ミ4,'ノ气,舟,づ一叉ノ「ナ

111ミノ

.

匡一

メ,

讐'

11途,爽

^

0 /'

,本'、ー・"り゛

'宏岐 JJ.. J゛'門、'ー

む契4が1,tJ膨二謬¥そ参ンゞ§・・"・ーt 学t尋蚕二●参1勇参1や

1"'1.^毛t浄11tj釜ま,戸1・逵ザ1,'1努美、'喜戸'、ゞy゛、》三,t-'注と多

,ン.、,'一会1,4'β轟、1.ゞ豆毛冬多1念^J轟、゛ y

J'

.

"

4ι、手ぬ,

1除ノ、

牙二参1

ゞナ◆一

y

'多、

y

券

女並,膨ナ■、1゛¥

ノ^

で

4ーガ埋灸゛、リ

ミ弓冬,f,1,梦,毛、,,eL'ι'諺二藩,会")魯倭

,塗 )会゛ノ

ジー

y4 .,

加巨

"

.

^^

K

子

淡

y'ゾj

?¥、

え

扮工

ヂX

'^

t

1.'卓" 1、

'~ミ

才,ハ"

J 11 、才

"

武

包

、,ν

工契'

4

'ヤ

壽

ノ、, JI'ーミゞメず史j5ナψ、ノ'- YJ'ミ叉魚、●,

,'ーン゛、,

、1y琴.拳y ヲ1÷,'イ弓41Jぎ郵一ゞ^」、J

運f乎尋彫狗冬子二

J一共秀Jヂメ●'

Jゼ松

/

'

ン傑r

g

戦ン3傑際好ミf勢二珍',ヅづハ~田j写;f

'芽'紗一、'嵯ヲ§、ー、

'41,1シ"

'ξ

顎

(リjicialpuhlicah0πψがle 1πterπαh0παI C0π/edel'ati0π qf八lidu!iues

,ぎ戒j◆

'

."

余、,气、

ミ,、

g一影j

"゛→キ"゛門ナノ、フ

メ

'

イ,

弥'づ三途

え、叉

畠

イ＼

゛ゾ

謬

.

.

、凡゛

ン

影

覆ゞ

翻

警

.露

',',ノ,タ..ヘ,、

泌

巴一

毒、

泌

窪,イ、

1

,.

W;ψゞツ

・七'^二一^^,

4鴫^釜鄭

゛、、,

yg,シ昌一U゛

膨金t

气ノ''Y 、亀、●

■■"

ν÷ J

呉

"◆驚

.一

郭

一一」゛

1紗

心一.,

メ談茨

美●' J 論ノ灸

ン^ー^ξ^'

゛リー゛、之ιノ

多ゞA

t勢欝

1名

Xξ●リぢ

1一ゞ◆一^●

、゛ノ'/J

、ヨニゴ一,/ 4

一塾響都

^^^^《へ^ル,'

y、"琴

ハ

ψ,巡,六

ノ÷ Jハ,、 J ゛,J,ノ、」、、、

ナノノハ、 J 、、ゞ、ν、、 J ,、ノ一

十".^/4べ゛"ノ

゛J/,イ゛イ

ジ

"

,、, J /,>、ニゾ、J 、"゛

U塗,、七

リ、゛

」ノ゛ナ、」ノノノイ、イ,」', J

,●ξ,角

/ tニイ气ノ゛ハく、、心.J,訊シ一鼻゛

ン

心

ヤヲ

"、゛りダJ＼

ぞー支',,イー

.'ゞご、゛

参魯J,'ノ゛、一、>¥,

,-J゛^瓢^阿1<^J

Ctイ'ー、、''.

1L、●Y

疹.

べNX

武

'゛"A

^一弓''^>^,、.

ご

、

容y吋

Nゞyt女岡ノー●

、)く●、;,゛

t、1●

゛^^'^^^リ

欝弓琵,

〆

't、

会1,

"

'^ゞ咲然

点メ多1、ミ

六〆

弧

屍

ン心

獄

孝

ニー弓武ヅ耐j七ノイ

.、゛一ι』」 4气9゛、

途§゛,.・'武,、、

゛Jイノ、ン、,

玉y .

、^^^^、゛

一き、Jり

タ匙■

ず葬んメ

嵐

ノ ノ'、

ーーむへg司一''ハ"●4.膨yy

゛

゛

ξ

女

歓J迄、

.

シ

jノ予"゛

^一^^^^^^参ヅ^'

艮

J゛、ゞノ一J

J 、」ノ

ケノ

.ノ

ノ■ J

J /、 J 、、 J /

ニ^゛^触●

j/々゛ー、

戸

,ー'

◆烹

冬会

参、入'、ノ

一

, J 一一主

タミ●

霧男

゛

、、Ⅷ JO 、

》

子 1

'

Internationaljournalofchildbirth

Maria Helena Bastose, MD, MSC, phD

Marie Berg, phD, MNSC, MPH, RN, RMSusaD Bewley, MA, MD, FRCOGTerese Bondas, phD,1,icNSC, MNSC, RN, PHN

Sheena Byrom, RM, MA

NgaiFen cheung, phD, MSC, RM, RGNHannah Dahlan, RN, RM, BN(Hons),McommN,phD,FACM

Frances Day、stirkMarcos Dias, MD, phD

GraceEdwards,RN,RM,ADM,QrtEd,M.EdPゆ

Ienny Gamble, RM, MHlth, phDAtfGherissi, CM, MSC, phD

Ank de jonge, phD

EU8ene Declercq, phDRaymond De vrjes, phD

Dedan Devane, phD, MSC, pgDゆ(stats),DipHE, RGN, RM, RNT

Denis walsh, phD, RM

Divisi0110jMidwiferyUHiversity qi'NothH8hα抗

U"ited Kiπ8d0111

EdHors・in・chief

Deputy Editor

SOO Downe, RM, MSC, phD

Sιho01 ψHealthU11iversit), qi'ce11h41 ια11Cashire

U"ited Kiπgdo"1

Assodate Editors

Iudith T FU11etton, phD, CNM, FACNMVive廿e Glover, MA, phD, DSC

Mechthild Gross, RM, RN, MSC

GiⅡ Gyte, MphilEⅡeen Hutton, RM, RN, phDKen johnson, phD

H011y powe11Kennedy, phD, CNM, FACNM,FAAN

Patrick Lavery, MDNicky Leap, DMid, MSC, RMHeloisa Lessa, MS

AmaⅡ上okugamage, MBchB, BSC, MSC, MD,FRCOG

Iisa Kane LOW, phD, RN, CNM, FACNM

Ans Luyben, RM, PGDE, PDM, phD

Margaret Maimbolwa, phDRosemaryMander, MSC, phD, RGN,SCM, MTD

KerriD. schUⅡing, phD, CNM, FACNM, FAAN

DivisioH qi'AC4de1πic Aガ'4irsNortherπ MiCん宮4H Uπiversi砂

Uhited st4tes

FraDces Day・stirkPresideπt

Uπited Kmgd01"

Address Malata

Vice・PルSide11t

Mα1αH,i

Myrte de GeusTrensurer

The Neth甜14hds

Jemima Dennis・Antwi

Ghαπ4

Jayne MarshaⅡ, phD, MA, PGCEA, ADM,RM, RGN

Etsuko Matsuoko, phD

Rob抑 Maude,phD,MA (MidMfery),BN,RM,RNChris Mccourt, phD

Marianne Mead, RM、 phD

Iudith Mercer, BSN, MS, DNS

Maτγ Newburn, MSC

Kerreen Rei8er, MA, phDVerena schmidt, RM

Julia seng, phD, CNM, FAAN

Theresa Ann sipe, CNM, MPH, MN, phDNick Taub, phD

Jim Thornton, MD, FRCOG

Kerstin uvnas・Mober8, MD, phDSaras vedam, RN, MSN, sciD(hc)Kimwatts, phD, PGCAR MSC, RM, RN

International confederation ofMidwives

Frances Gan名esChi旦1'ExeιUh'veThe Nether1απds

1"terHatioh41jour"α10jchild6irth is P口blished quatterly by springer publishing company, LLC, New Y。rk

Busiπess0ガ1ιe:AⅡbusinesscorrespondence,indudiDgsubscriptions,Tenewals,andaddresschan es,shouldbeaddre edt s p bl・ h・ C王LC,11 West 42nd street,15th H., New York, NY I0036. WWIV.springerpub.com

Editoriα10ガ1Ce:M叙IuscriptS血rpublicationshouldbesubm近edelectronica11γUsin EditorialMa11a er:WWW.edit。rial /・・ b・th

SN6Scrψh'oh Rates (per 1ヒ4r/: For institutions: print & online,$300. For individuals: print & online,$73. outslde the united states f。r i n t・: P ・& online,$436. For individuals: pri川& online,$Ⅱ5、

Permissionis gnntedbythecopyrightownerfor]ibraries andothersregisteredwith血ecopyrightclearancecenter(CCC)t。 h。t。C。 t・ 1 h血r $5・oo per copy ofthe article・ payments should be sent diredly to: copyright clea捻nce center,27 Con ress street, salem, MA 01970. Th・・・holdsforcopyingdoneforpersonalorinternalre企rence use only;itdoesnotextendto otherkinds ofco in ,suchasc。 i f ld ・b ・advertisin30rpromouonalpurposes, creatingnewc011ective works, or血rresale. Requestsforpermissions orfurtherinf。rmati h ldb dd dSpri口ger pub]ishing comP飢y, L上C.

Post柳4Ster: send address ch釘lges t01れter"ati0παljourh41 ql'childBirth/springer publishing c。mpany, LLC,11 West 42nd street, New York, NY I0036.

Copyright @ 2016 Springer publishiDa company,ιLC, New York.1SSN 2156_5287

BoardMembers

Laurence Monteiro

Beπih

Serena Debonnet

Belgiu"1

Rita Borg・xuerebM41故

In今ela wiMundS1νedeπ

Irene de la Torre

Pιιerto Rico

Sandra oyarzo TorresChile

Sue Bree

Ne1ν Zeα1απd

MaryKirkAustr4ha

Rafat lan

Pakist口11

Internationaljournalofchildbirth

Volume 6, Number3,2016

ARTICIES

The Elidted verbalpain language ofchildbirth: A closer l,ook atPain Assessment Through a critical and lnterpretiveReview ofthe Literature

Steph411ie p01νeむ Fi0114 E. B080ssi411,1eππy str011g 411d R01411d sussex

Pain ReliefEffed ofcryotherapy in parNrientsOd4νio M. C. varge11S, soni4 NUπes,ιolit4 D. d4 Si1να,α11d1411e M. progi411h

Birth plans: A Narrauve Review ofthe Literature

Berπie Diνα11, Heleπ Spihy, julie Roberts,411d De11is walsh

The LENTE study: The Effectiveness ofprophylactic lntramuscularOxytodn in the Third stage ofLabot Among LOW・Riskwomen inPrimary care Midwifery practice: A Randomized contr0Ⅱed Trial

Suze M.丑 j. j4πS, Kathy c、 Herschdのルむ M4riet Th.ν4π Die1π, Mieke Ait加k,M4rlies Riiπders, Kαπ'πν411 der P41・de Bruiπ,α11d si111011e E. Buiteナ1diik

Perceived Barriers and Facilitators ofa New lvlodelin 入lanagingPregnant ~×1'omen いlith lron De丘dencyAnemia: A Qualitative study

Widyawah widy4W4ti, suze M.丑 1.1411S, we1111y Art411h Nis"1411, ElsiDwiH4PSαガ,Ieroeπν411 Di11e11,411d A11toiπette ιeoHard4 Maガa ι48ro・j4πSse11

134

149

157

173

183

ARTIC[ES

TheElidtedverbalpai11Iang11age ofchildbirth:Acloser王ookatpa加AssessmentThroughaCriticaland lnterpre廿Ve Reviewofthe literature

Steph4πie poweち Fi0114 Ξ. Bosossiaπ,1eπ11y str0πS, aπd R014πd sussex

OBIECTIVE: To provide a critical and interpretive review ofthe literature to investi8ate examples ofPain assessmenttools used in a childbirth context. ThroU8h these examples ofpain assessment,theConcept ofelidted verbalpain language isintroduced and explored.

METHODS: Electronic search strategies were used to identify primary research regarding maternalreports of pain (during labor, postpartum and retrospectively), which lvere captured by stal)dardizedPain assessment tools.

FINDINGS: The revie、v revealed the physi010gical(the sensory and affective dimensions ofpain,the intensity of pain, a11d the inauence of parity on pain perception), psydl010gical(the inauenceOfmaternal attitude, mood, and memory on pain perception), and ethnocultural(the impact oftheethnoculturalcontext on pain perception) components ofthe pain experience. The strengths andIimitations ofpain assessmenttools aTe hi名hlighted、 There were similarities in the reviewed studies'approaches to pain assessment despite the cross-culturalrepresentation ofbirth. possible implicationsfol cross-culturalpain assessment a11d communication are outlined.

CONCI'USION: The question remainsre8ardin今 the appropriateness ofimplementing standardizedPain assessmenttools across birth context. k) ongoing critique ofpain assessment may inform the pro、Vision ofbetter care overa11 for birthing women in multiculturalsocieties.

KEYWORDS: childbirth pain; pain measurement; pain expression;1abor assessment

INTRODUCτ10N

Childbirth unites many women in 仕leir understandingand experience of pain. Despite adva11Cements in painmeasurement and treatment, pain is stiⅡ Understood asa complexphenomenon. ThesensationS 企lt duringlaborare 0丘encategorizedaS4Cutepain. HO、vever,itis aunique,normal, nonpath010gical pain (Moore,1997a, P.3) thatf0ⅡOws a predictable pattern, ultimately resulting in thebirth ofababy Durh1号laborandbirth,thenature ofpainVaries from 壮le flrst stage where visceral pain is experi・enced^UsuaⅡy ftom ceNicaldilation and the expansionanddistension ofthelowerse号mentofthe uterus(Moore,1997b, P 4の through to second sta8e, where somatic

134

Pain is experienced (Baddock,2015) as the baby's headmovestoward 血e pelvic aoor and the impulsesreach theSacralspinalcord and stimulate ceⅡS produdn8 Pain thatCorresponds to where the structures are being pressed inthe body (waⅡ,2000, P.85). Acute pain C紅) conjure up arange of sensory, emotional, arld c08nitive experiencesand psych010今ical, autonomic, a11d behavioral responses(chapman,1984,P.1266;MCCO01,smith,&Aber昌2004);it can be transient in natare or result in mild, severe, or

Ongoing pain (Mccoolet al.,2004, P.475).Holvever,in comparison to other experiences, the

Sensations of labor cannot be dassi丘ed easily accord・in名 to the usual criteria for acute pain. studies 、vhichfocus on birth descriptions often use preexistin8 Pain

//VTE凡ⅣA刀0/VAI_ JOU月NAι OF CH/ιDB/月TH VO/ume 6,/ssue 3,2016

◎ 2m6 Springer publishing company, LLC WWW.springerpub.comh廿P:ガdx.doi.org/、10.189ν2156-5287.6.3.134

,

assessmenttoolssuch asthe MCGiⅡ Pain Questionnaire

(MPQ; Melzack,1975) or the visual Analogue scale(VAS; Gedye, Aitken,&Ferres,1961a,1961b; HUSMsson,1974)in、vhichlanguage is extractedbya predeterminedCriteTia. This form ofpain assessment offers an elicitedVerbalpain language (EVPL).ge (

is assessed and interpreted mayHow labor Paln

"normal" birth is viewed withinhowbe dependent ona particular health care model.1n a 叉/×1'estern context,h ca

birth is often polarized between a biomedical or tech・nocratjc model(Davis・Floyd,20OD, a women・centered,Sodalmodelofbirth (W'alsh &Newburn,2002), and the

mediaung biopsychosodalmodel(Beebe, Lee, carrieri・Kohlman,& Humphreys,2007), which indudes a focusOn the interacuve anatomic, physi010gical, psych010号i・Cal, sodal, cultural, and environmental characteristics

Ofbirth (Beebe et al.,2007, P 41D. Therefore, midwivesmay view birth from differing perspectives dependentOn their education,training, and the culture ofthe envi・ronmentin which theywork, and how their philosophyOfpractice relates to the aforementioned models ofcare.

An example of a standaTdized assessment usedgloba11y in clinical settings (Groeschel & Glover,2001;Tay & Yong,1996) is the partogram, which was intro・duced in the early 1970S (Beazley & K山jak,1972) andProvides a pictorialrepresentation oflabor in 、vhich cli・nicians are prompted to action in response to slowlaborPt0今ress (Lavender, Hart,& smyth,20B, P. D.

The midwifds professional 、vorldvielv and theirexpertise determine howthey assess a、vomads pr03ressin labor; yet without one designated pain assessmentto01, the midwife relies on professionalsMⅡ(technicaland nontechnicaD t08aU8e awomadssensations duringIabor. However, we contend thatthe midwifds personalethnocultural back号round may also inauence theirWorldview and thus impad on the type of pain assess・ment used and subsequent data captured.

Although lan8Uage is not usua11y the focus ofCate, it is a barrier to achievin8 quality birth care for a11Women (Hayes,1997). According to Narayan (201の,there are severalissues in pain management in a gen・eral pain context that indude (but are not limited to)the misinterpretation of language and nonverbal com・munication, culturaⅡy or lin号UisticaⅡy inapproprjatePain assessment tools, and underreporting or under・esumation of pain (PP.40-4D. A solution is offeredto value the individual by showing respect for culturalnorms thus enabⅡn号 be廿er communication, which inturn enables be廿er outcomes for the individual's pain

(Narayan,2010, P.45).1tis the health professionars roleto interpret the pain cues and t0 号Uide the individual

in maMn号 an i11f'or"1ed choice for their sped丘C needs(Narayan,2010, P 45).

In a clinical birth setting, more insight is neededinto how women express pain and how midwivesinterpret pain throU号h the use of standardized painassessment tools. verbal communication during laborbetween the midwife and the birthing woman informsPain assessment and thus impacts on the managementOf pain. AS Lowe (2002) notes,"[...] verbal reportPrimarily reaects the conceptuavjudgmental processes1...] and may not fUⅡy represent the emouonavmotivauonal or sodal/cultural aspects ofpain, paTticu・Iatly ぜ the measure only evaluates intensity"(P S18).The birthin8 Womalゞs abⅡity to communicate her painexperience (and the midlvifds ability to interpret painCues) may thus inauence her dedsion making duringIabor, forexample, whetherto addresspain bytreatmentPharmac010gicaⅡy or 、vith complementaTy methods orifnot equipped alreadylvith strategies,the mid、vife mayencourage the birthin3 Woman to use coping strategiesfor working 、vith pain in labor.

Therefore, the purpose of this artide is to explorethe elicited verbal expression of self・reported pain innorma11aborthrough a criticaland interpl'etiveliteraturerevie、v of the pain assessment tools used jn childbirth.This article outlinesthe strengths andlimitations ofstan・dardized pain assessment and the possible implicationsfor cross-culturalpain assessment a11d communication.

Elicited verbal pain Language po、ver et a/.135

METHOD

Approach

The 丘amework forthis review combineS 仕le disciplines

Ofapplied lin名Uistics and midwifery zborowsM a952),a pioneer in cross・culturalpain research, ach)owledgedthe importance of "C0Ⅱaborationl'(P 30) between theSodal sciences and the health sdences. Applied lin・

guistics explores lan3Uage issues in a real、vorld context(＼1Viddowson,2005), in this instance, the context ofChildbirth. A muludisdplinary approach may recognizethe complexity of pain and the unique nature oflabor(Hadjistavropoulos & craig,2002).

Search strategy

A search spanning lanuary 1950 to Apri1 2013 IvasConducted on cumulative lndex to Nursing a11d AⅡiedHea1仕11iteraNre (CINAHD, Medline, Modern Language

136 Eliclted verbal pain

Assodation (MLA) 1nternational Bibliography, a11d Lin_Suistic and Language Behavior Abstracts uS血g 壮le f。1_10Mn8 ke}'words in two search groups: P4iπ,14hour, and柳e4S記re and pai",14h01ιr, a11d 14118Uα8e. These searchesWere then combined a11d resultal)t tiues al)d abstractsScanned.1n addition, a丘lrthersearchwas conductedusinCombinations of more sped負C ke},words:14hor,14みOur,Ohstetric, childみirth, P4rturiti0π, al)d paiπ; 14118Uage斗五π_8UistiC斗, descri¥, seぴ:・report, a11d resp011Se; 1πe4S1ιre111e11t,SC41e, rati118, to01, and iπStr説1πe11t. A11releva11t artides wereCompiled in referendng s0丘Ware a11d dassi6ed accordinto the pain assessment to01. Arudes were then retrievedfrom their 61Ⅱ・text 血rmat onlme, via a doculnentre uestSeNice orvia a manualsearch ofphysicaljournals.

[anguage po、ver et a/

Study seledion

Studies were induded if they examined lab。r Palnthrough 廿le use of standardized Paln assessment tools,

met the criteria related to EVPL assessment measures,and satiS負edtwo criteriaindicauve ofpain as a stud vari_able a11d a11the publication criteria as listed in Table l. ASummary ofthe induded studies is provided in Table 2.The studies are arranged chron010gicaⅡy to view thedevelopment of standardized pain assessment over tw。and a half decades a984-201の.1n addition, an EVP王assessment key is provided in Table 3, which details theabbreviationS 釘)d termin010gy used in Table 2.

Secondaryto the pteceding questionsjsthe poten_tial in丑Uence or impad of the model of care on painassessment and labor.

REsuns

Nineteen studies met the indusion criteria indudin4 Studies from the 1980S,10 studies from the 1990S,4 Studies from the 200OS, and l study from 2010.Ten countries (Australia, canada, Finland,1Srael,1taly,jordan, Kulvait, sweden, scodand, and united states)acrosS 丘Ve continents lvere represented in the studies.Australia provided the most S加dies overaⅡ(π= 3),血110wedbytheunitedstates(π= 2) a11dsweden(π= 2).

Thestudyapproaches、verepredominanuydescrip_(Abushaikha & oweis,2005; capogna et al.,2010;tive

Lowe,1987,1992; Melzack & scha丘elberg,1987; pesce,1987; Ranta et al.,1995; si杜ner, Hudson, Grossman,&Gaston・10hansson,199& waldenstr6m, Bergman,&VaseⅡ,1996), that is, they were primaTily concernedWith the description of the existing variables (P。rta,2008), or they offered representations of the "1ived"experience of others (schwandt,2007). some studiesexplored lvithin group and between 8roup comparisons(Lawrence & perdval,1995; Niven & Brodie,1996;Ranta, Jouppila,& 10uppila,1996; sheiner, sheiner,Shoham・vardi, Mazor,& Katz,1999; waldenstr6m,2003; waldenstr6m & schytt,2009), which differedfrom the descTipuve studies in thatthey sought or r。_jected comparisons between sets of interpretations orObservationS σUPP,2006). The remaining studies usedCorrelational approaches (Baker, Ferguson, Roach,&Dawson,2001; Harrison,1991; Niven & Gijsbers, 1984;

Sheiner, sheiner,& shoham、vardi,199& sheiner et al.,1999).

Research Questions

CROUP3: PUBUCAτ10N

Peer・revieⅥ,ed scholarly articles

There aretwo main questions that 8Uide this review:

1・ which pain assessmenttools are used?

2・ How applicable are these tools t0 廿le d)ildbir仕Icontext?

januarγ 1950-Apri12013

TABIE1 1ndusionct丘etia

CROUP I: EVPI_ASS王SSMENT MEASURES

Self'reports of pain 介om the maternal perspec_tive captured durin81abor, P05tpartum orretrospectively

E11Cited verbal pain language restricted bya fixed number ohesponses (numbers orWords)

Pain is measured and aS5eS5ed using a setCrlterla.

Note. EVPI = elicited verbalpain lan今Ua8e.

CROUP2: PAINASSIUDYVARIABιモ

Pain Is a prlmary outcome measure

Any stage from onset of adive labor

Pain unⅢ arrival of baby (includingback pain during labor)

Preintervention or no intervention Eng11Sh lan8Ua8e onlyDescriptive and cornparative studiesCorrelation considered 、、/1th 5U仟icient

Ianguage data

Elicited verba1 隱in Language po、ver et a/.137

§之§にOY

ω>=叫」叫ユEOU

区区で岳め<>

(S剣、山~0則、器@§"嶋

↑に.、則、0に" 9 め<>

0区Σ'め

小小・之

0＼0的"に則U一」ωEく仁則U一」、<

-0＼ON小・Φ一{支一]]コZ

.

0＼0の" C圃U一」ΦEく

に愽U七、くす＼0[小 N Φ一一上三区三コΣ.

捻ω>心.入~ n Σ一区三コ乏

.

巴則Φ>0.寸N ιΣ一]"コZ

.

ミ三コΣ09 ιに

ヨコZ のC n S 峅C[ r に.

Φ>一一9」U山ωn

仁0=州一Φヒ0U

ΦE0の

U勇Zで岳(【匡一髭

、ミ、晋一勺コで三)0区Σ

山」司Φ>小.C~"Σ

、嶋如"にmにm-C=のω一遷

.

巴器> 0,入N "Σ、誤"に山仁一コ0でω血

.

山」器>寸.心N N Σ、入小"に血=一四ゞコy

.

[一[ n に●

(一長一四0-

で仁司圧閲仁一でコで仁一)0区Σ

一四一住山0上

U一三コ含C三仁コどで」ω一伺Σ

圃=巴一山コく

袷Φ>ハ.酷N-N,口一

.

の」愽Φ>如、如~"[・口一

.

山」番>寸."~ N Σ一口く●

(一~,ロ=誓ω」霊

C伺一一四こO E0二・仁何=巾」一ヨく如"に

、=・ロ= E0ム'仁邸=狸一 9 ・ミ【口く一

E0二,月一一m」一男くN~ι S 0寸"に

.

山」叫ω>如N "Σ

.

ミ三コΣ入[ N に

'一Σ一髭小N ・ S C寸'に.

血」愽ω>N小'八N "、之

.

の」叫Φ>C門1小一

{Φ一一支,仁0只[ nSω一一工三倉」0§

.

M圧"番牙,恢=閲こ山

.

金三コΣ需・に

主Σ一彫入[・ S 0嶋・に.

で一0巳田>需1入一

.

ω一一支.

書↑]コΣ嶋[・に

'一Σ亙区寸[・ S 小~しに.

ω>=9」U山Φ0

(一長晋モコ一U三)0区一之ω言一」UのΦ0

山ω>二Uω身」ω立

三豊仁一ωU仁則一」則>、0 誘ω仁Φ」品鷺

勺仁殉閲に一で仁四巳ΦでにコΦ捻ω」U三 9

山主Σ一配ル三仁一丑」0●叫一でωUにΦ一」

'ω住XΦで口角でω一Uω住Xωω」巴EOU0↑

一巴一牙0上仁司左0住0」一ωE

に二一Cコ一四司仁一曾、、一二ω>ω]、、

のΦ一巴めでω一モコΦ上↑

(でω>一ωUω」ω」州U一四邸E」ω住

仁0-U丑E二0仁でモで仁コ9如

,"U伺二U-E0に§0-U0の

曾Cコ0」国"U愽二U-E0§ω

6で吊ω巳Φ>一で)一四一牙0工

一一翌コy

ω>=9」U仇Φ合

(一長関三でコ一U仁一)

0区Σでω毛0Σ

]00↑↑Z山誘出誘ぐZ-く住

m」山εOE住一↑]コΣ

でに鄭ゴコZ Cωω三ω二」0二四こ0

都m四ミ」二0、如三」コで竺」0ユΦ」

仁一角住三めωU仁ω」ω出一でΦ一島=のΦ>に一0↑

仁0=叫一Φヒ0U

ΦE0の

(§一包EOU

一巴ヨ一己0-U0の)一仁ΦE誘Φ裕こ吾

仁一め<>-0ΦmコΦ一雪一m>Φ勺こ則山」Φ

'εOE ●付」く、0の今0」即Φω上一、0

ωU仁ω一」ωユXΦ毛三ωN一」ω一U吋」司上U0↑

一巴ミ仇0上U云己

仁伺ニヨニコ山、モ悼ヲ倉EΦ%Σ

伺=角誘コく

一四一牙0上一伺」Φ岳即

Φ即」愽一則仁二一CコU一」一ω一m二0

伺で側仁愽U

00工出Σ

獣小一

一邸>-U」Φ区でこN

ΦU仁Φ」玄伺".入

の住コ0」M

U一仁εωωΦ」ε仁ωω三ω二仁0一」ωモU

で為で仁俣M三劣毛三で=編U

、0仁一丑でω一」0五ω」Φ」二袷ω三 0↑

」0■阿一閲三」コで山一ω>ω一

仁一丑でω>一ΦU」ω旦U巴一で仁四三乳

」0■則一、0Φ魯上U母Φ仁一EmXΦ0↑

~小の一

一巴一牙0'

に則二」コ●ヨ倉にコEEOU

越巴のでω一三ユ山'↑

当、三め

0-ON0一寸如び一E0占功U毛=一めでUで=一リ三"ぢ■二、OUMd島憙]三悼、マeu>七U二U=叫

ωみ0].C

と伺E主仁一

(で仁剛=8巴

E0で如C立勺ω一三コω低

一冨一

仁0の一ヒ価工.峅

冨小一'冨一

mゼ0区ω」

三丑主↑]コΣで岳主Σ一監

仁一都Uにω」Φとモω一愚一山ω>E 0↑

八如の一

口Z一仁山め

三丑さ令一

、0倉誓ω一仁一で仁角Φ」三N仁誘ω裕0↑

入如小一

閲」ω二一ωと四での

でに叫ぎ価N一ΦΣ.角

ωUのω区.寸

入如小[

寸如小一

乏一<配ぐ山>

ω琴0].N

巳Φ保=ロ

で仁愽仁ω>-Z .↑

小如血一'如小一

古コ一仇

N叫冒ぐ一

138 Elicited verba1 距in Language power et a/

.

の仁0二四一UΦ区Xω

0一仁0=司一ω」 E でωUにω一」

,ω住XΦ三叫ユω」コめ母E

0一合ω一UΦユXΦこNε誘ω一

【一UコE 必誘Φ一、でΦ一Uω含XΦ

の則Φの」0勇ωm」0至

'UコE)のω>=叫Eω一一巾Φ>一、

こ0一山にΦ三モω>一ぢωと巾ω」コ血

・舟ωE 9 (山>.冒旻、Φ>

"へでCm山>乱山ミ、田>

[山」0上Uに巴ω一巴Ⅵ一に一0臣,ハ

1b一ψ仁Φ一三に吾ω」二捻ΦE

9 (に.、理山~■鬼に.、M郎尺.、

、Ⅵ§一で仁価、巴則に.姦、

0に●」0IUに巴Φ一愽U仇一仁一0企'ハ

のEΦ一一"ι」一悼仁仁0=●Φコ0

ω言一」U峅Φ0

ω>罵」叫ユEOU

のミZ

の」四Φ>のN "Σ

主↑"コΣ寸三ιに.

主Σ一密寸曽・に.

如入N n に.

の配>・一一'め血

令こωE誘Φ槍一巴一

'一ωε0旻ε0区Σ一~合ヨの

令CΦ>ωε」一0で=IU

、0 =mUω」でΦ」コ一Uコ」一血にコ

土0ルΣ一[昔三め

主Σ一氏 0入・に.

め二0匡<区>ー=尺 n に.

色辻コΣOZ臣口0入"に.

ω>=9bの山0

2ゼ三」Φと叫

峅浴で也 E昼司9お立寸NO、- n に

でC巾」0■則一即三ヨで[給"に

E0とでΦE巴●0のΦ」Oum 三全.

区三コΣ[の入・に.

、一Σ一配、OCM ・に.

巳ω言E 上の一こ仁一、一小0、["に

.

山」叫Φ>八N N Σ

.

]]コZ ・

角〔・に

N省ヨの

の」母>八N "Σ

.

C["之主↑"コΣ.

入[・に主乏亙、.

M角・に.

一台ヨめ

"00↑↑Z山誘出誘ぐZ一ぐ、

の一四一牙0'ω」叫U倉EΦ一則Σ

仁ωでωみめ

Φ>=叫」叫含EOU

毛一二

、0ΦUこΦ一」ω旻ω一叫」ωにΦ即勺仁円

に一霊」0●mこ0のωUこΦ一」ωOXΦ

の、にωE0み仁一に0舞m一畄>

三愽一ユXωで仁則ω二一」Uのωで0↑

倉」m0でに則のΦU岳

,一」ω区XΦε」一εこΦ」ωと一で'一亙

仇」Φと一OE に二0」一§に一霊」0、

凹仁ΦEΦ」一コずω」でこ叫Σ一山仁Φ一三

三則住如三で口一U仁一)峅ΦUにΦ一」ω住XΦ

に一州立三都UにΦ」Φともω一島=のω>Ξ 0↑

00工出Σ

一巴五の0工倉嶋」ω>一仁コ

で岳τ一、

UE=U

ε一悉工三一EコどΦ>=ωで

でに叫、m一狸ミm0工一州に0一如ω」

、一巴一住山0工倉山」Φ>一仁コ

で岳で江

どω>=Φで如三み0=0、

、Φ=ω」C-m住、0な巾コずω勺mヤ岳

仁0一一U四山一苗の一愽EΦ一叫E 仁0=

,姉Φ=ケ0も二偲』0'愽に0山Φ如器

ΦΦ」εM仁一」コでこ一巴Φ」コ袷ΦE

0二Φ=Φ」三霊」0●悼一」0、め仁0=

'四UωユXω、の」ωεOE に一邸ゼΦU袷 0↑

[合ヨご0仁0三で§

=§」三にΦ>-M三霊」0'愽一、0

仁0=9」U山Φでε三Φ」置Eoug

毛一0仁ω>一如」Φ>ωにヤ巾工0§

誓ΦεOE E0」、に一霊」0'm-、0

に0=巴にΦめω」立Φ」一一U=ω0↑"N昔三め

桧Φ>オm」Φ>OC一丑」0'伺一

、0分=雪ケ、0=巾Uω」、巴ΦεOE

、0ご愽」コUU悼ω仁一E叟ω0↑一↑>でヨの

へ、Nミ、署ミUささぺS寸如含三0戯のU毛三仂ヤUで三U占"ぢ●愽ごOU閑邸島反]仁窟、でeu>ヤU一で=叫

N叫一箆↑

岩住Σぐめ

C冨一

(でΦヒ●C-

叩仁三Φの毛一ε一四五の0工

仇Φ一四めでω一一仁コωと↑

=ω捻>

でこ何、仁叫EM」Φ血

、E心」窃仁Φで一豊

.↑[

C小小↑

則一ミ号0〔

勺に西、司一一&コ0-

、巴こ如配.0-

巾一ミ号0-

勺月、愽一一&旦

、還E一一0工

、則一ω"0{

、m一Φ」m則め

'袷即に叫y

血こモ一丑め

、四仁則匡.小

口Z一岳山

嶋小小一

Σ一ぐ配岱>

●歌[

Φも0主

で口巾仁Φ>-Z .如

>nコ↑の

Elicited verbal pain Lan8Ua8e p0レVer et a/' 139

. . . . . . . . . .

§尽趣OY

」母>[

一巴仁ΦE誘Φ誘邸一器企ω配

毛三で岳

」0●巾一、0一仁ωE誘Φ誘叫

一各0一叩」0一(ω>=島ω仁

↑Φ三一山0ユとΦ>)●ω>=

'巾EΦ一πでωこ一、Φでω」(一ω>一山

」0侭一、0

女m岳一仁一 E霊誘ω裕 0-

(に.、則、Φ這州S如則安,こで9-

ι入で仁心、巴州S愽、0に

"m」0上U仁巴

1Φ一邸U山一仁一0区,入

山εCOE N-<

山Eω一一0三一ω」一門C仁0=山Φ二0

の配>・の<>

ど氏閲仁モコ一U三)0止Σ,」山

ω>=如」超ユEOU

す＼0如.寸仇」母>畍M <一0＼0八.小C

の姦ω>の門1嶋N す＼0寸.山N山」阿ω>嶋N V

(め主女コΣ寸冷、一 1 に

一設一Σ亙ル寸八0、一' S 如~寸N "に

仁0=叫一ω」」OU

ω圧0め

一仁Φ仁0区EOU

の臣ε亙の<>

めω>三で一E 小"に

山」ωε0三叩E」00邸一口"に

山<>'Σ0区

RΣ0巴」ω一ωΣ'0'仁一心ル

仁0誘仁叫'0-,仁0一山δ

仁0=舟一Φヒ0U

ωE0の

姑>二角」丑EOU

m毛三一四一牙0と、mUモ一で

一巴円=Φ一こ阿、Φ岳UどΦ、一言一Σ

仁Φでω勇め

(CO=巴山ω閲山"ωωヲ~オ如巴仁ΦE0ヲ

上●一ヲω【で仁悼三コ0でωm入寸寸"に

(EU0[1如一[ωm四ミKN

父EU入1の~NΦ山四ミ)゛~言UオN

一一ωm四ミ)的~しに"でω一UΦ=8四叫n

Φ一一乏0＼00の

山」醐Φ>如入.入[ n Σ

ミ三コΣ

小一"に主Σ一氏寸N " S

の」ΦεOE 一岳U山ω一0で叫門["に

一則一一牙0上、ω一一コ血とΦ>=Φ口

四=国誘コく

Eゴゼ叫9山0区

姦Φ>,二伺、に一司関帽で仁円のε仁OE N

一伺ωU仁ω一」Φ区Xωε」一厶一一巾」ω>0

で仁叫仁一司住」0二四こ0山ΦU仁Φ

'一」ω住XΦの」ΦεOE ω」則住EOU0↑

ω>二旦Umω0

仇<>

仁0=悼一ωヒ0U

ΦE0め

」0保一、0のω山四山一一εコ0'関コ9ε

mω>一言一E でC愽の」ωεOE-0

のに0二住Φピωユ仁吾ω仁一E四XΦ0↑

三如住峅、」Φ'-OE、0仁0一一

'巴ω」9ω一仁一山、」ω勺一>0」区ω」偲Uで仁愽

仁一豊でΦゼ0含ω」,、一ωの、仇」ωεOE

仁Φω三ω二のωU仁ω」ωと一でU一仁εΦ

、0ωU仁ωコ一、仁一ω為如=のω>E 0↑

(山"ωω、三 N井如也

E」ω一一叫、"仇一」言一八寸寸 1 に

」Φ一仁ΦU一愽U一でω一2

一ω巴山一

零ON

一巴一でωE ΦE偶Φ」則上山で仁愽器」叫

ΦE叫山三Φで一扮」0上三住二0」国

U-Cεω一仁ω」ωと一で0乞、0ωU岳

'一」ω企Xω毛一'で一ZUΦ為住EOU0↑

(く長く巴

E心」一峅にωで一今.C-

仁om琴則n

で仁叫、上X0配

、仁om口関」Φ'

盲"阿山.山一

小0ON100●N

一四一牙0工

山Φ一四めでω一モコΦ上一

50~

」ω一仁ωU一舟U一でωΣ

ど一山」ω>-Cコ、E09 と山>=Φ0

一Φ票一

'mωU一とΦm

三丑」0●則一、山一仁ωU山Φ一0で伺、0

倉山仁ω一三で岳倉一則コずω毛Umωで0↑

仁一巾区」0●則こ0ゐ一」ω>Φ山9脚こ=コ

'二一」Eoum」0-U佃、U三Φ三0で仁舟

U一且側」叩OEωで0-U9Φ一島=山ω>仁一0↑

旦里勺仁殉

、」0~則Σ、モ」叫>

,E叫工0上め

、」ωに一Φ上め

、」ω仁一ω上山

.寸[

小の含

仁0誘仁側上0-

,C0一山叫口で仁伺

、仁得E誘0」口

、仁om勺コエ

、」Φ仁制一山.M-

一で」叫>

'ENI0上の

で仁愽、」ωEω上め

、」ω仁一Φ工の.~[

如の小[

器三

140 Elicited verbal paln Language power et a/

. . .

.U一巴の三則ルの§山,のル山一ω一巴のUコ即0唇<一雪の一>耆UΣ,0,三叫山"の<>,Σ0ル一(嶋冨εぢΣ)巴§一コΣヤ長占 U 色↑ぢΣ自三ψ一(鴫・N)巴§一=Σ"の=巳吋ル>,一一UでUめ言岳耆三邸山U一」U§Z "め冨Z

U一巴の即三為醒マeu>N の配>UマUの否酸一三0ル,一一"ニ'袷U上妥口0易U=0三愽ル宗中UΣ三さ山.一ぢ二切・ 0ルΣ'の曾巳§一一=仁"冒DZ-U為U切U島0一悼乏マ冴一>"め<>昔U切0IUの勺」0ヲ治言E=Z "U妾

一(比女立長彰菩勺ε即武=佃"三吋ル"(讐"山U一巴の倉磐U一三三愽、一=U器」ルΠ一ル、誇U看一鴫三一悼広三則ル"一"ル芯上妥二0ご桧づ0三邸ル鷲中UΣ"0ルΣ苗ミ三=E "色烏PΣ'烹合E一ミ"・U之

釜<>

父ミル閲仁も三U三)0区Σ,山の

巳則Φ>喚

でC則、」市Φ>一、山ε仁OE N

一則一にωE誘Φ槍一叫Φユω■

心一冒ヨめ

C一でωこ=一コ0山Eω一一0三

山"ωΦンノ如.如m .

山」番>N.叩N "Σ

.

」0●州一Φ一阿一里"に

の"ω田みめ.如門.

山」叫Φ>[.如N "、と

.

」0●阿一>一」母め~"に

心寸'に.

生↑]DΣ

山"Φω至[.小門.

袷ω>八N "》、

.

」0●m一Φ一叫一之め"に

φ"ωω>ノ門.小[.

の」愽Φ>寸.ハ~"、之

.

」0●叫二一」器【八 n に

↑N- r に.

]]コZ

ハ゛["に.

ω>=9」U都口

"00一↑Z山Σ誘山誘くZ-く倫

Φ>=角」m含EOU

めミZ

Φ>=9」Uのω0

給門、- H に

亙三コΣ゛.如Nで長の生Σ一配、

寸.NN ・Σ)の」器ご嶋.めN "Σ

ミ弓コΣ0嶋・之'一Σ一正区0嶋

n S の」ωと一OE "仇一」,言一 09 "に

血0工出Σ

竺七三一巴三の0上、山U一三一U

一四愽こω一仁N、ω」叫UとΦ、一言一一之

にω勺Φ玄め

一巴るの0工

>一四一

」0二邸こ0

Φ即Sので岳倉」豊盆勺ΦU岳コ一、E

ω二浴E」0●何一、0峅」0-9」UのΦで

Φ>三島OU、0倉の仁Φ一仁一でCm

>一=愽コず」Φεω'みω一則コ一雰ω0↑

§ミミ讐δ)三ON巳諮含E0占のUも三のでUで=-U占一ぢ■二、OU即輿島長]三佃、宅eu>ヤU一一U一一叫 N編箆↑

謝、Σくの

一巴五仇0工一巾」ωにΦM

」0一角E一三コ Eコ七伺9の0、

仁阿で」0-

ε」お」ωと巾の」母>の

でに則、」母>[、坑εCOE N為に吾

」0二巾こ0>」OEωE Φ一島=都>長 0↑

口Z一長の

仇」ΦεOE 仁m一に則で」0一如仁OE則

倉の仁ω一に一勺にm山ΦU岳一」ω旻Φ仁吾

」0二N一Φ包EOUや仁邸ω」0石XΦ0↑

モΦEOU」司」

で仁巾

、0仁一誘阿」司口

、一仁一一仁ω一愽>

、0」霊」=の

、叫一U」OE州U

、m仁如0立巾U .小一

M一●N'-ON

0石~

小00~

命長く主

長上U仂で月

E心」制岳勺一豊.如[

Σ一ぐ

山0ON

乏山>

の一Φ至0 でにN

伺と"一四恢三く.八一

>0コ一め

血dtedverbalpahl[飢gua名eAssessmentKeyTABI'E3

AssfssMENI

BS、11:11・point Box scaleFPS: FaceS 玲in scale

MPQ: Mcci11 Pain Questionnaire

NPIS: Numeric pain lnten5ity scalePOM: pain・0・Meter

POM、VAS:距in、0・Metervi5Ual Analogue scaleSF、MPQ: short、Form McciⅡ Paln Questlonnaire

VAS: visual Analogue scale

VAPS: visual Analogue 胎in scaleVRS: verbal Rating scale

INDICES OF MPQ

NVVC Number ofvvords chosen (1n Ⅵ,ord sets of MPQ)

PPI: pre5ent pain lntensity scale

PRI: pain RaⅡng lndexPRI(R): pain Ratlng lndex (Ranking)

MOTH[RS

The majority of the studieS 丘om 20oo t0 2009employed a form of Numeric pain lntensity scales(NPIS; Abushaikha & oweis,2005); for example, a"フ・point rating scale of pain intensity"(sheiner et al.,1999;~valdenstr6m,2003;~valdenstr6m &schy比,2009),With the exception of Baker et a11S (20OD study, whichUsed the sF・MPQ (which combined a ppl, a vAS, and

a vRS).

In 2010 (capogna et al.,201の, the sF・MPQ wasemployed, in addition to the visual Anal08Ue painScale (VAPS, a version ofthe vAS), which comprised aSHde rule with o-10o mm and the statements:πO P4iπ

(の and worst P4iπ ever a0の and a ppl、vith a ratingOf o-5,刃Vhich corresponded to the statementS πO P4iπto excruci4tiπg However, it is not dear from the text ifthese were administered as separate tools or as part ofthe sF・MPQ.

An analysis of the aims of the induded stud・ies revealed several factors 、vhich in丑Uenced 、vomeds

experiences oflabor pain and、vhich felHnto three broadareas of research: the physi010gical, the psych010gical,and the ethnocultural context.

NULL: NU"iparous

PRIM!P: primipara

MULTIP: Multゆara

H-V PAROUS: Multゆara (2-5)

CRAND MULTIP: crand Multipara (more than five)

モ1icited verba1 距in Language power et a/.141

The MPQ,induding the pain Rating lndex (PRD,Was used in aⅡ Studiesin the 1980S. Two studies also dis・

Cussed the present pain lntensity scale (PPI; Melzack &Schaffelberg,1987; pesce,1987), and pesce a987) alsoemployed number ofwords chosen (NWC)in conjunc・tion with the MPQ (ppland pRD.

The vAs was the most used method of pain

assessment in the 1990S (HaTrison,1991; Lawrence &

Perdval,1995; sheiner et al.,1998; sheiner et al.,1999;

Si壮ner et al.,1998), induding adaptations ofthe otiginalto01, for example, the "pain・0・Meter" VAS (POM・VAS;Si廿ner et al.,1998). T11ere 凡Vere other tools,、vhich were

employed加 ahybridform comprisingⅥSual, verbal, andnumericlanguage; forexample,thevAs with aFaces painScale (FPS) component (sheiner et al.,1999) or the ppl(usuaⅡy associated with the NIPQ) in conjunction withthe vAS (Lawrence & perdval,1995). There was alsoUse of multidimensional assessment such as the short

Form、MCGiⅡ Pain Questionnaire (SF・MPQ; Lowe,1992;

Niven & Brodie,1996), short questionnaires with 7・pointanchor scales and verbalstatements (气Valdenstr6m et al.,

1996), and verbavnumeric raung scales (Ranta et al.,1996) such asthe H・poi11tbox scale (BS・1D and the ver・bal Rating scale (VRS; Ranta et al.,1995).

Physi010gical

The physi010gical aspects of pain revealed much infor・mation regarding the sensory and affective dimen・Sions of pajn, the intensity of pain, and the inauenceOf parity on pain perception. Three different types of(functionaD labor pain were identi丘ed which Mel・Zack and scha丘elberg a987) described as in isolationOr in combination with a front (abdominaD pain orback pain and/or continua110w back pain. studiesestablished labor pain as severe in nature as per MPQ

assessment. For example, a vAs rating (as part of tbeSF、MPQ) bet、veen 7.1 and lo corresponded to thedescriptor severe (Baker et al.,20OD. severe pain wasalso assodated 、vith continuouslowback pain (Melzack& schaffelber8,1987) and second stage labor (Niven &Gijsbers,1984). one study indicated pain intensity 、vas名reater t0刃Vard the end of second stage labor accordin3to the vAs and the pplresponses from midwives andbirthing women (Baker et al.,20OD. However, whenPain levels reached that of severe from the matetnalPerspective,then midwives underestimatedthe intensityOf pain and thus 、vere unable to determine pain levelsaccurately (Baker et al.,20OD.

Durin号 labor almost aⅡ Women experienced ahigh level of sensory pain (叉Valdenstr6m et al.,1996);the sensory dimension refers to temporal, spaual,

142 Elicited verbal pain Langua8e power et a/

Pressure, thermal, or other proper廿es as outlined by入4elzack a975) in the origina1 入IPQ. However, sen、Sory pain was greater in nulHpara during active labor(4-7 Cm cervical dilation; LO、ve,1992), and this isreaected in the higher pain scores on multidimen、Sionalinstruments such as the sF、MPQ (Lowe,1992).NU11iparous women reported 8reater affective pain(1,owe,1992); the affective dimension refers to tension,fear, and autonomic properues as per MPQ (Melzack,1975). pain rating scales used during labor such as theVAS (si廿ner et al.,1998)号ave the hi号hest sensory andaffective pain scores, which suggests that the intensityOfpain increases as labor progresses.

Both primipara and multゆara Wonlen ln

Abushaikha and oweis'S (2005) study considered laborto be painf口Iwith high levels ofintensity and an avera8erating of 8.8/10 on an NPIS. pain experienced duringIabor increased in intensity according to the vAs scores(from early labor through to active labor) and the levelOfantidpated pain was equalto that ofthe actual Paln

experienced duTing active labor (上alvrence & perdval,1995). Forty・seven percent ofwomen in ~、1'aldenstr6m、(2003) study maintained the same assessment ofinten、Sity at 2 months and at l year a丘er birth.

In capogna et a11S (2010) study, the meanintensity of pain increased lvith dilation in both nul、Iiparous and muluparous women as reaected in the

VAps and ppl ratings.1n one study, the majorityOf primiparous and multiparous women had severeOr worse pain than expected, but prior to interven、tion or pain relief, primiparous women had hi名herPain scores (Ranta et al.,1995) and experiencedmore pain than expected (叉Valdenstr6m et al.,1996).Another study indicated that primiparous womenexperienced greater pain in 丘rst stage labor andIess pain during second stage labor (1'owe,1987).Two studies indicated that multiparous women hadhi号her ratings of pain (Harrison,1991; Ranta et al.,1996). Furthermore, primiparous women recaⅡedPain "be廿er" than multiparous women, and more

multiparous 、vomen reported less pain at l year f01、10wing birth (waldenstr6m,2003). However, one

Study showed no difference in the vAs ratings ofpainbet、veen parous women (Ranta et al.,1995).

Higher parity equated t0 10wer levels of Paln

(气Valdenstr6m et al.,1996), which suggeststhatpreviousIabor experiences may decrease intensity in futureIabor experiences (凡Valdenstr6m et al.,1996). HOW、

ever, similar t0 入I×1aldenstr6m and schytt'S (2009) stady,Abushaikha and oweis (2005) found that paritydid notCorrelate with pain intensity.

Psych010gkal

The psych010gical aspects of pain showed the 血丑U、ence ofmaternal a廿itude, mood, and memory on paln

Perception. There 、vas a difference between pain reportsCaptured during labor and retrospeC廿Vely, even in theimmediate postpartum period (within 2 hours ofbirth),Which supports the theory that retrospecuve accountsOf labor pain may not always be reliable or accurate(Norve11, Gaston・10hansson,& Fridh,1987). Further、more, waldenstr6m and sch川(2009) conduded in af0Ⅱ0IV・up study that more women forgot labor painthan remembered it accurately and this was a continualProcess in which they graduaⅡy forgot for many yearsa丑er birth. For example, there 刃Vere no differencesbetween primipara and multゆara at 2 months and at lyear; however, multipara recorded lower pain sc01'es atthe 5・year mark (waldenstr6m & schytt,2009).

Howeve二 there is evidence to show otherwise

(Niven,1988); retrospecuve accounts can be quite vividbut not as predse (Niven & Murphy・Black,200の. ThisIast point was demonstrated in Niven and Brodk'S

(1996) study in which womeds semantic memory pro、Vided details about the context of birth but sho、ved

inaccurades in the recaⅡ ofthe quality ofthe pain expe、rienced (P.387).

MPQ descriptors used at birth were not reliablyChosen 3-4 years later, and recaⅡ of birth and Paln

assessed was variable over a 3・ t04・year time; however,this is dependent on the aspects of reca11 bein8 inves、tigated and the methods employed in the assessment(Niven & Brodie,1996). Furthermore, mood and af企C、

tive states (Ranta et al,1995), in addition to a廿itude

(凡Valdenstr6m et al.,1996), were achlowledged as fac、tors that can inauence pain memory For example,justUnder half of the study partidpants in ~、1aldenstr6met a11S a996) study viewed pain as a negative experi、ence, and thus they experienced pain more severely(as captured by the sF・MPQ) because oftheir a1Ⅸietyduring labor and theiT dissatisfaction with the informa、

tion they had received durin8 their labor care. Fina11y,a de6nite link was found between previous pain events(not telated to birth) and lower levels of reported pain(Niven & Gijsbers,1984).

EthnocU1加ral context

The S加dies also revealed 血e inauence ofthe ethnocul、

turalcontext on pain pel'cepuon. culturalvalues and cd、turalbehaviors may play a role in pain communication;

for example, Bedouin womenls absence ofpain behaviorWas in stark contrastto theit vAs pain ratings (Harrison,199D. klabsence ofovert pain behavior maylead to anUnderestimation ofwomeds pain by midwives asshownin a similar ethniC 3roup ofBedouin 、vomen in sheineret a11S a999) study However, peS化's a987) studyreported no signi6Cant results and conduded that thenature and qualityofpain catlbe expressed equaⅡyacrossethniC 号roups; in this instal)ce,1talia11・born women,Australian women with ltalian parentage, and Australia11・born won)en.

DISCUSSION

Despite the representation of 5 Continents and lonations, the approaches of the studies demonstrateVery 8eneraⅡy the biomedical view and what has alsobeen referred to as a atechnocratic" model ofbirth care

(Davis、Floyd,1994,2001,2004), where there is an onusOn techn010gy and Nvhere birth pain is viewed, treated,and assessed with the qualities of an acute path010gy(Davis、Floyd,1994). Thus, a womalゞs pain should begready reduced, and as such, she js entitled to pain relief(Davis、Floyd,1994), This is the pain relief approach,Where pain is deemed unnecessary and "treatable"(walsh,2012, P.86).1n comparison, a woTMng・with・Pain approach empowers women in healthy, straight・forward childbirth to be informed and work with the

functional pain of labor, to rely less on analgesics andto have strategies in place for dealin8 With pain (walsh,2012, P 86).

The biomedical context reaects the predominantmodels of maternity care, and in this review refers toIarge suburban, teaching, or metropolitan hospitals.Hence, it 凡Vas inferred (、vhen not overtly stated in thetext) that aⅡ Studies also maintained a biomedical per・

Spective in the examination ofthe labor experience andin the assessment of pain, most likely, because of thedevelopment ofthese toolsin a biomedicalparadi8m.

review, the MPQ leads the way throughout aⅡ decadesPerhaps because of its practicality in assessing two ormore components of the pain experience concurrently(MCGuire,1992). The MPQ combines a pRI, PPI, and

an inventory ofwords 、vhich describe affective, sensory,and evaluative aspects (Melzack,1975). one or morethan one tool may be used in combination lvith others(MCGuire,1992, P.316) and thus they potentia11y 0丘ermore insightint0 杜)e pain experience. The sF・MPQ hasalso been used in the birth context and it also has the

Capadty to measure and capture intensity, sensory, anda丘ective dimensions ofpain, and for that reason aloneWas considered a comprehensive toolby some research・ers (Baker et al.,2001, P.173).

The hybrid tools and new tools developed in the1990s were adopted else、vhere. For example, the poM・VAS (si廿ner et al.,1998) appears more than a decadeIater in a study for acupuncture treatment of pregnantWomen with low back pain and pelvic pain (Ekdahl& petersson,2010). The diversity of tools is reaectedelse、vhere in bjrth research cross・culturaⅡy and cross・IinguiS廿CaⅡy such as the 入IPQ, which was adoptedin the assessment of perineal pain in portU名Uese inBraziHan culture くPitangui, de sousa, Ferreira, Gomes,& Nakano,2009), and the sF・MPQ, which was used in

an investigation in spanish about epiduraltreatmentand pain (ordufia GonZ五lez, L6Pez carbaⅡ0, camblorSU会rez,& L6Pez ROUCO,2009).

ThemultidimensionaltooHncapognaeta11S(201のStudy reaects a descriptive approach to birth research,Whichhasincreasin名lybecomemorecommon.1tdemon・Stratestools such aS 仕le vAs and the ppl, which provide

insightinto the intensity ofthe pain and the dimensionsOf pain such as the a任ective, sensory, and evaluativeaspects(as perMPQ; capogna et al.,201の, which can befound earlier in Baker et a11S (2001) research.

Elicited verbal pain Lan三Uage po、ver et a/.143

Development ofTO0IS

In the 1970S, pain scaleS 今re、v not only in quantity butalso invarietyaccordingto sped丘C pain contexts (Nobleet al.,2005). The primary aim of pain assessment is toCreate a refeTence point from 、vhich evaluations regard・ing treatment can be made, and relevant interventionsCarried out (MCGuire,1992, P.315). Multidimensionaltools a110w for greater comprehension of pain.1n this

ApplicabⅡity and valid託y of EVPI. Assessment

Pain assessment is chaⅡenging in a clinical contextbecause ofthe multidimensionalexperience ofpain andthe Ⅱmited blowledge regarding contextua11y appro・Priate pain assessment; for example, measuring painaccording to the type of pain, an individuars ethnocul・ture, and sodalfactors (MCGuire,1992).

The advantages pain assessment tools a丘ord aClinical context are many Because of the systematicnature of assessment, clients' outcomes can be antid・

Patedsoonerinthemanagementoftheirpain (MCGuire,1992, P 315). of particular benefit to both the health

144 Elicited verbal pain Language power et a/

Care professional and dient is the process, which wasShown in theinduded studies ofthisreview,Nvhere painIvas identi丘ed, rec0号nized, described, and quanti丘ed(MCGuire,1992, P.315).1n addition, fot the individual,theymaybecome more ptoactivein the mana号ement oftheir pain through self-report assessment and tbroughknowing that their pain can be documented of6CiaⅡy,Which maylead to the le8itimization oftheir pain expe、rience (MCGuire,1992, P.315).

Sin81e dimension tools are 0丑en used in contexts,

Which requiresped丘Cinformation regarding physi0103ic(10cation), sensory (血tensity), af企Ctive (distress), cogni、tive (relief), andbehaviotalcomponents (MCGuire,1992,P.316). Thetendencyto administertoolssuch asthevAS(Baker et al.,2001; cap08na et al.,2010; Harrison,1991;Lawrence & perdval,1995; sheiner et al.,1998; sheiner

et al.,1999; sittner et al.,1998), forms ofnumeric ratingScales (Abushaikha & oweis,2005; Ranta et al.,1996;

Waldenstr6m,2003; waldenstr6m & sch川,2009), andthe vRS (Baker et al.,2001; Ra11ta et al.,1995) mayreaedthe clinicalenvironment: siteations、vhere time islimited

and information regarding pain intensity in parucularis required quicNy (Noble et al.,2005). so these tools

are considered more advantageous because they ca11 beadministeredverbaⅡyonthespotand usedwith avarietyOf popdations, for example, individuals with cognitiveimpairment(Bird,2003). There may be some advantageto using such rapid assessment in birth. Furthermore,tools such as the FPS (sheiner et al.,1999) al・e considered

easy to administer in part due to theiT CU1加raland gen、der"neutrality" and thus maybe suitable when assessin8the pain of cultura11y and lin号Uistica11y djverse (CALD)individuals (The joint commission on Accreditation of

Healthcare organizations & The National pharmaceuti、

Cal council,20OD. culturalneutrality is also consideredimporta11tin 廿le assessment ofbirth pain.

The multidimensional MPQ is considered a

Valid assessment to01, particularly in capturing someOf the complexities of labor pain (Niven & Gijsbers,1984, P.1349). consistency found in pain intensitiesthat correlated with parity, sta号es of labor, and lengthOf labor was evidenced in a clinical context and was

Validated cross・culturaⅡy (Niven & Gijsbers,1984,PP 1349-1350). Furthermore, an interpretation ofPain is made based on women's descriptions of theirSensations accordin号 to the MPQ's predeterminedCriteria. The results from these measures, in addition

to a physical assessment, can provide objective data(Niven & Gijsbers,1984). Qualitative narratives andquantitative measures aⅡOw for be杜er Colnparlson

Of experiences across different pain contexts and of

Pain across different bjrth contexts (Niven & Gijsbers,1984, P.135の. Thus, multidimensional tools may

be be壮er suited to certain contexts lvhere sin81e、dimension tools may oversimpHfy a complex painevent (The joint commission on Accreditation of

Healthcare or号anizations & The Nauonalpharmaceu、tical council,20OD.

ⅡmHations of eiC託ed verbal pain

王anguage Assessment

Tomeasurethepainexperience, understandthelangua号eCues in labor and gain insightinto the experience oftheindividual birthing 、voman, the use of a standardizednumeric or verbal ratin8 Scale is limitiTlg because thesetools 0丘en deal with one dimension of pain only^theintensity-despite noxious stimuli elidting sensatjonsaccording to intensity, quality,10cation, and duration(Gracely & wolskee,1983, P.389). Baker et al.(20ODquestioned the value of using sinele・dimension toolsSuch as the vRS, and other researchers ach)owledgedthe limitauons ofthe NPIS,、vhich lacked statisticalrich、

ness ofa "丑1Ⅱ・1engtH' scale (Abushaikha & oweis,2005).Furthermore, pesce (1987) mentioned that there

Were no boundaries to ethnidty and pain expression;ho、vever, the concept of ethnicity is different from cul、tural responses.1n this instance, the subcultures of the

three groupsin pesce'sstudy are not ach)owledged, andneither is the issue ofthe language in which the assess、ment was adlninistered, the language in 、vhich the data

Ivere analyzed, or from which language the tool mayhave been adapted. studies such as pesce's do make

8eneralizations regardin8 Culture, ethnidty, and pain,and thus may create cultura11y aunsafd' practjce in painassessment (Fen、vick,2006).

Despite their advanta号es in an acute or patho、103ical clinical context,凡/×1ilson,~、1Ⅱliams, and Butler(2009) found tools such as the MPQ were not ef企Ctive

in capturing the multifaceted and subjective nature ofPain and they did not adequately describe a complexPain experience. They sU号gest that more individual、ized descriptors for pain may convey the event better(wilson et al.,2009, P.57).

Baker et al.(20OD highlighted the dispariwbetween the individual womads pain experience andthe mid、vives understanding of maternal pain via paintools. sensorywords found in sF・MPQ assessmentsuchas st4hbiπ8 and 8π41νiπ8 are considered individual andPrecise qualiues, which are hard to ascertain in another

Person (Baker et al.,2001, P.17フ).

Moreover, a studyregarding pain and gender sug・gested thatthe use ofthe MPQ or a numeric scale alonemight notbe as e丘ective in capturin晉Pain data and maynot provide an opportuniw for women t0 飢ly expresstheir pain through imagery or similes (strong et al.,2009, P 94); this type of 110π・elicited lat1号Uage formsPart ofwomeds natura11an3Uage when they are talMngabouttheir labor pain.

We contend that the pain assessment tools aremore likely to be used in a technocratic model ofbirthCare.1n tbe rapid assessment ofbirth pain, similar to theassessment in other acute pai11 Contexts, the evidenceWe have reviewed shows there are some advantages to

Sitlgle、di111ension tools such as the vAs a11d forms of杜lenumeric rating scale. However, in the context of indi・Vidualized care,血e standardized pain assessment tools

exemplifled in this artide do not capture adequately theUnjque pain of labor, and thus,丘lrther investigation isneeded re名arding care outcomes and pain assessment,and the use ofpain assessmentin other models ofbjrせ)Care. perhaps other models of care in which a worMngWithpainapproach isused,forexample,thesodalmodel,Would be more condudve to capturing and exploringalternative forms of pain communicauon, particularlynonelicited pain language. These questions provide anintroduction to criticaⅡy analyzing 杜le language elicited丘om standardized pain assessmentto question the valid・ity ofsuch assessmentin a normalbirth care context.

To provide more contextua11y appropriate painassessment,、vomedS π0πelicited langua号e may provideinsi今ht into those cues not 0杜)erwise caP加red in stan・dardized pain assessment.~、10men can narrate withintheir own frame凡Vork, that is, they are not obliged toadapt solely to a to01, which originated from a westernOr technocratic health system (Davis・Floyd,2004).1tPrompts the question:1f a woman were empowered toWork Mth pain during labor (walsh,2012), for example,Would that then impact on 杜leir language and wouldthe midwife be be廿er able to tune into and interpret

the maternal cues of labor? The type of language usedin a pain relief approach conveys pain as problematic,Whereas in a working wi血 Pain approach,the lan号日ageConveys pain as a normal phenomenon (walsh,2012,P 86; presentin8 the work ofl.,eap & Anderson,2008).1tisimporta11tto considerthe impad ofbir杜Icare lan名Uagethat is used in labor preparation a11d durin号 labor andhow maternal actions or words may revealif a womanis experiendng a 61nctional or dyS丘lnctionalpain sensa・tion. Moreover, hoW 壮lis pain is assessed may re丑ed aParticular modelofcare.

A 6nalimplication is that of cultural diversity.Only recendy has the culturalsafety ofpain assessment(induding the suitability and applicability of assess・ment according to language, culture, and the pain con・text) be名Un to be questioned (Fen、vick,2006); this alsoimpacts on the validity ofpain assessment.

EⅡCited verbal pain Language p0レVer et a/.145

Implications

There is al、vaysthe potentia1血r misinterpretation ofnon・Verbal behavior, espedaⅡy if there are particular cult{1ralPa廿erns or "rules" that 廿le 血dividual adheres to, such asmaintaining stoicism while i11 Pain (入UiⅡiams,1985). TOreduce potential miscommunication arld enable dearerCommwlication between midwives a11d birthing women,Some researchers have argued that it is most e丘ective toUse 血formauon eⅡCited from pai11 assessment, hl addi・tion t0 号leatling in血rmation from obseNable cues dur血名Iabor (Ber号h, Ek,& Martensson,2013, P.146; Lowe,2002,P S17). This was idenU丘ed 血 Baker et a1太(20OD stady,Which indicated 杜lat nonverbalcues mi号ht not be reliableas a paitl measure as the intensity increases in later labor.Furthermore, although nonverbal cues may be use丘Ⅱ in壮)e generalassessmentofpail), verbalcommunicationmaybe廿errevealactaaloptionsrequired 血rpa加 ma11a3ement(Bakeretal.,2001, P.178). Therefore,itwas condudeddlatboth verbala11d nonverbalcues are necessaryhldedpher・

加gthe bir血加gwom釘11S care needs(Bakeret al.,20OD.

CONCI.USION

The standal'diza廿on of pain assessment tools brin号SWit、 it a doser examination oftheir quality and validity.This review highligbted the relevance and advantagesOfcertain single・dimension and multidimensionaltoolsin the assessment of labor pain in a clinical context.It idenU丘ed hybrid tools,、vhich 、vere created fromStandardized assessment, such as t11e poM・VAS, and a

Stl'ong repTesentation of multidimensionaltools, suchas the popular MPQ. The stated aims of tbe studiesin this review varied, yet similarities existed in theirapproaches despite tbe cross・cultural representation ofbirth. These similarities may be caused by the biomedi・Calculture and frameworkin whichthe pain assessmenttools、vere origina11ydeveloped; usua11ydirected to acuteCare. Assessmenttools were then transferred to a cljnical

birth context, where functiona11abor pain was man・

aged and treated as path010gy. so the question remainsregarding the adequacy and apptopriateness of imple・menting these standardized tools in a normalbirth care

146 Elicited verbal pain Language p0レVer et a/

Context. Furthermore, consideration needs to be 呂Iven

to other models of care. For example, a woman who isexposed to birth care langua8e that conveys a 6、1nctionalnormative pain and who is observed by a midwife whonotes her nonverbal, verbal, and behavioral cues may

be supported in worMng with her pain. The midwiferyinterpretation of these cues may then be considered aformal part ofpain assessment rather than the onus on

a clinicaltoolthat elicits predetermined language.However, the midwi企's pr0企SsionalsMⅡ develop、

ment and their o、vn ethnoculture may ad as a 釧ter.1tmay impact on what type of maternal pain langua号e iselicited in a pain relief approach or ho、v the EVPL isinterpreted in a worMng with pain approach. FinaⅡythe diversity of approaches to pain assessment highlightthe need for whatis described elseNvhere in research as a

multidisdplinaryapproach to pain care (入ICGuire,1992).An ongoing critique ofpain assessment may inform thePr0ⅥSion ofbe廿ercare overa11for birthing women espe、da11y in continuaⅡy evolving multiculturalsodeues.

Abusl〕aikha, L.,& oweis, A.(2005). Labour pain experienceand intensity: A lordanian perspective.111terπαti01141/0川"41 qf'Nwsi"8 Prndi化,11(D,33-38. h廿Pゾ/d".doi.orgno.1111/j.1440-172×2005.00496.X

Baddock, S.(2015). physi010gical changes during labour.1nS. pairman,1. P加Combe, C. Thorogood,&S.Tracy(Eds.),Midwif'ery: preP4r4ti011jorpr4dice Brded., PP.607-625).Chatswood, Australia: churchiⅡ Livin8Stone.

Baker, A., Ferguson, S. A., Roach, G. D.,&Dawson, D.(20OD.Perceptionsoflabourpainbymothetsandtheirattendingmidwives.10ur1141qf'Adva11CedN1ιおiπg,35(2),171-179.http:ノノdx.doi.ot8/10.1046/j.B65-26482001.01834.X

Beazley, J. M.,& Kurjak, A.(1972).1nauence of a parto、graph on the active maTlagement of labour.ι411Cet,2(フフ73),348-351. h杜Pゾ/dx.doi.org/10.1016/S0140-6736(72)91735-フ

Beebe,K. R.,1.ee, K、 A., carrieri・Kohlman,V,&Humphreys,J.(2007). The effects of childbirth self、ef負Cacy andanxiety during pregnancy on prehospitalizationIabor./our11αl qf' obstetric, GyHec0108'ic,411d Ne0π4、t41Nursiπ8,36(5),410-418. h廿Pゾ/dx.doj.orgno.1111/j.1552-6909.2007.00170、X

Bergh,1. H., ER, K.,& M証tensson, L. B.(2013). MidM企WStudents a廿ribute differe址 qU飢titative meanings tohuTt, ache aTld pain: A cross・seC廿onalsuNey. WO"1e114"d Birth,26(2),143-146. h廿Pゾ/dx.doi.org/10.1016/j.wombi.2012,11.001

Bird,1.(2003). selecuon of pain measurement tools. NursiπgSt飢dard,18(13),33-39.

Capogna, G, camorda, M., surparo, S., valentini, G.,Garassino, A.,& Farcomeni, A.(201の. Multidimen、

Sional evaluation of pain during early and late labor:A comparison ofndliparous and multiparous women111terπαti0π41 10ur1141 qf' 0みStetric A11esthesia,19(2),

167-170. h杜P://dx.doi.org/10.1016/j.jjoa2009.05.OB

Chapma11, C. R.(1984)、 New directions in the understand、

ing and management of pain. soci41 ScieπCe 6 Medi、

Ciπe,19a2),1261-127フ. http:ノノdx.doi.org/10,1016/027フ-9536(84)90014-5

Davis・Floyd, R. E. a994). The technocratic body. Ameri、Can childbirth as cultural expression. sod41 ScieπCe

6 MediciHe,38(8), H25-1140. h杜P://dx.doi.org/10、1016/027フ-9536(94)902283

Davis・Floyd, R. E.(20OD. The technocratic, humaniS廿C, andholistic parad培ms of childbirth.1πter11αti0π41 /our1141

ψ Gyπ4ec010宮y 4"d 0みSt'tガ'S,75(D, S5-S23. h廿Pゾノdx.doi.or8no.1016/SO020-7292(01)

Davis・Floyd, R. E.(2004). ways ofhlowing open and dosedSystems. M"idwif'ery Tod4y v、7ith 111ter11αti0πα1 ハ1idwif'e,69,9-13.

Ekdahl, L.,& petersson, K.(201の. Acupundure treatmentOfpregnant women 、vith low back and pelvic pain-anintervenuon study sCαπdi"4νia11 jourπαI Qf' C4ガH8ScieπCes,24(1),175-182. h廿P://dx.doi.org/10.111νj、1471-67122009.00704.X

Fenwick, C.(2006). Assessing pain across the cultural gap.CentralAustralian indigenous peoples' pain assessment.C0πte111Por4ry Nurse,22(2),2玲一227. h杜P://dx.doi.orgno.5172/conU2006222218

Gedye,}. L., Aitken, R. C. B.,& Ferres, H. M.(1961a). subjec、tive assessmentin clinical research. The British MediC41

/ourπ41,1(5242),1828、

Gedye, J. L., Aitken, R. C. B.,& Ferres, H. M. a961b). subjec、tive assessmentin clinicalresearch. The British MediCα1

10ur1141,2(5252),646-647.

Gracely, R. H.,& wolskee, P. j.(1983). sema址iC 丘lnctional

measurement of pain; 1ntegrating perception and lan、guage. P4iπ,15,389-398.

Groeschel,N.,&Glover,R (2001).Thepart08raph.useddailybutrarely queS廿oned. Aushaliα1110urπ41 qf'Midwi1之1)1 14(3),22-27. h如ゾ/dx.doi.orglo.1016/SIU5-4386(OD80021-5

Hadjistavropoulos, T.,& craig, K. D.(2002). A theore廿、Cal framework for understanding self,report andObservational measures of pain: A communjcations

model. Beh4νiour Rese4rch α11d Ther4Py,40,551-570.h如ゾ/dx.doi.or号/10.1016/SO005-7967(01)00072-9

Harrison, A. a991). childbirth in Kuwait: The experlences

Of thTee groups of Arab mothers.ノ'ourπ41 qf' P4iπ 411d

RfFERENCES

Sy111Pt0柳 M411α8e1πeπt,6(8),466-475. h杜P://dx.doi.orgno.1016川885-3924(9D90002・L

Hayes,1,. a997). A cultural experience of pain.1n s、 Moore(Ed.), U11derst411diπ8 Paiπ 411d its relicf iれ 1αbour

(PP 7フ-84). New York, NY: church辺上ivingstone.

Huskisson, E. a974). Measurement of pain.ια11Cet,2(7889),1127-1131.

The loint commission on Accreditation of Healthcare orga・nizations & The National pharmaceutical council.

(20OD. paiπ: curre11t U11derstα11diπg qf'4SsesS1πeπt,机απ・

α8'e111e11t,α11d tre4t111e11ts. sedi011 11: AssesS1πeπt qf'paiπ(PP 21-29). Retrieved from h廿P://WWW.npcnow.or創Publication/pain・current・undetstanding・assessment・management・and-treatments

)UPP,Υ(2006). comparative method.1n v JUPP 促d.), TheSAGE didio"のy qf'即'i"1郷'"πh 抗'th0ゐ(PP、 34-35).London, united Kingdom: sa8e. Retrieved from http://

Srmo.sagepub.com.ezproxy.1ibraryuq.edu.au/view/the・Sage、dictionary・of・sodal・research・methods/SAGE.帥11

Lavender, T., Hart, A.,& smyth, R. M. D.(2013). Effect of

Partograln use on outcomes for women in spontane・Ous labour at term. The cochrα11e Datab4Se qf'syste机・4tic Reviews,(フ), CDO05461. http://dx.doi.0鴫no.1002/14651858.CDO05461Pub4

Lawrence, S. M. F.,& perdval, R a995). comparison of

expected and experienced labour pain of primiparousC011egiαπ,2(4),32-38. h杜P://dx.doi.or創10^Olnen

.1016/SB22-7696(08)60127-4

[eap,N.,&Anderson, P.(2008). Theroleofpaininnormalbirthandtheempowermentofwomen.1ns.Downe(Ed.),Nor・柳41Childbiπh: EvideπCe aHd deb4te (2nd ed, PP.25-4の.

London, united Nngdom: church辺 LiⅥngstone.

Lowe,N. K.(1987). parityandpainduringparturiuon.j0川πα1

ql' ohstetric, Gyπec0108ic,411d Ne0π4t41 Nursiπ8',16(5),340-346. h杜P://dx.doi.orgno.11Ⅱ/j.1552-6909.1987.tb01593.X

Lowe, N. K.(1992). Di丘erences in 6rst 飢d second stage

IaboT pain beNeen nU11ゆarous and multiparous women.jourπαI Qf' psychosolH4tic obstetricS 6 GyHec010gy,13,243-253.

工Owe, N. K.(2002).Thenatureoflaborpain. A柳eriC4π10ur1141

ψ obstetガCS 4πd Gyπec010gy,186(SUPPI.5), S16-S24.h杜Pゾ/dx.doi.or8/10.1016/SO002-9378(02)70179-8

MCCO01, W E, smith, T.,&Aberg, C.(2004). pain in wom飢'Shealth:Amulti・facetedapproachtowatdunderstanding.

10ur11αIQf'Midw!fery 西' WOIHe11、 He41th,49(6),473-481.h杜P://dx.doi.or合/10.1016/j.jmwh2004.09.001

MCGuire, D. B. a992). comprebensive and multidimen・Sional assessment and measurement ofpain. jour11alQf

PaiH 4πd sy111Pto"1 M4παge加eπt,フ(5),312-319. h廿P://dx.doi.org/10.1016川8853924(92)90064-0

Melzack, R. a975). The MCGiⅡ Pain Questionnaire: Maj0τ

Properties and scoring methods. P4i11,1(3),27フ-299.h廿P:ノ/dx、doi.or名/10.1016/0304-3959(75)900445

Melzack, R.,& scha丘elberg, D.(1987). LOW・back pain duringIabor. A111eriια11 10ur1141 Qf' obstetガCs aHd Gy11ec0108y,156(4),901-905.

Moore, S.(Ed.).(1997a).1ntroduction.1n U11derst4"diπ8P4iπ

伽diおル1河i" 1"b0川(PP.1-8).N.WYO"k,NY. chuKhiuLiⅥngstone.

Moore, S.(Ed、)、(1997b)、 physi010部 ofpain.1n Uπderst4πdiπgPaiπ 411d its reli旦f加 1αbour (PP 23-46). NewYotk, NY:Churchi11Livingstone.

Narayan, M. C.(201の. culturds e丘ects on pain assessmentand mana名ement. The A"1eriια11 jourπ410jN1ιrsiπg,Ⅱ0(4),38-47.

Niven, C. A.(1988). labour pain: Long・term recaⅡ andConsequences.10ur11αl qf' Reprodudive α11d 1πf411tPsych0108'y,6(2),83-87. h杜Pゾ/dx.doi.orgno'1080/02646838808403546

Niven, C. A.,& Brodie, E. E.(1996). Memory for labor pai比Context and qualjw. pai",64(2),387-392. h杜P:ノ/dx.doi.org/10.1016/03043959(95)0OB4-4

Niven, C. A、,& Gijsbers, K.(1984). A study of labour painUsing the MCGiⅡ Pain Questionnaire. sodal scieπCe6 Mediciπe,19(12),1347-B51. httPゾ/dx.doi.or今/10.1016/027フ-9536(84)90023-6

Niven, C. A.,& Murphy・Black, T.(200の. Memory for laborA review of the literature. Birth,27(4),244-253.Paln:

http://dx.doi.org/10.1046/j.1523-536×.2000.00244.X

Noble, B., clark, D., Meldrum, M., ten Have, H., seymour,

J., W加SION M.,& paz, S.(2005). The measurement

Of pain,1945-2000.10川παl qf' P4iπαHd sy"1Pt0抗M4π4ge111eHt,29(D,14-21. h杜Pゾノdx.doi.org/10.1016/j.jpainsymman2004.08.007

NorveⅡ, K., Gaston・10hansson, E,&Fridh, G.(1987). Remem・

brance of labor pain: HO、v valid are retrospective painmeasurements? P4iH,31(1),フフ-86. h杜P://dx.doi.0弔/10.1016/0304-3959(87)90008・X

OrdU負a Gonzale2, M.1., L6Pez carba110, C., camblorSU会rez, E.,& L6Pez ROUCO, M.(2009). Trata"1ie"to

epidur41 del d01ω eπ isque"1i4 ν4SCU1αr per泥riC4.Parte 11. Revisi611 bibli08r4戸C4 b4S4da e111α evideH・da del h4t41πieπto epidural e1114 isque柳i4 ναSCU14r

Per泥riC4. Revist4 de 14 Socied4d 三Spah01α del D01ω[Epidural pain treatment in peripheral vascular isch・emia qD],16(3),160-181. h杜Pゾ/dx.doi.org/10.1016/SIB4-8046(09)71008-0

Pesce, G.(1987). Measurement of reported pain of child・

birth: A comparison beNeen Australian and RalianSubjects. P4iπ,31(D,87-92. h廿Pゾ/dx.doi.orgno.1016/03043959(87)90009-1

モ1icited verbal pain Language power et a/.147

148 モⅡCited verbal pain Language power et a/

Pitan号Ui, A. C. R., de sousa, L., Ferreira, C. H. J., Gomes, E

A',& Nakano, A. M. S.(2009). Mensurag豆o e carac、teristicas da dot perineal em primゆaras submetidas a

episiotomia lMeasurement and characteriS廿Cs of peTi、nealpain in primipaTous undergoing episiotomy]. Ad4Pa"h'sta D'Eがe加α8e抗,22(D,フフ-82.

P0血, M.(Ed.).(2008). A didio"a,y qf'epide挽i010gy. NewYork, NY: oxford university press. Retrieved fromhttp:ノ/WW、V.oxfordreference.com/view/10.1093/acref/9780195314496.001.ooovacref、9780195314496、e・497

Ranta, P., jouppila, R,& 10uppila, R. a996). The inten、

Sity of labor pain 加 grand multiparas. Ad4 A114es、thesi0108iC4 SC411diπανiC4,75,250-254. http://dx.doi.org/10.3109/00016349609047096

Ranta, P., spalding, M., Kangas・saarela, T.,)okela,R., H0Ⅱmen, A.,10uppila, R,& 10uppila, R.(1995).Maternalexpedations and experiences oflabour pain-Options of l091 Finnish patturients. Act4 A114esthesio、108iC4 SCα11diπανica,39(1),60-66.

S'hwondt, T. A.(Ed.).(2007). The sAGE di'tiのWy げqU41it4hve iπquiry (3rd ed., P 64). Thousand oaks,

CA: sage. Retrieved from h廿P:ノノSrmo.sagepub.comezproxy.1jbrary.uq.edu.au/vieWんhe・sage・dictionary、of、qualitative・inquiry/SAGE.×1nl

Sheiner, E. K., sheiner, E. K.,& shoh抑、vardi,1. a998). Therelationship between parity andlaboTpain.111ter11αti01141/ourπ41 qf' Gy"aec0108y 411d ohstetriιS,63,287-288.h壮Pゾノdx,doi、orgno.1016/SO020-7292四8)00164-フ

Sheine二 E. K., sheiner, E. K., shoh蝕)、vardi,1., Mazor, M.,&

Katz, M. U999). Ethnic differencesinauence cal'e giver'SeS廿mates of pain during labout. P4i11,81(3),299-305.h杜P:ノ/dx.doi.org/10.1016/S0304-3959(99)00019-6

Sittner, B., Hudson, D. B., Grossman, C. C.,& Gaston、

}ohansson, E a998). Adolescents' perceptions of painduring labor. cli11iC41 Nursiπ呂' Research,フ(D,82-93.h廿P:ノ/dx.doi.org/10.117フ/10547乃89800700107

Strong,}., Mathews, T., sussex, R., New, F., Hoey, S.,& Mitch、e11, G.(2009). pain language and 8ender di丘erencesWhen describin8 a past pain event. P4i11,145(1-2),

86-95. http://dxdoi.or8/10.1016/j.pain2009.05.018

Tay, S. K.,& Yon8, T T. a996)、 visual effed of partogramdesigns on the mar)agement and outcome of labour.

The Austr41mπ● Ne1ν Ze41α11d /our1141 qf'ohstebicS 6.Gyπαec010gy,36(4),395-400. h杜Pゾ/dx.doi.org/10.111νj.1479-828×.1996.tb02179.X

Waldenstr6m, U、(2003). womenls memory ofchildbirth attwomonths and oneyeara丑erthebirth. Birth,30(4),248-254.

Nvaldenstr6m, U., Bergman, V;,& vaseⅡ, G. a996).The complexity of labor pain: Experiences of 278

jourπ41 ql' psychoso"14tic 0みStetガCSWolnen.

4πd Gyπaec010gy,17(4),215-228. h廿Pゾ/dx.doi.org/103109/01674829609025686

Waldenstr6m, U.,& schytt, E.(2009). A longitudinalstudyOfwometゞs memoryoflabour pain一丘om 2 monthsto5 years a丑er the birth. B/OG,116(4),57フ-583. h杜P://dx.doi.0τ8/10.1111/j、1471-05282008.02020.X

WaⅡ, P.(200の. P4iπ: The scieπCe qf'SUが'eriπg. New York, NY:Columbia university press.

Walsh, D.(2012). Evide11Ce 411d ski11Sfのπor加4114bour 411dBi光h, A8ωdejbr 柳idwives(2nd ed.). Abingdon, unitedKingdom: Rouuedge.

Walsh, D.,& Newburn, M.(2002). Towards a sodalmodelof

Childbirth: part l. Brih'sh lourHal qf'Midwifery,10(8),476-481.

Widdowson, H. G.(2005). Applied linguistics,血terdisdplin、arity, and disparate realities.1n R Bruthiaux, D. AtMn、Son, W G. Eggington, W Grabe,& V; Ralnanathan

(Eds、), Diredi0那 iπαPplied li118Uistics; Essays iπ h0110rqf R06ert B. K4P1απ(PP.12-25): clevedon, unitedKingdom: MultilingualMatters.

WiⅡiams,E.1.a985).Medicalanthrop010gyMedicalEduC4ti0π,19(D,1-2. ht中ゾ/dx.doi.orgno.1111/j.1365-2923.1985.tb01131.X

Wilson, D., wiⅡiams, M.,& Butler, D.(2009). Language andthe pain experience. physiother4Py Research 111terH4、tio"41,14(1),56-65. h杜P:ノ/dx.doi.org/10.1002/pri.424

Zborowski, M. a952). cultural components in responses toPain./ourπ41 qf'sociα11Ssues,8(4),16-30. h杜P://dx.doiOrg/10.1111/j.1540-4560.1952.tb01860.X

Aιk"owledg111e11ts. The authors wish to thank the reviewers

fortheir valuable feedback on the manuscript.

Correspondence re8arding this article should be directed toStephanie power, The university of Queensland, scho01 0fNursin8, Midwifery and sodal work,1,eve1 3, chamberlainBuilding (#35), st.1、uda QID 4072, Australia. E、majl.Stephanie'power@uq.net.au

Stephanie power, BA, MA (Applied linguistics), phD can、didate, scho010fNursing, MidwifeTy and sodalwork, TheUniversity ofQueensland, Australia.

FionaE. Bogossian, RN, RM, DipAppsd-NEd, BAppsd-N(価Stindion), MPH, phD, FACM,scho010fNurS加g, MidM企Wand sodal work, The university ofQueensla11d, Australia.

Ienny strong, BOCCThy, Moccny, phD, scho010fHea1血 a11dRehabilita廿on sdences, The university of Queensla11d, A11Stralia.

Roland sussex, MA (Hons), phD, OAM,1nstitute 血r

Teaching and l,earning lnnovation, scho010f王anguagesand cU1加res, The university ofQueensland, Australia.

PainReliefE丘edofcryotherapyillparturients

Oct4νi0 入1'. C. V4rge11S, S011m NU11es,ιolit4 D. da si1ν4,411d14πe M. prosiaπti

INTRODUCTION: pain in childbirth and strategies forrelieving it have been a subjed ofinteresttoresearchers for many years. The use of cold (cryotherapy), as a pain relief technique genera11y,is quiteWeⅡ hlown and studied. However, few studies have addressed the use ofcryotherapy as a strategy for

relievin名 the pain of childbirth.

OBIECTIVE: To evaluate the effects ofcryotherapy in Telieving childbirth pain.

METHOD: pilotintervention study using prospective data in a single intervention group,the outcome

being the pain relie丘n women in labor. The sample comprised 36 Parturients atthe HospitalMaterni・dade C笹mela Dutra, Rio de janeiro, Brazil. cryotherapy was applied to the parturients'thoracolumbar

region at cervical dilation of 5,フ, and/or 9 Cm, using an icepack belt.1n aⅡ,48 applications were made.The responses regarding the action ofcTyotherapy on pain were recorded on a sped6C form. TheNumeric Rating scale (NRS) was used. F0110Mng a form,the parturients' behavior duTing the applica・tion ofcryotherapy was also observed

RESUI,TS:1t was found that 91.67%(outcome) ofthe women reported pain relief and betterConditionsin which to experience childbirth. The behavior of 75qo ofthe women in labor was calm

and partidpatory; some slept (5.56yo), others took shoTt naps (19.449'0).

CONCIUSION: cryotherapy proved e丘edive in relieving pain in childbirth. Because characteristica11y,

Cryotherapy does not interfere in the physi010gicalprocess of childbirth,it can be used in care forWomen in labor.

KEY、、10RDS:1abor pain; pain relief; midwifery; cryotherapy; childbirth

INTRODUCTION

In Brazil, despite e丘orts by the Ministry of Health, theannual rate of cesarean section deliveries is sti11 high.The 20H united Nations childreds Fund (UNICEF)

State of the world's children Report σives the cesar・ean rate in Brazil aS 40%, maMng it the highest in theWorld (UNICEE 20ID. The world Health or名anization(凡I×1HO) has found that, at most,15% of deliveries need

to be surgical(Bogg, Huang, Long, shen,& HemminM,201の. Another study found that demand for cesareanSections was direcdy assodated lvith fear offeeling pain(van den Bussche, crombez, Ecdeston,& SUⅡNan,

2007). At present, epidural analgesia is one ofthe main

&/N7εRIVAT/0IVAI_ JOU月/VAι_ OF CH/ιDB/RTH VO/ume 6,/ssue 3,2016

◎ 2016 Springer pub!ishing company, LLC VVWW.springerpub.comh廿P:ガdx.doi.0四/10.189V2156-5287.63.149

Pharmac010gical methods used to relieve expedantmothers' 1abor pains. There are limitations on its use,however,induding the possibility oflowblood pressureand motor block in labor, which make surgical deliverynecesS紅y (landolt & MⅡlin3,20ID induding severalinterventionssuch asinstrumentaldelivery (forceps andVacuum) and also oxytodn infLlsion, Kriste11er maneu・Ve二 and epjsiotomy

In Brazil, the Ministry of Health is encouragingPhysi010gical delivery assisted by obstetric nurses as aStrategy for redudng cesarean section rates (Depart・ment of Health policy,20OD.1t is in this context thatCryotherapy (therapy using cold) applied to relieve pain,re1鯉 musdes, and reduce edemas (Ma,1e,1eong, Kim,

■y'Ξ

149

150 pain Re11ef E仟ed of cryotherapy V討gens et a/

& Kim,2013) is emerging as a practice in the processOf obstetric nursin8 Care to relieve perineal pain afterChildbirth (Francisco, de oliveira, Leventhal,& deBOSCO,2013; Leventhal, de oliveira, Nobre,& da silva,

20ID. HO、vever, only one arude approached the useOf cryotherapy to relieve the labor pains of 、vomen inChildbirt五(Nunes &V釘gens,2007).

BACKCROUND

Pain perception is a physi010gical process involvingreceptors, conducting path、vays and cerebraHntegratingmechanisms. Bet、veen the stimulus of the tissue lesion

and the subjective experience ofpain, four electricalandChemical phenomena occur: transductjon, ttansmis-Sion, perception, andmodulation (Nationalpharmaceu、廿Cal council,20OD.

Pain starts with transduction, the excitation of

nociceptors, which are arranged in the upper layers ofSkin, musdes, and internaltissues, such as the Perl-

Osteum, arterial 、va11S, articular surfaces, viscera, and

tooth pulp. Nociceptors are chemosensitive,in thattheyCan be activated by algogenic substances, that is, pain、indudn8 Substances, such as bradyMnin, histamine,Potassium ions, hydrogen ions, prostaglandins, and leu、kotrienes (Melzack,2005).1n addition, the nodceptors'themselves produce transduction・augmenting material,known as substance p (p for pain), which has power6.11Vasodilatory and edema8enic properties.

Transmission is a complex processin which stim、Ulito nodceptors are conduded to the central nervous

System by two differenttypes of6ber which are respon、Sible for sharp (epicritic) pain or dU11(protopathic)Pain. The two mostimportant pain transmission tractsare the spinothalamic trad, represenun今 the a丘ectiveComponents of pain (suffering), and the spinoreticulartrad, which is involved in the phenomenon ofwaMnsand neurovegetative and emotionalresponses (NationalPharmaceutical council,20OD.

Modulation, the process by 、vhjch transmissionOf the pain stimulus is facilitated or inhibited, involvesendogenous biochemicalsubstances and neuralcircuits.Perception of, and reaction to, pain occur when the

Painful sensation reaches the cerebral cortex, causingConsdous perception. At this stage, the pain thresholdCan be lowered by conditions such as fear, sadness,depression, isolation, and insomnia or it can be raised

to improve pain tolerance by a friendly environment,hope丑.11ness, sleepiness, ana18esics (National pharma、Ceutical council,20OD.

The lnternational Association for tbe study ofPain de丘nes P4iπ as an unpleasant sensory and emo、tional experjence assodated with adual or potentialtissue dama3e or described in terms of such damage(Akba§& oztunc,2008).

There are various possible methods for relievingthe pain oflabor, where the mechanisms described ear、Iier also occur.

This study is grounded in the application ofCryotherapy or cold therapy as a nonpharmac010gicalmethod (Gutierrez Espinoza, Lavado Bustalnante,&Mendez perez,201の. cryotherapy causes vasoconstric、tion,10wers metaboHc rate, inaammation and Paln, as

WeⅡ as releasing endorphins and enkephalins. cryo、therapy is hlown to reduce pain transmission by nerve介bers, decrease the excitability of free nerve endings,raise the 丘bers' pain threshold, and reduce the speed ofPropagation of nociceptive stimuli(Robertson,刃~1ard,LOW,& Reed,2009).

This study is、varranted because research to evalu、ate the effectiveness of resources of this kind in reliev、

血g labor pain holds out the possibility of applyin8Various different therapeutic opuons that contributeto less interventionjst and medicalized practices. Thisis in line with wHo recommendauonS 血r hospitalrouunes considered unnecessary, risky, or excessivelyinterventionist. The ~、1Ho proposes not to eliminateinterventions butto reduce them to those proven to benecessary (WHO,1996).

This study was conducted in the li名ht of theseConsiderations, with a view to evaluating the effects ofCryotherapy in relieving the pain oflabor.

The data presented here are believed to contributeto the health care process by opening up an innovativePossibility in the field of obstetric nursing, Mth a viewto improving the quality of care provided to womenin labor by fostering the safe a11d ra廿onal use of cryo、therapy for this population.

This pilot study, based on a sin81e intervention groupand using prospective data, lvas conducted at a mater、

nity hospitalin Rio de laneiro. The primary outcomeWas pain relief. only two outcomes were possible:Cryotherapy did or did not relieve the pain. Forty、eightapplications were made (S加dy 11 = 48), always at cervi、Cal dilation of5,フ, and/or 9 Cm.

The study population comprised 刃Vomen selectedOn the f0Ⅱolving criteria: They agreed to take partin the

METHOD

Study; they 、vel'e assisted by obstetric nurses; their laborProgressed atlo、v risk; and they signed a dedarauon offree and informed consent. ofthe women admitted in

Iabor 丘om lanuatyto october 20H,36 metthe criterja.The intervention consisted in the application of

Cryotherapy between vertebrae T11 and L2, to lvheteSensory information from the 名ravid uterus is con・ducted. The applicauons lasted 20 minutes, alwaysUnder the same conditions in terms of progression ofIabor: at dilation of 5,フ, and/or 9 Cm. The self・reportedPain level; blood pressure; fetal heart rate; pa廿ern ofUterine activity; and also the、vomads observed behaviorbefore, during, and a丑er the applications ofcryotherapyWere aⅡ recorded.

T、vo parameters were used in assessing pain relief:

1. Reliefofpain selfreported on the Numeric RatingScale (NRS; van Dijk et al.,2012). This is a numeri・Calscale from o t05 (where o meanS πOP4iπ; and 5,extre111el),severe P4iπ) 0丘ered to the woman in laborto a杜ribute a value to the intensity ofthe pain she isfeeling at any given time.

2. Reliefofpain as obseTved in the behavior oftheWoman in labor durins application ofthe cryo・therapy Here, the intenuon 、vas to pointto behav・ior reaecting pain relief. Accordingly, behaviorObserved and recorded on a spedfic form thatinduded the 、vomanls sleepin昌 dozing, or calmingand relaxin8, even in active labor or during contrac・tions. This form was not validated as a to01.1t 、vas

a strategy to enable the researcher to re3ister thebehavior ofthe partidpants, beyond the answers址ready registered in the NRS.

It is important to state that we did not considerthe temperature in the maternity 、vard for control dur・ing the study lt was an air・conditioned ambient、vheretemperature was maintained between 20゜c and 25゜C.The maternaltemperature was not contr0Ⅱed, either.According to the hospital guidelines, parturients, whoPresented temperature higher than 37゜C, whicb is con・Sidered subfebrile condition (Dior et al.,2014), could

not have their childbirth attended by obstetric nurses.Thus, it 刃Vas accepted that a11 Parturients maintainedbody temperature S 37゜C.

The S加dywas performedwith authorization fromthe Research Ethics committee of the Rio de Janeiro

MuniCゆal Health Department.

F治in Relief E仟ed of cry0小erapy varge那 et a/.151

The same person, that is, an obstetric nurse,member of the research team, Nvho had prior instruc・tion and training, performed a11 data c011ection. Beforedata c0Ⅱection, the research team had eight meetingsfor discussing eventual aspects of the application ofCryotherapy itself, as 、veⅡ as circumstantial events thatCould interfere with data c011ection, related to the par・

tidpants, ambient, and personalsta丘 Cond武ions in thedelivery room.

Cryotherapy was applied by ねking six ice cubesfrom the freezer, pladng them in a plastic bag, dosingthe mouth and then inserting the dosed plasticbag intoa belt ba3 0f nonwoven fabric (N刃XIF), and then thenapplied in the thoracolumbar region. statistical record・ing 、vas based on simple descriptive statistics. Extra iceCubes were available to re6Ⅱ the belt bag during theapplication ifnecessary

RfsuLTS

Cryotherapy was applied t0 36 Women. The womenWere predominantly (75%) in the 21・ t0 30・year a8erange, f0ⅡOwed by 31t040 year olds (13.89%). Regard・ing education, most (88.89%) reported having com・Pleted secondary scho01, whereas only one declaredhaving completed higher education.1n terms of parity,most(36.11%) were in their 丘rst pregnancy f0ⅡOwedbythose in their second (3333%).

In a11,48 applications of cryotherapy 、vere per・formed, always at 5,フ, a11d/or 9 Cm dilation (Table D.

Pain Relief Hfed of cryotherapy

As can be seen in Fi8Ure l, pain before application ofCryotherapywasselfreported at LevelS 3,4, and 50n theNRS (severe pain, verysevere pain, and extremelyseverePain, respectively). During appHcauon of cryotherapy,reported pain intensity mi8rated to Levels l t03 aitdePain, moderate pain, and severe pain).1n this study,the first, immediate effed of the cryotherapy reported

TABIEI TotalApplicationsofctyotherapyto叉Vomeninl'abor(HospitalMaternidadescarmelaDutta,磁o de1卸eito, Brazi12011)

APPⅡCATION OF

CRYOTHERAPY

One apPⅡCation

丁~vo apPⅡCationsTotal

NUMBfR

OF、VOMEN

IN I.ABOR %

T0丁AI.APPUCATIONS

n

50

50

100

4 2 6

2 1 3

4 4 8

2 2 4

152 Paln Relief ε仟ed of cryotherapy V討gens et a/

8,16

16.33

Beforeapplication ・・◆・, Dudngapplication ・・^、ー A丑erapplication -ー^

FIGURE I. Frequency distribution ofpain intensitybefore, durin& a11d a丘er useOfcryotherapy, on the Numeric Rating scale. Hospita11Vlaternidades carmela Dutra(HMCD), Rio de ja11eiro, BI'azi12011.0 = 110paiπ; 1 = 1ittlepaiπ; 2 = 1110der4tePα1'π; 3 = severeP4i松 4 = very severeP41'π; and 5 = extre111ely severepaiπ.

by most (2&フフ.78%) ofthe women in labor, resardlessOfthe stage of cervical dilation, was relief ofback pain.Only three ofthe women in labor reported no bene6tfrom cryotherapy

0

44.91

12.24

22.45

◆.34.69

モ仟ect of pain Relief by cryotherapy on BehaviorOf 、vomen ln l_abor

26.53

The second parameter used in this study to assess painWasthe behavior ofthe 、voman in labor assodated with

the pain relief. Table 2 Shows the distribution ofbehav、

ior observed during application ofcryotherapyAlthough cryotherapy was being applied, the

behavior ofmost(75%) ofthelvomen in labor was calm

and partidpatory: They conversed with their compan、ions, the obstetric nurses, and even on the telephone.During application of cryotherapy, some slept (5.56%),Others took short naps a9.44%) 1ying in bed or sittingin chairs.

1429

◆.28.57

22.45

3

◆ 22.45

4

16.33

5

Note that cryotherapy did not interfere in thePa廿ern of contractions, which remained consistent (in

musde tone, intensity, a11d frequency) during pr08res、Sion of the pa杜ern of cervjcal aC廿Vity and labor andChildbirth overaⅡ.

TAB王E2 DistributionofBehaviorAssodated

Withcryotherapyinwomenin王abot(Hospit虹Matel'nidades carmela Dutra, Rio deja11eiro,Brazi12011)

BEHAⅥOR

DISCUSSION

Deel) sleepS1柏「【 napsCalm and relaxed

Total

Pain Relief モ仟ed of cryotherapy

Durin晉 applicauon of cryotherapy, self・reported inten、Sity of pain was mostly 、veak and moderate to sttong.The women in labor in this study reported thatthejirst,i111111edi4te eが'ed of the cryotherapy was relief of backPain (フフ.78%).

As is already hlown, one of the main discom、

forts reported by women 80ing into labor is painthat be号ins in the lumbar region (Lee et al.,2012;Macedo, pr08ianti, vargens, santos,& silva,2005),

migraung from there to the suprapubic region durin号Contractions.

Perception of painfulsensations in the back, andOfreliefdurins the contractions oflabor and childbirth,results from the functionalinnervatjon ofthe uterus byParasympathetic nerves originating in vertebl'ae S2 toS4 and sympathetic nerves originating in vertebrae T7to T8. Re号arding the sensory innervation ofthe uterus

responsible for perception of labor pain (Ting含ker &Irestedt,2010), this is hlown to take the form ofvisceral

afferent 丘bers originating in the corpus uteri,刃Vhich

n

5.56

19.44

75.00

100.00

%

6.12

8.16

27

1◆

2

6◆21

76

23

enterthe spinalmedU11a atthelevelofvertebraeTⅡ andT12 (Fernandes & 1Unqueira,2009).

The literature describes how pain can be reducedby applying cold through several different techniques,Such as cold compresses (ice packs), ice to、vels,ice mas・Sage, and cryotherapy,is nowwe11hlown in treatment ofSprains and musde contractures and in rheumatic dis・eases (costeⅡ0, Mdnerney, BleaMey, selfe,& DonneⅡy,2012; De Dios sancho & Martin・Noguereas,2011).

Accordingly, probably one ofthe greatest bene丘tsOfcryotherapy is its analgesic e任ed (Gutierrez Espinozaet al.,2010). To bene丘t from that, the peculiarities ofIabor pain have to be understood to determine the rightmomentto applythetechn010gy

The pain is triggered by liberation of the hor・mones estrogen, prostaglandin, and oxytodn (selma11 &johnston,2010). Thatpainoccursfromthe丘rst3 monthsOfpregnancy to childbirth proper. As a result ofh電berIevels of estrogen, prostaglandin levels rise late in preg・nancy, and itisthe prostaglandinsthatstimulate contrac・tion of the smooth muscula加re of the uterus. DuringIabor, the higber levels ofprostagla11djn trig8er myome・trialcontractions, as、veⅡ as redudngthe resistance oftheCervix, which then s0丑ens, effaces, and dilates.

One important occurrence toward the end ofPre号nancy is the increase in the number of oxytodnreceptors in the uterus,、vhich increases sensitivity toCirculating oxytodn.1tisimportantt0 山lderstand, how・ever, that uterine contractiljty is not an isolated fadorduring labor and childbirth. various different anatomi・Cal structures are involved at that point: The myome・trium, cervix, placenta, and fetus worktogetherto assureSuccessful delivery (Luria et al.,2009).

It is h)own that to obtain therapeuuc benefjts,Skin temperature must fa11to around 13.8゜c to achieveideal reduction in local blood aow and t0 14.4゜c for

analgesia to occur (starkey,2003).Applying cold to the skin activatesthe mechanism

thatis considered to conserve heat atthe bodycore,tr培・gering a series of metabolic and vascular events whichresults in the bene丘dale丘ects mentioned earlier. Appli・Cation of cold for 20 minutes can reduce transmission

Of pain impulses by up t0 29.4%, and that effect lastsaround 30 minutes after the cold is withdrawn (oliveira,

Silva, Riesco, Latorre Mdo,& Nobre,2012).

Cryotherapy has been used in maternity fadlitiesto reduce the edemas and hematomas in perineum, toreduce hemorl'hagin8 at these same sites as a result ofepisiotomy or lacerauons, and to suppress lactation inPostpartum women who cannot breastfeed (van derHorst et al.,2009).

In the cases mentioned, cryotherapy induces sev・eraldifferent actions besides ana18esia, such as extravas・Cular absorpuon ofliquids in edema (Brown & Hahn,2009) and reabsorption of hematomas and vasocon・Striction to staunch bleeding (East, sherburn, Nagle,Said,& Forster,2012).

In obstetrics, an essaypublished in 20070n the useOfcryotherapy to relieve the pain oflabor also reported丘ndings pointing to posiuve results from its use in t11isSituation (Nunes & vargens,2007).

F治in Re"ef [仟ed of cryotherapy va唱ens et a/.153

Pain Relief 断fect of cryotherapy on Behavior of、vomen in t.abor

Researcher's presence may inauence, directly or indi・rectly, the behavior of the partidpants, the so・ca11edHawthorne effed (Mccambridge,い7i廿on,& Elbourne,2014).1n this pilotstudy, even ifit刃Vas not a spedalcon・Cern,it was dedded to combine the responses recordedin the NRs lvith the observation of the partidpants'behavior re号istered by the researcher.

Regarding the behavior observed while cryother・apy was being applied, the data show thatthe behaviorOf most (75%) of the women in labor was calm a11d

Partidpatory: They conversed with their companionsand the obstetric nurses. some slept (5.56%),、vhereasOthets took short naps a9.44%) 1yin3 in bed or si杜in宮in chairs.

Pain in 牙eneral and patticularly labor pain causesdiscomfort, anxiety, and stress, preventing the individu・als a丘eded from relaxing or even sleeping. some par・tidpants presented stress before the cryotherapy; they、vere agitated, screamin号 or crying, asking for somemedidne for pain relief.

During and a丑er the cryotherapy, the women inIabor were found to feel comfortable 、vith cryotherapyTheyavoidedkeepin今to thebed, eveninthe mostactiveState oflabor, when contractions are most frequent andintense.1ndirectly, that behavior reaected the abilityOf cryotherapy to produce pain relief, even in the 丘nalStages oflabor.

It can thus be seen both that the ain relief

achieved by using cryotherapy favored or ptoduced thisbehavior in the women in labor and thatthis behavior

adua11y is indicative that cryotherapy fosters pain relief.It was also found that some 、vomen in labor asked for

the ice belt to be kept in place in their lumbar regionfor longer than the recommended 20 minutes, so thatthey could bene負t for lon名er from the telief that thetechnique broughtthem.

154 Pain Relief E仟ect of cryotherapy V討ge那 et a/

One woman in labor 、vho received cryotherapyat 9 Cm dilation progressed quicMy in cervical dilation,entered tbe expulsion stage shordy a丘er 20 minutes ofapplication, asked to continue with the ice in place, andPreferred to stand with herthorax supported by the bedWhile her chjld was being born.

In this study, cryotherapy displayed the properwOf favoring the physi010gical prosress of childbitth. ASalready mentioned, that result is not al、vays achievedIvith pharmac010gicaltechniques such as epidural orSpinal anesthetjcs, from which adverse effects may

ensue (Niveen & NeviⅡe,20ID.

Uterineactivitypr0号ressednormaⅡy,withoutcom、Plicauons,in aⅡ the women in labor monitored duringthe study, evidence that cryotherapy, when appliedappropriately, reduces painfulsymptoms, without inter、fering in the pa杜ern of uterine activity or pr08ress inIabor, nor in blood pressure or other clinical condi、tions of women in labor (Hajiamini 入lasoud, Ebadi,Mahboubh,& Matin,2012; Nunes & vargens,2007).

In spite of wHo e丘orts to encourage physi、010gical childbirth for its bene6ts to mother and child(X/×1HO,1996), some more recent studies are found to

approve and encourage the use of analgesia and cesar、ean sections, while disregarding the superiority of anatural birth over the use of pharmac010gical meth、Ods, given tbe related possible adverse effects al)d/orComplicauons.

In pracuce, nonpharmac010gical methods arebein名 found to produce good results, are recommendedby the 刃、1HO, and are provin8 themselvesto be positiveStrate3ies.

Scope 血r comparison with data obtained in other situa、tions. othersNdy desi号n Hmitations were thesmaⅡ nuln、ber of applications of cryotherapy and the fad that theresults were notrepHcatedin anotherinstituuonalcontext.

However, the study did yield promising data,induding the pain reliefreported bymost ofthewomenin labor and the calm, proactive behavior ofmost ofthe

Women, even at the height of the acuve stage oflabor.These data indicate that 員lrther research with Cryo・

therapy is needed so that it can become established in

Obstetric nursin号 as a noninvasive care techn010gy thatCan be 、vjdely used.

The cryotherapy examined in this study can beConsidered a techn010oicalinnovation when used byObstetric nul'sing by virtue of its noninvasive nature,Whichbene丘tsthe naturalprocess ofchildbirth byreduc、ing the pain五11 Sensation oflabor.1n addition, given its10w complexity and high ef6Cacy,it canbe used in child、birth care services, to 、vhich it can representlower costs.

Accordin号ly, we consider itimportantthat furtherStudies be conducted with a view to m01'e in、depth eval、Uation of its pain reliefe任ects and its health economicsimplications.

CONCI.USION

On applying cryotherapy to women in labor, what was

Observed was pain relief a11d the womeds being betterable to experience their childbirth.

R wasthus possible to see in cryotherapy a nonin-Vasive, pain・relieving care techn010gythat differs in sev-eralrespectS 丘om the pharmac010gicalmethods usua11yemployed to relieve pain in childbirth.

ItS 6.1ture use can represent a major gain both inaccomplishing the prindples of humanized childbirthand for growth in obstetric nursing pradices, which inturn aimsto strengthenthe use ofnoninvasive caretech、

n010gies regarding the physi010名icalsta8es ofchildbirth.Some weah)esses of the stady could not be sur、

m0山lted, such as the dif6Culty ofworMng with a largerPopdation and longer time frame, which limited the

REFERfNCES

Akba勗 M.,& oztung, G、(2008)、 Examination ofhlowledgeabout and nursing interventions for the care ofpatientsin pain of nurses who work at cukurova universitymedical faculty Balcali hospital. paiπ M4114ge111eπtNUおiπ8,9(3),88-95.

Bogg, L., Huang, K., Long, Q., shen, Y.,& HemminM, E.(2010). Dramatic increase of cesarean deliveries in the

midst ofhealth reformsin ruralchina. sod41ScieπCe 6

Mediciπe,70aの,1544-1549.

Brown, W C.,& Hahn, D. B.(2009). Frostbite ofthe feet a丘er

Cryotherapy: A report ofNo cases. Thejourπαlqf'FootαπdAπkle surgery,48(5),57フ-580.

Coste110, j. T., Mclnerney c. D., BleaNey, C. M., selfe, J.,&DonneⅡy, A. E.(2012). The use of thermal Imagln8

in assessing sMn temperature f0ⅡOwing cryotherapy:A revie、V./ourπ41 qf'Ther柳αI Bi0108'y,37(2),103-110.

De Dios sancho, E. R,& Martin・Nogueras, A. M.(2011).Inauence of the physicaltherapy on the heaRh andquality of life of the rheumatic patient. Reιι力1αt010gfaCliπiC4,フ(4),224-229.

Department ofHealth policy.(20OD. P4rt04hのto epuerPどrio:4SsiS詑πCI'4 hU111411iZ4d4 a 1πUlher [childbirth, abortion

and postpartum: humanized assistance to womenl.Brasilia, Brazil: Minist6τio da sa11de、

Dior, U P., Kogan, L., calderon・Margalit, R., Burger, A.,Amsa11em, H., Elchalal, U.,... Ezra, Y.(2014). The asso・

Ciation ofmaternalintrapartum subfebrile temperatureand adverse obstetric and neonatal outcomes. paediat・

riC α11d periれαt41 EpidelHi010gy,28,39-47.

East, C. E., sherburn, M., Nagle, C., said,1.,& Forster, D.(2012). perineal pain f0110wing childbirth: prevalence,effects on postnatal recovery and ana18esia usage、Midwife沙,28(D,93-97.

Fernandes, M. L.,&junqueira, F. C.(2009). Analgesiade parto:Bases anat6micas e 6Si016又icas [Labor analgesia: ana・tomicalandphysi010gicalbases]. RevMedMiπαS Gerais,19(3 Pt. D, S3-S6.

Francisco, A. A., de oliveira, S. M., Leventhal, L. C、,& de

BOSCO, C. S.(2013). cryotherapy a丘er childbirth. TheIength ofapplication and changes in perinealtempera・加,0. R卯ist4 d4 ESC01" de Eπf'e加"8肌 d" USP,47(3),555-561

Guti6rrez Espinoza, H, j., Lavado Bustamante,1. P.,& M6ndezP6re2, S.1.(201の. Revisi6n sistem五tica sobre el efecto

analgesico de la crioterapia en el manejo del d010r deOrigen mosculo esque16tico [systematic review of theanalgesic effect of cryotherapy in the mana号ement ofmusculoskeletal pain]. Revista de 1α Soded4d 三Spah01αdelD01の,17(5),242-252

Hajiamini, Z., Masoud, S. N., Ebadi, A., Mahboubh, A.,&Matin,A. A.(2012). comparing the effects ofice massage andacupressure on labor pain reduction. C0111Ple"1e11taryTherapies iπ CliπiC41 Pr4dice,18(3),169-172

Landolt, A. S.,& Mi11in名, L. S.(20ID. The ef6Cacy ofhypnosisas an intervention for labor and delivery pain: A com・Prehensive method010gical review、 chπical psych0108yRevie1ν,31,1022-1031.

Lee, N., webster,1., Becknann, M., Gibbons, K., smith, T.,

Stapleton, H.,& Kildea, S.(2013). comparison of aSingle vs. a four intradermal sterile water injection forrelief oflower back pain for women in labour: A ran・domised 'ontm110d t丘al. Midwif'ery,29(6),585-591.

Leventhal, L. C., de oliveira, S. M., Nobre, M. R.,& da silva,

F. M.(20ID. perineal analgesia with an ice pack a丑erSpontaneous vaginal birth: A randomi2ed contr0Ⅱedtrial. jourπαl qf' Midwifery 6 W0111e11太 He41th,56(2),141-146.

Ofadhesive capsulitis ofthe shoulder. Archives qf'physi・C41Medici"e 4πd Rehα6im4ti011,94(D,9-16.

Macedo,R O.,progianti,1.M.,vargens,0.M. C.,santos,VI、. C.,&silva, C. A.(2005). W'omen andtheperception ofpainatthe delivery room: The inauence ofthe environmentat the delivery room. Revista E11jer"1α8elH U三RI,13(3),306-312.

Fねin Relief E仟ed of cryotherapy Vωgens et a/、 155

Mccambridge,}.,~vitton,}.,& Elbourne, D. R.(2014).Systematic revie、v ofthe HaMhorne e丘ect: New con-Cepts are needed to study research participation effects.10ur1141 qf'cli11iC41 五Pide111i010gy,67(3),267-27フ

Melzack, R.(2005). The MCGiⅡ Pain Questionnaire: From

description to measurement. A11esthesi0108y,103(D,199-202.

Nationalpharmaceuucalcouncil.(20OD. paiれ: curre11t1ιπdef・

St411di"8 qf' 4SsesS111e11t,柳απαge111e11t, aHd tre4t111ents.Washington, DC Authot. Retrieved from http://WWW.npcnow.org/pubHcauon/pain・current・understanding・assessment・management-and・treatments

Niveen, W.,& NeviⅡe, R.(20ID. Analgesia and anaesthesia inIabour. obstetrics. Gy11αec010gy 6 Reprodιιdive 入ledi・Ciπe,21(5), B7-141

Nunes, S,,& vargens,0. M. C.(2007). cryotherapy as a strat・egy for pain relief in childbirth: an exploratory studyRevist4 Ξ11fer揃αge机 UERI,15(3),337-342.

Oliveira, S. M., silva, F. M., Riesco, M., Latorre Mdo, R.,

& Nobre, M. R.(2012). compatison of applicationtimes for ice packs used to relieve perineal paina丘er normal birth: A randomised clinjcal trial.ノ'our・

π41 qf' C五πiC41 Nursiπ8,21,3382-3391. http://dx.doi、or名/10.1111/j.1365-2702.2012.04195.X

Robettson, V, ward, A., LOW,1.,& Reed, A.(2009).三lehote・

rapia expliC4da: priπCψios e prdtica [ElectrotherapyExplained: prindples and pradice].(4th ed.). Elsevier.

Selman, T.,& johnston, T.(201の. Mecha11isms and manage・ment ofnorma11abor. ohstetガCS, Gy11ec010gy4HdRepro・ductive Mediciπe,20(フ),201-206.

Starkey, C.(2003). RecUおOs teraptuticos elHjisioter4Pi4 [Ther・apeuuc Resources in physiotherapy]. sao paulo, Brazil:Manole.

Tin8含ker, B. K.,& 1restedt,上.(201の. chal)ges in utetineinnervation in pregnancy and during labour. curre11tOP加i0π iπ A"aesthesi010gy,23(3),300-303.

United Nations childr印'S EmergencyFund.(20ID. UNIC五F41ert4 Sobre o alto pa'centU41 de ceS4riαπαS 110 Br4Sil{UNICEF alerts to the h地h percentage of caesareanSections in Btaziu、 Retrieved from http://WWW.unicefOrg/brazivpvmedia_22984.htm

Van den Bussche, E., crombez, G., Eccleston, C.,& SUⅡivan,

M.1.(2007). why women prefer epidural analgesia

Luria,0., jaffa, A., Farine, D., Hassan, S,, LysiMewicz, A.,Kees, S.,& Barnea,0.(2009). Effects of the individualUterine contraction on fetal head descent and cervical

dilatation during 血e adive stage of labor. Eumpeαπ/our11αl qf' ohstetrics, G),11ec010gy,411d Reprod1ιdiveBi010gy,144(SUPPI. D, SI01-SI07.

Ma, S. Y.,Je, H. D.,1eong,j. H., Kim, H' Y.,& Kim, H. D.(2013).E丘ects ofwhole・body cryotheTapy in the management

156 距ln Relief E仟ed of cryotherapy V田gen5 et a/

durjng childbirth: The role of beliefs about epiduralanalgesia and pain catastrophizin8. Europeαπ jour1141qfP4iπ,11,275-282.

Van der Horst, C., chasela, C., Ahmed, Y., Hoffman,1,

Hosseinipour, M., Khight, R.,... jalnieson, D.(2009)Modi丘Cations ofalargeHlv prevention dinicaltrialto nt

Ch飢gingre虹ities: AcasestudyoftheBreastfeedin8,Anti、retroviral, and Nutrition (BAN) protocolin Lilon8We,Malawj. C0πte1πPor4ry aiπiCα1 乃ials,30(D,24-33.

Vat) Dijk, J. E, val) wijck A.1., Kappen, T. H., peelen, L. M.,

Kalhna11, C.j.,&schuurma11S, M.1.@012). postoperativePain assessmentbasedonn如lerjc ratin8Sis notthe salne

丘)r patients and professionals: A cross-sectional study1πterHati0παljour11αl ql'Nursiπ8 S加dies,49(D,65-71.

World Hea1血 0弔anization.(1996). C4re iππor抗41 birth,A pradicalguide. Geneva, switzerland: Author.

Correspondence regardino this artide should be ditected to

Odavio M. C. var8ens, RN, RNM, phD, Faculty ofNursin8,No de janeiro state universiw (UERD, AV.28 de setem、br0 157/7 andar, vila lsabel, Rio de }aneiro, B皿Zil. E、mail:

Omcvargens@U01.com.br

Odavio M. C. var名ens, RN, RNM, phD,t北Ular professor, Fac、Ulty ofNursing, Rio de janeiro state university.

Sonia Nunes, RN, RNM, Faculty ofNursing, Rio de laneiroState universiw.

Lolita D. da silva, RN, phD, assodate profess0二 Faculty ofNursin3, Rio de J師eiro state university

Iane M. progianti, RN, RNM, phD, assodate professor,Faculty ofNursing, Rio de }aneiro state university

Birth plans: ANarrative Review'ofthe 王iterature

Berれie Diν4ル Heleπ Spib%/ulie Roberts, aπd Deπis W41Sh

OBjECTIVE: To describe and summarize the current body ofevidence on the subjed ofbirth plansto

develop a research agenda.

MEIHOD: A narrative reviewwas undertaken to 0丘er a comprehensive overview ofthemes emergin8

from previous research in this area.

FINDINGS: Thirty一丘Ve paperS 丘om 33 Studies、vere retrieved and grouped into three main themes:the impad ofbirth plans on obstetric outcomes,、vomen's experiences and opinions ofcompleting andUsing birth pla那, and health care professionals' beliefs about and experiences ofthe use ofbirth plans.Key findings relate to beliefs aboutthe bene丘ts and chaⅡenges ofbirth plans, as described bywomenand health care professionals and the impad ofbiTth plans on a ran合e ofobstetric outcomes.

CONC王USION: Thisreviewbrin8S 加gether a range ofstudies ar0如d birth pla11S and syTlthesizes keythemes. little homogeneitywas seen in the studies identi6ed, al)d a wide variety ofcare contexts and child・bir廿Iphilosophies 、vere represented. Findings suggestthe need for 6.1r廿ler research into whe壮ler there areidealcircumsta11Ces and enⅥtonments f0τ壮le completion ofbirth plans a11tenat祉ly and whether dispari・

Ues between expedations described in women's pla11S a11d e)甲eriencesin labor and birせ) can be reduced.

KEY、VORDS: birth preferences; birth cboice; bir杜Ipla11S; maternity care; birth e}甲eriences

INIRODUCTION

Formal, writtenbirth plans were introduced in the 1980Sas a11 a杜empt by women to gain a sense ofcontr010verthe childbirth experience (Beech,2011) and by child・birth educators to help women avoid escalating inter・Ventions (Lothian,2006). As an example ofthe contextinto which birth plans were introduced, Beech (20IDCites Herbert Barrie, a consultant pediatrician 、vriting inCharing cross Hospital'S Faculty Ne、vs in 1985:

A stendy trickle Qfstr4118e ladies is blf11trιlhπgthe syste柳 nnd α打'iviπg iπ 1αb01ι1' M/nrds uP απdd01ν11the cou"カ), with 4jh"1iliar shoppiπg list qfde1π4nds telhπg doctorS α11d 柳id1νives what to do

These Pαガe11ts te11d t041'rive,1νith01ιt Wιlr11i"g,iπ the labour W4rd with t11eir leth41Shoppiπg lists

They nre πot e11titled to te11 doctors how to do

、、,ξ,゛左

157

卓

.

がleir 1νork. T11ey are πot e11tル1ed to ask us to

101νel'pr0ルSsi0πnlst411d4rdS 4hd to jeopardiseみαbies' 1ives、

//VTER/VA7/0/VAι JOU月/VAι OF CH/ιDB/R7H VO/ume 6,/ssue 3,2016

◎ 2側6 Springer pub11Shing company, LLC WWW.springerpub.comh廿P:ガdx.doi.org/10.189ν2156-5287.63,157

By early in the new miⅡennium, Kitzinge二 one ofthe earlyu.K. advocates ofbirth plans, believed them tobe a normal part of maternity care, n010nger elidtingthe heated debate they once did (Kitzinger,2005, P.89).In the united Kingdom, birth plans have become anestablished part of maternity care, with many NationalHealth service (NHS) trusts offering a dedicated spacein maternalhandheld notes, where women are encour・

a8ed to articulate their wishes and preferences for laborand birth. Birth plans can be seen to re丑ect contempo・rary practice in childbirth,lvith a杜ention given to suchConcerns as pain relief methods (both pharmac010gicaland nonpharmac010gicaD, birth environment, positionsfor labor and birth, a11d care ofthe baby in the immedi・ate postnatalpetiod.

'ξ 1-^ト/' 4,

158 Birth plans Diva// et a/

The ubiquity of bjrth plans in the u.K. settingmight also be seen as a reaection ofthe Department ofHealtHS (DH) commitment to the promotion of per、Sonalized care, which explidtly addresses the subjed ofbirth plans within the 、vider care environment:

We wi11 e11Courage loC41Services to qが'er α111VO"1e11the opti011 qf'h4νiπ8 α bil'th P14π. This birth P1απShould cle4rly set 01ιt lvhat opti011S are αν4i14ble,jor eχα所Ple hのπe or hospitalbirth,απd recordeaC111ν0111α1乃Preルre11CesjorPα1'11 reli4jood,1110ve111e11t, aπd so 011. A hir所 P1α11 iS πot qf'courseα11 e11d iπ itse41t 11eeds to be discussed through、Outpre811ahcy to thepoiπt qf'6il't11 aπd bey011d4hd α1πe11ded to take accoUπt qf'α1リノιhαπges iπαW0挽α11、 C110ices qfsituati011.(DH,2003, P.43)

Similarly,inrecentantenatal(2008,modi丘ed2014)and intrapartum (2014) guidelineS 丘om the NationalInstitute for Health and care Exce11ence (NICE), birthPlans are assodated with the involvement ofwomen in

their own care, informauon giving by and establishin号effective communication with health care pracutioners,andtheempowermentofwomento haveasense ofcon、trol during childbirth.

Else刃Vhere, however, and particularlyin the unitedStates, there appears to be a conunued reludance tofotmalize the writing of birth plans (simkin,2007;＼vhite・corey,2013). Nthough sped負C national con、texts need further investigation, this may reaect thedominance of the biomedical paradigm within whichChildbirth takes place (Davis、Floyd,1994).

Iuthough itmayappea二 inthe u.K. contextatleast,

that birth plans are n010n8er the contested pracuce theyOnce were, severalissues emerged durin今 Our earlyexplo、ration of this topic.刃、7e found that birth plan templates,induded in maternity records held by women, ranged丘om detailed explanauons ofavailable optionsto ablankPage on which 、vomen wete invited to write their own

Pre企rences. similarly any lnternet search en8ine wiⅡProduce a range ofpossible f01'mats for parents wishingto construd a birth pla11. one example, NHs choices

(h廿P://凡V、V、V.nhs.uk/conditions/ptegnancy、and、baby/Pages/birth・plan.aspx) 0丘ers a series of highly detailedPa8es, covering n山nerous eventualities, from which par、ents are encouraged to dedde on their birth pre企rences.Another, the National childbirth Trust (NCT; h壮P://INWW.nd.org.uk), a u.K. parenting charity,indudes tem、Plates for both hospital and home birth arran8ements.This range ofchoices, options, and templates is reaected

inthediscussionboardsoflnternetforumswherewomen

Share their thoU名hts, experiences, and concerns (e.今.,http://WWW.mumsnet.com/, h廿P://WWW.netm山ns.comハ,evidenced by the numerous caⅡS for adⅥCe a11d subse、quent discussions on the subjed ofbirth plans.

In view ofNHs policylevelsupportfotthe impor、tance of 、vomel)'s choice around childbirth, the lack of

Consistency seen in maternity handheld notes, the con、Siderable discussion of birth plans on internet forums,and the fact that no systematic review of literature onthe subjed has yet been published, we offer a narrativereview ofstudies undertaken to date. our aim is to Pro・

Vide an overview ofthe currentstate ofliterature around

birth plans, synthesizing flndin今S from empirical workinto key themes.凡/×1e also suggest possible directions forfuture research based on 6ndings reported inthisreview.

MEIHODOLOCY

Narrative reviews of literature offer a comprehensiveSynthesis of previously published studies, giving read、ers a broad perspective on a particular topic (Green,10hnson,& Adams,2006). However,血ey have beenCritidzed for a lack ofmethod010gicalrigor in searchingforliterature (BaumeisteT & Leary,1997) and a focus onOpinion・oriented arguments rather than objective con、dusions based on the literature reviewed (Green et al.,2006). There appears a lack of consensus as to whether

individualstudies should be criticaⅡy appraised for thePurposes ofa nal'rative review (Green et al,2006).

The purpose of this review 、vas to bring together負ndings from studies undertaken in a range ofcontextsand 、vhich have applied a number of method010gicalapproaches.~~1e demonstrate a systemauc approach tothe identification ofrelevant studies and their indusion

in the review.凡/X7e draw a杜ention to limitations ofstudies

btoadly rather tha110ffering a detailed appraisalofeach,in Ⅵew ofouraim to provide an overview ofthecurrentState ofresearch into birtb plans.

METHOD

叉Vesearched within currentlndexto Nursinsal)dAⅡiedHealth Lite松加re (CINAHL), Applied sodal sciencesIndexal)dAbstracts(ASSIA), MedicalLiteratureAnalysisand Retrieval system online (MEDUNE), psychlNFO,Maternal & 1nfant care, and Midwiveslnformation and

Resource service (MIDIRS) databases, as weⅡ as GoogleScholar, usin今 Combinations of the tel'ms birth P14π呼

birth choicex', and hirth prcf'ere11Ce". paralneters were setto artides in the En名lish language, published between1980 and september 2015. These parameters Teaed thePeriod during which birth plans have been in use.

The 丘rst author undertook initial searches.

No method010gica11imitations were apPⅡed becausethe aim wasto offer a comprehensive revie凡V ofavajlableIiterature (Green et al.,2006). F0110lving discussion withthe second autl)or, some studies were induded where

birth plans were a signi6Cant theme in t11e reported負ndings, despite not being the prindpalsubjed oftheresearch (e.g., carlton, ca11ister, christiaens,&凡Valker,2009; Doherty、 2010; Thompson,2013). studies wereexduded ifthey 、vere not reported in English.

Findings

Thirty・丘Ve papers representin833 Studies 、vere selectedfor indusion in this revie、V. studies were carried out in

a range ofsettings, representing childbirth cultures al)dCare patterns from around the world. contextsindudedCountries in 、vhich birth plans have been widely intro-duced, such as the united Kingdom and sweden, andOthers where there is a less weⅡ・established history,Such asthe united states, Mexico, and Tajwan. ReportsOfstudies date from 1985 t02015, reaecting an ongoin8interestin the subjed ofbjrth plans from womeds andhealth care professionals' perspectives.

Three centralthemes emerged 丘om our explorationOftheliterature as detailed血Tables l-3 (AppendicesA-C):the impad of birdl pla11S on obstetric outcomes, hea1壮)Care practitioners' a廿it口des t0 釘ld e>甲eriences of work・i113 M壮l b辻仕I P1釘)S,紅ld womeds experiences a11d opi11-ions of 血rmula血g al)d usi11g bir廿I pla11S. severalstudiesaddressed opil)ionS 笹ld experiences of b0仕l hea1廿I carePracutioners a11dwomen (Aragonetal.,2013; Gra11t, sueda,& Kaneshiro,2010;刃Vhitfotd et al.,2014; Yaln, Grossma11,

Gold11)an,& Garda,2007),如d tbese are i11duded itl b0杜)

relevatlttables. The 血110wil)g discussion exploteS 廿le 廿lreeCentra1 廿)emes i11 turn, a11d we 仕len 0丘el' a synthesis ofthese themesto h唱hlight d)eirinteracuon.

2015; Deering, zaret, MCGaha,& satin,2007; Hadar,

Raban, Gal, Y08e又& Melamed,2012; Hidalgo・ιOpezosa, Rodri8Uez・Borrego,MU負OZ・viⅡanueva,2013;jones,1Saacs, chen昌& caU8hey,2009; smoleniec &James,1992). T、vo studies describe evaluation of case

notes (Deering, He11er, MCGaha, Heaton,& satin,2006;jones et al.,1998). The two studies undertaken in the

United Kingdom σones et al.,199& smoleniec & 1ames,1992) date from the 1990S. The other six studies are

more recentbutreport on research undertaken in coun・tries 、vhere care is more likely to be obstetric・1ed.

The studiesindude a wide range ofoutcome mea・Sures, with the most common being the impad ofbirthPlans on epidural use and cesarean section rates. Themajority found a decrease (Afshar et al.,2015; Deeringet al.,2007; 10nes et al.,2009; 10nes et al.,199& smoleniec

& James,1992) or no change (Hidalgo・Lopezosa et al.,2013) in epidural use, with only one study reporting anincrease in epidurals (Hadar et al.,2012).1n relation to

Cesarean section rates, studies lar名ely found a decrease(Hadar et al.,2012) or no difference (Afshar et al,,2015;

Deerin8 et al.,2007; Hidalgo・Lopezosa et al.,2013;jones et al.,2009),、vith only one study reporun名 anincrease σones et al.,1998).

Severalofthe studies reporting obstetric outcomesdescribe some demographic details of、vomen complet・ing birth plans (Deering et al.,2006; Hidalgo・Lopezosaet al.,2013;jones et al.,2009;10nes et al.,199& smoleniec

& 1ames,1992).1n these cases, women writin8 a birthPlan were more likely to be primigravid, older, and edu・Cated to a higher level. This finding 、vas seen in studiesUndertaken in the united Kingdom as weⅡ as in otherContexts; ho、vever, given that the u.K.・based studiesWere undertaken in the 1990S, uptake ofbirth plans lvasarguablylesS凡Videspreadthan itisin contemporary u.K.maternity care systems.

In some cases, study authors believe womedsdemographic details may be significant in relation toObstetric outcomes. jones et al.(2009),、vho identi丘ed

increased rates of slow labor and pr010nged ruptureOf membranes, suggest these outcomes may be relatedto the higher levels of education among women com・Pletin号 birth plans because such women are less likelyto agree to interventions such as arti丘dal rupture ofmembranes. similarly, smoleniec and lames (1992)describe a demography of be杜er educated women inrelation to a desire for reduced intervention and a more

anatural" experience of childbirth.10nes et al. a998),h0凡Vever, offer an alternative explanation for their 丘nd・ing that women with birth plans were more likely tohave assisted rather than spontaneous vaginal birth.

Birth plans Diva// et a/.159

DISCUSSION

Obstetric outcomes

Appendix A details the eight studies that address theimpad of birth plans on obstetric outcomes, with themajorityemployingacasecontrolappl'oach (Afsharetal.,

160 Birth plans Diva// et a/

The authors achlowledge that perhaps women withbirth plans might request fewet interventions such as

Oxytodcs and al)aleesics and were thus more likely torequire obstetric intervenuons in the face ofpr010n8edIabor. HO、vever,they also sUσ8estthat women with birthPlans might be receivine less support and encourage、ment throughout their lab0二 Which they a廿ribute to"irritati01ゞ' on the part of health cate profヒSsionals,Although the researchers 0丘er no evidence to supportthis sug号estion, the f0ⅡOwing section may a丘ord someCredibility to their condusion.

Health care prad託ioners' opinions and Experiences

Appendix B details the nine studies addressing the per、Ceptions and experiences ofhealth cate practitioners inrelauon to the use ofbirth plans, The majority describea qualitauve approach, employing indiⅥdual or 8roupintervie、VS (carlton et al.,2009; Thompson,2013; TO0,1996a; welsh &symon,2014;xvhitford et al、,2014; Yam

et al.,2007), wbereas two took the form of question、naires (Aragon et al.,2013; Grant et al.,201の, a11d oneinvolved the analysis of intel'aC廿on pa廿erns betNveennurse・midwives and women (Doherty,2003). Nlost ofthese studies also induded the pa'ceptions and experi、ences ofwomen, which are reported later in this article.

AⅡ four of the studies undertaken in the united

Kingdom t11at explore health care practiuoners' views(Thomson,2013; TO0,1996a; welsh & symon,2014;凡Nhitford et al.,2014) relate sped丘Ca11y to midwives.1nOne ofthese,the vieNvs ofobstetricians and generalprac、廿tioners were also induded (叉~hitford et al.,2014). TheOther 丘Ve studies were undertaken in contexts Nvhere

Care is delivered within a strongly obstetrjc、1ed model,and so "health care practitioners" induded nurses, gen、eral practitioners, physidans, and doulas rather thanmidwives (Aragon et al.,2013; carlton et al.,2009;Doherty、 2003; Grant et al.,2010; Yam et al.,2007).

Severalstudies found thathealth care practiuonersheld ne8ative vie、vs about women presentin号 in laborWith birth plans (carlton et al.,2009; Grant et al.,2010;Thompson,2013). Grant et al.(201の found that 65% of

their sample believed women presenting in labor with abirth plan would have worse obstetric outcomes overaⅡ

than women without birth plans. similarly, partidpantsin the studybycarlton et al.(2009) described apotential"jinx" e丘ed. studies tended to find negative views relat、ing to womenwhose birth plans wereconsidered inaex、ible or rigid (Aragon et al.,2013; carlton et al.,2009;TO0,1996a) and assodated with a concern that such

Wome11's expedations would be unrealistic and therefore

Unachievable (Thompson,2013), risking a sense of dis、appointment or feelings offailure (Aragon et al.,2013).These perceptions 、vere particularly evident in studiesUndertaken in obstettic-1ed contexts.

ElseNvhere, health care professionals-particularlymidlvives^have voiced concerns about their profes、Sionalroleinthecontextofbirthplans(Thompson,2013;TO0,1996a; welsh & symon,2014). This relates largelyto the chaⅡenge of enactjn8 Women、 pre企rences andChoices as expressed jn birth plans. Thompson (2013)and Too a996a), for example, descTibe a dif丘Culty formidwives in negotiating with women whose choicesIie beyond lvhat is considered usual or safe, lvritin80fthe cha11enge for midwives in 元Vorking as advocates forWomen while atthe same time operaun8 Within profes、Sionaland or号anizationalresponsibilitjes and structures.Echoing the opinion expressed by lones et al. a998),叉Uelsh and symon (2014) found evidence that midwives

Were at times "irritated" by birth plans although thebasis for this irritation 、vas different according to theContextin which they worked. Although sta丘 Workingin midwiferyled units complained thatthey felt刃VomenWith birth plans sometimes did not trust their profes、Sional experience and sN11S, jrritation among obstetricUnit sta丘 arose from a sense that women 、vere overlyOpumistic and inaccurate in their expedations for laborand their ability to control proceedings. Both 今roups ofmid、viveS 企lt that certain consumer advocacy groupsm唱ht be presenting midwivesin a negauvelight, whichWasin丑Uendng womeds birth plan requests.

In some st口dies, health care professionals identi、aed practical chaⅡenges to helping women completeand use birth plans. V、1hit血rd et al.(2014) describe this

in terms of health care professionals not being givenadequate time and training to ensure they are able toexplore options, wishes, and preferences suf6CiendyWith women during antenatalappointments. Yam et al、(2007) found caregivers expressing doubts about thefeasibility of introdudng birth plans into antenatal careWithout the stron8 bacMng of hospital administratorsWho would commit to providing physicalspace and6nandalincentives necessary for successfulimplemen、tation. Too a996a) describes oTganjzationalconstraintsinhibiting midwives from suppoTting women to usetheir birth plans in lab0二 induding lack of resourcesand facilities, sta丘 Shortages, and hospital polides andProtocols.

Although concerns about birth plans are signi6、Cant and wide ranging, studies also describe severalpos、itive 6ndings,1argely related to areas such as maternal

education opportunities (Aragon et al.,2013; TO0,1996a), enhanced communication between women and

health care professionals (Aragon et al.,2013; Doherty,2003; Grant, et al.,2010; TO0,1996a), shared dedsion

making (Ara80n et al.,2013; TO0,1996a), and individu・alized care provision (TO0,1996a). Health care practi・tionersidenti6ed birth plans as a means ofempowerinσWomen in an idealscenario:1fwomen are able to gainawareness and understanding of choices and optionsaround labor and birth throU名h discussions with theirCaregivers, then ultimately, birth plans might be seenas a means of improving the experience of childbirt11(Aragon et al.,2013; TO0,1996a; Yam et al.,2007).

、Nomen'S Experiences and opini0那 of 引rth plans

Appendix c detailsthe 22 induded studiesthat addressWomelfs experiences and opinions ofbirth plans. A今ain,the majority of studies have been undertaken outsidethe unitedKingdom andin care settings where obstetricmodels of childbirth are the norm. study method010・gies cover quantitative, qualjtative, and mixed methodsapproaches,induding two randomized contr011ed trials(Kuo et al.,2010; Magoma et al.,2013).1n a11 Studiesthat included an intervention and a control group, theintervention took the form ofpartidpants completing abirth plan durin8 the antenatalperiod (Berg, Lundgren,& Lindmark,2003; Kuo et al.,2010;王Undgren, Berg,&上indmark,2003; Magoma et al.,2013; springer,1996).

~vomen appearto have mixedviews ofbirth plans,、vith several benefits and disadvantages identi丘ed inthe studies revie、ved here. positive perceptions Nvere

Centered on increased awareness of available options

(Aragon et al.,2013; Brown & Lumley,1998; Magomaet al.,2013; Moote & Hopper,1995; TO0,1996b); explo・ration, dari6Cation, and discussion of preferences andWishes (Moore & Hopper,1995; peart,2004; penne11,Salo・coombs, Herring, spielman,& Fecho,2011;~vhitford et al.,2014); and effective and open commu・nication with health care professionals (Aragon et al.,2013; Doherty、 2003; peart,2004; penne11 et al.,2011;Moore & Hopper,1995; xvhitford et al.,2014). womenin these studies believed that bitth plans have thePotentialto enhance their sense ofinvolvement in andContr010ver dedsion maNng in labor and birth (Brown& Lumley,199& Kuo et al.,2010; Lewis et al.,2014; Yamet al.,2007) through opportunities to document wishesand prefetences (Ekeocha & Jackson,1985; Yam et al.,2007). This preparation and shared approach to dedsionmakingmighthelp women feelmorecon丘dent(Aragon

et al.,2013; Moore & Hopper,1995) and reduce atⅨietyaround labor and birth (Ekeocha & jackson,1985;

SPTin8er,1996).~vhether these optimal circumstances result in a

Positive experience of childbirth is a contested issue.Kuo et al.(201の UndeTtook a single・blind randomizedContr0Ⅱed trial, in which the intervention was comple・tion ofa birth plan. These authors found no differencebetween 名roups in antenatal birth expectations but aSignificant difference in de留rees offU1丘11ment, mastery,andpartidpation amongwomen who completed a birthPlan. The study conduded that birth plans constitute ameans ofcommunication between women and health

Care professionals, which aⅡ0、vs women to partidpatein the dedsion・making process fortheir own care. simi・Iarly, in a prospective cohort study, penneⅡ et al.(2011)found that 凡Vomen completing a birth plan believedtheir biTth experience was enhanced because of a senseOf contr01, darincauon of thoughts, and improvedCommunication with health care providers. Notably,this favorable vjew of birth plans was held even whenPteferences were not fU1飢led or where complicationsOccurred. These positive 丘ndings support the viewthat birth plans are valuable as an educauon andCommunication to01.

Howeve二 two swedish papers describe less favor・able outcomes assodated with completjng a birth planduring the antenatal period (Berg et al.,2003; Lundgrenet al.,2003).1n labor, women who had been 0丘ered

the chance t0 凡Vrite a birth plan were found to be lessSatiS6ed witb their interaction with the 6rst midwife

they encountered (Lundgren et al.,2003), and 、vomenat high risk for complications felt an increased nega・tivity toward childbirth a丑er completing a birth plan(Berg et al.,2003). This is a contrast with the 6ndingsdescribed by springer a996), who found no negativeimpact in a study of womeds anxiety f0ⅡOwing anintervention of、vriung a bitth plan, and,in fact, a trendtoward a reduction in state a11Xiety. Berg et al.(2003)recommend caution in advocatin今 birth plans as a nor・malpart ofantenatal care because it may be that certaingroups of刃Vomen^Particularlythose consideredathighrisk for complications-are made to feelincreasin81yanxious if potential outcomes and necessary interven・tions are hi8hlighted.

These mixed 丘ndin名S on whether birth plansenhance womeds experiences of childbirth reaed sev・etal concerns raised in the reviewed studies. AlthoU3hbirth plans have been described as helP鎚 in wom・eds explorauons of options and preferences for laborand birth, jn some studies,、vomen describe a lack

Birth plans Diva// et a/.161

162 Birth plans Diva// et a/

Of awareness as to 、vhat birth plans are (Grant et al.,

2010; whitford et al.,2014), a lack of opportunity orProfessional support to complete birth plans (lewiset al.,2014; whitford et al.,2014) and a cha11engerelated to the langua8e used in formulating birth plans(peart,2004). Three studies (peart,2004; TO0,1996b;

Xvhitford et al.,2014) also found that women, althoughaware of birth plans, were reludant to "over plan;' cit、ing the unpredictable nature of labor and birth. ot11er

Studies echo this concern, W北h women believing anjnsuf6denuy aexible approach to labor and unrealis、tic expedations may result in a loss of controlshould

events necessitate a change in plans (Ara号on et al.,2013;Cook & 1'oomis,2012).

Malacrida and Boulton (2014) and Too a996b)take a criucal view on ideas of contr01, choice, and

empowerment,、vhiC11 are centralto the encouragementOf birth plans at policy level. These authors suggestthat such concepts are i11Usory,、vith Malacrida andBoulton conduding thatitiS 血e act oflabelin3 Womenas "consumers" of childbjrth which is problematic:Althoughwomenmayfeeltheyareempoweredthroughthe ad offormulaung a birth plan, this empowermentis lost in the chaⅡenge of enactin牙 the plan in a highlymedicalized model ofchildbirth. Again, the net resultisa sense of disappointment or personal failure if eventsdo not f0Ⅱ0、V 、vomenls stated preferences and plans.

Health care professionals are crudalto helpingIvomen understand birth processes (peart,2004; TO0,1996b), and centralto this is ensuring e丘ective inter、action and communication throU宮hout the childbear、in8 episode (Too et al.,1996b;＼Nhitford et al.,2014).Although studies have described the positive views ofWomen in relation to communicauon with bealth care

Professionals during the formulauon of birth plans,Women are sensitiveto the a廿itudes ofcaregivers duringIabor. severalstudies have suggested that w'omelゞs senseOfcontrolmaybelost duringlaborifthey企elcare8Nersdo not pay a廿ention to or resped their birth plans(Brown & Lumley,1998; TO0,1996b; whitford et al.,2014;xvhitford & H辺an,1998).

(Aragon et al.,2013; Brown & Lumley,199& Magomaet al.,2013; Moore & Hopper,1995; penneⅡ et al.,2011; TO0,1996a; xvhitford & HⅡlan,1998); a means

Of enhandng communication between women and

their caregivers antenataⅡy and during labor (Ara80net al.,2013; Doherty、 2010; Ekeocha & 1ackson,1985;Grant et al.,2010; Moore & Hopper,1995; peart,2004;PenneⅡ et al.,2011; TO0,1996a,1996b;~vhitford et al.,

2014; Yam et al.,2007); and an effective metbod of

increasing womeds sense of contr01, empowerment,,

autonomy, and involvement during childbirth (Aragonet al.,2013; Brown & Lumley,1998; Doherty,2010; KUOet al.,2010; Lewis et al.,2014; Moore & Hopper,1995;Owens,2009; penneⅡ et al.,2011; TO0,1996a; Yam et al.,2007).

In an ideal context, these themes can be linked

together to produce a scenari0 元Vhere formulatin留 abirth plan is a highly positive experience.1n such aScenario, the process of c0Ⅱaboration supports womento explore options, preferences, and lvishes, while atthe same time enabling health care pr0企Ssionals toadequately describe local options and potentialinter、Ventionsin labor. communication between women al)d

theircaregiversis enhanced through this oppor加nity toexplore options and make informed dedsions aroundIabor and birth. This posiuve experience is continuedduring labor and birth because women feel adequatelyPrepared for 刃Vhat is often an unpredictable course ofevents, and caregivers are assured that women retain anecessary degree ofaexibiHty and trust. womelfs senseOfcontrol can be maintained in the face ofunexpectedChanges because of the on今oing communication withand support from health care professionals.

In contrast to the positive scenario describedearlier, studies in this review have identi6ed sevetal

ChaⅡen8es assodated with formulating and using birthPlans. Again, there is a convergence in the vie刃Vs andexperiences of women and health care professionals,With both 号roups describing chaⅡenges relatin8 to theOpportunity to complete birth plans during antenatalCare appointments (Grant et al.,2010; 1.ewis et al.,2014;

XN'hitford et al.,2014; Yam et al.,2007); the impact ofan inaexible approach or unrealistic expectations onWomeds experiences oflabor and birth (Aragon et al.,2013; carlton et al.,2009; Thompson,2013; TO0,1996a);and a concern that choice may be more policy rhetoricthan clinical reality, resulting in a false sense of contr01(Aragon et al.,2013; cook & Loomis,2012; Malacrida& Boulton,2014; peart,2004; TO0,1996b; xuhitford

& HiⅡan,1998). However, the reasons behind these

Cha11enges differ bet、veen the tw0 旦roups. For health

Women andhealth careptofessionals holdsimilarbeliefsabout the potential bene6ts of birth plans. As we havedescribed in our summary ofthe major themes arising丘om existingliterature, birth plans are perceived to be aPotentiaⅡyvaluableeducauon and dedsion、maMngto01

Relationships Between 、1Vomen andHealth care professionals

Care professionals, there is a process of negotiation inattemptin号 to support womeds wishes and preferencesIvhile at the same time operating within organiza・tional and professional strictures (Thompson,2013;TO0,1996a; welsh & S抑10n,2014). For women, how・ever, cha11enges lie in negotiatin8 a discourse of choiceand personalized care within structures that actuaⅡyIimit available choices and failto promote a model ofCare in which women are able to fUⅡy develop relauon・Ships with caregivers from pregnancyto labor and birth(Malacrida & Boulton,2014; owens,2009; TO0,1996b).

凡Vithin the literature reviewed here, birth plansbave not been shown to adversely a丘ect obstetricOutcomes. This may reinforce the view that negativePerceptions held by some health care professionals lackany stron8 foundation in evidence. on the other hand,it may reaed the sma11body ofresearch in this area.1neither case, this does not alter the fact that caregivers'Views may inauence their relationships with and careOfwomen who present in labor with birth plans. Mid・Ivives and other caregivers have expressed the view thatbirth plans can be a source of irritation (carlton et al.,2009; TO0,1996a; welsh & S抑)on,2014), and this isSupported by womeds views that,in some cases, care・givers do not pay adequate a廿ention to thejr plans andPreferences during labor and birth (Brown & Lumley,1998; peart,2004; TO0,1996b;＼Nhitford & HiⅡan,1998)

and do not necessarily support them in their attemptsto discusstheir wishes and formulate birth plans duringPregnancy (Lewis et al.,2014; lvhitford et al.,2014).

The phrase "birth planl' itself may be consideredProblematic.1n this article, concerns、vere raised in bothgroups.~×10men in some cases considered it dif負Cultto make plans based on the concern that they cannotknowwhattheirpreferences mightbein relation to suchOptions as pain relief, priorto experiendng labor (peart,2004; TO0,1996b; xvhitford et al.,2014). Furthermore,

Plans are cha11enging in the face of the unpredictablenature oflabor and birth, and 、vomen considered theymisht be at 3reater risk of disappointment and a senseOffailure ifaplan could notbe f0ⅡOwed during thebirthexperience (Ara30n et al.,2013; cook & Loomis,2012;Malacrida & Boulton,2014; pea式,2004). This theme

、vas echoed in the vieNvs of health care professionals,Ivho expressed concerns about what they consideredOverly rigid plans (Aragon et al.,2013; carlton et al.,2009; TO0,1996a). H0刃Vever, caregivers voiced a 会.1rtherConcern, believing that reduced flexibility may meanWomen are at risk for refusing interventions designedto ensure the safety of themselves and their babies(Thompson,2013; TO0,1996a).

In the study by welsh and S沖on (2014), alterna・tives to the term hirthpla11S were suggested. Health careProfessionals believe alternauves such as "birth prefer・ences" or "birth wishes" may address the unpredictablenature oflabor and birth and sho、v recognition that attimes women may be advised to accept obstetric inter・Ventions beyond the ideals set outin their birth plans.

Birth plans Diva// et a/.163

ⅡMnA110NS

1、1though everye任orthas beenmadeto searchforpapersSystematicaⅡy and 仕10roughly, it is always possible 壮)atHterature in lan今Uages other tha11 English have beenmissed or exduded. studies reviewed here have been

Undertaken jn many dj丘erent contexts and care se廿i11gsand have employed a range of research method010gies.Furthermore, although we have not undertaken a criticalanalysis oftheinduded studies, wehave foundlimitationsin terms ofl'eportin8. For example,some S加dies describethe completion ofa birth plan asthe intervention but didnotindude the birth plan in 壮)eir reports. However,杜lisreview 0丘ers a11 UP・to・date discussion ofkey 血emes inrelation to the formulation and use jn labor ofbirth plansand provides a basis fot a 6、1ture research a8enda.

CONC【.USION

A]though some health care professionals believe 北 tobe the case, this revie、v has found thatthere is li杜le evi・

dence that birth plans per se resultin increased obstetticinterventions or poor outcomes. HO、vever, the reviewCan offer Httle robust evidence that birth plans in them・Selves i111Prove womeds experiences oflabor and birth.Studies have identi負ed both bene丘ts and cha11enges tothe construction and use of birth plans, and there isevidence ofcontinued cha11en号es for health care profes・Sionals in assisting and supportin名 Women in maNngand enacting choices.

Supporting cboice remains a commitment inmaternity care. several factors appear necessary if birthPlans are to achieve their potential value in relation toWomeds choiceand informed dedsion maMng in child・birth. AntenataⅡy, women and health care professionalsneed to work together to explore and discuss availableOptions. This requires time, space and adequate train・ing for caregivers, and rec0号nition of the (sometimes)Unpredictable nature of labor and birth on the part ofWomen. Flexibility is dearly required from both parues,and or号ani2ations need to match the rhetoric of choice

164 Bidh plans Diva// et a/

With realsupportin terms oftime and h山nan resources

to carryoutthis activity A chal)8e oftermin010gymaybenecessaryto reaedthecomple幻廿es ofP1αππiれgforlabor.

In labor, health care professionals must rec0号nlze

and resped womeTゞs stated preferenceS 肌d wishes andShow atl understal)ding that, on the evidence available,bir[h P1釘Is do not h〕crease the risk ofobstetric interven_

tion. A continued aexibility and open discussion is nec、

essary between women and 廿leir caregivers, particularlyin the face of unexpeded but necessary cha11名es duringIabor al〕d birth, based on evidence that 血dusion in ded_

Sion making is more likelyto resultin women retai11ing aSense ofcontrolandulumatelyapositivebirth e>中erience.

Implications for Further Research

No systemauc review ofthe use ofbirth plans or theirimpad on clinical and psychosodal(e.g., self、ef6Cacy)Outcomes has yet been undertaken, and this would be a

Valuable addition to the currentbodyofliterature. Thereis a 今rowing achlowledgement ofwomeds fear oflab0二

and future work could address the place ofbirth plansin this context. Research might also address the review丘ndings around womeds feeⅡn8S when plans made inthe antenatal period are not enaded in labor.

FutuTe research might address alternative W'ays

Of exploring and discussing women's labor and birthPreferences during the antenatal period, for example,through an explorauon ofwhether there is a bene丘tin

moving a、vayfrom the termin010gy of"birth plans, anddiscovering whether there is an optimum time and set_ting in which such discussion mighttake place.

Given this review、 discussion ofchaⅡenges fadnghealth care professionals in supporting wome11's prefer、ences,6.1ture research could address these chaⅡenges todetermine their impad on caregivers' overaⅡ Views onbirth platls.

Fina11y, research into birth plans in the context ofmidwifery units would be of contemporary relevance,given u.K. policy suppor廿n8 midwifery units as arecommended place of birth for women with low、Tisk

Pre8nandes (B,OCMehurst et al.,2011; NICE,2014).

Aragon, M., chhoa, E., Dayan, R., Klufun名er, A.,王ohn, Z.,&Buhler, K.(2013). perspectives ofexpectant women andhealthcare ptoviders onbirthplans.j0川π41qf'obstetガCS4πd Gyπαec0108y Cαπad4,35al),979-985.

Baumeister, R. E,& Leary, M. R. a997). writin8 narrative lit、erature reviews. Review qj'Geπer41 Psych010gy,1(3),311.

Beech, B'(20ID. cha11engin8 the medicalisation of birth.AIMS /ourπ41,23(2). Retrieved from h杜P:ノノaims.org.uk/jouTnal/V0123N02/chaⅡengingmedicalisation'htm

Berg, M., Lundgren,1.,& Lindmark, G.(2003). childbirth

experience in women at high risk:1Sitimproved by useOfabirth plan? Thejour11αlqf'periπ4talEduC4ti0π,12(2),

Afshar, Y;, Mei, j., wong, M., Gre号orヌ K.,鬮Patrick s.,&Esak0丘, T.(2015). The role of廿le birth plan in obstetricaland neonatal outcomes and bir仕l e)甲erience satisfaction.A"1eriC41110ur11αIQf'OBstetricS 6 Gyπec010g,212(D, S282.

BrocMehurst,R,Hardy,R,H0ⅡOweⅡ,}.,1'inse11,L.,Macfarlane,A.,Mccourt, C.,... stewaTt, M.(20ID. perinat祉即d mater、

naloutcomesbyP1飢nedplaceofbirⅡ)forhealthywomenMth low risk pregnaTldes: The bir壮Iplace 加 En号latldnationalprospedive cohortstudy BM/,343, d7400,

Brown, S.1.,& Lumley, j.(1998). communication and

dedsion・maMng in labour: Do bjrth plans make adifference? Health Exped4ti0那,1(2),106-116

Carlton, T., caⅡister, L., christiaens, G.,& walker, D.(2009).Labor and delivery nurses' perceptions of caring forChildbearing women in nurse・managed bjrthing units.MCN. TheA1πeriC4π jotιr11αlqf'M4t臼'πalchildNursiπ8,34(D,50-56.

Cook, K.,& Loomis, C.(2012). The impact of choice andContr010n womeds childbirth experiences. The lourπ41ψPeガ加t"1Edumti0π,21(3),158-168.

Davis・Floyd, R. a994). The technocratic body. AmericanChildbirth as cultural expression. sodal science 6Mediciπe,38(8),Ⅱ25-1140.

Deering, M. A., HeⅡer, J., MCGaha, K., Heaton, j.,& satin, A.1.(2006). patients presentin名With birth plansin a militarytertiary care hospital: A descriP廿Ve stLldy of plans andOutcomes, Military Mediciπe,171(8),フ78-780.

Deerin郵 S. H., zaret, j., MCGaha, K,,& satin, A.1.(2007).Patients presenting with birth plans: A case、contr01Study ofdelivery outcomes. The lour11αlqf'ReproductiveMediciHe,52(1の,884-887.

Department of Health.(2003). Building on the best: choice,responsiveness and equity in the NHS. He41th Exped4、ti011S,フ(2),176-179. Retrieved from ht中ゾノWebarchivenationalarchives.gov.uk/20B0107105354/, http:ノ/WWWdh.gov.uk/prod_consum_dh培roups/dh_digjtalassets/@dh/@en/documents/di8italassevdh_4068400.pdf

Dohertyi M. E.(2003). Birth plan dedsion、maMng. pat、terns of interadion.111terπαti011α110ur1141 qf' childhirth三duC4ti0π,18(2),27-33.

Doherty、M.E.(201の. MidwiferyC雛e. Re丑edi0船ofmidwiferydjents. The /'our1141 qf'perl'"4talEdUι4h'011,19(4),41-51

1-15

REFERENCES

Ekeocha, C. E.,& 1ackson, P.(1985). The 'birth planl experi・ence. B/OG,92(D,97-101.

Grant, R., sueda, A.,& Kaneshiro, B.(201の、 Expert opinion

VS. patient perception of obstetrical outcomes in labor・ing women with birth plans. The loun141 qj'Reproduc・tive MediC加e,55(1-2),31-35.

Green, B. N.,}ohnson c、 D.,& Adams, A.(2006). writingnarrative literature revie、vs for peer・revielved journalsSecrets of the trade、 jourπαl qf' chiropr4dic Mediciπe,5(3),101-117.

Hadar, E., Raban,0., Gal, B., Yogev, Y.,& Me1血ed, N.(2012).Obstetricaloutcome in women with self・prepared birth

Plan. The lour1141 Qf'Mater11α1・Feta16 Ne0παt41 Medi・dπe,25(1の,2055-2057

Hidalgo、Lopezosa, P., Rodriguez・Borrego, M. A.,& Muiioz・ViⅡanueva, M. C.(2013). Are birth plans assodated

With improved maternal or neonatal outcomes? MCN.The A111ericaH lour11αlqf'Mater1141 Child NUおiπg,38(3),150-156.

Jones, C.,1Saacs, J., chen8, Y.,& caughey, A.(2009). whatisthe assodation bet、veen birth plan characteristics and

Pregnancy outcomes? A1πeriCαπ jourπ41 qけ obstetガCS4πd Gyπec010gy,201(6), S126.

Jones, M. H., Barik, S., Mangune, H' H.,)ones, P., Gregory, S. J.,

&spring,1. E.(1998)、 Do birth plans adversely a丘edtheOutcome of labou【? Bガtish jour11αl qf'Midwifery,6(D,38-41

Kit力ng.む S.(2005). Th'politi"げbi光h. EdiobU熔h, S'otlond.Elsevier.

KUO, S. C., Lin, K. C., HSU, C. H., Yang, C. C., chang, M. Y.,Tsao, C. M.,& Lin,上. C.(201の. Evaluation ofthe e丘ects

Of a birth plan on Taiwanese womenls childbirth expe・riences, control and expedauonS 丘1161ment: A ran-domised contr011ed trial.111ter114ti011α1 /our1141 qf

Nursiπ8' studies,47(フ),806-814

Lewis, L., Hauck, Y 上., Ntchie, S., Barnett, L., Nunan, H.,&

Rivers, C.(2014). Austra}ian womeds perception of

their pteparation for and actual experience of a recentKheduledcoosaro.nbitth.Midwifery,30(3), eBI-0136.

Lothian,1.(2006). Birth plans. The good, the bad, and thefuture.10ur1141 qf' obstehic, Gy11ec0108ic,α11d Ne0πatalN併Siπg,35(2),295-303.

Lund8ren,1., Ber8, M.,&上indmark, G.(2003).1S the child・birth experience improved by a birth plan? 10urπ41 qfMidWザ町y 6・ W0抗."1H即lth,48(5),322-328.

Ma号oma, M., Requejo,1., campbe11,0., cousens, S., Merialdi,M.,& Fi1ゆPi, V (2013). The effediveness of birthPlans in increasin3 Use of sN11ed care at delivery andPostnatalcare in ruralTanzania: A duster randomisedtrial.乃OpiC41 Mediciπe 61Hter11αti0παI He41th,18(4),435-443.

Malacrida, C.,& Boulton, T.(2014). The best laid plans?

Wome11's choices, expedations and experiences inChildbirth. Health,18(D,41-59

Moore, M.,& Hoppe二 U.(1995). Do birth plans empowerWomen? Evaluationofahospitalbirthplan. Birth,22(D,9-36.

Nationa1 1nstitute for Health and care Exce11ence.(2008).

A11teπαt41 Carejor U11C01πPliC4tedpre811411Cies. Retrievedfrom https://WWW.nice.org.uk/guidance/cg62

Nationa11nstitute for Health and care ExceⅡence.(2014).

111tr4P4rtU1π C4re: C4ル qf' he41thy w0111e11 411d theirb46ies duriHg childhi光h. Retrieved from https:ノ/WWW.nice.org.uk/guidance/C名190

Owens, K. H.(2009). confronting rhetorical disability:A critical analysis ofwomelゞs birth plans. Wガtte11 C0111・IHU11iC4ti011,26,247-272.

Peart, K.(2004). Birth planning-is it bene丘dalto pregnantWomen? Austr41ia1110urπαI Qf'Midwifery,17(D,27-29.

Penne11, A., salo・coombs, V;, Herring, A., spielman, F.,&Fecho, K.(20ID. Anesthesia and analgesia・related

Preferences and outcomes of women who have birthPI0那. j0川"41 qf'Midwif'討y 6 W0加πI H."1th,56(4),376-381.

Sheridan, C. P., YeMnni,1., oyeye, G., ogunleye, K, oluyede,Higgins,1. R.(2011). compar・G.,0'SU11ivan, K.,

ing birth plan preferences among lrish and Nige・rian women、 British lour11αl qf' Midwifery,19(3),172-17フ.

SimMn, P.(2007)、 Birthplans: After25years,women stiⅡWantto be heard. Birth,34(D,49-51.

Smoleniec, J. S.,& j狐es, D. K. a992). Does having a birth

Plan a丘ect operative delivery rate? jour1141 Qf'obstetriιS4"d Gy"4ec0108y,12(6),394-397.

Springer, D. a996). Birth plans: The effed on anxiety加 Preg・na11t women.1πter11αti011a110ur1141 Q1丁Childhirth EduC4・ti0π,11(3),20-25.

Thompson, A.(2013). Midwives' experiences of caring forWomen whose requests are not within clinical polidesand guidelines. Bガhsh lour11al qf' Midwifery,21(8),564-570.

TO0, S. K. a996a). Do birthplans empower women? A S加dyOfmidwives' vie、VS、 Nursi11g st4πdard,10(32),44-48.

TO0, S. K.(1996b). Do birthplans empower women? A studyOftheir vie、VS. N川Sing stαれdard,10(31),33-37.

Welsh,1. V,& S川on, A. G,(2014). unique and proformabirth plans: A qualitative exploration of midwives'0"pai即鄭. Mdwif町y,30(フ),885-891.

White、corey, S.(2013). Bir血 Plans. Ticketsto the oR? MCNThe A柳eriCαπ journ41ql'M4te柳al child Nursiπg,38(5),268-273.

Birth plans Diva// et a/.165

166 Birth plans Diva// et a/

Whitford, H. M、, EnNistle, V A.,van Teij1血8en, E., Aitchison,R E., Davidson, T., Humphrey, T.,& TUCRer,j. S.(2014)、Use of a birth plan within woman、held maternityrecords: A qualitative study with women and sta丘 inNortheast scotland. Birth,41(3),283-289.

Whitford, H. M.,& HiⅡan, E. M. a998). womelゞs perceptionsOfbirth plan■. Midwif'.,y,14(4),248-253.

Yaln, E. A., Grossman, A. A., Goldman, L. A.,& Garcia, S. G(2007).1ntrodudng birth plans in Mexico: An explor、atory study in a hospitalserⅥnglow、income MexicansBirth,34(1),42-48.

Correspondence regarding this article should be dirededto Bernie DivaⅡ, phD, MA, Enhanced Diploma prere istra_廿on Midwjfery, university of Nottingham, Division of Mid_Wぜay, scho010f Health sciences, Floor 12, Tower Buildin ,

Universitypark, Nottingham, Notunghalnshire, united King、dom NG72RD. E・mail: bernadeせe.divaⅡ@n0廿ingh如1.ac.uk

Bernie Diva11, research feⅡOwin maternitycare, phD, MA,enha11Ced diplomapreregistration midMferヌ Division ofMidMfery, scho010fHea1廿Isdences, university ofN0廿血8haln.

Professor Helen spjby, professor ofmidWぜery, Mphil, RM,Division ofMidWぜay, scho010fHealth sciences, universityOfNottingham.

Julie Roberts, research feⅡOw jn maternity care, phD, MA,BSC, Division ofMidwifery, scho010fHealth sciences,University ofN0廿加号haln.

Denis walsh, assodate professor in midwifery, phD, RM,Division ofMidwifeTy, scho010fHealth sdences, universityOfNotungham.

APPENDIXA

AUTHORSAND SモπINC

Afshar et al.(2015)

United states of America

Thelmpad ofBirth pla11S on obstetricoutcomes

METHOD010CY, METHODS,AND SAMP圧 SIZE

Hidalgo・Lopezosa et al.(2013)Spain

Quantitative

Prospedive contr011ed Mal143 Cases,157 Controls

ト(adar et al.(2012)

Israel

jones et al.(2009)United Sねtes of America

Quantitative

Retrospective case control study52 Cases,130 controls

HNDINCS

. No significant di仟erence in Lscs rate, use of lv ana18esia,0「 1ength of labor

. Adjusting for a8e, primigravid women Ⅷth a birth plan lessIike1γ to deliver vagina11γ

. Yvom印Ⅷth bir小 Plan5 1ess like1γ to have pitocinaugmentation, ARM, or use epidurals

. vvomen with bir小 Plans 、vere less satisfied and described abir小 experience they did not exped, felt less in contr01.

. vvomen with bir小 Plans 、vere older and educated to ah1月her level.

. NO S唱nificant di仟erence bet~veen ca5e5 and controls forany obstetric outcomes of 5・min AP8ar scores

. vvomen with birth plans less like1γ to have a baby ⅧthCord blood pH belo~V 7.24

. vvomen vvith birth plans more like1γ to use epidurals orhave fiTst・ and/or 5econd・degree perlnealtear

. vvomen witb birth plans less likely to undergo intrapartumLscs or use Ⅳ ana1名esia

. vvom印 With birth plans more like1γ to be primi8ravid andaged 35 γear50r older, white, and of higher 50cioeco・nomlc status

. Higherrates ofslo、v adive labor and pr010nged ROM

. More 11ke1γ to have spontaneous va81nal birth

. Le55 11kely to use epiclurals or have operative va8inal birlh

. No di仟erence in Lscs rate5, third・ arw/orf0Ⅲth・degree[ears, PPH, or chorioamnionitis rates

. No di仟erences in Lscs or episiotomy rates

. vvom印 With birth plans less like1γ to use epiclurals inVaginal birth

. vvomen with bir小 Plans we『e g印era11y older and weueducated.

. Mean bir小 Plan length waS 19 Pages

. M05t common requesls: being mobile in labor, noepislotomy, no pain medicatlons, no epidural

. Despite plans to avoid an el)idural, most dlanged theirminds

. primi8ravid 、vomen more Ⅱkely to have a bir小 Plan

. vvomen with birth plans had increased rates of instrumen・tal birth and LSCS

. vvomen with birth plans had lower epidural and sponねne・Ous va8inal birth rates

. women Ⅷth bir小 Plans 、べere of highersocioeconomicStatus.

. Those with birth plans genera11y requested no "obstetrlcInterfefence" and "natural" childbirth

. vvomen wlth birth plans more 11kely to use no analgesia,TENS, or Entonox

. women Ⅷth birth plans less like1γ to use epidural orPethidine

. No di仟erence in operatlve delivery rate bet~veen 8roups

Quantitative

Retrospedlve case control study154 Cases,462 Controls

Deering et al.(2007)United states of America

Birth plans Diva// et a/.167

Deering et al.(2006)United states of America

Quan蹴ative

Prospedive cohort studySample size:1,285; 90 with

bir[h plans

jones et al.(1998)

United Kingdom

Quantitative

Case control study64 Cases,128 Controls

QuantitativeEvaluation of note5

67 ~vomen with birth plans

Smoleniec and jame5 (1992)

United Kingdom

QuantitativeEvaluation of case notes

Sample size:1,172 10W・ri5kWomen; 42 Vvith birth plans

Quantitative

Retrospedive ca5e control study62 Ca5es,62 Controls

168 Birth plans Diva// et a/

APPENDIXB

AUTHORSAND sfTTINC

We15h and symon (2014)Unlted Kingdom

Health care practitioners'opinions andEゆerlences

METHODOLOCY, MモτHODS,AND PARTICIPANIS HNDINCS

QuaⅡtative, focus groupmtervle、1VS

Nlne midvvive5

Whitford et al.(2014)

United Kingdom

Thompson (2013)United Kin8dom

Qualitative, exploratoryintervieW5

24 Sta仟

Ara80n et al.(2013)Canada

QuaⅡlative, semistructuredintervie~VS

10 midwives

Doherty (2003)United states of America

Termin0108γ Can be misleading:"planning".

birth, and problemsWith "unique" 1)1ans that rejed policies and Procedures becomin8"5tandardized"

' Blrth plan js a source of irrltation for mid、vives' Birth plan5 Put pressure on midwives

' sta仟 8eneraⅡy positive about birth plan5 in handheld notesRec08Π川on ofthe need to supportvvomen vvith bi州リ)1an completion

.

Sta仟 need time and trainin8 to better 、Nork with vvomen,8ivin.

them confidence lo arⅡCulate concem5 and document values

Women made themselve5 "hi8h rlsk" by not ad1氾ring to policies.

Professional/organi2ational conflid for midwive5 in these.

Clrcumstances

' Midwives' negotiation role bet゛/een ob5tetricians and 、~,omen; 1。SSOf professional contr01

Anxiety about addressin8 、vomen's wishes and safety of mother.

and baby. vvomen'5 UnderSねnding ofri5k

Birth plans valuable for comrnunication and education; inforn氾d.

decision makin8;~vomen's control and empowerment; fostering aPositive outlook loYvard birth

POSS山ility of unrealistic exl)edations, inflexibility,.

false sense of

Contr01, risk of disappolntn氾nt for women

1勺in mana8ement, the m05t common1γ Cited reason for a birlh plan,.

Plus comfort measures, postpartum preferences, control atmosphere' Minority routine1γ discussed birth P1引Is wi小、vomen; most

believed birth plans not frequen11γ Used.43ツ0 believed Internet wa5 Primary resource for paⅡents dra介ing a

birth plan

Mosl believed bir小 Plans aS50ciated wi(h poor 01)stetrlc outcomes,.

includin8 LSCS,1)PH, episiotomy, C1扣rioamnionitis' Most felt slmng1γ that bir小 Plans ad as a "jinx"

Negative feelin8S of lwrses associated wl【h rigidi1γ of blrth plans.

Complications considered more 喩ely with a lack of parenねl flexibilit.

Bir小 Plans can improve 小e chⅡdbirth experience for 、vomen and.

HCPS

' Facilities often lack P11ysica1 5Pace and financialincentives for birthPlan pr08ram5

' Doubts expl'essed re: commitment of hospital admini5trators toProvidlng space and incentlves for 5UcceS5fU11mplementatlon.

' Tlvee dlstjnd pattems ofinteradion bet、veen nurse、midwives aηdWonlen

' 1nteradion varied bet、veen pattems of diredives (nurse、midv、/ifedireding as Yvomen had not yet formulated a plan); pattems ofemergence (birth plan evolvin8, nurse,midv、/ife more guided by、vomen s concerns and questions); and patterns of vaⅡdation 山irthPlan formulated already, nurse・midwife 0仟ering validation andStressing need for flexibiⅡty)

'距壮em of validation seen in 11 0ut of 20 cases

' Birth plans can be beneficialto b0小 Vvomen and mid、vive5: C。m_munication of preferences; education; adive partlC中ation in care;indlvldua11Zed care

Timing of birth l)1an W爪ing/formulatingCha11e"8es of sLlpportin8 Women^giving up contr01 小enおelves;Stereotγ1〕ing of 、vomen;、vomen making rigid/1nflexible plans;hierarchical or8anizational and professional strudures

Qualitative, intervie、VS18 nurses

Crant, sueda, and

Kane5hiro (2010)United S捻les ofAmerica

Mixed methods, queSⅡonnaire1 10 care providers, including

nurses, CPS, midwlves,doulas, obslelricians

Qua1北aⅡVe,1ntervie、VS10 midⅥ,ives

Qualitatlve, intervie、V5Seven nurses, social ~vorkers

and physicians

.

Carlton et al.(2009)United states of America

Too a 996a)

United Kingdom

Yam et al.(2007)Nlexico

Quantitative, survey103 nurse5 and physician5

Qualitative, analysis ofinteraction patterns

Eight nur5e・midwives;20 vvomen

.

Women'S Eゆeriences and opinionsAPPENDIXC

AUTHORSAND SETTINC

Lewis et al.(2014)

Australia

Whitford et al.(2014)

United Kin8dom

MEIHODSAND PARTICIPANTS

Mixed methods; P05tal surveyand intervieⅥ,S

117 Surveys,38 intervievvs

Ara80n et al.(2013)Canada

QuaⅡtative interviews

42 Participants

HNDINCS

. Benefits of completing a birth plan ahead of 5ChecluledCe5arean sedion (SCS): guiding their caTe (59ツ0), fee11nginvolved and included in their scs (839、0)

. some feltthey had been denled option to plan for bir小一viami5Sed opportunity

.18norin80r breaklng the "contract"(b1此h plan) 1ed to animosity

. Havin8 Someone enforce the birth plan Yvould be useful andempo~verlng

.1n叩ortance of~vhole team respedin目 idea of bir小 Plans

. vvomen generaⅡγ Positive about provision of birth planSectlon 川 notes

. Benefits: opportunity to hi8h1唱ht preferences, enhanceCommunication, stimulate di5CU5Slons, address anxietie5

. cha11enges:1ack of avvareneS50f opportunity; not under・Standlng purpose of birth plan5; unable to access support tobecome confidentln choices; reluctance to plan too much

. Bir小 Plans valuable for communication and education,enhanced autonomy, inforrned decision making, positiveOutlook toward birth, fee11n8S of control and empowerment

. cha11en目es: risk of disappointment if plan5 CannoH)e f0110wed;Unrealistic expedations; inflexibility; false sense of contr01

. Key elements: pain management, comfort measures, postna-tal preferences, contr010f atmosphere

. Lon8er consU1ねtion in intervention group (average 40 min vs20 min in contr01); greater di5Cussion of preferred delivery siteand tran5Port arrangemen6

. creater number in intervenⅡon group delivered in a healthUnit and earlier uptake of postnatal care

. Reports on sati5fadion with care did not differ slgnificantlybetween groups-saU5fadlon genera11y hi8h in both groups

. Discourses of "choice" move responslbⅡity for birthOutcome5 to vvomen as consumers, therefore culpable forincreasing teclmocratization of birth

. vvomen planned for a5 natural birth as possible, but livedexperiences did not match plans

. Difficultles of medlcal encounter

. urgency and lack of clarity in makina birth decisions

. Respon5ib川ty/gu"t when "choices" go against plan5

. women re1γ on expertise oftrusted Hcps to make decisionsabout birth during the planning phase

. Birth plans are helpful but not essential

. Those Ⅷth flexible birth plans feltthey had more room fornegotlation during labor and birth

.1mpact of changes to birth plans depended on de8ree of d松ngeand amount of controlfelt over change5 as they occurred

. Those 、vho felt supported ln decision making 引村~vho trustedHcps had more positive rec011edion of birth experience5

. vvomen moving to consultant care and unable to consultⅧth midwife felt greater loss of contr01

. Ni8erian ~vomen tended to book later,~vere much more keento have a vaalnal de11Very,1ess keen to have husband/partnerPresent, more likely to exped additional presence of adodor (along with mw), more like1γ to prefer no pain re11ef,more likely to prefer semlrecurnbent labor and supine birth

イContmuedj

Magoma et al,(2013)Tanzania

Mixed me小ods questionnaire122 respondents

Birth plans Diva// et a/.169

Malacrida and Boulton 促013)

Canada

Quantitative, cluster RCT

905 PartiCゆant5

Cook and Loomis (2012)

Canada

Qualitative, narratlve intervie゛/S

22 PartiCゆants

Qualitatlve, narrative lntervie~、/S;

15 ParⅡCゆants

Sheridan et al,(2011)

Ireland

Quantitative que5tionnaire

113 Nlgerian respondents;5191rish resporldents

170 Blrth plans Diva// et a/

APPENDIXC 叉Vomen'S Experiences a11d opinionS イC011ti11Ued/AUTHORSAND SETrlNC MEIHODSANDPARTICIPANTS HNDINCS

Penne" et a l.(2011) Quantitative, prospedive Demographics of、べomen completing bidh plans: primarⅡy.

United state50f America C01扣rt study Vvhite, C011e8e・educated, under care of certified nurse、midwife63 Set50f notes; ' central part of birth plan related to anelgesjc preferences

38 que5tionnal『e >50% wi5hed to avoid epidural but 65% had one;>90%。frespondents th05e receivlng epidurals were pleased

Most a8reed birth plan enhanced birth experiences, added.

Contr01, cla「愉ed thoU8hts, and improved communicationWi廿1 1氾alth care providers

' Favorable view of bir小 Plans even vvhen preferences 、verenot fU1州led or complications occurred

Qualitative intervie、VS ' Midwives assisted vvomen in completin8 bi此h plans,12 PartiCゆan【S encoura8ed them to be flexible in expectations and birth plan

Midwives' encouragementto develop a birth plan enhanced.

Communication betⅥ,een 、vomen and 小eir partners(e.gリ mutual birtb prefe陀nces, expedations)

' Heightened sense of control because lhey had dloices,Sense of self as adive participant enga8ed in C0Ⅱaborative

deci5ion making with mw

、Nomen believed realistic and flexible birth l)1ans.

Contributed to their salisfadion and positive bir小 experienceQuantitative, single、b11nd RCT, ' 1ntervention group had higher de目ree of positive birlh

questlonnalres experiences and degree of birth contr01296 Participants ' No di仟erence betvveen groups in antenatal birth expeda、

tlons but si8ni介Cant difference in degree 0仟U1刑ment inPostnatal que5tlonnaire; higher degree of mastery and par_tlclpatlon in intervenuon group

Quant託ative questionnaire ' 28% did not know 、vhat blrth plan was, did nol an5Wer113 respondents questions about 5Ubsequent outcome5

' 209'o of those who knevv about birth plans reported learnin ,about them from their physician

' 1429"o reported lnternet as main resource for drafting abirth plan

Most did ηot believe obstetric outcomes adverse1γ a仟eded.

by completion of birth plansQualitative, ana1γSis of online 、Nomen wrile birth plans in partl)ecause they expectto be

.

Childbirth narrativesl survey; Unable to communicate otherⅥ/1Se during labor: hospitalana1γSis of birth plans; biπh context,、、,here techn010gical authority haS 5Upplanted

34 Survey responclents; bodily authority5 birth plans ' vvomen accessed online templates/advice, care providers

end blrthing classes to 、vrite blrth plans、Nomen used "P0ⅡteneS5 Strate8ies"^Polite dem引ld5 rather

.

than commands or demands-shovvin合"rhetoricalsavvyUnder5tanding" of power hierarchies

' Benefit of birth plan as an educational to01:~vriting re uiresresearch, which leads to knowled8e, which lead5 to lessdidactic interadlons wjth HCPS

Qualitative intervievvs、vomen completln8 birth plans found the experience hi8hl

.

Nine parⅡdpants Satisfying, eV印 if birth did not 11appen accordin8 to the planParticipants appreciated value of documenting'di5Cussing

.

WiS1杷5 With HCPS

' parucularly enjoyed the idea of informed, partiCゆatory birlhexpenence

Doherty (2010)Uniled states of America

Kuo et al.(2010)TaiⅥ/an

イContmued/

0、uens (2009) united slates

Of America

Crant, sueda, andKaneshiro (2010)

Uniled states of America

Yam et al.(200刀人4exico

叉Uomen'S E】中eriences andophlionSイC0πtiπUed)APPENDIXC

AUTHORSAND SETrlNC

Peart(2004)

Australia

MモτHODSAND PARTICIPANTS

Mixed methods, questlonnaireand interviews

42 PartiCゆants

Lundgren, Berg, andUndmark (2003)

Sweden

HNDINCS

Berg, Lundgren, andLindmark (2003)

Sweden

. Half had prepared written birth plans, half had verba11yexpressed preferences to fam11γ/HCPS

.12 Used hospital birth plans,10 、vrote 小eir o、vn

. vvrltten plans: evidence 0仟lexibilily ln vvomen's plans

. verbal planner5: did not、Nant restridionS 小ey a550ciated v、/ithhospital birth plans; fear of "failure" if a wr轍en bir小 Plan devi・ated because of unprediCねble events; some Hcps discouragedWritten bi州) plans; di伶Cult language in Yvri廿en blrth plans

. No plan completed because of unpredictable nature ofChildbirth

. Ha1仟Ound makin8 a birth plan unhelpful: unpredictabnity ofChildbirth; 1ack of knowledge in relation to Yvhatto exped;Iack of understandin8 in relation to Techn010gical processes;Iittle professiona1 5Upport

. purpose served by birth plans: created dial08Ue bet、veenWomen and HCPS, clarified needs, alerted Hcps to vvomen'S

needs, proper preparation for blrth.1ntervention not effective in improving ~vomen's experiences

Of chⅡdbirth

.1ntervention group: significant1γ 10wer scores for relatlonshipWi小 first mw they me[ durin8 de"very re: 1i5tenin目 and pay・ing attention to needs and desires, support, guiding, re5Pect

. vvomen 、vith complications in pregnancy and/or birth ap・Peared to have more ne8ative feelin8S than "normal"、uomen

. Bir小 Plan preceded by questionnaire completion intensifiedne8ative feeling5 1n women with complications

.90% completed birth plans

. process of completion useful by a110、ving discU5Sion of ava11・able option5 Prior to labor

. Half said blrth plan made no difference to feelings of contr01durin81abor

. Many felt not enough a廿ention wa5 Pald to what 小ey had、、1Πtten

. Majority said they Ⅵ,ould use a blr小 Plan in future pregnancy

. Those completing a birth plan were more like1γ to be younger,Wlthout a partner,1iving out5ide metropolitan area5, with lowerincome and no private hea1小 insurance, and primゆarous

. vvomen attending a speda11St ob5tetrlcian as a privatePatient lea5t likely to use a bir小 Plan; those with team mid・

Wifery care in a blrth center most like1γ to U5e one. Ha1仟Ound the bir小 Plan useful during labor and birth; 5.6ツ0

found it d画nite1γ Unhelpful. T~VO・thirds felt there Yvere advantages in having written down

thoughts arld wishes in advance

. Main advanta8es: opportunity to consider and leam about op・tion5 available before onset of labor and to be able to inform

Hcps ahead of labor; opportunity for dlscusslon 、vith partner/HCP5; a means of menta11y preparing them5elves for birth

. Main disadvantages:instances vvhere Hcps did notread/Were dismissive of/did not f0110Yv wishes outlined; 1imited

Capacity of plans to refled 小e fU11 range of p05SibⅢties. vvomen wi小 bi此h plans more 11kely to be verγ 1ねPpy about

Pain renef and felt more involved in care declsions; also moreIikely to rate dodors present durin81abor小irth aS 8ivin8 Some/Iittldno help; no differences in terms of helpfulness of mid・Wives, access to information, or overa11 ratin80f laborゐirth care

Whitford and HⅢ舶(1998)

Scotland

Quantitative questionnalre271 intervention partiCゆants

(formulation of birth plan),271 Contr01

Birth plans Diva// et a/.171

Quantitative queslionnaire271 intervention partlCゆan【S

(formulation of birth plan),271 Contr01

Quantitative questionnaire143 respon〔1ents

Brown and Lumley (1998)AU5tralia

Mixed method5 questionnaire270 re5Pondents

icontinuedナ

172 Birth plans Diva// et a/

APPENDIXC 叉Uomen'S Experiences a11d opinionS イC011ti11Ued)AUTHORSAND SETTINC MモτHODSANDPARTICIPANTS FINDINCS

TO0 σ996b) Qualitative intervie、ヘ/S ' hれPortance of matching effedive communication andUnited Kin8dom 10 partlCゆants information giving antenata11y wi小 experience in labor

' 1mpad of contr01(or lack of it) on experience of laborand bir小

.川Usions of choice

' cha11en8e 0仟ormulating birth plans-pradical(time, support, education) and ide0108ica1 φrofe55ionalsbe11eved to kn0Ⅵ, be5t)

Quantitative questionnaire No staustica11γ Significant di仟erence in anxiety bet、veen groups.

21 interventlon parlicipant5; P =.06 for state anxiety-SU8gests a trend loward lo~ver.

24 Contr01State anxiety in experimental groul)

Mixed methods survey ' 95% thought birth plan is easy to complete,87%小OU8ht it10o respondents Is easy to use

Wh0 小ey would discuss plans with:75% partner,31% other.

famⅡy,20% friends,28% midwife,17% chⅡdbirth eclucati。n8roup,199,1, dodor

' Felt birth plan lmproved under5ねΠdin8:939,{, in labor,899,{,delivery,84ツ0 after birth

' 339"o felt birth plan did not encourage them to ask questionsOftheir HCP

' Birth plan enabled expre5Sion of preferences/needs:929,。 inIabor,88'%, at delivery,909,1, after birth

' 95%、vould encouraae 0小ers to U5e the birlh plan. Reasonsimproves under5tanding,80od for preparing and plannin卸gives awarene5S of options,1ets sta仟 know preference5and needs,8ive5 Confidence and a 5ense of conlr01, andImproves comm山licatlon between women and HCPS

Mixed methodsM05tfound 小e plan "helpful" and "reaS5Uring"

.

Questlonnaire and InlervlevV5 Opinions via postnatal questionnaire:98% said birth.

Plan10o parⅡCipants Was very 80od or good; 2% 5aid no value

' on1γ 7% felt they achieved half or less of wiS1氾S as statedOn birth plan

' Take up of blrlh plans was around 20'%, of antenatal 、vomen

Springer (1996)United states of America

Moore and Hopper(1995)Australia

Ekeocha and jackson σ 985)United Kingdom

ThelENTES加dy:TheE丘ecuvenessofProphylacticlntramuscular oxytoC血 intheThirdsta今eoflaborAmon号工OW・RiskWomen in pr血arycareMidW廿erypractice:ARandomizedcontr0ⅡedTri凪

Suze 入1. R /. j411S, K4thy c. Herschdel:f'eち<4侃riet Th. vaπ Die111,MiekeAitiπk, M4rlies Riiπders, K4riπνan der P41・de Br呪i11,411dSi1110πe E. B伽te11dijk

PURPOSE: To testthird stage mana8ement oflaboT forlow・risk women comparing routine prophylac・tic intramuscular oxytodn management versus modi6ed expectant management.

STUDY D更SIGN: Randomized contr0Ⅱed multicentertrialin primary care midwifeTy practice.

MAIORFINDINGS:32.4qo ofwomen in the prophylacticintramuscular oxyrodn managementgrouphad blood loss of 50o mL or more versuS 44.2qo in the modi丘ed e}甲ectant management 8roup, rela・tive risk (RR) 0.61,95% con丘dence interval(CD [0.50,0.74]. The percentage ofwomen experiendngPostpartum hemorrha合e (PPH) de6ned as more than l,ooo m上 blood loss waS 63ψoin the prophylacticintratnuscular oxy[ocin management group versuS 11.9q、o in the modi6ed expedant management 名roup(RR O.50,9"O CI{036,0.71D. The type ofmanagementshowed no signi丘Cant di丘erences betweenthe No groups in clinicaⅡyrelevantindicators ofwomen'sshort・term health such asthe number ofreferrals,treatment 名iven, hemoglobin leve136 hours postpartum, and bTeastfeeding rates a丑er l week.Medium-term health such as hemoglobin levelat 6 Weeks postpartum,、vomen's perceptions oftired・ness, and breastfeedin名 rates at 3 months after biTth also showed no di丘erences between 杜le two groups.

CONCI,USION: Third stage management by means ofroutine prophylactic intramuscular oxytodnreduced the risk ofpostpartum hemorThage in a group ofchildbearing women atlow risk of complica・tionsin primary midMfery caTe compared to modi丘ed expectantthird stage mana8ement, butthereWas no evidence this was assodated with a reduction in clinica11y Televant adverse health outcomes.

KEYWORDS: postpartum hemorrhage; primaTy midwifery care;third stage management; maternaland child health

INTRODUC110N

Caregivers throughout the 刃Vorld are keenly a凡VareOf the risk of postpartum hemorrhage (PPH), whichCan lead to serious maternal morbidity and mortality(Lalonde, Daviss, Acosta,& Herschderfer,2006).1n the

Past decades, severaltrials have been carried out that

&/ⅣTER/VAT/0/VAι JOURNAι_ OFCH/ιDB/nTH VO/ume 6,/ssue 3,2016

◎ 2016 Sprlnger publishlng company, LLC WWW、spr1ηgerpub.comh廿P:ガdx,doi.org/10.1891/2156-5287.6.3.173

tested the e丘ectiveness of routine active third stagemanagement. Their results reportthat active third stagemanagement signi6Cantly reduces the risk of ppH,anemia postpartum, as we11 as redudn8 the need fortherapeutic uterotonics postpartum σangsten, Mattson,ιyckestam, HeⅡStr6m,& Ber晉,2010; Nordstr6m,Fogelstam, Fridman,1arsson,& Rydhstroem,1997;

往澎

173

174 The L[NTE study /ans et a/

Prendivi11e, Hardin号, Elbourne,& stirrat,198& R。 erset al.,1998).

Although the condusions of a cochrane review

in 2002 indicated that active managementis superior toexpectant management for women expecting to have anormalvaginalbirth 血 a maternity hospital, prendiviⅡe(2007) underlined the urgent need to assess the bene丘tsOf active mana名ementin domiciliary practice. The cur、rent cochrane review does not explidtly address thiseither (Begley, Gyte, Devane, MCGuire,& weeks,2015).

Most of the previous third stage trials studied aPopulation ofchildbearing women lvith mixed obstetri_Cal risk pr0丘les and in hospital settings with caregiveTSWho did not have a comparablelevelofexperience withboth techniques (Bais, Eskes, pel, Bonsel,& Bleker,2004; Begley et al.,2015).

The Netherlands, with its long tradition ofCommunity・based midwifery care and home birth, wasConsidered to be an appropriate se壮ing to test the effec、tiveness of the management ofthe third stage oflab。rin a low、risk population (atlow・risk for the occurrenceOf complications during labor in accordance with theNational obstetric lndication List [ziekenfondsraad,1987D in a domiciliary se廿ing.

MidwivesintheNetherlandsaretrainedtoapproachthird Stage mana号ementin much the same way as birtbitself: as a physi010gical eventlvith no need for interven_

tion unless dearlyindicated、 Third stage mana8ementinthe Netherlandsis a modi負ed expeda11tmethod consist_ing oflvaitin号forsi8ns ofplacentalseparation and ur8ingthe mother to push the placenta and membranes out,helping ifnecessaryby applyin8 abdominalsupport. TheCord is usuaⅡy not damped a11d cut untilit has stoppedPulsating.~、1hen indicated, that is, a history of ppn,baby estimated to be large 血r gestational a8e, pr010n8ed6rst or second stage of labor and hemoglobin leve11essthan 6・o mm0υ1 四.7 g/dD, Dutch midwives (certainlyatthe time the studywas conducted)ねke a prophylacticapproach to the third stage of labor 、vhich consists 。f

51Uoxytodn administeredintramuscularlydirecdya丘erthe birth ofthe babya丘er which the birth ofthe lacentaand membranesis achievedassoon aspossiblebymater_nale丘ort eitherwith orwithoutli8ht 6.1ndalpressure andエ¥ithout sped6C 血Struction for contr0Ⅱed cord traction(CCT) or cord dalnping. Active management and moreSped負CaⅡy ccT, as described in the recently u datedCochrane review (Be名ley et al.,2015), is not a meth。dtaughtin Dutch midwifery schools.

The pl'esented trialaimed to answer the f0ⅡOwinresearch question:~vhat is the inauence of routine useOfprophylactic intramuscular oxytocin management of

the thjrd stage oflabor as described earlier when com_

Pared to modifled expedant managementin a popula_tion oflow、risk pregnant women in primary midwiferyCare on the inddence ofppH and adverse effects.

Thistrialwas designed in the mid、1990s and wasthe 丘rst primary care midwifery research project inthe Netherlands. circumstances prevented the studfrom being published when the results were anal zed.Despite this, the study is h)own by researchers inter_ested in the subjed, and results are sti11 Used to Supportmidwi企ry policymaking in the NetherlandS σans &Beenues,201の. Moreover, the results of this study areSUⅡ relevant for the cochrane revie、v on prophylacticOxytodn forthe third stage oflabor and can be indudedin a future update because it is critical for Systematlc

reviews to have aⅡ available data (W'esthofε Cotter,&T010sa,2013). publication ofthe data therefote remainsappropriate, enabling the use of the results for a 、vider

audience ofmidwives, researchers, and policymakers.

Objectives

To testthe h沖othesisthatroutine use ofthe ptophylacticintramuscular oxytodn management ofthethirdstage ofIabor, as described earlierin a population ofchildbearinWomen of lo、v obstetrical risk,10wers the inddence ofPPH and its adversee丘ects when compared to the modi_6ed expedant management ofthe third stage oflabor.

METHOD

The hypothesis wastested in a raTldomized contr011edtrial.

Population and sample size

Based on the ppH rate recorded in the Dutch NauonalPerinatal Database of 1991, it was calculated that a

Sample of 2,ooo women a,ooo prophylactic manage、ment and l,ooo expedant management) would providean 80% chance ofdetecting a difference atthe 5% 1evelOf statistical signi丘Cance, if prophylactic managementreduced the inddence of ppH (de丘ned as blood l。SS

>50o mD from 7% t03.5% and ppH accordin8 to theDutch de6nition (de丘ned as blood loss >1,ooo m上

Ziekenfondsraad,1987)丘om 3% t01%.

After a nationalcaⅡ for parudpauon,20 indepen_dent midwifery practices partidpated in the trial basedOn criteria induding practice size, number ofmidwives

and temporary staff, and no policy ofroutine prophylac・tic third stage management. The practices 、vere locatedthroughoutthecountryinurban as weHasinruralareas.

~vomen received trialinformation leaaets from

their midwi企 at 34Week' gestation andwere recruited inthe 37せI week a丑er written consent was obtained. TheyWere eli3ible 血r trialindusion if the midwife expectedthatthe birth 、vould take place under hercare or 血 otherWords, when no complications were expected,resulting 血a tranS企r ofcare from primaryto secondarylevel. Exdu・Sion criterialvere determinedaccordingto the indicationsforaprophyladicapproachtothethirdstagema11a8ementin primary midwifery care as described in the "1ntroduc・Uod' section.~×10men with poor command ofthe DutchIanguage were exduded from trialP紅tidpation.

Randomization、vas achieved using two numberedand sealedopaqueenvelopes. Each envelope containedaSticker indicatin80ne ofthe aⅡotted treatments.~×1henthe midwife was confident that the birth would be

Completed in her care (de丘ned for primigravid womenWhen a large part ofthe baby's head was presentin牙 andfor muluparous women atthe beginning ofthe secondStage oflabor), the 刃Voman herselfor someone else des・ignated by her 、vould choose one ofthe two envelopes.Indusion into the trial at this late stage was chosen toensure a minimum ofexdusions a丘er treatment aⅡOca-

tion. The midwives returned aⅡ randomization materi・

alsinduding the unopenedleftover envelope afterwardsfor inspection of compliance lvith treatment aⅡOcation,and this 、vas recorded accordin31y

Blinding for tteatment aⅡOcation with a placeboWas considered during the initialproposaldevelopment.It、vas later agreed that because the trial、vas designed toStudy the effed of routine prophylacuc intramuscularOxytodn ma11agementin aprimarycarepradicesettin8,blinding for treatment aⅡOcation could intetfere withStandard practice and subsequent actions associatedWith thetwo types ofmanagement. The midwife at[end・ing the birth carried out most ofthe daね C0Ⅱection.

Outcomes

The primary outcome, PPH, was de負ned as blood loss>50o ml, reaectin8 the standard international de丘ni・tion at the time and currently sUⅡ Used qnternationalConfederation ofMidwives [1CM]& 1nternationalFed・

eration of Gynec010gy and obstetdcs [FIGO],2011).The study als0 10oked at ppH as de丘ned in theNetherlands,>1,ooo ml and severe ppH >1,50o ml

(ziekenfondsraad,1987). Blood loss was measuredfrom the moment ofbirth unti11 hour a丘erthe birth of

Placenta and membranes、 Trialprotocolwas designed tofacilitate a measurement of blood without contamina・

tion by amniotic auid. This meantthatthe 6rstinconti・nence pad used during the momentthe baby was bornWas discarded in aⅡ the births induded in the S加dybecausethisincontinence padwould primarilycatch thegulp ofliquor diredly f0ⅡOwing the birth ofthe baby

The number of refぞrrals to hospital care duringthe 廿lird sta8e and the immediate postpartum periodfor ppH al)d/or retained placenta; hypotension (bloodPressure く90/55 mmHg) 20 minutes postpartum; andtreatments such as intravenouS 丑Uids or blood tranS丑1・

Sion, hemoglobin levels within 36 hours of 8iving birthand 4 t06 days poS中artum, and the number ofwomenbreastfeeding i11the 丘rst week were recorded as earlyindicators of the clinical relevance of poS中artum blood10SS. The hemoglobil)1evel at 6 Weeks' postpartum alongWithwomelゞs perceptions oftiredness and杜le number ofWomenbreast企edingat3 months a丘erbirth3ave al)indi・Cation ofthe midterm effects of poS中artum blood loss.Other outcomes were the therapeutic use ofoxytocics or0寸ler uterotonics during tbe third stage a11d immediatePOS即art山11Period and length of血ethird stage oflabor.

The L〔NTE study /ans et a/.175

Intervention and comparison

The intervention consisted ofthe routine administration

Of 5 1U oxytoC血 intramuscularly immediately a丑er thebaby was born. The intervention was compal'ed Nvi杜lthemodifledexpedantm飢agementmethodwhichconsistedOfwaiting 血rsigns ofplacentalseparation and urging 杜)emotherto push the placenta al)dmembranes out, helpingifnecesS雛ybyapplying abdomi11alsupport. Thecotdwasnot dalnped and cut 山tⅡ ithad stoppedpU1訟ting.

Measurements and Equipment

The methods for establish血g trial outcome measure・ments were dearly described, al)d 仕)e eqUゆment used fbrmeasuring was sta11dardized a11d validated. To faCⅡitate al)accurateassessmentofpoS中artU11)bloodloss,thepradicesWere supplied Mth digit飢 SC址es for measur血g blood loss.Theresearchteam also suppliedsets ofstal)dardizedeqU中・ment 血r blood c0Ⅱection at bir仕1血dudil)g lo disposablePreweighedi11Continence pads(a smaⅡimpermeable mul・tilayered sheet with high absorbency) a11d 号raduated mea・S山hlg cups. The method of hemoglobhl measuri11g wasSta11dardizedby supplyi11g 廿le midwiferypradices wi壮) anautolet 611ger prick system for 杜le c011ection of caP丑laryblood al)d a portable digitalhemoglob血 meter.

176 The LENTE studγノans et a/

The hemoglobin meters were validated bimonthl

through a national quality controlpr08ram for hospitalIaboratory instruments. A110ther equipment used in thetrial,induding the midwife's own sphygmomanomete二Were subjeded to periodic quality contr01 tests per・formed by a supplier ofmedicalinstruments.

Daね C011edion and statistics

入ιidwives used the standard National perinatal Data_base form for primarymidW迂ery care (The NetherlandsPerinatalRegister,1996) andtwoquesuonnairesdesignedfbr the trialto record data on pregnancy, birth, and thePuerperium.刃、10men completed a short questionnairein the 6rstfぞW days f0ⅡOwing birth to provide details 。fthe randomization process and the treatment aⅡOcation,Which was usedto verifywhethertrialprotocolhadbeen丘)Ⅱ0、ved. A short questionnaire 、vas used to record thehem0呂10bin levelatthe 6・weekpostnatalf0ⅡOW_U ,

Differences in groups were tested with the X2 test血r cate80rical data and t11e two、sided t test for c。n_tinuous data. A p value ofless than .05 Was consideredStatisticaⅡy si8ni負Cant. RRs are ptesented with 95% CI.Analysis was carrjed out on an intention to treat basis.

Approval was obtained from the Medical EthicsBoard ofthe Netherlands organization for Applied sd_ence Research (TNO). Trialprogress was monitored byan independent advisoryboard. The trial、vas fundedbthe preven廿on Fund ofthe Netherlands.

Statistical analysis was conducted with the Pro・

gram spss version 6.1 for windows and rerun inOctober 2011 With spss version 15.o for wind。WS.

Who randomized forthe study were referred to second_arycare afterrandom treatment a110cation. Missing datamade it impossible to trace hospital records for theseWomen, and they were subsequenay lost to the studyThese cases occurred primarily during the early sta esOfthe trial, and a丘erthe research group emphasized theimportance of c011ecting data even a丘er referralto sec_Ondary care, the partidpating midlvives complied anddata c0Ⅱection improved. Two cases were not eliiblefor analysis because of lvithdrawn consent. The t。talnumber of women in the primary analysis 、vas l,686:851in the prophylactic management group and 835 in

the expectant management group (see Fi8Ure D.No si3ni丘Cant differences were found in baseline

maternal and child characteristics between the t、V。groups (Table D.

The dif企rences between the two management8roupsin terms ofmeasured blood loss and risk ofppH

are shown in Table 2. The risk ofppH wassigni6Cand10werforwomen in the prophylactic group compared tothatintheexpedant8roup inaⅡthreecategories ofppH:>50omlRR = 0,61,95%CI[0.50,0.74];>1,ooomlRR=0・50,95% CI [036,0.71]; and >1,50o ml RR = 0.50,95% C1 1026,099].

Table 3 Shows the relevant secondary outcomes.Signi6Cant differences were found bet刃Veen the rou sfor the risk of postpartum anemia on Day 4_6 RR =1・フ,95% CI [13,2.3]; iron thaapy given during the負rst week postpartum RR = 0.73,95% CI [0.60,0.90];and the therapeutic use ofoxy[odcs in the third stage 。fIabor and the immediate postpartum period RR = 032,95% CI [0.25,0.47]. For a11the cited outcomes, womenin the prophylacuc intramuscular oxytocin 8roup wereIess atrisk compared to women in the modi丘ed exped_ant 8roup.

No differences between the groups were foundin clinica11y relevant short・term health outcomes suchas postpartum hypotension, treatments such as intra_Venous auids or blood transfusion, side effects 。f

Oxytodn, mean length ofthe third stage, or a third stage10nger than 30 minutes. on midterm health indicators

Such as anemia at 6 Weeks postpartum, the percentageOf women breastfeedin今 at 3 months postpartum andgeneral、veⅡ・bein8, the 8roups were also comparable.

Expressed as the number needed to treat

(NNT),9 Women need treatment with prophylacticintramuscular Oxytodn mana8ement to prevent onemeasured ppH according to the standard internationalde6nition (>50o mD and 18 Women need treatment

to prevent one measured ppH according to the Dutchdefinition (>1,ooo mD.

RESUI.TS

Data were c0Ⅱeded from May 1996 to August 1997、A丘er lo months of data c0Ⅱection, the advisory boardrecommended redudng thesample sizet01,30o womena丑erarecalculauon usin8the ppH rateS 命rboth 50o mland l,ooo mlfrom interim data, which 、vas higher thanthe rate origina11y expected.

Of the 3,362 Women who gave written informedConsent,49%(π= 1,658) lvere not induded in the trial(Figure D. Although the reasons for nonindusion arenot documented, this percentage corresponds with thenumber of referrals to secondary care expeded in thePeriod bet、veen consent (36 Iveeks' 8estation) and ran_domization aate second stage oflabor; The NetherlandsPerinatal Registry,1996). sixteen of the l,704 W。men

3,362 Women consenting to participation

859 Women a110cated to

Prophylactic management

1,704 Women randomizedto S加dy

710stto study because ofrefe杠alto hospital

1,658 Women notincluded in study

The LENTE studγノans et a/.17フ

852 Women received

Prophylactic management

851 included in main analysis

I wi廿ldrawa1 丑'om S加dy

824 Women analyzed at6 Weeks postpartum

845 Women a110cated to

modi丘ed expectantmanagement

フ79 Women analyzed at3 months postpartum

910stto study because ofrefenalto hospital

836 Women received

modi負ed expectantmanagement

Characteristics of、、10menlndudedinthestudyTABιEI

I wi廿ldrawal fTom st口dy

Flowchart ofpartidpation throU名h trial.FIGURE I

Mother

Dutch or唱in

Mean (SD) a8e at birth in year5

Prlmゆarous

Multlparous >5

Mean hem0810bin (SD) at 36 Ⅵ,eeks' gestation in mmovlChⅡd

Mean bir小、velghtin 8rams (SD)

Mean 8e5tational age (SD)下emale

835 included in main analysis

807 Women analyzed at6 WeekspoS如art噂1

764 Women analyzed at3 months postpartum

ACTIVE

(n = 851)

825 (979'0)

30 (4.09)

328 (3少向

4 (0.59,'0)

728 (.59)

ExpfcrANT

(n = 835)

3,517 (417)

40 (2.3)

443 (529'0)

807(9ア向

30 (4.07)

330 (4伊向

11 a 39,'0)

フ.33 (.59)

3,519 (440)

40 (12)

425 (519'0)

178 丁he LENTE study /ans et a/

TABI・E2 MeasuredBlood王OssandRiskofpostpartumHem。r hAC"vf

N = 851

Measured blood loss n

<50o ml 575

500-999 ml 222

1,000-1,499 ml 41

>1,50o ml 13

PPH defined as

>50o ml 276

>1,ooo ml 54

>1,50o ml 13

Note. RR = relative risk; PPH = postpartum haemorrha e"P =.00,""P =.50

fo,50,0.741*

10.36,0.711*

[026,0.99]**

DISCUSSION

Postpartum Hemorrhage

This ratldomized, contr011ed trial has sholvn that thirdStage matlagementbymeans ofrouune prophylacticintra、muscularinjecuon of51U ofoxytoC血 ComparedM血血emodi6ed expedal)tmanagementreduced theriskofppHin a group of low・risk childbearing women in Pnmary

midwifery care but was not assodated wi杜l a reducu。nin clinicaⅡy releval)t adverse health outcomes. Alth。u hthe studywas conducted i11the mid、1990S,the resultsst避Contribute to the ongoing discussion ofthe most a r。、Priate wayto mal)age the third stage oflabor. The f会Ctthatthe study was conducted in pr血ary care and 加dudedOnly women who are atlow risk 血r ppH espedaⅡ addsnewinformation to the existin8 bodyofhlowled8e.

In many populations, PPH de6ned as more than50o ml of blood loss may be appropriate,、vhereasPostpattum bloodloss up t01,ooo mlmaybe consideredPhysi010gica1 血 a hea1廿)y population of childbearin、vomen as is the case in the Netherlands (Gyte,1992;Lalonde et al.,2006; sloan, Durocher, Ndrich, Blum,& winik0丘 201の.1t has also been suggested that itmay be more use会.11to consider the hemat010gical a11dPhysicalimplications of third stage ma11agement ratherthan the absolute amount ofblood loss because it can beargued thatitis the clinicaⅡy relevant adverse outcomesresU1廿n8 from the blood loss that inauence the healthOf childbearin8 Women (Gyte,1992). No dif企rence inmea11hemoglobin levels was found in the 6rst weeka丑erbirth and although the prophylactic intramuscular o

group had a lower risk ofpostpart口m anemia andtodn

a decreased use ofiron therapy, the clinical relevance 。fthese outcomes needs to be wei8hed a8ainstthe absence

Clinical Relevance of

ツ。

67.6

26.1

4.8

1.5

fstimated versus Measured

fxpECTANT

N = 835

n

466

270

74

25

32.4

6.3

1.5

ツ。

55.8

32.3

8.9

3.0

369

99

25

RR

442

11.9

3.0

Of d迂ferences found between the study 8roups regard_ing other indicators of iⅡ healtb resulting from ppH6・e・, hypotension 20 minutes poS中artum, the numberOfreferrals to hospital for ppH and/or retained placentaa丑er birth, and treatments such as intravenous auids 。rblood tranS丘Ision). EspedaⅡy because a110ther recentDutcb studyfoundthat fatigue andhealth status postpar_tum did notseem to be inauenced by anemia (van derWoude, pijnenborg, verzijl, van 刃Vijk,& de vries,2014).

Unfortunately,血e LENTE study did notlook atthe effed on infants such asjaundice and admission tothe neonatalunit as is described in the recent cochrane

Update (Begley et al.,2015). However, this S加dy didShow thatno differenceinbreastfeedin8 rates wasfoundbetween the tw0 牙roups.

The study reinforces Begley and c0Ⅱeagues'(2015)6ndings of a statistica11y significant hi号her use oftherapeutic uterotonics in the third or fourth sta e 。f

Iaborintheexpectant arm. unlike the cochraneupdate,this study showed that rouune prophylactic intramus_Cular Oxytoan management was not assodated with

Side effects such as nausea, vomiting, headaches, anda丑erpains. This may be a廿ributed to the fact that 。todn 、vas the uterotonic ofchoice and notsyntometrinWhich is assodated lvith a higher risk of side effects(MCDonald, Abbot,& Higgins,2004) and would arouein favor ofprophylactic mana8ement as described here.

95% 0

0.61

0,50

0.50

Postpartum Blood l.OSS

Caution is needed 、vhen interpreung the results of thisStudy because an overaⅡ hi今her inddence of ppH wasfound in this trialcompared to other studies atthe time.This dif企rence is mostlikelyrelated to the method used

Secondaryoutcomes(Denomhlators MayDi丘erBecauseofMissin牙Data)TABιE3

Refe『rals to hospital care in third orfourth 5tage for hemorrhage and/orretained placenta

Use of 小erapeutic uterotonlcs in the thlrdOr fourth stage

Length of third stageMean len8小 in minutes (SE)>30 minutes

Treatments

Infusion drゆBlood transfU5ion

Iron ねblet5

Hemoglobln first day poS中artumMean in mm01/1(range)

Anemia く6.5 mm01/1(<10.5 g'dl)Hem0810bin on Day 4-6 Postpartum

Mean in mmovl(range)

Anemia く6.5 mm01/1(<10'5 g/'db

Hemoglobin at 6 Vveek5 Postpartum

Mean in mm01/1(range)

Anemia く6.5 mm01/1(<10.5 g、dl)

Blood pressure 20 min postpartum

Systolic く90 mmHg

Diastolic く55 mmHa

Women's perceptions of we11・being at3 months p05tpartum

Experiencin8 (some) fatlgue

Le55 energy than before birthBreastfeeding

First Yveek postpartum

3 months postpartumSide effeds (a什er birth)

Nausea

VomitingHeadache

Painful uterine contradlons

PROPHYI.ACTIC

22椙51 (2.6ツ。)

79侶42 (9.4ツ。)

13 (0.58)

69/847 (8.191.)

里XP壬CTANT

24椙51 (2,8)

10/851 (12ツ。)

255/851 BO.0ツ。)

The LENTE study /a那 et a/.179

29/835 (3.59,'。)

195ノ給0 (23.5ツ。)

73 (4.6-102)

113/829 (13.6ツ。)

14 (0.50)

59/828 (フ.1%)

フ.5 (4.3-10.4)

87/834 (10.49'0)

RR [C11

0.7410.42,13]

24/835 (2.9ツ。)

12/835 (1.49,'。)

308/835 B6.99,、。)

フ.9 (62-10.2)

5/818 (0.69,、。)

Note. RR = relative risk.

"P く.005

032 1025,0,471*

フ.2 (43-113)*

157/817 (19.29'。)

2/842 (02ツ。)

6侶42 (0.79/。)

12 【0.81,1.刀

in our study for determinin今 the amount of postpar・tum blood loss: Blood loss was measured as opposedto estimated. Because the partidpating midwives wereresponsible for treatment aⅡOcation as weⅡ as dataC011ection and therefore could not be blinded for the

号iven treatment, postpartum blood loss 、vas weighedUsing standardized measuring equipment to minimizethe likelihood ofobserver or detection bias. However,it

is possible thatthis may have played a role.The Hinchingbrooke trial used visual

Of blood loss and found lo、ver rates of ppH

フ.4 (4.4-9.8)*

139/817 (17.09/。)

662/797 侶3.1'%,)

402/フ79 (51.63,'。)

0.98 10,55,1.刀

0.82 [035,1.91

0.73 *10.6,091

フ.9 (62-102)

4/806 (0.5ツ。)

68フノフ76 (79.3ツ。)

308/617 (49.9ツ。)

0.66 {0.51,0.861*

V827 (0'1%)

12/826 (1.59、。)

22/841 促.6ツ。)

6/840 (0.フ'羚)

18侶36 (2.2ツ0)

327/841 B899/'。)

0.57 [0.43,0.761*

647/フ74 (83.5ツ。)

386/764 (50.5ツ。)

123 10.33,4.6091

606/7印(79.6ツ。)

305/605 (50.49、0)

1.9 10.18,21.刀

0.49 10.82,1.31

24/821 (2.9ツ。)

4侶20 (0.5ツ。)

14侶17 (1.79,'0)

359/824 (43.79'。)

0,96 [0.74,13]

1.0 [0.86,13]

Corresponding category (Rogers et al.,1998). These丘ndings are consistent lvith studies that found a ten・dencytoNvardvisualunderestimation ofblood loss espe・daⅡy 、vhen this is higher than 30o mL (Bose, Regan,& paterson・Brown,2006; Brant,1967; levy & Moore,1985; Razvi, chua, AruMumaran,& Ratman,1996).

A study on the inddence and determinants ofPPH carried out in the Netherlands also showed a

higherinddence ofppH comparedto otherstudies. Theauthors sug今estthatthis may be caused by the packageOf prophylactic management as described in the study

0.98 10,フフ,131

0.98 [0.79,121

0.89 10.50,1.61

1.5 10.41,521

13 【0.63,2.51

0.85 【0.68,121

estimates

In every

180 The LENTE study /ans et a/

Which does not necessarily indude eaTly cord dampinin conjunction witb ccT (Bais et al.,2004). The current血ddence ofppH in the Nethetlands, de丘ned as blo。d10SS >1,ooo mL within 24 hours a丘er birth,is found t。be6% Which is comparable to the results in the prophy_Iactic arm (perinatal care in the Nethetlands,2012).Cutrent practice in the Netherlands shows that use ofProphylactic ma11agement has significantly increasedWhich could explain tbis flnding (smit et al.,2013).

Package and components ofActlve ManagementOf the lhird stage of [abor

Active management ofthe third stage oflabor(AMTSL)refers to a sequence of prophyladic clinical actionsComposed of three components: administration of aUterotonic immediately a丘er birth ofthe baby, CCT, andmassage of血e uterine 丑111dus a丘er the placenta is deliv_ered (Tun〒alp, souza,&Galmezoglu,2013; worldHealth0,ganiza廿on [W'HO],2012). However, studies have

Shown that a large variation b) tbe pracuces re今ardh1号AMTSI, existsin both the developed al}d the develo inWorld (Festin et al.,2003, sloan et al.,2010; winter et al.,2007)・1n the groW血gbodyofresearch regardingpreven_UonofppH,emergingevidenceexistswhichsuggeststhatavariationinthethreecomponents orpartofthecompo_nents does not reduce the effectiveness ofAMTSI.(Hのjet al・,2005). supported by the study ofGahnezoglu et al.(2012) which sho、ved 血atthe administration ofa uter。_tonicwastbe mostimport飢tcomponentofAMTSL,theWHo has issued guidance that the adlninistration of aUterotonic is the most important prophyladic action inthepreventionofppH. Theothercomponents ofAMTSιare to be carried out only if a skiⅡed birth a杜endant isPresent (刃、1HO,2012). F0110wing the recent discussionsOn the bene6ts of delayed cord dampin号 because thisaⅡONvs placentaltransfusion by which the baby receivesits natural amount ofblood which is estimated aS 30%_40% morecomparedwith earlycord damping,the wHOnow recommends delayed cord damping (Ansari,2015;Farrar et al.,2011; WHO,2015). Moreover, the recentCochrane review on ccT conduded that ccT onl hasIimited e丘ects a11d thatit can be omi壮edif血isis a w。m_

ads wish wi血Out the fear of adverse effects (Hofmeyr,Mshweshwe,& G田mezoglu,2015).

Other recent consensus agreements have also

deemphasized the practice of early cord damping andhave brought forward the recommendation for uteTine/fundal massa3e a丑er the placenta has been delivered t。ensure uterine contraction qclvl& FIGO,20ID.

The prophylactic intramuscular oxytodn manage_ment ofthe thirdstage as carried outinthisstudyreaectsthe standard practice in Dutch mjdwifery care durinthe 1990S, which did not indude early cord dam inand ccT.1n the Netherlands, damping of the cord isUsuaⅡy carried outNvhen the umbilical cord has stop edPulsating. Nevertheless, this type ofmanagement couldbe seen as one of tbe many variations of the A入ITSLProcess, and the 6ndings in this study are comparableWith other robust third stage trials in demonstratinthe effectiveness ofrouune AMTSI,(Begley et al.,2015;Prendivi11e,198& R0号ers et al.,1998). Althougb theadministration of uterotonics in primary care practicein the Netherlands has signi負Canuy increased, it is stiⅡnot standard practice (smit et al.,2013).

CONCI_USION

The se廿in留 in which care is provided remains a crudalfactor in the dedsion・making process with resped to aPolicy OfroU廿ne AMTSL. ourstudy has demonstratedthat in the Nethetlands, with a population of healthChildbearing women who give birth at primary careIevel, a policy of routine prophylacuc intramuscularOxytodn management of the third stage si8nificantly10、vers the risk ofppH but is not necessarily associatedWith a reduction in clinicaⅡy relevant health risks. Thisis most Hkely caused by the good health status ofchild_bearin8 Women induded in thisstudy

In general,the results from thisstudyhave pradiceand policy implications for the Netherlands and otherdeveloped countries as、veⅡ aS 血rl0元V・resource countriesas succesS6.11implementation and scalin今 Up ofAMTSLin loNV・resource countries requires skiⅡed and Colnpe・

tentcareproviders attendin8births asinthe NetherlandsIvhere professional midwives provide maternity carein the community The wHO,thelcM, and the NGO

recommend that AMTsl should be practiced only bSki11ed providers because of the risk of inversion of the

Uterus during ccT which issupported byHofmeyretal.(Hofmeyret al.,2015;1CM &HGO,2003,2007; Lalondeet al・,2006; WHO,2012). The method described in thisStudy shoNved that a reduction in blood loss ca11 also beachieved withoutthe use ofccT.

Caregivers, policymakers, al)d mana3ers through_Out the Nvorld need to assess the demonstrated e丘ective_ness ofroutineactivethirdstagema11a号ementwithintheir0、vn contextandworkse廿in今in rela廿on to itsshort、term

and long・term health bene6tS 血r childbearing women.This S加dy adds to the available body of evidence to

Support professionals concerned 、vith maternaland childhea1血 to develop regulations and polidesthatprovidethebest and most appropriate care taMng hlto considerationavailabⅡity of sMⅡed caTe provision and a 丘lnctioninghealth system with transport a11d refセrralmecha11isms asWeⅡ asthe needs and preferences ofwomen.

The results of this study wiⅡ Support women inmakin8 an informed choice aboutthe mana名ement ofthe third stage oftheit labor. They can be informed thatroutine use of5 1U ofintramuscdar oxy[odn as dem・Onstrated in this study did reduce the amount ofblood10SS. Also that althoU名h blood loss may be increasedduringthe modified expedant management ofthethirdStage oflabor used in this study, a difference in adverseClinical effects 、vas not identi負ed.

NOTE

1. The text refers to the 1987 edition ofthe National

Obstetric lndication List because this 、vas the edi・

tion used atthe ume ofthe study The 2003 editionOfthe list is the one currently in use (obsteric lndi・Cation 上ist, vademecum. CVZ. Diemen,2003).

Festin, M., Lumbiganon, P., T010sa, J. E., Finney, K. A.,Ba・Thike, K., chゆato, T,... Daly, S.@003).1nterna・tionalsurvey on variation in practice of the mana3e・ment of the third stage of labour' BU11eti11 qfthe vvorldHe41th orgαπiZ4ti0π,81(4),286-291、

Giihnezoglu, A. M., L山nb弔al)on, P.,1,andoulsi, S., widlner, M.,Abdel・Neem, H., Festin, M.,... Elbourne, D.(2012).

Adive management ofthe tMrd stage oflabour Mth a11dMthout contr0Ⅱed cord traction: A Ta11domised, con、

tr0Ⅱed, noninferioritytdal.ι4枇et,379(9827),1721-1727

Gyte, G、 a992). The signi丘Cance of blood loss at deliveryMIDIRSMidwifのyD習est,2(D,88一兜

Hofmeyt, G.1., Mshweshwe, N. T., Gulmezoglu, A. M.(2015)、Contr011edcordtradionforthethirdstageoflabour. TheCochr411e D4tabase Qf'syste抗4tic Reviews,1, CDO08020.http:ノノdx.doi.orgno.1002/14651858,CDO08020、pub2

H仍j, L., cardoso, P., Njelsen, B. B., Hvidman, L., Nielsen, J.,

& Aaby, P.(2005). Effed of sublingual misoprost010nSevere postpartum haemorrha名e in a primaTy healthCentre in Guinea・Bissau: Randomised double blind

dinicaltrial. BMI,331(7519),723

International confederation of MidMves & 1nternational

Federation of Gynec010宮y and obstetrics.(2003). j'oiHtState111eπt: M4114ge111eπt qf the third stage qf' 1αhourto preveHt post・partU1π h4e1πorrhas'e. London, un北edKingdom:1nternauonal Federation of Gynec010gy andObstetrics.

International confederation of Midwives & 1nternational

Federation of G沖ec010gy and obstetrics'(2007). pre・Ven廿on and treatment of poS中artum haemorrha今e:New advances for low-resource settin8S.111ter114h01141/our11αI Qf'Gy11ec010gy aHd ohstetrics,97(2),160-163.

International confederation of Midwives & 1nternational

Federation of Gynec010gy and obstetrics.(20IDPreveπガ011 αHd treat柳e11t qf'post・partU111 h4e"10rrh4ge:Ne1ν 4dναπCesjor l01ν・resource setti118S. joiπt st4telHe11t.Retrieved from www.internationalmidwives.org

Ians s.,& Beentjes M.(201の. A11αe111ia i" 111idwifery pradiceG御'deliπe. utTecht, Netherlands: KNOV

}angsten, E., Ma杜Sson, L. A.,1、yckestaln,1., He11Str6m, A. L.,& Ber8, M.(20ID. comparison of adive manage・ment and expedant management ofthe third stage ofIabour: A S、vedish randomised contr011ed trial. BIOG,

118(3),362-369. http://dx.doi.orgno.H11/j.1471-05282010.02800.X

Lalonde, A., Daviss, B. A., Acosta, A.,& Herschderfer, K.

(2006). postpartum hemorrhagetoday江CM/NG0 血i・tiative 2004-2006.1πter114ti011αl jour1141 qf' Gy114ec010gy4πd 06Stetrics,94(3),243-253.

Lew, V,&Moore,}.(1985). The midwives management ofthethird stage oflabour. NursiH8 Ti柳es,81,47-50.

REFERENCES

The LENTE studγノa那 et a/.181

Ansari, A.(2015)、 rhe 8re4t u"1bilicnl cord・cuttiπg de●αte.Retrieved from www.cnn.com/2015/05/29/heaRh/

Cut・the・cord/

Bais, j. M., Eskes, M., pel, M., Bonsel, G.}.,& Bleker,0. R

(2004). postpartumhaemorrhageinnUⅡiparous、vomen:Inddence and risk fadorsin low and high riskwomen.A Dutchpopulauon・basedcohortstudy onstandard (>Or = 50o mL) a11d severe (> or = 10oo m王、) POS中artumhaemorrhage.三Uropeα11 jour11αl qf' obstetガCS, Gy11ec01・Ogy 411dRepmdudive Bi010gy,115,166-172.

Begley, C. M., Gyte, G. M. L., Devane, D., MCGuire, W,&~veeks, A.(2015). Active versus expectant managementfor women in the third sta8e of labour. The cochr411eD4mhase qf' systelhatic Reviews,3, CDO07412. http://dx'doi.0弔/10.1002n4651858.CDO07412.pub4

Bose, R, Reg飢, E,&paterson・Brown, S.(2006).1mpr0血g theaccuracy of estimated blood loss at obstetric haemor・rhageusingclinicalreconstructions. BIOG,113,919-924.

Brant, H. A. a967)' precise estimauon ofpostpartum haem・Orrhage: Dif6Culties and importance. BMj,1,398-400.

Farr註, D., Airey, R., Law, G., TU丘ne11, D., ca廿le, B.,& Duley, L.(20ID. Measuring placentaltranS6.1Sion for term births:Weighingbabies with cord intad. B/OG,118,70-75.

182 The 圧NTE study /ans et a/

MCDonald, S,, Abbot,1. M.,& H弔呂ins, S. P.(2004). prophylac_tlc er80metrine・oxytocin versus oxytodn for the thirdStage of labour. The cochr4πe D4mみαSe qf' syste柳4h'CReviews,(D, CDO00201.

The Netherlands perinatal Registry a996)' verloskU11de iπNeder14114 Grote 珂11e11 1989、1993 [obstetrics in theNetherlandS 1989-1993]. utrecht, Netherlands: SIGZorginformatie.

Nordstr6m, L., Fogelstaln, K., Fridman, G., Larsson, A,,&Rydhstroem, H. a997). Routine oxytodn in the thirdStage of labour: A placebo contr011ed ra11domised trial.

BriガSh /oarπ41 qf' ohstetガCs a11d Gy11αec0108y,104,781-786.

Perinatal Care in the Netherlands.(2012). stichtiπ8 Periπ4_tale Regishatie Neder1α11d. Retrieved fTom http://WWW・perinatreg.nvuploads/150/150/1aarboek_zorg_in_Nederland_2012_Tabels_B032014.pdf

PrendiVⅡle, W I., Elbourne, D.,& MCDonald, S.(2007). ActiveVersus expectant mana号ement in the third stage ofIabour (cochrane Review).1n: The cochrane Library,Issue 4. oxford. withdrawn

Prendivi11e, W J., Hardjng,1. E., Elbourne, D. R.,& surrat,G・ M・(1988). The Brjstolthird stage trial: Adive versusPhysi010gical management ofthe third stage oflabour.BM/; 297,1295-BO0

Razvi, K., chua, S., AruNumaran, S.,& Ratman, S. S. a996).A comparison between ⅥSual estimation and labora_

tory determination ofblood loss during the third sta eOf labour. The Australi4π 6 New zeα1411d /our1141 qf0みStetガCS 6 Gyπαec010gy,36(2),152-154.

Rogers,1・, wood, j., Mccandlish, R., Ayers, S., Truesdale,A.,& Elbourne D. a998). Active versus expect・

ant management of third stage of labour: TheHinchingbrooke randomised contr011ed trial.ιαHcet,351,693-699.

Sloal), N.上., Durocher, J., Aldrich, T., Blum,1.,& winik。丘 B.(201の.what measured blood loss te11S us about Post・

PaTtum bleedin号● A systematic review. BjoG, U7(フ),788-800.

Smit, M., van stralen, G、, wolterbeek, R., van Di11en, j., vanRoosmalen,1.,& slootweg, Y.(2013). survey of pro_Phylactic use ofuterotonicsin the 血ird stage oflabourin the Nether1■n心. Mdwif町y,29(8),859-862. h杜Pゾ/dx.doi.org/10.1016/j.midW2012.09.004

Tun〒alp,0., SOU2a,1. R,&G田mezoglu, M.(2013). NewwHOrecommendations onprevenuon andtreatment ofpost_Partum hemorrhage.1πter114h'011α1 /'our1141 qf' Gy11ec01_Ogy a11d 0みStehiιS,123,254-256.

Van Der woude, D., pijnenborg,1. M., verzijl, J. M., vanWijk, E. M.,& De vries, j.(2014). Health status andfatigue of poS中artum anemic women: A prospective

Cohort study Europeαπノ0uf11αl qf' ohstetrics, Gyπec01_Ogy,6 Reprodudive Bi0108y,181,119-123. http:ノ/dx.doi.org/10.1016/j.ejogrb2014.07.028

Westhoff, G., cotter, A. M.,& T010sa, j. E.(2013). pr。 h _Iactic oxytodn for the third sta号e of labour to pre_Vent postpartum haemorrhage. The cochr4πe Damhase

ψ Syste柳ωic R卯i■WS, aの, CDO01808. h杜Pゾノd,.d。i.org/10.1002n4651858.CDO01808.pub2

Winter, C., Macfarlane, A., Dene岻、Tharaux, C., zhan , WH., Alexander, S., BrocMehurst, P.... Troe8er, C.(2007).Varjationsin policies for maflagement ofthe third stageOflabour and the immediate management of postpar_tum haemorrhage in Europe. B/OG,114(フ),845-854.

World Health organi2atjon.(20]2). WHo rec0柳井le11dati0πSjbr thepreve11ti011411d treat1πe11t qf'postP4rtU111 h4e1110r_rhage. Geneva, switzerland: Author.

Xvorld Health organization.(2015). opti11141 ti"1iπ8 qf' cordd4"1PiHgjor the preventi0πψ iro" deflcie"cy απαe抗iaiπ iπjhhts. Retrieved from www、who.invelenaんitles/Cord_damping/en/

Ziekenfondsraad, a987). verloskUπd鴫eiπdimtie1加t[obstetricIndications List]. Amstelveen, Netherlands: Author.

AckπOwledg柳e11ts. we wish to thank aⅡ the women and

midwifery ptactices foT their commitment and particjpationin this study This study was made possible with the 6nandalSupport ofThe Netherlands or8anization for Health Researchand Development.

Cotrespondence re今arding this article should be directed toSuzeM. P.1.1ans, phD, MSC, RM, TNO Qualityofιife, PO B。X2215,230I CE Leiden, The Netherlands. E、mail: Suze)ans@dds.nl

Suze M. P.1.Jans, phD, MSC, RM, TNO Quality ofLife andThe Netherlands and RoyalDutch organisation ofMidwjves,KNOV; The Netherlands.

Kathy c. Herschderfer, RM,independent consultant, TheNetherlands.

Mariet Th. van Diem, MSC, RM, formerly university MedicalCentre Gronin号en, The Netherlands.

Mieke Ait血k, MSC, RM, policy advisor, RoyalDutchOrganisation ofMidwives, KNOV; The Netherlands.

MarⅡes Rijnders, phD, RM, TNO Quality ofufe, TheNetherlands.

Karin M. van der pal、de Bruin, PhD, TNO Quality ofLife,The Netherlands.

Simone E. Buitendijk, MD, phD, vice、Rector Ma8n論CUS,medicalfaculty,1,eiden university, The Netherlands.

Perceived Barriers a11d Facilitators ofa

NewModelinMana今i11gpre痕nant刃、romen刃、7ithIron DeficiencyAnemia: A Qualitative S加dy刃Vidy4Wati w'idy4W4ti, suze 入1. R /. j411S, V、7e1111y Arta11ti NiS111411,ΞIsiDwiH4PS4ri, jemeπν4π Di11eπ,4πdA11toi11e此e ιe0πarda 入lari侃ι4Sro・ノ'a11Sse11

A new model ofantenatalcare to manage pregnant women with iron de丘Ciency anemia at pubⅡC healthCenters in lndonesia has been studied. This study aimed to explore the facilitators and the barriers ofthis new modelintroduction by using focus group discussionsto nurse-midwives and nurse-midwifeCoordinators. Ttaining and information booNets,the improved con丘dence in providing comprehensiveCare, and adequate support 丘om supervisors were peTceived as facilitators ofthe new model. FinatldalSupport and public transportation necessary to reach the optimum treatment according to the newmodel,1imited health insurance coveTage, and shortage of sta丘 and iron tablets were the barriers, simi・Iar barTiers should be antidpated for 6.1rther implemenねtion、 A lasting support of policy and dedsionmakers therefore is essential.

KEYWORDS:iTon deficienq anemia; pregnanq; public health;the Four pi11ars Approach

INTRODUC110N

Among members of the Assodation of south EastAsian Nauons (ASEAN),1ndonesia ranks fourth in the

Prevalence of anemia in pregnancy with a rate ofmore血an 40%(world Health 0弔anization [WHO],2005).Slightly belo、v the national pl'evalence rate of anemiain pregnancy, Yogyakarta spedal province has a rate of39%(MinistTy of Health Republic of lndonesia,2014).Iron de丘Ciency is the most common cause of anemiain pregnancy in lndonesia, f0ⅡOwed by hookwotm andOther related infectious diseases (Nurdiati, sumarni,

Suyoko, HaMmi,& winkvist,20OD、Anemiaduringpregnancycanhaveadversee丘ects

On the mother and the fetus, such as miscarriage, pre・mature birth,10、v birth weight, and less reserve capac・ity to adjust to postpartum hemorrha今e (AⅡen,2000;Haider et al.,2013).1n 1970, an iron supplementationProgram for a11 Pregnant women in lndonesia was

implemented to overcome these problems (1Zwardy,2014; schultink, van der Ree, Matulessi,& Gross,1993).

Holvever, constraints such as inadequate supply ofirontablets, poor quality of counseling by health care pro・Viders,1ack ofhlowledge, and concern about maternalanemia by health care providers 、vere reported, asWeⅡ aslow motivation and resistance among pregnantWomen to take iron supplements because of the sideeffects experienced (Ga110way et al.,2002; scbultinket al.,1993).

Involvin号 the pre号nant womenls husbands inantenatal care program has a positive inauence onbealth care utilizatjon during pregnancy (singh,ιam・Ple,& Earnest,2014). However, in lndonesia, thisPartidpauon in antenatal care pr0名rams is hamperedy male perceptions of pregnancy; it is thought to be

Solely a womalゞs domain. The ma11's main responsibil・ity is to provide 丘nandalsupport rather than accom・Panyin留 his wife to a廿end the antenatal care program

&//VTER/VA刀0/VAι. JOURIVAι. OF CH/ιDB/RTH VO/ume 6,/ssue 3,20ブ6

◎ 2016 Springer publishlng company, LLC WWW.springerpub.comhせP://dx.doi.org/10.189ν2156-5287.6.3.183 183

184 Managing pre8nant women ~vith lron

(shefner・R08ers & sood,2004). But, even when thehusband is Present, health care providers mosdy focusOn interaction with tbeir female dients (Erlindawa廿& 1Saranuruq,2008; shefner・Rogers & sood,2004;叉Vidya、vati,1ans, utomo, et al.,2015).

Based on these results and experts opinions,、vedesigned a new modelto manage the pregnant womenWith iron de6dency anemia in public health centers(PHCS)、 This new model was caⅡed the Four piⅡarsApproach. The content ofthe Four pi11ars Approach isWomel)'s healthy lifestyle and husbands' and/or familymembers' sodalsupport as the first and second pi11arsto empower the women and adequate midwifery treat_ment and nurse・mid、vives' professional attitudes as thethird and fourth piⅡars to empower nurse、midwives(widyawati et al.,2014).

The intervention of this new model has beenConducted in 2012-2013 at 19 PHcs in 丘Ve dis_tricts of Yogyakarta spedal province in lndonesia asan lntervention group sped丘C training and moduleWere given to the nurse・mid、vives. The trained nurse_

midwives recruited partidpants with a 今estational a8eIess than 12 Weeks, hem0今10bin leve11ess than 11 /dl(WHO,20ID, and living together with their husbandsOr family Based on the Four pi11ars Approach, someinterventions have been given to the pregnant womenand their husbands/famⅡy members, indudin8 ir。ntablets to the pregnant women with anemia、 TheProgress ofthe anemic status ofpatients recruited 、vasmonitored for about 6 months. The level ofhemogl。_bin 、vas rechecked when the patients' gestations 、vereat 35-37 Weeks. The effectiveness of the ne、v model

Was indicated by (a) the differences of hemoglobinIeve1 塗0.5 g/dl, before and after intervention;(b) ante_natal care more than regular visits;(C) the attendanceOf professional health provider during labor. The 6rsttwo mentioned outcome measurementsimproved Slg・

njficantly in the intervenuon group compared to the

Controls. SO, based on these 丘ndings, the new modelhas promisin名τesultsto manage pregnant women withiron de負Ciency anemia in pHCS (V、1idyawati,1ans, B。r,et al.,2015).

As part of our main projed to develop a newmodelin managing pregnant women with anemia and

to strengthen the results of this quantitative study,、veWere interested to klow more into depth about barriersand facilitators ofthis newmodeldurin8the implemen_tation period at pHcs in Yogyakarta spedal provincefrom the perspective of trained nurse、mid、vives andnurse・midlvife coordinators of the family health r。_8ram at district level.

Deficiency Anemia レVidyavvati et a/

METHOD

Study Design

Xve performed a qualitative study using focuS 号roudiscussions (FGD) with four groups ofnurse、midwivesWorkin名 at pHcsin Yogyakarta spedal province. FOCUSgroups are particularly suited to understand opinionsand a廿itudesthroU8h generaung discussion and interac_tion amongpartidpantst0丘lrtherdeveloptheirthoU号htsand opinions (Duggleby 2005; GⅢ, stewart, Treasure,&Chadwick,200& onwuegbuzie, DicMnson,1'eech,&Zoran,2009). ForlogiS廿C reasons, two focus groupstookPlace in November 2013 and two in Apri12014.

Participants and procedure

AⅡ the nurse・mid、vives invited were trained in the FourPiⅡars Approach and work on a daily basis in a pHCWhicb implemented the Four pi11ars Approach. Thenurse・midwife coordinators of the family health pr。_8ram 丘om the 丘Ve districts' health of6Ces were invited

to parudpate in a separate group because they havedifferent roles in the intervention of the Four pi11arsApproach. Each focuS 8roup consisted of 丘Ve to sevennurse・mid、vives.~×1e informed aⅡ Partidpants abouttheaim ofthe 血Cus group and asked forinformed consent.

A topiclistbased on theliterature and expert opin_ion 、vas developed to guide the discussions (Table D.Xve adjusted the list a丑er discussion by the researcherteam at scho01 0f Nursing, universitas Gadjah Mada.Experienced moderators from the scho01 0f Nursing,Universitas Gadjah Mada guided the discussions. Themoderators were familiar with obstetric care because

they had been 、vorMng as senior ledurers in maternitynursing for more than lo years. The focus groups were丘111y recorded and transcribed verba廿m.

Data Analysis

Three researchers (WW WAN, EDH) analyzed thetranscript of each session. The researcherS 6rst inde_

Pendendy a廿ached codesto the themes emergin8 fromthe text.1n discussion, they reached consensus aboutthe codes and the themes. According to the method ofConstant comparative analysis, these codes were com_

Pared with the text of the transcript during an iterativeProcess, adjusted and re6ned accordingly F0ⅡOwing theinitial coding process, the three researchers discussed

TAB王EI

PARTICIPANTS

Coordinators

Offam・

ily healthProgram

InteNiewGuide

TOPIC

The barriers on the

implementation oftheFour piⅡars Approachin managin8 Pregnantいノ0men with anemia in

Public health centersThe faC川tators on the

implementation oftheFour pi11ars ApproachIn managln8 Pregnant、vomen with anemia in

Public health center5The barrlers on the

Implementation oftheFour P訓ars ApproachIn managln8 PregnantWomen ~vith anemia in

Public health centersThe faCⅡiねtors on the

implementation oftheFour pi11ars ApproachIn managlng pre8nantWomen ~V託h anemia ln

Public hea1小 Centers

Managing pregnant vvomen with lron Deflclency Anemia Ⅵノidyawati et a/.185

Trained nur5e・

midM/ives

DISCUSSIONS

. could you teⅡ Us your experlence in supervising the implementation of Four pil・Iar5 Approach in public hea1小 Centers?

. Have the Four P川ars Approach been implemented as you expected? Te11 me

. As a pr08ram coordinator, did you find any problems or di仟iculties to coordinateOr facilitate the implementation of Four piⅡars Approadl? HO~v did you face iぜ

. Regardlng thiS 5tudy results,伽e Four pHlars Approach give the poS川Ve effed onthe Hb increasing ofthe pregnant 、vomen with anemia,、vhat d0 γOU 小ink aboutthis? vvhat are the supporting fadors? Te11 me..

the 丘ndin8S and combined codes into broader catego・ries (Duggleby,2005; onwuegbuzie et al.,2009). TheSoftware prooram ATLAS.ti version 6.1 Was used toSupport data analysis.

. could you te" us your experiences ln implementln8 the Four pi11ars Approach tomanage pregnant 、vomen 、vith anemia in public hea1小 Centers!

. Have you found any problem50r di仟iculties durin8 the implementation of theFour pi11ars Approach?

.~vhat are the b唱gest problems or di仟iculties you have faced? Hovv do youhandle 迅

. Based on your experiences, did you succeed in managing pregnant Yvomen withanemla usin8 the Four pi11ars Approach?O lf ye5, Yvhy ..、?O lf not, why ..,?

. Accordin8 t0 γOur opinion, vvhy did the Four P川ars Approach succeed (or not)tomana8e pregnant、vomen with anemialTe11 me

. could you explaln ゛/hat are the supporⅡn8 factors of thi5 Succe55?丁e11 me .

Ethical consideration

The Ethical committee of the Faculty of Medidne,Universitas Gadjah Mada, Yogyakarta,号ave the ethicalapproval for this study on December 15,2011 (Ref. no.:KE/FK/730/EC)

REsuns

FaCⅡitators

Nineteen trained nurse・midwives and 丘Ve nurse・midwife

Coordinators partidpated in 仕le FGDS (Table 2 andTable 3). The 19 nurse・midwives were divided into

丑)ree group discussions (FGD 2,3, and 4) and the 6Venurse-midwife coordinators in one group discussion(FGD D. Themea11ageofthetrainednurse・midwiveswas37.5 ye紅S (SD 士 12.フ) and ofthe coordinatorS 46.6 years(SD 士 1.D. Themajotityofthenurse・midwiveshadmorethan lo years worMng experience in pHCS.

Three main themes emer号ed as facilitators ofthenew approach:improved nurse-mid、vives' competences,improved nurse・midwives' con負dence in providingmidwiferytreatment, and adequate supportfrom super・VisoTS. As barriers, the f0ⅡOwing three themes calne up:丘nandal and transport obstades to achieve a healthyIifestyle or to attend parenting dasses,1imited healthinsurance coverage, and limited resources such as staffShortage and unavailabiHty of iron tablets. A thematicrepresentation ofthe themes is presented in Table 4.

1抗Prove柳eπt ofNurse-M'id1νives' C0抗Pete11Cies

A]1the trained nurse・midwivesin a11groups mentionedthattheyfeltsupportedin theirworkbythetraining andthe provision ofa booNetto give to the women whichOffered information about a healthy lifeswle for preg・nant women. They stated that both were veryhelP会.11inProvidingadequatehealthinformation. ThebooMet alsomade it easier for the trained nurse・midwives to under・

Standthewomadshealth condition inbet、veen antenatal

Visits because most women made notes in the booMet

aboutthe healthproblemstheyexperienced.1n addition,

186 Managing pregnant vvomen with lron Deficiency Anemia レVid aレVati et a/

TABIE2 Partidpa11ts' characteristics

Age (in years)Trained nur5e・midwives

S30 years

3040 years

>40 years人4ean

SD

Nurse・midwife coordinators

三30 year5

3040 years

>40 years 5 (100)八Aean 46.6

SD 士1,1

、Norking experience in public health cenler (in years)Trained nur5e・mldwives

三5 γears

6-10 years

> 10 years人人ean

SD

Nurse・midwife coordinators

S5 γears

6-10 years

>10 years 5 (100)人んean 20.4

SD土1.1

Work location in public health centersUrban 討ea

Rural area

Near the cityTrainin目 experience in the last 3 years

The Four pi11ars Approach

Risk pregnancy managementHea11h counseling

Nや向

4 (21.0)

8 (42.1)

フ(36.9)

37.5

土12.フ

None of the nurse・midwives in a11 groups feltinconvenience W北h the presence of patient's husbandin the antenatalcare pr08ram. Moreover,in FGD 3,thenurse・midwives found that sodalsupport 丘om hus_bands and family members (the second pi11ar) broughtthem into doser contad with their pauents and theirfamilies.

nla1ず lhe11 イhuSみa11ds) Cα1πe t08ethel' withtheir wives to the ANc dbliC 1νithoutjeeli11g41νk1ν4rd ... they 1νere eveπαSkiπg s0111e ques、ti0πS ...(nurse・mid、vife,12 γears' experience,FGD 3 Partidpant 4)

24 a0の

6 (25.0)

フ(292)

4 (16.フ)

4 (16.フ)

1 1 (66.6)

9.9

土4.9

CO"jldeπCe i↑Iprovidiπ宮'C0柳Prehensive C4reAⅡ groups a号reed that competency improvementensured nurse-midwives to be more con丘dentin man_

a81n8 Pregnant women with anemia, They stated thata consultation Was easy to carry out and they feltCompetent to offer adequate treatment which seemedto improve work satisfaction. Furthermore, the nurse、

midwives mentioned that they reaⅡy wanted to blowthe effeC廿Veness ofthe care they delivered.

the nurse・midwives in aⅡ groups also mentioned that,because ofthe extra trainin島 they felt be杜er eqUゆPedto communicate adequatelywith their patients and theirfamilies. The trainin今 offered the opportunity to learnhow to monitor patients' health pr0今ress more easjly

The Four pi11αrs Approach "1ake 1れe 1110reC011jldeht to provide 11eι11th i"jor111αh'0π 411d to1π011itor the health progress qf'e4C11 Patie11t .(nurse・midwife,4 γears' experience, FGD 2PartiCゆant D

AdeqU4te supportFr0柳 SupervisorsIn the group of nurse・midwife coordinators, FGD Iexplained earnestly that supervision and advice 丘omthe nurse・midwifヒ Coordinators were helpful for thetrained nurse・mid刃Vives to provide adequate 8Uiding ofPregnant women and theirfamily according to the FourPⅡlar Approach. The coordinators of nurse、midwives

mentionedthatsomeheads ofpHCS 8avemoralsupportto the trained nurse・midwives and aⅡOcated the budgetto copductthe parentaldasses atthe pHCS.

5 (20.8)

10 (41.フ)

9 B7.5)

They lthe P4ガe11tS14re e11Courα8ed t01νritedoWπα11their health co"1P1αi"ts iπ the c0111"1eπtsC011ι111π qftheir booklet nπd l C411j01101ν t11eirheahh st4加S Uπガ1 their 11ext 411te114t41 νisit.(nurse・midwife, B years' experience, FGD 2PartiCゆant 5)

Ijeel d1α11e118ed 6y thiS 4PpronC11 αhe F0伽'Pi114rs/,14"1 en8er to ha11dle t11e case to its c011、dusi0π a11d to k1101ν the outco"1e qf'所e treat111e11tthat l hmぞ 8ive11...(nurse・midwife,15 years'experience, FGD 4 PartiCゆant 7)

00

00

ThematicA11alysis ofthe DataTABIE3

τOPICS

Barriers

THEM郎モMERcf

. This approach spent a lot of ume.

. Need a more simple reportform

. Di仟icultto make a schedule for parenting dasses 、、,hich can be a廿ended by patien6, husbands, or otherfam11y member

. The first P川ar of Four P川ars Approach was di仟icult to achieve, especia"y for patient's eating pattem that is influ・enced by flnancial constraints.

. Not a11 nurse・midwives in public health centers have been trained on the Four piⅡars Approach; therefore, themana8ement of pregnant vvomen with anemia is hi8h1γ dependent on the presence ofthe trained nur5e・mid、vives.

. ceographical constraints and unavailabホty of pub!ic tran5Portation to or from certain public Health centers atany tlme

. Nationalinsurance has not covered the additional cost of Hb test

. Long bureaucratic system to order the facilities that are needed by the public health centers

. very excitin合 With the new concept

. Enjoy to be a counselor in parenting classes

. curious to know the progress of patient's health status

. New experience in handling the cases comprehensively

. Havin8 Close lnteraction5 not on1γ With paⅡent but also with the fami1γ

. More chaⅡenging; the Four pi11ars Approach has di仟erent procedure5 than the old one

. More responsible to monitor the results of the program to antiCゆate 小e unpredictable results (e'gリ ComplaintsOn the proaram orthe treatments)

. By U5ing the booklet of Four pi11ars Approach a5 a guidance, supervision became more easy

. More confidence in glving a hea1小 Consultation (The booklet and the four pi11ars approach guidelines were ve「γhelpfu l.)

. Having good interadion with patient and husband as we" as family member so that nurse・midwives were easi1γto monitor the progreS50f patient's health status

. T1地 5Upports from head of public health center

. Financial aⅡOcation to condud 小e parenting classes

. The availabⅡity of leaming resources (trainlng module and bookleo for 小e nurse・midいノ1Ves and a150 forthe paⅡents

. The cornmitment ofthe trained nurse・mid、vives in public health centers to implementthe Four piⅡars Approach

. cood communication bet、Neen researchers, program coordlnators, and trained nurse・mid゛/ives

FaC山tators

Mana8ing pre8nant vvomen with lron Deficiency Anemia いノidyaレVati et a/.187

1νheπ 1 νisited pare11tiπg dasses i11 Puskes・m"'1PHCI,1畝W th.h即d ojP那kお剛郎 IPHCI

Preseπt8iviπg advice 110t 011b to the trabled"urse・"1id1νives but 41So to the patie11ts n11dj111hily ...(nurse・mid、vife coordinator,19 years'

experience, FGD l partidpant 3)

Ohstadesto Rench theAi柳S oftheNe1ν入10delThe trained nurse・midNvivesin GrouP 2 mentioned thatSometimes, the achievement of a patients' healthy life・Swle was hamperedbythe patientsthatcouldnota丘ordto buyfood ofanimalorigin such as meat, milk, ore3gs.Furthermore,in GrouP 3,the nurse・midwives deploredthat there were some pauents lacMng sodalsupportfrom theirhusbands orfamilymembers. Theyexplainedthat patients' husbands could not attend the dasses dur・in8 WorMng hours, but patients could be accompaniedby another family member. The other partidpants inGrouP 3 also mentioned that women who did notlivedose to the pHc could not eaSⅡy partidpate in parent・ing dasses. A11trajned nurse-midwivesin GrouP 3 Con・負rmedthatmanypatients usedpublictransportto reachthe pHC,、vhich was not available at aⅡ times and in a11

Situations. one ofthe trained nurse・mid、vives in Group3 mentioned that pauents who lived far away from thePHc were visited by the nurse・midwife at their homes

The supetⅥSion waS 3iven not only by the nurse・midwifecoordinatorsbutalso bythe head ofthe pHc asmentioned by one ofthe partidpantin FGD 4.

He lthe he4d Qf'PHcl nsked us lthe tr4bled

πUrsesl to c011ti11Ue 所eprogralH qfthe Four pil・

14rs Approach i11 PuskeS1πιIS IPHcl eveπ thoU8hthe iπterve11ガ011 qfthe study hasjbliS11ed .α11d he g4νe hisper"1issi0π thatP4re11tiπg classes"1αy use the BOK lthe operah'011αl budgetljU11ds ...(trained nurse・n〕idlvife,10 years'expetience, FGD 4 Partidpant 5)

Barriers

188 Mana8ing pre8nant vvomen with lron Deficiency Anemia レVid aヤVati et a/

IABιE4

TOPICS

ProceS50fthe Four . Barriers

P川ars Approachimplementation

ThematicA11alysis ofthe Data

CATECORIES SUBCATfcoRIES

. This approach speηt a lot oftime.

. Need a more simple reportformsDi仟icultto make a 5Chedule for parenting classes which can

.

be attended by patients, husband5, or other famHy memberT1犯价St pi11ar of Four piⅡars Approach was di仟Icultto achieve,

.

especiaⅡy for patient's eatin8 Pattem that is influenced byfinancial constraints.

' Not a11 nurse・mid~vives in pubⅡC health centers have beentrained on the Four piⅡars Approach; therefore, the manage_ment of pregnant、Nomen with anemia i5 highly dependent onthe presence ofthe trained nurse、midwives.

Ceographical con5traints and unavaⅡabⅡlty of public transpor,.

tation to or from cer捻in public health centers at any tlmeNationalinsurance has not covered the additional c05t of Hb test.

.

' Lon8 bureaucratic system to order the faci"ties that needed bythe pub"c hea1小 Centers

' very excited with the nevv concept' Enjoy to be a coun5elor in parenting classes' curious to knoW 小e P伯greS50f patient'5 health 5tatus

Ne、v exl)erience in handling tbe cases comprehensively.

Havin菖 Close interadions not only with patient but also wkh.

the family

' More cha11enging, the Four piⅡars Approach ha5 differentProcedures than the old one

More responsible to monitor the 陀5U11S ofthe program 如.

antiCゆate the unl)redictable results (example: complaints on小e pl'08ram orlhe treatment5)

' By uslng the booklet of F0Ⅲ P川ars Approach as a guidance,Supervision became more easy

' More confidence in giving a health consultation (The booklet

and the four pi11ars approach 8Uidelines 、vere very helpful)' Heving good interaction ~V川I patient and husband as Y、1e11 as

fami1γ member so that nurse、midvvives vvere eaS11y to monitorthe progress of patient's health status

' The supports from head of public health centerFinancial a"ocation to condud the parenting classesThe availab市ty of leaming resource5 (training module andbooklet) for lhe nurse・midwives and a150 for the patientsThe commitment of 小e trained nur5e,mid、vive5 in pub11Chealth centers to implementthe Four piⅡars ApproachCood communication bet、veen researchers, program coordl_nators, and trained nurse、midwives

.

It is diが'iC1ιltjor us lthe πUrse・111id1νif'el to "1011、itor the S1ιCcess qfthejirstpi11arjor s0111epntieπtsWhe11 がley S4id がlnt they Cαπ110t qガ【'ord t0 み1ιyjoodqfα11力πα10rig'H, especin11γ"1eat ..,みeCα1ιSe it isexpehsive ...(nurse・midwife,8 γears' experienceFGD 2 Partidpant2)

. Facilitators

区i抗itedHenlth 111Sur4πCe cover4SeIn GrouP 4, nurse・midwives felt hampeted in providingOpumum midwifery treatment because ofthe Ⅱmited

.

1. 1mprovement ofnurse・mid、vives

Competencles2. confidence in

Provlding compre、hensive care

3. Adequate 5Upportfrom supervi50rs

.

THEMES

1. obstades to reach

the aim50fthe new

model

2. Limited health in、

Surance covera8e3. Limited resources

...1Used the puskeS111αSY'PHC太1 νe11icle to visit 4Patient at h0111ejorpare11h'π8 d4Sses,6eC4Use sheIives veryjhrjr0111 PuskeS111αS IPHCI ...απd 4118・kot1ンUblic trαπSport4ti0111 is rare ...(nurse、midwife,14 γeats' experience, FGD 3 PartiCゆant 6)

for a parenting dass usin号 the vehicle owned by pHC.Sometimesthe nurse・midwife had to pay forthe petr01.

.

health insurance coverage for laboratory tests. Nationalhealth insurance for pre3nant women only covers theCost of laboratory tests t、vice durin8 Pregn釘Icy HOW・ever, some pregnant women mi8ht need a hem0号10bintest more than t、vice.1n this situation, the women were

expected to pay the addiuonal costs themselves.

Eveπ 411Patie11ts use 4 Speciflc he41th i九Sur・απCejbr a11te11αta1 α"d birth ...6Ut s0柳e patie11ts1νh011eed 柳ore 1αbor4tory tests, they hανe topay

jor the additi01141 Costs ... beC4Use the iπSurαπCe0111y covered thejlrst a11d sec0πd Hb tests ...1ンH4fr4id that lcould πotprovide 4Proper treat"1eπtjor the111...(trained nurse・mid、vife,6 years'experience, FGD 4 Partidpant 2)

The Facinねtors

Managing pregnant vvomen with lron Deficiency Anemia vvidya、vati et a/.189

ιi机ited Resources

Nurse・midwives in GrouP 2 agreed thatthey appearedto be burdenedbythe results ofan overstretched system.They experienced shorta名es of sta丘 and the unavail・ability of iron tablets preventing them from doing theirWork according to demands. They stated thattheywereresponsible for the management of pregnant womenWith anemia. Nevertheless,1ack oftime made itimpos・Sible to perform the tasks involved. A11 group membersSU3gested thatthe number oftrained nurse・midwivesinevery pHc should be increased.

a丘ord to buy nongeneric iron tablets prefeTred theseOverthe free medication. Nloreover,the nurse・midwives

in GrouP 3 mentioned that free iron tablets were notalways available, and women someumes had to wait fordays before new supplies arrive.

.1t、vas almost a week that、ve did not have any

iron tablet ,..丘naⅡy,、ve give prescription to the

Women to buy it (atthe drug store)...(nurse・

midwHe,7 years' experience, FGD 3 Participant 3)

The nutse・mid、vives in GroupS 2,3, and 4 alsomentioned thatthey thoughtthe side e丘ects ofthe freeiron tablets supplied by the government were strongerthan the nongeneric iron tablets which ca11 be boughtfrom private drug stores. Those women who could

From aⅡ FGDS, it was sU今号ested that tbe imple・mentation of the Four P田ars Approacb to managePregnant women with anemia should be weⅡ Prepared,espeda11y for the availabⅡity ofiron tablet and ofbook・Ietsin every pHC.

1νe are hl,o lthe 11ιι111ber qftr41'πed 11Urse-抗id1νiyesl ...4πd lve hανe t0 加aπα宮e 1110re th4π

10pre8πa11t ヤν0111eπ With 4πe111i4...1 thi11k ...We 11eed 11101'e ltr4i11ed 111ιrse・111id1νifel ...(nurse・midwife,12 γears' experience, FGD 2 Participant 5)

The trained nutse・midwives in our study experienceda lot of help by having a trainin今 and 紅linformationbooNet for 杜leir pauents and fa111ily. They also felt com・Petentto deliver high quality ofcare to pregn釘lt womenWith iron de6dency anemia. They were more con丘dentand capable to communicate during interaction with theIvomen and their family members as weⅡ as with theirC0Ⅱeagues and supervisors. The commitment of nurse・midwivesto catry outthe Four PⅡlars Approach and toProvide conti11Uity of care lvas remarkable but is sup・Portedbyother丘ndingswhich showthatcon6denceandCommitment ofhealthworkersrisewith increasing com・Petendes.1n addition, weⅡ・informedhealth careworkersfセeHncreased commitlnentto the duties assignedto them

DISCUSSION

. P4tieπts registr4ti011 C411πot be stopped U11til11 4.111., whe11 the re宮istr4ti011 11U111ber iS 抗oret114π 25, it 1πeαπS that 1νe 11eed extr4 tilhe to

take care qf'411thepah'eπts that h4νe beeπ re8・istered th4t d4y α11d half'Qfthe111 1νere απe111ic

(nurse・mid、vife,7 years' experience,IV01"e11

FGD 4 Participant 3)

凡Ive found three facilitators and three barriers of the

intervention of the Four pi11ars Approach as a newmodelin mana8ing pregnant women with iron de丘・Ciency anemia in pHcsin Yogyakarta. The 杜)ree fadli・tators indude the trained nurse・midwives bein8 WeⅡequipped and feeling competent by the trainin牙, gain・ing confidence in providing comprehensive care, andreceiving adequate support from supervisors. The threebarriers are the lack of 負nandal and public trans・Porta廿on necessary to reach the optimum treatmentaccording to the Four pi11ars Approach,1imited healthinsurance coverage, and limited resources.

190 Mana三ing pregnant vvomen with lron Deficlency Anemia レVid aレVati et a/

(Adib Hajba8hery & salsali,2005; Adib Hajbaghery,Salsali,& Ahmadi,2004; Banchani & Tenkorano,2014).

Thetheoryofaor8anizauonalreadinessforchangd'States that positive interaction and adequate superⅥSionrepresentthe readiness for change and tbe readiness forChan8e W辺 develop commitmentt08etthe work done(Nancarrow et al.,2013;刃~7einer,2009).1n our study,the nurse・midwife co01'dinator represented a facilitauveSupervision,凡Vhereby supervisors focus to observe theneeds oftheir sta丘(Aikins et al.,2013). The essentialroleOfthe fadlitative supervisor 、vas to enable sta丘to man_age the quality improvement process,to meetthe needsOftheir patients, and to implement organization goals.

A S加dy in low income countries reveals that thee丘orts in health System strengthening were charac、terized y increasin名 birthing fadlity, increasing thenun)ber Of midNvives, decreasin8 丘nandal barriers, and

Iate a廿ention forimproving the quaHty ofcare. Further_more, resped6、11Woman・centered care has receivedli廿le

Or no a廿ention (van lerber昌he et al.,2014). Howeve二the Four piⅡars Approach emphasizes monitoring,'ointProblem solving, and two・way communication betweenthe supervisor and those being supervised,justthe 、vayasthe 6Ve nurse-midwife coordinatorsin ourstud ad.

the trained nurse・midwives mentioned that, becauseOfthe Hmited number oftrained nurse、midwives, thehave to work overtime to mana8e aⅡ the patients.

During the period of intervention of the Four

Pi11ars Approach,1ack of availability of iron tabletsfor several days in some pHcs was mentioned by thetrained nurse・midwives. However, Impr0Ⅵng access

to maternal health logisucs is an essential Component

Of strengthening maternal health pr0σrams and out_Comes (Ber3eson・上Ockwood, Madsen,& Bernstein,2010; He},wood & choy,2010; Lule et al.,2005;Madsen, Bergeson・Lockwood,& Bernstein,201の. H aWeⅡ、designed program is not backed up by adequateresources and support at a higher level, resU1廿ng in lackOf a gua羚nteed supply ofiron tablets at pHc and lim_ited insurance coverage, then the successfulimplemen_tation ofthe program could be at risk.

The Barriers

The failure to achieve the optimaltreatment ofthe 6rstand the second pi11ars ofthe Four piⅡars Approach wasPerceived by some nurse・midwives as being a result ofPatients' 6nandal dif負Culties and public transporta_tion limitations. However, this condition might only befound in certain areas in Yogyakarta spedal provinceWhich are situated in mountainous areas and in loca_

Uons which are dif丘Cultto reach by public transport.Limited health insurance covera8e was perceived

as a constraint to provide adequate treatment. TheCoverage of health insurance for pregnant women isimportant, espedaⅡy when the pregnant women needmore than regular antenatal care visits and laboratorytests, such as those with anemia or hypertension durinPre8nancy (DO、vswe11 et al.,2010). A study reveals thatadequate antenatalcare services are inauenced byhealthInsurance coverage (comfort, peterson,& Ha廿,2013;Montgomery,20OD.

Another perceived barrier was sta丘 Shortage. TheSta丘 Shorta8e mi名ht have implications in terms Of a

reducuon in the quality of services, increased work_10ad, and reduced time for patients (Bangdiwala, Fonn,Okoye,& T011man,2010; Fritzen,2007).1n our Study

Ⅱm託ations and strengths

~ve 血Cused on nurse・midwives asthe prime health careProviderin theintervention ofthe FourpiⅡarsApproachin pHC. The trajned nurse・mid刃ViveS 丘om ever pHCand the nurse・midwife coordinators from 丘Ve distrid

health of丘Ces partjdpated in the FGDS. The homogene_ity ofpartidpantsin each group made a positive interac_tion in topics discussed; therefore,、ve could not exploreany contrast opinions among the partidpants. ourS加dy represents aⅡ PHcs which were jnvolved in theintervenuon ofthe Four pi11ars Approach in YogyakartaSpedalprovince. Howeve二 thisstudy does notincorpo_rate the opinions of heads of pHcs and policymakersaboutthe implementation ofthe Four piⅡars Approach.As a consequence, ourstudy6ndingslackfヒedbackfromthese leaders 、vhich is also important 血r the 11nprove-

ment and continuity ofa newmodelin pHC.ιast, because qualitative study is designed to

identify themes, results cannot be generalized.~、1e caτ1_not presume that our 6ndings are applicable becauseWe interviewed only the nurse midwives and nurse_

midwife coordinators, who were very dedicated to thenew model.

CONC【.USION

Faci1北ators ofthe Four piⅡars Approach in pHc are thefeelingofcompetence and con負dence bythenurse、mid_Wives in addition to adequate supervision. The barriers,as perceived by the nurse・midwives, are limitauons

regarding resources (6nance, transport, and treatment)and sta丘Shortage.

Concerning 杜le sustainability of the Four pi11arsApproach in pHC, distrid health of丘Ces (DHO), andthe provindal health 0丘ice (PHO) need to be aware ofthese barriersto give better antenatalcare services, espe・daⅡy for pregnant women with anemia.1n addition,DHo and pHo should facilitate trainin号 a11d learningresources for nurse・mid、vives in pHC. crudaⅡy, the会lture implementauon of the Four piⅡars Approachneedsthe support ofpolicy and dedsion makers.

REFERENcfs

Managing pregnant women wlth lron Deficiency Anemia レVidyaレVati et a/.191

AdibHajbaghery,M.,&salsali,M.(2005)、Amodelforempow・ermentofnursinginlran.BMCHe41thservicesResenπh,5,24. http://dx.doi.orgno'1186n472-6963-5-24

Adib Hajbaghery, M., salsali, M.,& Ahmadi, F.(2004).The fadors facilita廿n宮釘ld inhibitin名 e丘ecuve dinicaldedsioD-making in nursin8: A qualitative study BMCNursiπg,3,2. h杜P://dx.doi.org/10.1186n472-6955-3-2

AiMns, M., Laar, A., Nonvignon,1., sackey, S,1keda,1.,Woode, G.,... Nyonator, E (2013). Evaluation offacilitauve supervision visits in primary health careService delivery in Nothern Ghana. BMC Health ser・

Rese4rch, B,358, http://dx.doi.org/10.H86/νIces

1472-6963-13-358

AⅡen,1,. H.(200の. Anaemia and iron defidency: Effects onPregnancy outcome. The A111eriCαπノ0ur11αl qf' cli11iC41NutritioH,71,1280S-1284S.

Banchani, E.,& Tenkorang, E.Υ(2014).1mplementationCha11enges of maternal health care in Ghana: TheCase of health care providers in the Tamale Metropo・Iis. BMC He41th services Rese4rch,14,フ. h杜P://dx.doi

.org/10'1186n472-6963-14-フ

Bangdiwala, S.1., Fonn, S., okoye,0.,& T0Ⅱman, S.(201の、~votkforce resources for health in developing countries、P1ιblic Health Revie1νS,32(1),296-318.

Bergeson・Lock、vood,}', Madsen, E. L.,& Betnstein,1.(201の.ハ44ter11αl henlth supplies iπ Bαπ8'1αdesh.いlashin8ton,DC population Action lnternational. Retrieved fromhttp://pai.or号/IVP・contenvuploads/20H/12/maternal・health・bangladesh.pdf

Comfort, A' B., peterson, L. A.,& Hatt, L. E.(2013). Effed of

health insurance on the use and provision ofmaternalhealth services and maternal and neonatal health out・

Comes: systematic review. jour1141qf'He41th, POPU1αh'on,4πd Nutriti0π,31(4), S81-SI05.

DO、VS、ve11,T.,carroli, G.,D口ley,L.,Gates,S.,Galmezoglu,A.M.,Khan・Neelofur, D.,& piaggio, G.(201の. Alternative

Versus standard packages of antenatal care for low・riskPregnancy cochr4πe D4t464Se qf' syste111ahc Revielvs,(1の, CDO00934. h廿P://dx.doi.org/10.1002/14651858.CDO00934Pub2

Dug81eby,W (2005). whataboutfocusgroupinteractiondata?Qualit4tive Health Research,15(6),832-840. h杜Pゾ/dx.doi.or8/10.117フ/1049732304273916

Erlindawati, C. j.,& 1Saranuruq, S.(2008). Factors related tothe utilization of antenatal care services amon号 Pre晋nant women at health centets in Aceh Besar district,

Nangroe Aceh Darusalaln province,1ndonesia. jour1141qfpuhliι Health α11d DeveloplHe"t,6,99-108.

Fritzen, S. A,(2007). strate名ic management of health work・force in developing countries:~vhat have we learned?HU111α11 Resources jor He41th,5,4. http://dx.doi.orgno、H86/1478-4491-5-4

GaⅡ0、vay,R.,Dusch,E.,Elder,L.,Achadi,E.,Grajeda,R.,Hurtado,E.,... stephen, C.(2002). womeds percepuons of ironde6dency and atlemia prevention and controlin eightdevelopingcountries.socialscieπCeMediιiπe,55,529-544

GiⅡ, P., stewart, K.,& Treasure, E.,& chadwick, B.(2008).

Methods ofdata c0Ⅱection in qualitative research:1nter・Views and focuS 合roups. British Deπt4110urπ41,204(6),291-295. h廿P://dx'doi.org/10.1038/bdj2008.192

Haider, B. A.,010nn,1.,いlang, M., spieσelmen, D., Ezzau, M.,& Fawzi, W. W.(2013). Anaemia, prenataliron use, and

risk ofadverse pregnancy outcomes: systematic reⅥewand meta・analysis. BM/',346, B443. http://dx.doi.org/http:ノ/dx.org/10.1136/bmj.f3443

Heywood, P.,& choi, Y.(201の. Health system performanceat the distrid levelin lndonesia a丘er decentralization.

BMC 1πterH4ti0π41 He41th α11d HU111α11 Rights,10,3.http://dx.doi.orgno.1186n472-698×・103

12Wardy, D.(2014). Nutriti011411d he41th statuS α11dPル8r4111 qfiπf411tS α11d yoU11g childre11iπ 1πd011esi4. Retrieved fromht中://WWW.ilsi.org/SEA_Region/Documents/2014%20Seminar%20on%20Maternal,%20lnfant%20and%20

Young%20child%20Nutrition%20in%20lndonesia/6・pak%20Doddy.pdf

Iule, E., Ramana, G. N. V, ooman, N., EPP,1., Huntington, D.,& Rosen,1. E.(2005). Achieviπg the 111i11eππiu"1 develop・111eπt g041 qf'i111Pfovi"g 111ateアπ41 he41th: deter"1iπ4πts,iπterve11h'0πS aHd ch411e118es. washington, DC: worldBank, Retrieved from h杜Pゾ/siteresources.worldbank.org/HEALTHNUTRITIONANDPOPULATION/Resources/281627-1095698140167/LuleAchievingtheMDGFinalpdf

Madsen, E.1'., Bergeson・Lockwood,1.,& Bernstein,1.(201の.M4terHal he41th supplies m ug411d4. W'ashington, DC:Population Action lnternational. Retrieved from http:/ノPai.org/IUP・contenvuploads/20H/12/maternal・health・U8anda'pdf

192 Managing pregnant vvomen vvlth lron Deficlency Anemia レVid aレVati et a/

Ministry of Health Republic of lndonesja.(2014).1πd0πesi4he41th pro"1e 2ω3. Jakarta,1ndonesia: Author.

Retrieved from http://WWW.depkes.go.id/resources/download/pusdatinゆrofil・kesehatan、indonesia/Indonesia%20Health9620profile%2020B%20_%20

V2%20untuk%20webpdf

Montgomery, K、 S.(2001). Maternal・newborn nursing Thir、teen cha11enges that inauence exce11ence in Practlce.

The /our11αl qf'perl'π4t41三ducati011,10(D,31-40. h廿P:ノノdx.doi.org/10.1624/105812401×88039

Nancarrow, S. A., Booth, A., ATiss, S., smith, T., Enderby, P.,&Roots, A.(2013). Ten prindples ofgood interdisdplin、ary team work. HUアπ411 ResoUπes jor He41th,11,19.http://dx.doi.org/10.1186/1478-4491、H、19

Nurdiati, D. S., sumarni, S., suyoko, A., HaMmi, M.,&Winkvist, A.(20OD.1mpad of intestinal helminthinfection on anemia and iTon status during pregnancy:A community based study in lndonesia. The southe4StAsi4πノ0urπ41 qf'乃Opical Mediciπe 4πd pUみlic Health,32,14-22.

Onwuegbuzie, A.1., DicMnson, W. B.,上eech, N. L.,& zoran,A・ G.(2009)、 A qualitative frameworkforc0Ⅱecting andanalyzing data in focus group research.111terπαhoHα1/our11αl qf'QU41it4tive Methods,8(3),1-21.

Schultink, W, van der Ree, M., Matulessi, P.,& Gross, R.a993). Low compliance with an iron supplemenねtionPr0名raln: A study among pregnant women in lakarta,Indonesia. The A1πeriCαπノ01ιr1141 qf' cliπiC41 Nutriti011,57,135-139.

Shefner・Rogers, C. L.,& sood, S.(2004).1nvolvin今 husbandsin safe motherhood: Effects of the suami sia8a C帥1_Paign in lndonesia./our1141 He41th c0111111U11iC4ti011,9,233-258.

Singh, D.,1如Ple, M.,& Earnest, j.(2014). The involve_ment of men in mateTnal health care: CTOSS-sec_

tional, pilot case studieS 丘om Maligita and Kibibi,Uganda. Reprodudive Health,11,68. http://dx.doiOrg/10.1186/1742-4755-11-68

Van Lerberghe, W;, Ma杜hews, Z., Achadi, E., Ancona, C.,C如PbeⅡ,1., channon, A., Turhnani, S.(2014).

Country experience with stTen8thening of health sys、tems and deployment of midwives jn countTies with

high maternalmortali可.ιαπCet,384,1215-1225. h廿P:ノ/dx.doi.org/10.1016/S0140-6736a4)60919-3

Weine二 B. j.(2009). A theory of organj2ationa1 ルadiness forChange.1"1Ple111eπt4ti0π SdeπCe 4,67. ht[P://dx.doi.or8/10.1186/1748-5908-4-67

Widyawati, W,1ans, S., Bor, H., sisMshanto, R、, van Di11en,1.,&Lagro・Janssen, A.ι. M.(2014). Arandomisedcontr0Ⅱed

trialon the Four PⅡlars Approach in managingpregnantWomen Mth al)aemia in Yogyakarね・1ndonesia: A study

Ptotoc01. BMcpre宮παπCy α11d childhirth,14,163. h廿P:ノ/dx.doi.org/10.1186n471-2393、14-163

Widyawati, W、,1ans, S., Bor, H., van DiⅡen, J.,& LagroJans_Sen, A.上. M.(2015). The e丘ectiveness ofa new model

In managln今 Pregnant woman with iron denciencyanaemia in lndonesia: A nonrandomized contr0Ⅱed

intervention study Birth,42(4),337-345. ht中:ノ/dx.doi.org/10.111νbirt.12181

Widyawati, W., jans, S,, utomo, S., van DiⅡen, j.,& Lagro_janssen A' L. M.(2015). A qua1虻auve study on barri、ers in the prevention of anaemia durin今 Pregnancy inPublic health centres: perceptions oflndonesian nurse_midwives. BMcpre8π4πCy4πd childbirth,15,47. h杜P://dx.doi.org/10.1186/S12884-015-0478-3

Wodd H■■lth 0璃■niねtion.(2005). Wのldwid. P脚"1e枇e げ4παe1πiα 1993-2005: WHo gloBal dat4h4Se 0πα114e111iaGeneva, switzerland: Author Retrievedfromht中ゾノapps.who.inviris/bitstrealn/10665/43894/1/9789241596657eng.pdf

World Health ot号anization.(20ID. H4e1110globiπ C011Ce11tra、ti0πS jor the diα8Hosis qf απαe"1i4 411d 4SsesS111eHt qf'Severity. Geneva, swit2er]and: Author. Retrieved from

h廿P:ノ/WWW.who.invvmnis/indicators/haemoglobin.pdf

Correspondence regarding this article should be directedto widyawati widyawati, BSC Nursing, scho01 0f Nursin ,Faculty of Medidne, universitas Gadjah Mada,1Sman80enBuilding,2nd aoor, JI. Farmako, sekip utara, Y08yakarta,Indonesia. E・mail: A.凡Vidyawati@radboudumc.nl

Widyawatiwidyawati, scho010fNutsin島 Faculty ofMedidne, universitas Gadjah Mada, Y0部akarta,1ndone、Sia; Department of prjmary and community care, Gender& womeds Health, Radboud university Medicalcentre,Nijmegen, The Netherlands.

Suze M. P.1.Jans, Department ofcommunity Genetics,theEMGO+ 1nstitutefor Health and care Research, vu uni_VeTsity Medical centre, Amsterdam, The Netherlands; Ro alDutch organization ofMidwives, utrecht, The Netherlands.

WennyArtanti Nisman, scho010fNursing, Faculty ofMedi、dne, universitas Gadjah Mada, Yogyakarta,1ndonesia.

ElsiDwiHapsari, scho010fNursing, FaC田ty ofMedicine,Universitas Gadjah Mada, Y08yakarta,1ndonesia.

Ieroen van DiⅡen, Department ofobstetrics and Gynec01、Ogy, Radboud university Medical centre, Nijmegen, TheNetherlands.

Antoine廿e Leonarda Maria LagroJ飢Ssen, Department ofpri、mary and community care, Gender & womenls Health, Rad、boud university Medicalcentre, Nijmegen, The Netherlands.

Author GuideHnes

The 111ter114ti0π41/our1141 qf'childbirth is a quarterly, peer・revieNved publication 、vith a global focus on childbearin号.Thejournalinvitesthe submission ofmanuscriptsthat address research, practice, education, and theory as weⅡ as casereports, personal narratives, and commentaries on aⅡ aspects ofchildbirth.

The f0Ⅱ0、vin8 Presentation style should be observed when submitting manuscripts:

a cliπiC41α11d B4Sic scieπCe Rese4πh artides should indude an Abstrad,1ntroduction, Material and Methods,

Case History (ifapplicable), Results, Discussion, conclusion, and References.轟 Review articles should provide a comprehensive synthesis ofthe available information on their chosen topic.They mustindude headinss and reference citations.

岳 C4Se Repofts should be briefreviews ofeither typical or atypicalbiTths and should indude an Abstrad,Introduction, case Report data and 丘ndin3S, Discussion, condusion, and References.

遍 Pers0παIN4rratives should 丘rst・hand accounts ofchildbirth experiences. References are not required but may beinduded when needed to support data or quotations from published sources.

Manuscript preparation

The manuscripts should be prepared in accordance with the publicati0π八1411U41 qf the A柳eriC4π Psych0108iCα1Assodati011, which should be consulted foT ma杜er ofstyle and formatting,induding text, references, and tables.

ιength. submissions are generaⅡy expected to be 15 t025 Pagesin leng[h; however,thejournalconsiders manuscriptsthat are lon8er or shorter.

Cover page. A cover page separate from the main manuscript mustindude the artiddstide and the names, academicdegrees, mailing addresses, and e・mail addresses ofeach ofthe contributing authors.

Abstract. Research artides, review articles, and case reports should indude an abstrad ofbetween 125 t0200 、vordsthat concisely states the artide's purpose, the study design, major 負ndings, and main condusion.

Summary.~~1hen an abstractis not appropriate forthe wpe ofarticle submitted, authorsshould indude a summary ofbet凡Veen 125 t0200 、vords that ptovides a synopsis ofthe artidds thesis and condusions.

Appendices.1nstruments or lar号e tables of data may be induded as an appendix to the manuscript. The publicationOfappendices is atthe discretion ofthe editors.

ιetters to the Editor. Le廿ers to the editor should be concise comments regarding articles published in the journal andmay indude references. Le廿ersshould be under 30o words. Those accepted for publication maybe edited or abridged.

Phot0名raphs, Drawin名S, and Graphs.1ⅡUstrationsshould be submitted asindividual, high resoluuon ima号esin jP8,tiff, or eps graphicS 61e formats (graphs created in Excel are also acceptable). Digitalimages should indude the 丘gurenumber in the 負le name. AdditionaⅡy, a copy ofeach iⅡUstration should be embedded atthe end ofthe manuscriptafter the reference list and tables.

Submission

Authors should submit manuscripts electronicaⅡy at www.editorjalmana号er.com/ijcbirth

CopyrightAgreement

The f0ⅡOwing dated agreementsi8ned by aⅡ authors must accompany each manuscriptsubmitted for publication:

The undersigned author(S) transfers aⅡ Copyri8ht 0刃Vnership of the article entided [iπSert the title ofyour artide]

to the springer pubHshing company, LLC, in the event that the article is published in the lnternationa110urnal of

Childbirth. This transfer of copyright indudes, but is not limited to, the worldwide ri8hts to any and aⅡ forms of

Publication now hlown or herea丘er developed,indudin留 aⅡ forms of print and electronic media. The undersi名ned

author(S)凡Varrants and representsthatthe article is original,is not under consideration byanotherjournal, has notbeen

Published previously, and contains no matter that is libelous, unla、vful, or that infringes upon another copyri号ht.