Journal of Advanced Nursing, 1999, 29(4), 877±884
Issues and innovations in nursing practice
Satisfaction in childbirth and perceptions of personal control in pain relief during labour B. Hally McCrea RN RM BSc DPhil Lecturer
and Marion E. Wright RN RM BSc DPhil Lecturer, School of Health Sciences Ð Nursing, University of Ulster, Cromore Road, Coleraine, Co. Londonderry BT52 1SA, Northern Ireland, UK
Accepted for publication 29 May 1998
McCREA B.H. & WRIGHT M.E. (1999) Journal of Advanced Nursing 29(4), 877±884 Satisfaction in childbirth and perceptions of personal control in pain relief during labour Satisfaction in childbirth is in¯uenced by individual and environmental factors. Of speci®c interest in this study is the extent to which women feel that they have been able to control what happened to them during labour. The main purpose of this study was to examine the in¯uence of personal control on women's satisfaction with pain relief during labour. A questionnaire-based retrospective study of women's pain experiences within 48 hours of delivery was carried out on the postnatal ward of one teaching hospital in Northern Ireland. One hundred women who had had a vaginal delivery consented to take part in the study. Two main measures were used in the study; personal control in and satisfaction with pain relief during labour. The key ®nding of this study indicates that feelings of personal control in¯uenced positively the women's satisfaction with pain relief during labour. Demographic and other psychosocial variables had little impact on the women's satisfaction scores. These ®ndings have implications for clinical practice and for the management of maternity services and are discussed.
Keywords: childbirth, labour pain, pain relief, personal control, satisfaction, expectations of pain, parity, social class, education, maternity services
INTRODUCTION Satisfaction in childbirth is an important indicator of the quality of maternity care given to women today. Prior preoccupation with maternal and perinatal mortality as outcome measures have been shown to be inadequate given the falling death rates among mothers and babies in Correspondence to: Dr Marion Wright, School of Health Sciences Ð Nursing, University of Ulster, Cromore Road, Coleraine, Co. Londonderry BT52 1SA, Northern Ireland, UK.
Ó 1999 Blackwell Science Ltd
the United Kingdom (Tew 1990). Instead, increasing attention is being given to the psycho-social aspects of maternity services and particularly assessment of women's satisfaction with their childbirth experiences. This includes satisfaction with pain relief. Positive childbirth outcomes such as satisfaction are, however, exposed to a range of individual/environmental factors which must be taken into account in any assessment. Of speci®c interest in this study is the relationship between satisfaction with and personal control in pain relief during labour.
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B.H. McCrea and M.E. Wright Client satisfaction is a much-studied but, as yet, illde®ned phenomenon in health care, and one of the dif®culties in interpretation is probably due to the fact that it requires both quantitative and qualitative analyses. In the area of childbirth qualitative assessment is gaining prominence principally because the experience is unique and personal. This experience includes satisfaction with pain relief. Morgan et al.'s (1982) ®nding that low pain scores are not related to high levels of satisfaction lends support to this assumption, the implication being that satisfaction may be more concerned with how women feel they have coped with labour pain rather than the effectiveness of pain relief. Pain relief is the way in which women feel that they have coped with pain during labour. This may involve the use of pharmacological or non-pharmacological techniques or a combination of these methods. Examples of non-pharmacological methods of pain relief include relaxation, hypnotherapy, the use of imagery, therapeutic touch, acupuncture, music, biofeedback, psycho-prophylaxis, massage, hydrotherapy, homeopathy, supported positions for comfort and lay and professional support. Pharmacological methods include inhalational analgesia, opioid drugs, regional analgesia/anaesthesia and infrequently general anaesthesia. Pain relief is used in this paper to refer mainly to pharmacological methods of coping with labour pain. Labour pain is probably the most painful event in the lives of women (Melzack 1984), consequently the majority of women today require and use some form of analgesia during labour (MacArthur et al. 1993). However, labour pain is more than a physiological process; it is emotional and complex with feelings of ful®lment and achievement (Salmon et al. 1990). It is not surprising, therefore, that satisfaction may not necessarily be related to the ef®cacy of pain relief (Morgan et al. 1982). To the contrary, early evidence suggests that social and psychological resources such as antenatal preparation play an important role in positive childbirth outcomes (Henneborn & Cogan 1975, Brewin & Bradley 1982). Other demographic and psycho-social factors that may affect the quality of women's childbirth experience include age (Norr et al. 1977), social class (Nelson 1983, McIntosh 1989) and expectations of pain (Doering et al. 1980, Niven & Gijsbers 1984). More recently attention has focused on the in¯uence of personal control on satisfaction levels in childbirth. An important point raised by studies of women's interpretations of the term `control' in childbirth is the fact that the concept means different things to different individuals (Willmuth 1975, Schroeder 1985, Annandale 1987). Accordingly, and with justi®cation, studies of personal control in childbirth have drawn on both quantitative and qualitative measures to further our understanding of the complex concept.
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Extensive research into women's long-term memories of their ®rst birth experiences (Simkin 1991, 1992) found that women who recorded being highly satis®ed were more inclined to `feel in control' compared to women who recorded being less satis®ed; the latter felt that they had little or no control during childbirth. These ®ndings are supported by the evidence from Green et al.'s (1990) work which reported a relationship between feelings of control and positive psychological outcomes in childbirth. Focusing on a broad de®nition of personal control, Slade et al.'s (1993) research reported relationships between satisfaction with self and the following control variables: ability to control panic, use of exercises, personal control over duration of labour, ef®cacy of exercises used and control over position in labour. Extrapolating from these ®ndings, it is feasible to suggest that similar relationships exist in the area of pain relief. Thus far little research has focused on personal control in pain relief yet this is a dimension which re¯ects how women feel they have coped with labour pain and could have an impact on the outcomes of their birth experiences such as satisfaction. The main purpose of the study reported here was to examine the in¯uence of personal control on women's satisfaction with pain relief. The impact of demographic and other psycho-social factors was also investigated. Personal control was de®ned as: (a) the women's feeling of being in control as opposed to staff being in control; (b) their input into decision-making governing pain medication; and (c) use of personal coping resources to cope with labour pain. These de®nitions are based on women's perceptions of control as described in the literature (Willmuth 1975, Schroeder 1985, Annandale 1987) and one of the researcher's (BHMcC) experience of working in the labour ward.
THE STUDY Methods The study was conducted at one large teaching hospital in Northern Ireland with an annual birth rate (live) of »3000. Ethical approval to carry out the study was obtained from the Research Ethics Committee of the hospital concerned. Once approval was given, discussion took place with the midwife manager in order to gain access to a sample of women. Of the 146 women who met the criteria for inclusion in the study, 100 (50 primigravidae and 50 multigravidae) who delivered during the data collection stage of the study participated. Women who had epidural analgesia and/or delivered by caesarean section were excluded. It was felt that these women would not have been involved actively in decision-making on issues such as whether to use pain relief and the timing and type of pain relief to use (medical policies govern the administration of epidural and spinal anaesthesia) and therefore
Ó 1999 Blackwell Science Ltd, Journal of Advanced Nursing, 29(4), 877±884
Issues and innovations in nursing practice
Personal control and satisfaction with labour pain relief
would not be `in control'. Moreover, they would not have experienced pain (provided that the epidural worked) and would therefore make little or no use of personal coping resources such as breathing and relaxation learned at antenatal classes. The uptake of epidural analgesia in this maternity unit (22%) was a major constraint in accessing women (especially primigravidae) to the study. Time and resource constraints also restricted the sample size, hence the study was small and limited. The dominant model of care in the unit where this study took place was based on the medical perspective of active management of labour. The majority of women had their labour induced or accelerated, had continuous fetal monitoring, vaginal examination 2-hourly and were not allowed to eat during labour. The use of continuous fetal monitoring placed limits on the variety of positions that could be adopted by the women in this study. Indeed, the only two choices that were available to them were either to sit up in a chair or lie in bed. This limitation explains why the decision was made to omit Slade et al.'s (1993) question on position from the questionnaire. The purpose of the research was explained to the women and their written consent obtained to participate in the study. This consent included the women's right to withdraw from the study at any stage. They were asked to complete a questionnaire to describe their experience of labour pain and how they felt it was managed.
Table 1 Items on the Personal Control in Pain Relief Scale
Construction of questionnaire
Did not decide
Items on the questionnaire were designed to explore three sets of variables related to satisfaction. The ®rst set of questions requested information on the demographic pro®le of the women. These questions were followed by items which explored the women's expectations of labour pain, including their feelings about the painfulness of labour, the anxiety caused by thinking about labour pain and their anticipation of the severity of the pain. This scale was developed from the literature reviewed. In the concluding section of the questionnaire a modi®ed version of Slade et al.'s (1993) personal control scale was used to explore the women's perceived control in managing their labour pain. This scale consisted of eight items which related to pain relief, but excluded six items which were unrelated to the study (personal control of duration of labour, staff control of duration of labour, importance of controlling panic, ability to control panic, whether they had been taught any exercises, control over position during labour). Items on the personal control in pain relief scale were measured using visual analogue scales and the women were asked to put a cross on a 10-cm line at a point which best described how they felt their labour pain was managed. The items with anchors are illustrated in Table 1. The questionnaire concluded with a single item to assess the women's satisfaction with the way they felt
Items (1) Who was most in control of the way your labour pain was managed? 0 10 cm Yourself
The midwife
(2) How much were you able to control the pain you felt during labour? 0 10 cm Could not control it at all
Could control it completely
(3) How much were the midwives/doctors able to control the pain you felt during labour? 0 10 cm Could not control it at all
Could control it completely
(4) How much were you able to decide whether you used something to help with the pain? 0 10 cm Did not decide
Decide completely
(5) How much were you able to decide when to take something to help with the pain (if you did take something)? 0 10 cm Decided completely
(6) How much were you able to decide what kind of pain relief to take? 0 10 cm Did not decide
Decided completely
(7) Did you use any exercises learned at the antenatal classes (if you attended) to help cope with the pain? 0 10 cm Not at all
All of the time
(8) How well did the exercises work? 0
10 cm
Not at all
Extremely well
their labour pain was managed. The women were asked to rate their level of satisfaction by placing a cross on a seven-point scale and scores were allocated using a Likert scale (1 very dissatis®ed, 7 very satis®ed). Items on the questionnaire were based on the literature reviewed and the questionnaire was subsequently peerreviewed by a panel of ®ve experts. There was complete agreement that items on the questionnaire would generate
Ó 1999 Blackwell Science Ltd, Journal of Advanced Nursing, 29(4), 877±884
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B.H. McCrea and M.E. Wright information to meet the purpose of the study. The instrument was piloted, using a sample of 20 women from a hospital that was not involved in the main study. Results from the pilot study indicated that the questionnaire would provide data to meet the purpose of the study. Once the sample was obtained for the study, the women were approached on the postnatal ward by one of the researchers (BHMcC, a midwife who was known to the staff in the maternity unit, but not to the women involved in the study) and asked to complete the questionnaire within 48 hours of delivery. This was necessary to avoid problems with recall which could result in inaccuracy of information provided. The completed questionnaires were subsequently collected by the same researcher, which provided the opportunity to thank the women personally for their help and co-operation in the study. All the returned questionnaires (100) were checked for completeness prior to coding of responses obtained and input onto the computer. Data were analysed using the computer software Statistical Package for Social Sciences (Hedderson 1987). Means (SD) and, where necessary, frequency distributions were computed for each variable and Pearson's correlation coef®cient (r) and chi-square were calculated to establish relationships between personal control/demographic/psycho-social variables and satisfaction with pain relief scores. All the variables, dependent and independent (with the exception of parity, social class and educational status) were measured on ordinal scales and were analysed using parametric tests including Pearson's correlation (Bryman & Cramer 1994). Data on parity, social class and educational status were categorical and were examined using the chi-square test. An independent t-test was carried out to investigate if a difference existed between primigravidae and multigravidae's reported satisfaction with pain relief. A p-value of 0á05 (5%) was set as the cut-off point for accepting signi®cant ®ndings.
Results Demographic pro®le of the women
Mean age for the sample of primigravidae (n 50) was 25á6 years (SD 4á86) and for multigravidae (n 50) 29á48 years (SD 3á84). Forty-®ve primigravidae and 36 multigravidae were working prior to becoming pregnant. Twenty-seven primigravidae and 32 multigravidae recorded educational attainment to GCSE level, 13 reached `A' level (®ve primigravidae, eight multigravidae), 18 obtained degree level education (nine primigravidae and nine multigravidae) and 10 achieved quali®cations in typing or catering (nine primigravidae and one multigravidae). All the women who took part in the study were from Northern Ireland and were Caucasian. Only women who
880
Table 2 Social class of participants Social class 1
2
3n
3m
4
5
Primigravidae Multigravidae
± ±
13 14
10 12
11 12
10 9
6 3
Total
±
27
22
23
19
9
had had hospital delivery were included in the study, principally because so few women deliver at home in Northern Ireland. This is compounded by the ®nding in a study in the north-west of England that a large proportion of women, especially primigravidae, showed a preference for hospital con®nement (Fordham 1997). The women in this study received care during labour from midwives who were unknown to them until their admission to the labour ward. Most of the women were married (37 primigravidae, 44 multigravidae), 10 were living with their partner (six primigravidae, four multigravidae) and nine were single (seven primigravidae, two multigravidae). Using the 1991 Of®ce of Population Censuses and Surveys Classi®cation and based on the occupation of the head of the household, the women fell into social classes as illustrated in Table 2. The ®ndings illustrated in Table 2 suggest that most of the social classes were represented in the sample. Most of the women (96) had a partner present during labour and of these 86 (partners) were present throughout the women's labour and delivery. This support could have an in¯uence on personal control and is an area for further investigation.
Expectations of labour pain
Mean scores and SD were computed for items (2) on the Expectations of Labour Pain Scale. These items were measured on a ®ve-point scale with values ranging from `very painful/worried' (1) to `quite painful/worried' (2), `painful/worried' (3), `a little painful/worried' (4) and `not at all painful/worried' (5). The ®ndings are shown in Table 3. The mean scores shown in Table 3 indicate that the women expected labour to be `quite painful' and that they were `worried' about the painfulness of labour. These
Table 3 Mean scores for expectations of labour pain Items
Mean
SD
Painfulness of labour Worried about labour pain
1á57 2á80
0á71 1á10
Ó 1999 Blackwell Science Ltd, Journal of Advanced Nursing, 29(4), 877±884
Issues and innovations in nursing practice
Personal control and satisfaction with labour pain relief
Table 4 Mean scores for items on the Personal Control in Pain Relief Scale Items
Mean
SD
1. You were most in control of how your labour pain was managed 2. You were able to control the pain you felt during labour 3. The midwives/doctors were able to control the pain you felt during labour 4. You were able to decide whether to use pain relief 5. You were able to decide when to use pain relief 6. You were able to decide what to use for pain relief 7. You used exercises learned at antenatal classes (if attended) to cope with pain 8. You found the exercises most useful
4á14
2á17
5á38
2á14
5á86
2á25
7á63
1á96
7á81
1á95
7á84
1á91
6á77
2á49
6á62
2á51
®ndings suggest that the women held realistic expectations about labour pain. When asked to describe the nature of labour pain, the majority of the women (26 primigravidae, 39 multigravidae) felt that it was different from period pain and only seven primigravidae and six multigravidae said it was the same as period pain. It was surprising that 17 multigravidae said they `did not know' given that they had prior experience of labour pain. This ®nding may be a re¯ection of the variability of labour pain and should be taken into consideration in planning care for pain relief during labour.
Personal control in pain relief
Mean scores were computed for each item (in cm) on the Personal Control in Pain Relief Scale and the ®ndings are illustrated in Table 4. There are a number of points to note concerning these ®ndings. The lower mean score for item one, for example, implies that the women felt that they were in control of pain relief. In contrast the mean scores for items two and three suggest that the women felt that they and the midwives/doctors were able to control the pain they felt. Mean scores for items four, ®ve and six, on the other hand, indicate that the women felt that they made decisions governing pain relief in labour. Sixty women attended antenatal classes, therefore mean scores for items seven (made use of exercises learned at antenatal classes) and eight (usefulness of the exercises used) were calculated based on the number of attenders (60). In view of resource constraints to carry out this study, it was not practical to check on whether the exercises used by the women were actually taught. Nevertheless, the high mean score (Table 4) indicates that the women found them useful.
Table 5 Women's satisfaction with pain relief during labour Satisfaction level
Frequency No.
Very dissatis®ed Quite dissatis®ed Dissatis®ed Neutral Satis®ed Quite satis®ed Very satis®ed
± 3 9 9 27 21 31
Satisfaction with pain relief
The women's satisfaction with the way their labour pain was managed was assessed on a seven-point scale and a mean score of 5á47 (SD 1á40) was obtained. The women were therefore `satis®ed' with pain relief. An independent t-test showed no statistically signi®cant difference between mean scores for primigravidae and multigravidae. However, examination of the frequency distribution showed considerable variation between the women's responses as illustrated in Table 5. It is evident from Table 5 that over a quarter of the sample (31) were `very satis®ed' with pain relief and three-quarters of the overall sample of women (79) reported varying levels of satisfaction. This ®nding compares favourably with the evidence on satisfaction levels for women in the United Kingdom as a whole (Oakley 1993). However, account must be taken of the 12 women who registered dissatisfaction if the aim is to provide effective pain relief to all women.
In¯uence of personal control, demographic and psycho-social factors on satisfaction with pain relief
Pearson's correlation coef®cients (r) and, where appropriate, the chi-square test were computed to establish whether satisfaction with pain relief was in¯uenced by personal control, demographic factors and expectations of labour pain. The ®ndings are shown in Table 6. The evidence illustrated in Table 6 is clear indication that personal control is an important factor which could in¯uence satisfaction with pain relief. The signi®cant relationships between satisfaction with pain relief and feelings of being in control, being actively involved in decision-making governing pain medication and use of personal coping resources support this claim. Demographic variables and expectations of labour pain had little impact on satisfaction level.
DISCUSSION Before discussing the ®ndings of this study, there are a number of methodological issues surrounding measurement of satisfaction which must be addressed. Foremost is
Ó 1999 Blackwell Science Ltd, Journal of Advanced Nursing, 29(4), 877±884
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B.H. McCrea and M.E. Wright Table 6 Relationship between satisfaction with pain relief and personal control/demographic/psychosocial variables
Variables
Correlation Signi®cance coef®cients level
Demography Age 0á13 Parity 7á55* Social class 5á36* Educational status 4á95* Expectations of labour pain Painfulness of labour )0á08 Worried about labour pain 0á01 Anticipation of the severity of 0á00 labour pain Personal control You were most in control of pain )0á31 management You were able to control pain felt 0á29 Midwives/doctors were able to 0á29 control pain you felt You were able to decide whether 0á34 to use pain relief You were able to decide when to 0á24 use pain relief You were able to decide what 0á29 pain relief to use 0á36 You made use of exercises learned at antenatal classes to cope with labour pain You found the exercises used 0á25 most useful
0á182 0á183 0á374 0á421 0á556 0á919 0á969
0á002 0á003 0á003 0á000 0á015 0á003 0á004
0á054
* Chi-square values, d.f. = 5.
the criticism that measurement within the ®rst few days following delivery may not re¯ect women's actual experience. The experience of childbirth, especially a bad one, could in¯uence their response. It is also possible that some women may not want to be too critical of their care while in hospital, presumably because they may feel that this could affect the care they receive. Set alongside these criticisms, however, is the dilemma that feelings may change over time as women become `wrapped up' with their baby. Some may feel that having `a healthy baby' compensates for any distress experienced. There is also the problem that recall of information may not be accurate. These problems could be resolved by using different measures at different stages of the postnatal period so that ®ndings from one scale could be substantiated by results from other instruments. A further methodological issue to consider is the possibility that satisfaction with pain relief during labour may be in¯uenced by experiences during the antenatal period, but the constraints on time and resources available to carry out research limit what can be achieved in a single
882
study. To this end further research could investigate, for instance, patterns of antenatal care and preparation on pain relief and their in¯uence on satisfaction with pain relief during labour. The most important ®ndings to emerge from this study are the signi®cant relationships between personal control variables and satisfaction with pain relief. These ®ndings compare favourably with those of Slade et al.'s (1993) and indicate that satisfaction with pain relief is in¯uenced by feelings of `being in control' and having an input in decision-making on pain relief. Being involved actively in their care may help to promote feelings of `being in control' and enhance women's con®dence in their own ability to control pain experienced. That these factors are interrelated and important to feelings of satisfaction is evident. However, note must be taken of the ®ndings on feelings of `being in control'; they may appear contradictory given that a signi®cant relationship was also established between satisfaction with pain relief and midwives/doctors' ability to control pain experienced. One possible explanation for the con¯ict in results is provided by Bluff & Holloway's (1994) ®ndings that, although women in their study regarded midwives as experts who knew best, they (the women) nevertheless anticipated playing an active role in the control of their labour. Berg et al. (1996) similarly report that women in their study expected midwives to support, encourage and guide them, but to do so on their terms. Women, it would appear, ®nd reassurance from being told what to do by midwives (Garcia & Garforth 1990) but this does not mean losing control to professionals. Instead, a partnership approach is implied. Personal control, as the evidence from this study implies, goes beyond decision-making about pain relief; it involves making use of personal coping resources such as breathing/ relaxation exercises to cope with labour pain. That antenatal preparation can reduce the uptake of analgesia is well established (Nettlebladt et al. 1976, Simkin & Enkin 1990). However, evidence from Slade et al.'s (1993) study indicates that using exercises had little effect on perceptions of pain intensity, rather it seems to in¯uence the ability to tolerate pain. This dimension of personal control may involve feelings of ful®lment and mastery and is clearly important to consider when planning for pain relief in labour. Midwives should be working with women to identify personal coping strategies and encourage them to make ef®cient and effective use of these resources. None of the demographic variables including social class had an impact on women's satisfaction with pain relief. This ®nding is contrary to prior evidence that working class women look for speed and pain-free labour and are less concerned with personal satisfaction with their birth experiences (McIntosh 1989). Women are more informed today and it is not surprising therefore that they
Ó 1999 Blackwell Science Ltd, Journal of Advanced Nursing, 29(4), 877±884
Issues and innovations in nursing practice
Personal control and satisfaction with labour pain relief
would expect their birth experiences to be ful®lling regardless of social/educational backgrounds. Expectations of labour pain also had no in¯uence on satisfaction level, a ®nding that is in concordance with those of Slade et al. (1993). One possible explanation for the non-signi®cant ®nding may be because the women held realistic expectations; their antenatal care may have prepared them for the reality of labour.
managers. Midwives' initiatives must be recognized and encouraged and the resources made available to put them into practice. In this way midwives and managers can work with women to enhance personal control and increase satisfaction with pain relief and childbirth overall.
CONCLUSION
The ®nancial assistance of the National Birthday Trust Fund is gratefully acknowledged.
The ®ndings of this study suggest that women's satisfaction with pain relief during labour is complex and involves feelings of personal control over pain experiences. These results have implications for clinical practice and for the management of maternity care. Midwives have a responsibility to encourage personal control during childbirth. Women should be encouraged to be active and equal partners in the care process so that they are involved in decisions about pain relief. This would tie in with the recommendation of the Changing Childbirth Document (Department of Health 1993) that women should have more control of their care during childbirth. Obviously they (the women) would need accurate and adequate information on which to make informed decisions. This partnership approach to care should begin early in antenatal care to prepare women for the experience. Preparation is crucial to the concept of control (Thompson 1981) presumably because it enhances con®dence and thus encourages personal control. The value of women's own coping resources should be recognized and maximized in pain relief instead of emphasis being placed on pain medication. To this end women should be encouraged to identify and strengthen personal coping resources; this self-awareness should begin well before the last few weeks of pregnancy. Time is crucial to help prepare women to exercise control, important preparation which should not be relegated to the last few weeks prior to childbirth. Unfortunately, the women in this study were cared for by midwives whom they did not know before being admitted into the labour ward. Thus there may not have been the time needed for the midwives to identify coping strategies and this could have resulted in the overuse of pain medication. This assumption must be tested however, before any ®rm conclusions can be drawn. Ideally a system of continuity in carer, where one midwife or a small group of midwives work with the women throughout their pregnancy and childbirth, would foster and encourage personal control in pain relief. The named midwife concept and the development of midwife-led units would be valuable in implementing these recommendations. Finally, effective pain relief depends not only on innovative practice but it also requires the support of
Acknowledgements
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Ó 1999 Blackwell Science Ltd, Journal of Advanced Nursing, 29(4), 877±884
Issues and innovations in nursing practice
Satisfaction in childbirth and perceptions of personal control in pain relief during labour B. Hally McCrea RN RM BSc DPhil Lecturer
and Marion E. Wright RN RM BSc DPhil Lecturer, School of Health Sciences Ð Nursing, University of Ulster, Cromore Road, Coleraine, Co. Londonderry BT52 1SA, Northern Ireland, UK
Accepted for publication 29 May 1998
McCREA B.H. & WRIGHT M.E. (1999) Journal of Advanced Nursing 29(4), 877±884 Satisfaction in childbirth and perceptions of personal control in pain relief during labour Satisfaction in childbirth is in¯uenced by individual and environmental factors. Of speci®c interest in this study is the extent to which women feel that they have been able to control what happened to them during labour. The main purpose of this study was to examine the in¯uence of personal control on women's satisfaction with pain relief during labour. A questionnaire-based retrospective study of women's pain experiences within 48 hours of delivery was carried out on the postnatal ward of one teaching hospital in Northern Ireland. One hundred women who had had a vaginal delivery consented to take part in the study. Two main measures were used in the study; personal control in and satisfaction with pain relief during labour. The key ®nding of this study indicates that feelings of personal control in¯uenced positively the women's satisfaction with pain relief during labour. Demographic and other psychosocial variables had little impact on the women's satisfaction scores. These ®ndings have implications for clinical practice and for the management of maternity services and are discussed.
Keywords: childbirth, labour pain, pain relief, personal control, satisfaction, expectations of pain, parity, social class, education, maternity services
INTRODUCTION Satisfaction in childbirth is an important indicator of the quality of maternity care given to women today. Prior preoccupation with maternal and perinatal mortality as outcome measures have been shown to be inadequate given the falling death rates among mothers and babies in Correspondence to: Dr Marion Wright, School of Health Sciences Ð Nursing, University of Ulster, Cromore Road, Coleraine, Co. Londonderry BT52 1SA, Northern Ireland, UK.
Ó 1999 Blackwell Science Ltd
the United Kingdom (Tew 1990). Instead, increasing attention is being given to the psycho-social aspects of maternity services and particularly assessment of women's satisfaction with their childbirth experiences. This includes satisfaction with pain relief. Positive childbirth outcomes such as satisfaction are, however, exposed to a range of individual/environmental factors which must be taken into account in any assessment. Of speci®c interest in this study is the relationship between satisfaction with and personal control in pain relief during labour.
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B.H. McCrea and M.E. Wright Client satisfaction is a much-studied but, as yet, illde®ned phenomenon in health care, and one of the dif®culties in interpretation is probably due to the fact that it requires both quantitative and qualitative analyses. In the area of childbirth qualitative assessment is gaining prominence principally because the experience is unique and personal. This experience includes satisfaction with pain relief. Morgan et al.'s (1982) ®nding that low pain scores are not related to high levels of satisfaction lends support to this assumption, the implication being that satisfaction may be more concerned with how women feel they have coped with labour pain rather than the effectiveness of pain relief. Pain relief is the way in which women feel that they have coped with pain during labour. This may involve the use of pharmacological or non-pharmacological techniques or a combination of these methods. Examples of non-pharmacological methods of pain relief include relaxation, hypnotherapy, the use of imagery, therapeutic touch, acupuncture, music, biofeedback, psycho-prophylaxis, massage, hydrotherapy, homeopathy, supported positions for comfort and lay and professional support. Pharmacological methods include inhalational analgesia, opioid drugs, regional analgesia/anaesthesia and infrequently general anaesthesia. Pain relief is used in this paper to refer mainly to pharmacological methods of coping with labour pain. Labour pain is probably the most painful event in the lives of women (Melzack 1984), consequently the majority of women today require and use some form of analgesia during labour (MacArthur et al. 1993). However, labour pain is more than a physiological process; it is emotional and complex with feelings of ful®lment and achievement (Salmon et al. 1990). It is not surprising, therefore, that satisfaction may not necessarily be related to the ef®cacy of pain relief (Morgan et al. 1982). To the contrary, early evidence suggests that social and psychological resources such as antenatal preparation play an important role in positive childbirth outcomes (Henneborn & Cogan 1975, Brewin & Bradley 1982). Other demographic and psycho-social factors that may affect the quality of women's childbirth experience include age (Norr et al. 1977), social class (Nelson 1983, McIntosh 1989) and expectations of pain (Doering et al. 1980, Niven & Gijsbers 1984). More recently attention has focused on the in¯uence of personal control on satisfaction levels in childbirth. An important point raised by studies of women's interpretations of the term `control' in childbirth is the fact that the concept means different things to different individuals (Willmuth 1975, Schroeder 1985, Annandale 1987). Accordingly, and with justi®cation, studies of personal control in childbirth have drawn on both quantitative and qualitative measures to further our understanding of the complex concept.
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Extensive research into women's long-term memories of their ®rst birth experiences (Simkin 1991, 1992) found that women who recorded being highly satis®ed were more inclined to `feel in control' compared to women who recorded being less satis®ed; the latter felt that they had little or no control during childbirth. These ®ndings are supported by the evidence from Green et al.'s (1990) work which reported a relationship between feelings of control and positive psychological outcomes in childbirth. Focusing on a broad de®nition of personal control, Slade et al.'s (1993) research reported relationships between satisfaction with self and the following control variables: ability to control panic, use of exercises, personal control over duration of labour, ef®cacy of exercises used and control over position in labour. Extrapolating from these ®ndings, it is feasible to suggest that similar relationships exist in the area of pain relief. Thus far little research has focused on personal control in pain relief yet this is a dimension which re¯ects how women feel they have coped with labour pain and could have an impact on the outcomes of their birth experiences such as satisfaction. The main purpose of the study reported here was to examine the in¯uence of personal control on women's satisfaction with pain relief. The impact of demographic and other psycho-social factors was also investigated. Personal control was de®ned as: (a) the women's feeling of being in control as opposed to staff being in control; (b) their input into decision-making governing pain medication; and (c) use of personal coping resources to cope with labour pain. These de®nitions are based on women's perceptions of control as described in the literature (Willmuth 1975, Schroeder 1985, Annandale 1987) and one of the researcher's (BHMcC) experience of working in the labour ward.
THE STUDY Methods The study was conducted at one large teaching hospital in Northern Ireland with an annual birth rate (live) of »3000. Ethical approval to carry out the study was obtained from the Research Ethics Committee of the hospital concerned. Once approval was given, discussion took place with the midwife manager in order to gain access to a sample of women. Of the 146 women who met the criteria for inclusion in the study, 100 (50 primigravidae and 50 multigravidae) who delivered during the data collection stage of the study participated. Women who had epidural analgesia and/or delivered by caesarean section were excluded. It was felt that these women would not have been involved actively in decision-making on issues such as whether to use pain relief and the timing and type of pain relief to use (medical policies govern the administration of epidural and spinal anaesthesia) and therefore
Ó 1999 Blackwell Science Ltd, Journal of Advanced Nursing, 29(4), 877±884
Issues and innovations in nursing practice
Personal control and satisfaction with labour pain relief
would not be `in control'. Moreover, they would not have experienced pain (provided that the epidural worked) and would therefore make little or no use of personal coping resources such as breathing and relaxation learned at antenatal classes. The uptake of epidural analgesia in this maternity unit (22%) was a major constraint in accessing women (especially primigravidae) to the study. Time and resource constraints also restricted the sample size, hence the study was small and limited. The dominant model of care in the unit where this study took place was based on the medical perspective of active management of labour. The majority of women had their labour induced or accelerated, had continuous fetal monitoring, vaginal examination 2-hourly and were not allowed to eat during labour. The use of continuous fetal monitoring placed limits on the variety of positions that could be adopted by the women in this study. Indeed, the only two choices that were available to them were either to sit up in a chair or lie in bed. This limitation explains why the decision was made to omit Slade et al.'s (1993) question on position from the questionnaire. The purpose of the research was explained to the women and their written consent obtained to participate in the study. This consent included the women's right to withdraw from the study at any stage. They were asked to complete a questionnaire to describe their experience of labour pain and how they felt it was managed.
Table 1 Items on the Personal Control in Pain Relief Scale
Construction of questionnaire
Did not decide
Items on the questionnaire were designed to explore three sets of variables related to satisfaction. The ®rst set of questions requested information on the demographic pro®le of the women. These questions were followed by items which explored the women's expectations of labour pain, including their feelings about the painfulness of labour, the anxiety caused by thinking about labour pain and their anticipation of the severity of the pain. This scale was developed from the literature reviewed. In the concluding section of the questionnaire a modi®ed version of Slade et al.'s (1993) personal control scale was used to explore the women's perceived control in managing their labour pain. This scale consisted of eight items which related to pain relief, but excluded six items which were unrelated to the study (personal control of duration of labour, staff control of duration of labour, importance of controlling panic, ability to control panic, whether they had been taught any exercises, control over position during labour). Items on the personal control in pain relief scale were measured using visual analogue scales and the women were asked to put a cross on a 10-cm line at a point which best described how they felt their labour pain was managed. The items with anchors are illustrated in Table 1. The questionnaire concluded with a single item to assess the women's satisfaction with the way they felt
Items (1) Who was most in control of the way your labour pain was managed? 0 10 cm Yourself
The midwife
(2) How much were you able to control the pain you felt during labour? 0 10 cm Could not control it at all
Could control it completely
(3) How much were the midwives/doctors able to control the pain you felt during labour? 0 10 cm Could not control it at all
Could control it completely
(4) How much were you able to decide whether you used something to help with the pain? 0 10 cm Did not decide
Decide completely
(5) How much were you able to decide when to take something to help with the pain (if you did take something)? 0 10 cm Decided completely
(6) How much were you able to decide what kind of pain relief to take? 0 10 cm Did not decide
Decided completely
(7) Did you use any exercises learned at the antenatal classes (if you attended) to help cope with the pain? 0 10 cm Not at all
All of the time
(8) How well did the exercises work? 0
10 cm
Not at all
Extremely well
their labour pain was managed. The women were asked to rate their level of satisfaction by placing a cross on a seven-point scale and scores were allocated using a Likert scale (1 very dissatis®ed, 7 very satis®ed). Items on the questionnaire were based on the literature reviewed and the questionnaire was subsequently peerreviewed by a panel of ®ve experts. There was complete agreement that items on the questionnaire would generate
Ó 1999 Blackwell Science Ltd, Journal of Advanced Nursing, 29(4), 877±884
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B.H. McCrea and M.E. Wright information to meet the purpose of the study. The instrument was piloted, using a sample of 20 women from a hospital that was not involved in the main study. Results from the pilot study indicated that the questionnaire would provide data to meet the purpose of the study. Once the sample was obtained for the study, the women were approached on the postnatal ward by one of the researchers (BHMcC, a midwife who was known to the staff in the maternity unit, but not to the women involved in the study) and asked to complete the questionnaire within 48 hours of delivery. This was necessary to avoid problems with recall which could result in inaccuracy of information provided. The completed questionnaires were subsequently collected by the same researcher, which provided the opportunity to thank the women personally for their help and co-operation in the study. All the returned questionnaires (100) were checked for completeness prior to coding of responses obtained and input onto the computer. Data were analysed using the computer software Statistical Package for Social Sciences (Hedderson 1987). Means (SD) and, where necessary, frequency distributions were computed for each variable and Pearson's correlation coef®cient (r) and chi-square were calculated to establish relationships between personal control/demographic/psycho-social variables and satisfaction with pain relief scores. All the variables, dependent and independent (with the exception of parity, social class and educational status) were measured on ordinal scales and were analysed using parametric tests including Pearson's correlation (Bryman & Cramer 1994). Data on parity, social class and educational status were categorical and were examined using the chi-square test. An independent t-test was carried out to investigate if a difference existed between primigravidae and multigravidae's reported satisfaction with pain relief. A p-value of 0á05 (5%) was set as the cut-off point for accepting signi®cant ®ndings.
Results Demographic pro®le of the women
Mean age for the sample of primigravidae (n 50) was 25á6 years (SD 4á86) and for multigravidae (n 50) 29á48 years (SD 3á84). Forty-®ve primigravidae and 36 multigravidae were working prior to becoming pregnant. Twenty-seven primigravidae and 32 multigravidae recorded educational attainment to GCSE level, 13 reached `A' level (®ve primigravidae, eight multigravidae), 18 obtained degree level education (nine primigravidae and nine multigravidae) and 10 achieved quali®cations in typing or catering (nine primigravidae and one multigravidae). All the women who took part in the study were from Northern Ireland and were Caucasian. Only women who
880
Table 2 Social class of participants Social class 1
2
3n
3m
4
5
Primigravidae Multigravidae
± ±
13 14
10 12
11 12
10 9
6 3
Total
±
27
22
23
19
9
had had hospital delivery were included in the study, principally because so few women deliver at home in Northern Ireland. This is compounded by the ®nding in a study in the north-west of England that a large proportion of women, especially primigravidae, showed a preference for hospital con®nement (Fordham 1997). The women in this study received care during labour from midwives who were unknown to them until their admission to the labour ward. Most of the women were married (37 primigravidae, 44 multigravidae), 10 were living with their partner (six primigravidae, four multigravidae) and nine were single (seven primigravidae, two multigravidae). Using the 1991 Of®ce of Population Censuses and Surveys Classi®cation and based on the occupation of the head of the household, the women fell into social classes as illustrated in Table 2. The ®ndings illustrated in Table 2 suggest that most of the social classes were represented in the sample. Most of the women (96) had a partner present during labour and of these 86 (partners) were present throughout the women's labour and delivery. This support could have an in¯uence on personal control and is an area for further investigation.
Expectations of labour pain
Mean scores and SD were computed for items (2) on the Expectations of Labour Pain Scale. These items were measured on a ®ve-point scale with values ranging from `very painful/worried' (1) to `quite painful/worried' (2), `painful/worried' (3), `a little painful/worried' (4) and `not at all painful/worried' (5). The ®ndings are shown in Table 3. The mean scores shown in Table 3 indicate that the women expected labour to be `quite painful' and that they were `worried' about the painfulness of labour. These
Table 3 Mean scores for expectations of labour pain Items
Mean
SD
Painfulness of labour Worried about labour pain
1á57 2á80
0á71 1á10
Ó 1999 Blackwell Science Ltd, Journal of Advanced Nursing, 29(4), 877±884
Issues and innovations in nursing practice
Personal control and satisfaction with labour pain relief
Table 4 Mean scores for items on the Personal Control in Pain Relief Scale Items
Mean
SD
1. You were most in control of how your labour pain was managed 2. You were able to control the pain you felt during labour 3. The midwives/doctors were able to control the pain you felt during labour 4. You were able to decide whether to use pain relief 5. You were able to decide when to use pain relief 6. You were able to decide what to use for pain relief 7. You used exercises learned at antenatal classes (if attended) to cope with pain 8. You found the exercises most useful
4á14
2á17
5á38
2á14
5á86
2á25
7á63
1á96
7á81
1á95
7á84
1á91
6á77
2á49
6á62
2á51
®ndings suggest that the women held realistic expectations about labour pain. When asked to describe the nature of labour pain, the majority of the women (26 primigravidae, 39 multigravidae) felt that it was different from period pain and only seven primigravidae and six multigravidae said it was the same as period pain. It was surprising that 17 multigravidae said they `did not know' given that they had prior experience of labour pain. This ®nding may be a re¯ection of the variability of labour pain and should be taken into consideration in planning care for pain relief during labour.
Personal control in pain relief
Mean scores were computed for each item (in cm) on the Personal Control in Pain Relief Scale and the ®ndings are illustrated in Table 4. There are a number of points to note concerning these ®ndings. The lower mean score for item one, for example, implies that the women felt that they were in control of pain relief. In contrast the mean scores for items two and three suggest that the women felt that they and the midwives/doctors were able to control the pain they felt. Mean scores for items four, ®ve and six, on the other hand, indicate that the women felt that they made decisions governing pain relief in labour. Sixty women attended antenatal classes, therefore mean scores for items seven (made use of exercises learned at antenatal classes) and eight (usefulness of the exercises used) were calculated based on the number of attenders (60). In view of resource constraints to carry out this study, it was not practical to check on whether the exercises used by the women were actually taught. Nevertheless, the high mean score (Table 4) indicates that the women found them useful.
Table 5 Women's satisfaction with pain relief during labour Satisfaction level
Frequency No.
Very dissatis®ed Quite dissatis®ed Dissatis®ed Neutral Satis®ed Quite satis®ed Very satis®ed
± 3 9 9 27 21 31
Satisfaction with pain relief
The women's satisfaction with the way their labour pain was managed was assessed on a seven-point scale and a mean score of 5á47 (SD 1á40) was obtained. The women were therefore `satis®ed' with pain relief. An independent t-test showed no statistically signi®cant difference between mean scores for primigravidae and multigravidae. However, examination of the frequency distribution showed considerable variation between the women's responses as illustrated in Table 5. It is evident from Table 5 that over a quarter of the sample (31) were `very satis®ed' with pain relief and three-quarters of the overall sample of women (79) reported varying levels of satisfaction. This ®nding compares favourably with the evidence on satisfaction levels for women in the United Kingdom as a whole (Oakley 1993). However, account must be taken of the 12 women who registered dissatisfaction if the aim is to provide effective pain relief to all women.
In¯uence of personal control, demographic and psycho-social factors on satisfaction with pain relief
Pearson's correlation coef®cients (r) and, where appropriate, the chi-square test were computed to establish whether satisfaction with pain relief was in¯uenced by personal control, demographic factors and expectations of labour pain. The ®ndings are shown in Table 6. The evidence illustrated in Table 6 is clear indication that personal control is an important factor which could in¯uence satisfaction with pain relief. The signi®cant relationships between satisfaction with pain relief and feelings of being in control, being actively involved in decision-making governing pain medication and use of personal coping resources support this claim. Demographic variables and expectations of labour pain had little impact on satisfaction level.
DISCUSSION Before discussing the ®ndings of this study, there are a number of methodological issues surrounding measurement of satisfaction which must be addressed. Foremost is
Ó 1999 Blackwell Science Ltd, Journal of Advanced Nursing, 29(4), 877±884
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B.H. McCrea and M.E. Wright Table 6 Relationship between satisfaction with pain relief and personal control/demographic/psychosocial variables
Variables
Correlation Signi®cance coef®cients level
Demography Age 0á13 Parity 7á55* Social class 5á36* Educational status 4á95* Expectations of labour pain Painfulness of labour )0á08 Worried about labour pain 0á01 Anticipation of the severity of 0á00 labour pain Personal control You were most in control of pain )0á31 management You were able to control pain felt 0á29 Midwives/doctors were able to 0á29 control pain you felt You were able to decide whether 0á34 to use pain relief You were able to decide when to 0á24 use pain relief You were able to decide what 0á29 pain relief to use 0á36 You made use of exercises learned at antenatal classes to cope with labour pain You found the exercises used 0á25 most useful
0á182 0á183 0á374 0á421 0á556 0á919 0á969
0á002 0á003 0á003 0á000 0á015 0á003 0á004
0á054
* Chi-square values, d.f. = 5.
the criticism that measurement within the ®rst few days following delivery may not re¯ect women's actual experience. The experience of childbirth, especially a bad one, could in¯uence their response. It is also possible that some women may not want to be too critical of their care while in hospital, presumably because they may feel that this could affect the care they receive. Set alongside these criticisms, however, is the dilemma that feelings may change over time as women become `wrapped up' with their baby. Some may feel that having `a healthy baby' compensates for any distress experienced. There is also the problem that recall of information may not be accurate. These problems could be resolved by using different measures at different stages of the postnatal period so that ®ndings from one scale could be substantiated by results from other instruments. A further methodological issue to consider is the possibility that satisfaction with pain relief during labour may be in¯uenced by experiences during the antenatal period, but the constraints on time and resources available to carry out research limit what can be achieved in a single
882
study. To this end further research could investigate, for instance, patterns of antenatal care and preparation on pain relief and their in¯uence on satisfaction with pain relief during labour. The most important ®ndings to emerge from this study are the signi®cant relationships between personal control variables and satisfaction with pain relief. These ®ndings compare favourably with those of Slade et al.'s (1993) and indicate that satisfaction with pain relief is in¯uenced by feelings of `being in control' and having an input in decision-making on pain relief. Being involved actively in their care may help to promote feelings of `being in control' and enhance women's con®dence in their own ability to control pain experienced. That these factors are interrelated and important to feelings of satisfaction is evident. However, note must be taken of the ®ndings on feelings of `being in control'; they may appear contradictory given that a signi®cant relationship was also established between satisfaction with pain relief and midwives/doctors' ability to control pain experienced. One possible explanation for the con¯ict in results is provided by Bluff & Holloway's (1994) ®ndings that, although women in their study regarded midwives as experts who knew best, they (the women) nevertheless anticipated playing an active role in the control of their labour. Berg et al. (1996) similarly report that women in their study expected midwives to support, encourage and guide them, but to do so on their terms. Women, it would appear, ®nd reassurance from being told what to do by midwives (Garcia & Garforth 1990) but this does not mean losing control to professionals. Instead, a partnership approach is implied. Personal control, as the evidence from this study implies, goes beyond decision-making about pain relief; it involves making use of personal coping resources such as breathing/ relaxation exercises to cope with labour pain. That antenatal preparation can reduce the uptake of analgesia is well established (Nettlebladt et al. 1976, Simkin & Enkin 1990). However, evidence from Slade et al.'s (1993) study indicates that using exercises had little effect on perceptions of pain intensity, rather it seems to in¯uence the ability to tolerate pain. This dimension of personal control may involve feelings of ful®lment and mastery and is clearly important to consider when planning for pain relief in labour. Midwives should be working with women to identify personal coping strategies and encourage them to make ef®cient and effective use of these resources. None of the demographic variables including social class had an impact on women's satisfaction with pain relief. This ®nding is contrary to prior evidence that working class women look for speed and pain-free labour and are less concerned with personal satisfaction with their birth experiences (McIntosh 1989). Women are more informed today and it is not surprising therefore that they
Ó 1999 Blackwell Science Ltd, Journal of Advanced Nursing, 29(4), 877±884
Issues and innovations in nursing practice
Personal control and satisfaction with labour pain relief
would expect their birth experiences to be ful®lling regardless of social/educational backgrounds. Expectations of labour pain also had no in¯uence on satisfaction level, a ®nding that is in concordance with those of Slade et al. (1993). One possible explanation for the non-signi®cant ®nding may be because the women held realistic expectations; their antenatal care may have prepared them for the reality of labour.
managers. Midwives' initiatives must be recognized and encouraged and the resources made available to put them into practice. In this way midwives and managers can work with women to enhance personal control and increase satisfaction with pain relief and childbirth overall.
CONCLUSION
The ®nancial assistance of the National Birthday Trust Fund is gratefully acknowledged.
The ®ndings of this study suggest that women's satisfaction with pain relief during labour is complex and involves feelings of personal control over pain experiences. These results have implications for clinical practice and for the management of maternity care. Midwives have a responsibility to encourage personal control during childbirth. Women should be encouraged to be active and equal partners in the care process so that they are involved in decisions about pain relief. This would tie in with the recommendation of the Changing Childbirth Document (Department of Health 1993) that women should have more control of their care during childbirth. Obviously they (the women) would need accurate and adequate information on which to make informed decisions. This partnership approach to care should begin early in antenatal care to prepare women for the experience. Preparation is crucial to the concept of control (Thompson 1981) presumably because it enhances con®dence and thus encourages personal control. The value of women's own coping resources should be recognized and maximized in pain relief instead of emphasis being placed on pain medication. To this end women should be encouraged to identify and strengthen personal coping resources; this self-awareness should begin well before the last few weeks of pregnancy. Time is crucial to help prepare women to exercise control, important preparation which should not be relegated to the last few weeks prior to childbirth. Unfortunately, the women in this study were cared for by midwives whom they did not know before being admitted into the labour ward. Thus there may not have been the time needed for the midwives to identify coping strategies and this could have resulted in the overuse of pain medication. This assumption must be tested however, before any ®rm conclusions can be drawn. Ideally a system of continuity in carer, where one midwife or a small group of midwives work with the women throughout their pregnancy and childbirth, would foster and encourage personal control in pain relief. The named midwife concept and the development of midwife-led units would be valuable in implementing these recommendations. Finally, effective pain relief depends not only on innovative practice but it also requires the support of
Acknowledgements
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