Pain Management Policies Research Articles

Neonatal analgesic prescription practices in central India: A cross-sectional survey.

This descriptive survey assessed knowledge, attitude and practice regarding analgesic prescription practices in neonates. A web-based questionnaire was developed and circulated to 150 physicians working in public and private neonatal intensive care units, of whom 87% were aware of neonatal pain perception; however, only 57.3% had any definite pain management policy. Some 66% were aware of a pain assessment tool in neonates, yet none had used it, though 80% used analgesics in their neonatal intensive care unit but only 44.3% were satisfied with the subsequent pain management. The most commonly used agents were midazolam and fentanyl. A total of 55% thought that opioid analgesia should not be used in neonates and morphine was used by only 5%; however, there seemed a general acceptance of opioid use since 86% used fentanyl as an analgesic. Non-pharmacological methods were used by 81%. Pain treatment in neonatal intensive care units is thus suboptimal and requires more attention.

Nurses′ knowledge and practice about neonatal pain management in public hospitals in West Oromia, Ethiopia, 2022: multi-centered cross-sectional study

BackgroundIn low-and middle-income countries inadequate neonatal pain management persists as a significant public health issue despite the availability of guidelines. Newborns often experience pain from routine medical and surgical procedures, with limited nurses’ knowledge and suboptimal practices posing common obstacles to effective neonatal pain management in hospital settings. Hence, this study aimed to evaluate nurses’ knowledge and practices related to neonatal pain management and the factors influencing them in public hospitals in West Oromia, Ethiopia, in 2022.MethodsA multicenter cross-sectional study was conducted among 203 nurses working in public hospitals in West Oromia from 8th May-6th June 2022. Data was gathered using structured, self-administered questionnaire and sampled through simple random sampling. The collected data were coded and entered into a computer using Epi-Data version 4.6 Statistical Software. They were analyzed using the Statistical Package for Social Science (SPSS; IBM Corporation) version 26. Binary logistic regression was used to identify significant independent variables at p < 0.05.FindingsIn this study, 127 (62.6%) exhibited adequate knowledge, while 33 (16.3%) nurses demonstrated good practice in neonatal pain management. Attending lectures or receiving training about neonatal pain management was found to be significantly associated with nurses’ knowledge of neonatal pain management [AOR, 2.31, 95%CI; 1.29–4.27]. On the other, having adequate knowledge of neonatal pain management [AOR, 3.3, 95%CI; 1.14–9.32]; the presence of a pain management policy in place [AOR, 5.44, 95% CI; 1.92–15.37] and attending lectures on neonatal pain management [AOR, 2.55, 95% CI; 1.09–5.97] were found to be significantly associated to nurses’ practices.ConclusionGiven the substandard level of nurses’ practice in neonatal pain management. It is suggested to enhance the nurses’ knowledge and practice about neonatal pain management by providing refreshment courses, training sessions, or facilitating nurses’ opportunity access to reading resources about neonatal pain management.

Pain Assessment and Management Practices via Education & Reinforcement (PAMPER): A Quality Improvement Initiative.

To establish neonatal pain management practices as an essential developmental supportive measure at a tertiary care unit. This quality improvement initiative was conducted as per Point-of-Care-Quality-Improvement Model over 6 mo, followed by 2 y of sustenance phase at a Neonatal Intensive Care Unit (NICU) in northern India. Infants of birth weight ≤1800 g were included and assessed for pain. Pain Assessment and Management Practices via Education and Reinforcement (PAMPER) group was created by resident doctors and nursing staff. The Premature Infant Pain Profile score was used for the assessment of pain. Limiting factors were analyzed using a fishbone diagram and interventions were done in multiple Plan-Do-Study-Act cycles. At the end of interventions, 100% of procedures were assessed for pain. The mean (standard deviation) documented pain score for the first seven days was reduced from 12.8 (0.3) in the baseline phase to 7 (2.5). These interventions helped to sustain the practice in >70% of infants in the next 2 y. Low-cost interventions improved the pain assessment and management policy of authors' NICU with the establishment of a standard protocol. Audits and reinforcement at regular intervals helped in its long-term sustenance.

Comparing the Effectivity of Intravenous Analgetic Tramadol and Intravenous Paracetamol for Acute Post-Percutaneous Nephrolithotomy

There are many management strategies and interventions both preoperative, intraoperative, and postoperative that can be carried out in dealing with postoperative pain. Guidelines for pain management have been prepared by the American Pain Society (APS) with recommendations from the American Society of Anesthesiologists (ASA) where there are many recommendations in postoperative pain management in adults or children by promoting the provision of preoperative education, the use of various modalities both pharmacological and non-pharmacological to the establishment of pain management procedures or policies in each institution. For this reason, the author was interested in examining the comparison of the effectiveness of analgesia between intravenous tramadol and intravenous Paracetamol in minimally invasive Percutaneous Nephrolithotomy (PCNL) postoperative patients at RSUP Dr. M. Djamil Padang. The research was a prospective study with a single-blind randomised controlled trial design. The data used were sourced from clinical trials conducted on post-PCNL patients divided into two subgroups given intravenous tramadol analgetics and others given Paracetamol tablets. In this study, the incidence of Nephrolithiasis was obtained, which was dominated by the male sex, compared to women and suffered a lot at the age of 41-60 years. There was a significant difference in VAS effectiveness between the use of Paracetamol IV and Tramadol IV in post-PCNL patients. The use of Paracetamol may be considered to replace tramadol in the disappearance of acute pain after PCNL postoperative patients in those patients who are allergic to tramadol.

Pain management in infant immunisation: A cross-sectional survey of UK primary care nurses.

Childhood immunisation is a critically important public health initiative. However, since most vaccines are administered by injection, it is associated with considerable pain and distress. Despite evidence demonstrating the efficacy of various pain management strategies, the frequency with which these are used during routine infant vaccinations in UK practice is unknown. This study aimed to explore primary care practice nurses' (PNs) use of evidence-based pain management strategies during infant immunisation, as well as barriers to evidence-based practice. A questionnaire was developed and distributed to nurses throughout the UK via convenience sampling in paper and online formats. Questions assessed the frequency of pain management intervention use during infant immunisation and barriers to their use. A total of 255 questionnaire responses were received. Over 90% (n=226) of respondents never used topical anaesthetics or sweet solutions during immunisations, while 41.9% advised breastfeeding occasionally (n=103). Parent-/caregiver-led distraction was the most frequently used intervention, with most nurses using it occasionally (47.9%, n=116) or often (30.6%, n=74). Most practices had no immunisation pain management policy (81.1%, n=184), and most PNs' previous training had not included pain management (86.9%, n=186). Barriers to intervention use included lack of time, knowledge and resources. Excluding distraction, pain management strategies were infrequently or never used during infant immunisation. Key barriers to using evidence-based strategies were lack of time, knowledge and resources.

Trends in pharmaceutical opioid consumption in the WHO Eastern Mediterranean Region, 2010-2019.

Pharmaceutical opioid consumption has been increasing worldwide, but disparities in access to these medications exist. Few countries of the WHO Eastern Mediterranean Region have well defined pain management policies. This study presents trends in the consumption of pharmaceutical opioids in the 22 countries in the Eastern Mediterranean Region from 2010 to 2019, with comparative intra- and extra-regional analyses; the correlation between pharmaceutical opioid consumption and human development index rankings; and pharmaceutical opioids use in the region. We calculated the defined daily doses for statistical purposes (S-DDD) per million inhabitants per day of pharmaceutical opioids from 2010 to 2019, and used the mixed effects models to assess changes in consumption. We used regression analyses to establish the strength of associations between human development index level and consumption in the region and elsewhere. Pharmaceutical opioid use has fluctuated in the region since 2010, with a mean sum of S-DDD of 2547 for 2010-2019. Consumption is relatively low in the region irrespective of the human development index. The highest-consuming country reported 369 S-DDD in 2019 and the lowest reported 1 S-DDD. The most used pharmaceutical opioids in the region were fentanyl, morphine, pethidine, oxycodone, and codeine. Consumption could be considered inadequate in several countries of the region. Supporting these countries to improve collection and reporting of consumption data, and providing humanitarian assistance to enhance access to pain relief, should be a priority for the international community.

Pain management policy formulation at a tertiary care teaching institute in India: A prospective observational study.

Access to pain management has been recognized as a fundamental human right. Inadequate pain relief hampers the quality of life and has a physiological and psychosocial impact on the patient and caregivers. Inadequate pain relief remains the leading cause of suffering in hospitalized patients worldwide. The objective of this article is to provide adequate pain relief to hospitalized patients through proper assessment, treatment, and monitoring of pain by the trained health-care workers through a sustainable and effective institutional pain management policy. The formulation of pain management policy at a tertiary care teaching institute was conducted in three phases - Phase 1: need assessment by an open-label, uncontrolled, prospective observational study over 1 month period, Phase 2: teaching, training, and awareness of health-care workers, and Phase 3: constitution of the committee at the institute level with the formation of pain resource teams. An open-label, prospective observational study conducted over 1 month revealed that among 814 hospitalized patients, 108 out of 235 (46%) patients in medical and 385 out of 579 (66.5%) patients in the surgical cohort had NRS score of ≥3, implying an inadequate pain relief even at 24 h following medical or surgical intervention, respectively. The provision of effective and adequate pain relief to hospitalized patients requires trained health-care workers and a uniform and structured pain management policy at the institutional level. Recognition and addressal of the barriers and challenges while framing an institutional pain policy is of utmost importance.

Opioid Prescribing for Chronic Pain in Federally Qualified Health Centers Post–Centers for Disease Control and Prevention Guidelines

This study provides important insight on the demographic characteristics, knowledge, practices, and perceptions of primary care providers (PCPs) prescribing opioids to patients at federally qualified health centers (FQHCs). Findings suggest that FQHCs would benefit from examining their current pain management policies and practices and addressing issues as they arise. FQHCs need to provide continuing education on pain management for PCPs and partner with external organizations and social service agencies to facilitate patient use of recommended alternative pain treatments. Future research should examine the efficacy of such strategies for improving opioid prescribing practices among PCPs at FQHCs.

Knowledge and Practice of Nurses and Associated Factors in Managing Neonatal Pain at Selected Public Hospitals in Addis Ababa, Ethiopia, 2020.

IntroductionHospitalized neonates experience moderate to severe, acute or chronic pain. Recent study indicates that health care providers especially in developing countries have a knowledge and skills gap related to neonatal pain management.ObjectiveThe aim of this study was to assess the neonatal ICU nurses’ knowledge and practice and factors associated with neonatal pain management at selected public hospital of Addis Ababa, Ethiopia.MethodsFacility-based cross-sectional study design was employed at four selected public hospitals in Addis Ababa, from April to May 2020. A simple random sampling method was used to recruit study participants using a semi-structured and self-administered questionnaire. The logistic regression model was used to identify the association, and odds ratio was used to test the strength of the associations between outcome and predictor variables.ResultsThis study was conducted with 119 nursing staffs working in the neonatal intensive care unit with a 96.6% response rate. The study reveals that 68.7% of nurses had adequate knowledge and only 32.2% of them had good practice of neonatal pain management. There was a significant relationship between nurses’ knowledge scores and receiving in-service training on neonatal pain management. Having an infant pain management policy in place, getting training on neonatal pain management and knowledge category were factors significantly associated with practice of nurses in neonatal pain management.DiscussionAccording to the results of the current research, the majority (85.2%) of participants knew that the vital signs of new-borns can be affected by pain. However, only 60.9% of nurses considered pain as one of the vital signs in new-borns. This indicates that neonatal pain may not be assessed as frequently as a vital sign. And the finding reveals that nurses had poor practice but had adequate knowledge in managing neonatal pain. The respective hospitals and Ethiopian Ministry of Health should provide gap-filling training on neonatal pain management to the nurses.

A New Era of Pain Management: Finding the Moral Frameworks

Treating the pain of those who suffer has long been held as a moral obligation of nurses. But which moral frameworks support pain management in an era of opioid abuse, increased patient autonomy, and moral pluralism? Changes in the public and professional moral viewpoint regarding pain contribute to changes in government and institutional policies and treatment protocols. New practice protocols and pain management policies may use different moral underpinnings. Moral clarity in policy and treatment protocols can prevent confusion over what is right for patients with pain, thus preventing nurse moral distress, patient stigma, and suboptimal pain care. The aims of this presentation are 1) to introduce nurses to the moral theories/frameworks that may inform pain management policies and practice, and 2) encourage nurses to begin to ask pertinent and effective moral and ethical questions when making pain management practice and policy decisions.

The Association Between Pain and Fall Among Middle-Aged and Older Chinese

BackgroundFalls and fall-induced injuries in elderly people are common worldwide. However, few reports have examined the association between body pain and fall in middle-aged and older Chinese adults. The objective of this study is to access the association between pain and fall among middle-aged and older Chinese. MethodsData were drawn from the 2011 China Health and Retirement Longitudinal Study (CHARLS) from respondents who were middle-aged and older (over 45 years old). A logistic regression model was used to estimate the odds ratios (AOR) and 95% confidence interval (95% CI) of the association between body pain and fall, after controlling for confounders. ResultsAfter adjusting for demographic characteristics, socioeconomic status, lifestyle, health status and comorbidity, those participants who had pain were 73% more likely to report falls than those who did not have pain (AOR = 1.73, 95% CI 1.56-1.92). Elder age was associated with a higher risk of fall (AOR = 1.77, 95% CI 1.47-2.13). Comparing to female, male was associated with a lower risk of fall (AOR = 0.64, 95% CI 0.56-0.74). Lifestyle such as drinking status, self-reported health status, chronic diseases, vision impairment and disability were significantly associated with fall. ConclusionBody pain is significantly associated with fall among middle-aged and older Chinese adults. Appropriate pain management programs and policies are needed in fall prevention.

The Characteristics and Effectiveness of Interventions for Frequent Emergency Department Utilizing Patients With Chronic Noncancer Pain: A Systematic Review.

Patients with chronic noncancer pain (CNCP) present unique challenges to emergency department (ED) care providers and administrators. Their conditions lead to frequent ED visits for pain relief and symptom management and are often poorly addressed with costly, low-yield care. A systematic review has not been performed to inform the management of frequent ED utilizing patients with CNCP. Therefore, we synthesized the available evidence on interventional strategies to improve care-associated outcomes for this patient group. We searched Medline, EMBASE, CINAHL, CENTRAL, SCOPUS, and Web of Science from database inception to June 2018 for eligible interventional studies aimed at reducing frequent ED utilization among adult patients with CNCP. Articles were assessed in duplicate in accordance with methodologic recommendations from the Cochrane Handbook for Systematic Reviews of Interventions. Outcomes of interest were the frequency of subsequent ED visits, type and amount of opioids administered in the ED and prescribed at discharge, and costs. Methodologic quality was assessed using the Cochrane Risk of Bias in Non-Randomized Studies of Interventions and Risk of Bias tools for nonrandomized and randomized studies, respectively. Thirteen studies including 1,679 patients met the inclusion criteria. Identified interventions implemented pain policies (n= 4), individualized care plans (n= 5), ED care coordination (n= 2), chronic pain management pathways (n= 1), and behavioral health interventions (n= 1). All of the studies reported a decrease in ED visit frequency following their respective interventions. These reductions were especially pronounced in studies whose interventions were focused around individualized care plans and primary care involvement. Interventions implementing opioid restriction and pain management policies were largely successful in reducing the amounts of opioid medications administered and prescribed in the ED. Multifaceted interventions, especially those employing individualized care plans, can successfully reduce subsequent ED visits, ED opioid administration and prescription, and care-associated costs for frequent ED utilizing patients with CNCP.

Pain management policies and reported practices in Swiss emergency departments: a national survey.

Acute pain is the most common complaint of patients presenting to emergency departments (EDs). Effective pain management is a core ED mission, but numerous studies have pointed to insufficient pain treatment or oligoanalgesia. According to a 1997 national survey in Swiss EDs, a validated pain scale was used in only 14%, an analgesia protocol in &lt;5%, and 1.1% had a nurse-initiated pain protocol. Since then, numerous societal and health care factors have led to improved ED pain care. The aim of this study was to assess the state of ED pain management in Switzerland. Hospital-based Swiss EDs open 24 hours a day and 7 days a week in 2013 were surveyed using a questionnaire. Data from 2013 were collected. Questions queried the pain management process by nurses and physicians in each ED. The response rate was 115 of 137 eligible EDs (84%). Pain intensity was assessed with a validated instrument in 71% of waiting rooms and in 99% of treatment areas. A nurse-initiated analgesia protocol was available in 56% of waiting rooms and in 70% of treatment areas. Physician pain protocols were available in 75%, and analgesia-sedation protocols in 51%. The pain management processes in Swiss EDs have improved over the last 17 years, and are now equivalent to other western countries. Our study did not, however, assess if these improvements resulted in better analgesia at the bedside, an important topic that will require further study.

Barriers to Cancer Pain Management Among Nurses in Kenya: A Focused Ethnography

BackgroundUp to 80% of cancer patients in Kenya suffer from untreated moderate to severe pain. AimThis study explored barriers to cancer pain management among nurses caring for oncology patients in Kenya. This was part of a larger study whose primary objective was to understand the role of nursing subculture on cancer pain management. DesignA focused ethnographic was used in this study. SettingsAn oncology private unit in large referral hospital in Kenya. ParticipantsTwenty-five (n = 25) nurses participated in this study. MethodsSemi- structured interviews and observations were used to collect data. Nurses were recruited through purposive, snowball sampling strategy. Content analysis led to identification of key barriers to optimal cancer pain management. ResultsOrganizational, cognitive, professional and patient/family related barriers to cancer pain management were noted. Specifically, barriers such as lack of accessibility to pain management guidelines and training, professional collaboration, restrictive dispensing guidelines, and opioid related fears were identified. ConclusionsInterventions should streamline palliative care training and implementation of pain management guidelines in both units. Interventions should consider the influence of different subcultures while implementing pain management policies and training.

Implementation of an opioid weaning protocol to improve pain management, and to prevent or decrease iatrogenic withdrawal syndrome in the neonatal intensive care.

The aim of this evidence implementation project was to improve pain assessment and management of the neonate receiving an opioid infusion, and to prevent or decrease the incidence of iatrogenic withdrawal syndrome (IWS). The current project was carried out in two intensive care areas of a 79 bed tertiary Neonatal Unit in Australia. A pre/postaudit design was utilized. Patient charts were reviewed to collect baseline audit data on pain assessments and titration of opioids. A weaning protocol was developed and implemented along with targeted staff education to align current practice with best practice recommendations. A postimplementation audit was then conducted to evaluate changes in practice. A total of 32 charts (13 pre/19 post) were reviewed to evaluate pain assessment, titration of opioids, and the identification of any signs and symptoms of IWS. The results demonstrated an improvement in the completion of pain assessments by 34%, and 100% compliance to withdrawal assessment following the introduction of an IWS assessment tool. For neonates receiving analgesics for less than 4 days, adherence to the weaning schedule occurred in 75%. No clinical signs of IWS were seen in this cohort. For neonates receiving analgesics for greater than 4 days, adherence to the weaning schedule occurred in only 55%. Of those neonates where the protocol was not followed, 67% developed clinical signs of IWS. Although this project demonstrated improvements in pain assessment and the identification of IWS, lack of adherence to the pain management policy and weaning tool has increased awareness of the importance of collaboration within the multidisciplinary team to improve outcomes. Several barriers were identified prior to implementation and various methods were employed to overcome these. Despite this, consistency of practice and change-management remain a challenge in clinical care.

4E Bioethics and Pain Management: A New and Practical Application

The field of Bioethics provides clinicians with a framework that combines ethics and empirical evidence to help them make the right decision when faced with complex clinical dilemmas. However, bioethics has not been widely applied to pain management situations even though treatment decisions frequently include moral/ethical considerations, especially in the current context of the opioid abuse epidemic. The aims of this presentation are to review the principles of ethics related to pain care, move practically from ethics to values-based decision-making, and apply the bioethical framework of ethical and empirical evidence to complex pain management issues. Methods used to support this discussion include a review of historical, bioethical, and empirical literature as well as real-world case studies. The results of the literature review reveals that there has always been a moral imperative to treat pain and suffering, yet those who reported suffering without visible evidence (“pain without lesion”) were often suspect of ulterior motives, stigmatized, and poorly treated. The field of Bioethics developed as a philosophical and practical approach to providing moral/ ethical guidelines for patient care to decrease bias, stigma, and unfair application of medical treatment. Currently, advances in pain science with new treatment options abound, yet there is evidence that stigma continues and pain is still not well managed; a model of values-based pain management decision-making has emerged to partially explain this phenomenon. Combining the empirical evidence of pain management science with moral/ethics theory can help solve clinical issues in practical ways by informing better pain assessment, understanding patient autonomy, deciding whose risk vs. whose benefit takes priority in treatment decisions, and supporting ethics-driven pain management policies. In conclusion, it is the practical application of bioethics to pain management quandaries that will provide the answer to the ultimate pain care question: what is the right thing to do?

A theory-based hybrid II implementation intervention to improve pain management in Swiss nursing homes: A mixed-methods study protocol.

To present a protocol for evaluating an implementation intervention to improve pain management in nursing homes by addressing behaviour change of the care workers. Pain management in nursing homes often is inadequate despite the availability of evidence-based pain management guidelines. Barriers to pain management in nursing homes occur on several levels including lack of knowledge and negative beliefs towards pain of care workers. A comprehensive approach incorporating contextual and behavioural factors is needed to sustainably improve pain management practice. A hybrid type II effectiveness-implementation design comprising an incomplete non-randomized stepped-wedge design and concurrent focus groups is proposed. A convenience sample of six nursing homes will be included. Implementation of a facility pain management policy will be facilitated by introduction of a facility pain champion and training of all care workers in pain assessment and management. Quantitative outcomes assessed at baseline, after 3 and 6 months include self-efficacy in pain management and attitudes to pain of care workers and functional interference from pain and pain intensity in residents. Feasibility and acceptability of the intervention and implementation strategies and potential barriers to implementation will be explored in focus groups and interviews. (Protocol approved in October 2017). The proposed intervention implementation has been developed in a participatory approach involving relevant stakeholders. To further improve the contextual fit, development of implementation strategies was guided by the consolidated framework of implementation research. Findings of this research are expected to inform adaptions to the implementation of the intervention. ClinicalTrials.gov: NCT03471390.

Factors Influencing Neonatal Pain Management from the Perspectives of Nurses and Physicians in a Neonatal Intensive Care Unit: A Qualitative Study

Background: Despite scientific advances on pain measurement and intervention, pain management for infants has remained a challenge for health teams. This is because infants are not able to talk and defend themselves when they are in pain. Prevention of pain is important, not only because it is an ethical expectation, but also because repeated painful exposures can have harmful consequences. The aim of this study was to explore factors influencing neonatal pain management from the perspectives of nurses and physicians in a neonatal intensive care unit (NICU). Methods: A qualitative content analysis study was carried out. The participants were the nurses and physicians working in the NICU of Alavi medical training center in Ardabil, Iran. Twenty-five nurses took part in focus group discussions and five physicians attended private interviews. Four focus group discussions and five interviews were carried out until data saturation was ensured. Data analysis was performed using conventional content analysis. All the participants were provided with information about the purpose and the nature of the study, and provided informed consent. Results: Data analyses indicated two effective themes about barriers of implementation of infant pain management, namely “Individual Factors” and “Organizational Factors”. The first theme consisted of the categories “knowledge of the personnel” and “commitment of the personnel”. The second theme included three categories namely “pain control policy”, “work environment condition” and “management issues”. Conclusions: Our findings indicated that lack of educational courses, absence of an infant pain management policy, and management issues were the main obstacles in the way of implementation of infant pain management by nurses and physicians at the NICU. Therefore, strategies are required to reduce or remove these barriers.

Pain and Opioids: Call for Policy Action

Abstract Opioids were once the cornerstone in treating severe disabling pain and are now known to underlie an epidemic of substance use disorders and overdose deaths. Nurse practitioners are in key positions to influence opioid and pain management policy. As clinicians in primary care and specialty settings, nurse practitioners frequently encounter patients in pain. A white paper developed through the Nurse Practitioner Healthcare Foundation titled Managing Chronic Pain with Opioids: A Call for Change 2017 offers a multifaceted approach to pain management and provides timely recommendations to move policies and practices forward. Key recommendations from the white paper are highlighted.

Barriers to spousal contribution to childbirth pain relief in Nigeria.

The aim of this study was to investigate the barriers inhibiting the use of spousal presence for childbirth pain relief in health facilities and recommendations from three perspectives: the midwife, the woman, and the spouse. Spousal presence is a non-invasive, participatory and inexpensive technique used in pain management during childbirth. Although it contributes to a large extent in relieving childbirth pain, it is underutilized in Nigerian hospitals. Overcoming the challenges impeding spousal presence and participation during childbirth will improve maternal outcome, satisfaction and midwifery care practices. A cross-sectional survey conducted in four hospitals in Nigeria involving midwives (n=100), women (n=142) and their spouses (n=142) from June to December 2014 using pretested questionnaires. Five themes were identified: poor infrastructural facility, lack of adequate pain management policy, lack of midwife pain management practices, midwives' attitudes towards spousal presence during childbirth and feelings about spousal presence during childbirth pain relief. Infrastructural defects in the health facilities resulting in the lack of privacy in maternity units for both spouses and partners negatively influence the presence of a spouse during childbirth and pain relief. Adopting effective strategies such as good infrastructural facilities, staff training and spouse-friendly hospital policies will encourage spouses to fully participate in and contribute to childbirth pain relief. This study identified poor staff attitudes towards pain relief and spousal presence during childbirth as barriers. Providing adequate policies on pain management, continuous staff education and orientation on spousal relationship will improve active spousal participation and maternal satisfaction during childbirth.