Coping strategies for labor pain, related outcomes and influencing factors: A systematic review

INTRODUCTION Laboring women’s ability to cope with pain is likely to be dependent on a variety of inter-related factors, including the level of pain intensity, the nature of the environment and the perceived support. The aim of this systematic review was therefore to explore coping strategies used by laboring women, related outcomes and factors influencing coping with labor pain. METHODS A mixed-methods systematic review was undertaken. Electronic databases (Medline, EMBASE, CINAHL, PsycInfo) were searched to identify eligible studies from December 2020 to November 2021. The quantitative findings were narratively synthesized and reported thematically. The final mixed-methods synthesis involved gathering qualitative and quantitative data and producing a set of synthesized findings. RESULTS Twenty-three studies were included. Three themes were identified: 1) definition of coping and types of coping strategies, including behavioral and cognitive based techniques; 2) coping strategies related outcomes, including improvements in self-efficacy and reduction of pain intensity, fear, anxiety, time of admission and labor duration; and 3) factors influencing coping with labor pain, including continuity of carer; environment; presence of a birth companion; cardiotocography monitoring; and antenatal education. CONCLUSIONS This systematic review provides midwives and healthcare professionals with information to recognize coping strategies spontaneously adopted by laboring women and promote the use of a variety of techniques, as required by individual needs and preferences. Midwives are also provided with up-to-date knowledge on coping strategies related outcomes and influencing factors, which they can utilize to guide evidence-based practice decision-making and facilitate women and families’ informed choice.


INTRODUCTION
Labor pain is a complex and multifaceted element of childbearing women's experiences 1 . Pain is defined as an intense and unpleasant sensory experience, associated with contractions that the woman would like to avoid or alleviate 2 . The difference between pain and suffering is key in supporting laboring women's physical and emotional wellbeing. Suffering is a distressing psychological state that includes feelings of helplessness, fear, panic, loss of control, and loneliness 2 . Simkin et al. 3 suggest midwives should focus on the ability of woman to cope with pain, rather than the pain itself. Coping is defined as the person's cognitive and behavioral efforts meant to manage challenging or stressful situations. Non-pharmacological coping strategies such as postural changes, breathing techniques, vocalization and relaxation, could be powerful resources in the management of intrapartum anxiety and pain 4 . NICE guidelines 5 recommend to consider the woman's emotional and psychological needs and to observe how women deal with pain and manage it. WHO guidance 6 advises healthcare providers to consider relaxation techniques for pain management, such as muscle relaxation, massage, application of warm packs, breathing, music, mindfulness and other techniques, depending on the woman's preferences. Laboring women's ability Eur J Midwifery 2022;6(November):67 https://doi.org/10.18332/ejm/156440 Review paper to cope with pain is likely to be dependent on a variety of inter-related factors, including the level of pain intensity, the nature of the environment and the perceived support 6 .
Previous research on coping strategies mainly focused on these individually 7-10 , with international guidance partially covering them 5,11 and a systematic literature evidence synthesis of these not being available. The aim of this systematic review was therefore to explore coping strategies used by laboring women, related outcomes and factors influencing coping with labor pain.

Design and literature search strategy
A mixed-methods systematic review was undertaken. Electronic databases (Medline, EMBASE, CINAHL, PsycInfo) were searched to identify eligible studies from December 2020 to November 2021, published in English or Italian. Search terms included: 'wom*n', 'pain', 'lab*r', 'coping', and 'strategies'. Synonyms and MeSH terms were identified and included in the search strategy. Keywords were combined using Boolean AND and OR in search strings; truncation was used when required.
Articles were included in the review if they met the following criteria: English or Italian language; systematic reviews, quantitative or qualitative primary research studies; published up to November 2021; focus on labor coping strategies and related influencing factors. Exclusion criteria were: secondary data analysis, literature reviews and commentaries; focus on coping strategies with pain other than labor pain. We conducted the search and reported the findings according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines 12 . The literature search and inclusion process are detailed in the PRISMA flow diagram 12 in Figure 1. All references retrieved during the systematic search were stored in EndNote. After removal of duplicates, titles and abstracts were initially screened for eligibility. Articles whose abstracts alluded to the search topic were selected for full-text screening and if relevant, data were extracted and recorded for inclusion in this review. The reference lists of relevant studies were searched manually to identify additional relevant articles, and their full texts screened to ensure that all potentially useful articles were included. A list of articles meeting the inclusion criteria was compiled. Two authors independently evaluated the studies' fulfillment of the inclusion criteria, with any discrepancy discussed with a third author until a final set of relevant studies was agreed upon.

Quality assessment
The quality of studies included in the review was evaluated using a range of established critical appraisal tools selected for the study design and Joanna Briggs Institute 13 levels of evidence: Critical Appraisal Skills Programme 14 tools for qualitative, cohort and case control studies; STROBE check-list for observational studies 15 ; and MMAT QA tool 16 for mixed-methods studies. Two independent researchers Review paper assessed the quality of the selected articles and banded studies as low, medium or high quality, with consensus achieved. Although no studies were excluded on the basis of quality, the quality assessment was used to critically consider the strengths and limitations of the evidence retrieved 17 .

Data abstraction and synthesis
Data abstraction forms were independently completed by two researchers. Qualitative findings were interpreted and organized into themes and sub-themes following a thematic analysis approach 18 . The quantitative findings were narratively synthesized and reported thematically 19 . The final mixed-methods synthesis involved gathering qualitative and quantitative data and producing a set of synthesized findings.

Findings
Twenty-three studies were included. These were conducted between February 1985 and March 2021 in the United Kingdom (n=9), Iran (n=2), Netherlands (n=2), USA (n=3) and other countries (n=7). The quantitative articles (n=15) included 4 randomized controlled trials, 5 correlational studies, and 6 observational studies. There were 2 mixed-methods studies and 6 qualitative studies. The following data were extracted from the included studies: general information (authors, publication year, country of investigation), population (number of participants), study design, key findings and outcomes (Table 1).
Three themes were identified: 1) definition of coping and types of coping strategies, including behavioral and cognitive based techniques; 2) coping strategies related outcomes, including improvements in self-efficacy and reduction of pain intensity, fear, anxiety, time of admission and labor duration; and 3) factors influencing coping with labor pain, including continuity of carer, environment, presence of a birth companion, cardiotocography monitoring, and antenatal education. Themes and subthemes are summarized in Table 2. Behavioral and cognitive coping methods, factors influencing coping with labor pain and sources from where these were reported are included in Table 3.

Theme 1: Definition of coping and types of coping strategies
The first theme identified related to the definition of coping and to the range of coping strategies women adopt to stay with pain during labor.
Amongst the 22 selected articles, only three 4,20,21 provided a definition of coping. Two articles 4,20 refer to the definition given by Lazarus and Folkman 3 , describing coping as the person's cognitive and behavioral efforts aimed at handling challenging or stressful situations, intended as an on-going individual adjustment process in order to be effective.
One article 21 reports two definitions of coping from Beutler and Moos 22 and from Brown and Nicassio 23 . The first definition refers to coping as a complex and multidimensional phenomenon with cognitive, emotional and behavioral qualities, leading to changes and adaptation 22 . The second one explains coping as particular thoughts and behaviors adopted to stay with the pain or with the emotions generated from the pain 23 .
Women use a variety of coping strategies for managing labor pain, including behavioral and cognitive based techniques 21 . Behavioral strategies are defined by Beebe et al. 20 as 'those activities that participants mentioned physically doing'; whereas cognitive strategies referred to 'those things they were thinking about that were associated with managing their labor'.
Nine articles 4,7-10,20,21,24,25 included a range of behavioral coping strategies used by women to deal with labor pain and four techniques were identified: breathing, maternal positions, holding/pressure, and use of voice.
Breathing was the most used by women, in particular the 'slow, deep breath' techniques are the most cited methods 4,7-10,21,24,25 . One source mentioned the 'slow sigh' strategy 9 and another one the 'blow' as breathing techniques 24 . A variety of movements and maternal positions were adopted by laboring women, including walking, rocking, swaying 4,7,9,10,20,21,24 , squatting 9,21 , all fours, one side, sitting, and upright 4 . Additional methods reported by women to manage labor pain are the use of hands for holding something or for applying pressure 4,10,20,21 . The use of voice was mentioned by five articles 4,8,20,21,25 including vocalization, singing, and murmuring. One article cited also the method of counting numbers during contractions 8 .
Eight sources 4,7,9,20,21,24-26 included a variety of cognitive coping strategies used by women to manage labor pain and seven techniques were identified: distractions, attention, imagination, focusing on pain, relaxation, and spirituality.
Three articles 4,21,24 mentioned using distraction as a cognitive coping strategy frequently used by women, meaning the need to take the mind off their pain, such as counting numbers 4 or thinking about future events such as the imminent birth of their baby 21 . Attention was proposed by one study 26 as a mechanism that laboring women adopt to stay with the pain. Women with limited mobility during labor, looked at the contractions on the cardiotocography monitor as a method to get away from the pain stimulus.
Imagination was found in two sources 21,24 as a technique that women used to think of a different place rather than the birthplace, or a way to visualize their baby's body and face 24 , or the exact moment of birth 21 .
Three articles 4,21,24 described focalization on labor pain as helpful for laboring women. Of these, one 22 reported that women focused on thinking of a positive purpose for the pain, that pain is limited over time, and how other women before them experienced and coped during that time. In addition, women tried to prepare themselves for each contraction during labor, being aware that although very painful they would be able to manage them 21 .
Amongst the three selected articles 7,9,25 that considered relaxation techniques as very important strategies to deal with labor pain, none reported what they intended specifically with this term. One article 21  Correlational study When coping strategies were used, they were generally continued for substantial proportions of time.
Greater proportions of use of breathing and relaxation were associated with labor being experienced as less frightening. High proportions of women believed that using coping strategies would be associated with benefits in particular enabling feeling more positive, calm and in control and reducing pain in labor. Women were less likely to believe that use of coping strategies would lead to reductions in use of analgesia. The range of coping strategies women use to manage pain and anxiety prior to and during first experience of labor

primiparous mothers
Qualitative semi-structured interviews The findings indicate that it is possible to help women during pregnancy to identify and describe, in their own words, the range of coping strategies used to manage previous experiences of pain and anxiety.
In addition, they provide understanding of the coping strategies used during labor by women who had not attended antenatal classes.
Niven et al. 24 1996 United Kingdom Coping with labor pain 51 women An exploratory research design The results of this study indicate that a considerable range of coping strategies was used by women during childbirth. Many of these seemed, in essence, similar to those considered in the empirical literature and resembled strategies that women had used previously. The total number of strategies used in labor was negatively correlated with levels of labor pain, suggesting that the use of coping strategies in labor can modulate the pain.
Asl et al. 25 2018 Iran Relationship between behavioral indices of pain during labor pain with pain intensity and duration of delivery 120 low risk pregnant women Cross-sectional study Behaviors demonstrated by women in labor had effects on their pains in the course of delivery, and there was also a relationship between the duration of stages of labor and severity of pain.
Shiloh et al. 26 1998 Israel Interactive effects of viewing a contraction monitor and information-seeking style on reported childbirth pain 48 low risk women giving birth in a hospital near Tel Aviv Within-subjects experimental design Monitored women experienced less pain‚ and blunted more pain while viewing the monitor‚ controlling for contraction amplitudes. Women viewing the monitor used more attention and control-predictability strategies than when not viewing‚ particularly if they had a monitoring information-seeking style; when not viewing the monitor they used more distraction strategies‚ particularly if they had a blunting information-seeking style. Reported use of attention‚ distraction‚ and control-predictability coping strategies had significant negative correlations with pain reports. Pain anxiety was positively‚ and self-efficacy expectations negatively‚ related to pain reports.
Klompt et al. 27 2017 Netherlands A qualitative interview study into experiences of management of labor pain among women in midwife-led care in the Netherlands

women
Qualitative interview study Women reported that control over decision making during labor (about dealing with pain) helped them to deal with labor pain, as did continuous midwife support at home and in hospital, and effective childbirth preparation. Some of these women implicitly or explicitly indicated that midwives should know which method of pain management they need during labor and arrange this in good time. Women reflected positively on how, throughout pregnancy and labor, their midwives promoted a sense of their ability to cope with the challenge of labor pain. These experiences enhanced women's ability to overcome fears and self-doubt about coping with pain and led to feelings of pride, elation, and empowerment after birth. An exploratory qualitative study Three categories, including 'involvement of the spouse in the labor process', 'asking for a companion during labor', and 'mother's self-care to cope with labor pain', emerged during data analysis. These categories were merged to form the main theme of 'trying to comply with the labor process'. Experimental design In Study 1 (N=48) pain and negative moods showed a sharp decline at Stage 2 (active labor) for women told to monitor and those who had attended classes; there was no decline for the control group. In Study 2 (N=29), women attending Lamaze classes reported a similar decline in pain during active labor and were more energetic and less tired at admission.
Güder et al. 36 2019 Cyprus The effect of childbirth preparation training on primiparous women's birth plans and the childbirth processes 70 primiparous women A quasi-experimental/ non-randomized trials and prospective study Midwives and nurses play an active role in the realization of the birth plans that are within the framework of prenatal education courses. The experimental group had a lower rate of planned cesarean, were more satisfied with their childbirth experiences, received more support during the birthing process, and used more techniques for coping with pain during labor.
Naidu et al. 37 2020 India A study to assess the effect of childbirth education on intrapartum coping behaviors of primiparous women in a selected maternity center of a tertiary level hospital in Pune 60 registered primigravidae attending the ANC OPD of a hospital at Pune A prospective quasi-experimental study Primigravidae were poorly informed about childbirth preparedness and not prepared for the experience of childbirth. Majority had no concept regarding the severity of pain, duration of labor and coping measures stress of labor. Significant reduction in episiotomy rates, use of analgesics and improvement in coping behaviors found among the experimental group. Randomized controlled trial Women who attended CSE classes used enhanced coping strategies for a larger proportion of their labor than women who attended standard classes who used taught coping strategies. Birth companions were more involved in women's use of enhanced than taught strategies. Self-efficacy for use of coping strategies and subsequent experiences of pain and emotions during labor were equivalent between groups.
Spiby et al. 39 1999 United Kingdom Strategies for coping with labor: does antenatal education translate into practice?

primiparous women
An exploratory within-subjects research design The findings of this study of a group of well-prepared women raise questions about the correct components of antenatal classes and how midwives and birth companions can be involved optimally in this aspect of a woman's labor.   Review paper such as praying, reading holy books, having confidence in God, and trying to find a scope and a meaning for pain.

Theme 2: Coping strategies related outcomes
A decrease in the overall average level of labor pain 24 and lower pain scores during labor at home 20 were observed in women who adopted more coping strategies. Amongst behavioral coping strategies, Slade et al. 9 report that women using breathing techniques rated pain as less severe. Women who used more behavioral coping strategies stayed home longer in the early labor phase 20 . Childbearing women's self-efficacy related to the number of management strategies adopted, rather than the type of techniques used 20 . Breathing and relaxation techniques were associated with labor being experienced as less frightening 9 . The use of cognitive coping strategies lowered women's levels of anxiety (measured by the Spielberger State-Trait Anxiety Inventory scale) 20 . Behavioral indicators (e.g. face expressions, verbal expressions, tone of voice, body movements, relaxation and breathing patterns) during labor were significantly and inversely associated with the duration of the active phase of the first stage of labor and the duration of the second stage of labor 25 . An increased average score of behavioral indicators during labor reduced the overall duration of the first and second stage of labor 25 . Behavioral indicators were significantly and inversely correlated with the perceived intensity of labor pain 25 .

Theme 3: Factors influencing coping with labor pain
The factors influencing coping with labor pain identified within the selected articles are: continuity of carer, environment, presence of a birth companion, cardiotocography monitoring, and antenatal education. The continuity of carer facilitated by caseload models enabled the establishment of a trusting relationship and good communication between the woman and midwife, impacting positively on the woman's self-efficacy and active involvement in the decision-making process in regard to pain relief strategies, therefore improving the ability to cope with pain 27,28 .
A positive coping experience seemed to be facilitated by the woman laboring in an environment of her choice in accordance to individual needs and preferences 29, 30 .
The presence of a birth companion played a key role within the woman's ability to cope with pain, mainly through the use of verbal and non-verbal encouragement, calming approach and physical touch 22,31 .
Cardiotocography may have beneficial effects on coping with pain due to laboring women implementing control and predictability strategies when looking at the monitor 26 . The use of cardiotocography did not seem to impact on breathing and relaxation techniques, but limited the laboring woman's positions and movement 7 .
A number of articles present the positive impact of different types of antenatal education on the woman's ability to cope with labor pain and to use a variety of coping strategies 27,32-37 , mainly due to: increased selfefficacy 27,32-34 ; more accurate perception of childbirth; improvement of perceived safety; reduced pre-labor distress; and encouragement of positive feelings in regard to labor and birth 35 . When women were encouraged to think about a birth plan as part of antenatal education, it was more likely they would apply coping strategies in labor resulting in increased pain control 27,36 . The effectiveness of different antenatal education approaches may be dependent on an individual woman's needs 38 . Spiby et al. 39 report that some women found the coping strategies taught during antenatal education classes unsatisfactory, with <5% of women feeling extremely competent in implementing each strategy. Antenatal classes were less effective in regard to more advanced labor stages and especially during the second stage of labor, due to the increased difficulty in applying coping skills 34 .

DISCUSSION
This systematic review explored coping strategies used by laboring women, related outcomes, and factors influencing coping with labor pain. The findings of our systematic review identified a variety of behavioral and cognitive coping strategies and recognized increased benefits when women adopted these during labor, including improvements in self-efficacy and reduction of pain intensity, fear, anxiety, time of admission and labor duration. The combination of several strategies, rather than the type of techniques used, particularly improved women's self-efficacy, highlighting the multidimensional and complex nature of labor pain 1 . The promotion and use of non-pharmacological pain relief coping strategies is recommended by WHO 11 as part of respectful and supportive maternity care. Fetal and neonatal outcomes in relation to the use of coping strategies in labor were not reported by any of the selected article. In regard to maternal outcomes, emotional wellbeing was mainly explored within the retrieved sources, with only few clinical outcomes investigated (pain intensity, time of admission, and labor duration). Our findings identified antenatal and intrapartum factors influencing coping with labor pain, including antenatal education, continuity of carer, environment, birth companion, and cardiotocography. The impact of antenatal education on coping has been widely explored within the selected articles, highlighting the key role of information provision during pregnancy and prior to labor 40 to improve maternal satisfaction with the childbearing event 41,42 . Borrelli et al. 43 recommended midwives should dedicate time to discuss with women and birth partners what coping strategies or pain relief they have been considering, ideally during the second or third trimester of pregnancy. Limited evidence was found on the other influencing factors mentioned above. Despite that only two of the selected articles described the presence of a birth companion as key within the woman's ability to cope with pain 4,31 , it is broadly acknowledged that birth partners play a significant role with the woman's overall childbearing experience and satisfaction 44 . The same applies to continuity of carer 27,28 , with the consistency of a known midwife or small team of midwives being recognized as crucial to the successful design and delivery of maternity