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\begin{document}

\title{Novel grouping of planned coping strategies for managing the intensity
of labour: A qualitative study}



\author[1]{Laura Whitburn Y}%
\author[1]{Janine Shifman}%
\author[1]{Lester Jones E}%
\author[2]{Mary-Ann Davey}%
\author[1]{Christine  East}%
\affil[1]{La Trobe University}%
\affil[2]{Monash University}%


\vspace{-1em}



  
  \date{June 14, 2024}


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\selectlanguage{english}
\begin{abstract}
Objective: It is common for women to explore and plan strategies to cope
during labour. These strategies are usually focused on pain control and
described as either pharmacological or non-pharmacological. As labour is
an individual experience, each woman should be enabled to choose
strategies that best suit them, and that reflect what they feel
influences their sense of capacity to cope. By exploring women's
intentions and choices of strategies, this study aimed to understand how
coping strategies can better reflect women's individual needs and
expectations. Design: Survey of 56 pregnant women, including open-ended
questions. Setting: Australian tertiary maternity hospital. Population:
Nulliparous women. Methods: Content and thematic analysis of open-ended
responses. Main outcome measures: A qualitative description of women's
planned coping strategies for labour. Results: Themes related to how
women frame the intensity of labour, how they strive for a relationally
safe environment and a need to be prepared and knowledgeable. Strategies
chosen by women could be grouped into two categories: intrinsic and
extrinsic. Intrinsic strategies could be self-generated by women (such
as breathing techniques and movement), while extrinsic strategies
required either equipment (such as a bath) or others to administer (such
as epidural analgesia). Conclusions: Women value having a range of
intrinsic and extrinsic strategies that enable autonomy or require
external support. This moves beyond the `pharmacological and
non-pharmacological' categorisation of strategies. The findings provide
a foundation for more targeted research into how women can be supported
to individualise and implement these coping strategies in labour.%
\end{abstract}%



\sloppy


TITLE PAGE

Novel grouping of planned coping strategies for managing the intensity
of labour: A qualitative study

\emph{Shifman J} \textsuperscript{1,2}, Jones LE\textsuperscript{1,3},
Davey M-A\textsuperscript{4}, East C\textsuperscript{1,5}, Whitburn
LY\textsuperscript{1}

\textsuperscript{1} La Trobe University, Bundoora, Australia

\textsuperscript{2} St Vincent's Hospital, Fitzroy, Australia

\textsuperscript{3} Singapore Institute of Technology, Singapore

\textsuperscript{4} Monash University, Clayton, Australia

\textsuperscript{5} Mercy Hospital for Women, Heidelberg, Australia

Janine Shifman

Judith Lumley Centre, School of Nursing and Midwifery, La Trobe
University, Bundoora Australia 3086

St Vincent's Hospital, Fitzroy Australia 3065

Lester E Jones

Judith Lumley Centre, School of Nursing and Midwifery, La Trobe
University, Bundoora Australia 3086

Singapore Institute of Technology, Dover Drive, Singapore, 129784

Mary-Ann Davey

Department of Obstetrics and Gynaecology, School of Medicine, Nursing
and Health Sciences, Monash University, Clayton Australia 3168

Christine E East

Judith Lumley Centre, School of Nursing and Midwifery, La Trobe
University, Bundoora Australia 3086

Mercy Hospital for Women, Heidelberg Australia 3084

Laura Y Whitburn (corresponding author)

Judith Lumley Centre, School of Nursing and Midwifery, La Trobe
University, Bundoora Australia 3086

Department of Microbiology, Anatomy, Physiology and Pharmacology, School
of Agriculture, Biomedicine and Environment, La Trobe University,
Bundoora Australia 3086

ABSTRACT

Objective: It is common for women to explore and plan strategies to cope
during labour. These strategies are usually focused on pain control and
described as either pharmacological or non-pharmacological. As labour is
an individual experience, each woman should be enabled to choose
strategies that best suit them, and that reflect what they feel
influences their sense of capacity to cope. By exploring women's
intentions and choices of strategies, this study aimed to understand how
coping strategies can better reflect women's individual needs and
expectations.

Design: Survey of 56 pregnant women, including open-ended questions.

Setting: Australian tertiary maternity hospital.

Population: Nulliparous women.

Methods: Content and thematic analysis of open-ended responses.

Main outcome measures: A qualitative description of women's planned
coping strategies for labour.

Results: Themes related to how women frame the intensity of labour, how
they strive for a relationally safe environment and a need to be
prepared and knowledgeable. Strategies chosen by women could be grouped
into two categories: intrinsic and extrinsic. Intrinsic strategies could
be self-generated by women (such as breathing techniques and movement),
while extrinsic strategies required either equipment (such as a bath) or
others to administer (such as epidural analgesia).

Conclusions: Women value having a range of intrinsic and extrinsic
strategies that enable autonomy or require external support. This moves
beyond the `pharmacological and non-pharmacological' categorisation of
strategies. The findings provide a foundation for more targeted research
into how women can be supported to individualise and implement these
coping strategies in labour.

FUNDING

This research received funding from the Mercy Health Academic Research
and Development Committee, and La Trobe University.

KEYWORDS

Pregnancy; Labour; Childbirth; Coping; Pain; Strategies

1 INTRODUCTION

The strategies nulliparous women plan to use to cope with the intensity
of labour remain underexplored.\textsuperscript{1,2} Expectations of
first-time mothers, and their intended coping strategies, vary, and
while some women plan their coping strategies, others choose not
to.\textsuperscript{1} Childbirth preparation typically reflects what
care providers assume is important for women to know, but often this
differs from women's perceptions of quality
care.\textsuperscript{1,3}For first-time mothers, this can manifest in
uncertainty and discrepancy between women's expectations and actual
lived experience.\textsuperscript{1,3}

The World Health Organization (WHO) promotes a positive childbirth
experience for all women and the importance of woman-centred
care.\textsuperscript{4} This acknowledges that labour pain is
experienced differently by individuals, with varying meaning and with a
range of preferences for coping.\textsuperscript{5} Other factors,
including expectations,\textsuperscript{3} state of
mind,\textsuperscript{6} care provision and perceived
support,\textsuperscript{2} are associated with positive childbirth
experiences. Access to respectful maternity care in midwifery-led
continuity of care models, as well as effective pain management options,
are recognised as essential in the care of childbearing
women\textsuperscript{4,7}. Women need information on risks and benefits
of pain relief strategies to plan effectively.\textsuperscript{4}

Most research investigating women's coping in labour focuses on the
efficacy of strategies for pain relief,\textsuperscript{8,9} which are
usually grouped as pharmacological or
non-pharmacological.\textsuperscript{7,8,10} This is a convenient way of
grouping strategies and reflects traditions of medical involvement in
birth, but risks de-emphasising the range of non-pharmacological
strategies that can be used throughout the continuum of labour. Evidence
supports non-pharmacological strategies for improving pain experience,
satisfaction with pain relief, and overall childbirth
experience.\textsuperscript{11} As such, women should be enabled to
identify a range of preferred coping strategies, especially those that
have broader influences than just pain relief.

Therefore, this study aimed to explore women's individual preferences
and intentions, including the strategies they planned to adopt to cope
with labour pain and their first childbirth experience.

2 METHODS

2.1 Design

This descriptive study collected data from women having their first
birth. Participants completed a questionnaire in late pregnancy. This
paper focuses on two open-ended questions from this questionnaire that
sought women's perceptions of their expected ways of coping with labour
pain. The questions were: ``What strategies do you plan to use to help
you cope during labour?'' and ``What do you believe are important things
that will help you cope with pain during labour?''. Ethical approval was
obtained from Mercy Health and La Trobe University Human Research Ethics
Committees (2019-034) and all participants provided consent.

2.2 Setting and participants

Women were recruited via notices displayed in the antenatal clinic of a
large tertiary maternity hospital in metropolitan Melbourne, Australia,
or inserted in information packs given to women at their 28-week
gestation hospital appointment. A quick response (QR) code in the notice
provided access to an online form describing the study. To be eligible,
the women must have been nulliparous with a singleton pregnancy,
planning a vaginal birth and able to understand written and spoken
English. Women were then contacted to confirm eligibility and provide
clarity about the study and their role as participants. Willing
participants received a link via email to complete an online consent
form and the study questionnaires in Research Electronic Data Capture
(REDCap), a secure, web-based platform.\textsuperscript{12}

2.3 Data collection

Data collection occurred between February and October 2021. A link to
the survey in REDCap was emailed to women in late pregnancy
(\textgreater{}30 weeks' gestation), with a follow up reminder email
sent to non-responders, two weeks later. Limited maternal
characteristics were abstracted from the health records with
participants' consent and summarised descriptively as number and
percent.

2.4 Data analysis

Inductive thematic analysis\textsuperscript{13} was used to generate
patterns in the data. Time was taken to read and become familiar with
responses, then initial codes were generated independently by JS and LW,
using descriptive and focused coding
methods.\textsuperscript{14}Discussions and comparisons of codes were
held with JS, LW and LJ, which led to a deeper interpretation of codes
and generation of themes. Content analysis was additionally used to
categorise the coping strategies listed by participants. Content
analysis allowed for counting and coding of coping strategies and the
calculation of frequency for each. Analysis was completed independently
by JS and LW, who then consulted with LJ to confirm and agree upon codes
and categories. NVivo 12 software\textsuperscript{15} was used to manage
data analysis.

3 RESULTS

Fifty-six participants completed the questionnaire. Around three
quarters were born in Australia, with 63\% aged between 25 and 35 years.
Over half were enrolled in midwifery-led care (59\%), with the remainder
accessing shared care (13\%), public (25\%), or private obstetric care
(4\%). Participant characteristics are presented in Table 1.

3.1 Planned coping strategies

Women were asked to describe the strategies they planned to use during
labour to help them cope. Many women pre-planned multiple strategies
that could be uniquely grouped into two broad categories: intrinsic and
extrinsic.

Intrinsic strategies were `self-generated' strategies that women could
call upon themselves, without assistance from devices, medication, or
other people. Extrinsic strategies were those that required either
equipment or assistance from others. Some of the strategies classified
as extrinsic were easy to administer but still required an external
resource, while others were more complex and required medical
intervention and specialist care. All strategies, and the percentage of
participants mentioning each one, are presented in Figure 1.

3.1.1 Intrinsic strategies

The most common intrinsic strategy planned was breathing techniques
(n=33; 59\%). Movement and ``keeping active'' (ID24) was planned by 28
participants (50\%). Other common intrinsic strategies included
meditation/prayer (n=13; 23\%) and generating a positive mindset (n=14;
25\%), such as ``focusing on the purpose of pain and {[}the{]} outcome''
(ID17) and using positive internal self-talk. Also planned were
hypnobirthing language and tools (n=5; 9\%), resting and staying relaxed
(n=4; 7\%), using vocalisation (n=4; 7\%) and visualisation techniques
(n=3; 5\%).

3.1.2 Extrinsic strategies

Extrinsic strategies that required basic equipment included a bath or
shower (n=27; 48\%), use of a TENS machine (n=21; 38\%), listening to
music (n=11; 20\%), using hot or cold packs (n=6; 11\%), dimming lights
to create a calm physical space (n=6; 11\%), displaying affirmation
cards (n=5; 9\%), and using aromatherapy (n=2; 4\%),

Other extrinsic strategies included the importance of the social
environment, such as having physical contact (touch and massage) from
support people (n=19; 34\%), and the presence of a known support person
(n=17; 30\%).

The extrinsic strategies that required specific medical assistance
included use of pharmacological pain relief, especially epidural
analgesia (n=14; 25\%), and use of nitrous oxide and oxygen (n=7; 13\%).
Of the 14 women who discussed epidural analgesia, nine were open to
using it if needed but preferred to try to manage without it. The
remaining five women had a definite plan to use it, with one wanting an
``early epidural'' (ID25) and stating she was ``all for it'' when it
came to medical pain relief. The use of sterile water injections was
also planned by two participants (4\%).

3.2 Elements that women believe will contribute to coping with pain
during labour

Women were asked what they thought were important elements that would
help them cope with pain during labour. Three overall themes capture
what women valued. The first was \emph{framing labour intensity as
productive and purposeful} ; the second was \emph{creating a
relationally safe environment} ; and the third was \emph{a sense of
preparedness and knowing} .

3.2.1 Framing labour intensity as productive and purposeful

Framing labour intensity as productive and purposeful involved
developing a mindset of self-trust, generating a positive and accepting
attitude towards the experience, and focusing on the purpose of labour
pain.

Developing a mindset for self-trust included recognising that labour and
birth are normal processes, and that overthinking or attempting to
control the process were futile.

.

\emph{Most importantly to trust my body and use the relaxation
techniques to help me feel physically, mentally and spiritually
prepared. Therefore, reducing my fear, anxiety and pain during the
birth.} (ID1)\emph{Mindset, staying calm. Understanding that it's a
completely natural and normal process. I just have to let my body do
what it knows how to do and get my mind out of the way.} (ID56)

Approaching childbirth with a ``positive mindset'' (ID10) was important
to helping women cope. This involved reframing the experience of pain to
``a good pain and not a bad pain'' (ID36), and acknowledging that, even
if they expected it to be hard, the pain was purposeful, finite and also
a shared experience amongst women.

\emph{I expect that it will be the most pain I would probably have felt
previously but am hopeful that I can frame it as only being intermittent
and that it is there for a good reason.} (ID55)\emph{Thinking
positively, reminder that we are not alone in the experience, excitement
of meeting my baby.} (ID11)

However, the experience of labour itself was not of importance for all
women, with one explaining that ``I am reminding myself labour is about
getting the baby out rather than the experience itself'' (ID34) and this
thought process was satisfactory to help them cope with labour.

3.2.2 Creating a relationally safe environment

Women identified that feeling psychologically and emotionally safe
during labour would help them cope. This sense of safety involved
feeling emotionally supported, well informed, and listened to by those
around them. This relationally safe environment was sometimes created
intentionally by the woman's selection of specific support people and
models of care, and at other times assumed as part of their expected
care.

\emph{Relying on my partner and knowing he will be my spokesperson if I
can't cope well. Trusting that I'm in a safe space, surrounded by
experts who can help if things go wrong.} (ID23)\emph{Trusting the
nurses, midwives and doctors to have mine and baby's best interests.}
(ID21)\emph{..having all decisions run by me and be given choices.}
(ID55)\emph{Reassurance from midwives about the normal expectations and
{[}whether{]} what I am feeling is normal or not.} (ID52)

The importance of this relationally safe environment was a prominent
theme and emphasises that both psychological safety and physical safety
are important during labour and birth.

3.2.3 Sense of preparedness and knowing

Birth is an unknown journey for first time mothers. In this study, all
except one woman, who planned ``nothing in particular'' and was planning
to ``just see how it go goes'' (ID7), had researched and actively sought
knowledge to prepare for labour.

\emph{I am going into birth having done as much research into labour and
childbirth as possible so I feel as prepared as I can be.} (ID10)

\emph{Being educated, so that my expectations of the pain are
realistic.} (ID39)

Some women identified that a lack of knowledge or preparedness made them
feel some anxiety about how they would cope and that once they had
gained knowledge, they felt better prepared.

\emph{I don't feel especially prepared or well-educated and I have a bit
of anxiety about what will happen\ldots{} This has meant I have had to
seek out my own educational resources, including reading ''Birth
Skills'' and other books on the process, watching a free webinar on
labour, and listening to a podcast with an obstetrician explaining the
process and interventions. This has helped me feel better prepared to
cope with labour and the pain.} (ID34)\emph{Knowledge - having a clear
understanding of what is happening to my body. I feel that knowing about
the process has already helped ease a lot of fear and has made me feel
more calm and prepared for what will happen.} (ID49)

For some women, this also included understanding what pharmacological
analgesia was available and the implications of these options.

\emph{{[}Having{]} a strong knowledge of the process and the pain relief
available for me.} (ID35)\emph{Knowing what my analgesia options are and
when is the right time for them, for instance if I decided I couldn't
cope and want an epidural, when is it too late for this etc.} (ID52)

Knowledge on all aspects of the birth, including the physiological
process and possible complications, as well as being prepared with a
`tool kit' of intrinsic and extrinsic strategies, were important to
women in this study, and contributed to reducing concerns about the
unknown and increasing confidence to cope with the challenges of labour.

Drawing together the two questions asked of women in this research, we
reach a deeper understanding of women's individual needs in relation to
coping in labour. Framing labour intensity as productive and purposeful
links with the intrinsic categorisation of coping strategies. Women
planned to use mental strategies that focused on the purpose of the
experience and develop a positive mindset towards the challenges of
labour involving self-trust. Creating a relationally safe environment
links with the extrinsic categorisation of coping strategies that
included support people, where having known and trusted carers and
support people, and creating a calm environment in which to birth, was
important to many women. It was important for women to have a sense of
preparedness and knowing, to help them cope with the unknown. The coping
strategies women identified to manage these uncertainties, involved a
variety of strategies, both intrinsic and extrinsic. These findings are
presented visually in Figure 2.

4 DISCUSSION

4.1 Main findings

This study aimed to identify what nulliparous women felt were important
elements that would help them cope during labour, and what strategies
they planned to use. Despite birth being a common and unifying
experience, sense of coping is individual and multifaceted. Our findings
describe three critical components that women identified as important to
help them cope during labour. First, framing labour intensity as
productive and purposeful, which included developing a mindset of
self-trust, generating a positive attitude towards the experience, and
focusing on the purpose of pain in labour. Second, creating a
relationally safe environment, which meant ensuring those around them
made them feel supported, informed, and heard. And third, having a sense
of preparedness and knowing, which included developing a `tool-kit' of
strategies to help them cope.

We used a novel grouping for strategies that women planned to use in
labour: intrinsic and extrinsic. Intrinsic strategies were those that
women could utilise autonomously, without the need for aids or
assistance from others. Many intrinsic strategies were mechanisms to
help women develop and maintain a positive mindset and mindset of
self-trust, to frame labour intensity as productive and purposeful.
Extrinsic strategies were those that women could not initiate
independently. This included support from other people, contributing to
a relationally safe environment and several non-pharmacological and
pharmacological pain relief strategies, such as TENS machines and
epidural analgesia. All women planned to use a combination of intrinsic
and extrinsic strategies, acknowledging that coping in labour would, at
various points, involve both self-trust and autonomy, as well as
external support.

4.2 Strength and limitations

This study extends the literature on coping in labour from the woman's
perspective, which is not adequately reported in existing literature.
Understanding women's views on factors that help them cope in labour,
and their individual preferences and intentions in terms of coping
strategies, will provide a foundation for targeted research into how
best to address women's individual needs.

Our findings are not intended to be representative of all women giving
birth. Although the sample was diverse in terms of country of birth,
model of maternity care and levels of pregnancy risk, level of education
of participants could influence how active they were in seeking
information on labour and birth. Further work should aim to include
women across education levels, birthing in other types of maternity
services and from regional and rural communities, where support and
access to information during pregnancy may be less available.

4.3 Interpretation

Our approach of categorising strategies as intrinsic and extrinsic moves
beyond the pharmacological and non-pharmacological categorisation. It
removes assumptions regarding what individual women may need to help
them cope, which may include pain management for some, but for others
may include alternative strategies, such as movement, a positive
mindset, or support.\textsuperscript{7} A growing body of literature is
now recognising that promoting the natural release and cycle of birthing
hormones\textsuperscript{16,17} can support women to manage the
intensity of labour, which in turn supports the use of intrinsic and
extrinsic strategies that minimise disruption and promote a sense of
safety.\textsuperscript{18} When medical interventions are needed or
requested, it is important that a woman's sense of control and autonomy
are not diminished.\textsuperscript{4,7,19}

A recent systematic review on coping strategies for labour
pain\textsuperscript{20} used a different grouping: cognitive or
behavioural. Whilst this is a step in the right direction, grouping
strategies this way risks confusion due to the overlap of some
techniques as having both behavioural and cognitive effects. For
example, breathing techniques may be described as behavioural, but also
have cognitive effects on focus and relaxation. The intrinsic and
extrinsic approach to categorising resolves this issue, and centres on
the more practical feature of whether the strategy can be initiated or
performed autonomously, or whether it requires external support to
utilise.

Using this novel grouping potentially has implications for how women
prepare for labour and how caregivers provide support. It acknowledges
that labour is dynamic and women need to draw on different strategies at
different times.\textsuperscript{6} In practice, strategies can be
adopted to help a woman move away from a `distracted and distraught'
state, and access or re-access a `mindful acceptance' state, a state
associated with ability to cope.\textsuperscript{6} This emphasises the
role of the caregiver in actively supporting women's selection of
strategies beyond the `pain relief menu'
approach,\textsuperscript{21}which assumes that labour is linear and
suggests that intrinsic strategies are only helpful at the start of
labour, rather than valuable throughout labour to help women refocus and
return to a state of `mindful acceptance'. Extrinsic strategies can also
be useful at various points, even early in labour to help reengage the
more autonomous intrinsic strategies. This supports the importance of
women maintaining their sense of control over their
labour\textsuperscript{19} even if more support from external sources is
required at times.

Women in our study identified the value in developing a mindset of
self-trust to help cope in labour, aligning with the autonomous
strategies that we classified as intrinsic. Framing labour intensity as
productive and purposeful contributes to this. A positive attitude to
childbirth has been found to positively affect a woman's experience of
childbirth pain.\textsuperscript{22} Women in our study also identified
the importance of creating a relationally safe environment, which
included known and trusted caregivers and support people, and creating a
calm environment in which to birth. These views are also strongly
supported in the literature.\textsuperscript{1,23,24} This aligns with
midwife-led continuity models of care, which are associated with more
positive birth experiences\textsuperscript{25,26} and reduced medical
interventions, including caesarean section rates.\textsuperscript{27}The
dynamics of these relationships can also influence the implementation of
strategies learnt in childbirth education in positive and negative
ways.\textsuperscript{28} Caregivers and support people can foster
safety and be in alignment with the woman, helping implement preferred
strategies\textsuperscript{28,29} and create a supportive
alliance.\textsuperscript{28} Alternatively, disruptive encounters with
caregivers can make a woman feel her care is being managed by others and
reduce her autonomy to effectively apply planned coping
strategies.\textsuperscript{28}

When caregivers and support people understand what matters to women, and
emphasise strategies that promote birthing women's autonomy, they will
be equipped to support care approaches that facilitate more positive
birth experiences. The WHO guidelines\textsuperscript{4} recognise a key
aspect of a positive childbirth experience is one where a woman is in a
``psychologically safe environment with continuity of practical and
emotional support from a birth companion(s) and kind, technically
competent clinical staff'' (page 12). Care that considers women's
individual wants and needs, further contributes to positive
psychological birth outcomes.\textsuperscript{30}

Our research has captured the individual preferences and intentions of
women but also has demonstrated a new way of thinking about coping
strategies: One that moves away from a choice between a pharmacological
approach, or not, and where the decision-making centres on the need for
medical assistance and an assumption that pain relief is the priority.
Instead, we propose, the grouping of coping strategies into intrinsic or
extrinsic, which better promotes the woman's autonomy and what she
brings to labour.

5 CONCLUSION

Our research has aimed to improve our understanding of what nulliparous
women identify as important to help them cope with labour, and what
specific strategies they plan to utilise. We have proposed a new
approach to categorising coping strategies, grouping as either intrinsic
or extrinsic. This enhancement acknowledges the dynamic nature of
labour, and centres on women's autonomy and sense of control, beyond
what is possible with the common grouping based on the pharmacological
nature of a strategy. We propose that caregivers help women prepare
coping strategies in each category based on the women's choice and that
researchers further explore the ways strategies from each grouping can
be coordinated for the best outcome for women and their babies.

ACKNOWLEDGEMENTS

The authors would like to thank participating women for dedicating time
to share their thoughts and experiences for this project.

DISCLOSURE OF INTERESTS

None declared. Completed disclosure of interest forms are available to
view online as supporting information.

CONTRIBUTION TO AUTHORSHIP

The study was designed with contributions from authors LW, LJ, CE and
MD. LW completed the data collection. The process of data analysis and
writing the manuscript was led by author JS in close collaboration with
authors LW and LJ. All authors contributed to editing and approved the
final manuscript.

ETHICS APPROVAL

Ethics approval was obtained from the Human Research Ethics Committee of
the health service where recruitment took place, and through La Trobe
University (2019-034).

FUNDING

This research received funding from the Mercy Health Academic Research
and Development Committee, as well as La Trobe University.

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