Evaluate the effectiveness of using non-pharmacological intervention during childbirth: an improvement project in Jordanian maternity hospitals

Abstract

Background

Unnecessary childbirth interventions are still common in most hospitals in Jordan. Despite the recommendations from the WHO that unnecessary interventions during childbirth should be avoided, these interventions are still used. Non-pharmacological pain management interventions are considered a convenient alternative to unnecessary childbirth interventions because they can prevent unsafe side effects for mothers during childbirth. The study aims to determine the feasibility of non-pharmacological pain management interventions during childbirth and then to evaluate their influence on mothers’ experience.

Methods

Between May and June 2022, we implemented a quality improvement project with a bundle of non-pharmacologic comfort measures during childbirth. We started our project by (1) approaching all low-risk pregnant mothers who visited the hospital’s antenatal clinic with a gestational age greater than 36 weeks. (2) Following the agreement, the researcher indicated that she would accompany the mother during the birthing process. (3) The researcher discussed different non-pharmacological pain management techniques and asked the mothers to choose how and when to utilize them. Non-pharmacological pain management techniques include breathing exercises, back massages, enabling mothers to move around, and providing modest amounts of water and soft food. (4) A few days after birth, the mother was interviewed one-to-one utilizing semi-structured audio-recorded interviews. The researcher interviewed eighteen postpartum mothers at a place of their choosing.

Results

Three main themes emerged from the interview analysis. The following themes were selected from the participants’ own words: “Positive, respectful, and satisfying childbirth experience”; “Maintain mother’s sense of control and cope with childbirth pain”; and “Birth outcome”. These themes are connected and impacted by one another.

Discussion

Different research studies from diverse cultures recommend limiting the unnecessary use of interventions during childbirth and not interfering with childbirth unless medically necessary. Our participants expressed satisfaction with the use of culturally appropriate birth interventions during childbirth. These interventions were generally simple and safe, resulting in a satisfying birthing experience.

Conclusion

The study findings contribute to achieving Sustainable Development Goal #3, “Good health and well-being” by reducing maternal and neonatal mortality, providing evidence of the effectiveness of non-pharmacological pain management, and avoiding unnecessary childbirth interventions.

Introduction

The concept of evidence-based interventions was originally established by the World Health Organization (WHO), which recommends avoiding unnecessary interventions during childbirth and only interfering with the natural labor process when necessary [1]. A wide range of potential interventions are utilized during childbirth [2]; and many of them are unnecessary for healthy, low-risk mothers. The WHO recently emphasized the need to minimize harm to mothers and infants caused by unsafe maternal and neonatal care throughout pregnancy, labor, and after birth [3]. Childbirth pain must be effectively managed; otherwise, it can cause injury, such as extended labor, and an increase in the risk of fetal distress, head compression, intrauterine fetal mortality, low Apgar scores, and physical injuries to newborns [3]. Pharmaceutical interventions can provide immediate pain relief while also satisfying the mother. Nonetheless, they can have serious complications or side effects, such as the mother’s inability to push effectively, ending up with a prolonged second stage labor. The prolonged second stage increases the likelihood of developing complications for the mother and her fetus.

Non-pharmacological pain management during labor refers to methods used to boost comfort, encourage rest, help the mother cope with labor pain, and avoid suffering without the use of medications [4]. They include education for birthing preparation, breathing exercises, frequent changes of position during labor, having a warm bath, sitting on the birth ball, massage, and listening to music [5]. It’s important to note that these interventions are inexpensive; some are free, widely available, and can be used to enhance or complement other therapies without the need for assisted childbirth [6]. Non-pharmacological intervention for pain management is proven to be effective in managing low-risk labor due to the active involvement of midwives and nurses in taking on responsibility for managing the childbirth process [3].

Non-pharmacological pain management interventions have several advantages, such as having no harm to the mother and her newborn baby, not interfering during birth, and even being satisfying for the mother [3]. Several supportive therapies have been recommended to relieve labor pain, and numerous research studies have been undertaken in this field, suggesting that labor is aided by mothers who feel protected and have good pain control [7]. Fear of labor pain and negative feelings combined with the lack of awareness of the many methods for reducing labor pain increased cesarean-section rates [8, 9]. When compared to vaginal birth, there is a higher risk of perinatal and maternal mortality following a medically unnecessary cesarean section. The National Maternal Mortality Report 2021 from Jordan states that vaginal deliveries accounted for 11.9% of maternal deaths, while cesarean deliveries accounted for 64.8% of cases of maternal mortality [10]. Considering the reduction of childbirth interventions and establishing the appropriate environment for pain management in hospitals and maternity wards in Jordan may increase the likelihood of mothers having a satisfied, complication-free natural vaginal birth [11] These interventions provide some hope for reducing labor pain while causing little or no harm to the mother, fetus, or birth process. Research indicates that using these interventions during low-risk labor can reduce the need for assisted birth or anesthesia [12, 13].

In Jordan, 98% of births occur in health institutions with a qualified healthcare provider. Maternity care in Jordan is divided into three stages: antenatal care, birthing care, and postnatal care. The Ministry of Health provides antenatal care through 506 healthcare centers and hospitals. In Jordan, antenatal care is almost accessible, with 98% of expectant mothers receiving care from a qualified healthcare professional, such as a doctor, nurse, or midwife, throughout their pregnancy [14]. The utilization of non-pharmacological pain management techniques during labor and childbirth in Jordan is limited [14]. Several factors have been identified for the limited application of non-pharmacological pain management interventions in Jordan, such as inadequate staffing, scheduling limitations, and individual preferences [14]. Numerous studies indicate that mothers in Jordan have received insufficient healthcare support in hospitals during childbirth. Earlier research has shown that mothers were often unsatisfied with their childbirth experiences [15, 16].

Despite the availability of evidence-based national guidelines to standardize the practice of healthcare providers working in labor and birth units [11], the protocols in place at Jordanian maternity hospitals are not in compliance either with them or with the World Health Organization’s guidelines for natural childbirth, especially for mothers considered low-risk [17]. Observations show that many interventions and procedures are used unnecessarily, often in situations and circumstances where they are unnecessary. Even more, instead of being reserved for high-risk childbirths, many interventions are also being performed in low-risk situations [15].

The high maternal mortality ratio (MMR) of 29.8 per 100,000 live births in Jordan and the steadily rising number of cesarean births suggest that healthcare providers be equipped with evidence-based practices and strategies for managing and monitoring the first and second stages of labor. To help achieve this, a collection of non-pharmacological pain management techniques might be beneficial.

Research aims and objectives

The research study aimed to assess the feasibility of specific non-pharmacological pain management interventions during childbirth and to evaluate their impact on the mothers’ experience.

Research question

What is the feasibility of non-pharmacological interventions during intrapartum care?

What is the impact of non-pharmacological interventions on patient experience?

Materials and methods

Study design and setting

The project took place at the maternity ward in Al-Zarqa New Governmental Hospital. From May to June 2022, we gathered the research data through semi-structured key informant interviews. Participants were selected from the hospital’s Obstetrics and Gynecology departments in Zarqa, Jordan.

Participants

The study included all mothers who met the inclusion criteria and agreed to use our research intervention during childbirth. Recruitment was carried out successively until the point of saturation was achieved.

Inclusion criteria: All participants were multipara (1–3 children), free of chronic diseases, and had no prior Cesarean birth or history of obstetrical or gynecological disease. Her pregnancy was conceived naturally, with no active issues, and there were no maternal or fetal variables that elevated the likelihood of difficulties. The target population consisted of all low-risk Jordanian mothers admitted to Al-Zarqa Governmental Hospital. The accessible group consisted of low-risk laboring mothers who visited the hospital. A total of 18 mothers met the inclusion criteria and agreed to use the selected non-pharmacological interventions.

Data collection procedure

We approached all eligible participants at the prenatal clinic to explain our quality improvement project. They were provided verbal and written material regarding the study, such as a brief description of the research objectives, and questions for the interviews to take home. Once they decided to participate, they contacted us at the phone number provided. The names of eligible participants were sent to the head nurse, and all care providers in the ward were instructed to contact the researcher on the day of participant admission. During labor, the researcher assisted in clarifying the intervention for the mother while she was cared for by the midwife. The researcher then scheduled an interview date at a time convenient for the participant. All participants were interviewed in Arabic. To ensure participants’ privacy, interviews were conducted in a place of their choice. The average interview lasted 40–60 min. The principal investigator asked the mother to explain her experience from admission to leaving the hospital. The questions that were asked were: “Could you please describe your experience of your last childbirth?“, and “Can you tell me in detail about the care you received in the hospital?” Follow-up questions like “Can you explain more?” and “What do you think about this?” were used as needed (see Table 1).

Table 1 Interview questions

All interviews were conducted face-to-face, captured on a digital recording device, and promptly transcribed. Any missing details from the interviews were gathered from the mother’s medical records. Our data is considered reliable because we achieved saturation in the research, meaning that responses became consistent across most participants.

The participants were given the chance to choose the non-pharmacological intervention they would like to use. All interventions were explained by the researcher to the participants in detail. These interventions included:

• 1. Breathing exercises: This is the most used intervention in Jordanian hospitals.

• 2. Massaging the mother’s back to ease pain, cope with contractions, and reduce anxiety.

• 3. Sitting on the birth ball: This helps the mother stay active, ease her labor pain, reduce the pain of her contractions, and help the mother get into a more upright position to bring the baby’s head further down into the pelvis.

• 4. Allowing mothers to walk around the room to enhance fetal descent, as well as for pain relief/coping and to better position the baby for labor progression and birth.

• 5. Allowing mothers to drink sips of water.

The mother used most of the interventions herself, except for the back massage, which was performed by a midwife overseeing her care from admission to postpartum (see Table 2).

Table 2 The interventions that were introduced as part of the intervention

Ethical considerations

The Hashemite University Institutional Review Board [No.5/3/2021/2022] and the Ministry of Health approved the study [Moh/REC/2021/234]. All research participants signed a consent form. To protect their identity, individuals’ information and places were anonymized, and all data files were protected by passwords.

Data analysis

The researchers followed Braun and Clarke’s (2006) [18] six steps of data analysis: (1) Two researchers transcribed the interviews from audio recording devices, checked each other’s transcription for accuracy, and analyzed the interviews using a manual Thematic and Content Analysis Tool (TCAT). Then, transcripts were read and reread several times to familiarize the researchers with the data, (2) interesting sentences relevant to the aims of our study were then systematically coded, (3) then, the researchers grouped all data related to each other to find the initial themes, (4) the researchers checked and rechecked all initial themes concerning the coded extracts and the entire dataset to generate a thematic map, (5) after the researchers completed the thematic map, a final names were given to the themes, (6) the last step was to select vivid and compelling extract examples and final analysis of the selected extracts was carried out. The researchers linked the final themes to the research question and literature to produce the final report [18, 19]. The project also involved responder validation, where five randomly selected transcripts of the in-depth interviews and the resulting themes were returned to the participants for review and confirmation that they reflected what they said during the interviews [18]. Although the research has been interpreted and simplified, participants should still accept the data as genuine and, at this point, may possess the ability to improve the researcher’s understanding.

Results

Eighteen mothers agreed to participate in our quality improvement project. Their ages ranged between 22 and 37, with an average age of 27.6. The babies’ weights ranged from 2300 to 3800 g. Their husbands’ ages ranged from 26 to 39, the average = 32.9. At the time of marriage, their ages ranged from 19 to 26. The duration of marriage ranged from two to twelve years, with an average of 6.9 years (see Table 3).

Table 3 Demographical data

Three major themes were extracted from the interviews. These themes were found to be interconnected and influenced by each other. The themes were derived from the participants’ own words:

• 1. “Positive, respectful, and satisfying childbirth experience”.

• 2. “Maintaining mother’s sense of control and coping with childbirth pain”.

• 3. “Birth outcome”.

Theme one: positive, respectful, and satisfying childbirth experience

The non-pharmacological approach to pain management increased our participants’ respect and satisfaction, leading to positive feedback on their new experiences. One mother described her experience as “wonderful,” with less pain and greater respect “I am so pleased” (Mother 9, Q20). The use of these interventions combined with ongoing professional care, dramatically reduced labor pain and improved relaxation as reported by Mother 2 (Q6): “Despite experiencing intense pain during childbirth, …the nurse provided me with relief through water, breathing techniques, and back massage. … My labor pains have reduced.”

Some participants reported having had an amazing birthing experience and being happy with everything “This was one of the most wonderful birth experiences I ever imagined…” (Mother 9, Q22). Compared to their previous birth, they reported feeling less stress and less exhaustion “This time I felt good, … not tired…” “I was not exhausted after giving birth…” (Mother 13; Q17). They felt more comfortable and safer as well “In my previous childbirth, I screamed a lot and cried too… but this time was different…. I felt safe” (Mother1, Q3).

Our participants reported that pain management interventions provided through childbirth were comfortable and considerate. For example, one participant explained “This time, my childbirth was a more respectful and stress-free experience… it’s a nice new birth experience” (Mother 10, Q12).

Respecting the mother’s decision and avoiding unnecessary interventions improved their satisfaction with childbirth. The implementation of non-pharmacological interventions played a crucial role in ensuring maternal satisfaction and creating a positive and memorable childbirth experience for both mother and her family “Breathing exercise and the back massage were excellent…” I was amazed at how much it helped me… my family and I were extremely pleased about the whole process (Mother 1, Q1). “The midwife explained different ways to manage my childbirth pain, all were non-pharmacological. … Honest, surprising, and pleasant experience. I am quite satisfied” (Mother7. Q7). The one-on-one care during childbirth also gave mothers a sense of security “The nurse was always there to support me … she gave me a back massage, accompanied me around the room, and made sure I was doing well…” (Mother 9, Q11).

When compared to their previous childbirth experiences, our participants found that non-pharmacological techniques were extremely successful in treating labor pain. They showed satisfaction with performing breathing techniques and massaging the perineum with a birth ball, claiming that these treatments effectively reduced pain and boosted their sensation of relaxation. One participant stated, “Compared to my previous childbirth, this childbirth is an experience to remember” (Mother 2, Q6). Another mother also said, “This time, my childbirth was easier than previous ones and less painful” (Mother 6, Q15). Throughout the postpartum period, some mothers persisted in using relaxation techniques. For instance, one of our participants said, “I now use the breathing exercise whenever I feel stressed. It’s a lifelong skill” (Mother 2, Q52).

Theme two: maintain mother’s sense of control and cope with childbirth pain

Our participant’s sense of control was increased by allowing her to choose the preferred pain management intervention. They also reported feeling more involved since they could choose the intervention and the time they wanted to apply. They stated that this was their first experience deciding how and when to apply the intervention to relieve their discomfort. “This experience differed from the prior one. I felt like I could choose what I wanted and reject what I didn’t like. For the first time, I felt respected and dignified”. (Mother7; Q53)

Several mothers reported that non-pharmacological techniques helped them distract and manage their contractions. They indicated that exercising with their bodies through taught or adapted non-pharmacological pain management methods gave them a sense of strength and independence. One mother stated, “I felt like I could handle the pain on my own and didn’t need to call the nurse " Honestly, I felt strong and independent” (Mother 17, Q62).

Theme three: birth outcome

The final theme emerged from analyzing the researcher’s field notes about the birth outcome after childbirth. Most of our participants—a total of 18 participants and 18 neonates—were free from complications related to childbirth. Only two mothers (3.6%) had an episiotomy, and only three mothers (16.6%) needed analgesics. In every mother, amniotic membranes spontaneously broke. All mothers were highly cooperative and showed remarkable resilience during childbirth. Without assistance or a cesarean birth, every one of our participants delivered their baby naturally. Additionally, all newborns’ Apgar scores were normal at 3 and 5 min, meaning they didn’t require resuscitation or NICU transfer. All participants had early skin-to-skin contact, and breastfeeding started immediately.

Discussion

A national initiative to decrease avoidable cesarean section deliveries is desperately needed, as seen by the rising trend of cesarean section deliveries in Jordan. We believe this quality improvement project is a great success and will contribute positively toward improving the available maternity healthcare services.

Positive, respectful, and satisfying childbirth experience

Overall, our quality improvement project set a favorable childbirth experience for our participants after performing normal vaginal childbirth using non-pharmacological pain management techniques. In general, our findings suggest that our participants were satisfied with their experience of using non-pharmacological interventions for the management of pain during labor and birth. Compared to their previous childbirth experience, our participants felt relaxed and autonomous. They also cooperated with staff and accepted care providers’ orders and comments. They felt respected, cared for, comforted, and experienced less fear.

The application of non-pharmacological pain management techniques to alleviate birth discomfort with one-to-one nursing attention to each mother resulted in a positive birth experience. All participants reported a better experience than their previous experiences or expectations. Mothers stated that this birth experience will live in their memories forever. A recent systematic review (2023) reported that non-pharmacological pain management interventions offer a promising alternative or complement to traditional pharmacological methods, potentially improving labor outcomes, reducing side effects, and benefiting both mothers and their newborns. They also stated that these strategies use the body’s inherent pain management mechanisms to enhance relaxation, comfort, less anxiety, and more happiness with the birth experience [20].

Maintain mother’s sense of control and cope with childbirth pain

Our participants’ satisfaction was associated with the use of non-pharmacological pain treatment, and giving respectful care to minimize unnecessary medical interventions proved useful in increasing mothers’ pleasure with childbirth. Non-pharmacological therapies were critical in improving mothers’ satisfaction and comfort. Furthermore, most of our participants reported feeling satisfied with the professional support they received. Nurses were available with the participant to serve and help her during childbirth hours. A critical review of 10 qualitative research studies suggested that continuous health professional presence and support throughout childbirth promote mothers’ satisfaction [21].

A randomized controlled trial (RCT) conducted at the Maternity and Children Hospital (MCH) in Saudi Arabia investigated how breathing exercises, foot reflexology, and massage therapies affected labor pain, anxiety, labor duration, stress hormone levels, maternal satisfaction, maternal vital signs, and infant APGAR scores. The intervention decreased labor pain intensity, boosted oxytocin levels, and reduced labor duration. Intervention during the first stage of labor resulted in reduced labor pain, anxiety (2.9 vs. 4.2, p < 0.001), shorter labor duration, and better maternal outcomes (vital signs, maternal satisfaction, higher oxytocin levels, and reduced cortisol) [22]. In addition, a recent Egyptian study discovered that breathing techniques and back massages helped primigravida mothers experience less anxiety and pain during the first stage of labor [23]. Our findings were congruent with a recent study that concluded that the use of non-pharmacological therapies was efficient in reducing the effects of labor and childbirth, such as pain, duration of labor, anxiety, laceration, and episiotomy [24].

Another trial supported our findings, which included nine different nonpharmacological strategies for lowering labor pain. This study found that nonpharmacological therapies significantly increased participant satisfaction and comfort and reduced labor pain This finding also aligns with a study from Germany that revealed increased satisfaction during labor when women were involved in decision-making and received support during birth [25]. These findings contradict the findings reported in a recent Brazilian study which found no difference in labor pain intensity between the patients who used non-pharmacological methods and those who did not use them during the active phase of labor [26].

Conclusions

Childbirth is a significant event in the lives of all mothers. It is typically associated with discomfort, stress, and fear, all of which harm the outcome of childbirth for both the mother and her baby. Non-pharmacological interventions not only reduced labor pain and assisted our participants in having a vaginal birth; they also allowed them to actively interact with their physiological reactions and establish a ‘team’ approach with their care provider. Some mothers continued to utilize relaxation methods throughout the postpartum period, which benefited them, their babies, and their families, implying that adopting these skills established lifelong success.

Non-pharmacological interventions such as breathing techniques, back massage, birth balls, walking, and position changes are safe for both the mother and the fetus, and they improve birthing outcomes. Non-pharmacological methods are effective in helping with coping with childbirth pain, reducing anxiety and fear during childbirth, feeling satisfied and respected by the healthcare provider in the childbirth unit, and creating a positive birth experience. Given the increasing prevalence of cesarean section deliveries in Jordan, non-pharmacological pain management interventions can reduce the need for anesthesia or painkillers and cesarean births. Our findings emphasized the importance of promoting and providing as many approaches as possible so that mothers can access methods that align with their preferences and beliefs. They also highlighted the value of offering a full explanation of each procedure. We understand that, due to Jordan’s heavy workload and resource shortages, notably for nurses and midwives, it may not always be possible to assist all mothers. However, teaching mothers’ self-help skills may make a difference.

Strengths of the study

To our knowledge this is the first quality improvement project to evaluate Jordanian mothers’ experiences with non-pharmacological pain relief during childbirth in public hospitals. Our project has identified critical areas that must be addressed to promote the provision of routine nonpharmacological pain management choices for mothers during childbirth. All participants agreed that using non-pharmacological pain management measures during childbirth was beneficial and encouraged other mothers to learn them.

Limitations of the study

The project sample consisted mostly of mothers who gave birth at a public hospital in Al-Zarqa City. It is worth noting that mothers who gave birth at various hospitals (public and private) from multiple areas might have experienced distinct views and experiences. Gathering their viewpoints is crucial for obtaining a comprehensive picture of birth experiences in different settings. Furthermore, encouraging mothers to choose labor over pharmacological pain relief therapies has proven to be a significant challenge.

Convincing the head of the department to assign a midwife to conduct the childbirth naturally with the application of the required non-pharmacological pain management intervention was sometimes a challenge due to the shortage of staff.