|Year : 2014 | Volume
| Issue : 1 | Page : 18-22
Perception of labor pain and utilization of obstetric analgesia by Igbo women of Southeast Nigeria
Johnson A. Obuna, Odidika Ugochukwu J. Umeora
Department of Obstetrics and Gynecology, Ebonyi State University/Federal Teaching Hospital, Abakaliki, Ebonyi State, Nigeria
|Date of Web Publication||20-May-2014|
Odidika Ugochukwu J. Umeora
P.O. Box 980, Abakaliki - 480 001, Ebonyi State, Postal Code: 480001
Source of Support: None, Conflict of Interest: None
Context: Pain is subjective and labor pain perception is said to be influenced by personality, culture, parity, educational status and maternal weight. Objectives: This study assessed the Igbo Women's perception of labor pain and evaluated factors influencing their perception of labor pain as well as ascertained the level of utilization of obstetric analgesia by parturients.
Materials and Methods: This was a cross-sectional study that spanned 6 months (January 1, to June 30, 2011) and involved parturients of Igbo extraction who delivered by vaginal route in 3 different referral hospitals. They were interviewed with self-administered questionnaires within the first 24-48 hours postpartum. Labor pains were rated using a 3-pont verbal rating scale (VRS). Data were analysed with MathCAD 7 statistical soft ware package.
Results: A total of 530 parturients were interviewed but only 500 were analysed. Fifty-two percent of parturients rated labor pain as severe. While 67.6% of parturients desired labor pain alleviation, only 38% actually requested for analgesia, and only 27% of parturients received pain relief during labor. The commonest pain relief available was intramuscular injection of Pentazocine Hydrochloride (92.6%) The influence of age, parity, educational status, maternal weight and companionship, on pain perception was statistically significant.
Conclusion: Though most Igbo women found labor painful, they tend to cope with it. Most Igbo parturients did not request for pain relief and only a fraction of those who did request received it. Adequate antenatal preparation for the birthing process is necessary.
Keywords: Companionship, culture, Igbo, pain, prenatal education
|How to cite this article:|
Obuna JA, Umeora OJ. Perception of labor pain and utilization of obstetric analgesia by Igbo women of Southeast Nigeria. J Obstet Anaesth Crit Care 2014;4:18-22
|How to cite this URL:|
Obuna JA, Umeora OJ. Perception of labor pain and utilization of obstetric analgesia by Igbo women of Southeast Nigeria. J Obstet Anaesth Crit Care [serial online] 2014 [cited 2020 Feb 28];4:18-22. Available from: http://www.joacc.com/text.asp?2014/4/1/18/132815
| Introduction|| |
Pain is a subjective sensation involving a complex interaction of physiologic, psychosocial, cultural and environmental influences.  The pain of the birthing process from earliest times has been aptly described as distressing and intensely excruciating. ,
The pain of the first stage labor usually experienced by the parturient as visceral diffuse, abdominal cramps over the lower abdomen, lower back and sacrum originates from the rhythmic uterine contractions and progressive cervical dilatation, transmitted by spinal nerve segments T 10 -L 1 . Although, the second stage labor is shorter, the pain transmitted by the spinal nerve segments S 2 -S 4 and resulting from overstretching of the vagina, vulva and the perineum is usually more intense. ,
Perception of pain at each stage of labor has wide individual variation and seems to be influenced by some factors. Whereas nulliparity, oxytocin use, younger maternal age, increased maternal and fetal weight, dystocia, fetal malposition, maternal fear, western education tend to correlate with greater pain perception, factors like companionship in labor and prenatal education on the birthing process tend to modulate the pain. , Other factors, which have been reported to influence pain perception in labor, include culture and ethnicity. 
Young women in some cultures are taught that labor pain is natural and inevitable and that the ability to accept and endure it is a sign of womanhood.  This is found commonly among the Hausas of Northern Nigeria, hence women from this part of the world grow with this psychology and show same during labor. Perception of labor pain by pregnant women attending antenatal clinic and the effects of education on pain perception in labor in the immediate post-partum period has been evaluated in different studies. , While the former studies failed to take cognizance of the fact that though childbirth is a memorable event in a woman's life, maternal recall of labor events 10 or more weeks postpartum have been found to be poor.  This study evaluated labor pain perception among Igbo women of South Eastern Nigeria and examined the factors that influence such perception and the analgesia utilized during labor.
| Materials and Methods|| |
Ebonyi State was created in 1996 from the largely rural areas of the pre-existing Enugu and Abia States. It has three senatorial districts and 13 local administrative units or local government areas (LGAs), one urban, one semi-urban and the rest rural. It has an estimated population of 2.1 million and occupies a landmass of 5932 km 2 , sharing boundaries in the west with Enugu State, Cross-River in the South and Benue State in the North. The population comprises mainly subsistent farmers and petty traders while Christianity forms their major religion.
There are 13 general hospitals, one in each LGA; four mission hospitals, one in each of the Ebonyi North and Central Senatorial districts respectively and 2 in the Ebonyi South Senatorial district. There are 2 tertiary hospitals (Federal Medical Center and the State Teaching Hospital) both located in the state capital, Abakaliki. The two tertiary health institutions and the four mission facilities serve as referral centers and received referrals from both the general hospitals, primary health care centers and privately-owned hospitals and clinics.
The only referral center located in the Ebonyi Central senatorial districts and one each from the three in the North and the two in the South Senatorial districts selected by balloting were sites for the study. These centers were the Ebonyi State University Teaching Hospital (EBSUTH) Abakaliki, the Mater Misericordiae Hospital Afikpo and the Saint Vincent Hospital Ndubia-Igbeagu. The latter two were mission hospitals. These hospitals also covered the urban, semi-urban and rural populations of the state. The first and second stages of labor in all the centers are managed in different suites. The first stage suites are designed in such a way to accommodate companions of the parturients as they are screened from one another using mobile room dividers. Pain relief is not universal in any of the centers, but offered only on demand or at the Accoucheur's prescription. Intramuscular injection of pentazocine hydrochloride or tramadol is often employed.
An average of 150, 50 and 35 women deliver monthly at EBSUTH, Mater Misericordiae Hospital and the Saint Vincent Hospital respectively. Women who achieved spontaneous vertex delivery in these hospitals during the study period were recruited into the study following an informed consent. Excluded from the study were women who delivered by caesarean section or had any form of instrumental delivery. Also excluded were those who presented in the second stage labor, parturients who were not Igbo by birth, who had confirmed intrauterine fetal death or oxytocin/misoprostol administration for whatever reason in labor or had epidural analgesia from the onset of labor.
This was a cross-sectional study that spanned 6 months (January 1 st -June 30 th 2006). Permission was obtained from the ethics and research committees of each hospital. The nature and purpose of the study were explained to each participant who gave verbal consent before she was interviewed. The parturients who picked "YES" from the pool of sealed "YES and NO" options were interviewed within the first 24-48 h postpartum using self-administered questionnaires. The literate ones filled theirs while trained research assistants who understood the local dialects helped the non-literate women.
Labor pain was rated using the 3-point verbal pain rating scale (mild, moderate and severe).  Data obtained was analyzed using the math CAD 7 statistical software package of PTC, (PTC, Needham MA, USA). Chi-square test was used to test for significance and a P < 0.05 is taken as significant.
| Results|| |
A total of 530 women were interviewed but 500 were analyzed. The remaining 30 questionnaires were not properly filled. The socio demographic variables are summarized on [Table 1]. The respondents ranged in age from 15 to 39 years, with mean age of 27.5 ± 8.6 years (2 standard deviations [2SD]). There were 20 teenagers while majority (39.2%) was aged between 25 and 29 years. Primiparas comprised 44.6% of the women while grand multiparas were 35.8%. Most of the respondents had at least education up to the secondary school level. Only 4.0% had no formal education [Table 1]. The mean weight was 66.8 kg ± (2SD).
Nearly 52% of the parturients described the labor pain as severe, 40% described it as moderate while 8% as mild. 162 of these parturients (32.4%) would want nothing done to the labor pain, 252 (50.4%) wanted some relief, while 17.2% wanted the pain eliminated. 26.6% of the parturients were concerned about the labor pain, while the majority, 58.2% were more concerned about the safety and survival of their babies in utero. Thirty-six parturients (7.2%) were more concerned about possible labor complications. Only 38% of parturients did request for pain relief during their labor.
Nearly 73% of parturients did not receive pain relief during labor while 27% receive some form of analgesia. Those that needed pain relief received intramuscular injection of pentazocine hydrochloride or tramadol. Of those who received analgesia, 114 (84.4%) obtained adequate pain relief from the drugs administered while 15.6% experienced no relief of their pain. 106 parturients (21.2%) were afraid of the side-effects of the analgesia.
Totally, 307 parturients (61.4%) had some form of companionship during labor, while 38.6% did not. The most common companion was the husband (40.8%), followed by sister (24.7%). Others included: Mother-in-law (14.3%), mother (13.0%), neighbor (4.3%) and the least were brothers (2.9%).
Majority (84.8%) of parturients described the attitudes of nursing staff that attended to them during labor as friendly, while 10.4% described the relationship between them and the nursing staffs as purely professional. Others described their attitudes as indifferent or hostile (1.0% and 3.8% respectively).
Three hundred and forty-seven (69.4%) parturients would not like to experience such labor pain in future while 30.6% would not mind.
Concerning the various factors, which influence the perception of labor pains the influence of age on the perception of labor pain was found to be statistically significant (χ2 = 40.53, P < 0.05, df = 8). The highest percentage of women (69.4%) between the age ranges of 20 and 24 years, described the labor pain as severe [Table 2]. [Table 3] shows the relationship between parity and perception of labor pain, with more primipara (85.2%) describing the pain as severe. The influence of parity on labor pain perception was statistically significant (χ2 = 168.73, P < 0.05, df = 4).
The influence of education on labor pain perception was statistically significant (χ2 = 91.39, P < 0.05, df = 6). The higher the educational attainment, the more severe labor pain is perceived [Table 4].
|Table 4: Relationship between educational status and severity of pain (n = 500) |
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The higher the maternal weight from 50 kg, the more severe labor pain is perceived by parturients. Parturients, whose weights were below this (50 kg), tend to perceive labor pain as mild. Overall, the influence of maternal weight on labor pain perception was statistically significant (χ2 = 131.66, P < 0.05, df = 6) [Table 5].
|Table 5: Relationship between weight (kg) and severity of pain (n = 500) |
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Parturients who had companions during labor tended to perceive labor pain more severe than those who did not have companions. As high as 62.9% of women who had some companionship during labor described labor pain as severe. The influence of companionship in labor was found to be statistically significant (χ2 = 12.05, P < 0.05, df = 2).
| Discussion|| |
Labor pain represents one of the most severe forms of pain and discomfort experienced by a woman in her lifetime  and yet many obstetric units in developing countries including Nigeria do not offer obstetric analgesia routinely. The Biblical view that "in pain shalt thou bring forth thine offsprings" seem to color the practice of these units. The pain of labor should be alleviated to make the birthing process more bearable and comforting. 
The parturients involved in this survey coped satisfactorily with the pain of the birthing process. This might have been culture-bound as studies have indicated. , While Hausa woman of Northern Nigeria are acculturated to bear labor pains without expressing it, the Yoruba women of Southwestern Nigeria are said to have low pain threshold in labor and do express it. The Igbo culture holds very sacred, vaginal delivery and women are tutored from childhood on the significance of accomplishing childbirth through this route "whatever the pain." Womanhood is assessed based on the ability of the woman to pass through the labor successfully and deliver vaginally. Having imbibed this cultural code, the Igbo woman enters labor with high mental motivation and expectation. She is more concerned about the delivery of a healthy baby per vaginam than the labor pain. It was therefore not surprising from this study that majority of the respondents were more concerned about the well-being of their babies than the painful labor process.
In this study only a fraction of the parturients who desired pain relief actually requested for it. This exposes the gaps in prenatal health education as regards the availability of obstetric analgesia and the women's right to demand it in labor. Earlier studies in Nigeria have shown that though many laboring women would desire or expect pain relief during labor process, only few actually ask for it and many go through the labor process without any form of pain relief.  A study by Chigbu and Onyeka found similar experience among paturients in Enugu in the same Southeast Nigeria.  Although ignorance of the availability of pain relief by Nigerian parturients and cultural inclinations may account for low request of pain relief during labor, , the scarcity of the analgesic drugs in our health institutions and the reluctance of the attending health personnel to routinely offer them when available may account for the poor utilization of obstetric analgesia. In a survey of 650 parturients at the University College Hospital Ibadan, Southwest Nigeria, only 19.5% of the participants were aware of the availability of epidural analgesia for pain relief in labor. 
The influences of maternal age, parity, educational status and maternal weight on labor pain appreciation in this study were found to be statistically significant. Kuti and Faponle in Ile-Ife Southwest Nigeria also found similar associations.  In Enugu, Southeast Nigeria, Onah et al. found that only educational status correlated with pain perception in labor while primigravidity had a significant negative correlation among Igbo parturients.  Vincent and Chestnut have earlier documented similar observations among women within the 20-24 years age bracket and primipara in American populations.  The younger age group and primipara are inexperienced and seem not adequately psychologically prepared for labor. The significant influence of maternal age and parity on pain perception in our study disagreed with the report from Ife by Faponle and Kuti  who noted no such association. While no reason for the discordance in the findings between the two studies could immediately be proffered, it may not be unconnected with the timing of the studies. The Ife study was undertaken on prenatal women whose past labor pain experience might have been attenuated with time.
Maternal weight above 50 kg was associated with more pain appreciation. It is known that obese parturients tend to have prolonged labor due to either in coordinate uterine contractions , or their inability to exert maternal effort during the second stage.  Parturients with prolonged labor tend to express more pain because of maternal dehydration and exhaustion, which lead to release of more catecholamines and other mediator substances whose concentrations tend to be relatively more because of maternal dehydration.  Furthermore, obese woman tend to have macrosomic babies and parturient with macrosomic babies have been reported to perceive labor pain as more severe.  This is probably because macrosomic baby is associated with labor dystocia and subsequently prolonged labor. 
The higher the Western education, the more severe the pain perception.  This is probably because education tends to create more awareness of the need for and the availability of such obstetric analgesia. Educated women demand for more pain relief during labor more than the less educated women.  Companionship in labor has been associated with reduced labor pain but the type of companionship is very important. The companionship offered by the trained traditional Doualas tends to reduce pain perception in labor than the companionship offered by the professional midwifes.  It has also been reported that the presence of the husband in labor tend to heighten the perception of labor pain by the parturients.  This was noted in our study. Perhaps, women whose husbands are present during labor seek more attention and appreciation from their spouses through an exaggerated response to their pain. In this study, husbands accounted for greatest proportion of companions during labor. This may partly explain why companionship was significantly associated with increased labor pain perception by the women.
| Conclusion|| |
Perception of labor pain by the Igbo women is influenced by their personality, culture and other factors such as maternal age, parity, weight and educational status. While most of the Nigerian health institutions lack basic pain relief facilities, the available agents should be routinely and liberally offered to parturients. There is need for adequate prenatal maternal preparation for the process labor.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]