A survey of healthcare providers’ knowledge and attitudes regarding pain relief in labor for women in Ethiopia

This is the first survey that we are aware of exploring HCPs knowledge and attitudes to pain relief for women in labor in Ethiopia highlighting that there is an attitude that labor is a natural process and that women should be able to cope. We did not include questions to differentiate attitude toward pain relief with regard to the first or second stages of labor, delivery and the postnatal stage or between women undergoing different mode of deliveries e.g. operative vaginal (forceps or vacuum) or abdominal delivery (Caesarean section). In addition, we did not set out (and the sample size was therefore not large enough) to assess if there was an association between age, sex, place of work and cadre of HCP on the awareness and attitudes to the provision of pain relief to women in labor. Going forward, the questionnaire needs to be refined with clearer linkages between questions.

There are a small number of studies conducted in LMIC to assess HCP’s views of pain relief in labor. In our study, the majority of HCPs understood that women can feel moderate to severe pain in labor and most HCPs felt that labor pain should be relieved. This is similar to findings from a study in India among 100 obstetricians where 92% agreed that pain relief in labor was required, with 87% keen for the provision of epidural analgesia [11]. In this study, 45% of obstetricians wanted to provide opioid analgesia for their patients and considered opioids safe, non-invasive, easy to administer and not requiring monitoring or the presence of an anesthetist [11]. The authors conclude that despite a certain degree of awareness there is still a need to further educate, train and to increase communication between obstetricians, anesthetists and women regarding the implementation of effective pain relief in labor in India [11].

There are a number of studies in LMIC to assess women’s views of pain relief in labor. In a study conducted of 124 mothers in Nigeria, only 4% could recall using any form of pain relief in their previous pregnancy [12]. In India, the expectation of labor pain among 205 women was very common although the majority (71%) tolerated it as a natural phenomenon [13]. However, when given the option of pain relief, 98% reported that they would ask for and were prepared to pay for effective pain relief [13]. In South Africa, 56% of 151 pregnant women reported severe pain during a previous labor and 65% of respondents believed that this was unacceptable [14]. Nearly all of the women (99.3%) believed that HCPs had an important role to play in helping to relieve labor pain [14]. In Uganda, 88% of 1293 pregnant women were keen for the pain to be relieved, 79% felt that HCPs should provide this pain relief but only 7% reported knowledge of different options available [15]. For the small number of women who did not want pain relief for their next delivery (10%), their reasons included: wanting a natural childbirth, pain relief was against the will of God, it would harm the baby, they would love their baby more and some women viewed the pain as a form of birth control [15]. There was a similar finding among 450 pregnant women in Niger of which 24% declined pain relief indicating that labor is a ‘natural process’, faith in divine intervention and concerns about side effects [16].

In our study, more than half of all HCPs were concerned about the effect of pain relief on the baby, mother and the labor process. Previous studies have found that these concerns are shared by women as well. One study in Nigeria found that women were afraid of the potential side effects of pain relief on the baby (20%), on themselves (17%) and 3% were concerned regarding the additional cost [12]. However, in South Africa, 78% of pregnant women expressed no concern about potential problems associated with pain relief methods, although 83.4% expressed little confidence in the forms or labor pain relief available in their setting [14].

One large systematic review concluded that a woman’s desire for and choice of pain relief during labor is influenced by many factors: personal expectations, the amount of support from HCPs, the quality of the relationship between the woman and the HCP and the woman’s involvement in decision making [8]. This majority of studies included in this review were conducted in HIC and highlighted that the influences of the attitudes and behaviors of the HCPs can be as important that the influences of pain, pain relief and intra-partum interventions on women’s satisfactions scores of the experience of labor [8].

Communication between a woman and her HCPs is the first step towards preventing distress during labor. The National Institute of Clinical Excellence (NICE) in the UK recommend that all healthcare professionals consider how their own values and beliefs inform their attitude to women coping with pain in labor and that they should ensure their care supports the woman’s choice [1]. In a low resource setting with low levels of utilization of healthcare facilities, such as Ethiopia the provision of pain relief in labor could be a useful incentive to help change negative attitudes and behavior to facility delivery. It is therefore important to include pain relief options as part of any comprehensive, quality of care package offered to women in low resource settings. Whilst the priority in LMIC is to provide evidence-based practices and care (including skilled birth attendance), we argue that equal attention must be given to quality of care, including the provision and experience of care. Quality of care is considered a key component of the right to health and this requires appropriate skills and attitude of HCPs striving to provide a good experience of care for laboring women in a supportive environment [17]. This can be achieved if all HCPs work together in a multidisciplinary approach to refine and implement guidelines for pain relief options for women in labor in LMIC. This should be safe, effective, timely, efficient, equitable, woman-centered and culturally acceptable. Furthermore, efforts must be made to raise the awareness of pain relief options available through education and to empower women and their families to demand pain relief as part of good quality care in labor.

Qualitative research is necessary to explore the underlying reasons for the attitudes of HCPs found in this survey. HCPs working in the community and at primary healthcare facility level also need to be assessed. The timing, best method and benefits of providing cost-effective pain relief in labor needs clarity in a low resource setting.