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Comfort during prepared childbirth as a function of parity, reported by four classes of participant observers
Journal of Psychosomatic Research, Vol. 19, pp. 33 to 37. Pergamon Press, 1975. Printed in Great Britain
COMFORT DURING PREPARED CHILDBIRTH AS A FUNCTION OF PARITY, REPORTED BY FOUR CLASSES OF PARTICIPANT OBSERVERS* ROSEMARY
(Received
COGAN
2 July 1974)
PAIN of childbirth has been discussed in a wide range of literature. Empirical studies have been summarized by Chertok [I, 21, Buxton [3], and Richardson and Guttmacher [4], while Mead and Newton [5] have summarized descriptions of childbirth pain in many cultures. Wessel[6] has analyzed early written materials describing childbirth. The subjective nature of pain, with the additional uncertainty concerning its initiating stimulus in the childbirth situation, has probably been a limiting factor in the study of pain in childbirth. In addition, the complex changes in feelings and behavior which occur throughout childbirth [7] have largely been ignored in the literature. In attempting to evaluate pain experienced during childbirth, investigators have focused upon reports made by observers during labor and/or birth. Chertok [I] and Velvovski [8] reviewed many studies in which investigators demonstrated the effectiveness of psychological approaches to pain relief during childbirth by describing reports of the behavior of women in labour made by observers attending the childbirth. Recently, Huttel et al. [9] similarly reported observations of less “complaint” and “tension” behaviors among women who elected childbirth education classes compared with women who did not elect classes. Application of a quantitative measurement of pain during childbirth has been reported by Hardy and Javert [lo] who indicated that, when pain was measured with the dols scale, pain increased during childbirth, reaching a maximum intensity during expulsion. The dols scale has been discussed critically by Beecher [ 111, and no attempt seems to have been made to replicate the study by Hardy and Javert [IO]. Women have been asked to report on their experience of labor and birth in studies by Enkin et al. [12] and Chertok [2]. In both instances, however, women’s reports of their own experiences were combined with other reports in such a way that the women’s direct reports about pain experienced during childbirth were not available. Enkin et al. [12] asked women to respond six months after delivery to an adjective check list indicating the extent to which a series of adjectives applied to their childbirth experience. Women who attended childbirth education classes reported more positive experiences in both labor and birth when compared with a control group who wanted but did not receive classes and a control group who neither wanted nor received classes. In each of the three groups the expulsive phase of labor was reported as being a more positive experience than the dilation phase of labour. Chertok [2] has considered women’s behavior and experience during four phases of labor: dilation,
THE
* This research was supported by the Institute for Human Resources, Texas Tech University, Lubbock, Texas and by the Childbirth Without Pain Education League, Inc., 4043 Seventh Street, Riverside, California.
33
ROSEMARYGJGAN
34
transition, expulsion, and issue. Chertok’s evaluation of pain during childbirth combined the observed behavior of women during child birth with an interpretive pain index based on these observations of women, interviews with the women, and clinical intuition as to the expressive style of each woman in the sample. The resulting measures are complex, combining the reports of women with the observations of others. Pain and behavior measures of women who did and women who did not select childbirth education classes were compared. Women who attended classes were judged to experience less pain than women who did not attend classes.Reduction in pain occurred throughout the course of childbirth, and particularly during dilation. Both groups of women were judged to feel less pain during expulsion and issue as compared with dilation and transition. Thus, both Enkin et al. [12] and Chertok [2] report similar findings. Although social and psychological variables have been related to pain during childbirth [2], effects of parity do not seem to have been investigated. Since labors of multiparous women are usually shorter than labors of primiparous women [13], it might be expected that less pain would be experienced by multiparous women. In the present study, the effects of parity upon pain during childbirth were investigated. Women’s own reports of pain experienced during childbirth were investigated and compared with reports of husbands, physicians, and childbirth education instructors who participated in the births at various stages. METHOD Sample From a population of women who were students of a childbirth education group* offering classes in many parts of the United States, a group of 32 births were drawn. Sixteen of the mothers were primiparous and sixteen were multiparous. Births were selected which met the following restrictions: induction of labor was not used; medication was not administered during either first or second stage labor; the husband accompanied his wife during both labor and birth; the birth was vaginal; an episiotomy was given; and reports of the birth were complete from the mother, father, and childbirth education instructor. The mothers ranged in age from 19 to 31 yr. Primiparous mothers averaged 25 yr; multiparous mothers averaged 25.5 yr. Primiparous and multiparous mothers attended an average of 6.1 class meetings; multiparous fathers attended an average of 5.1 classes; and primiparous fathers attended an average of 5.9 class meetings. Among primiparous mothers, first stage labor average 8-15 hr; transition averaged about 13 contractions; and second stage labor averaged less than 45 min. Among multiparous mothers, first stage labor averaged 6-13 hr, transition averaged about 8 contractions, and second stage labor averaged less than 30 min. Procedure The mothers, fathers and childbirth instructors involved were given questionnaires before the births. In these post-partum questionnaires, they were asked to estimate the amount of pain experienced by the mothers during four phases of childbirth described by Friedman [13]: the latent phase of labor (04 or 5 cm), the accelerated phase of labor (4 or 5 cm-7 or 8 cm), the phase of deceleration or transition of labor, and birth itself. Physicians were asked to report their estimation of pain experienced by their patients during late labor and birth only. In each case, respondents were asked to indicate whether, (1) the mother was unaware of the part of labor under consideration or whether she seemed to feel, (2) no pain, (3) no pain but much effort, (4) moments of discomfort or pain, (5) some pain, or (6) severe pain. RESULTS Although
AND DISCUSSION
the pain scale may be regarded as a simple ordinal scale, and many statistical
* Childbirth Without Pain Education
League, Inc.
tests
35
Comfort during prepared childbirth
assume more sophisticated measurement techniques than ordinal scaling, the analysis of variance has been shown to be a robust test in the face of violation of assumptions about measurement scales. Differences between reports of mothers, fathers and teachers over the four reporting periods were evaluated using a repeated measures analysis of variance. Differences in reports from the three respondents were reliable (F(2,90) = 28.5, p < 0.01). As can be seen in Fig. 1, teachers consistently evaluated the pain experienced by women as being about one scale value lower than either mothers or fathers. Pain reports differed reliably across the four reporting times (F(3,334) = 47.76, p < 0.01). In Fig. 1 it can be seen that there was a general increase in pain reported from the beginning of labor to transition and a decrease in pain reported during expulsion by mothers, fathers, and teachers.
6x--i; Primiporos 4 c-4 Multiparas /
It
4+-k+Teachers
I
A
I
I
8
C
Mothers
I D
I
A
I
I
I
B
C
D
Fathers
FIG. l.-Comfort level of primiparous and multiparous women during early dilation (a), later dilation (b), transition (c), and the second stage of labor (d) as reported by childbirth education teachers, mothers, and fathers.
Less pain was reported for multiparas than for primiparas throughout most of labor, as can be seen in Fig. 1. Only during transition was more pain reported for multiparas. These differences were reflected in the reliable interaction between time and parity (F(3,334) = 2.96, p < 0.05). Comparison of the reports of the three observers, shown in Fig. 1, indicates that fathers reported a decrease in pain during transition among primiparous mothers. All observers reported less pain among multiparas than among primiparas during the second stage. Only among fathers evaluating births of primiparous mothers was no decrease in pain reported during the second stage of labor. These differences were reflected in the reliable interaction between time, parity and reporter (F(6,334) = 66.56; p < 0.01). Differences in pain reports from mothers, fathers, and teachers during birth make the reports of the attending physicians of special interest. Physician reports were complete for eight of the primiparous mothers and for twelve of the multiparous mothers. In order to facilitate statistical analysis, eight births of multiparous mothers with complete physician reports were randomly selected to achieve equal numbers in the two parity groups. A repeated measures analysis of variance was used to test differences in reports of all four respondents during the phases of transition and birth. Teachers reported less pain than did mothers, fathers, or physicians, as can be seen in Fig. 2, and this effect approached conventional standards of reliability (F(3,57) = 2.72, p < 0.07). Less pain was reported during the second stage of labor than during transition, and the effect of time period was reliable (F(1,55) = 7.18, p < 0.01). However, the four reporters differed in their estimates of pain in late labor and birth. As can be seen in Fig. 2, a decrease in pain during second stage was reported only by mothers and teachers, while fathers and physicians reported slight increases in pain during second stage. These differences were reflected in the reliable interaction between time and reporter (F(3,55) = 5.68, p < 0.05). No effects of parity were reliable, suggesting that parity in this population did not affect reports of pain during late labor. The reason for the difference in pain reported during the second stage of labor by mothers and teachers as compared with fathers and physicians is not clear. Reports of women showed regular changes throughout the course of labor, suggesting that women were able to evaluate changes in the relative presence of pain in their own reports. Orderly variation in the reports of both multiparous and primiparous women suggests that the reports of mothers as to their relative pain are probably very meaningful. Husbands and physicians may tend to interpret the noisy behavior characteristic
36
RosEh9m~
COCSAN
x7x
Primiparas
o--a Multiparas
1 C
Teachers
D
Mothers
C
Fathers
D
PhysIcIons
FIG. 2.-Comfort level of primiparous and multiparous women during transition (c), and the second stage of labor(d) as reported by childbirth education teachers, mothers, fathers, and physicians. of this very active part of childbirth [7] as signalling pain, particularly when the stimuli associated with an episiotomy are present while the stimuli associated with medication are absent. The present data provide support for Chertok’s report [2] of maximum discomfort during transition. Discomfort was reported to increase throughout the first stage of labor, whether the reports of mothers, fathers, or childbirth instructors were considered. In concord with the reports of both Chertok [2] and Enkin ef al. [12], mothers and teachers reported that discomfort was reduced during birth itself. Thus the present data suggest that similar information may be found about pain experienced during the course of childbirth whether reports are obtained directly from mothers or indirectly from childbirth instructors, except that the reports from childbirth instructors will be consistently lower. The reason for the consistently lower reports of pain during childbirth made by teachers is not clear. Teacher’s estimates are based on conversations with students after the birth. Thus, teacher’s reports are second-hand estimates. It is possible that students may tend to under-report pain experienced when talking with teachers. On the other hand, it is possible that teachers do not accurately perceive reports of their students. REFERENCES 1. CHERTOKL. Psychosomatic Methods in PainIess Childbirth. Pergamon, New York (1959). 2. CHERTOK L. Motherhood and Personality. Psychosomatic Aspects of Childbirth. Lippincott, Philadelphia (1969). 3. BUXTON C. L. Study of Psychophysical Methods for Relief of Childbirth Pain. Saunders, Philadelphia (1962). 4. RICHARDSONS. A. and GUTTMACHERA. F. (Eds.) Childbearing: Its Social and Psychological Aspects. Williams & Wilkins, New York (1967). 5. MEAD M. and NEWTONN. Cultural patterning of perinatal behavior. In: Childbearing: its Social and PsychoIogical Aspects. (Edited by RICHARDSONS. A. and GUTT~ACHERA. F.). Williams & Wilkins, New York (1967). 6. WESSELH. S. Natural Childbirth and the Christian Family. Harper & Row, New York (1963). 7. AFFONSOD. Report of MaturationaE Crisis: a Psychological Approach to Maternity Care. Workshop 1: maturational crisis of childbearing. Crisis of labor and birth. University of Hawaii Press, Honolulu (1971). 8. VELVOVSKY I., PLATONOVK., PLJXJCHERV. and SHUGONE. Painless Childbirth through Psychoprophylaxis Foreign Languages Publishing House, Moscow (1960). 9. HU~TEL F. A., MITCHELLI., FISCHERW. M. and MEYER A. E. A quantitative evaluation of psychoprophylaxis in childbirth. J. Psychosom. Res., 16, 81 (1972).
Comfort during prepared childbirth
37
10. HARDY J. D. and JAVERTC. T. Studies on pain: measurements of pain intensity in childbirth. J. Clin. Invest. 28, 153 (1949). 11. BEECHERH. D. Meusuvement ofsubjective Responses. Oxford University Press, New York (1959). 12. ENKIN M. W., SMITHS. L., DERMERS. W. and EMMETTJ. 0. An adequately controlled study of the effectiveness of PPM training. In: Psychosomatic Medicine in Obstetrics and Gynaecology, Third Int. Congress. (Edited by MORRISN.). London, 1971, Steiner, Base1 (1972). 13. FRIEDMANE. A. Functional divisions of labor. Am. J. Obstet. Gynec. 109,274 (1971). 14. BRUMNG J. L. and KINTZ B. L. Conpatational Handbook of Statistics. Scott, Foresman, Glenview, Illinois (1968).
COMFORT DURING PREPARED CHILDBIRTH AS A FUNCTION OF PARITY, REPORTED BY FOUR CLASSES OF PARTICIPANT OBSERVERS* ROSEMARY
(Received
COGAN
2 July 1974)
PAIN of childbirth has been discussed in a wide range of literature. Empirical studies have been summarized by Chertok [I, 21, Buxton [3], and Richardson and Guttmacher [4], while Mead and Newton [5] have summarized descriptions of childbirth pain in many cultures. Wessel[6] has analyzed early written materials describing childbirth. The subjective nature of pain, with the additional uncertainty concerning its initiating stimulus in the childbirth situation, has probably been a limiting factor in the study of pain in childbirth. In addition, the complex changes in feelings and behavior which occur throughout childbirth [7] have largely been ignored in the literature. In attempting to evaluate pain experienced during childbirth, investigators have focused upon reports made by observers during labor and/or birth. Chertok [I] and Velvovski [8] reviewed many studies in which investigators demonstrated the effectiveness of psychological approaches to pain relief during childbirth by describing reports of the behavior of women in labour made by observers attending the childbirth. Recently, Huttel et al. [9] similarly reported observations of less “complaint” and “tension” behaviors among women who elected childbirth education classes compared with women who did not elect classes. Application of a quantitative measurement of pain during childbirth has been reported by Hardy and Javert [lo] who indicated that, when pain was measured with the dols scale, pain increased during childbirth, reaching a maximum intensity during expulsion. The dols scale has been discussed critically by Beecher [ 111, and no attempt seems to have been made to replicate the study by Hardy and Javert [IO]. Women have been asked to report on their experience of labor and birth in studies by Enkin et al. [12] and Chertok [2]. In both instances, however, women’s reports of their own experiences were combined with other reports in such a way that the women’s direct reports about pain experienced during childbirth were not available. Enkin et al. [12] asked women to respond six months after delivery to an adjective check list indicating the extent to which a series of adjectives applied to their childbirth experience. Women who attended childbirth education classes reported more positive experiences in both labor and birth when compared with a control group who wanted but did not receive classes and a control group who neither wanted nor received classes. In each of the three groups the expulsive phase of labor was reported as being a more positive experience than the dilation phase of labour. Chertok [2] has considered women’s behavior and experience during four phases of labor: dilation,
THE
* This research was supported by the Institute for Human Resources, Texas Tech University, Lubbock, Texas and by the Childbirth Without Pain Education League, Inc., 4043 Seventh Street, Riverside, California.
33
ROSEMARYGJGAN
34
transition, expulsion, and issue. Chertok’s evaluation of pain during childbirth combined the observed behavior of women during child birth with an interpretive pain index based on these observations of women, interviews with the women, and clinical intuition as to the expressive style of each woman in the sample. The resulting measures are complex, combining the reports of women with the observations of others. Pain and behavior measures of women who did and women who did not select childbirth education classes were compared. Women who attended classes were judged to experience less pain than women who did not attend classes.Reduction in pain occurred throughout the course of childbirth, and particularly during dilation. Both groups of women were judged to feel less pain during expulsion and issue as compared with dilation and transition. Thus, both Enkin et al. [12] and Chertok [2] report similar findings. Although social and psychological variables have been related to pain during childbirth [2], effects of parity do not seem to have been investigated. Since labors of multiparous women are usually shorter than labors of primiparous women [13], it might be expected that less pain would be experienced by multiparous women. In the present study, the effects of parity upon pain during childbirth were investigated. Women’s own reports of pain experienced during childbirth were investigated and compared with reports of husbands, physicians, and childbirth education instructors who participated in the births at various stages. METHOD Sample From a population of women who were students of a childbirth education group* offering classes in many parts of the United States, a group of 32 births were drawn. Sixteen of the mothers were primiparous and sixteen were multiparous. Births were selected which met the following restrictions: induction of labor was not used; medication was not administered during either first or second stage labor; the husband accompanied his wife during both labor and birth; the birth was vaginal; an episiotomy was given; and reports of the birth were complete from the mother, father, and childbirth education instructor. The mothers ranged in age from 19 to 31 yr. Primiparous mothers averaged 25 yr; multiparous mothers averaged 25.5 yr. Primiparous and multiparous mothers attended an average of 6.1 class meetings; multiparous fathers attended an average of 5.1 classes; and primiparous fathers attended an average of 5.9 class meetings. Among primiparous mothers, first stage labor average 8-15 hr; transition averaged about 13 contractions; and second stage labor averaged less than 45 min. Among multiparous mothers, first stage labor averaged 6-13 hr, transition averaged about 8 contractions, and second stage labor averaged less than 30 min. Procedure The mothers, fathers and childbirth instructors involved were given questionnaires before the births. In these post-partum questionnaires, they were asked to estimate the amount of pain experienced by the mothers during four phases of childbirth described by Friedman [13]: the latent phase of labor (04 or 5 cm), the accelerated phase of labor (4 or 5 cm-7 or 8 cm), the phase of deceleration or transition of labor, and birth itself. Physicians were asked to report their estimation of pain experienced by their patients during late labor and birth only. In each case, respondents were asked to indicate whether, (1) the mother was unaware of the part of labor under consideration or whether she seemed to feel, (2) no pain, (3) no pain but much effort, (4) moments of discomfort or pain, (5) some pain, or (6) severe pain. RESULTS Although
AND DISCUSSION
the pain scale may be regarded as a simple ordinal scale, and many statistical
* Childbirth Without Pain Education
League, Inc.
tests
35
Comfort during prepared childbirth
assume more sophisticated measurement techniques than ordinal scaling, the analysis of variance has been shown to be a robust test in the face of violation of assumptions about measurement scales. Differences between reports of mothers, fathers and teachers over the four reporting periods were evaluated using a repeated measures analysis of variance. Differences in reports from the three respondents were reliable (F(2,90) = 28.5, p < 0.01). As can be seen in Fig. 1, teachers consistently evaluated the pain experienced by women as being about one scale value lower than either mothers or fathers. Pain reports differed reliably across the four reporting times (F(3,334) = 47.76, p < 0.01). In Fig. 1 it can be seen that there was a general increase in pain reported from the beginning of labor to transition and a decrease in pain reported during expulsion by mothers, fathers, and teachers.
6x--i; Primiporos 4 c-4 Multiparas /
It
4+-k+Teachers
I
A
I
I
8
C
Mothers
I D
I
A
I
I
I
B
C
D
Fathers
FIG. l.-Comfort level of primiparous and multiparous women during early dilation (a), later dilation (b), transition (c), and the second stage of labor (d) as reported by childbirth education teachers, mothers, and fathers.
Less pain was reported for multiparas than for primiparas throughout most of labor, as can be seen in Fig. 1. Only during transition was more pain reported for multiparas. These differences were reflected in the reliable interaction between time and parity (F(3,334) = 2.96, p < 0.05). Comparison of the reports of the three observers, shown in Fig. 1, indicates that fathers reported a decrease in pain during transition among primiparous mothers. All observers reported less pain among multiparas than among primiparas during the second stage. Only among fathers evaluating births of primiparous mothers was no decrease in pain reported during the second stage of labor. These differences were reflected in the reliable interaction between time, parity and reporter (F(6,334) = 66.56; p < 0.01). Differences in pain reports from mothers, fathers, and teachers during birth make the reports of the attending physicians of special interest. Physician reports were complete for eight of the primiparous mothers and for twelve of the multiparous mothers. In order to facilitate statistical analysis, eight births of multiparous mothers with complete physician reports were randomly selected to achieve equal numbers in the two parity groups. A repeated measures analysis of variance was used to test differences in reports of all four respondents during the phases of transition and birth. Teachers reported less pain than did mothers, fathers, or physicians, as can be seen in Fig. 2, and this effect approached conventional standards of reliability (F(3,57) = 2.72, p < 0.07). Less pain was reported during the second stage of labor than during transition, and the effect of time period was reliable (F(1,55) = 7.18, p < 0.01). However, the four reporters differed in their estimates of pain in late labor and birth. As can be seen in Fig. 2, a decrease in pain during second stage was reported only by mothers and teachers, while fathers and physicians reported slight increases in pain during second stage. These differences were reflected in the reliable interaction between time and reporter (F(3,55) = 5.68, p < 0.05). No effects of parity were reliable, suggesting that parity in this population did not affect reports of pain during late labor. The reason for the difference in pain reported during the second stage of labor by mothers and teachers as compared with fathers and physicians is not clear. Reports of women showed regular changes throughout the course of labor, suggesting that women were able to evaluate changes in the relative presence of pain in their own reports. Orderly variation in the reports of both multiparous and primiparous women suggests that the reports of mothers as to their relative pain are probably very meaningful. Husbands and physicians may tend to interpret the noisy behavior characteristic
36
RosEh9m~
COCSAN
x7x
Primiparas
o--a Multiparas
1 C
Teachers
D
Mothers
C
Fathers
D
PhysIcIons
FIG. 2.-Comfort level of primiparous and multiparous women during transition (c), and the second stage of labor(d) as reported by childbirth education teachers, mothers, fathers, and physicians. of this very active part of childbirth [7] as signalling pain, particularly when the stimuli associated with an episiotomy are present while the stimuli associated with medication are absent. The present data provide support for Chertok’s report [2] of maximum discomfort during transition. Discomfort was reported to increase throughout the first stage of labor, whether the reports of mothers, fathers, or childbirth instructors were considered. In concord with the reports of both Chertok [2] and Enkin ef al. [12], mothers and teachers reported that discomfort was reduced during birth itself. Thus the present data suggest that similar information may be found about pain experienced during the course of childbirth whether reports are obtained directly from mothers or indirectly from childbirth instructors, except that the reports from childbirth instructors will be consistently lower. The reason for the consistently lower reports of pain during childbirth made by teachers is not clear. Teacher’s estimates are based on conversations with students after the birth. Thus, teacher’s reports are second-hand estimates. It is possible that students may tend to under-report pain experienced when talking with teachers. On the other hand, it is possible that teachers do not accurately perceive reports of their students. REFERENCES 1. CHERTOKL. Psychosomatic Methods in PainIess Childbirth. Pergamon, New York (1959). 2. CHERTOK L. Motherhood and Personality. Psychosomatic Aspects of Childbirth. Lippincott, Philadelphia (1969). 3. BUXTON C. L. Study of Psychophysical Methods for Relief of Childbirth Pain. Saunders, Philadelphia (1962). 4. RICHARDSONS. A. and GUTTMACHERA. F. (Eds.) Childbearing: Its Social and Psychological Aspects. Williams & Wilkins, New York (1967). 5. MEAD M. and NEWTONN. Cultural patterning of perinatal behavior. In: Childbearing: its Social and PsychoIogical Aspects. (Edited by RICHARDSONS. A. and GUTT~ACHERA. F.). Williams & Wilkins, New York (1967). 6. WESSELH. S. Natural Childbirth and the Christian Family. Harper & Row, New York (1963). 7. AFFONSOD. Report of MaturationaE Crisis: a Psychological Approach to Maternity Care. Workshop 1: maturational crisis of childbearing. Crisis of labor and birth. University of Hawaii Press, Honolulu (1971). 8. VELVOVSKY I., PLATONOVK., PLJXJCHERV. and SHUGONE. Painless Childbirth through Psychoprophylaxis Foreign Languages Publishing House, Moscow (1960). 9. HU~TEL F. A., MITCHELLI., FISCHERW. M. and MEYER A. E. A quantitative evaluation of psychoprophylaxis in childbirth. J. Psychosom. Res., 16, 81 (1972).
Comfort during prepared childbirth
37
10. HARDY J. D. and JAVERTC. T. Studies on pain: measurements of pain intensity in childbirth. J. Clin. Invest. 28, 153 (1949). 11. BEECHERH. D. Meusuvement ofsubjective Responses. Oxford University Press, New York (1959). 12. ENKIN M. W., SMITHS. L., DERMERS. W. and EMMETTJ. 0. An adequately controlled study of the effectiveness of PPM training. In: Psychosomatic Medicine in Obstetrics and Gynaecology, Third Int. Congress. (Edited by MORRISN.). London, 1971, Steiner, Base1 (1972). 13. FRIEDMANE. A. Functional divisions of labor. Am. J. Obstet. Gynec. 109,274 (1971). 14. BRUMNG J. L. and KINTZ B. L. Conpatational Handbook of Statistics. Scott, Foresman, Glenview, Illinois (1968).