Background

Labor pain is considered an “excellent model for acute pain” [1]. Unlike other acute pain that is usually associated with injury or pathology, they are part of a normal physiological process [2]. The American College of Obstetricians and Gynecologists (ACOG) confirmed the severity of labor pain by stating that no other condition was as severe as labor pain [3]. There are two elements of labor pain: visceral and somatic. The Visceral Pain occurs during the first stage of labor and is associated with tension placed on the cervix, causing it to dilate. Somatic pain appears at the end of the first stage and continues into the second stage. It is caused by the force applied to the vaginal part of the cervix, the vagina, and the perineum [4].

Pain management during labor entails several activities, including pain assessment, pain control, and pain relief. Therefore, obstetric care providers must use safe and effective interventions [5]. A variety of pharmacological and non-pharmacological interventions have been developed to manage labor pain, including opioids, nonopioids, epidural analgesia, spinal-epidural analgesia, inhalation agents, pudendal blocks, transcutaneous electrical nerve stimulation, massage, acupuncture, immersion in water, yoga, music therapy, biofeedback, continuous support, positioning, ambulation, hypnosis, and breathing techniques [6, 7].

Several organizations, including the ACOG and the American Society of Anesthesiologists (ASA), have stated that it is unacceptable for clients to suffer untreated severe pain under the care of a physician and obstetric analgesia should be offered upon request by mothers [3, 8]. Additionally, the National Institute for Health and Care Excellence (NICE) of the UK recommends that women be educated about the options and availability of effective analgesia during labor to ensure that they receive the best pain relief [9]. The Ethiopian Food, Medicine, and Health Care Administration and Control Authority (FMHACA) has developed and implemented standard treatment guidelines, which include administering analgesics and anesthetics to pregnant mothers without adversely affecting their condition or that of the fetus [10].

Labor pain and pain relief methods are major concerns for childbearing women and their families, with major implications for the course, quality, outcome, and cost of intrapartum care [11]. The worst pain a woman experiences is during labor [12]. Previously conducted researches indicate the magnitude of obstetrics analgesia utilization among obstetrics care providers that ranges from 38.9 to 93.5% [13, 14]. When a woman experiences extreme pain during labor, she experiences emotional discomfort, depression, and anxiety.

Moreover, psychosocial aspects such as cultural beliefs, support from family, marital and social status, and past experiences of difficult labor can also play a role in increasing the pain experienced during childbirth. Furthermore, these factors can influence the mother’s health and her bonding with the child, with potential effects lasting both in the short and long term [15].

In addition to fear of labor pain, a lack of appropriate labor pain management causes laboring mothers to become concerned about or request cesarean sections, which exposes them to financial hardships [16]. It is important to note, however, that complete pain relief may not always equate to a more satisfying birth experience [17].

The provision of pain relief during labor is ignored despite the need, benefits, and drawbacks of pain relief options, particularly pharmacological options [6]. The main factors affecting care providers’ use of labor analgesics in developing countries are drug availability, healthcare delivery systems, and healthcare providers’ knowledge, attitudes, and skills to provide labor analgesia [7]. The ACOG recommends that maternal request be a sufficient medical indication for pain relief during labor, unless there is a medical contraindication [3]. In Contrast to being an important component of the Ethiopian Federal Minister of Health (EFMOH) efforts to improve the quality of maternal health services available to Ethiopians, labor pain management methods are not widely used [18].

Despite national recommendations for obstetric analgesia use during labor, little is known about its utilization by care providers in the study area. This study aimed to assess the magnitude of obstetric analgesia utilization and associated factors in the study area.

Method and materials

Study design and setting

A facility-based cross sectional study was conducted in hospitals in the West Arsi and Arsi Zones from March 10 to April 20, 2023. The West Arsi and Arsi zones are two of the 20 administrative zones found in the Oromia regional state in Southwest and Southeast Ethiopia. The central city for the west Arsi zone is Shashemene, located 250 km from Addis Ababa, while Asella is the central city for the Arsi zone, located 175 km from Addis Ababa. The West Arsi zone has seven public hospitals and four private hospitals, while the Arsi zone has eight public hospitals and two private hospitals. In total, there were twenty one hospitals in the two zones, of which fifteen were public hospitals and six were private hospitals.

Source population

All obstetric care providers in hospitals in the West Arsi and Arsi Zones of the Oromia region composed the source population. The study population included randomly selected obstetric care providers working in the hospital of West Arsi and Arsi Zone during the study period.

Inclusion criteria and exclusion criteria

Obstetric care providers working in the hospitals of West Arsi and Arsi Zone during the study period were included in the study, while those absent due to annual and sick leave during the study period were excluded from the study.

Sample size determination

The sample size was determined by using a single population proportion formula.

by considering the following assumptions: n = sample size, p = proportion of obstetric analgesia utilization from study performed in West Shewa 46% [19], Z = standard normal distribution curve value for 95% confidence level with the value of 1.96, d = margin of error to be tolerated (d = 0.05). By using this formula, the sample size become 382. By adding 10% non-response rate the final sample size for the study become 421 obstetric care providers.

Sampling technique and sampling procedure

All hospitals in the West Arsi and Arsi Zones were included in the study. The study included; Shashemene Comprehensive and Specialized Hospital, Melka oda General Hospital, Negele Arsi primary Hospital, Dodola General Hospital, Gambo General Hospital, Loke Primary Hospital, Feya Primary Hospital, Negele Arsi General Hospital and Medical College, Kokosa Primary Hospital, Essa Primary Hospital, Kula Primary Hospital, Chancho Primary Hospital, Dr. Firaol Primary Hospital, Arsi University Referral and Teaching Hospital, Bokoji Primary Hospital, Abomsa Primary Hospital, Gobessa Primary Hospital, Kersa Primary Hospital, Robe Dida Primary Hospital, Chilalo shade Primary Hospital, and Rohobot General Hospital. The total sample size was proportionally allocated to each hospital by reviewing the number of obstetric care providers working there and the final study participants to be included were selected randomly through the lottery method, using the staff list as a sampling frame (Fig. 1).

Fig. 1
Fig. 1
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Diagrammatic presentation of sampling procedure of obstetric care providers working in hospitals of West Arsi and Arsi Zones, Oromia region, Ethiopia, 2023. H1- Shashemene comprehensive and Specialized Hospitals, H2- Melka oda General Hospital, H3- Negele Arsi primary Hospital, H4- Dodola General Hospitals, H5- Gambo General Hospital, H6- Loke primary Hospital, H7- Feya primary Hospital, H8- Negele Arsi General Hospital and Medical College, H9- Arsi university Referral and Teaching Hospital, H10- Bokoji primary Hospital, H11- Abomsa Primary Hospital, H12- Gobessa primary Hospital, H13- Kersa Primary Hospital, H14- Robe dida Primary Hospital, H15- Rohobot General Hospital, H16- Kokosa Primary Hospital, H17- Kula Primary Hospital, H18- Chancho Primary Hospital, H19- Dr. Firaol primary Hospital, H20 Chilalo Shade Hospital, H21 Essa Hospital

Data collection tool

The data were collected using a structured, pre tested, and self-administered questionnaire adapted from different studies [19,20,21,22]. The questionnaire was developed in English for all respondents to understand. It consisted of four essential components related to obstetric analgesia utilization in labor pain management, including providers’ sociodemographic characteristics, individual-related factors, facility-related factors, and client-related questions. The knowledge-related questions comprise fourteen items, and the attitude-related question comprises ten items with five possible options on a Likert scale (strongly disagree, disagree, undecided, agree, and strongly agree), and all statements were affirmatively stated. Cronbach’s Alpha test was calculated using SPSS window version 26 to test the internal consistency of the items, and the Cronbach’s Alpha test for the item was 0.835, which is considered reliable.

Data collection procedures

Twelve BSc holding midwives were recruited as data facilitators, and two MSc holding nurses were recruited for supervision. The purpose of the study and the importance of their involvement were explained to the respondents, and those who volunteered participated in the self-administered questionnaires.

Study variables

Dependent variable

Utilization of obstetric analgesia for labour pain management.

Independent variable

Socio-demographic characteristic

Age, Sex, Religion, Clinical Experience, Profession, and Level of Hospital.

Facility related factors

Availability of labor analgesia and Equipment, Protocol and Guideline, Number of Skilled providers, and Cost of analgesic drug.

Individual related factors

Attitude of care providers, Knowledge of care providers, Training, having heard of WHO pain ladder, Expectation of Labour pain, Level of Qualification, and Allowing companion.

Client related factors

Maternal Refusal.

Operational definition

Utilization of obstetric analgesia

Obstetric care providers were considered to have utilized obstetric analgesia if they reported using any form of pharmacological or non-pharmacological method for labor pain management at least once during the past month prior to data collection [19].

Obstetric care providers

Skilled health professionals who were giving maternal care service (i.e., Midwives, Nurses, Health officers, General Practionaire, Residents, obstetrician and gynecologist, IESO, Anesthesiologists, Anesthetists).

Adequate knowledge

Obstetric care providers who answered more than or equal to the mean knowledge of obstetric analgesia related questions were considered to have adequate knowledge of obstetric analgesia, while those who answered less than the mean value were considered to have inadequate knowledge of obstetric analgesia [19,20,21].

Favorable attitudes

Obstetric care providers who answered greater than or equal to the mean value for attitudes related questions were considered to have favorable attitudes toward the use of obstetric analgesia, while those who answered less than the mean value were considered to have unfavorable attitudes toward the use of obstetric analgesia [19].

Data quality control

To ensure the quality of the data, a pretest was conducted on 5% of the total sample size. Findings and experiences from the pretest were used to modify and refine the data collection tools. Training was provided to the data collectors and supervisors on the study objective, confidentiality of information, and data collection techniques. The completeness of the data was checked for missing values by the supervisors.

Data processing and analysis

The data were coded, cleaned, and entered into Epi data statistical software version 3.1 and then exported to SPSS window version 26 for further analysis. Descriptive statistical analysis was used to summarize the data.

Bivariate regression models were first built for each explanatory variable with the outcome variable. Variables with a p-value < 0.25 in bivariate regression were fitted into multivariable logistic regression models for analysis. Multivariate logistic regression analysis was conducted to control for confounders and identify association between each explanatory variable and the outcome variable. Variables with a p-value < 0.05 with a 95% confidence interval in the final model were considered as having a significant association with the use of obstetric analgesia.

The Hosmer and Lemeshow statistical test were used to assess model fitness, and the results indicated a good fit (X2 = 2.07, df = 8, p = 0.978). The variance inflation factor (VIF) test was used to assess multicollinearity in the regression model, and all the VIF values were below 10, indicating no multicollinearity issues.

Results

Sociodemographic characteristics of study participants

Out of the 421 participants enrolled in the study, 413 completed and returned a response, yielding a response rate of 98.1%. The median age of the participants was 30 years (IQR = 27.5–33), and the median clinical experience of the participants was 5 years (IQR = 2–7). Of the respondents, 50.8% were male, and 41.6% were midwife professionals (Table 1).

Table 1 Sociodemographic characteristics of obstetric care providers in hospitals of West Arsi and Arsi zones, Oromia region, Ethiopia, 2023
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Individual, facility, and client-related characteristics

About 52.1% of the respondents had adequate knowledge of obstetric analgesia methods for labor pain management. Among the methods, 88.9% and 66.3% of the respondents knew NSAID and epidural analgesia as pharmacologic method, while 88.6% and 72.9% of them knew back massage and Psychotherapy from non-pharmacologic methods for labor pain management. The findings of the study revealed that 60.8% of the participants had a favorable attitude toward the use of obstetric analgesia for labor pain management. Among the total participants, 67.8% confirmed the availability of analgesic drugs in their facilities, and 51.8% had never asked a laboring mother to provide pain relief (Table 2).

Table 2 Individual, facility, and client related characteristics of obstetric care providers working in Hospitals of West Arsi and Arsi zone, Oromia region, Ethiopia, 2023
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Utilization of obstetric analgesia

Of the 413 obstetric care providers who participated in this study, 52.3% reported practicing labor pain management methods in the previous month. Only 39.8% provided labor pain management methods on a routine basis. Regarding labor pain management methods, 21.5% of the participants used non-pharmacologic methods, 16.2% used pharmacologic methods, and 14.5% used both methods in the previous month. Furthermore, 23.5% of participants preferred non-pharmacologic methods. The unavailability of drugs (44.0%), high patient flow (27.9%), and lack of knowledge (16.4%) were some of the reasons mentioned by participants for not utilizing obstetric analgesia. Meanwhile, 13.7% of the participants responded that they had no reason for not practising the methods.

Factors associated with the utilization of obstetric analgesia

Among the candidate variables included in the multivariable logistic regression model, four factor (sex of respondents, level of hospital, knowledge, and Attitude) were found to be significantly associated with the utilization of obstetric analgesia.

Female professionals had a 1.86 times higher likelihood of using obstetric analgesia methods (AOR: 1.86, 95% CI: 1.14, 3.04). Obstetric care providers working in general and primary hospitals were 2.86 times more likely to use obstetric analgesia (AOR: 2.86, 95% CI: 1.41, 5.80), while those working in comprehensive and specialized hospitals were 3.89 times more likely to use obstetric analgesia (AOR: 3.89, 95% CI: 1.85, 8.17).

Obstetric care providers with adequate knowledge of obstetric analgesia methods were 1.94 times more likely to use obstetric analgesia than those with inadequate knowledge [AOR: 1.94(95% CI: 1.05, 3.57)]. Similarly, obstetric care providers who have a favorable attitude towards using obstetric analgesia were 6.92 times more likely to use obstetric analgesia than their counterparts [AOR: 6.92(95% CI: 3.97, 12.06)] (Table 3).

Table 3 Multivariable logistic regression analysis of factors associated with utilization of obstetric analgesia among obstetric care providers working in hospitals in the West Arsi and Arsi Zones, Oromia region, Ethiopia, 2023
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Discussion

A total of 413 obstetric care providers participated in this study. Among them, 52.3% reported using obstetric analgesia methods to manage labor pain in the previous month. The utilization of labor pain management methods was significantly associated with factors such as being female, hospital level, knowledge, and attitude of obstetric care providers. However, it is important to note that this proportion is insufficient to meet the needs of women seeking pain relief during labor and delivery.

The findings of this study are consistent with those of studies conducted in Belgium (47.8%), Nigeria (48.4%), Eastern Ethiopia (50.9%), Debre Markos (49.1%), and East Gojjam (48.9%) [7, 20, 23,24,25]. However, the utilization in this study was lower than that in studies conducted in Australia (68.4%), Norway (75%), and Kenya (61.5%) [26,27,28]. This discrepancy could be due to differences in the advancement of the healthcare system, availability of analgesic drugs and materials, and increased awareness of the use of obstetric analgesia among obstetric care providers.

Moreover, the findings of this study were higher than those of studies conducted in southern Ethiopia (37.9%), Amhara Referral Hospital (40.1%), West Shewa (46%), and Addis Ababa (36.6%) [19, 21, 29, 30]. This variation might be due to the difference in sample size and the time difference related to previous studies. Additionally, the current study involved only healthcare providers working at the hospital level, where the possibility of obtaining highly qualified professionals was high.

In this study, female obstetric care providers were 1.86 times more likely to practice labor pain management methods than their male counterparts. This finding aligns with those of a study conducted in Nigeria, Harari, and eastern Ethiopia, where female providers were more likely to provide obstetric analgesia [23, 31, 32]. The justification for this is that female professionals, having likely experienced childbirth themselves, can more readily relate to the pain of labor and have greater empathy for other women.

According to the findings of this study, obstetric care providers with adequate knowledge of labor pain management methods were 1.94 times more likely to use obstetric analgesia. This finding is consistent with that of a study conducted in Zaria Nigeria, Addis Ababa, and Harari [7, 21, 31]. A possible justification for this is that having comprehensive knowledge of different labor pain management methods allows obstetric care providers to make informed decisions and practice appropriate labor management methods.

However, these findings conflict with those of a study conducted in Kembata and the Amhara regional state, which found that inadequate knowledge was an influencing factor in the use of obstetric analgesia [29, 30]. This might be due to individual differences in the awareness of obstetric analgesia methods and the fact that the average score of each participant determined the level of knowledge in the study.

Having a favorable attitude toward using obstetric analgesia was found to be associated with the provision of obstetric analgesia, as obstetric care providers with favorable attitudes were 6.92 times more likely to provide obstetric analgesia. This finding is similar to those of studies conducted in central Ethiopia, Harari, Hawasa City, Kembata Tembaro, and Tigray General Hospital, where a favorable attitude was found to be an indicator of the utilization of obstetric analgesia [19, 29, 31, 33, 34]. This could be because those obstetric care providers with favorable attitudes are aware of the severity and pain experienced by laboring women and are knowledgeable about the safety and efficacy of different methods, which allows them to provide the appropriate method.

The findings of this study revealed that professionals working in general and primary hospitals were 2.86 and 3.89 times more likely to use obstetric analgesia, respectively. This finding conflicts with a study conducted in Nigeria, where obstetricians working in tertiary hospitals were more likely to use epidural analgesics [32]. This variation might be because these hospitals specialize in managing complicated and high risk cases, and may focus on managing complicated conditions, and providing routine labor and delivery care may not be prioritized in these settings.

Limitation of this study

The limitation of this study is that it did not directly observe obstetric care providers while they were practicing the methods. Furthermore, the study did not compare variations between public and private hospitals.

Conclusion

The findings of this study indicate that the utilization of obstetric analgesia is low compared to previous studies. According to the findings, obstetric care providers’ utilization of obstetric analgesia was influenced by having adequate knowledge, a favorable attitude, being a female professional, and the level of the hospital in which they work.

To improve the utilization of obstetric analgesia methods for labor pain management, we recommend that obstetric care providers be equipped with current knowledge of available obstetric analgesia method, their associated benefits, and risks. For researcher, we suggest conducting additional studies that integrate observation of obstetric care providers while they practice the method and entail a comparative study between private and public hospitals. Additionally, we recommend that a future study that include health centers are needed to provide a more comprehensive picture of the situation across all levels of healthcare facilities.