TITLE PAGE

Novel grouping of planned coping strategies for managing the intensity of labour: A qualitative study

Shifman J ^1,2, Jones LE^1,3, Davey M-A⁴, East C^1,5, Whitburn LY¹

¹ La Trobe University, Bundoora, Australia

² St Vincent’s Hospital, Fitzroy, Australia

³ Singapore Institute of Technology, Singapore

⁴ Monash University, Clayton, Australia

⁵ Mercy Hospital for Women, Heidelberg, Australia

Janine Shifman

Judith Lumley Centre, School of Nursing and Midwifery, La Trobe University, Bundoora Australia 3086

St Vincent’s Hospital, Fitzroy Australia 3065

Lester E Jones

Judith Lumley Centre, School of Nursing and Midwifery, La Trobe University, Bundoora Australia 3086

Singapore Institute of Technology, Dover Drive, Singapore, 129784

Mary-Ann Davey

Department of Obstetrics and Gynaecology, School of Medicine, Nursing and Health Sciences, Monash University, Clayton Australia 3168

Christine E East

Judith Lumley Centre, School of Nursing and Midwifery, La Trobe University, Bundoora Australia 3086

Mercy Hospital for Women, Heidelberg Australia 3084

Laura Y Whitburn (corresponding author)

Judith Lumley Centre, School of Nursing and Midwifery, La Trobe University, Bundoora Australia 3086

Department of Microbiology, Anatomy, Physiology and Pharmacology, School of Agriculture, Biomedicine and Environment, La Trobe University, Bundoora Australia 3086

ABSTRACT

Objective: It is common for women to explore and plan strategies to cope during labour. These strategies are usually focused on pain control and described as either pharmacological or non-pharmacological. As labour is an individual experience, each woman should be enabled to choose strategies that best suit them, and that reflect what they feel influences their sense of capacity to cope. By exploring women’s intentions and choices of strategies, this study aimed to understand how coping strategies can better reflect women’s individual needs and expectations.

Design: Survey of 56 pregnant women, including open-ended questions.

Setting: Australian tertiary maternity hospital.

Population: Nulliparous women.

Methods: Content and thematic analysis of open-ended responses.

Main outcome measures: A qualitative description of women’s planned coping strategies for labour.

Results: Themes related to how women frame the intensity of labour, how they strive for a relationally safe environment and a need to be prepared and knowledgeable. Strategies chosen by women could be grouped into two categories: intrinsic and extrinsic. Intrinsic strategies could be self-generated by women (such as breathing techniques and movement), while extrinsic strategies required either equipment (such as a bath) or others to administer (such as epidural analgesia).

Conclusions: Women value having a range of intrinsic and extrinsic strategies that enable autonomy or require external support. This moves beyond the ‘pharmacological and non-pharmacological’ categorisation of strategies. The findings provide a foundation for more targeted research into how women can be supported to individualise and implement these coping strategies in labour.

FUNDING

This research received funding from the Mercy Health Academic Research and Development Committee, and La Trobe University.

KEYWORDS

Pregnancy; Labour; Childbirth; Coping; Pain; Strategies

1 INTRODUCTION

The strategies nulliparous women plan to use to cope with the intensity of labour remain underexplored.^1,2 Expectations of first-time mothers, and their intended coping strategies, vary, and while some women plan their coping strategies, others choose not to.¹ Childbirth preparation typically reflects what care providers assume is important for women to know, but often this differs from women’s perceptions of quality care.^1,3For first-time mothers, this can manifest in uncertainty and discrepancy between women’s expectations and actual lived experience.^1,3

The World Health Organization (WHO) promotes a positive childbirth experience for all women and the importance of woman-centred care.⁴ This acknowledges that labour pain is experienced differently by individuals, with varying meaning and with a range of preferences for coping.⁵ Other factors, including expectations,³ state of mind,⁶ care provision and perceived support,² are associated with positive childbirth experiences. Access to respectful maternity care in midwifery-led continuity of care models, as well as effective pain management options, are recognised as essential in the care of childbearing women^4,7. Women need information on risks and benefits of pain relief strategies to plan effectively.⁴

Most research investigating women’s coping in labour focuses on the efficacy of strategies for pain relief,^8,9 which are usually grouped as pharmacological or non-pharmacological.^7,8,10 This is a convenient way of grouping strategies and reflects traditions of medical involvement in birth, but risks de-emphasising the range of non-pharmacological strategies that can be used throughout the continuum of labour. Evidence supports non-pharmacological strategies for improving pain experience, satisfaction with pain relief, and overall childbirth experience.¹¹ As such, women should be enabled to identify a range of preferred coping strategies, especially those that have broader influences than just pain relief.

Therefore, this study aimed to explore women’s individual preferences and intentions, including the strategies they planned to adopt to cope with labour pain and their first childbirth experience.

2 METHODS

2.1 Design

This descriptive study collected data from women having their first birth. Participants completed a questionnaire in late pregnancy. This paper focuses on two open-ended questions from this questionnaire that sought women’s perceptions of their expected ways of coping with labour pain. The questions were: “What strategies do you plan to use to help you cope during labour?” and “What do you believe are important things that will help you cope with pain during labour?”. Ethical approval was obtained from Mercy Health and La Trobe University Human Research Ethics Committees (2019-034) and all participants provided consent.

2.2 Setting and participants

Women were recruited via notices displayed in the antenatal clinic of a large tertiary maternity hospital in metropolitan Melbourne, Australia, or inserted in information packs given to women at their 28-week gestation hospital appointment. A quick response (QR) code in the notice provided access to an online form describing the study. To be eligible, the women must have been nulliparous with a singleton pregnancy, planning a vaginal birth and able to understand written and spoken English. Women were then contacted to confirm eligibility and provide clarity about the study and their role as participants. Willing participants received a link via email to complete an online consent form and the study questionnaires in Research Electronic Data Capture (REDCap), a secure, web-based platform.¹²

2.3 Data collection

Data collection occurred between February and October 2021. A link to the survey in REDCap was emailed to women in late pregnancy (>30 weeks’ gestation), with a follow up reminder email sent to non-responders, two weeks later. Limited maternal characteristics were abstracted from the health records with participants’ consent and summarised descriptively as number and percent.

2.4 Data analysis

Inductive thematic analysis¹³ was used to generate patterns in the data. Time was taken to read and become familiar with responses, then initial codes were generated independently by JS and LW, using descriptive and focused coding methods.¹⁴Discussions and comparisons of codes were held with JS, LW and LJ, which led to a deeper interpretation of codes and generation of themes. Content analysis was additionally used to categorise the coping strategies listed by participants. Content analysis allowed for counting and coding of coping strategies and the calculation of frequency for each. Analysis was completed independently by JS and LW, who then consulted with LJ to confirm and agree upon codes and categories. NVivo 12 software¹⁵ was used to manage data analysis.

3 RESULTS

Fifty-six participants completed the questionnaire. Around three quarters were born in Australia, with 63% aged between 25 and 35 years. Over half were enrolled in midwifery-led care (59%), with the remainder accessing shared care (13%), public (25%), or private obstetric care (4%). Participant characteristics are presented in Table 1.

3.1 Planned coping strategies

Women were asked to describe the strategies they planned to use during labour to help them cope. Many women pre-planned multiple strategies that could be uniquely grouped into two broad categories: intrinsic and extrinsic.

Intrinsic strategies were ‘self-generated’ strategies that women could call upon themselves, without assistance from devices, medication, or other people. Extrinsic strategies were those that required either equipment or assistance from others. Some of the strategies classified as extrinsic were easy to administer but still required an external resource, while others were more complex and required medical intervention and specialist care. All strategies, and the percentage of participants mentioning each one, are presented in Figure 1.

3.1.1 Intrinsic strategies

The most common intrinsic strategy planned was breathing techniques (n=33; 59%). Movement and “keeping active” (ID24) was planned by 28 participants (50%). Other common intrinsic strategies included meditation/prayer (n=13; 23%) and generating a positive mindset (n=14; 25%), such as “focusing on the purpose of pain and [the] outcome” (ID17) and using positive internal self-talk. Also planned were hypnobirthing language and tools (n=5; 9%), resting and staying relaxed (n=4; 7%), using vocalisation (n=4; 7%) and visualisation techniques (n=3; 5%).

3.1.2 Extrinsic strategies

Extrinsic strategies that required basic equipment included a bath or shower (n=27; 48%), use of a TENS machine (n=21; 38%), listening to music (n=11; 20%), using hot or cold packs (n=6; 11%), dimming lights to create a calm physical space (n=6; 11%), displaying affirmation cards (n=5; 9%), and using aromatherapy (n=2; 4%),

Other extrinsic strategies included the importance of the social environment, such as having physical contact (touch and massage) from support people (n=19; 34%), and the presence of a known support person (n=17; 30%).

The extrinsic strategies that required specific medical assistance included use of pharmacological pain relief, especially epidural analgesia (n=14; 25%), and use of nitrous oxide and oxygen (n=7; 13%). Of the 14 women who discussed epidural analgesia, nine were open to using it if needed but preferred to try to manage without it. The remaining five women had a definite plan to use it, with one wanting an “early epidural” (ID25) and stating she was “all for it” when it came to medical pain relief. The use of sterile water injections was also planned by two participants (4%).

3.2 Elements that women believe will contribute to coping with pain during labour

Women were asked what they thought were important elements that would help them cope with pain during labour. Three overall themes capture what women valued. The first was framing labour intensity as productive and purposeful ; the second was creating a relationally safe environment ; and the third was a sense of preparedness and knowing .

3.2.1 Framing labour intensity as productive and purposeful

Framing labour intensity as productive and purposeful involved developing a mindset of self-trust, generating a positive and accepting attitude towards the experience, and focusing on the purpose of labour pain.

Developing a mindset for self-trust included recognising that labour and birth are normal processes, and that overthinking or attempting to control the process were futile.

.

Approaching childbirth with a “positive mindset” (ID10) was important to helping women cope. This involved reframing the experience of pain to “a good pain and not a bad pain” (ID36), and acknowledging that, even if they expected it to be hard, the pain was purposeful, finite and also a shared experience amongst women.

However, the experience of labour itself was not of importance for all women, with one explaining that “I am reminding myself labour is about getting the baby out rather than the experience itself” (ID34) and this thought process was satisfactory to help them cope with labour.

3.2.2 Creating a relationally safe environment

Women identified that feeling psychologically and emotionally safe during labour would help them cope. This sense of safety involved feeling emotionally supported, well informed, and listened to by those around them. This relationally safe environment was sometimes created intentionally by the woman’s selection of specific support people and models of care, and at other times assumed as part of their expected care.

The importance of this relationally safe environment was a prominent theme and emphasises that both psychological safety and physical safety are important during labour and birth.

3.2.3 Sense of preparedness and knowing

Birth is an unknown journey for first time mothers. In this study, all except one woman, who planned “nothing in particular” and was planning to “just see how it go goes” (ID7), had researched and actively sought knowledge to prepare for labour.

Being educated, so that my expectations of the pain are realistic. (ID39)

Some women identified that a lack of knowledge or preparedness made them feel some anxiety about how they would cope and that once they had gained knowledge, they felt better prepared.

For some women, this also included understanding what pharmacological analgesia was available and the implications of these options.

Knowledge on all aspects of the birth, including the physiological process and possible complications, as well as being prepared with a ‘tool kit’ of intrinsic and extrinsic strategies, were important to women in this study, and contributed to reducing concerns about the unknown and increasing confidence to cope with the challenges of labour.

Drawing together the two questions asked of women in this research, we reach a deeper understanding of women’s individual needs in relation to coping in labour. Framing labour intensity as productive and purposeful links with the intrinsic categorisation of coping strategies. Women planned to use mental strategies that focused on the purpose of the experience and develop a positive mindset towards the challenges of labour involving self-trust. Creating a relationally safe environment links with the extrinsic categorisation of coping strategies that included support people, where having known and trusted carers and support people, and creating a calm environment in which to birth, was important to many women. It was important for women to have a sense of preparedness and knowing, to help them cope with the unknown. The coping strategies women identified to manage these uncertainties, involved a variety of strategies, both intrinsic and extrinsic. These findings are presented visually in Figure 2.

4 DISCUSSION

4.1 Main findings

This study aimed to identify what nulliparous women felt were important elements that would help them cope during labour, and what strategies they planned to use. Despite birth being a common and unifying experience, sense of coping is individual and multifaceted. Our findings describe three critical components that women identified as important to help them cope during labour. First, framing labour intensity as productive and purposeful, which included developing a mindset of self-trust, generating a positive attitude towards the experience, and focusing on the purpose of pain in labour. Second, creating a relationally safe environment, which meant ensuring those around them made them feel supported, informed, and heard. And third, having a sense of preparedness and knowing, which included developing a ‘tool-kit’ of strategies to help them cope.

We used a novel grouping for strategies that women planned to use in labour: intrinsic and extrinsic. Intrinsic strategies were those that women could utilise autonomously, without the need for aids or assistance from others. Many intrinsic strategies were mechanisms to help women develop and maintain a positive mindset and mindset of self-trust, to frame labour intensity as productive and purposeful. Extrinsic strategies were those that women could not initiate independently. This included support from other people, contributing to a relationally safe environment and several non-pharmacological and pharmacological pain relief strategies, such as TENS machines and epidural analgesia. All women planned to use a combination of intrinsic and extrinsic strategies, acknowledging that coping in labour would, at various points, involve both self-trust and autonomy, as well as external support.

4.2 Strength and limitations

This study extends the literature on coping in labour from the woman’s perspective, which is not adequately reported in existing literature. Understanding women’s views on factors that help them cope in labour, and their individual preferences and intentions in terms of coping strategies, will provide a foundation for targeted research into how best to address women’s individual needs.

Our findings are not intended to be representative of all women giving birth. Although the sample was diverse in terms of country of birth, model of maternity care and levels of pregnancy risk, level of education of participants could influence how active they were in seeking information on labour and birth. Further work should aim to include women across education levels, birthing in other types of maternity services and from regional and rural communities, where support and access to information during pregnancy may be less available.

4.3 Interpretation

Our approach of categorising strategies as intrinsic and extrinsic moves beyond the pharmacological and non-pharmacological categorisation. It removes assumptions regarding what individual women may need to help them cope, which may include pain management for some, but for others may include alternative strategies, such as movement, a positive mindset, or support.⁷ A growing body of literature is now recognising that promoting the natural release and cycle of birthing hormones^16,17 can support women to manage the intensity of labour, which in turn supports the use of intrinsic and extrinsic strategies that minimise disruption and promote a sense of safety.¹⁸ When medical interventions are needed or requested, it is important that a woman’s sense of control and autonomy are not diminished.^4,7,19

A recent systematic review on coping strategies for labour pain²⁰ used a different grouping: cognitive or behavioural. Whilst this is a step in the right direction, grouping strategies this way risks confusion due to the overlap of some techniques as having both behavioural and cognitive effects. For example, breathing techniques may be described as behavioural, but also have cognitive effects on focus and relaxation. The intrinsic and extrinsic approach to categorising resolves this issue, and centres on the more practical feature of whether the strategy can be initiated or performed autonomously, or whether it requires external support to utilise.

Using this novel grouping potentially has implications for how women prepare for labour and how caregivers provide support. It acknowledges that labour is dynamic and women need to draw on different strategies at different times.⁶ In practice, strategies can be adopted to help a woman move away from a ‘distracted and distraught’ state, and access or re-access a ‘mindful acceptance’ state, a state associated with ability to cope.⁶ This emphasises the role of the caregiver in actively supporting women’s selection of strategies beyond the ‘pain relief menu’ approach,²¹which assumes that labour is linear and suggests that intrinsic strategies are only helpful at the start of labour, rather than valuable throughout labour to help women refocus and return to a state of ‘mindful acceptance’. Extrinsic strategies can also be useful at various points, even early in labour to help reengage the more autonomous intrinsic strategies. This supports the importance of women maintaining their sense of control over their labour¹⁹ even if more support from external sources is required at times.

Women in our study identified the value in developing a mindset of self-trust to help cope in labour, aligning with the autonomous strategies that we classified as intrinsic. Framing labour intensity as productive and purposeful contributes to this. A positive attitude to childbirth has been found to positively affect a woman’s experience of childbirth pain.²² Women in our study also identified the importance of creating a relationally safe environment, which included known and trusted caregivers and support people, and creating a calm environment in which to birth. These views are also strongly supported in the literature.^1,23,24 This aligns with midwife-led continuity models of care, which are associated with more positive birth experiences^25,26 and reduced medical interventions, including caesarean section rates.²⁷The dynamics of these relationships can also influence the implementation of strategies learnt in childbirth education in positive and negative ways.²⁸ Caregivers and support people can foster safety and be in alignment with the woman, helping implement preferred strategies^28,29 and create a supportive alliance.²⁸ Alternatively, disruptive encounters with caregivers can make a woman feel her care is being managed by others and reduce her autonomy to effectively apply planned coping strategies.²⁸

When caregivers and support people understand what matters to women, and emphasise strategies that promote birthing women’s autonomy, they will be equipped to support care approaches that facilitate more positive birth experiences. The WHO guidelines⁴ recognise a key aspect of a positive childbirth experience is one where a woman is in a “psychologically safe environment with continuity of practical and emotional support from a birth companion(s) and kind, technically competent clinical staff” (page 12). Care that considers women’s individual wants and needs, further contributes to positive psychological birth outcomes.³⁰

Our research has captured the individual preferences and intentions of women but also has demonstrated a new way of thinking about coping strategies: One that moves away from a choice between a pharmacological approach, or not, and where the decision-making centres on the need for medical assistance and an assumption that pain relief is the priority. Instead, we propose, the grouping of coping strategies into intrinsic or extrinsic, which better promotes the woman’s autonomy and what she brings to labour.

5 CONCLUSION

Our research has aimed to improve our understanding of what nulliparous women identify as important to help them cope with labour, and what specific strategies they plan to utilise. We have proposed a new approach to categorising coping strategies, grouping as either intrinsic or extrinsic. This enhancement acknowledges the dynamic nature of labour, and centres on women’s autonomy and sense of control, beyond what is possible with the common grouping based on the pharmacological nature of a strategy. We propose that caregivers help women prepare coping strategies in each category based on the women’s choice and that researchers further explore the ways strategies from each grouping can be coordinated for the best outcome for women and their babies.

ACKNOWLEDGEMENTS

The authors would like to thank participating women for dedicating time to share their thoughts and experiences for this project.

DISCLOSURE OF INTERESTS

None declared. Completed disclosure of interest forms are available to view online as supporting information.

CONTRIBUTION TO AUTHORSHIP

The study was designed with contributions from authors LW, LJ, CE and MD. LW completed the data collection. The process of data analysis and writing the manuscript was led by author JS in close collaboration with authors LW and LJ. All authors contributed to editing and approved the final manuscript.

ETHICS APPROVAL

Ethics approval was obtained from the Human Research Ethics Committee of the health service where recruitment took place, and through La Trobe University (2019-034).

FUNDING

This research received funding from the Mercy Health Academic Research and Development Committee, as well as La Trobe University.

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