https://doi.org/10.15218/ejnm.2023.05 Erbil j. nurs. midwifery, Vol. 6, No. (1), May 2023 Original Article Knowledge, Practices, and Attitudes of Nurses Regarding Non- Pharmacological Pain Management in the Midwifery Ward ABSTRACT Background and Objectives: Pregnant women are frequently worried about labor pain, and it is usually the most important problem for them and their relatives. Non- pharmacological pain relief methods provide several benefits, such as no harmful effects on the fetus or baby, no interruption of labor, and even being pleasurable for the mother and fetus. The aim of this study was to assess the nurse’s knowledge practice and attitude toward non-pharmacological pain management methods in the delivery room in Erbil Governorate. Method: The descriptive cross-sectional design was utilized to determine nurses' knowledge, practices and attitudes about labor pain and non-pharmacological pain man- agement, as well as to monitor nurses' practices in the delivery rooms during labor and delivery. A total of 78 nurses from public and private hospitals in Erbil Governorate partici- pated in the study. Structured questionnaires and an observational checklist were used to collect data and used SPSS version 26 was used to analyze it. Result: Nurse’s knowledge (N=27, 50.0%), (N=9, 37.5%) in public and private hospitals was at a good level, and they had a positive attitude (N=32, 59.3%) in public hospitals and a positive attitude (N=14, 58.3%) in private hospitals. But had a fair practice (N=19, 35.18%) in public hospitals and good practice (N=10, 41.7%) in private hospitals towards labor pain and non-pharmacological pain management. This is due to the lack of time, inadequate staff and the great workload of the staff. Conclusion: This survey showed that the knowledge of most of the nurses was at a good level, but it was weak in items such as (cold therapy, acupuncture and acupressure tech- nique), as well as majority of them do the following practices: relaxation technique, give psychological support and, ensure that women's relatives are there during the entire labor process; and they do not use other types of non- Pharmacological pain reliving method like: hypnosis, ice packs, intradermal water block. It is required to design a pain-relieving non-pharmacological training course for nurses. Keywords: Labor pain; Non-pharmacological; Nurses. Shahla Shkak Shareef; Department of Nursing, College of Nursing, Hawler Medical University, Kurdistan Region- Iraq. (Correspondence: shahlashkak89@gmail.com) Tiran Jamil Piro; Department of Nursing, College of Nursing, Hawler Medical University, Kurdistan Region- Iraq. 34 Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. Received: 20/06/2022 Accepted: 21/08/2022 Published: 30/5/2023 mailto:Shahlashkak89@gmail.com?subject=Shahlashkak89@gmail.com https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.05 Erbil j. nurs. midwifery, Vol. 6, No. (1), May 2023 Original Article Pregnancy is one of the most crucial and wonderful times in a mother's life. It finish- es with the birth of a baby during the labor phase. Labor pain is one of the most terri- ble experiences. Because it is an inevitable aspect of the birth process, this pain is unique from others. It is not a sign of injury or tissue damage; it declines naturally, is regular and consistent, eventually becomes tight, and leads to a wonderful event, child- birth. Some delivery positions are more painful than others, such as lying on your back. Changing postures and being mobile throughout labor might help to alleviate discomfort. Amniotomy, vaginal examina- tions, and monitoring can all cause discom- fort by restricting a woman's movement or generating concern Analgesics are now sel- dom used for pain management during de- livery due to maternal and newborn com- plications, and non-drug and complemen- tary medicine options are growing more prominent [1].Labor ache is a horrible, complicated, and highly personalized expe- rience that includes either sensory or emo- tional elements. The way the woman han- dles childbirth and how it manifests physi- cally and mentally might affect how much pain she experiences. For women of all rac- es and cultures seeking services for child- birth in hospitals, pain management may be of the highest significance and a crucial part of therapy. Many women may benefit from the midwifery style of treatment since it highlights the usual natural process of labor and delivery in low-risk pregnan- cies and encourages the use of non- pharmacological approaches [2].True labor starts when the female has bloody flow, her membranes tear, and she has severe uterine contractions that produce cervical effacement and dilation. The specific path- ophysiology that causes this to happen is unknown. It is essential to identify between real and fake labor. A characteris- tic of the first one is the onset of uterine contractions every three to five minutes, lasting 20 to 60 seconds, at regular inter- vals. When labor begins, uterine contrac- tions do not stop, and the uterine cervix dilates as a result. Inconsistent contrac- tions and cervical dilatation, often known as Braxton-Hicks contractions, are the mar- kers of false labor. In particular, for nullipa- rous women, false contractions become more frequent during the 31st week of pregnancy, generating confusion and con- cern [3].Abdominal pains, pelvic pain, and backache are common symptoms of labor pain. Women who have gone through la- bor recall the high intensity of the pain and categorize it as mild, moderate, or severe, with the severity rising from the start of contractions to full dilation of the cervix Pain during labor can be either physiologi- cal or psychological/emotional. Fear, uncertainty, and a lack of knowledge can all exacerbate emotional pain. Even though it won't fix the issue, childbirth education is a good strategy to address it. The lower uterine segment and cervix dila- te in the early stages of labor, which cau- ses pain. The fetus' descent down into the birth canal produces distension and tearing of tissues in the vagina and perineum in the late first and second phases of labor, resulting in discomfort. Dilation and labor could be slowed down, which would make them more painful if the woman holds her breath and attempts to fight off the contractions. The woman's posture is cru- cial during the childbirth process [4].Suffering throughout delivery should be seen as a real phenomenon that poses no harm to a mother's pregnancy; nonethel- ess, most of these events rely on the as- sistance of midwives during labor pain. In- dividual characteristics of midwives, such as years of work or 35 Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. INTRODUCTION https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.05 Erbil j. nurs. midwifery, Vol. 6, No. (1), May 2023 Original Article to music, and using breathing techniques. Some other therapies include hydrothera- py, acupressure, acupuncture, massage, hypnosis, aromatherapy, hot and cold ap- plications, and transcutaneous electrical nerve stimulation. A more therapeutic ap- proach will help lower the pain threshold or divert attention away from the discom- fort of childbirth [9].Around the world, medication therapies are commonly used during labor and delivery. Despite the fact that epidural analgesia is regarded to be a good painkiller, it is not always associated with a positive delivery experience. Fur- thermore, this sort of pain therapy is ex- pensive, can impair women's sense of competence, lengthen the second stage of labor, and increase the likelihood of subse- quent interventions (such as instrumental birth or cesarean surgery) [10].Non- pharmaceutical, psychological, and physio- logical treatments are the three main cate- gories of childbirth pain management treatments. Non-pharmacological pain re- lief methods provide several benefits, such as inexpensive, no harm to the woman, her baby, or the course of the birth and no interruption with labor, and even being pleasurable for the mother and fetus. The nurse's primary key responsibilities are to find the issues of the woman in labor, pro- vide appropriate information about differ- ent modalities of pain relief during labor, assist the women in labor in ventilating all of their doubts through interpersonal in- teractions, assist the women in labor in choosing the appropriate modality for effective pain relief, and to effectively ap- ply alternative modalities of pain manage- ment throughout the first phase of labor, thereby reducing the risk of complications [11]. experience and the number of births per- formed, may impact or effect on labor pain evaluation and management meth- ods [5].Healthcare practitioners must as- sist women with pain management during childbirth [6].Moms were attended by ex- perienced women, most generally known as traditional birth attendants, in the cen- turies past, and monitoring was held at their homes. The carers performed pray- ers, created herbal mixtures, and utilized charms to help lessen the discomfort of contractions [7].Proper delivery practices are those that are closely linked to the hu- manization phase of obstetric care. These should include, among other things, au- tonomy, respect for women's and families' rights, empathic support for health profes- sionals, encouragement to adopt noninva- sive and non-pharmacological pain relief methods, freedom of position, and clinical practice based on current evidence, ac- cording to WHO recommendations [8].Since the dawn of time, humans have been aware of pain and have attempted to manage it in various ways. There are two main approaches for alleviating and con- trolling pain during childbirth. Pharmaco- logical therapies are typically expensive and have undesirable side effects. Phar- macological therapy is used to alleviate pain. It’s a common practice found in many nations across the world. The most common prescriptions are analgesic drugs like Entonox, epidural analgesia, diamor- phine, tramadol, and pethidine.Physically, the pain would be reduced, but the moth- ers' psychological and emotional well- being would be overlooked. Receiving opi- oid pain relievers such as pethidine is one alternative for pharmacological pain treat- ment. Also, non-pharmacological thera- pies are used to control pain. Some tech- niques include changing positions, move- ment, and progressive muscle relaxation, which can happen through yoga, listening 36 Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.05 Erbil j. nurs. midwifery, Vol. 6, No. (1), May 2023 Original Article In Erbil Governorate, a cross-sectional study was conducted in public and private hospitals. Data were collected by using a non-Probability (Purposive Sample) tech- nique. The inclusion criteria composed all nurses working in delivery room and exclu- sion criteria included the nurses who had at least one year of experience in delivery room. Data was collected through an ob- servational checklist and format for a ques- tionnaire. The questionnaire consists of 4 parts. Part one includes socio- demograph- ic characteristics and professional back- ground of the nurses this part contains in- formation like (age, marital status, aca- demic qualification, length of experience in the delivery room, working shift, satisfac- tion in the workplace, participation in a non-pharmacological pain management training course, the number of mothers who are responsible by the nurse at the same shift, and types of pain management during labor for reliving labor pain). Part two related nurses’ knowledge of labor and non-pharmacological pain management during labor by 40 items assessed. The to- tal average means of all items is about 2.47 of a standard deviation 0.53, so the statisti- cal analysis revealed that the means value of all items was more than the standard of study value ≥2.34. This part revealed a high acceptance rate, and this shows the high level of all the questions about the knowledge of nurses about labor pain and management. The queistonerie was scored by following the scoring protocol by provid- ing a corresponding letter relating to the chosen answer for frequency of consump- tion ranging from 1(I don’t know), 2 (incorrect), 3(correct).Part three related to nurses’ practices about different methods of non-pharmacological pain management during labor and was assessed by 27 items scored Likert scales, which is about 27 items reached a low degree. The total average means of all items is about 1.55 of a standard division of 0.35, so the statisti- cal analysis revealed that the means value of all items was less than the standard of study value 2.34. This part revealed a low acceptance rate, and this shows the low level of all the questions about the practic- es of nurses regarding applying non- pharmacological pain methods in the deliv- ery room. Part four related to an attitude of nurses regarding pain management dur- ing labor, assessed by 22 items, which about 22 items reached a high degree. The total average means of all items is about 2.81 with standard division 0.44, so the statistical analysis revealed that the means value of all items was more than the stand- ard of study value ≥2.34. This part revealed a high acceptance rate, and this shows the high level of all the questions about the attitude of nurses regarding pain manage- ment during labor .The study's limitation was Covid-19 Pandemic. In general, people handled the situation delicately and avoid- ed getting too near to one another [28]. The study was accepted by the Nursing Ethical Committee of Hawler Medical Uni- versity College of Nursing on7 October 2021 number 109, and official authoriza- tion was acquired from the Ministry of Health's Director of Health in Erbil. The re- spondents' rights and confidentiality were protected throughout the study. They were informed and explained the goal of the study as well as the confidentiality of the information through a verbal permis- sion process. Data analysis: Statistical Package for Social Science (SPSS) version 25 was used to analyze and organize the data. The mean and standard divisions for determining the acceptance rate of partici- pants. 37 Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. METHODS https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.05 Erbil j. nurs. midwifery, Vol. 6, No. (1), May 2023 Original Article 38 Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. Table 1 revealed that most of the sample members were in public hospitals within the category of 39-49 years old, the high- est percentage (35.2%), and in private hospitals shows that most of the partici- pants of the sample study were within the category of 28-38 with a percentage of (41.6%). The majority of the sample of the study in both areas (public, private) hospitals was in married marital status, which is about (70.4%, 70.8%). Most of the sample members in public and private hospitals at the level of education hold a secondary school of nursing degree, with a percentage of (25.9% , 25.0%).Regarding working shifts in public and private hospi- tals, the result indicates that the majority of them working in the circulating form- work is about (35.2% , 29.2%). As for the working experience in delivery rooms in public hospitals, it indicated that most of the participants were in the category 10- 20 years, which was about (55.6%), which indicates the hospitals focused on highly experienced nurses. As for the working experience in delivery rooms in private hospitals, it indicated that most of the participants were in the category of less than 10 years, which was about (70.8%). According to the results of the study in public hospitals, hours per day, we have two groups close to each other, and most of them work less than 10 hours a day, which was about (38.9%), While other parts work more than 15 hours a day, with a percentage of (37%).The work- ing hour per day In private hospitals shows the majority of them work more than 15 hours a day which was about (45.8%). RESULTS Variables Public Private F (%) F (%) Age group 18-27 6 (11.1) 1 (4.2) 28-38 17 (31.5) 10 (41.6) 39-49 19 (35.2) 7 (29.2) 50 above 12 (22.2) 6 (25.0) Marital status Single 12 (22.2) 5 (20.8) Married 38 (70.4) 17 (70.8) Widowed 3 (5.6) 1 (4.2) Divorced 1 (1.9) 1 (4.2) Academic qualification Training course 4 (7.4) 4 (16.7) Primary school of nursing 6 (11.1) 0 (0) Secondary school of nursing 14 (25.9) 6 (25.0) Secondary school of nurs- ing department (midwifery) 8 (14.8) 5 (20.8) Diploma of nursing 8 (14.8) 2 (8.3) Diploma of nursing depart- ment (midwifery) 10 (18.5) 1 (4.2) College of nurs- ing 3 (5.6) 3 (12.5) College of nurs- ing department (midwifery) 1 (1.9) 3 (12.5) Working shift Morning 12 (22.2) 5 (20.8) Evening 8 (14.8) 3 (12.5) Night shift 15 (27.8) 4 (16.7) Circulating 19 (35.2) 7 (29.2) Working experience in delivery room < 10 18 (33.3) 5 (20.8) 10-20 30 (55.6) 17 (70.8) > 20 6 (11.1) 7 (29.2) Working hours per day < 10 21 (38.9) 8 (33.4) 10-15 13 (24.1) 5 (20.8) > 15 20 (37.0) 11 (45.8) Total 54 (100) 24 (100) Table 1 :Socio-demographic characteristics of study sample in Public and Private Hospitals https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.05 Erbil j. nurs. midwifery, Vol. 6, No. (1), May 2023 Original Article 39 Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. Table 2 revealed that the majority of nurs- es in public were satisfied with working in the delivery room, which is about (98.1%). Table 3 shows that all of the nurses were satisfied with working in the delivery room, which is about (100%). As a result of the study sample, the majority of nurses did According to the study sample, all nurses did not participate in any training course about pain . management of labor, with a percentage (100%). not participate in any training course about pain management of labor, with a percentage (95.8%), while one nurse par- ticipated in the training course 5 years ago. Table 2: Personal Information in the Public hospitals Items F (%) Are you satisfied with working in delivery room? Yes 53 (98.1) No 1 (1.9) Total 54 (100.0) Did you participate in training course about pain management of labor? No 54 (100.0) How many mothers are you responsible for at the same time in your working shift? Less than 5 11 (20.4) 5-10 35 (64.8) More than 10 8 (14.8) Total 54 (100) Do you apply any pain management methods for women in labor? Yes 54 (100.0) Table 3: Demographic Information in the Private Hospitals Items F (%) Are you satisfied with working in delivery room? Yes 24 (100) Did you participate in training course about pain management of labor? Yes 1 (4.2) No 23 (95.8) A. If yes, when did you participate in such training course? 23 (95.8) 5 Years Ago 1 (4.2) B. If yes, how much time did it long? 1 Day 1 (4.2) Total 24 (100) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.05 Erbil j. nurs. midwifery, Vol. 6, No. (1), May 2023 Original Article 40 Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. Table 4 shows levels of nurses' responses in the public and private hospitals regard- ing knowledge of nurses about labor pain and management and practices of nurses regarding applying non-pharmacological pain methods in the delivery room. The result in public hospitals was as follows: (50%) of nurses were at a good level, while (16.7%) were at a fair level, and (33.3%) of them were at a poor level, and in private hospitals knowledge of nurses about labor pain and management was as follows: Table 5 shows the response levels of public and private hospital nurses regarding nurs- es' attitudes toward labor pain manage- ment as follows: (59.3%) nurses were at the positive level and (40.7%) were at the (37.5%) of nurses were at a good level, while (33.33%) were at a fair level, and (29.16%) of them were at a poor level. The performance of nurses in public hospitals regarding the use of non-medicinal pain methods in the delivery room is as follows: 31.48% at a good level, 35.18% at a fair level and (33.33%) at a poor level, also in private hospitals using non-medicinal pain methods in the delivery room, it was as follows: (41.7%) of nurses were at good level, (25.0 %) at the appropriate level and 33.3% at a poor level. negative level. While in private hospi- tals, the results of nurses' attitudes about pain management during labor were as follows: (58.3%) of nurses at good level and (41.7%) at negative level Table 4: Levels of the knowledge, and practices in the Public and private Hospitals Table 5: Levels of the attitude in the Public and Private hospital Overall Level Public Hospitals Private Hospital Good Fair Poor Good Fair Poor F (%) F (%) F (%) F (%) F (%) F (%) Knowledge of nurses about labor pain and management 27(50) 9(16.7) 18 (33.3) 9(37.5) 8(33.33 ) 7 (29.16) Practices of Nurses regarding applying non pharmacological pain methods in delivery room 17 (31.48) 19 (35.18) 18 (33.3) 10 (41.7) 6(25.0) 8(33.3) Overall Level Public Hospitals Private Hospital Positive Negative Positive Negative F (%) F (%) F (%) F (%) Attitude of nurses regarding pain manage- ment during labor 32 (59.3) 22 (40.7) 14 (58.3) 10 (41.7) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.05 Erbil j. nurs. midwifery, Vol. 6, No. (1), May 2023 Original Article 41 Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. Table 6 shows the comparisons between variables Knowledge, Practice, and Attitude in public hospitals and the private hospital. The results were as follows: the mean val- ue of public hospitals was 2.44, and for pri- vate hospitals was 2.55 for items regarding knowledge of nurses about labor pain and management. While public hospitals were 1.46 and for private hospitals were 1.76 for items related to practices of nurses regard- ing applying non-pharmacological pain This study revealed that nurses’ knowledge of labor and pain management in public and private hospitals was at a good level. These results were congruent with a study carried out on 87 nurses and midwives done by [24] in Ibadan, Nigeria, which re- vealed moderate knowledge about labor pain management among their study par- ticipants. Also, the finding of the present study is supported by using a simple ran- dom sampling study done by [14] among 209 professional nurses, who revealed that nurses had adequate knowledge about non -pharmacological pain management. While these results are not consistent with the result of a previous study done by[18] in Egypt on 88 healthcare providers demon- strated that healthcare professionals are more or less familiar with several of the non-pharmacological methods, this result disagrees with the study done by [19] among 246 nurses who reported that methods in the delivery room, and the mean value of public hospitals was 2.80 while the private hospitals were 2.84 for items regarding the attitude of nurses re- garding pain management during labor. The result revealed that the knowledge, practice, and attitude in the private hospi- tals were better and higher compared to the knowledge, practice, and attitude in the public hospitals, with the exception of the sample size difference in these two sectors. nurses did not have adequate knowledge. Regarding the practices of nurses in pri- vate hospitals, it indicated that the major- ity of nurses had good practice. This may be due to adequate space, staff, and equipment. It comes along with a study done by [21] in Ethiopia on 336 skilled attendants who, revealed that more than half of the study participants had good practice. This is similar to a cross- sectional study carried out by [22] in Ethi- opia among 464 healthcare professionals. While the finding of the present study in public hospitals shows that the majority of nurses had fair practice, The possible reasons may be inadequate staff, lack of time, lack of training on non- pharmacological pain management, in- corporation of physicians with nurses or nurses with mothers, and lack of staff, this finding is similar to a cross-sectional study done by [20] among 420 obstetric Table 6: Differences between overall level variables knowledge, practice, and attitude in the Public Hospitals and the Private Hospitals Variables Public Hospitals N Private Hospitals N Mean Std. Deviation Mean Std. Deviation Knowledge 2.44 0.527 54 2.55 0.494 24 Practice 1.46 0.283 54 1.76 0.288 24 Attitude 2.80 0.440 54 2.84 0.366 24 DISCUSSION https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.05 Erbil j. nurs. midwifery, Vol. 6, No. (1), May 2023 Original Article 42 Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. care providers in Hawassa, also finding comes along with study done in Ethiopia by [13] which revealed that poor practice dur- ing labor pain management. Moreover, the results of the present study are supported by [17] in Egypt, who found that about half of the respondents didn’t use non- pharmacological methods. The finding of the present study in public hospitals is that more than half of nurses had a fair attitude towards non-pharmacological pain man- agement during labor. The current study's findings are similar to a previous study done by [17] in Ethiopia on 169 nurses, which revealed that the majority of nurses have an unfavorable attitude towards non- pharmacological pain management meth- ods. In private hospitals, it shows that more than half of nurses had a good atti- tude. This result agrees with the result of a previous descriptive study which was done by [23] in Ethiopia on 299 obstetric care- givers who found that the majority of the study participants had a positive attitude toward labor pain relief methods, and this comes along with a study done by [24] who studied 233 skilled attendants in Tigry re- gion. In this study, the contrasts between knowledge, attitude, and practice were found in both public and private hospitals. The results were as follows: the mean val- ue of public hospitals was 2.44 and for pri- vate hospitals were 2.55 for items regard- ing knowledge of nurses about labor pain and management. While public hospitals were 1.46 and for private hospitals were 1.76 for items related to practices of nurs- es regarding applying non-pharmacological pain methods in the delivery room, and the mean value of public hospitals were 2.80 while the private hospitals were 2.84 for items regarding the attitude of nurses re- garding pain management during labor. It comes along with a study done by [21] in Ethiopia, which revealed that skilled birth attendants who were working at private primary hospitals were 6.55 times more likely to have good knowledge about la- bor pain removing methods as compared to skilled birth attendant working at pub- lic primary hospitals, this result is similar to the study done by [18] among 88 health-care providers in Abha, Saudi Ara- bia, which are agreement with the result of the present study in private hospitals and disagreement with the result of pre- sent study in public hospitals. Toward the practice of nurses applying non- pharmacological work in the labor world revealed that poor practice in public hos- pitals compared with private hospitals. This comes along with a study done by [13] in Gamo and Gofa zones that found that practice of non-pharmacological la- bor pain management was poor in public health facilities; also this finding is similar to a descriptive study done by[27] on 120 nurses at Makkah El-Mukarramah. The result of the present study in private hospitals indicated a positive attitude and good practice of nursing staff regarding non-pharmacological methods .This is supported by cross-sectional study done by[26] on 299 f obstetric caregivers working at labor ward in public health centers of the east Gojjam zone, Amhara region, Ethiopia, which demonstrat- ed that obstetric caregivers who had a positive attitude toward managing labor pain were 2.45 times more likely to use labor pain management methods than those who had a negative attitude for la- bor pain management. This result is sup- ported by a study done by [16] in Ethiopia who found that nurses with a favorable attitude to non-pharmacology pain man- agement methods were statistically sig- nificantly associated with good practice of non-pharmacology pain management. Also, the finding is supported by a study done in Ethiopia by [13] on 272 skilled attendants who revealed that https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.05 Erbil j. nurs. midwifery, Vol. 6, No. (1), May 2023 Original Article 43 Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. respondents who had favorable attitudes towards labor pain management were 2.82 times more likely to do good practice than others. Moreover, the results of the pre- sent study is supported by [20] in Hawassa city on 305 obstetric care providers who found that a favorable attitude towards labor pain management, were 2.97 times more likely to practice labor pain manage- ment compared to their counterparts. The study concluded that the majority of the nurses in public and private hospitals were with the mean age of 42.00 years old, most of them married, in secondary school, satisfied with working in a delivery room, and did not participate in a training course about pain management of labor. The overall usage of labor pain manage- ment strategies by nurses in public hospi- tals was poor. Nurse’s knowledge, practice and attitude had shown statistical signifi- cance association with age, level of educa- tion and years of experience. Hiring nurses who are graduates from the college of Nursing, especially (department) of mid- wifery. [1] Fadhil S. 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