TITLE PAGE
Novel grouping of planned coping strategies for managing the intensity
of labour: A qualitative study
Shifman J 1,2, Jones LE1,3,
Davey M-A4, East C1,5, 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
women4,7. 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.
.
Most importantly to trust my body and use the relaxation
techniques to help me feel physically, mentally and spiritually
prepared. Therefore, reducing my fear, anxiety and pain during the
birth. (ID1)Mindset, staying calm. Understanding that it’s a completely
natural and normal process. I just have to let my body do what it knows
how to do and get my mind out of the way. (ID56)
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.
I expect that it will be the most pain I would probably have felt
previously but am hopeful that I can frame it as only being intermittent
and that it is there for a good reason. (ID55)Thinking positively, reminder that we are not alone in the
experience, excitement of meeting my baby. (ID11)
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.
Relying on my partner and knowing he will be my spokesperson if I
can’t cope well. Trusting that I’m in a safe space, surrounded by
experts who can help if things go wrong. (ID23)Trusting the nurses, midwives and doctors to have mine and baby’s
best interests. (ID21)..having all decisions run by me and be given choices. (ID55)Reassurance from midwives about the normal expectations and
[whether] what I am feeling is normal or not. (ID52)
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.
I am going into birth having done as much research into labour and
childbirth as possible so I feel as prepared as I can be. (ID10)
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.
I don’t feel especially prepared or well-educated and I have a bit
of anxiety about what will happen… This has meant I have had to
seek out my own educational resources, including reading ”Birth Skills”
and other books on the process, watching a free webinar on labour, and
listening to a podcast with an obstetrician explaining the process and
interventions. This has helped me feel better prepared to cope with
labour and the pain. (ID34)Knowledge - having a clear understanding of what is happening to
my body. I feel that knowing about the process has already helped ease a
lot of fear and has made me feel more calm and prepared for what will
happen. (ID49)
For some women, this also included understanding what pharmacological
analgesia was available and the implications of these options.
[Having] a strong knowledge of the process and the pain relief
available for me. (ID35)Knowing what my analgesia options are and when is the right time
for them, for instance if I decided I couldn’t cope and want an
epidural, when is it too late for this etc. (ID52)
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
hormones16,17 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 experiences25,26 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 strategies28,29 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.
REFERENCES
1. Borrelli SE, Walsh D, Spiby H. First-time mothers’ expectations of
the unknown territory of childbirth: uncertainties, coping strategies
and ‘going with the flow’. Midwifery. 2018;63:39-45.
2. Van der Gucht N, Lewis K. Women׳ s experiences of coping with pain
during childbirth: a critical review of qualitative research. Midwifery.
2015;31(3):349-58.
3. Lally JE, Murtagh MJ, Macphail S, Thomson R. More in hope than
expectation: a systematic review of women’s expectations and experience
of pain relief in labour. BMC Med. 2008;6:1-10.
4. World Health Organization. WHO recommendations on intrapartum care
for a positive childbirth experience. Geneva: World Health Organization;
2018. Report No.: 924155021X.
5. Whitburn LY, Jones LE, Davey M-A, Small R. The meaning of labour
pain: how the social environment and other contextual factors shape
women’s experiences. BMC Pregnancy Childbirth. 2017;17(1):1-10.
6. Whitburn LY, Jones LE, Davey M-A, Small R. Women s experiences of
labour pain and the role of the mind: An exploratory study. Midwifery.
2014;30(9):1029-35.
7. Thomson G, Feeley C, Moran VH, Downe S, Oladapo OT. Women’s
experiences of pharmacological and non-pharmacological pain relief
methods for labour and childbirth: a qualitative systematic review.
Reprod Health. 2019;16(1):1-20.
8. Chang C-Y, Gau M-L, Huang C-J, Cheng H-m. Effects of
non-pharmacological coping strategies for reducing labor pain: A
systematic review and network meta-analysis. PLoS One.
2022;17(1):e0261493.
9. Escott D, Slade P, Spiby H, Fraser RB. Preliminary evaluation of a
coping strategy enhancement method of preparation for labour. Midwifery.
2005;21(3):278-91.
10. Tan A, Wilson AN, Eghrari D, Clark H, Tse WC, Bohren M, et al.
Outcomes to measure the effects of pharmacological interventions for
pain management for women during labour and birth: a review of
systematic reviews and randomised trials. BJOG. 2022;129(6):845-54.
11. Jones L, Othman M, Dowswell T, Alfirevic Z, Gates S, Newburn M, et
al. Pain management for women in labour: an overview of systematic
reviews. Cochrane Database Syst Rev. 2012(3).
12. Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG.
Research electronic data capture (REDCap)—a metadata-driven
methodology and workflow process for providing translational research
informatics support. J Biomedical Informatics. 2009;42(2):377-81.
13. Thomas DR. A general inductive approach for analyzing qualitative
evaluation data. Am J Eval. 2006;27(2):237-46.
14. Saldaña J. The coding manual for qualitative researchers. 3rd ed.
Glasgow, United Kingdom: SAGE Publications; 2016.
15. NVivo Qualitative Data Analysis Software (Version 12). QSR
International Pty Ltd; 2020.
16. Olza I, Uvnas-Moberg K, Ekström-Bergström A, Leahy-Warren P,
Karlsdottir SI, Nieuwenhuijze M, et al. Birth as a neuro-psycho-social
event: An integrative model of maternal experiences and their relation
to neurohormonal events during childbirth. PLoS One.
2020;15(7):e0230992.
17. Buckley SJ. Hormonal physiology of childbearing: evidence and
implications for women, babies, and maternity care. Washington, D.C.:
Childbirth Connection Programs, National Partnership for Women &
Families, January; 2015.
18. Newnham E, Whitburn LY, Jones LE. Paradigm of pain in the birth
sphere. In: Davies L, Crowther S, editors. Mindfulness in the Birth
Sphere London: Routledge; 2022. p. 147-63.
19. McCrea H, Wright ME, Stringer M. Psychosocial factors influencing
personal control in pain relief. Int J Nurs Stud. 2000;37(6):493-503.
20. Fumagalli S, Borrelli S, Bulgarelli M, Zanoni A, Serafini M,
Colciago E, et al. Coping strategies for labor pain, related outcomes
and influencing factors: A systematic review. Eur J Midwifery.
2022;6(November):1-13.
21. Leap N, Hunter B. Supporting women for labour and birth: a
thoughtful guide: Routledge; 2022.
22. Karlsdottir SI, Sveinsdottir H, Kristjansdottir H, Aspelund T,
Olafsdottir OA. Predictors of women’s positive childbirth pain
experience: findings from an Icelandic national study. Women Birth.
2018;31(3):e178-e84.
23. Whitburn LY, Jones LE, Davey M-A, McDonald S. The nature of labour
pain: An updated review of the literature. Women Birth.
2019;32(1):28-38.
24. Klomp T, Manniën J, de Jonge A, Hutton EK, Lagro-Janssen AL. What do
midwives need to know about approaches of women towards labour pain
management? A qualitative interview study into expectations of
management of labour pain for pregnant women receiving midwife-led care
in the Netherlands. Midwifery. 2014;30(4):432-8.
25. Sandall J, Soltani H, Gates S, Shennan A, Devane D. Midwife‐led
continuity models versus other models of care for childbearing women.
Cochrane Database Syst Rev. 2016(4).
26. Forster DA, McLachlan HL, Davey M-A, Biro MA, Farrell T, Gold L, et
al. Continuity of care by a primary midwife (caseload midwifery)
increases women’s satisfaction with antenatal, intrapartum and
postpartum care: results from the COSMOS randomised controlled trial.
BMC Pregnancy Childbirth. 2016;16:1-13.
27. McLachlan HL, Forster DA, Davey M-A, Farrell T, Gold L, Biro MA, et
al. Effects of continuity of care by a primary midwife (caseload
midwifery) on caesarean section rates in women of low obstetric risk:
the COSMOS randomised controlled trial. BJOG. 2012;119(12):1483-92.
28. Sutcliffe KL, Dahlen HG, Newnham E, Levett K. “You are either with
me on this or not”: A meta-ethnography of the influence birth partners
and care-providers have on coping strategies learned in childbirth
education and used by women during labour. Women Birth.
2023;36(4):e428-e38.
29. Escott D, Slade P, Spiby H. Preparation for pain management during
childbirth: the psychological aspects of coping strategy development in
antenatal education. Clin Psychol Rev. 2009;29(7):617-22.
30. Byrne V, Egan J, Mac Neela P, Sarma K. What about me? The loss of
self through the experience of traumatic childbirth. Midwifery.
2017;51:1-11.