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Perception toward Non-Pharmacological Strategies in Relieving Labor Pain:

An Analytical Descriptive Study

Research · January 2013

DOI: 10.13140/RG.2.2.10859.64805

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Journal of Natural Sciences Research www.iiste.org
ISSN 2224-3186 (Paper) ISSN 2225-0921 (Online)
Vol.4, No.2, 2014

Perception toward Non-Pharmacological Strategies in Relieving

Labor Pain: An Analytical Descriptive Study
Mona Almushait1*,Rania Abdel Ghani2
1. Obstetrics & Gynecology Department, Faculty of Medicine, King Khalid University, Abha, Saudi Arabia
2. Maternal and Newborn Health Nursing, Faculty of Nursing, King Khalid University, Abha, Saudi Arabia
and Faculty of Nursing, Cairo University, Egypt
*
E-mail of the corresponding author: [email protected]

Abstract
The study was conducted to determine the perception, actual practices and perceived barriers among health-care
providers regarding non-pharmacological pain relief during labor as well as explore women’s opinion towards
their labor pain management experience. This was a cross sectional study of 88 health-care providers such as
doctors, registered nurses and interns and 400 healthy puerperal women who experienced uncomplicated normal
deliveries performed at Abha Maternity Hospital between December 2012 and April 2013. Data were collected
using self-administered structured questionnaires and each participant was invited to share his/her experiences in
a one-to-one interview format. Analysis of data obtained showed that participants on most of the pain relief
methods samples reported that they knew of different types of non-pharmacological pain relief methods and
expressed their agreement toward their different benefits. On the other hand, lack of time, regulatory issues, lack
of knowledge, patient unwillingness and strong beliefs in analgesia were recorded as the highest barrier
percentage, while women who went through childbirth reported moderate levels of satisfaction regarding their
birth experience. Role and benefits of non-pharmacologic methods of pain relief during labor cannot be ignored.
There are many barriers preventing non-pharmacological pain therapies from being used related to hospital
regulations and policies. In addition, most women denoted that they were able to cope with labor pain through
non-pharmacological management.
Keywords: non-pharmacological strategies, barriers, benefits, perception, health-care providers, labor pain,
puerperal women

1. Introduction
Pain during labor is a physiological phenomenon. The evolution of pain during the first stage of labor is
associated with ischemia of the uterus during contractions. In the second stage, pain is caused by the stretching
of the vagina and perineum and compression of pelvic structures (Ralph, Yarnell & John, 2004). However, pain
sensation is a response of the total personality to the birthing experience and is therefore a subjective
phenomenon. Labor is not a permanent practice and pain relief in childbirth is subject to many social and cultural
modifiers which are continuously changing. Today both modalities are available. In the former, the main
emphasis of pharmacological methods is largely on the elimination of the physical sensation of labor pain;
whereas in the latter, the non-pharmacological methods, the emphasis is largely on preventing suffering (Hodnett
2002). Narcotics and sedatives may be used during the first stage of labor to help the mother relax, while
regional anesthesia lessens or completely blocks the pain in a specific area of the body (Paech et al. 2002). With
either narcotic pain relief or regional anesthesia, the mother can stay awake and play an active role in the birth.
Besides conventional approaches, many complementary or alternative methods have been used effectively; these
methods emphasize the interaction between mind, body and environment (Leeman et al. 2003). In addition,
positioning a woman in labor and providing her with support from a doula (i.e. doula is a nurse who provides
continuous support to the laboring woman throughout the stages of labor, similar to a mid-wife) is considered an
important part of natural pain relief methods (Tournaire & Theau-Yonneau 2007). In order to provide the best
pain management available and obtain the best outcomes, nurses need to be able to combine non-
pharmacological pain management as a complementary therapy. Many physicians believe that the main
determinant of maternal satisfaction with childbirth is major pain relief during labor and invariably,
pharmacological pain relief is resorted to as the only method known to us. Lack of emotional support and
excessive medical intervention regarding parturient women care are factors that may be related to increased
intensity of pain (Zwelling, Johnson & Allen 2006). The most important factor associated with increased
maternal satisfaction was the degree of participation in decision-making among health-care providers during
labor (Hodnett 2002). Therefore, health-care providers’ attitudes and knowledge of non-pharmacological pain
management therapies need to be assessed. At the same time, considering women’s perceptions towards their
birth experience provides health-care providers with directions to assist women in having empowered birth
experiences.

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2. Materials and methods

2.1 Study population
A cross sectional study conducted at Abha Maternity Hospital in Abha, Saudi Arabia from December 2012 to
April 2013 using self-administered structured questionnaires developed by the researchers to determine the
perception, actual practices and barriers among health-care providers regarding non-pharmacological pain relief
during labor. In addition, delivered women were interviewed in the postpartum unit. They were asked to rank
their satisfaction level and clarify the extent they perceived non-pharmacological pain relief management. The
study population consisted of a total sample of 88 health-care providers known as doctors, registered nurses and
interns along with a total sample of 400 delivered women. An approval was taken from the King Khalid
University’s Ethical Committee (REC # 2012-12-06) and the previously mentioned hospital to conduct the study.
An informed written consent was secured from the participant.
2.2 Questionnaire interview
Data were collected using a self-administered structured questionnaire which involved two major parts. The first
part was designed to examine health-care providers’ perception related to non-pharmacological pain relief
methods while the second part assessed women’s birth experiences. The first part was divided into four main
sections: the first section includes demographic data, the second section includes four main categories of non-
pharmacological pain relief, the third section of the questionnaire reflects the health-care provider’s opinion
towards the benefits of non-pharmacological pain relief methods and finally, the fourth section of the
questionnaire examines the subjects’ opinions regarding barriers for using non-pharmacological pain relief
methods using the four point likert scale (agree, strongly agree, disagree, strongly disagree).
2.3 Data collection procedure
All health-care providers were invited to share their experiences in a one-to-one interview format and were
interviewed once in addition to the delivered women. A pilot study of ten intern nurses and forty delivered
women was conducted during a two week period in order to examine the clarity of the questionnaire. The
reliability coefficient was calculated and revealed Cronbach’s alpha for the first part of the questionnaire = 0.82
and 77.0 for the second part of the questionnaire indicating good internal consistency. This study is grounded by
the goal attainment theory which was developed by Imogene King in the early 1960s.
2.4 Statistical analysis
Data were coded, validated and analyzed using the Statistical Package for Social Sciences (SPSS). Frequency,
percentage, arithmetic mean for describing the central tendency of observation for each variable studied and
standard deviation for the measure of dispersion of results around the mean were used to present the data. Values
of P ≤ 0.05 were considered to indicate significant differences.

3. Results
A total of 88 health-care providers known as doctors, registered nurses and interns along with 400 delivered
women were included in the present study.
3.1 Demographic characteristics
Table 1 shows demographic data as well as other characteristics of the study samples. The age of the 88 health-
care providers ranged between 20 to 50 years of age with a mean age of 27.17 + 8.66 years, 67 of which were
aged between 20 and 30 years of age (76.1%). Staff ranks come in all medical categories and 40 are intern nurses
(45.5%). The health-care providers’ experience in the field amounted to over 15 years and about 60 subjects had
a five-year-working experience (68.2%). As for the 400 delivered women, the mean age was 28.08 + 5.68 years.
The highest level of education recorded is university level in 160 (40.0%) cases. Three hundred thirty three
respondents reported to having less than 5 children born to them (83.0%).

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Table 1. Demographic characteristics of the study

Health-care providers characteristics n=88
Age Range No. %
20-30 67 76.1
31-40 15 17.2
41-50 2 2.2
50+ 4 4.5
Age Mean 27.17 ±8.66 SD
Staff categories
Doctor 11 12.5
Head nurse 4 37.5
Staff nurse 33 4.5
Intern nurse 40 45.5
Years of experience
0-5 years 60 68.2
6-10 years 12 13.6
11-15 years 3 3.4
Above 15 years 13 14.8
Delivered women characteristics n=400
Age Mean 28.08 ± 5.68 SD
No. %
Newborn sex
Male 204 51.0
Female 196 49.0
Level of education
Illiterate 31 7.7
Read and write 1 0.2
Primary 35 8.8
Intermediate 75 18.8
Secondary 98 24.5
University 160 40.0
Parity
Para < 5 333 83.0
Para ≥ 5 67 17.0
3.2 Utilization of non-pharmacologic pain relief methods
The utilization of non-pharmacological pain relief methods is shown in Table 2. Most of the samples reported
that they knew different types of non-pharmacological pain relief methods. Data denoted that most of the
methods were known but not used. The most widely known and used interventions were related to techniques
that reduced painful stimuli and techniques of active birth. On the other hand, the techniques that were not
known and not used were related to peripheral sensory receptors activation techniques.

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Table 2. Utilization of non-pharmacological pain relief methods

n= 88
Non-pharmacological pain relief methods Known Known Not known
& Used but not used & Not used
No. % No. % No. %
Techniques that reduce painful stimuli
1.1. Movement and changes in position 68 77.3 18 20.5 2 2.2
1.2. Counter pressure 48 54.5 26 29.5 14 16.0
1.3. Breathing exercise 56 63.6 23 26.1 9 10.3
Techniques that activate peripheral sensory receptors
2.1. Touch and massage 37 42.0 42 47.7 9 10.3
2.2. Reflexology 16 18.2 44 50.0 28 31.8
2.3. Acupuncture 0 0.0 56 63.6 32 36.4
2.4. Aromatherapy 16 18.2 35 39.8 37 42.0
2.5. Trans-cutaneous electrical stimulation 14 15.9 42 47.7 32 36.4
2.6. Water immersion 14 15.9 52 59.1 22 25.0
2.7. Intra-dermal injection of sterile water 0 0.0 59 67.0 29 33.0
2.8. Thermal regulation (heat & cold applications) 25 28.4 36 40.9 27 30.7
Techniques of active birth
3.1. Avoid unnecessary routines e.g. shaving, 47 53.4 30 34.1 11 12.5
enema, NPO, IVI
3.2. No intervention (e.g. artificial rupture of 42 47.7 33 37.5 13 14.8
membranes, routine use of oxytocin)
3.3. Birth companion 0 0.0 64 72.7 24 27.3
3.4. Midwifery psychological support 47 53.4 41 46.6 0 0.0
3.5. Adjust room temperature 49 55.7 21 23.9 18 20.4
3.6. Minimizing noise 49 55.7 22 25.0 17 19.3
Techniques that enhance descending inhibitory pathway
4.1. Hypnosis 0 0.0 59 67.0 29 33.0
4.2. Imagery 0 0.0 65 73.8 23 26.2
4.3. Relaxation 47 53.4 29 33.0 12 13.6
4.4. Distraction 37 42.0 28 31.8 23 26.2
3.3 Benefits of non-pharmacological pain relief methods
Table 3 shows the benefits of non-pharmacological pain relief methods. Most of the study samples expressed
their agreement about different benefits of non-pharmacological pain relief methods. Absence of side effects (70,
79.5%) and an improved sense of patient self-control (78, 88.6%) are found to be of the highest benefits
respectively, whereas the least benefit recorded was cost effective (51, 58.0%).
Table 3. Benefits of non-pharmacological pain relief methods
n=88
Benefits Agree Disagree
No. % No. %
Absence of side effects 70 79.5 18 20.5
Improve sense of patient self-control 78 88.6 10 11.4
Postpone need of medications 59 67.0 29 33.0
Provide sense of comfort and relaxation 68 77.3 20 22.7
Cost effective 51 58.0 37 42.0
Available 61 69.3 27 30.7
Easy to use 69 78.4 19 21.6
Build trusting relationship 71 80.7 17 19.3
3.4 Barriers that interfere with the utilization of non-pharmacological methods
Table 4 illustrates the barriers that interfere with the utilization of non-pharmacological methods which are
interrelated between the health-care system, health-care providers and patient related barriers. The highest
percentages of agreement were recorded as lack of time (47, 53.4%), regulatory issues (49, 55.7%), lack of
knowledge (60, 68.2%), patient unwillingness (50, 56.8%) and strong beliefs of analgesia (42, 47.7%)
respectively.

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Table 4. Barriers for using non-pharmacological pain relief methods

T n = 88
Type of Barriers Agree Strongly Disagree Strongly
agree disagree
Health-care system related barriers
Lack of time 47 (53.4) 20 (22.7) 21 (23.9) 0 (0.0)
Regulatory issues (policy) 49 (55.7) 28 (31.8) 9 (10.2) 2 (2.3)
Inadequate nursing staff numbers 33 (37.5) 23 (26.2) 26 (29.5) 6 (6.8)
Health-care provider related barriers
Lack of knowledge 60 (68.2) 12 (13.6) 14 (15.9) 2 (2.3)
Difficult to apply 48 (54.5) 11 (12.5) 27 (30.7) 2 (2.3)
Dr./RN unwillingness 46 (52.3) 13 (14.8) 20 (22.7) 9 (10.2)
Patient related barriers
Patient unwillingness 50 (56.8) 25 (28.4) 10 (11.4) 3 (3.4)
Sometimes not as concrete 38 (43.2) 34 (38.6) 11 (12.5) 5 (5.7)
Strong beliefs of analgesia 42 (47.7) 31 (35.2) 9 (10.2) 6 (6.8)
3.5 Delivered women’s perception of their labor experience
Table 5 indicates delivered women’s perception of their labor experience. The mean time the nurses spent with
delivered women during the first stage of labor was 15.3 ± 10.8 minutes and the frequency of time that the
nurses provided nursing care ranged between 2-7 times during the first stage of labor, while medical
observations ranged between 4-5 times. Furthermore, the instruction most reported received by delivered women
to cope with their pain was to take deep breaths with each uterine contraction (330, 82.5%). Three hundred sixty
two (90.5%) women stated their satisfaction with their labor experience and only 38 (9.5%) were not satisfied.
The mean degree of women’s satisfaction is recorded as 6.2 + 2.8. Furthermore, 174 (43.5%) women preferred
pharmacological methods of pain relief while 226 (56.5%) desired non-pharmacological methods. Finally, they
reported a moderate degree of satisfaction related to their labor experience and 73 (18.3%) confirmed their need
for psychological support.
Table 5. Delivered women’s perception of their labor experience
n=400
Mean SD
Frequency of time the attending nurse provided service to the 3.88 2.03
delivering woman
Mean time the nurse attended with the delivering woman (minutes) 15.32 10.87
No. of times the delivering woman was assessed by the attending doctor 2.29 1.58
Non-pharmacological methods the delivering woman received during the first stage of labor
No. (%) No. (%)
Yes No
a) Movement and changes in position 264 (66.0) 136 (34.0)
b) Breathing exercises 330 (82.5) 70 (17.5)
c) Touch and massage 9 (2.2) 391 (97.8)
d) Bathing 8 (2.0) 392 (98.0)
e) Thermal regulation (heat and cold applications) 3 (0.8) 397 (99.3)
f) Positive feedback 294 (73.5) 106 (26.5)
g) Adjustment of room temperature 136 (34.0) 264 (66.0)
h) Noise minimization 120 (30.0) 280 (70.0)
i) Relaxation 140 (35.0) 260 (65.0)

Women’s satisfaction with their labor experience 362 (90.5) 38 (9.5)

Degree of women’s satisfaction recorded by visual analogue scale Mean 6.22 ± 2.85 SD
Women preferences related to methods of pain relief
* Pharmacological methods 174 43.5
* Non-pharmacological methods 226 56.5
3.6 Factors that affect the mothers’ choice of labor pain management
On multiple regression analysis, table 6 shows the factors that affect the mothers' choice of labor pain relief
strategies. Maternal age, level of education, number of deliveries, number of medical observations and degree of

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mother’s satisfaction were found to be positive predictors (R2) 98.3% when working in relation to each other. On
the other hand, there was a weak negative correlation, and therefore not statistically significant between maternal
choices of non-pharmacological pain and the total time spent by nurses during the first stage of labor.
Table 6. Factors that affect the mother’s choice of labor pain management
Factors R P
Maternal age 0.12 0.0001*
Maternal education 0.09 0.0001*
No. of deliveries 0.24 0.0001*
Time spent by nurses in minutes 0.014 0.78
No. of medical observations and vaginal examinations 0.11 0.02*
Degree of mother’s birth experience satisfaction 0.11 0.02*
*Level of significance ≤ 0.05

4. Discussion
Results of the present study demonstrated that health-care professionals are more or less familiar with several of
the non-pharmacological methods presented in the survey. Managing labor pains using these methods are limited
regarding many barriers. With regards to sample characteristics, it was noticed that different professional levels
of health-care providers were shared in the present study. The conclusion is that all health-care providers' from
different categories play an important role in guiding pain management during labor, especially during an
emergency situation.
Most interventions known and used were related to techniques of active birth. On the other hand, most of the
techniques not known and not used were related to peripheral sensory receptors’ activation techniques. The
present results are congruent with Jones et al. (2012) who reported that most methods of non-pharmacological
pain management are non-invasive and appear to be safe for mother and baby, however, their efficacy is unclear,
due to limited high quality evidence. Many non-pharmacological techniques need special training from expertise
in fields such as imagery, hypnosis, biofeedback, relaxation, distraction and acupressure. In addition, there are
other techniques that need special preparations in the hospital setting like aromatherapy and birthing pools for
water births. Raybern (2010) stated that, an aroma therapist loves the challenge of creating a unique blend for
each individual patient. Therapists’ work environments include private practices and private settings in hospitals
and care institutions.
Regarding benefits of non-pharmacological pain relief methods, the present study revealed that their most
important action was absence of side effects, improved sense of patient self-control, building a trusting
relationship and being cost effective. The present study is on the same line as the study conducted by Spiby et al.
(2003) who reported that coping strategies during labor such as breathing techniques, postural changes, and
relaxation techniques were effective in relieving labor pain among 121 women. In addition, Payan, et al. (2008)
asserted that a wide variety of cognitive, behavioral and sensory interventions may contribute to parturient pain
management and overall sense of comfort. Furthermore, Hoodent et al. (2002) added that the attributes of the
benefits of non-pharmacologic pain techniques in labor are to be found in the fact that they are non-intrusive,
non-invasive, low-cost, simple, effective, and without adverse effects. With regards to the factors that may
interfere with applying non-pharmacological pain relief methods, results of the present study revealed that most
barriers were interrelated. They were related to the health-care system in the hospital where inadequate nursing
staff numbers in one shift may contribute to lack of time in providing adequate care. Indeed, lack of time is the
most frequently cited barrier to effective pain management (Schafheutle, Cantrill & Noyce 2001). It is
documented as an issue for emergency nurses and a possible contribution of oligoanalgesia (Ehrenberg, 2001).
Hwang et al. (2006) suggested that during emergency situations, staff is likely to be less attentive and responsive
to complaints of painful conditions.
Concerning health-care providers’ barriers, nursing staff’s knowledge and attitudes and upgrading their
knowledge through continuous training programs as well as attending external conferences depend on their self-
learning or hospital regulations which in turn may reflect on the quality and type of pain assessment and
management. This result supports Fielding and Irwin’s (2006) results who confirmed that inadequate knowledge
remains a significant barrier to pain management because clinicians failed to recognize their own knowledge
deficit and therefore also the need for change. On a more positive note, Sleutel et al. (2007) reported that nurses
in their study also said that teaching hospital environments influenced nurses' ability to provide labor support
techniques because more emphasis was placed on evidence-based care. As regards patient related barriers, in
most hospital settings, women in labor were alone and often frightened by the intermittent appearance and
disappearance of unknown people, including obstetricians, midwives, and nurses (Enkin, et al. 2000). During
pregnancy, women should be told about the benefits and potential adverse effects of each method. Khaskheli &
Baloch (2010) showed that antenatal knowledge of the birth experience, either self-acquired due to previous

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deliveries or antenatal counseling, shows acceptable response towards medical staff instructions in the majority
of cases 183 (69.3%). In the present study, with regards to delivered women’s perception of their labor
experience, it was reported that nurses spent little time with them during the first stage of labor. Abushaika et al.
(2005) showed that emotional support, holding the patients’ hands and being physically close to them made a
difference during labor. Nurses’ interpersonal skills are perceived as more important than technical skills for
mother and baby. Labor support does not always occur because nurses tend to have coexisting responsibilities
towards more than one woman in labor, spend large amounts of time managing technology or keeping records,
and begin or end shifts in the middle of women's labors (Hodnett, etal. 2007). The present result supports
Gagnon, Waghorn & Covell (1997) who demonstrated that labor nurses in some institutions spend as little as
6.1% of their time performing supportive activities for the women in labor who are in their care. Barnett (2004)
calculated the actual time a nurse spent with a woman in the first stages of labor using a special computer
program and concluded that nurses spent an average of 31% of the observed labors in the patients' rooms. Of that
time, 63% was spent in the performance of other professional duties such as documentation and assessment of
patient condition and 41% in supportive activities.
Besides, delivered women in the present study reported a moderate level of satisfaction related to their birth
experience. This may be related to the type of supportive care they received, environmental factors such as noise
or an unfamiliar environment which may be contributors to an increase in stress. Green & Baston (2003)
suggested that childbirth satisfaction depended on various pre-delivery and intra-partum factors. The present
results support Parsons, Bidewell, Griffiths (2007) who stated that noise, temperature of the labor room, light
and the feeling of being observed are some of the main factors that can stimulate human neo-cortex. Furthermore
negative experiences regarding hospital delivery were reported in the delivery room: women were compelled to
adopt birthing positions according to existing policies, privacy is not well maintained and health-care providers
are often rude, impatient and reluctant to listen to or solve their patients’ concerns. All are factors which affect
the satisfaction of their birth experience (Afsana & Sabina, 2001).
The present study shows that the instructions delivering women received the most to cope with their pain was to
take deep breaths with each uterine contraction. We can interpret this result as being easy to perform as breathing
techniques do not require a nurse to be present with each woman. This finding supports Hodnett’s study (2002)
who reported that relaxation, breathing techniques, positioning/movement, massage, hydrotherapy, hot/cold
therapy, music, guided imagery, acupressure, and aromatherapy are some self-help comfort measures women
may initiate during labor to achieve an effective coping level of their labor experience. Moreover, in the present
study, delivered women reported their preferences for non-pharmacological methods. These results are similar to
those of Khaskheli & Baloch’s (2010) who asserted that many women are willing to experience some pain in
childbirth, but don’t want the pain to overwhelm them.
Finally, regarding factors that affect a mother’s choice of labor pain relief strategies, data denoted that maternal
age, level of education, number of deliveries were positive predictive variables that may contribute to increasing
women’s awareness levels toward risks and benefits of each pain relief strategies. In addition, there was a
positive relationship between the mother’s choices of non-pharmacological pain relief methods and the numbers
of medical observations. We interpreted these results as women in labor needing companionship, empathy and
help. Medical observations can be provided and guided by emotional, informational and physical support as well
as advocacy in order to achieve maximum coping. On the other hand, there was weak negative correlation and,
therefore not statistically significant, between maternal choices of non-pharmacological pain and the total time
spent by nurses during the first stage of labor. These results are in line with Barnett (2004) who reported that the
amount of time spent in the room did not significantly correlate with patient satisfaction. However, all cultures
have their own ways of attending and coaching delivering women, some explain their customs to give a more
logical explanation for the system they apply. The results of this study will help to approximate the point of
views in order to modify the perception toward non-pharmacological pain relief strategies.

5. Conclusion
Medical practitioners are well oriented regarding different types of pain relief methods. Non-pharmacological
pain management therapies have the potential to be extremely beneficial for labor pain management. There are
many barriers preventing non-pharmacological pain therapies from being used related to hospital regulations and
policies. Some traditional professional boundaries need revision in order to improve maternity care. In addition,
most women denoted that they accepted labor pain as a physiological process, and were capable of coping with it
through non-pharmacological management.

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