The Attitudes of Women During Labour
Chapter One
Objectives
General Objective
To assess the knowledge and attitude regarding pain relief options amongst pregnant women attending antenatal clinic at UATH‟s Abuja Nigeria from August to October 2022
Specific objectives
- To determine knowledge of labour pain relief amongst pregnant women attending antenatal clinic at UATH‟s Abuja Nigeria
- To determine the attitude towards labor pain relief
- To examine factors influencing knowledge and attitude towards labor pain relief
CHAPTER TWO
LITERATURE REVIEW
Maternity care
Maternity care is described as the services for women from the period of pregnancy to about 10 days after childbirth but could last up to 6 weeks after birth (Paparella, 2016). The components of maternity care services are categorised into three stages: antenatal (during pregnancy), intrapartum (childbirth) and postnatal care (after birth). It can also encompass neonatal care if the child has not been discharged from the health facility (Paparella, 2016; Public Health England, 2016). Maternity care should be evidence-based and woman-centred services that acknowledge pregnancy, birth, and parenting as important life events for women (Lincetto et al., 2010). Women-centred maternity care encompasses their needs and preferences and enables them to access objective, evidence-based information that supports informed choices about the services. It could also require service planning and provision that is designed and implemented to respond to the health needs of women. The following sections discuss the various stages of maternity care.
Antenatal care
The WHO (2016b) defines antenatal care as the services given to pregnant adolescent girls and women by qualified health professionals to ensure the mother and child have the best health conditions during pregnancy. The antenatal care period usually commences between 9–12 weeks of pregnancy (Paparella, 2016). A minimum of 4 visits between 8 and 38 weeks of pregnancy is recommended for pregnant women (Lincetto et al., 2010), and this approach is referred to as focused or basic antenatal care. The strategy ensures that all women receive antenatal services at crucial periods during pregnancy and prepares them for the childbirth and postpartum stages (Lincetto et al., 2010; Izugbara, Wekesah and Adedini, 2016).
Routine health information systems can be used to provide estimates of antenatal care coverage, but in many low- and middle-income countries (LMICs), it is captured using large population-based investigations like the Demographic and Health Surveys (DHS) (Benova et al., 2018). Reports show significant difference in the antenatal care coverage in different regions of the world. Access to antenatal care in LMICs may have improved since the introduction of the model that recommends women have a minimum of four antenatal visits (Lincetto et al., 2010); but recent evidence suggests the coverage and quality is still poor (Sharma, Connor and Rima Jolivet, 2018). According to the WHO (2018b), in 2015, about 40% of pregnant women received the recommended minimum of four antenatal care visits in LICs. In HICs, nearly every woman has a minimum of four antenatal care appointments and is cared for by skilled healthcare staff up to the postpartum period (WHO, 2018b). However, the number of antenatal care contact women have with HCPs does not seem to provide adequate information on what the appointments involve (Moran et al., 2016). In addition, antenatal care coverage may not reflect the quality of healthcare services delivered to women (Hodgins and D’Agostino, 2014). Since these parameters appear to capture only the number of times women visit HCPs for antenatal care, Hodgins and D’Agostino (2014) and Ng et al. (2014) pointed out the need for indicators that focus on the content of these antenatal appointments.
A guideline, proposed within the human rights perspective focuses on person-centred care for a positive pregnancy experience (WHO, 2016b). The guideline also recommends a minimum of eight antenatal care visits, and a pregnant woman’s first contact with a skilled healthcare professional should be within the first trimester (12 weeks of gestation), increasing to five visits by the third trimester (WHO, 2016b). The 49 antenatal care recommendations within the guideline for a positive pregnancy focus on: nutritional interventions, interventions for common physiological symptoms, maternal and foetal assessment, health systems interventions to increase the use and quality of antenatal care, and preventive measures (WHO, 2016b).
Good antenatal care offers pregnant women with information that focuses of their birth preparedness and readiness for complications that could occur during the pregnancy, childbirth and postpartum period (Lincetto et al., 2010; Izugbara, Wekesah and Adedini, 2016; WHO, 2016b). It offers a platform for significant reproductive health services, such as risk identification, screening and diagnosis, health education, disease prevention and health promotion (WHO, 2016b). It also creates an opportunity for service providers to communicate with and support women and their families in a respectful way at a time that is crucial in their lives.
CHAPTER THREE
RESEARCH METHODOLOGY
Study Design:
This was a prospective cross-sectional study
Site
Study participants were recruited from The University of Abuja teaching hospital – University Teaching Hospitals () Antenatal Clinic. The clinic runs every morning form Monday to Friday with an average of 1500 women being attended to on a monthly basis.
Target population
Pregnant women attending Antenatal clinic in Abuja
Study population
The studied – population were women attending antenatal clinic at WNB-UTH who met the eligibility criteria
CHAPTER FOUR
RESULTS
After interviewing 385 antenatal women, the results are shown in tables 2 – 9 below:
Table 2: Descriptive Statistics of Social and Demographic Characteristics of 385 Antenatal Women.
CHAPTER FIVE
DISCUSSION OF FINDINGS, CONCLUSION AND RECOMMENDATIONS
DISCUSSION
Knowledge of labour Pain Relief
In this study, 23 percent of the respondents were prime gravidas whilst 77 percent were multigravidas. The majority of the women were fairly well educated, 87 percent of whom had secondary school level of education and higher (see Table 2). Of the women interviewed, 35 percent had knowledge of labour pain relief which is really low. These low levels of knowledge are in conformity to findings by Naithani et al (2011), and Nabukenya et al.(2015), in which the knowledge levels were even much lower at 9.5 percent and 7 percent respectively. Seemingly, levels of knowledge are low in LMIC‟s. Contrary to expectation, even the parous women who are expected to have come into contact with health workers in previous pregnancies and probably received labour analgesia also had low levels of knowledge. This warrants further investigation to establish whether it is due to unavailability of analgesics or low usage by healthcare providers.
The main methods of labour pain relief known were the injections (39 percent), breathing exercises (30 percent) and epidural analgesia (26 percent). These results are consistent with the fact that injectable analgesics are the main form of labour pain relief available at the health facilities. Possible limitations to use of epidural analgesia in public facilities include high cost of epidural kits, inadequate facilities (i.e. equipment and high health provider to patient ratio) to allow individualised patient monitoring during the intra-partum period.
In contrast to these findings, higher levels of knowledge were observed by Mugambe et al (2007) in neighbouring South Africa where 56.3 percent of the respondents had knowledge of pain relief. Similarly Barakzai et al (2010) noted that 61.1 percent of the women were aware that labour pain could be relieved. The latter study however had excluded prim gravid women. Since more than half the respondents (51.1 percent) had received pain relief in the previous delivery(s) leading to increased exposure, increased knowledge of labour analgesia came as no surprise. In this study, an alarming 89 percent of the parous women had not received labour analgesia during previous deliveries. The low usage of labour analgesia likely had an impact on the low levels of knowledge even among the parous women, contrary to expectation.
The main sources of information among the respondents with regards knowledge of pain relief were Health workers, 40 percent, followed by the internet sources at 24 percent. Friends only accounted for 15 percent. These findings again are in contrast with those in other studies where major sources of information were friends and family ((Barakzai et al., 2010) (Nabukenya et al., 2015) (Naithani et al., 2011)). According to Ogboli-Nwasor et al (2011) the major source of information on labour pain relief for Nigerian women was from health workers (15 percent Doctors, 79.4 percent Nurses). The fact that health workers were the main source of information in this study reflects the importance of including some lessons on labour analgesia in antenatal care. Traditionally, Nigerian women are taught to be prepared for labour pain and counseled to be „Strong‟ so as to endure the ordeal. This cultural norm is a possible explanation for the low number of women learning of labour pain relief from family and friends and may also play a role in its acceptance. The high cost of internet services might be a limitation to accessing of information by the pregnant women.
Attitude towards labor pain relief
Among the parous women, 71 percent described labour pain as severe. This is in keeping with the findings by Lowe et al (2002). It is not surprising therefore that most of the women (74 percent) expressed a desire to receive labour pain relief at the next delivery, once they were informed that such a facility exists. Similarly, Mugambe et al (2007) had 78.8 percent and Nabukenya et al (2015) 87.7 percent desiring analgesia at next delivery.
Of the remainder, who declined analgesia during next delivery, the desire to experience natural child birth (57 percent) followed by the fear that the medications or interventions given might be harmful to the baby (32 percent), were the major concerns. Although only 1 per cent thought it would be culturally unacceptable to receive labour pain relief, the fact that most of those who declined analgesia expressed a desire to experience natural child birth could be an indicator of cultural conditioning as well as religious considerations (some women indicated that the Bible clearly states that labour will be painful from the time of Eve‟s fall in Eden).
Factors influencing knowledge and attitude towards labor pain relief
There was a significant relationship between knowledge and education (P = < 0.001, CI 2.18 – 4.61), knowledge and employment (P = <0.001, CI 2.04 – 5.03) as well as knowledge and age (P= 0.02). The study showed that educated and employed women are 3 times more likely to have knowledge of labour pain relief than the uneducated ones. From the multivariable analysis, education and occupation were the key determinants of knowledge. This may be due to the fact that educated women have more access to information via internet sources and books. In like manner, a Saudi Arabian study by (Hanem et al., 2013), noted a significant correlation between knowledge, education and income. The latter study also found a correlation between knowledge and parity, contrary to our findings; however, the study was specifically looking at awareness and attitude towards epidural analgesia and no other forms of labour pain relief.
The study did not find a significant correlation between parity and knowledge (P= 0.063). This is contrary to expectation since from a previous delivery, one is expected to have had contact with health workers and possibly been exposed to labour analgesia. However, it is important to note that only 11% of the parous had received any form of pain relief in previous deliveries and this could have had a bearing on the results. It also reflects low usage of labour pain relief in health facilities. More information on place of last delivery and health worker attitude towards administration of labour analgesia (which was not included in this study) could perhaps shed more light in this vein.
Analysis of the attitude towards receiving labour pain relief at next delivery did not show an association with knowledge nor the other independent variables i.e. neither parity, monthly income nor Age) (Tables 8 and 9). This is in keeping with the fact that labour pain relief is a basic human right, cutting across barriers of education and socioeconomic status. All whether rich or poor, educated or illiterate feel pain and desire its relief.
Religion as a factor affecting knowledge and attitude towards labour pain relief was not analysed as only 0.5 percent of the respondents were non-Christian.
Conclusion
The study found that knowledge about labour pain relief is low among the pregnant women attending antenatal clinic at the University of Abuja teaching hospital. Education and employment were the main factors affecting knowledge towards labour pain relief. The main sources of information on labour pain relief from the few that had knowledge of it were health workers, followed by the online reading. Despite the low knowledge on labour pain relief, once they knew that such an option exists, most of the women expressed a desire to receive analgesia at next delivery.
Recommendations
- To strengthen lessons on labour pain relief, given by health workers during antenatal visits/contacts.
- To strengthen the use of the internet and television for health education even on matters pertaining to pregnancy and labour pain relief so as to increase awareness in the general public and possibly alleviate any fears and concerns
- A follow-up multicenter studies to determine the knowledge and attitude of both health workers and pregnant women towards labour pain relief and its administration
REFERENCES
- ACOG Practice Bulletin (2002) Clinical Management Guidelines for Obstetrician- Gynecologists. (Goetz, L.M) Obstet Gynecol 100(1): 177-19 [Online] Available From https://www.ncbi.nlm.nih.gov/pubmed/12100826 [22/12/16]
- ACOG Committee Opinion (2004) Pain Relief During Labor. No.295. Obstet Gynecol; 104(1):213. [Online] Available From https://www.ncbi.nlm.nih.gov/pubmed/15229040 [22/12/16]
- Anim-Somuah, M, Smyth, R, Howell, C. (2005) Epidural Versus Non-Epidural or No Analgesia in Labour. The Cochrane Database of Systematic Reviews, (4): CD000331. DOI: 10.1002/14651858.CD000331
- Apondi ,C. (2012) A Survey of Knowledge and Attitude and Practice Regarding Labour Analgesia Among Obstetricians at the Kenyata National Hospital. Unpublished MSc Anaesthesia dissertation. University of Nairobi.
- Barakzai A, Haider G, Yusuf F, Haider A, Muhammad N. (2010) Awareness of Women Regarding Analgesia During Labour. J Ayub Med Coll Abbottabad; 22(1): 73-5. [Online] Available From: http://www.ayubmed.edu.pk/JAMC/PAST/22-1/Barakzai.pdf [20/12/18] Biswas, G, Hariharan, V. (2002) A survey of antenatal women on their knowledge of pain relief methods in labour. Royal Coll Anaesth. 11: 530–1.
- Hanem, F, Alqantani, J, Almobaya, N, Aldosari, M, Alnajay, H. (2013) Women‟s Awareness and Attitude Toward Epidural Analgesia. Journal of Biology and Healthcare. 3(6). [Online] Available From www.isitte.org [20/12/18].
