 – 50
|
|
17
|
|
14.5
|
51 – 60
|
|
9
|
|
7.7
|
Min. – Max.
|
|
27.0 – 60.0
|
Mean ± SD.
|
|
38.44 ± 7.41
|
Profession
|
|
|
|
|
Anesthesiologist
|
|
16
|
|
13.7
|
Midwife
|
|
48
|
|
41
|
Obstetrician
|
|
53
|
|
45.3
|
Duration of practice (years)
|
|
|
|
|
≤5
|
|
16
|
|
13.7
|
6 to 10
|
|
62
|
|
53
|
10 to 15
|
|
27
|
|
23.1
|
16 to 20
|
|
8
|
|
6.8
|
≥21
|
|
4
|
|
3.4
|
Min. – Max.
|
2.0 – 26.0
|
Mean ± SD.
|
9.54 ± 4.94
|
Pattern of provision of labour analgesics by maternal healthcare providers.
Seventy-two respondents (61.5%) provided some form of labour analgesia routinely. Of these, 88.9% reported offering both pharmacological and non-pharmacological methods, while 11.1% provided only pharmacological methods. Slightly more than half of the respondents (55.7%), reported routinely providing non-pharmacological methods of labour analgesia. Non-opioids were the most common pharmacological method prescribed, by 13.4% (n=15) of the respondents. Nine (8.7 %) participants reported routinely providing opioids. Regional analgesia was routinely prescribed by 3.6% (n=4) of respondents. Labour pain management by inhalational analgesics was not routinely practised by any of the MHCPs.
Figure 1 illustrates the frequency of provision of labour analgesia as reported by anesthesiologists. Non-opioids as routine labour analgesia was reported by 30.8% of the anesthesiologists. Opioids were provided by 23.1% (n=3) of the respondents within this cadre while regional analgesics and non-pharmacological methods of pain relief were each provided by 13.3% (n=2) of the respondents. Inhalational analgesics were not provided by any of the anaesthesiologist respondents. No response was obtained from 3 out of 16 respondents within the cadre.
Of the 48 midwife respondents, a majority (75%), reported providing non-pharmacological methods for labour pain management.
Non-opioids were the most routinely provided pharmacological treatment for labour pain by 6.4% (n=3) of the midwives. None of the midwife respondents reported routine provision of opioids, regional and inhalational methods for labour analgesia (Figure 2).
Half (50%), of the obstetrician respondents reported providing non-pharmacological modes of labour pain management. Nonopioids were the primary pharmacological agents provided by the majority (15.4%) of respondents, and 11.8% (n=6) reported providing opioids routinely. Regional analgesics were provided by 3.8% (n=2) of the respondents while none of the obstetrician respondents reported providing inhalational agents for labour pain management (Figure 3).
Cumulatively, tramadol was the most routinely provided opioid analgesic, by 88.9% (n=8) of the maternal healthcare providers. Buscopan and paracetamol were the most routinely (66.7%) prescribed non-opioid analgesic. Epidural analgesics was the most preferred regional analgesia by 75% (n=3) of MHCPs. The four most routinely prescribed non-pharmacological methods for labour analgesia were: Touch and massage (93.8%), deep breathing /patterned breathing (Lamaze techniques) (81.3%), maternal movements and positional changes (81.3%) and social support (reassurance) (79.7%) (Table 2).
Table 2
Types of labour analgesia provided by maternal healthcare providers who routinely offer labour analgesia at MTRH (N=117)
Agent
|
|
Frequency
|
|
%*
|
Opioids
|
|
|
|
|
Tramadol
|
|
8
|
|
88.9
|
Morphine
|
|
5
|
|
55.6
|
Pethidine
|
|
3
|
|
33.3
|
Fentanyl
|
|
3
|
|
33.3
|
Reported provision of any opioid
|
|
9
|
|
8.7
|
Non-Opioids
|
|
|
|
|
Buscopan
|
|
10
|
|
66.7
|
|
|
10
|
|
66.7
|
Diclofenac
|
|
2
|
|
13.3
|
Reported provision of any non-opioid
|
|
15
|
|
13.4
|
Regional
|
|
|
|
|
Epidural
|
|
3
|
|
75.0
|
Spinal
|
|
2
|
|
50.0
|
Reported provision of any regional
|
|
4
|
|
3.6
|
Non-pharmacological
|
|
|
|
|
Touch and massage
|
|
60
|
|
93.8
|
Deep breathing /patterned breathing (Lamaze)
|
|
52
|
|
81.3
|
Maternal movements and positional changes
|
|
52
|
|
81.3
|
Social support (Reassurance)
|
|
51
|
|
79.7
|
Audio analgesia
|
|
24
|
|
37.5
|
Yoga
|
|
3
|
|
4.7
|
Intermittent local heat and cold therapy
|
|
1
|
|
1.6
|
Acupuncture
|
|
1
|
|
1.6
|
Reported provision of any non-pharmacological
|
|
64
|
|
55.7
|
* Percentages do not add to 100% because some respondents reported providing multiple methods for labour analgesia.
|
Knowledge and attitude towards labour analgesics
Knowledge
The majority of surveyed MHCP’s (53.0%) had poor knowledge of labour pain management. Only 4.3% (n=5) of respondents rated as having good knowledge. All the consultant anaesthesiologists, 70% of the resident anaesthesiologists and 52.6% of the consultant obstetricians rated moderately in terms of overall knowledge of labour analgesia. The proportion of those who rated as having poor knowledge of labour analgesia was higher among resident obstetricians (70.6%) and midwives (60.4%). Based on the composite score of 6.7, MHCP’s at MTRH generally had poor knowledge of labour analgesia, as assessed using the modified Blooms cut-off points (Table 3).
Table 3
MHCPs’ Knowledge on labour analgesia, (N=117).
CADRE
|
GOOD
|
MODERATE
|
POOR
|
AVERAGE SCORE*
|
% SCORE
|
Anesthesiologist (N=6)
|
0 (0.0%)
|
6 (100%)
|
0 (0.0%)
|
9.5
|
63.3
|
Resident anesthesiologist (N=10)
|
0 (0.0%)
|
7 (70.0%)
|
3 (30.0%)
|
7.4
|
49.3
|
Midwife (N=48)
|
1 (2.1%)
|
18 (37.5%)
|
29 (60.4%)
|
6.2
|
41.3
|
Obstetrician (N=19)
|
3 (15.8%)
|
10 (52.6%)
|
6 (31.6%)
|
7.7
|
51.3
|
Resident obstetrician (N=34)
|
1 (2.9%)
|
9 (26.5%)
|
24 (70.6%)
|
6.1
|
40.7
|
TOTAL N=117
|
5 (4.3%)
|
50 (42.7%)
|
62 (53.0%)
|
6.7
|
44.7
|
* Maximum score of 15
In the self-assessment of previous education concerning labour analgesia 81.2% (n=95) of the participants had a “yes” response. The reported sources of the labour analgesia knowledge were; as part of the curriculum in previous education (60.8%), in-service education (52.6%), literature / the internet (39.2%), and from fellow colleagues (27.8%) (Table 4).
Table 4
Sources of MHCPs’ knowledge on labour analgesia by percentage.
Items
|
Anesthesiologist (N=13)
|
Midwife (N=38)
|
Obstetrician (N=46)
|
TOTAL (n=97)
|
1. As part of the curriculum in previous education
|
76.9
|
55.3
|
60.9
|
60.8
|
2. During in-service education (C.M.E, seminars etc.)
|
69.2
|
42.1
|
56.5
|
52.6
|
3. Literature / the internet
|
30.8
|
34.2
|
45.7
|
39.2
|
4. From colleagues
|
7.7
|
23.7
|
36.9
|
27.8
|
A total of 72.6% (n=85) of MHCPs reported being aware of the universal pain assessment tools, however only 36.8% used these tools in the assessment of labour pain. Notably, 65.8% of respondents had awareness of the WHO analgesic ladder. Of these, 47.0% used this tool during labour pain management. Overall, anesthesiologists had better knowledge of the pain assessment tools compared to the other cadres surveyed (table 5).
Table 5
Percentage of maternal HCPs’ who use pain assessment tools in managing Labour pain.
|
|
|
Universal pain assessment tools
|
|
Cadre
|
WHO analgesic ladder(N=55)
|
|
Numerical
|
Visual
|
Verbal
|
Total using UPA* (N=43)
|
Anesthesiologist (N=16)
|
81.3
|
|
42.9
|
71.4
|
28.6
|
43.8
|
Midwife (N=48)
|
31.3
|
|
21.8
|
34.8
|
74.0
|
47.9
|
Obstetrician (N=53)
|
50.9
|
|
30.1
|
38.4
|
30.8
|
24.5
|
|
|
Total†
|
27.9
|
41.9
|
53.5
|
|
Total (N=117)
|
47.0
|
|
|
|
|
36.8
|
† Values do not add up to 100% because some respondents reported using more than one tool
|
UPA*: Universal pain assessment tools
|
There was overall poor knowledge of opioid dose properties, with only 23.7% (n=27) of all the respondents being aware that opioids do not have a ceiling effect. More than half (58.1%) of the MHCPs’ were aware that non-pharmacological pain relief methods are safer compared to pharmacological analgesics and 76.1% were also aware that pharmacological pain relief methods increase the comfort of women in Labour as compared to non-pharmacological analgesics.
Attitude
Based on the composite score of 13.3, 88.7% of MHCP’s at MTRH generally had a positive attitude towards the provision of labour analgesia, as assessed using the original Blooms cut-off points (Table 6).
Table 6
Providers’ attitude towards the provision of labour analgesia (N=116).
CADRE
|
POSITIVE
|
NEUTRAL
|
NEGATIVE
|
AVERAGE SCORE†
|
% SCORE
|
Anesthesiologist (N=6)
|
6(100.0%)
|
0(0.0%)
|
0(0.0%)
|
13.2
|
88
|
Resident anesthesiologist (N=10)
|
9(90.0%)
|
1(10.0%)
|
0(0.0%)
|
13
|
86.7
|
Midwife (N=48)
|
45(93.8%)
|
3(6.3%)
|
0(0.0%)
|
13.2
|
89.3
|
Obstetrician (N=19)
|
18(94.7%)
|
1(5.3%)
|
0(0.0%)
|
13.4
|
89.5
|
Resident obstetrician (N=33)
|
31(93.9%)
|
2(6.1%)
|
0(0.0%)
|
13.5
|
90
|
TOTAL N=116
|
109(94.0%)
|
7(6.0%)
|
0(0.0%)
|
13.3
|
88.7
|
|
|
|
|
|
|
†Maximum score of 15
|
|
|
|
|
|
Forty-three (36.8%) respondents expected women to feel pain during labour. A majority (82.1%) of the respondents agreed that labour pain should be relieved with an equal number also agreeing that relief of labour pain improves the overall maternal experience. Ten (8.5%) of the study subjects however believed that labour is a natural process that does not require any analgesia, 17.1% were unsure, while the remaining 74.4% disagreed.
Health system factors.
A majority (91.7%) of maternal healthcare providers at MTRH reported experiencing health system factors that hindered their provision of labour analgesia. These included: non-availability of drugs and equipment (58.1%), lack of clear protocols and guidelines (56.4%) and absence of adequate skilled personnel (55.6%).
Other barriers/factors hindering the provision of labour analgesia as reported by maternal healthcare providers at MTRH included (N=117):
- Fear of foetal distress (47.1%)
- Fear of adverse maternal effects (41.8%)
- Cost implications (perceived as expensive) (36.7 %)
- Fear that it may increase the incidence of caesarean sections and instrumental delivery (34.2%)
Thirteen (11.1%) respondents reported that oftentimes, patients decline labour analgesia.
Almost all the participants (94%), reported that the introduction of labour analgesia guidelines would improve the management of labour at MTRH while 95.7% indicated that regular courses on effective labour analgesia would be useful in their practice of labour analgesia.
In the bivariate logistic regression analysis, there was no significant association between the provision of labour analgesia and age, knowledge, and attitude of the MHCP’s. A higher proportion of female MHCP’s (72.7%) reporting use of labour analgesia routinely compared to males 46.4% (COR=0.33; 95%CI:0.14,0.71).
Midwives were four times more likely to provide labour analgesia compared to anaesthesiologists (COR=4.32; 95%CI: 1.33, 14.9). Maternal health care providers having more than 10 years of experience were almost ten times more likely to provide labour analgesia than those with less than 10 years of experience (AOR: 9.85, 95% CI 1.52, 1.96) (Table 7).
Table 7
Factors associated with the provision of labour analgesia by MHCP’s at MTRH (n=117)
Variable
|
Use labor analgesia
|
COR
|
95%CI
|
AOR
|
95%CI
|
|
No (N=45)
|
Yes (N=72)
|
|
|
|
|
Age (years)
|
|
|
|
|
|
|
<=40
|
34 (37.4%)
|
57 (62.6%)
|
1
|
|
1
|
|
>40
|
11 (42.3%)
|
15 (57.7%)
|
0.81
|
0.34, 2.01
|
0.1
|
0.00, 0.82
|
Sex
|
|
|
|
|
|
|
Female
|
15 (27.3%)
|
40 (72.7%)
|
1
|
|
1
|
|
Male
|
30 (53.6%)
|
26 (46.4%)
|
0.33
|
0.14, 0.71
|
0.87
|
0.24, 3.28
|
Profession
|
|
|
|
|
|
|
Anesthesiologist
|
9 (56.2%)
|
7 (43.8%)
|
1
|
|
1
|
|
Midwife
|
11 (22.9%)
|
37 (77.1%)
|
4.32
|
1.33, 14.9
|
1.94
|
0.44, 8.79
|
Obstetrician
|
25 (47.2%)
|
28 (52.8%)
|
1.44
|
0.47, 4.58
|
0.7
|
0.18, 2.67
|
Duration of practice
|
|
|
|
|
|
<=10
|
32 (41.6%)
|
45 (58.4%)
|
1
|
|
1
|
|
>10
|
12 (31.6%)
|
26 (68.4%)
|
1.54
|
0.69, 3.58
|
9.82
|
1.52, 1.96
|
Knowledge
|
|
|
|
|
|
|
Moderate/Good
|
24 (44.4%)
|
30 (55.6%)
|
1
|
|
1
|
|
Poor
|
16 (44.4%)
|
20 (55.6%)
|
1
|
0.43, 2.35
|
1.03
|
0.38, 2.75
|
Attitude
|
|
|
|
|
|
|
Neutral
|
2 (28.6%)
|
5 (71.4%)
|
1
|
|
1
|
|
Positive
|
41 (38.0%)
|
67 (62.0%)
|
0.65
|
0.09, 3.19
|
0.94
|
0.10, 8.81
|
1=reference
|
|
|
|
|
|
|
Abbreviations: AOR, adjusted odds ratio; COR, crude odds ratio; CI, confidence interval
|
|