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Table 4 Review findings and CERQual ratings

From: Women’s experiences of pharmacological and non-pharmacological pain relief methods for labour and childbirth: a qualitative systematic review

Review finding

Studies contributing to the review finding

CERQual Assessment

Theme

EPIDURALS

1. Information and awareness influences women’s decisions to have an epidural: Women’s pre-birth decision for an epidural was influenced by a previous positive experience of epidural use, or through messages (positive or negative) from health professionals, members of their social networks or the media. In some occasions, the frequency of use of epidurals, and awareness of risks/perceived perceptions of safety were a positive influence on women’s decision (i.e. women from countries where epidural use is not the norm). Women felt reassured and relieved by knowing an epidural was available.

8 studies: [18, 28,29,30, 33,34,35,36]

Moderate

Desires for pain relief

2. Pre-existing desires for pain relief: Women expressed a desire for epidural due to reasons such as wanting a pain-free labour, a fear of pain and a desire to remain in control during labour

10 studies: [18, 27,28,29,30,31,32,33,34,35]

Moderate

Desires for pain relief

3. Pain relief as last resort: Women opted to have an epidural at a crucial point in their labour where the level of pain was unmanageable and/or feeling that the labour was out of their control.

7 studies: [27, 29, 32,33,34,35,36]

Low

Desires for pain relief

4. Fear of procedure and impact: Women expressed fears towards epidural use associated with pain at citing, potential ineffectiveness of the anaesthesia and negative implications for self and baby.

5 studies:

[28, 29, 33, 35, 36]

Low

Desires for pain relief

5. Pressure and persuasion by professionals and others (for epidural use): Women were actively encouraged, persuaded or pressured to have an epidural by health professionals, messages received via antenatal classes and lack of options for non- pharmacological methods.

7 studies: [18, 27, 28, 31, 34, 35, 40]

Low

Influence and experience of support

6. Negative impact on physiological and psychological responses: Women experienced adverse responses associated with pain/complications associated with needle insertion, negative side effects, lack of mobility, feeling disconnected from the labour and birth, and negative impact on their capacity to give birth physiologically. Women experienced negative emotions associated with epidurals such as conflict, guilt, disappointment and a sense of failure.

6 studies: [27, 32,33,34, 36, 40]

Low

Influence on focus and capabilities

Impact on wellbeing and health

7. Helped to facilitate positive labour and birth: Following an epidural women were able to relax, rest and to restore and renew their energy levels to enable them to cope and manage during labour. An epidural provided women with a sense of control where they could focus on labour signs and make decisions regarding progress. Patient controlled epidural was positively perceived and facilitated mobility. Women’s fears of epidural were not met and they were able to enjoy and actively participate in the birth with no/manageable side-effects. Some women felt that the epidural had enabled them to achieve a normal physiological birth

9 studies: [18, 27, 28, 30,31,32,33, 36, 40]

Moderate

Influence on focus and capabilities

Impact on wellbeing and health

8. Positive impact on pain: An epidural provided effective and significant pain relief for some women. Women were able to feel connected to the birth without experiencing constant pain.

6 studies: [18, 27, 28, 30, 33, 36]

Low

Impact on pain

9. Supported in their choice: Women valued having an epidural as a choice for pain relief, being able to make their own decision about the use of an epidural, and to be supported in their choice (by health professionals and family members).

6 studies: [28,29,30, 33, 35, 40]

Low

Influence and experience of support

10. Lack of consent/information: Women were not always fully aware of the risks or benefits of epidural use.

5 studies: [28, 32, 34, 36, 40]

Low

Influence and experience of support

11. Ineffective pain relief: Some women continued to experience pain/breakthrough pain after epidural citing. In some occasions the epidural was provided too late, wore off too early or requests for ‘top-ups’ were denied.

4 studies: [27, 33, 35, 40]

Low

Impact on pain

OPIOIDS

1. Pain relief as last resort: Women opted to have opioids at a crucial point in their labour where the level of pain was unmanageable.

1 study: [37]

Very low

Desires for pain relief

2. Positive impact on pain and labour: Opioids had a positive impact on pain, shortened and reduced the intensity of the contractions (pethidine and other forms of opioids) and with no side effects (pethidine and other forms of opioids). It increased the woman’s enjoyment and helped them to give birth (not referred to in relation of Pethidine).

1 study: [41]

Very low

Impact on pain

Impact on focus and capabilities

3. Negative impact on physiological and psychological responses: Following Pethidine women experienced negative physiological (e.g. sickness, ‘groggy’, slow labour, disconnected from the labour, inability to push) and psychological (e.g. disappointment, inability to remember the birth) affects.

2 studies: [37, 41]

Very low

Impact on focus and capabilities

Impact on wellbeing and health

4. Ineffective pain relief: Women continued to experienced pain due to the opioids being ineffective, provided too late or wore off too early. In some occasions, the pain was exacerbated (Pethidine only).

3 studies: [18, 37, 41]

Very low

Impact on pain

5. Lack of/insufficient support: Women were disappointed due to over-reliance on staff (due to need/desire for additional support or ongoing receipt of medication)

2 studies: [37, 41]

Very low

Influence and experience of support

6. Lack of information/consent: Women were not always fully aware of the route of administration or the risks of Pethidine use.

1 study: [37]

Very low

Influence and experience of support

MASSAGE

1. Massage techniques facilitated labour coping skills: Women found that massage techniques were useful to enable them to cope and manage the labour process.

4 studies: [23,24,25, 45]

Low

Impact on focus and capabilities

2. Positive way to ‘work with the pain’: The use of massage techniques gave women an alternative method to deal with labour pain - women reported that massage techniques reframed their approach of managing pain through the positive concept of ‘working with the pain’.

3 studies: [24, 25, 45]

Low

Impact on pain

3. Positive impact upon sense of relaxation and control: Women reported that massage techniques enhanced relaxation and provided inner resources to remain calm and maintain self-control.

4 studies: [23,24,25, 45]

Low

Impact on focus and capabilities

4. Enhanced wellbeing: Women reported that massage techniques were beneficial to their wellbeing, including finding massage reassuring, positive, a means to overcome anxieties and provided a sense of safety during the birth.

3 studies: [23, 25, 45]

Low

Impact on focus and capabilities

Impact on wellbeing and health

5. Enhanced participation of birth companions and health professionals: Women reported that taught massage techniques provided their birth companions with the tools to participate in labour preparation and during the birth. Additionally, when midwives performed the massage, this contributed to positive emotional and physical closeness.

3 studies: [24, 25, 45]

Low

Influence and experience of support

6. Ineffective pain relief: For a minority of women the techniques were not always effective in alleviating pain, or were negatively influenced by maternal position.

2 studies:

[23, 45]

Very low

Impact on pain

Impact on focus and capabilities

7. Valued variety of techniques: Where women were taught a range of techniques during the antenatal period, women valued the variety to adapt to their changing needs throughout labour.

1 study: [24]

Very low

Impact on focus and capabilities

RELAXATION

1. Increased confidence approaching childbirth: Women valued being taught relaxation techniques during the antenatal period in readiness for labour. For some, this was considered effective in reconstructing fears of labour, for others it increased their feelings of confidence approaching childbirth

4 studies: [24, 26, 38, 42]

Low.

Desires for pain relief

2. Relaxation techniques facilitated labour coping skills: Women reported that the variety of techniques previously taught enhanced their ability to cope, concentration, sense of calm as well as facilitating other coping methods such as breathing and visualisation.

4 studies: [23, 26, 39, 42]

Low

Impact on focus and capabilities

3. Relaxation techniques facilitated a positive labour and birth with effectiveness as a pain relief: Relaxation techniques had several positive purposes such as creating a peaceful birthing environment. The techniques were an effective pain relief method, either by lessening the perceived levels of pain or by making the contractions more bearable. Additionally, the women reported feelings of relaxation and an empowered sense of control. Together, this facilitated positive feelings regarding the labour and birth.

7 studies: [23, 26, 38, 39, 42,43,44]

Moderate

Impact on pain

Impact on focus and capabilities

4. Positive way to ‘work with the pain’: The use of relaxation techniques reframed the women’s approach to pain to a positive model of ‘working with the pain’. This was effective either through increased levels of confidence and ability to cope or as means of distraction away from the pain.

4 studies:

[24, 26, 42, 44]

Low

Impact on pain

5. Enhanced wellbeing during the birth and postnatal period: The relaxation techniques provided women with positive feelings of safety, strength, joy and connection. The women reported ongoing benefits throughout the postnatal period such as soothing the baby, coping with parenting and facilitating breastfeeding.

5 studies:

[23, 26, 38, 43, 44]

Moderate

Impact on wellbeing and health

6. Enhanced participation of birth companions and caregivers: Women reported that taught massage techniques provided their birth companions with the tools to participate in labour preparation and during the birth and enhanced their relationships with caregivers.

6 studies:

[24, 38, 39, 42,43,44]

Low

Influence and experience of support

7. Valued variety of techniques: Where women were taught a range of techniques during the antenatal period, they valued having a ‘toolkit’ they could use during the birth. In this way, they could adapt the techniques to meet their changing needs throughout labour and birth.

3 studies:

[24, 26, 42]

Very low

Impact on focus and capabilities

8. Not always effective: For a minority of women the taught techniques were not always as effective as they anticipated in alleviating pain.

2 studies:

[23, 44]

Very low

Impact on pain