Acta Obstetricia et Gynecologica.

2010; 89: 794800

MAIN RESEARCH ARTICLE

Psychoprophylaxis during labor: associations with labor-related outcomes and experience of childbirth
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MALIN BERGSTRM1, HELLE KIELER2 & ULLA WALDENSTRM1

1

Department of Womens and Childrens Health, Karolinska Institutet, Stockholm, Sweden, and 2Centre for Pharmacoepidemiology (CPE), Department of Medicine, Karolinska Institutet, Stockholm, Sweden

Abstract Objective. To study whether use of psychoprophylaxis during labor affects course of labor and experience of childbirth in nulliparous women. Design. Cohort study. Setting. Women were recruited from 15 antenatal clinics in Sweden between October 2005 and January 2007. Sample. A total of 857 nulliparous women with a planned vaginal delivery. Methods. Using data from a randomized controlled trial of antenatal education where the allocated groups were merged, we compared course of labor and experience of childbirth between women who used psychoprophylaxis during labor and those who did not. Data were collected by questionnaires in mid-pregnancy and three months after birth, and from the Swedish Medical Birth Register. Logistic regression was used to assess associations. Main outcome measures. Mode of delivery, augmentation of labor, length of labor, Apgar score, pain relief and experience of childbirth as measured by the Wijma Delivery Experience Questionnaire. Results. Use of psychoprophylaxis during labor was associated with a lower risk of emergency cesarean section (adjusted odds ratio (OR) 0.57; 95% condence interval (CI) 0.370.88), but an increased risk of augmentation of labor (adjusted OR 1.68; 95% CI 1.232.28). No statistical differences were found in length of labor (adjusted OR 1.32; 95% CI 0.951.83), Apgar score < 7 at ve minutes (adjusted OR 0.82; 95% CI 0.332.01), epidural analgesia (adjusted OR 1.13; 95% CI 0.841.53) or fearful childbirth experience (adjusted OR 1.04; 95% CI 0.621.74). Conclusion. Psychoprophylaxis may reduce the rate of emergency cesarean section but may not affect the experience of childbirth.

Key words: Psychoprophylaxis, cesarean section, augmentation of labor, pain relief, experience of childbirth

Introduction Psychoprophylaxis is a method for coping with labor pain by using patterned breathing techniques and relaxation. It is widely practiced by birthing women in many Western societies. Through regular practice during pregnancy and by responding to simulated contractions, the woman is expected to react in the same way when experiencing real contractions during labor (1) according to Pavlovs theory of conditioned response (2). The method was developed in Russia and then spread to Western Europe (3,4). In the 1960s, psychoprophylaxis was used by about half of all women who gave birth in France (5). In Sweden it was introduced in the beginning of the 1970s, lost

popularity two decades later (6) and is now regaining popularity (7). In the United States, a survey from 2006 reported that nearly 50% of women used breathing techniques during labor (8), as did 74% in a Canadian survey from 2009 (9). The experience of labor pain is complex, involving physiological, cognitive as well as psychological dimensions (10). Psychoprophylaxis is assumed to affect all these dimensions: physiologically by improving oxygenation and reducing muscle tension, cognitively by focusing on breathing and relaxation instead of pain as such, and psychologically by reducing fear and improving the sense of personal control (4). Simkin and Bolding suggested that relaxation and breathing techniques may contribute more to a

Correspondence: Malin Bergstrm, Department of Womens and Childrens Health, Retzius vg 13, Karolinska Institutet, SE-171 77 Stockholm, Sweden. E-mail: Malin.Bergstrom@ki.se (Received 14 August 2009; accepted 10 February 2010) ISSN 0001-6349 print/ISSN 1600-0412 online 2010 Informa UK Ltd. (Informa Healthcare, Taylor & Francis AS) DOI: 10.3109/00016341003694978

Psychoprophylaxis during labor womans ability to cope with labor pain rather than actually reducing the pain (11). Despite the extensive use of psychoprophylaxis, scientic evaluations are scarce. A Cochrane review of complementary and alternative therapies for pain management in labor included only one trial of psychoprophylaxis and this study suffered from methodological decits (12). Another review of non-pharmacological pain relief also concluded that randomized controlled trials were lacking (11). Observational studies report that women nd breathing and relaxation techniques effective and helpful in coping with labor pain, but do not evaluate the effect they may have on labor outcomes (6,8,11,13). In our recently published randomized controlled trial, the TUFF trial (KCTR CT20080007), we found that including psychoprophylaxis in antenatal education had no effect on subsequent use of epidural analgesia, labor outcomes or experience of childbirth (14). Though the ndings suggest that preparing for psychoprophylaxis during pregnancy is not effective, it is still unclear whether use of psychoprophylaxis during labor might affect these outcomes. The aim of this study was to investigate associations between use of psychoprophylaxis during labor and course of labor and experience of childbirth.

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women, 878 had a planned vaginal delivery, and answered the specic questions related to course and outcomes of labor. In addition to womens self-reported data, we used data from the Medical Birth Register (16). We excluded 21 women for whom we could not access register data or where register data were incongruent with self-reported mode of delivery. Of the remaining 857 women, 486 (57%) used psychoprophylaxis during labor and 371 (43%) did not. Of the 486 women who used psychoprophylaxis during labor, 351 (72%) had attended antenatal classes to prepare for this method: 315 within the frame of the trial, 36 in private classes and 399 (82%) had practiced the techniques at home during pregnancy. Of the 371 women who did not use psychoprophylaxis during labor, 113 (31%) had attended psychoprophylaxis classes during pregnancy within the trial and 165 (44%) had practiced at home.

Background characteristics From the mid-pregnancy questionnaire, we obtained information about socioeconomic background, height and pre-pregnancy weight, emotional and physiological wellbeing during pregnancy and expectations of childbirth and parenthood. The Wijma Delivery Expectancy Questionnaire, W-DEQ A, a scale with high validity and reliability, was used to measure antenatal fear of childbirth (17). The W-DEQ A includes 33 items with six-point response scales covering various feelings and cognitive appraisal of childbirth. The maximum score is 165 and a high score indicates a higher degree of fear. Cutoff for fear of childbirth during pregnancy was set at > 84 (18). Information about smoking in early pregnancy, gestational length and birth weight was obtained from the Medical Birth Register (16).

Material and methods Study population and recruitment For the purpose of this study, we used data from the TUFF trial of two models of antenatal education, one of which included psychoprophylactic preparation. Associations between use of psychoprophylaxis and experience of childbirth and labor-related outcomes were compared between users of psychoprophylaxis and non-users, regardless of their group assignment in the trial. Recruitment took place between October 2005 and February 2007, and women were eligible for the study if they were nulliparous, Swedish-speaking and attending any of the 15 antenatal clinics that had volunteered to participate in the trial. The clinics were spread over Sweden and were all part of and funded by the public sector. The women were recruited by their antenatal care midwife at approximately 19 gestational weeks. All who were included were asked to ll in two questionnaires, the rst in mid-pregnancy and the second three months after birth. More detailed information about the trial has been published elsewhere (14,15). Of approximately 1,300 women who were eligible for the trial, 1,087 agreed to participate and 986 completed the follow-up questionnaire. Of these

Explanatory and outcome variables The explanatory variable was womens use of psychoprophylaxis during labor, and this information was based on womens self-reports in the follow-up questionnaire. Such information was not available in the Medical Birth Register. Information about course of labor and experience of childbirth was obtained from the follow-up questionnaire. Data on mode of delivery were validated by comparing with data from the Medical Birth Register. Emergency cesarean section was dened as cesarean section preceded by labor, and instrumental delivery included forceps and vacuum extraction. Length of

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M. Bergstrm et al. weight (< 2,500, 2,5004,500, > 4,500 grams). The regional ethical review board in Stockholm approved the study (File record 978/31).

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labor was dened as length from onset of regular contractions with ve minutes interval, to birth. Data on Apgar score at ve minutes were collected from the Medical Birth Register. Cut-off for fearful childbirth experience on the W-DEQ version B was set at > 84 (18). This scale has the same structure as W-DEQ A, described above. The overall experience of childbirth was measured by a single-item question with ve response alternatives which were dichotomized to positive experience (very positive and positive) and negative experience (both positive and negative, negative and very negative) (19). Score 7 on a Likert scale ranging from 0 to 7 was dened as worst imaginable pain.

Results Women who used psychoprophylaxis during labor were older (p = 0.003), more often Swedish-born (p < 0.001), more educated (p < 0.02) and had a higher total household income (p = 0.03) compared with women who did not use psychoprophylaxis (Table 1). Also, their pregnancy was more often planned (p = 0.04). No statistically signicant differences were found in pre-pregnancy BMI, smoking in early pregnancy, self-rated health during pregnancy or expectations of upcoming motherhood. Expected use of pharmacological pain relief (epidural analgesia, pethidine/morphine or N2O) did not differ signicantly between users and non-users of psychoprophylaxis. In contrast, expected use of nonpharmacological pain relief was associated with subsequent use of psychoprophylaxis: shower/bath (p = 0.005) and acupuncture (p < 0.001). Mean gestational length was 280 (SD 11) days among both users and non-users, and the mean birth weight was 3,518 grams. The mean birth weight was slightly, but non-signicantly, higher among users compared with non-users: 3,536 (SD 512) versus 3,495 (SD 498) grams (Table 1). The total mean score for antenatal fear of childbirth, as measured by the W-DEQ A, was 65.4 (SD 20) for users and 64.3 (SD 22.9) for nonusers (p = 0.5). There was no signicant correlation between antenatal fear of childbirth and use of psychoprophylaxis: Spearmans Rho 0.04 (p = 0.26). Women who used psychoprophylaxis had a lower risk of emergency cesarean section (OR 0.64; CI 0.430.94) but a higher risk of labor augmentation (OR 1.67; CI 1.262.21) (Table 2). They had a longer mean duration of labor, 11.9 (SD 10.4) versus 10.4 (SD 9.4) hours (p = 0.05), and a slightly but not statistically signicant increased risk of labor length of nine hours or more (adjusted OR 1.32; 95% CI 0.95 1.83). Exclusion of women who delivered by emergency cesarean section had almost no effect on this result, and the mean duration was then: 11.7 (SD 9.2) versus 10.4 (SD 9.4) hours (p = 0.15). There were no statistically signicant differences in risks between users and non-users in induction of labor, Apgar score at ve minutes or use of pharmacological pain relief. The women in the psychoprophylaxis group used more non-pharmacological pain relief (Table 2). Psychoprophylaxis during labor was not associated with a less fearful experience of childbirth (Table 3).

Statistical analysis Statistical analyses were conducted in SPSS 15.0 (SPSS, Chicago, IL, USA). Associations between use of psychoprophylaxis and background and birth characteristics were calculated by bivariate analyses. Background data for the women are presented as numbers and percentages or means and standard deviations. For each woman, we calculated the pre-pregnancy body mass index (BMI) by weight (kg)/height2 (m), mean and median length of labor (hours). Continuous data were compared by Students t-test and categorical data by chi-squared tests. p-Value < 0.05 was considered statistically signicant. Cronbachs alpha scores for the standardized instruments are presented. The correlation between use of psychoprophylaxis and antenatal fear of childbirth was calculated by Spearmans rank correlation, which measures ranks instead of mean values and is suitable for ordinal or nominal data. To control for potential confounders, we used logistic regression analyses to assess associations between use of psychoprophylaxis during labor and mode of delivery (spontaneous vaginal/emergency cesarean section/instrumental vaginal delivery), induction and augmentation of labor, Apgar score < 7, use of pain relief (epidural analgesia/N2O/ pethidine or morphine/bath or shower/acupuncture), experience of childbirth (fearful/overall positive/worst imaginable pain) and labor length median length. Risks were calculated as crude and adjusted odds ratios (OR) with 95% condence intervals (95% CI). The multiple logistic regression included previously identied potential risk factors: maternal age ( 25, 2629, 3035 and 36), country of birth (Sweden vs. other country), educational level (elementary school, high school and college/university), pre-pregnancy BMI (< 25, 2530 and > 30), antenatal fear of childbirth (W-DEQ A > 84), smoking in early pregnancy (no smoking vs. any smoking) and birth

Psychoprophylaxis during labor

Table 1. Characteristics of users and non-users of psychoprophylaxis during labor. Users n = 486 Characteristics Maternal age 1625 2629 3035 36 or older Married or cohabiting Born in Sweden Education Elementary school High school College or university Total household income per month* Low Middle High Pre-pregnancy BMI < 25 2530 > 30 Pregnancy planned Smoking in early pregnancy Wanted a cesarean section Fear of childbirth: W- DEQ A > 84** Self-rated health in mid-pregnancy as very good Had very positive expectations of upcoming motherhood Expected use of pain relief Epidural analgesia N2O Pethidine/morphine Bath/shower Acupuncture Birth characteristics Gestational length 37 weeks Birth weight < 2,500 grams 2,5004,500 grams > 4,500 grams n % Non-users n = 371 n %

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pain: mean 5.2 (SD 1.4) versus 5.1 (SD 1.7) on a Likert scale (p = 0.35). Adjusting for potential confounders had only minor effects on the risk estimates (Table 2).

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102 173 185 25 471 464 9 192 281

21 35.7 38.1 5.2 96.9 95.7 1.9 39.8 58.3

108 120 109 30 356 329 11 177 178

29.4 32.7 29.7 8.2 96 89.6 3 48.4 48.6

Discussion In this cohort study, we found that women who used psychoprophylaxis during labor had a lower risk of emergency cesarean section compared with those who did not use the method. Experience of childbirth, memory of labor pain and use of pharmacological pain relief did not differ between users and non-users, but other methods of non-pharmacological pain relief were more common in those who practiced psychoprophylaxis. Women who used psychoprophylaxis were older, more often had a planned pregnancy and also a more favorable socioeconomic background, which is in line with previous reports of participants in antenatal education and psychoprophylactic preparation (20,21). The emergency cesarean section rate in the study population (14.5%) was slightly higher than the national rate of 13% in all women giving birth in Sweden in 2006 (16). One explanation contributing to this difference could be the higher mean birth weight in our study sample compared with the general population: 3,519 versus 3,419 grams (22). There may be different explanations for the association between psychoprophylaxis and a lower rate of emergency cesarean sections. Obviously women in the psychoprophylaxis group were more motivated to take an active part in the birth process by more extensive training during pregnancy. This might have boosted their condence and ability to endure a longer labor, and as a consequence some cesarean sections may have been avoided. It is also possible that women who were strongly committed to the use of psychoprophylaxis had more negative attitudes to medical interventions, which may have affected the behavior of the birth attendant to postpone a decision about terminating labor by a cesarean section. Also, more active coaching by the partner with whom the woman had practiced psychoprophylaxis at home during pregnancy might have improved condence and ability to endure a longer labor. Another explanation for the lower rate of cesarean section in women who used psychoprophylaxis might be that there are physiological benets of the patterned breathing and relaxation, which is assumed to increase energy and lower the risk of ineffective contractions (4). However, we have no data in this study to support such an explanation and concede that more research is needed to explore the potential physiological mechanisms of psychoprophylaxis. Yet another explanation could be

137 128 199 358 91 28 392 16 25 76 174 443

29.5 27.6 42.9 75.1 19.1 5.9 80.7 3.4 5.1 15.7 35.8 91.2

133 90 126 264 69 31 279 20 26 66 150 335

38.1 25.8 36.1 72.5 19 8.5 75.2 5.7 7 18 40.4 90.3

173 404 30 264 117

35.6 83.1 6.2 54.3 24.1

145 291 36 166 49

39.1 78.4 9.7 44.7 13.2

463 13 453 19

95.3 2.7 93.4 3.9

355 9 354 8

95.7 2.4 95.4 2.2

*Low 24,000 SEK, Middle 24,00129,999 SEK, High 30,000 SEK. **Cronbachs alpha 0.93. Note: BMI, body mass index; W-DEQ, Wijma delivery expectancy questionnaire.

The total mean score on the W-DEQ B was 50.6 (SD 25.4) in women who used psychoprophylaxis and 49.8 (SD 24.6) in those who did not (p = 0.65). Assessment of childbirth as a positive or very positive experience differed only slightly between the groups (OR 1.16; CI 0.891.52). Furthermore, there was no statistical difference in memory of labor

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Table 2. Comparisons of course of labor between users and non-users of psychoprophylaxis during labor expressed as crude and adjusted OR with 95% CI. Users n = 486 Outcomes Mode of delivery Spontaneous vaginal Emergency cesarean section Instrumental vaginal delivery Labor outcomes Induction of labor Augmentation of labor Labor 9 hours** Apgar < 7 at 5 minutes Pain relief Epidural analgesia N2O Pethidine/morphine Bath/shower Acupuncture n % Non-users n = 371 n % Crude OR 95% CI 0.881.6 0.430.94 0.821.81 0.571.18 1.262.21 0.991.79 0.361.9 0.811.39 0.751.79 0.512.43 1.121.96 1.563.29 Adjusted OR* 95% CI 0.891.74 0.370.88 0.781.82 0.61.33 1.232.28 0.951.83 0.332.01 0.841.53 0.721.5 0.52.5 1.041.88 1.413.16

357 57 73 74 329 216 12 238 397 16 223 119

73.3 11.7 15 15.2 68 49.8 2.5 49 81.7 3.3 45.9 24.5

260 64 47 66 207 131 11 176 300 11 135 46

70.1 17.3 12.6 18 55.9 42.7 3 47.4 80.9 3 36.4 12.5

1.18 0.64 1.22 0.82 1.67 1.33 0.83 1.06 1.06 1.11 1.48 2.27

1.25 0.57 1.19 0.89 1.68 1.32 0.82 1.13 1.04 1.11 1.4 2.11

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*Adjusted for maternal age, country of birth (Sweden vs. other), educational level, pre-pregnancy BMI, antenatal fear of childbirth (W-DEQ A > 84), smoking in early pregnancy and birth weight. **Median length of labor was 9 hours. Note: OR, odds ratio; CI, condence interval; BMI, body mass index; W-DEQ, Wijma delivery expectancy questionnaire. Table 3. Comparisons of experience of childbirth in users and non-users of psychoprophylaxis during labor expressed as crude and adjusted OR with 95% CI. Users n = 486 Outcomes Fearful childbirth experience: W-DEQ B > 84** Overall positive childbirth experience*** Worst imaginable pain**** n 43 237 91 % 8.9 48.9 18.8 Non-users n = 371 n 35 167 82 % 9.6 45.1 22.3 Crude OR 0.91 1.16 0.81 95% CI 0.571.46 0.891.52 0.581.13 Adjusted OR* 1.04 1.12 0.87 95% CI 0.621.74 0.831.5 0.611.25

*Adjusted for maternal age, country of birth (Sweden vs. other), educational level, pre-pregnancy BMI, antenatal fear of childbirth (W-DEQ A > 84), smoking in early pregnancy and birth weight. **Cronbachs alpha 0.94. ***Overall childbirth experience assessed as very positive or positive. ****Memory of labor pain rated as 7 on a Likert scale where 7 = worst imaginable pain. Note: OR, odds ratio; CI, condence interval; BMI, body mass index; W-DEQ, Wijma delivery expectancy questionnaire.

that an emergency cesarean section did not give women the opportunity to use psychoprophylaxis, which would then explain why the rate was higher in non-users. However, we believe this explanation is unlikely, considering that psychoprophylaxis usually is practiced from the early onset of labor, and the mean length of labor was only 1.5 hours shorter among non-users compared with those who used psychoprophylaxis. The lack of association between use of psychoprophylaxis and experience of childbirth or memory of labor pain was unexpected, since psychoprophylaxis is assumed to increase a womans feeling of control during labor, a feeling previously reported to be associated with a positive childbirth experience (19,23). Emergency cesarean section as well as

augmentation of labor has been associated with a negative birth experience (19), and the possible effects of these factors may have canceled each other out. The nding that psychoprophylaxis was not associated with a more positive birth experience is supported by the results of our randomized controlled trial, which showed that antenatal training in psychoprophylaxis did not affect the birth experience (14). Psychoprophylaxis did not reduce the need for additional pharmacological pain relief. Today, psychoprophylaxis is considered a method for improving a womans ability to cope with labor contractions and increasing personal control during labor, rather than reducing pain (11,2427). Women seem to use the method to calm down, as a distraction or as a way to control panic (28), and to complement rather than

Psychoprophylaxis during labor replace pharmacological pain relief (14). Green et al. showed in 1990 that well-educated women were more likely to prepare for birth with psychoprophylaxis, but were no more committed to the idea of a drug-free labor than less educated women (21). A strength of our study is the relatively large sample of 857 women who were recruited from all over Sweden. However, the fact that these women were participants in a randomized controlled trial might limit the generalizability of our ndings. Another limitation is the lack of information about the women who declined to participate in the trial. Although the most common reason was that they wished to attend larger lectures instead of small groups, we cannot exclude other possible differences between our study population and women giving birth in general (14). We used logistic regression analysis to control for confounders known to affect the course of labor, such as maternal age, BMI and birth weight (29,30). We also controlled for educational level since women with lower socioeconomic status may be less inclined to participate in decisions regarding their medical care and may be at higher risk of cesarean section (31,32). Even if risk assessments by logistic regression analyses in cohort studies for outcomes with an incidence > 10% may exaggerate the risk (33), we consider our ndings reasonably reliable, since controlling for the confounders resulted in hardly any change in the estimates. Also, use of psychoprophylaxis could theoretically be inuenced by whether the women anticipated problems during labor or not. However, we found no correlation between antenatal fear of childbirth and use of psychoprophylaxis. Despite our efforts, we cannot rule out that other factors which are unknown to us may have inuenced the results. The women who used psychoprophylaxis may have differed in attitudes and personality from the non-users, and they may also have been healthier and at lower risk of complications at the onset of labor. In conclusion, psychoprophylaxis may reduce the rate of emergency cesarean section but may not affect the use of epidural analgesia or the experience of childbirth. Declaration of interest: This work was funded by the Swedish Research Council and Karolinska Institutet. All authors state that they have no competing interests to declare.

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