Study design, study setting, and period

A facility-based cross-sectional study was conducted in Harari regional state health facilities in Ethiopia from May 20 to June 10, 2021. The region is located 526 km from Ethiopia’s capital city, Addis Abeba. Oromia is a regional state that encircles the Harari region. The Harari region is divided into nine woredas, three of them are rural and the other six are urban. The urban districts are divided into 19 kebeles (The smallest administrative units), while the rural districts are divided into 17 peasant associations (which is equivalent to kebeles in urban cases). The region’s total population (2021 projection based on the 2007 Census, CSA) is 270,000, with 136,000 males and 134,000 females (1). There are 59,487 total households [18]. In the region, there are two public hospitals, two private hospitals, two governmental hospitals, eight public health centers, and twenty health posts.

Study population

The study population consisted of all obstetric care providers working in Harari regional state health facilities during the study period. Because the source population in the study area was small, all obstetric caregivers who were available during the study period were included. Obstetrics care providers who were unable to collect data due to illness, annual leave, or training were excluded from the study.

Sample size determination and sampling procedure

The study was conducted at maternal health facilities including two public hospitals (HFSUH and Jugol hospital), one private hospital (Harar General hospital), two private clinics, and nine Harari regional state health centers. Because the number of OCPs in all health facilities was insufficient, the study included all obstetrics care providers (464).

Data collection methods and data quality control

A structured questionnaire was prepared by adapting from different studies [8, 9, 19]. The questionnaire developed for this study is provided as Additional File 1. The questionnaire included four essential components: socio-demographic characteristics of providers, knowledge, attitude, and utilization-related questions. Forty-two questions were included in the questionnaire’s four components. Before beginning the study, the adapted questionaries were validated. To adapt the questionaries, the first step was to review different types of similar literature. The second stage involved ensuring that the adapted questionaries were cross-validated. The tool was given to a group of English-speaking respondents, and their responses were compared to detect differences in incomprehension. Pre-testing was the final step. Before the study began, a pretest was administered to 25 obstetric care providers at Dil Chora referral hospital in Dire Dawa city administration. The questionaries were modified based on the pretest findings, such as typos and question suitability. The instrument’s validity and reliability were then evaluated. Cronbach’s Alpha was used to assess the quality of the instruments we used. The final score was 0.79. Following ethical approval, a letter of permission was written to all health facilities to allow us to proceed with the study. After obtaining permission, the data collectors provided a detailed explanation of the study’s purpose and the significance of their involvement with the obstetrics care providers. Respondents who volunteered to complete self-administered and pre-tested questionnaires were included. The questionnaires were given one-on-one. The information was gathered from all of the region’s healthcare facilities. The data were collected by five well-trained BSC-holding Nurses and supervised by two MSC-holding Midwives.

The collected data were checked for completeness and consistency on a daily basis. Supervisors and data collectors were also trained.


Outcome variable

Utilization of non-pharmacologic pain relief methods.

Independent variables

Socio-demographic variables, knowledge of OCPs towards non-pharmacologic pain relief methods, Attitudes of obstetrics care providers (OCPs) towards non-pharmacologic pain relief methods, and institutional related variables.


Non-pharmacological labor pain management methods

OCPs who used methods that were greater than or equal to the mean value of utilization-related questions [8, 9]. Twelve items were used to assess the use of non-pharmacological labor pain management methods. The questions were answered with yes or no/I don’t recall responses. Those who said “Yes” were coded with a “1,” while those who said “No/I don’t remember” were coded with a “0.” The total score was then computed. The lowest and highest possible scores were 0 and 9, respectively.

Obstetric caregivers

Midwifery, Nurses, Health Officers, and residents.


A total of 15 items were used to assess knowledge of non-pharmacological labor pain management methods. The questions were answered with yes, no, or I don’t know responses. During analysis, the correct answer was coded with “1” and the incorrect, or I don’t know, the answer was coded with “0.” The sum score (range 0–15) was then computed and categorized.

Adequate knowledge

Was defined as OCPs who answered more than or equal to the mean values (6.65) of knowledge-related labor pain relief method questions [8].

Inadequate knowledge

OCPs who answered less than the mean value (< 6.649) of knowledge-related questions were considered to have inadequate knowledge about labor pain relief methods [8].

Favorable attitude

OCPs who answered questions about attitude-related labor pain relief methods with a value greater than or equal to the mean value (≥ 7.5) were considered to have favorable attitudes toward labor pain relief methods [7].

Unfavorable attitude: OCPs who answered less than the mean value (< 7.5) of the total attitude-related questions were classified as having an unfavorable attitude toward labor pain relief methods [7].

Statical analysis

The data was coded, cleaned, and edited before being entered into Epi data statistical software version 3.1 and exported to SPSS window version 22 for analysis. The characteristics of study participants, such as socio-demographics, level of knowledge, and attitude of obstetrics care providers, were described using descriptive statistical analysis, such as simple frequency. The data was then presented in the form of frequencies, tables, and figures. Linear regression analysis was used to identify factors associated with the use of non-pharmacological labor pain management by treating the cumulative score of use of non-pharmacological labor pain management as a continuous variable. The variables were selected using bivariate analysis and dropped from further inclusion in the multivariate model if their p-values were greater than 0.25. Finally, the multivariable linear regression model was fitted using a backward stepwise elimination method, and variables with p-values less than 0.05 in the final model were considered significant predictors of non-pharmacological labor pain management utilization. The standardized with % CI was used to measure the amount by which the dependent variable changes if the independent variable is changed by one unit while the other independent variables remain constant. The Hosmer-Lemeshow statistic and omnibus tests were used to assess the goodness of fit. The multi co-linearity test was used to examine the correlation between independent variables using standard error and collinearity statistics (variance inflation factors greater than 10 and standard error greater than 2 were considered suggestive of the presence of multi co-linearity). P-value0.05 was used in this study to declare a result statistically significant.

Ethical considerations

Haramaya University’s College of Health and Medical Sciences’ Institutional Health Research Ethics Review Committee provided ethical approval for this study (HU-IHRERC). As needed, official letters to conduct a study were obtained from health facilities. The purpose of the study, as well as the risks and benefits of the study, were explained to the health facilities. Before data collection, informed, voluntary, written, and signed consent was obtained from health facility administrators and study participants.

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