Journalof PsychosomaticResearch,Vol. 20, pp. 523 to 533. PergamonPress, 1976. Printedin Great Britain
PREDICTORS OF PAIN DURING PREPARED CHILDBIRTH* ROSEMARY
COGAN,
WILLIAM
HENNEBORN
and
FREDERICK
KLOPFER
(Received 23 February 1976)
SINCEthe early part of this century, attempts have been made to apply psychosomatic approaches to pain relief during childbirth. Approaches have included the hypnosuggestive method in the Soviet Union, the natural childbirth approach of Reed in Great Britain, the psychoprophylactic method in the Soviet Union, France, the United States, and other countries, and recently derived modifications and combinations of various approaches in the United States. Although the roots of psychoprophylaxis were based to some extent upon Pavlovian experiments and theory, psychosomatic approaches to pain reduction in childbirth have generally been derived from practical experiences of physicians working in obstetrics. Given the tendency for programs to be based upon clinical experience, it is particularly striking to realize that virtually all programs contain common elements. Chertok [I] reviewed the varieties of psychosomatic methods applied to childbirth and concluded that almost all contain some type of learned relaxation, patterned breathing, information about labor and birth provided to the woman before birth, and support from attendants during labor and birth. The primary exception among programs of childbirth preparation was that of Jacobson [2] who explicitly advocated learned relaxation as being completely sufficient to provide pain relief for the woman in labor, at least during the first stage. Investigations of psychosomatic approaches to pain relief in childbirth have varied. Many sequences of case studies have been presented in an attempt to demonstrate the effectiveness of particular psychosomatic approaches to pain relief in childbirth. A smaller number of studies have compared birth experiences of women who either have or have not received some type of psychosomatic preparation for birth. In two early studies [3, 41, no effects of preparation were found. Rodway [3] investigated the effects of an exercise program which included relaxation training and found no evidence that pain was reduced during labor as a result of prenatal exercises. Davis and Morrone [4] compared births of women who had attended five or more prenatal classes with births of women who attended no more than one class. Patterned breathing, muscular relaxation techniques, and information about labor and birth were presented in classes. Although details of the assessment techniques are not clear, Davis and Morrone concluded that preparation reduced fears about pregnancy but had no effect upon the amount of sedation or anesthesia administered during labor and birth. It seems clear, however, that psychosomatic approaches to pain relief in childbirth do affect the birth experience. Chertok [5] has investigated relationships between
524
ROSEMARYCOGAN, WILLIAM HENNEBORNand FREDERICKKLOPFER
components of preparation for birth and other prenatal variables and the birth experience. Positive effects of preparation for birth have been reported in studies comparing birth experiences of women who did not elect to attend classes [5-lo] and in a study comparing birth experiences of women who either were or were not invited by their obstetrician to attend classes [ll]. Motivation to take classes was found not to affect the birth experience in two recent studies. Tanzer [12] compared birth experiences of women who elected to attend classes, women who were asked to take classes by their obstetrician, and women who neither elected nor received classes. Enkin et al. [13] compared birth experiences of women who elected and received classes, women who elected but did not receive classes (because of limitations in the availability of classes), and women who neither elected nor received classes. In both of these studies, women receiving prenatal classes received less medication, had more positive feelings about their birth experiences, and reported less pain during birth than women who did not receive classes. There were no differences in the birth experiences of women who elected or were assigned to classes and no differences between women who did not receive classes whether or not they had elected classes. In an extensive study of women who did or did not elect preparation, Chertok [5] correlated many background variables of the women with many components of their birth experience, including a complex measure reflecting the amount of pain women felt at each of four time periods within labor and birth. Although Chertok concluded that pain during labor was highly correlated with variables such as background negativity, use of relaxation skills during labor, etc. it is difficult from his study to evaluate the relative importance of background variables in influencing pain during labor and birth. Literature concerned with pain relief in situations other than childbirth suggests that information about forthcoming distressing experiences can reduce the emotional impact of stress [14-171. Learningper se may promote pain reduction [I 81and learning may be used to reduce pain [19]. Also, conditioned learning techniques such as relaxation techniques [20] and rapid breathing techniques [21, 221 may promote pain reduction. In the childbirth situation, providing women with additional clinic interviews during pregnancy has been shown to reduce medication required during childbirth [23]. Maternal anxiety [24-261, social relationships [27] and maternal “negativity” [5] have all been related to pain during birth. The present study is an attempt to explore the relative importance of prenatal variables related to psychosomatic preparation for childbirth in reducing pain during childbirth among a population of couples who selected preparation. By clarifying which of many prenatal variables most greatly influences pain, it should be possible to focus further investigation of psychosomatic approaches to pain relief during childbirth more clearly. METHOD Subjects
Teachers and students working with childbirth education classes sponsored by the Childbirth Without Pain Education League cooperated with the study. The Pavlov-Lamaze or psychoprophylactic approach was taught in a series of seven classes to groups of no more than 8 couples who elected the classes during their last trimester of pregnancy. The teachers were women who had experienced prepared childbirth, completed a common training process, used the same teaching materials, and followed the same class outline. Data were collected during 1972 and 1973. Since the 1973 data were
Predictors of pain during prepared childbirth
525
analyzed independently and were intended to serve as a replication of the earlier data, it is important to note that there were few differences in the subjects during the two years. In the following material, data describing the sample of the first year will be followed by the same information in parentheses describing the sample of the secona year. The 27 (40) teachers provided information about 255 (651) student births. The 255 (681) women provided information about their motivation for taking classes. Information was provided by 84 (228) wives and 81 (222) husbands about their nroaress in the classes after the fifth class meeting. Also responding were 8d (212) wives and 77 (199jhuibands who answered questions about their birth experiences and 35 (101) physician reports which provided information about the birth experiences of women in the population. Selectivity of questionnaire return was a factor only among returns of physicians [28] from whom questionnaires tended to be received if there had been no difficulties during the second stage of labor. A total 283 questions were asked about each birth. These included a wide range of questions about prenatal attitudes and experiences, activities related to preparation for birth, and birth experiences. Among questions about the birth experience were inquiries about the amount of pain felt by the woman during each of four time periods during labor and birth. The time periods included (1) dilation from about 0 to about 5 cm, (2) dilation from about 5 to about 8 cm, (3) dilation during transition [29] or dilation from about 8 to about 10 cm, and (4) the second stage of labor. Assessments of pain at all four time periods were requested from wives, husbands, and teachers. Assessments of pain during dilation and second stage were requested from physicians. Population
The wives averaged 24 (24) yr of age, ranging from 16 to 36 (16 to 38) yr. Ninety-eight per cent (94 %) of the wives were living with their husbands and 67 % (67 %) of the wives were primiparous. Wives attended an average of 7 prenatal classes and husbands attended an average of 6 prenatal classes during both years. Of the labors, 66% (62%) were from 2-15 hr in length. Induction was a factor in 36% (13 %) of the births. Medication was used before transition in 16% (21%) of the births, during transition in 22 % (22 %) of the births, and during second stage in 52 % (41%) of the births. Medication used during the second stage was most frequently a local injection. Episiotomies were performed in 88 % (87 %) of the births and forceps were used in 30 % (26 %) of the births. Husbands served as labor coaches during dilation in 95 % (96%) and as labor coaches during second stage in 75 ‘A (77 ‘A) of the births. Analyses
Stepwise multiple regression procedures [30] were applied to the data to identify the best predictors of each of the assessments of pain during labor. Predictor variables included all questions relating to events which occurred earlier in time than the criterion being predicted. In the case of the analyses of husband, teacher, and physician reports, the wives’ reported feelings during the time period involved were included among predictor variables. RESULTS A summary of the results of the regression equations is found in Tables 14. Two conservative criteria were used in determining cut-off points in the regression analyses. First, predictor variables were included only so long as the sequence of residual simple correlations decreased in size. Second, predictor variables were included only so long as their inclusion increased the multiple correlation by 5% or more. Thus an attempt was made to include in discussion only variables which contributed substantially to prediction of pain reports. DISCUSSION Table 1 suggests that there are profound differences in predictors of pain reported by wives, husbands, teachers, and physicians. To explore predictors of pain, it will be helpful to look closely at analyses for each of the four respondents during each period of labor. Wife’s report of pain
In the first sample, greater practice of the husband and wife together was related to greater pain reported by the wife during early labor. This might be accounted for by considering that extensive practicing together could have been a reaction to anxiety on the part of the couple about the impending labor. This anxiety might have been reduced more productively in some couples by talking together or by activities other than practicing. In the sample, other predictors of low pain in early labor involved economic motivation of the woman for taking classes being low, attendance by the wife at
second stage
transition
4 cm - transition
O-5 cm
.62
.69
.oa
Teacher's prediction of independence of wife during labor and birth
Teacher's evaluation of wife's skill -.oa at panting
.53
-.19
.36
.70
.63
.7a
.68
.59
.66
.61
.56
.39
MR
Teacher's report of wife's attitude toward second stage
.36
.34
Wife's skill at panting
Wife's amount of practice of breathing before birth
.63
-.13
Wife's preparedness to recognize transition
Wife's feelings during contractions from 5 cm - transition
.3a
.12
Physician's feelings about prepared childbirth
Rusbsnd's understanding of the theory of childbirth preparation
.12
Wife's recent attendance at a childcare or nursing information meeting
.59
-.37
Wife's feelings about the importance of economic motivation ’ for taking classes
Wife's feelings during contractions from O-5 cm
-.39
SR
Husband's report of amount of time he practiced with his wife
First Sample Second Sample
WIFE
Busband's report of wife's feelings during contractions from 5 cm transition
.30
.3a
.13
Identity of coach who worked with the wife during dilation Wife's feelings during contractions during transition
.2a
-.35
.59
.21
-.24
SR
Wife's feelings during contractions from 5 cm - transition
Identity of coach who worked with the wife during dilation
Wife's feelings during contractions from o-5 cm
Wife's preparedness at neuromuscular release
Husband's preparedness to help with pant blow technique
TABLE~.-?REDI(;TORSOFWWE'SFEJUNGSREPORTEDBY
.40
.3a
-37
.2a
.61
.59
.36
.24
MR
; s
g
2 B
6 a
E
p
E
2
"Z
f
E
B
F
3
o\
second stage
transition
5 cm - transition
o-5 (1p.
Wife's feelings about earlier birth experiences
.58
.27 A7
-.29
Husband's preparedness to help his wife with deep chest breathing
.49
Use of medication during first stage -.I6
.49
.62
.49
Wife's feelings during contractions during transition
Wife's feelings during contractions from 5 cm - transition
.56
.49 .49
.83
.72
.59
.58
.52
.40
MR
Husband's report of wife's feelings during contractions from 5 cm transition
-.06
.59
Wife's feelings about earlier birth experiences
Number of childbirth preparation classes attended by husband
.59
-.26
Wife's practice during the week before the birth
Wife's feelings during contractions from 5 cm - transition
-.28
.48
SR
Physician's previous experience with prepared childbirth
Wife's feelings during contractions from c-5 cm
First Sample
Husband's attendance at a childbirth movie
Use of medication during transition
Administration of a* episiotomy during second stage
Busband's report of wife's feelings during contractions from 5 cm transition
.19
-.22
.24
.46
..58
.44
Wife's feelings during contractions from O-5 cm
Wife's feelings during contractions during transition
.51
-.35
.59
SR
Husband's report of wife's feelings during contractions from O-5 cm
Identity of coach who worked with the wife during dilation
Wife's feelings during contractions from c-5 cm
Second Sample
TABLE 2.---PREDICTORSOFWIFE'SFEELINGSREPORTEDBYHUSBAND
.39
.33
.24
.66
.58
.60
.51
.64
.59
MR
G
E;. S
9 3. 8
0, a E. 1
7 % L. z! 0 ;!
transition
second stage
transition
San-
O-5 cm
.14
Teacher's report of attitude.of the wife's physician toward prepared childbirth
.73
.22 .lO
Physician's feelings about prepared childbirth
Length of'dilitiofi
.70
.47
Husband's understanding of the theory of childbirth preparation -.28
.47
.35
.21
Husband's preparedness to help his wife with pant blowing
Wife's feelings during contractions 'during second stage
Wife's attendance at childcare or nursing information meeting
.69
.59
.57
.57
Wife's feelings during contractions during transition
.66
Husband's understanding of the birth process -.45
.a1
.54
.63
.52
MR
.54
Teacher's report of wife's feelings during contractions from O-5 cm
.52
SR
Wife's feelings during contractions during second stage
Teacher's report of wife's feelings during dilation from 5 cm transition
.30
.39
.28
Use of medication during transition Physician's feelings about prepared
.3a
.39
.Wife's feelings during contractions during transition
Use of medication before transition
.52
-.23
Rusbaud's understanding of the birth process Teacher's report of wife's feelings during contractions from O-5 cm
-.27
SR .28
Length of time wife lived with baby's father before the birth
Length of dilation
Second Sample
WIFE'SFEELINGS REPORTED BY TEACHER
Wife's attitude toward birth after the fourth class
First Sample
TABLE 3.-PREDICTORSOF
.45
.39
.47
.38
.58
.52
.43
.37
MR .28
second stage
dilation
i
.22 .91
.64 .64
.46 .77
Husband's attendance at a birth movie
Husband's practice with his wife before birth
-.46 .80
Wife's understanding of the birth process
Husband's attitude before birth about.helping his wife during labor
-.57 .57
Second Sample
BY PHYSICIAN
.ll
.28
.51
Length of second stage
Wife's feelings during contractions from 5 cm - transition
-.26
.39
Physician's report of wife's feelings during contractions during dilation .64
Husbadd's preparedness to help his wife recognize transition
Husband's practice with his wife before birth
Husband's report of wife's feelings during dilation from 5 cm transition
WIFE'SFEELINGSREPORTED
Wife's parity
First Sanqle
TABLET.-F'REDICTORSOF
.79
.71
.64
-69
.58
.51
530
ROSEMARYCOQAN,WILLIAMHENNEBORNand FREDERICKKLOPFER
other child-related meetings, and positive physician feelings about prepared childbirth. All of these predictor variables may be regarded as social-emotional in nature. In the second sample, husband’s and wife’s feelings before birth of being well prepared to use techniques learned in class predicted lower reports of pain during labor. Particularly since it was the felt preparedness of the couple rather than either the judgment of preparedness made by the childbirth teacher or the amount of time spent in preparation that predicted pain, it seems most likely that the couple’s reported preparedness reflected their confidence in the mastery of skill learned during classes. In the second sample, pain during early labor was predicted less by variables reflecting interactions with social others and more by confidence of the couple in their developing skills. In both samples, the husband’s participation in preparation and birth was important. Perhaps what is most striking about these data are the variables which did not predict pain during early labor. Lower pain was not predicted by age or parity of the woman, reported attitudes of the wife, husband, or wife’s mother towards the birth experience, or such class-related variables as number of classes attended, time spent practicing, information acquired during classes, or attitude changes associated with attendance at classes. Mulcahy and Jamz [18] have found that pain thresholds assessedin anexperimental test are raised by 30 min of instruction and practice of techniques basic to childbirth education. The findings of Mulcahy and Jamz [18] and the lack of weighing of variables mentioned above in predicting pain during early labor suggest that the class-related variables among the present population may have been well above whatever minimum level is related to pain reduction associated with childbirth education. During dilation from 5 cm - transition and during transition pain reported by the wife was predicted primarily by her report of pain during the immediately preceding part of dilation. It is possible that a response-set is reflected in the association of each report with the previous report, of that pain experienced at one period of labor, is causally related to pain in later labor. From 5 cm - transition during the first sample, other predictors of low pain were the husband’s understanding of the theory of childbirth preparation and the wife’s preparedness before birth to recognize transition. In the first sample during transition, the wife’s skill at panting was a second order predictor of pain. During the second year for both periods, the identity of the coach who worked with the wife contributed to prediction of pain. If the husband served as labor coach, less pain was felt by the wife [31]. During the second stage, lower pain reported by the first sample was most closely related to more practice of breathing skills by the wife and the teacher’s estimation of the wife’s attitude toward second stage and degree of independence the teacheranticipated the wife would display in the management of labor and birth. In the second sample, pain during the second stage was most closely related to the wife’s feelings during transition and to the husband’s perception of his wife’s feelings earlier in labor. During the second stage, as during dilation, it is interesting to note that medication was not associated with pain. Administration of medication did not predict lower pain during second stage, [32]. Data during the second year did not replicate in close detail data from the first year. Throughout both years, however, many of the predictor variables reflect importance of social relationships with significant others in predicting pain during childbirth. During, both years, the activities of the husband appear to have special importance in predicting pain during prepared childbirth.
Husband’s report
of‘ wife'spain
Throughout dilation, but not in second stage, husband’s reports were most closely related to the wife’s reports. Other variables contributed rather little to prediction of the husband’s reports. During second stage, the wife’s reports of her feelings during second stage did not enter at all into prediction of the husband’s report in either year. Since husband’s reports of pain during second stage were available only from those husbands who were present during second stage, the absence of the wife’s feelings in predicting the husband’s report is striking. In the first sample, the wife’s feelings in earlier labor, the husband’s feelings of being well prepared before birth to help his wife with a breathing technique, and the wife’s positive feelings about earlier birth experiences predicted the husband’s report. It is particularly interesting to note that these predictors are not related to events or feelings of the second stage reported by wives. During the second year the administration of an episiotomy during the second stage predicted higher pain reports by the husband. Medication during transition predicted less pain reported by the husband and attendance at a childbirth movie also predicted lower pain reports by the husband. Perhaps the rather dramatic events of second stage, accompanied by vocalizations by the wife [33] and, frequently, an episiotomy, dominated the perception of second stage among husbands during the second year and provide stimuli which husbands interpreted as being associated with pain. In the present data as well as earlier data [34], wives but not husbands reported a decrease in pain during second stage (see Fig. 1).
Predictors
l --* .---• -A A---A
I
I
I
I
0-50-V
5cmtmn
Troll
Second
First
FIG. I.-Pain
531
of pain during prepared childbirth
year
stage
Wife’s report Husband’s report Teacher’s report Physician’s report I
I O-5cm
5cm-
tran Second year
experienced by wives during prepared childbirth husbands, teachers, and physicians.
I Tan
I Second
*ge
reported
by wives,
Teacher’s report of wife’s feelings Teacher’s reports of the wife’s pain during early labor were not related to the reports of the wife. During early labor in the tirst sample, the teacher’s reports of low pain were predicted by a positive attitude of the wife toward birth and the teacher’s perception of a positive attitude of the wife’s physician toward prepared childbirth. During the second year, teacher’s reports of low pain were predicted by shorter length of dilation, shorter length of time the couple had lived together, and less the husband’s understanding of the birth process. During 5 cm - transition, teacher’s reports were predicted primarily by the teacher’s reports of the wife’s pain earlier in labor. During transition, the wife’s feelings were the primary predictor of the teacher’s report in both years. The less understanding of the theory of childbirth education by the husband also predicted the teacher’s report of less pain in the first sample, while the use of less medication in transition and the less positive physician’s feelings about prepared childbirth were related to the teacher’s reports of less pain in the second group. During the second stage, the wife’s feelings during second stage were second order predictors of the teacher’s report during both years. Husband’s preparedness to help his wife with late labor pant blowing predicted the teacher’s reports of low pain the first sample and the teacher’s report of the wife’s feelings during dilation from 5 cm - transition predicted the teacher’s reports in the second sample. Teacher’s reports were not predicted by the wife’s reports during early labor, but were predicted by the wife’s reports during later labor. As can be seen in Fig. 1, teachers, like wives reported a decrease in pain during second stage (as has been reported earlier [34]). Teachers in this population were women who had themselves experienced prepared childbirth, which may be important in understanding the relationship of the teacher’s reports with the wife’s reports. It is apparent that teacher’s report of the wife’s pain throughout labor and birth were related to the teacher’s perception of the activities and attitudes of the husband and physician of the wife. Physician’s report of the wife’s feelings In neither dilation nor second stage were the physician’s reports predicted primarily by the wife’s feelings during labor. In the first sample, physicians reported less pain among multiparous than primiparous women, less pain with less understanding of the birth process reported by the wife after the fifth class meeting, and less pain the more positive the husband reported being about helping his wife during labor after the fifth class meeting. In the second sample, physicians reported less pain during dilation as a function of less pain reported by the husband from 5 cm - transition, less pain when the husband had practiced extensively with his wife, and less pain when the husband reported after the fifth class feeling well prepared to help his wife recognize transition. During the second stage, the physician reported less pain if the husband had attended a birth move and less pain if the husband practiced extensively with his wife. During the second year, physicians reported less pain during second stage if the physician reported less pain during dilation, if the wife reported less pain from 5 cm - transition, and if second stage was relatively short.
532
ROSEMARYCOGAN,WILLIAMHENNEBORNand FREDERICKKLOPFER
Particularly striking in the physician’s reports is the importance of husband-related variables in predicting the physician’s report. Just as the physician is a significant other from the viewpoint of the husband and the teacher, the husband is a significant other from the viewpoint of the physician. CONCLUSIONS
Preparation for childbirth has been found to reduce pain experienced in childbirth. At the same time, pain experienced during childbirth varies considerably among women who elect childbirth preparation, as can be seen most clearly in Chertok [5]. The present investigation was begun in a hope that by exploring predictors of variability among a population of women electing childbirth preparation, insight into the mechanisms by which childbirth preparation accomplishes pain reduction in childbirth might be achieved. Exploring predictors of pain in prepared childbirth has led in this investigation to the following findings: 1. Reports of the wife about pain experienced during prepared childbirth appear to be related to her confidence in her preparation and in the support of significant others, particularly her husband. 2. Many variables which are basic to preparation for childbirth did not contribute to the prediction of pain in any important way. It is possible that such variables as practice time, skills at techniques, attitudes toward birth and information about labor and birth are not particularly important in achieving pain reduction in childbirth and that other mechanisms, of a social-emotional nature, may be of more importance in the results achieved in childbirth education classes than has been previously expected. It seems more likely, however, that skill and technique-related variables of prepared childbirth may have been represented in the present population above whatever threshold value may be related to reduction of pain during childbirth. 3. Reports of significant others in the childbirth situation are not always like the wife’s reports. During dilation, the husband’s reports are related to the wife’s reports. During late labor and second stage, the teacher’s reports are more closely related to the wife’s reports than are the husband’s or physician’s reports. 4. Participants’ perceptions of pain during childbirth are affected by participants’ perceptions of significant others in the childbirth situation. For the husband and teacher, the physician is an important significant-other. For the physician, the husband is an important significant-other. REFERENCES 1. CHERTOKL. Psychosomatic methods in painless childbirth. Pergamon, Oxford (1954). 2. JACOBSONE. Relaxation methods in labor. Am. J. Obstet. Gynecol. 67, 1035 (1954). 3. RODWAYH. W. A statistical study on the effects of exercise on childbearing. J. Obstet. Gynecol. 54, 77 (1947). 4. DAVIS C. D. and MORRONEF. A. An objective evaluation of a prepared childbirth program. Am. J. Obstet. Gynecol. 84, (9), 1196 (1962). 5. CHER~OKL. Motherhoodand Personality: Psychosomatic Aspects of Childbirth. Lippincott, Philadelphia (1969). 6. DAVIDSONH. B. The psychosomatic aspects of educated childbirth. New York State Journal of Medicine, November, 1953, 2499-2503. 7. VAN EPS L. W. Psychoprophylaxis in labor. Lancet 2, 112 (1955). 8. KLXJSMAN, L. E. Reduction of pain in childbirth by the alleviation of anxiety during pregnancy. J. Consult. Clin. Psychol. (1975). 9. OLIVER W. A. Childbirth expectancies and experiences as a function of locus of control and Lamaze training. Unpublished Doctoral Dissertation, Ohio State University (1972).
Predictors of pain during prepared childbirth
533
10. ZAX, M., SAMEROFFA. J. and FARNUM J. E. Childbirth education, maternal attitudes and delivery. Am. J. Obstet. Gynecol., 123 185 (1975). 11. HU~LE F. A., MITCHELLI., FISHERW. M. and MEYERA. E. A quantitative evolution of psychoprophylaxis in childbirth. J. Psychosom. Res. 16, 81 (1972). 12. TANZERS. The psychology of pregnancy and childbirth: An investigation of natural childbirth. Unpublished Doctoral Dissertation, Brandeis University (1967). 13. 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 Gynecology, M. N. MORRIS(Ed.), 3rd Int. Congress, London, 1971. Steines, Base1 (1972). 14. JANISI. Psychological Stress. Wiley, New York (1958). 15. LAZARUSR. S., SPEISMANJ. C., MORDKOFFA. M. and DAVIDSONL. A laboratory study of psychological stress produced by a motion picture film. Psychol. Monogr. 76, 1 (1962). 16. LAZARUSR. S. and ALFERT E. Short circuiting of threat by experimentally altering cognitive appraisal. J. Abnorm. Social Psychol. 69, 195 (1964). 17. ECBERTL. D., BATTITG. E., WELCHC. E. and BARTLETTM. I. Reductions of postoperative pain by encouragement and instruction of patients. New England J. Medicine 270 (1964). 18. MULCAHYR. A. and JAMZ N. Effectiveness of raising pain perception threshold in males and females using a psychoprophylactic childbirth technique during induced pain. Nursing Res. 22. 423 (1973). 19. FORDYCEW. E., FOWLERR. S., LEHMANN,J. F. DELA~EURB. J., SAND P. L. and TRIESCHMANN R. B. Operant conditioning in the treatment of chronic pain. Arch. Phys. Med. Rehabiln 54, 399 (1973). 20. BOBEYM. J. and DAVIDSONP. 0. Psychological factors affecting pain tolerance. J. Psychosom. Res. 14, 371 (1970). 21. LEE B. The analgesic effects of rapid and forceful respiration. Philude/phia Med. Times, Philadelphia, 10,498 (1880).
22. BONWILL W. G. A rapid breathing a pain obtrude in minor surgery, obstetrics, the general practice of medicine and of dentistry. Phihzdelphia Med. Times, Philadelphia, 10, 1879 (I 880). 23. CARPENTERJ., ALDRICHC. K. and BOVERMANH. The effectiveness of patient interviews, a controlled study of emotional support during pregnancy. Arch. Gen. Psychiat. 19, 110 (1968). 24. DAVIDS A., DEVAULT S. and TALMADGEM. Anxiety, pregnancy and childbirth abnormalities. J. Consult. Psychol. 25, 74 (1961). 25. DAVIDS A. and DEVAULT S. Maternal anxiety during pregnancy and childbirth. J. Psychosom. Med. 24,464 (1962). 26. ZEMLICKM. and WATSONR. Maternal attitudes of acceptance and rejection during and after pregnancy. Am. J. of Orthopsychiat. 13, 570 (1953). 27. ROSENGREN W. R. Some social and psychological aspects of delivery room difficulties. J. Nerv. Ment. Dis. 132, 515 (1961). 28. COGAN R. and KLOPFER F. The delivery of childbirth reports: an analysis of sample bias in questionnaire returns. J. Psychosom. Res. 19, 39 (1975). 29. VELLAYP. Childbirth with Confidence. MacMillan, New York (1969). 30. NIE N. H., HULL C. H., JENKINSJ. G., STEINBRENNER, K. and BENT D. Stntistical Packagefor the Social Sciences. McGraw-Hill, New York (1975).
31. HENNEBORNW. J. and COGAN R. The effect of husband participation on reported pain and probability of medications during labor and birth. Paper presented at the Rocky Mountain Psychological Association, May, 1974. 32. KLOPFERF., COGANR. and HENNEBORNW. Second stage medical intervention and pain during childbirth. J. Psychosom. Res. 19, 289 (1975). 33. AFFONSOD. Crisis of labor and birth. In Maturational Crisis of Childbearing. ANN CLAR (Ed.), pp. 23-29 (1971). University of Hawaii, Honolulu, Hawaii. 34. C~CAN R. Comfort during prepared childbirth as a function of parity, reported by four classes of participant observers. J. Psychosom. Res. 19, 33 (1975).
PREDICTORS OF PAIN DURING PREPARED CHILDBIRTH* ROSEMARY
COGAN,
WILLIAM
HENNEBORN
and
FREDERICK
KLOPFER
(Received 23 February 1976)
SINCEthe early part of this century, attempts have been made to apply psychosomatic approaches to pain relief during childbirth. Approaches have included the hypnosuggestive method in the Soviet Union, the natural childbirth approach of Reed in Great Britain, the psychoprophylactic method in the Soviet Union, France, the United States, and other countries, and recently derived modifications and combinations of various approaches in the United States. Although the roots of psychoprophylaxis were based to some extent upon Pavlovian experiments and theory, psychosomatic approaches to pain reduction in childbirth have generally been derived from practical experiences of physicians working in obstetrics. Given the tendency for programs to be based upon clinical experience, it is particularly striking to realize that virtually all programs contain common elements. Chertok [I] reviewed the varieties of psychosomatic methods applied to childbirth and concluded that almost all contain some type of learned relaxation, patterned breathing, information about labor and birth provided to the woman before birth, and support from attendants during labor and birth. The primary exception among programs of childbirth preparation was that of Jacobson [2] who explicitly advocated learned relaxation as being completely sufficient to provide pain relief for the woman in labor, at least during the first stage. Investigations of psychosomatic approaches to pain relief in childbirth have varied. Many sequences of case studies have been presented in an attempt to demonstrate the effectiveness of particular psychosomatic approaches to pain relief in childbirth. A smaller number of studies have compared birth experiences of women who either have or have not received some type of psychosomatic preparation for birth. In two early studies [3, 41, no effects of preparation were found. Rodway [3] investigated the effects of an exercise program which included relaxation training and found no evidence that pain was reduced during labor as a result of prenatal exercises. Davis and Morrone [4] compared births of women who had attended five or more prenatal classes with births of women who attended no more than one class. Patterned breathing, muscular relaxation techniques, and information about labor and birth were presented in classes. Although details of the assessment techniques are not clear, Davis and Morrone concluded that preparation reduced fears about pregnancy but had no effect upon the amount of sedation or anesthesia administered during labor and birth. It seems clear, however, that psychosomatic approaches to pain relief in childbirth do affect the birth experience. Chertok [5] has investigated relationships between
524
ROSEMARYCOGAN, WILLIAM HENNEBORNand FREDERICKKLOPFER
components of preparation for birth and other prenatal variables and the birth experience. Positive effects of preparation for birth have been reported in studies comparing birth experiences of women who did not elect to attend classes [5-lo] and in a study comparing birth experiences of women who either were or were not invited by their obstetrician to attend classes [ll]. Motivation to take classes was found not to affect the birth experience in two recent studies. Tanzer [12] compared birth experiences of women who elected to attend classes, women who were asked to take classes by their obstetrician, and women who neither elected nor received classes. Enkin et al. [13] compared birth experiences of women who elected and received classes, women who elected but did not receive classes (because of limitations in the availability of classes), and women who neither elected nor received classes. In both of these studies, women receiving prenatal classes received less medication, had more positive feelings about their birth experiences, and reported less pain during birth than women who did not receive classes. There were no differences in the birth experiences of women who elected or were assigned to classes and no differences between women who did not receive classes whether or not they had elected classes. In an extensive study of women who did or did not elect preparation, Chertok [5] correlated many background variables of the women with many components of their birth experience, including a complex measure reflecting the amount of pain women felt at each of four time periods within labor and birth. Although Chertok concluded that pain during labor was highly correlated with variables such as background negativity, use of relaxation skills during labor, etc. it is difficult from his study to evaluate the relative importance of background variables in influencing pain during labor and birth. Literature concerned with pain relief in situations other than childbirth suggests that information about forthcoming distressing experiences can reduce the emotional impact of stress [14-171. Learningper se may promote pain reduction [I 81and learning may be used to reduce pain [19]. Also, conditioned learning techniques such as relaxation techniques [20] and rapid breathing techniques [21, 221 may promote pain reduction. In the childbirth situation, providing women with additional clinic interviews during pregnancy has been shown to reduce medication required during childbirth [23]. Maternal anxiety [24-261, social relationships [27] and maternal “negativity” [5] have all been related to pain during birth. The present study is an attempt to explore the relative importance of prenatal variables related to psychosomatic preparation for childbirth in reducing pain during childbirth among a population of couples who selected preparation. By clarifying which of many prenatal variables most greatly influences pain, it should be possible to focus further investigation of psychosomatic approaches to pain relief during childbirth more clearly. METHOD Subjects
Teachers and students working with childbirth education classes sponsored by the Childbirth Without Pain Education League cooperated with the study. The Pavlov-Lamaze or psychoprophylactic approach was taught in a series of seven classes to groups of no more than 8 couples who elected the classes during their last trimester of pregnancy. The teachers were women who had experienced prepared childbirth, completed a common training process, used the same teaching materials, and followed the same class outline. Data were collected during 1972 and 1973. Since the 1973 data were
Predictors of pain during prepared childbirth
525
analyzed independently and were intended to serve as a replication of the earlier data, it is important to note that there were few differences in the subjects during the two years. In the following material, data describing the sample of the first year will be followed by the same information in parentheses describing the sample of the secona year. The 27 (40) teachers provided information about 255 (651) student births. The 255 (681) women provided information about their motivation for taking classes. Information was provided by 84 (228) wives and 81 (222) husbands about their nroaress in the classes after the fifth class meeting. Also responding were 8d (212) wives and 77 (199jhuibands who answered questions about their birth experiences and 35 (101) physician reports which provided information about the birth experiences of women in the population. Selectivity of questionnaire return was a factor only among returns of physicians [28] from whom questionnaires tended to be received if there had been no difficulties during the second stage of labor. A total 283 questions were asked about each birth. These included a wide range of questions about prenatal attitudes and experiences, activities related to preparation for birth, and birth experiences. Among questions about the birth experience were inquiries about the amount of pain felt by the woman during each of four time periods during labor and birth. The time periods included (1) dilation from about 0 to about 5 cm, (2) dilation from about 5 to about 8 cm, (3) dilation during transition [29] or dilation from about 8 to about 10 cm, and (4) the second stage of labor. Assessments of pain at all four time periods were requested from wives, husbands, and teachers. Assessments of pain during dilation and second stage were requested from physicians. Population
The wives averaged 24 (24) yr of age, ranging from 16 to 36 (16 to 38) yr. Ninety-eight per cent (94 %) of the wives were living with their husbands and 67 % (67 %) of the wives were primiparous. Wives attended an average of 7 prenatal classes and husbands attended an average of 6 prenatal classes during both years. Of the labors, 66% (62%) were from 2-15 hr in length. Induction was a factor in 36% (13 %) of the births. Medication was used before transition in 16% (21%) of the births, during transition in 22 % (22 %) of the births, and during second stage in 52 % (41%) of the births. Medication used during the second stage was most frequently a local injection. Episiotomies were performed in 88 % (87 %) of the births and forceps were used in 30 % (26 %) of the births. Husbands served as labor coaches during dilation in 95 % (96%) and as labor coaches during second stage in 75 ‘A (77 ‘A) of the births. Analyses
Stepwise multiple regression procedures [30] were applied to the data to identify the best predictors of each of the assessments of pain during labor. Predictor variables included all questions relating to events which occurred earlier in time than the criterion being predicted. In the case of the analyses of husband, teacher, and physician reports, the wives’ reported feelings during the time period involved were included among predictor variables. RESULTS A summary of the results of the regression equations is found in Tables 14. Two conservative criteria were used in determining cut-off points in the regression analyses. First, predictor variables were included only so long as the sequence of residual simple correlations decreased in size. Second, predictor variables were included only so long as their inclusion increased the multiple correlation by 5% or more. Thus an attempt was made to include in discussion only variables which contributed substantially to prediction of pain reports. DISCUSSION Table 1 suggests that there are profound differences in predictors of pain reported by wives, husbands, teachers, and physicians. To explore predictors of pain, it will be helpful to look closely at analyses for each of the four respondents during each period of labor. Wife’s report of pain
In the first sample, greater practice of the husband and wife together was related to greater pain reported by the wife during early labor. This might be accounted for by considering that extensive practicing together could have been a reaction to anxiety on the part of the couple about the impending labor. This anxiety might have been reduced more productively in some couples by talking together or by activities other than practicing. In the sample, other predictors of low pain in early labor involved economic motivation of the woman for taking classes being low, attendance by the wife at
second stage
transition
4 cm - transition
O-5 cm
.62
.69
.oa
Teacher's prediction of independence of wife during labor and birth
Teacher's evaluation of wife's skill -.oa at panting
.53
-.19
.36
.70
.63
.7a
.68
.59
.66
.61
.56
.39
MR
Teacher's report of wife's attitude toward second stage
.36
.34
Wife's skill at panting
Wife's amount of practice of breathing before birth
.63
-.13
Wife's preparedness to recognize transition
Wife's feelings during contractions from 5 cm - transition
.3a
.12
Physician's feelings about prepared childbirth
Rusbsnd's understanding of the theory of childbirth preparation
.12
Wife's recent attendance at a childcare or nursing information meeting
.59
-.37
Wife's feelings about the importance of economic motivation ’ for taking classes
Wife's feelings during contractions from O-5 cm
-.39
SR
Husband's report of amount of time he practiced with his wife
First Sample Second Sample
WIFE
Busband's report of wife's feelings during contractions from 5 cm transition
.30
.3a
.13
Identity of coach who worked with the wife during dilation Wife's feelings during contractions during transition
.2a
-.35
.59
.21
-.24
SR
Wife's feelings during contractions from 5 cm - transition
Identity of coach who worked with the wife during dilation
Wife's feelings during contractions from o-5 cm
Wife's preparedness at neuromuscular release
Husband's preparedness to help with pant blow technique
TABLE~.-?REDI(;TORSOFWWE'SFEJUNGSREPORTEDBY
.40
.3a
-37
.2a
.61
.59
.36
.24
MR
; s
g
2 B
6 a
E
p
E
2
"Z
f
E
B
F
3
o\
second stage
transition
5 cm - transition
o-5 (1p.
Wife's feelings about earlier birth experiences
.58
.27 A7
-.29
Husband's preparedness to help his wife with deep chest breathing
.49
Use of medication during first stage -.I6
.49
.62
.49
Wife's feelings during contractions during transition
Wife's feelings during contractions from 5 cm - transition
.56
.49 .49
.83
.72
.59
.58
.52
.40
MR
Husband's report of wife's feelings during contractions from 5 cm transition
-.06
.59
Wife's feelings about earlier birth experiences
Number of childbirth preparation classes attended by husband
.59
-.26
Wife's practice during the week before the birth
Wife's feelings during contractions from 5 cm - transition
-.28
.48
SR
Physician's previous experience with prepared childbirth
Wife's feelings during contractions from c-5 cm
First Sample
Husband's attendance at a childbirth movie
Use of medication during transition
Administration of a* episiotomy during second stage
Busband's report of wife's feelings during contractions from 5 cm transition
.19
-.22
.24
.46
..58
.44
Wife's feelings during contractions from O-5 cm
Wife's feelings during contractions during transition
.51
-.35
.59
SR
Husband's report of wife's feelings during contractions from O-5 cm
Identity of coach who worked with the wife during dilation
Wife's feelings during contractions from c-5 cm
Second Sample
TABLE 2.---PREDICTORSOFWIFE'SFEELINGSREPORTEDBYHUSBAND
.39
.33
.24
.66
.58
.60
.51
.64
.59
MR
G
E;. S
9 3. 8
0, a E. 1
7 % L. z! 0 ;!
transition
second stage
transition
San-
O-5 cm
.14
Teacher's report of attitude.of the wife's physician toward prepared childbirth
.73
.22 .lO
Physician's feelings about prepared childbirth
Length of'dilitiofi
.70
.47
Husband's understanding of the theory of childbirth preparation -.28
.47
.35
.21
Husband's preparedness to help his wife with pant blowing
Wife's feelings during contractions 'during second stage
Wife's attendance at childcare or nursing information meeting
.69
.59
.57
.57
Wife's feelings during contractions during transition
.66
Husband's understanding of the birth process -.45
.a1
.54
.63
.52
MR
.54
Teacher's report of wife's feelings during contractions from O-5 cm
.52
SR
Wife's feelings during contractions during second stage
Teacher's report of wife's feelings during dilation from 5 cm transition
.30
.39
.28
Use of medication during transition Physician's feelings about prepared
.3a
.39
.Wife's feelings during contractions during transition
Use of medication before transition
.52
-.23
Rusbaud's understanding of the birth process Teacher's report of wife's feelings during contractions from O-5 cm
-.27
SR .28
Length of time wife lived with baby's father before the birth
Length of dilation
Second Sample
WIFE'SFEELINGS REPORTED BY TEACHER
Wife's attitude toward birth after the fourth class
First Sample
TABLE 3.-PREDICTORSOF
.45
.39
.47
.38
.58
.52
.43
.37
MR .28
second stage
dilation
i
.22 .91
.64 .64
.46 .77
Husband's attendance at a birth movie
Husband's practice with his wife before birth
-.46 .80
Wife's understanding of the birth process
Husband's attitude before birth about.helping his wife during labor
-.57 .57
Second Sample
BY PHYSICIAN
.ll
.28
.51
Length of second stage
Wife's feelings during contractions from 5 cm - transition
-.26
.39
Physician's report of wife's feelings during contractions during dilation .64
Husbadd's preparedness to help his wife recognize transition
Husband's practice with his wife before birth
Husband's report of wife's feelings during dilation from 5 cm transition
WIFE'SFEELINGSREPORTED
Wife's parity
First Sanqle
TABLET.-F'REDICTORSOF
.79
.71
.64
-69
.58
.51
530
ROSEMARYCOQAN,WILLIAMHENNEBORNand FREDERICKKLOPFER
other child-related meetings, and positive physician feelings about prepared childbirth. All of these predictor variables may be regarded as social-emotional in nature. In the second sample, husband’s and wife’s feelings before birth of being well prepared to use techniques learned in class predicted lower reports of pain during labor. Particularly since it was the felt preparedness of the couple rather than either the judgment of preparedness made by the childbirth teacher or the amount of time spent in preparation that predicted pain, it seems most likely that the couple’s reported preparedness reflected their confidence in the mastery of skill learned during classes. In the second sample, pain during early labor was predicted less by variables reflecting interactions with social others and more by confidence of the couple in their developing skills. In both samples, the husband’s participation in preparation and birth was important. Perhaps what is most striking about these data are the variables which did not predict pain during early labor. Lower pain was not predicted by age or parity of the woman, reported attitudes of the wife, husband, or wife’s mother towards the birth experience, or such class-related variables as number of classes attended, time spent practicing, information acquired during classes, or attitude changes associated with attendance at classes. Mulcahy and Jamz [18] have found that pain thresholds assessedin anexperimental test are raised by 30 min of instruction and practice of techniques basic to childbirth education. The findings of Mulcahy and Jamz [18] and the lack of weighing of variables mentioned above in predicting pain during early labor suggest that the class-related variables among the present population may have been well above whatever minimum level is related to pain reduction associated with childbirth education. During dilation from 5 cm - transition and during transition pain reported by the wife was predicted primarily by her report of pain during the immediately preceding part of dilation. It is possible that a response-set is reflected in the association of each report with the previous report, of that pain experienced at one period of labor, is causally related to pain in later labor. From 5 cm - transition during the first sample, other predictors of low pain were the husband’s understanding of the theory of childbirth preparation and the wife’s preparedness before birth to recognize transition. In the first sample during transition, the wife’s skill at panting was a second order predictor of pain. During the second year for both periods, the identity of the coach who worked with the wife contributed to prediction of pain. If the husband served as labor coach, less pain was felt by the wife [31]. During the second stage, lower pain reported by the first sample was most closely related to more practice of breathing skills by the wife and the teacher’s estimation of the wife’s attitude toward second stage and degree of independence the teacheranticipated the wife would display in the management of labor and birth. In the second sample, pain during the second stage was most closely related to the wife’s feelings during transition and to the husband’s perception of his wife’s feelings earlier in labor. During the second stage, as during dilation, it is interesting to note that medication was not associated with pain. Administration of medication did not predict lower pain during second stage, [32]. Data during the second year did not replicate in close detail data from the first year. Throughout both years, however, many of the predictor variables reflect importance of social relationships with significant others in predicting pain during childbirth. During, both years, the activities of the husband appear to have special importance in predicting pain during prepared childbirth.
Husband’s report
of‘ wife'spain
Throughout dilation, but not in second stage, husband’s reports were most closely related to the wife’s reports. Other variables contributed rather little to prediction of the husband’s reports. During second stage, the wife’s reports of her feelings during second stage did not enter at all into prediction of the husband’s report in either year. Since husband’s reports of pain during second stage were available only from those husbands who were present during second stage, the absence of the wife’s feelings in predicting the husband’s report is striking. In the first sample, the wife’s feelings in earlier labor, the husband’s feelings of being well prepared before birth to help his wife with a breathing technique, and the wife’s positive feelings about earlier birth experiences predicted the husband’s report. It is particularly interesting to note that these predictors are not related to events or feelings of the second stage reported by wives. During the second year the administration of an episiotomy during the second stage predicted higher pain reports by the husband. Medication during transition predicted less pain reported by the husband and attendance at a childbirth movie also predicted lower pain reports by the husband. Perhaps the rather dramatic events of second stage, accompanied by vocalizations by the wife [33] and, frequently, an episiotomy, dominated the perception of second stage among husbands during the second year and provide stimuli which husbands interpreted as being associated with pain. In the present data as well as earlier data [34], wives but not husbands reported a decrease in pain during second stage (see Fig. 1).
Predictors
l --* .---• -A A---A
I
I
I
I
0-50-V
5cmtmn
Troll
Second
First
FIG. I.-Pain
531
of pain during prepared childbirth
year
stage
Wife’s report Husband’s report Teacher’s report Physician’s report I
I O-5cm
5cm-
tran Second year
experienced by wives during prepared childbirth husbands, teachers, and physicians.
I Tan
I Second
*ge
reported
by wives,
Teacher’s report of wife’s feelings Teacher’s reports of the wife’s pain during early labor were not related to the reports of the wife. During early labor in the tirst sample, the teacher’s reports of low pain were predicted by a positive attitude of the wife toward birth and the teacher’s perception of a positive attitude of the wife’s physician toward prepared childbirth. During the second year, teacher’s reports of low pain were predicted by shorter length of dilation, shorter length of time the couple had lived together, and less the husband’s understanding of the birth process. During 5 cm - transition, teacher’s reports were predicted primarily by the teacher’s reports of the wife’s pain earlier in labor. During transition, the wife’s feelings were the primary predictor of the teacher’s report in both years. The less understanding of the theory of childbirth education by the husband also predicted the teacher’s report of less pain in the first sample, while the use of less medication in transition and the less positive physician’s feelings about prepared childbirth were related to the teacher’s reports of less pain in the second group. During the second stage, the wife’s feelings during second stage were second order predictors of the teacher’s report during both years. Husband’s preparedness to help his wife with late labor pant blowing predicted the teacher’s reports of low pain the first sample and the teacher’s report of the wife’s feelings during dilation from 5 cm - transition predicted the teacher’s reports in the second sample. Teacher’s reports were not predicted by the wife’s reports during early labor, but were predicted by the wife’s reports during later labor. As can be seen in Fig. 1, teachers, like wives reported a decrease in pain during second stage (as has been reported earlier [34]). Teachers in this population were women who had themselves experienced prepared childbirth, which may be important in understanding the relationship of the teacher’s reports with the wife’s reports. It is apparent that teacher’s report of the wife’s pain throughout labor and birth were related to the teacher’s perception of the activities and attitudes of the husband and physician of the wife. Physician’s report of the wife’s feelings In neither dilation nor second stage were the physician’s reports predicted primarily by the wife’s feelings during labor. In the first sample, physicians reported less pain among multiparous than primiparous women, less pain with less understanding of the birth process reported by the wife after the fifth class meeting, and less pain the more positive the husband reported being about helping his wife during labor after the fifth class meeting. In the second sample, physicians reported less pain during dilation as a function of less pain reported by the husband from 5 cm - transition, less pain when the husband had practiced extensively with his wife, and less pain when the husband reported after the fifth class feeling well prepared to help his wife recognize transition. During the second stage, the physician reported less pain if the husband had attended a birth move and less pain if the husband practiced extensively with his wife. During the second year, physicians reported less pain during second stage if the physician reported less pain during dilation, if the wife reported less pain from 5 cm - transition, and if second stage was relatively short.
532
ROSEMARYCOGAN,WILLIAMHENNEBORNand FREDERICKKLOPFER
Particularly striking in the physician’s reports is the importance of husband-related variables in predicting the physician’s report. Just as the physician is a significant other from the viewpoint of the husband and the teacher, the husband is a significant other from the viewpoint of the physician. CONCLUSIONS
Preparation for childbirth has been found to reduce pain experienced in childbirth. At the same time, pain experienced during childbirth varies considerably among women who elect childbirth preparation, as can be seen most clearly in Chertok [5]. The present investigation was begun in a hope that by exploring predictors of variability among a population of women electing childbirth preparation, insight into the mechanisms by which childbirth preparation accomplishes pain reduction in childbirth might be achieved. Exploring predictors of pain in prepared childbirth has led in this investigation to the following findings: 1. Reports of the wife about pain experienced during prepared childbirth appear to be related to her confidence in her preparation and in the support of significant others, particularly her husband. 2. Many variables which are basic to preparation for childbirth did not contribute to the prediction of pain in any important way. It is possible that such variables as practice time, skills at techniques, attitudes toward birth and information about labor and birth are not particularly important in achieving pain reduction in childbirth and that other mechanisms, of a social-emotional nature, may be of more importance in the results achieved in childbirth education classes than has been previously expected. It seems more likely, however, that skill and technique-related variables of prepared childbirth may have been represented in the present population above whatever threshold value may be related to reduction of pain during childbirth. 3. Reports of significant others in the childbirth situation are not always like the wife’s reports. During dilation, the husband’s reports are related to the wife’s reports. During late labor and second stage, the teacher’s reports are more closely related to the wife’s reports than are the husband’s or physician’s reports. 4. Participants’ perceptions of pain during childbirth are affected by participants’ perceptions of significant others in the childbirth situation. For the husband and teacher, the physician is an important significant-other. For the physician, the husband is an important significant-other. REFERENCES 1. CHERTOKL. Psychosomatic methods in painless childbirth. Pergamon, Oxford (1954). 2. JACOBSONE. Relaxation methods in labor. Am. J. Obstet. Gynecol. 67, 1035 (1954). 3. RODWAYH. W. A statistical study on the effects of exercise on childbearing. J. Obstet. Gynecol. 54, 77 (1947). 4. DAVIS C. D. and MORRONEF. A. An objective evaluation of a prepared childbirth program. Am. J. Obstet. Gynecol. 84, (9), 1196 (1962). 5. CHER~OKL. Motherhoodand Personality: Psychosomatic Aspects of Childbirth. Lippincott, Philadelphia (1969). 6. DAVIDSONH. B. The psychosomatic aspects of educated childbirth. New York State Journal of Medicine, November, 1953, 2499-2503. 7. VAN EPS L. W. Psychoprophylaxis in labor. Lancet 2, 112 (1955). 8. KLXJSMAN, L. E. Reduction of pain in childbirth by the alleviation of anxiety during pregnancy. J. Consult. Clin. Psychol. (1975). 9. OLIVER W. A. Childbirth expectancies and experiences as a function of locus of control and Lamaze training. Unpublished Doctoral Dissertation, Ohio State University (1972).
Predictors of pain during prepared childbirth
533
10. ZAX, M., SAMEROFFA. J. and FARNUM J. E. Childbirth education, maternal attitudes and delivery. Am. J. Obstet. Gynecol., 123 185 (1975). 11. HU~LE F. A., MITCHELLI., FISHERW. M. and MEYERA. E. A quantitative evolution of psychoprophylaxis in childbirth. J. Psychosom. Res. 16, 81 (1972). 12. TANZERS. The psychology of pregnancy and childbirth: An investigation of natural childbirth. Unpublished Doctoral Dissertation, Brandeis University (1967). 13. 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 Gynecology, M. N. MORRIS(Ed.), 3rd Int. Congress, London, 1971. Steines, Base1 (1972). 14. JANISI. Psychological Stress. Wiley, New York (1958). 15. LAZARUSR. S., SPEISMANJ. C., MORDKOFFA. M. and DAVIDSONL. A laboratory study of psychological stress produced by a motion picture film. Psychol. Monogr. 76, 1 (1962). 16. LAZARUSR. S. and ALFERT E. Short circuiting of threat by experimentally altering cognitive appraisal. J. Abnorm. Social Psychol. 69, 195 (1964). 17. ECBERTL. D., BATTITG. E., WELCHC. E. and BARTLETTM. I. Reductions of postoperative pain by encouragement and instruction of patients. New England J. Medicine 270 (1964). 18. MULCAHYR. A. and JAMZ N. Effectiveness of raising pain perception threshold in males and females using a psychoprophylactic childbirth technique during induced pain. Nursing Res. 22. 423 (1973). 19. FORDYCEW. E., FOWLERR. S., LEHMANN,J. F. DELA~EURB. J., SAND P. L. and TRIESCHMANN R. B. Operant conditioning in the treatment of chronic pain. Arch. Phys. Med. Rehabiln 54, 399 (1973). 20. BOBEYM. J. and DAVIDSONP. 0. Psychological factors affecting pain tolerance. J. Psychosom. Res. 14, 371 (1970). 21. LEE B. The analgesic effects of rapid and forceful respiration. Philude/phia Med. Times, Philadelphia, 10,498 (1880).
22. BONWILL W. G. A rapid breathing a pain obtrude in minor surgery, obstetrics, the general practice of medicine and of dentistry. Phihzdelphia Med. Times, Philadelphia, 10, 1879 (I 880). 23. CARPENTERJ., ALDRICHC. K. and BOVERMANH. The effectiveness of patient interviews, a controlled study of emotional support during pregnancy. Arch. Gen. Psychiat. 19, 110 (1968). 24. DAVIDS A., DEVAULT S. and TALMADGEM. Anxiety, pregnancy and childbirth abnormalities. J. Consult. Psychol. 25, 74 (1961). 25. DAVIDS A. and DEVAULT S. Maternal anxiety during pregnancy and childbirth. J. Psychosom. Med. 24,464 (1962). 26. ZEMLICKM. and WATSONR. Maternal attitudes of acceptance and rejection during and after pregnancy. Am. J. of Orthopsychiat. 13, 570 (1953). 27. ROSENGREN W. R. Some social and psychological aspects of delivery room difficulties. J. Nerv. Ment. Dis. 132, 515 (1961). 28. COGAN R. and KLOPFER F. The delivery of childbirth reports: an analysis of sample bias in questionnaire returns. J. Psychosom. Res. 19, 39 (1975). 29. VELLAYP. Childbirth with Confidence. MacMillan, New York (1969). 30. NIE N. H., HULL C. H., JENKINSJ. G., STEINBRENNER, K. and BENT D. Stntistical Packagefor the Social Sciences. McGraw-Hill, New York (1975).
31. HENNEBORNW. J. and COGAN R. The effect of husband participation on reported pain and probability of medications during labor and birth. Paper presented at the Rocky Mountain Psychological Association, May, 1974. 32. KLOPFERF., COGANR. and HENNEBORNW. Second stage medical intervention and pain during childbirth. J. Psychosom. Res. 19, 289 (1975). 33. AFFONSOD. Crisis of labor and birth. In Maturational Crisis of Childbearing. ANN CLAR (Ed.), pp. 23-29 (1971). University of Hawaii, Honolulu, Hawaii. 34. C~CAN R. Comfort during prepared childbirth as a function of parity, reported by four classes of participant observers. J. Psychosom. Res. 19, 33 (1975).
