Effects of Dance and Music on Pain and Fear During Childbirth

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Correspondence Hacer Alan Dikmen, PhD, Faculty of Health Sciences, Selcuk University, Selcuklu, Konya 42250. [email protected]

Effects of Dance and Music on Pain and Fear During Childbirth

Q1

_ Ilknur Münevver Gönenç and Hacer Alan Dikmen

Q20

ABSTRACT Objective: To test the effects of dance and music and music alone on pain and fear during the active phase of labor among nulliparous women. Design: Single-blind, randomized, controlled study. Setting: A maternity and children’s hospital in Konya Province, Turkey.

Keywords dance fear during childbirth labor pain maternity nurses music nulliparous women

Participants: A total of 93 nulliparous, pregnant women who were in the active phase of labor at term gestation with single fetuses in cephalic presentation. Methods: We randomly assigned participants to one of three groups: dance and music, music alone, and usual care (control). We collected data four times during labor using a personal information form, labor monitoring form, visual analog scale (VAS), and Version A of the Wijma Delivery Expectancy/Experience Questionnaire (W-DEQA) to measure fear. Results: Based on multivariate analysis of variance, the effect of time and study group interaction on VAS and W-DEQA scores was statistically significant (p < .05), and the effect of study groups and time on VAS scores was statistically significant (p < .05). The effect of the study groups on W-DEQA scores was statistically significant (p < .05), but there was no statistically significant effect of time on W-DEQA scores (p > .05). Conclusion: Dance and music and music alone significantly reduced pain and fear in nulliparous women during the active phase of labor. These interventions are easy for nurses and midwives to use, affordable, and effective, and they enable a woman and her partner to be actively engaged in the woman’s care.

JOGNN,

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2020. https://doi.org/10.1016/j.jogn.2019.12.005 Accepted December 2019

_ Ilknur Münevver Gönenç, PhD, is an assistant professor on the Faculty of Nursing, Ankara University, Ankara, Turkey. Hacer Alan Dikmen, PhD, is an assistant professor on the Faculty of Health Sciences, Selcuk University, Konya, Turkey.

The authors report no conflicts of interest or relevant financial relationships.

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P

ain during labor is described as severe, unique, and complex (Mamuk & Davas, 2010; Zahra & Leila, 2013), and it is the main cause of stress and fear during childbirth, especially in nulliparous women (Mete, 2013; Simavli et al., 2014). Thus, coping with pain during childbirth is critical and necessary (Iliadou, 2012). The methods used to support coping with pain during childbirth should be simple and not adversely affect the labor process (Ergin, 2014; Gokyildiz, Ozturk, Avcibay, Alan, & Akbas, 2018). Nonpharmacologic methods to manage pain are usually safe, have fewer adverse effects than pharmacologic methods, and are easy to use (Gokyildiz et al., 2018; Jones et al., 2012). Nonpharmacologic methods are used by midwives and nurses to reduce pain and fear during childbirth, which is one of the basic goals of intrapartum care (Hajiamini, Masoud, Ebadi,

Mahboubh, & Matin, 2012). For example, massage (Abdul-Sattar & Mirkhan, 2018), acupressure (Hajiamini et al., 2012), relaxation, aromatherapy (Zahra & Leila, 2013), warm showers (Lee, Liu, Lu, & Gau, 2012), dance (Abdolahian, Ghavi, Abdollahifard, & Sheikhan, 2014), and music (Gokyildiz et al., 2018; Gue´tin et al., 2018; Hosseini, Bagheri, & Honarparvaran, 2013; Liu, Chang, & Chen, 2010; Simavli et al., 2014) are used to help women cope with labor pain. In addition, changing positions reduces labor pain (Abdul-Sattar & Mirkhan, 2018; Gupta, Sood, Hofmeyr, & Vogel, 2017; Miquelutti, Cecatti, Morais, & Makuch, 2009; Ondeck, 2014), and squatting, kneeling, and walking help facilitate fetal rotation, accelerate labor, and reduce labor pain through the effects of gravity and changes in the pelvic dimensions (Miquelutti et al., 2009; Ondeck, 2014; Ricci, 2013).

ª 2020 AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses. Published by Elsevier Inc. All rights reserved.

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Dance and Music in Childbirth

Labor pain and fear during childbirth can have negative effects on the physiologic status of the mother and fetus.

The mechanisms that underlie these nonpharmacologic interventions may be explained by the gate control theory of pain. According to the gate control theory, a gating mechanism in the central nervous system can block the transmission of sensory and affective components of pain at the level of the spinal cord (Moayedi & Davis, 2013). This theory maintains that information transmitted via nonpain fibers or information transmitted downward from the brain may lower or eliminate the transmission of pain information before it is experienced. Therefore, independent of whether the gate is open or closed, the fibers transmitting information from various brain centers to the spinal cord influence the transmission of neural information upward (Fakhar, Rafii, & Orak, 2013; Katz & Rosenbloom, 2015; Melzack & Katz, 2013). This theory has influenced the understanding of pain among health care practitioners, changed how patients with pain are treated, and suggested that pain relief through nonpharmacologic means is a possibility (Melzack & Katz, 2013). Researchers (Durmaz & Komurcu, 2015; Vaajoki, Kankkunen, Pietila¨, & Vehvila¨inen-Julkunen, 2011) have suggested that a woman in labor can close the gate using cognitive–behavioral methods, such as dance and music or listening to music alone. The stimuli that stem from the pleasant music and movement through dance reorient the woman’s focus away from pain, produce muscular relaxation, and invoke a response that, via a descending inhibitory pathway, may close the gate and reduce the transmission of painful stimuli to higher cortical centers. Dance and music and music alone have no adverse effects on the woman or fetus, and they are easily used by midwives, maternity nurses, partners, and women (Simkin, Hanson, & Ancheta, 2017; Xavier & Viswanath, 2016). During labor, dance and music can reduce pelvic floor muscle activation by focusing the woman’s attention on something other than pain (Abdolahian et al., 2014; Iliadou, 2012). Furthermore, music alone has been reported to reduce pain and anxiety during labor (Gokyildiz et al., 2018; Gue´tin et al., 2018; Hosseini et al., 2013; Labrague, Rosales, Rosales, & Fiel, 2013; Liu et al., 2010; Simavli et al., 2014). The effects of dance and music and

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music alone on women’s pain during labor are consistent with the propositions of gate control theory (Moayedi & Davis, 2013). Nonpharmacologic methods are practiced during childbirth in Turkey; however, these methods often are not enough to help women cope with labor pain, fear, and anxiety. In addition, little research has been conducted on the use of dance and music in labor. Therefore, we aimed to investigate the effects of dance and music and music alone on perceived pain and fear in nulliparous women during the active phase of labor. Furthermore, we hypothesized that there would be significant differences in nulliparous women’s perceptions of pain and fear during active labor by group (dance and music, music alone, and usual care).

Methods Design The study was a single-blind, randomized controlled trial with one control and two intervention groups. The Consolidated Standards of Reporting Trials (CONSORT) diagram of the study phases is presented in Figure 1. The ethics boards of Selcuk University, situated in the province where the study was carried out, approved the study (institutional review board approval number 2017/52). We informed potential participants about the purpose of the study at the outset and obtained written, informed consent from each participant. To maintain the confidentiality of participant information, we coded the data set with unique study identifiers.

Setting and Sample We carried out the study in the childbirth unit of a maternity and children’s hospital in Konya Province, Turkey, between February 15, 2018, and June 15, 2018. Participants included pregnant women who fulfilled the inclusion criteria and agreed to participate. The inclusion criteria for participation were nulliparity, single fetus in the cephalic position at 38 to 42 weeks gestation with fetal weight of 2,500 to 4,000 g estimated by sonography, normal fetal heart rate, anticipation of normal birth, and active phase of the first stage of labor (3–7 cm dilatation) without use of analgesia or anesthesia. The exclusion criteria were voluntary withdrawal; abnormal fetal heart rate; unexpected complication in the mother or fetus; decision to use exogenous oxytocin, analgesics, or anesthesia; incomplete intervention and follow-up due to precipitous labor; and cesarean

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Figure 1. Flow diagram of the study.

birth before completion of the intervention or follow-up. We used the G*Power (Version 3.1.9) test to determine the sample size. We performed prior analyses based on multivariate analysis of variance (MANOVA) for repeated measures. Expected Cohen’s f value for the effect size was 0.25, which is a medium effect size. We attained a power level of 0.99 at the .05 significance level. The design of the study required a minimum sample size of 90 participants. Given the

likelihood of withdrawals, we assigned 33 participants to each group, with a total of 99 participants.

Measures Personal information form. We designed the personal information form to collect data on the personal and obstetric characteristics of the participants. The questionnaire included 10 items to inquire about sociodemographic characteristics (age, educational status, place of residence, family type, working status, income level, and

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Dance and Music in Childbirth

health insurance status) and information about the current pregnancy (gestational week, planned pregnancy, and health problems during pregnancy). Labor monitoring form. The labor monitoring form was used to gather information about the labor process, vital signs, and assessment of fetal heart rate. We used this form to evaluate the health status of each woman and fetus during active labor and before and after the interventions. Visual analog scale. The visual analog scale (VAS) was developed by Price, McGrath, Rafii, and Buckingham (1983). It is used to selfevaluate perceived pain on a 10-cm ruler scale, where 0 indicates no pain and 10 indicates the most severe pain. We asked each participant to mark her current level of perceived pain along the scale, and the number corresponding to the marked point was recorded as the pain score. In many studies in Turkey, the VAS is used as an assessment tool to measure the intensity of pain (Calik & Komurcu, 2014; Gokyildiz et al., 2018;  lu, 2019; Simavli et al., 2014). Go¨nenc¸ & Terziog

Q2

Version A of the Wijma Delivery Expectancy/ Experience Questionnaire. The Wijma Delivery Expectancy/Experience Questionnaire (W-DEQ) was developed by Wijma, Wijma, and Zar (2002) and is used to measure fear of childbirth among women before (Version A) and after (Version B) birth. The W-DEQA includes 33 items that are measured on a 6-point Likert-type scale. Responses are numbered from 0 to 5, where 0 means fully and 5 means never. Items 2, 3, 6, 7, 8, 11, 12, 15, 19, 20, 24, 25, 27, and 31 are reverse scored. The additive minimum and maximum scores for the scale range between 0 and 165, and greater scores indicate greater fear (Korukcu, Kukulu, & Firat, 2012). Korukcu et al. (2012) reported the Cronbach’s alpha coefficient estimate of internal consistency reliability of the Turkish form of the W-DEQA as .89 and the split-half reliability coefficient as .91. In our study, the Cronbach’s alpha coefficients were .90, .92, .93, and .94 for the first, second, third, and fourth measurements, respectively.

Procedure We randomly assigned the participants to one of the three study groups. One intervention group received dance and music (DM group), and the other intervention group was exposed to music alone (M group). The control group received

4

routine nursing care (C group). We placed participants in groups using the block randomization method with a Web-based computer program and determined the groups (DM, M or C) before interventions started. We used the block randomization method for the nulliparous women placed in the study groups randomly. We determined the block size to be nine after we calculated all possible balanced combinations of assignments within the block using a Webbased computer program. We randomly chose blocks to determine the participants’ assignments into the groups, and we assigned the participants to the groups according to the order in the blocks. We informed pregnant women who were hospitalized for childbirth and who met the inclusion criteria about the study in this order and invited them to participate. Women in the three groups were in different hospital labor suites to prevent cross-contamination between control and intervention groups. Of the 99 randomized participants, we excluded two women from the DM group (one experienced an emergency cesarean and one a precipitous labor), three from the M group (all three stopped listening to music before the 30-minute duration was completed and refused to continue), and one from the C group (emergency cesarean). Therefore, the sample included 93 participants: 31 participants in the DM group, 30 participants in the M group, and 32 participants in the C group (see Figure 1). After we randomly assigned the participants to the groups and they completed the personal information form, we completed the first (baseline) measurement of perceived pain and fear when cervical dilatation reached 4 to 5 cm. We then administered a 30-minute intervention to the participants in the DM and M groups and repeated the pain and fear measures soon after (second measurement), 30 minutes after (third measurement), and 60 minutes after the intervention (fourth measurement). Similarly, we obtained pain and fear measures for participants in the C group at baseline and after 30 (second measurement), 60 (third measurement), and 90 (fourth measurement) minutes. To prevent bias in the assessment of pain and fear, three maternity nurses who worked in the study hospital and were not involved with the study team or care of the participants administered the scales. We trained the maternity nurses involved in data collection on the use of data collection tools before initiation of the study.

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We did not restrict the liquid intake of participants during the study, and participants consumed water, juice, or soup during labor. During the interventions, participants in the DM and M groups were accompanied by a researcher. Participants in the control group received usual care by maternity nurses. The administration of all forms required approximately 10 minutes and was halted during contractions until women indicated that they could continue. After all study procedures were completed, participants were not able to use the music and/or dance and reverted to usual care.

Interventions by Group DM group. In addition to usual care, a 30minute intervention of dance and music was used by the 31 participants randomly assigned to the DM group. Disposable covers were used for the headphones and replaced for each participant. We asked each participant to choose three songs that they liked. Thirteen participants preferred pop music with an upbeat tempo, four preferred slow (soft) pop music, 13 preferred Turkish folk music, and one preferred mystic (religious) music. The participants listened to the music through a player connected to the Internet while they were assisted with the labor dance. The dance included four basic movements: a circular movement of the pelvis and waist, movement of body and pelvis left and right, semisquatting, and pelvic tilts. The researcher performed the movements with the participant. We allocated 5 to 6 minutes for each of the four basic movements. While performing the movements, the participant was in an upright position, and the researcher supported her. The participant transferred her weight to the researcher by putting her hands on the researcher’s shoulders. With this support, the participant performed the dance movements in time with the rhythm of the music. M group. In addition to usual care, the 30 participants randomly assigned to the M Group listened to music for 30 minutes and moved into any position they wanted while listening. We determined the 30-minute duration of the music intervention based on previous studies (Simavli et al., 2014; Taghinejad, Delpisheh, & Suhrabi, 2010). We asked the participants to choose three songs that they liked and that were meaningful to them. Nineteen of the participants preferred pop music with an upbeat tempo, seven preferred slow pop, two preferred Turkish folk music, and two preferred mystic (religious)

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Dance and music and music alone significantly reduced pain and fear during the active phase of labor among nulliparous women.

music. Participants listened to their music through a music player connected to the Internet. We used disposable covers for the headsets, and we replaced them for each participant. C group. The 31 participants randomly assigned to the C group received usual care (labor process, vital signs, and fetal heart tone monitoring). Hospital regulations prohibit women’s partners or relatives from being present in labor rooms, and as a result, women labor without support from anyone other than maternity nurses or midwives, who stay with the women during active labor.

Analysis We used SPSS Windows software package (Version 23.0) for statistical analysis, and we considered p less than .05 statistically significant. For the numeric variables, we calculated mean and standard deviation values as descriptive statistics and numbers and percentages for the categoric variables. We calculated Cronbach’s alpha coefficients to evaluate scale reliability. We used the chi-square statistic to test relationships between categoric variables (sociodemographic and obstetric characteristics of the participants by group). We assessed normality of distributions by calculating skewness and kurtosis and using the Shapiro–Wilk test. Skewness and kurtosis values ranged from 1.5 to þ1.5, which indicated Q3 normality (Tabachnick & Fidel, 2007) and that Q4 parametric tests were appropriate. We used repeated-measures MANOVA with a Bonferroni correction to test for significant differences in the pain VAS and W-DEQA scores across time among the three groups.

Results Sociodemographic characteristics Overall, 75.3% (n ¼ 70) of participants were 18 to 24 years old, and 89.2% (n ¼ 83) were at 38 to 40 weeks gestation. We found no significant differences in age or gestation among the three groups (p > .005) and no significant differences among the three groups related to education status, place of residence, family type, working status, income level, health insurance status, planned pregnancy, and health problems during pregnancy (see Table 1). We

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Dance and Music in Childbirth

Table 1: Sociodemographic and Obstetric Characteristics of Participants by Group (N [ 93) DM

M

C

Group, n (%)

Group, n (%)

Group, n (%)

(n ¼ 31)

(n ¼ 30)

(n ¼ 32)

Total, n (%)

Chi-Square p Value

18–24

25 (80.6)

21 (70.0)

24(75.0)

70 (75.3)

.628

25–34

6 (19.4)

9 (30.0)

8 (25.0)

23 (24.7)

29 (93.5)

22 (73.3)

26 (81.2)

77 (82.8)

2 (6.5)

8 (26.7)

6 (18.8)

16 (17.2)

Sociodemographic and Obstetric Characteristics Age in years

Education status Primary education High school or university

.108

Place of residence Town/village

8 (25.8)

12 (40.0)

9 (31.2)

29 (31.2)

23 (74.2)

18 (60.0)

23 (71.9)

64 (68.8)

Core family

13 (41.9)

19 (63.3)

15 (46.9)

47 (50.5)

Extended family

18 (58.1)

11 (36.7)

17 (53.1)

46 (49.5)

.217

4 (12.9)

5 (16.7)

7 (21.9)

16 (17.2)

.638

27 (87.1)

25 (83.3)

25 (78.1)

77 (82.8)

5 (16.1)

5 (16.7)

3 (9.4)

13 (14.0)

20 (64.5)

19 (63.3)

23 (71.9)

62 (66.7)

6 (19.4)

6 (20.0)

6 (18.8)

18 (19.4)

Yes

23 (74.2)

27 (90.0)

24 (75.0)

24 (75.0)

No

8 (25.8)

3 (10.0)

8 (25.0)

8 (25.0)

38–40

27 (87.1)

26 (86.7)

30 (93.8)

83 (89.2)

41–42

4 (12.1)

4 (13.3)

2 (6.2)

10 (10.8)

28 (90.3)

29 (96.7)

29 (90.6)

86 (92.5)

3 (9.7)

1 (3.3.)

3 (9.4)

7 (7.5)

Yes

23 (74.2)

14 (46.7)

21 (65.6)

58 (62.4)

No

8 (25.8)

16 (53.3)

11 (34.4)

35 (37.6)

City

.440

Family type

Working status Work No work Income level Low Middle High

.916

Having health insurance .227 Q12

Gestational week .596

Pregnancy planning Planned Unplanned

.571

Health problems during pregnancy .76

Note. C ¼ control; DM ¼ dance and music; M ¼ music alone.

observed no effects of the interventions on the fetal heart rates and vital signs of the participants.

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VAS and W-DEQA As a result of MANOVA analysis, the effect of time and study group interaction on VAS and W-DEQA

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Table 2: Investigation of Group and Time Effect on Pain and Fear Scores Descriptive Statistics Q13

Measure and Group

MANOVA Test Statistics

Time

n

Mean

SD

Group

Time

Group  Time

1

31

6.97

2.316

Fa ¼ 34.012

Fa ¼ 6.972 p ¼ .000

Fa ¼ 7.514 p ¼ .000

2.338

p ¼ .000

h ¼ .055

h2 ¼ .112

Q14

h ¼ .159

Ob. Pow. ¼ 1.000

Ob. Pow. ¼ 1.000

Q15

VAS DM group

2

31

5.00

2

3

31

6.97

2.549

4

31

6.87

2.754

1

30

6.03

1.65

2

30

6.33

1.668

3

30

6.57

1.813

4

30

7.13

2.145

1

32

6.28

1.170

2

32

7.03

1.576

3

32

8.56

1.366

4

32

9.12

1.641

1

31

48.26

20.596

2

31

25.90

15.409

3

31

29.32

19.153

4

31

28.81

17.728

1

30

42.33

23.599

2

30

37.87

20.374

3

30

37.97

21.379

4

30

35.17

21.044

1

32

40.78

22.291

2

32

56.12

19.132

3

32

69.22

19.477

4

32

76.56

20.651

2

Ob. Pow. ¼ 1.000

M group

C group

W-DEQA DM group

M group

C group

Note. The VAS was assessed before the intervention (Time 1), soon after the intervention (Time 2), 30 minutes after the intervention (Time 3), and 60 minutes after intervention (Time 4). The W-DEQA was assessed before the intervention (Time 1), soon after the intervention (Time 2), 30 minutes after the intervention (Time 3), and 60 minutes after the intervention (Time 4). C ¼ control; DM ¼ dance and music; M ¼ music alone; Ob. Pow. ¼ observed power; SD ¼ standard deviation; VAS ¼ visual analog scale; W-DEQA ¼ Version A of the Wijma Delivery Expectancy/Experience Questionnaire. a Multivariate analysis of variance (MANOVA) was performed.

scores was statistically significant (p < .05; see Table 2). Post hoc analysis showed statistically significant (p <. 05) effects of study groups and

Q16

time on VAS scores. Although there was a statistically significant (p <. 05) effect of study groups on W-DEQA scores, there was no effect of

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Dance and Music in Childbirth

Dance and music and music alone are easy-to-use, affordable, safe, and effective nonpharmacologic interventions that nurses and midwives can use independently.

Table 3: Post Hoc Analysis of the Effect of Group and Time on Pain and Fear Test Post Hoca

Q17

p ¼ .000

3 to 1.2

Q18

2.132

F ¼ 13.588

4 to 1.2

7.73

2.423

p ¼ .000

3 to 1.2

DM

33.07

20.167

M

38.33

21.513

F ¼ 66.700

C

60.67

24.377

p ¼ .000

1

43.77

22.178

2

40.16

22.146

3

45.84

26.339

F ¼ 2.033

4

47.29

29.101

p ¼ .109

Mean

SD

Statistics

DM

6.45

2.605

M

6.52

1.852

F ¼ 17.386

C

7.75

1.836

1

6.43

1.796

Discussion

2

6.13

2.055

In our study, the intergroup comparisons indicated that dance and music and music alone decreased perceived labor pain. Iliadou (2012) reported that labor dance reduced pelvic floor muscle activation by attracting the attention of the woman to sensations other than pain. Similarly, Abdolahian et al. (2014) found that the mean pain score in the dance group was significantly lower than that of the control group (p < .05) among 60 primiparous women during the first stage of labor. Movements made in the upright position (e.g., pelvic tilt, semi-squatting) and the music played are important. Miquelutti et al. (2009) reported that an upright position relieved labor pain and increased comfort and patient satisfaction in their study of 107 nulliparous women. Research findings have supported the idea that an upright position, squatting, and movements reduce perceived labor pain (Miquelutti et al., 2009; Ondeck, 2014). Researchers also have reported that listening to music during childbirth results in increased resistance to pain, improves mood, and helps the woman in labor engage in regular and deep breathing (Hosseini et al., 2013; Gue´tin et al., 2018; Labrague et al., 2013; Liu et al., 2010). Hosseini et al. determined that the music pregnant women listened to during the active phase of labor decreased pain. Simavli et al. (2014) found that listening to music had a positive effect on perceived labor pain, maternal–fetal parameters, and the need for analgesia. Similarly, other research findings showed that music reduced distress and pain and promoted relaxation for women during the active phase of labor (Gue´tin et al., 2018; Liu et al., 2010).

3

7.39

4

VAS

time on W-DEQA scores (p > .05). The VAS and W-DEQA scores of the C group were significantly higher than those of the M and DM groups. The VAS scores at the third and fourth data collection times were significantly higher than the VAS scores at the first and second times (p < .001; see Table 3).

Q5

In our study, the intergroup comparisons indicated that dance and music and music alone were effective to reduce fear during childbirth in the active phase of labor. During our literature

8

Group

Time

W-DEQA Group

3 to 1.2

Time

—

Note. C ¼ control group; DM ¼ dance and music group; M ¼ music group; SD ¼ standard deviation; VAS ¼ visual analog scale; W-DEQA ¼ Version A of the Wijma Delivery Expectancy/ Experience Questionnaire. a Post hoc Bonferroni.

review, we found no comparisons of the effects of dance and music and music alone on fear during childbirth. Dance and movements change feelings and promote positive emotions among women (Ho, Lo, & Luk, 2016). Dance merges multisensory, emotional, cognitive, and physical sensations. It can be used to promote motivation (in anything that a person is working on) and create positive emotions (Sturm, Baak, Storek, Traore, & Thuss-Patience, 2014). Rhythmic movements and rocking increase women’s ability to cope with labor pain (Simkin et al., 2017). Consistent with the gate control theory, the use of dance and music and music alone may diminish the transmission of pain signals to the brain by shifting the focus of women to stimuli other than pain. Neural flows created by these methods may suppress the neural gate and diminish the

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RESEARCH

_ M., and Dikmen, H. A. Gönenç, I.

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transmission of pain stimuli (Moayedi & Davis, 2013). Dance and music and music alone can reduce or may completely suppress the sensation of pain during labor in some women. The use of these nonpharmacologic methods by nulliparous women may help them feel that they are in control of their pain and strengthen their sense of having an active role during labor.

Implications

Q6

Maternity nurses and midwives are the health professionals who spend considerable time with women during labor and can use nonpharmacologic strategies, such as music and dance, to help women cope with labor pain and fear of childbirth. Because women labor without their partners or other supportive individuals in hospitals in Turkey, bringing partners into the labor room and incorporating them into the application of dance and music may further reduce women’s pain and fear and result in a healthier birth. Dance and music and music alone are easy to use, affordable, and can be easily taught to pregnant women to reduce pain and fear of labor and promote relaxation, even in the busiest labor and birth settings. Based on our experience during the study, the maternity nurse responsible for the care of a woman in labor could implement these interventions; thus, no additional staff is required. The inclusion of music and dance in routine care for women during labor is recommended. However, additional studies with larger samples and longer study periods are warranted. In addition, if further research measures the anxiety level of the woman in addition to birth pain and fear and evaluates fetal results in more detail, the effects of these two methods can be better understood.

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dance and music and music alone during the antenatal period and preparing them to use these methods may increase their effects. Another study limitation was data loss across groups and the repeated measurements. Our data loss was 6.1%, which is well less than the recommended  lu, 10% to 15% loss to reduce bias (Akin & Koc¸og 2017). In addition, the distribution of incomplete data in our study was balanced across groups. Therefore, although there were data losses, we used no method to impute the missing data. Q7

Conclusion We determined that dance and music and music alone reduced participants’ pain and fear compared with usual care in the active phase of labor. We recommend these two methods as effective, safe, and affordable nonpharmacologic interventions for nulliparous women during labor that can be used by nurses and midwives in most settings. Furthermore, these nonpharmacologic methods offer safe interventions for the mother and fetus and may decrease the use of invasive pharmacologic methods of pain management during labor. Dance and music and music alone may be especially appealing to women who desire more control over their labor experiences.

Q19

REFERENCES Abdolahian, S., Ghavi, F., Abdollahifard, S., & Sheikhan, F. (2014). Effect of dance labor on the management of active phase labor pain & clients’ satisfaction: A randomized controlled trial study. Global Journal of Health Science, 6(3), 219–226. https://doi.org/ 10.5539/gjhs.v6n3p219 Abdul-Sattar, K. A. S., & Mirkhan, A. H. (2018). Effect of change in position and back massage on pain perception during first stage of labor. Pain Management Nursing, 19(3), 288–294. https://doi.org/10.1016/j.pmn.2018.01.006  lu, D. (2017). Randomized controlled trials. Journal of Akin, B., & Koc¸og Hacettepe University Faculty of Nursing, 4(1), 73–92.

Limitations

Calik, K. Y., & Komurcu, N. (2014). SP6 noktasına akupresu¨r

We conducted our study in a single hospital in a homogeneous sample of nulliparous women, which limits the generalizability of our results. Because we measured pain and fear for only 90 minutes during the early active phase of labor, we did not evaluate the effect of dance and music throughout the duration of active labor. The lack of allocation concealment and not using the intention-to-treat population as part of our analyses are other limitations. In the dance and music intervention, the researcher is intimately involved in the provision of support to the woman in labor, which may represent a significant additional intervention of human presence, such that the dance and music intervention is actually dance, music, and support. Informing women about

 um eylemine ve akupresu¨r uygulauygulanan gebelerin dog masına ilis‚kin go¨ru¨s‚leri [The opinions of pregnant women about labor and acupressure application who received acupressure on their SP6 points]. Clinical and Experimental Health Sciences, 4(1), 29–37. https://doi.org/10.5455/mus-

Q8

bed.20140207083603 Durmaz, A., & Komurcu, N. (2015). Dogum agrisinin yonetiminde nonfarmakolojik

yontemler:

sistematik

inceleme

[Non-

pharmacological methods for pain management in labour: Systematic reviews]. Turkiye Klinikleri Journal of ObstetricWomen’s Health and Diseases Nursing, 1(3), 48–63. Ergin, A. B. (2014). Physiology of labor pain. In N. Komurcu (Ed.), Labor pain and management (pp. 22–26). Istanbul, Turkey: Nobel Medical Publishing. Fakhar, F. M., Rafii, F., & Orak, R. J. (2013). The effect of jaw relaxation on pain anxiety during burn dressings: Randomized clinical trial. Burns, 39(1), 61–67. https://doi.org/10.1016/j.burns.2012. 03.005

JOGNN 2020; Vol. -, Issue -

FLA 5.6.0 DTD
JOGN496_proof
11 February 2020
9:03 am
ce

9

RESEARCH

Dance and Music in Childbirth

1009

Gokyildiz, S. S., Ozturk, M., Avcibay, B. V., Alan, S., & Akbas, M.

[Use of nonpharmacologic relaxation and tactile stimulation

1062

1010

(2018). The effect of music on pain and anxiety of women

methods in labor pain]. Sisli Etfal Hastanesi Tıp Bulteni, 44(3),

1063

during labor on first time pregnancy: A study from Turkey.

137–142.

1011

Complementary Therapies in Clinical Practice, 30, 96–102.

1012

1064

Melzack, R., & Katz, J. (2013). Pain. Wiley Interdisciplinary Reviews:

https://doi.org/10.1016/j.ctcp.2017.12.015

Cognitive Science, 4(1), 1–15. https://doi.org/10.1002/wcs.

1065

1201

1066

1013

 lu, F. (2019). Effects of massage and Go¨nenc¸, I. M., & Terziog

1014

acupressure on relieving labor pain, reducing labor time, and

Mete, S. (2013). Stres, hormonlar ve dogum arasindaki iliski [Rela-

1067

1015

increasing delivery satisfaction. Journal of Nursing Research,

tionship between stress, hormones and labor]. Dokuz Eylul

1068

28(1), e68. https://doi.org/10.1097/jnr.0000000000000344

Universitesi Hemsirelik Fakultesi Elektronik Dergisi, 6(2), 93–98.

1016

1069

Gue´tin, S., Brun, L., Me´riadec, C., Camus, E., Deniaud, M., Thayer, J.

Miquelutti, M. A., Cecatti, J. G., Morais, S. S., & Makuch, M. Y. (2009).

1017

F., … Williams, D. P. (2018). A smart phone-based music

The vertical position during labor: Pain and satisfaction. Revista

1070

1018

intervention to reduce pain and anxiety in women before or

Brasileira de Sau´de Materno Infantil, 9(4), 393–398. https://doi.

1071

1019

during labor. European Journal of Integrative Medicine, 21, 24–

org/10.1590/S1519-38292009000400002

1072

1020

26. https://doi.org/10.1016/j.eujim.2018.06.001

Moayedi, M., & Davis, K. D. (2013). Theories of pain: From specificity

Ondeck, M. (2014). Healthy birth practice #2: Walk, move around, and

1075

change positions throughout labor. Journal of Perinatal Education,

1076

23(4), 188–193. https://doi.org/10.1891/1058-1243.23.4.188

1077

(2012). Comparing the effects of ice massage and acupressure

Price, D. D., McGrath, P. A., Rafii, A., & Buckingham, B. (1983). The

1078

on labor pain reduction. Complementary Therapies in Clinical

validation of visual analogue scales as ratio scale measures for

Practice, 18(3), 169–172. https://doi.org/10.1016/j.ctcp.2012.

chronic and experimental pain. Pain, 17, 45–56. https://doi.org/

thesia. Cochrane Database of Systematic Reviews, 2017, (5),

1023

CD002006. https://doi.org/10.1002/14651858.CD002006.pub4

1024

Hajiamini, Z., Masoud, S. N., Ebadi, A., Mahboubh, A., & Matin, A. A.

1025 1027

1074

https://doi.org/10.1152/jn.00457.2012

the second stage of labour for women without epidural anaes-

1022

1026

1073

to gate control. Journal of Neurophysiology, 109(1), 5–12.

Gupta, J. K., Sood, A., Hofmeyr, G. J., & Vogel, J. P. (2017). Position in

1021

1079 1080

10.1016/0304-3959(83)90126-4

05.003

1028

Ho, R. T., Lo, P. H., & Luk, M. Y. (2016). A good time to dance? A

Ricci, S. S. (2013). Essentials of maternity, newborn, and women’s

1081

1029

mixed-methods approach of the effects of dance movement

health nursing (3rd ed.). Philadelphia, PA: Lippincott Williams &

1082

1030

therapy for breast cancer patients during and after radio-

Wilkins.

1083

therapy. Cancer Nursing, 39(1), 32–41. https://doi.org/10.1097/

1031

Simavli, S., Kaygusuz, I., Gumus, I., Usluogulları, B., Yildirim, M., &

1084

Kafali, H. (2014). Effect of music therapy during vaginal delivery

NCC.0000000000000237

1032

Hosseini, S. E., Bagheri, M., & Honarparvaran, N. (2013). Investigating

on postpartum pain relief and mental health. Journal of Affective

1085

1033

the effect of music on labor pain and progress in the active

Disorders, 156, 194–199. https://doi.org/10.1016/j.jad.2013.12.

1086

1034

stage of first labor. European Review for Medical and Pharma-

027

1087

1035

cological Science, 17(11), 1479–1487.

Simkin, P., Hanson, L., & Ancheta, R. (2017). The labor progress

1088

handbook: Early interventions to prevent and treat dystocia (4th

Iliadou, M. (2012). Supporting women in labour. Health Science

1036

1089

ed.). Hoboken, NJ: John Wiley & Sons.

Journal, 6(3), 385–391.

1037

Jones, L., Othman, M., Dowswell, T., Alfirevic, Z., Gates, S., Newburn,

Sturm, I., Baak, J., Storek, B., Traore, A., & Thuss-Patience, P. (2014).

1090

1038

M., … Neilson, J. P. (2012). Pain management for women in

Effect of dance on cancer-related fatigue and quality of life.

1091

1039

labor: An overview of systematic reviews. Cochrane Database

Support Care Cancer, 22(8), 2241–2249. https://doi.org/10.

1092

1040

of Systematic Reviews, 2012, (3), CD009234. https://doi.org/10.

1007/s00520-014-2181-8

1093

1002/14651858.CD009234.pub2

1041

Tabachnick, B. G., Fidell, L. S., & Ullman, J. B. (2007). Using multivariate statistics (Vol. 5). Boston MA: Pearson.

Katz, J., & Rosenbloom, B. N. (2015). The golden anniversary of

Q9

1094

1042

Melzack and Wall’s gate control theory of pain: Celebrating 50

Taghinejad, H., Delpisheh, A., & Suhrabi, Z. (2010). Comparison be-

1095

1043

years of pain research and management. Pain Research &

tween massage and music therapies to relieve the severity of

1096

1044

Management, 20(6), 285–286. https://doi.org/10.1155/2015/

labor pain. Women’s Health, 6(3), 377–381. https://doi.org/10.

1097

1045

865487

2217/whe.10.15

1098

1046

Korukcu, O., Kukulu, K., & Firat, M. Z. (2012). The reliability and validity

Ucar, T., & Golbasi, Z. (2015). Nedenleri ve sonuclarıyla dogum kor-

of the Turkish version of the Wijma Delivery Expectancy/Expe-

kusu [Fear of childbirth, its causes and consequences]. Inonu

1047

rience Questionnaire (W-DEQ) with pregnant women. Journal of

Universitesi Saglik Bilimleri Dergisi, 4(2), 54–58.

1048

Psychiatric and Mental Health Nursing, 19(3), 193–202. https://

1049

doi.org/10.1111/j.1365-2850.2011.01694.x

1050 1051

Q10

1100

Vaajoki, A., Kankkunen, P., Pietila¨, A. M., & Vehvila¨inen-Julkunen, K.

1101

(2011). Music as a nursing intervention: Effects of music

1102

Labrague, L. J., Rosales, R. A., Rosales, G. L., & Fiel, G. B. (2013).

listening on blood pressure, heart rate, and respiratory rate in

1103

Effects of soothing music on labor pain among Filipino mothers.

abdominal surgery patients. Nursing & Health Sciences, 13(4), 412–418. https://doi.org/10.1111/j.1442-2018.2011.00633.x

Clinical Nursing Studies, 1(1), 35–42. https://doi.org/10.5430/

1052

1099

cns.v1n1p35

1104

Wijma, K., Wijma, B., & Zar, M. (1998). Psychometric aspects of the

1105

1053

Lee, S. L., Liu, C. Y., Lu, Y. Y., & Gau, M. L. (2012). Efficacy of warm

W-DEQ: A new questionnaire for the measurement of fear of

1106

1054

showers on labor pain and birth experience during the first la-

childbirth. Journal of Psychosomatic Obstetrics and Gynecol-

1107

1055

bor stage. Journal of Obstetric, Gynecologic, & Neonatal

ogy, 19(2), 84–97. https://doi.org/10.3109/01674829809048501 Q11

1108

Nursing, 42(1), 19–28. https://doi.org/10.1111/j.1552-6909.

1056

Xavier, T., & Viswanath, L. (2016). Effect of music therapy on labor pain among in active labor admitted in tertiary care hospital, Kochi

2012.01424.x

1057

Liu, Y. H., Chang, M. Y., & Chen, C. H. (2010). Effects of music therapy

1058

on labor pain and anxiety in Taiwanese first-time mothers.

1059

Journal of Clinical Nursing, 19(7–8), 1065–1072. https://doi.org/

1060

10.1111/j.1365-2702.2009.03028.x

1110

444–448. https://doi.org/10.16965/ijims.2016.145

1111 1112

reducing labor pain and reduction of labor: A randomized

1113

lanilan nonfarmakolojik gevseme ve tensel uyarilma yontemleri

10

City. International Journal of Integrative Medical Science, 3(11), Zahra, A., & Leila, M. S. (2013). Lavender aromatherapy massages in

Mamuk, R., & Davas, N. I. (2010). Dogum agrisinin kontrolunde kul-

1061

1109

controlled trial. African Journal of Pharmacy and Pharmacology, 7(8), 426–430. https://doi.org/10.5897/AJPP12.391

JOGNN, -, -–-; 2020. https://doi.org/10.1016/j.jogn.2019.12.005

FLA 5.6.0 DTD
JOGN496_proof
11 February 2020
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