Title: Evaluate The Effectiveness of Using Nonpharmacological Intervention During
Childbirth: An Improvement Project in Jordanian Maternity Hospitals
Version: 1 Date: 21 Feb 2024
Reviewer's report:
Thank you for conducting this research study.
Please refer back to the track changes that I used, since it was too difficult for me to put my
comments in this manuscript  with no page number and unnumbered lines
Abstract
Introduction: The purpose of this study was to evaluate the effectiveness of nonpharmacological
intervention during childbirth in Jordan. Unnecessary interventions what do you mean by this?
during childbirth are still common in Jordanian hospitals. Some Jordanian mothers still believe
that some interventions reflect high-quality care. Despite the recommendations from the WHO,
those unnecessary interventions during childbirth should be avoided, these interventions are
still desired by some. Nonpharmacological interventions are considered a convenient alternative
for unnecessary childbirth interventions because they can prevent unsafe side effects for
mothers during childbirth. Methods: A phenomenological qualitative research design was used
to conduct the study. We started our procedure by (1) approaching all low-risk pregnant mothers
who came to the hospital for birth. (2) We introduced our research study and explained that
we wanted to study normal physiologic childbirth without the use of unnecessary intervention.
(3) Our procedure would include allowing mothers to move freely, provide small amounts of
soft food, limit vaginal exams, and try to conduct childbirth without an episiotomy In Jordan
episiotomy performed for the first and second delivery. Please refer back to the inclusion criteria
We then interviewed those mothers after birth using one-on-one semi structured audio-recorded
interviews. We interviewed a total of eighteen postpartum mothers in a location of their choice.
Results: Three major themes emerged from the interview analysis. These themes were extracted
from the participants’ own words: “Positive, respectful and satisfying childbirth experience”;
“Maintain mother’s sense of control and cope with childbirth pain”; “Birth outcome”. These
themes are interconnected and influenced by each other. Discussion: Different research studies
from diverse cultures recommend limiting the unnecessary use of interventions during childbirth
and to not interfere with childbirth unless medically necessary. Our participants were satisfied
after using culturally sensitive childbirth interventions for conducting childbirth. In general,
using these interventions was easy and safe and resulted in a positive childbirth experience.
Conclusion: The study findings contribute to the achievement of sustainable development goal
# 3 “Good health and well-being” by targeting the reduction of maternal and neonatal mortality
and providing evidence of the effectiveness of avoiding unnecessary childbirth interventions
and allowing the childbirth process to proceed naturally.
Keywords: Childbirth experiences; physiological childbirth; nonpharmacological interventions;
pain management
Introduction
The concept of evidence-based interventions was originally established by the World Health
Organization (WHO), which recommends avoiding unnecessary interventions explain what do
you mean by this during childbirth processes and only interfering with the natural process
of labor when necessary. The WHO stresses the importance of intervening in the process of
childbirth only if there is tangible evidence that indicates the need to interfere due to certain risk
factors [1]. A meta-analysis study from Australia that systematically searched articles published
between 1989 and 2020 in six electronic databases included eight studies with 713 participants
with nine different nonpharmacological strategies for reducing labor pain. The traditional meta-
analysis demonstrated that nonpharmacological coping strategies were effective in reducing
labor pain [2]. Of these interventional strategies, the ranking probabilities analysis of the network
meta-analysis suggested that the Bonapace Method (massage on pressure points including
the sacrum, hand, and calf) may be the most effective strategy in reducing labor pain. This
systematic review, by synthesizing the body of evidence, demonstrated that nonpharmacological
interventions are effective in enhancing satisfaction and reducing labor pain among participants
[2].
Childbirth pain requires effective management; otherwise, it may cause harm including
prolonged labor and an increase in the risk of  maternal and fetal distress, head compression,
intrauterine fetal death, low Apgar scores and physical injuries to neonates [3]. Some mothers
experience normal or spontaneous labor or physiologic childbirth that requires no intervention
or augmentation. However, other mothers may experience more difficult labor that requires
assistance, and some may opt to go through high-risk labor experiences [4]. Recently, the WHO
highlighted the need to prevent harm to mothers and newborns caused by risky maternal and
newborn care during pregnancy, childbirth and after birth [1].
These interventions are better in managing low-risk childbirth because midwives and nurses
assume responsibility for managing the childbirth process [5,6]. Nonpharmacological methods
explain what do you mean by this, define the variable offer some hope in decreasing childbirth
pain, with minimal or no harm to the mother, fetus, and the progress of birth. They have the
capacity to reduce analgesic intake and are easy and cost-effective [6].
Nonpharmacological interventions are comfort measures, please define what do you mean by
comfort measures??  that provide highly effective natural pain relief during childbirth. They
are considered a convenient alternative to pharmacological methods in the childbirth process as
a form of pain relief. Current evidence indicates that using nonpharmacological interventions
with low-risk childbirth lowers the chance of using assisted birth or anesthesia [7]. They may
prevent the unsafe side effects of pharmacological agents given to mothers during childbirth.
It is important to also noted that nonpharmacological interventions are mostly cheap or free of
charge, applicable in a frequent matter, and can be used to augment, supplement, or complement
treatment methods without resorting to pharmacological drugs [8].
Even though the use of pharmacological interventions has proven highly effective, the
consequences of their uses and the risks and hazards of the side effects are a critical reason
to look for alternatives. Nonpharmacological interventions are considered a viable alternative
option when considering side effects. Jordan is no exception, as studies have proven that the
adopted practices of the medical system in Jordanian hospitals and in maternity clinics are not
aligned with the WHO recommendations for application of natural childbirth, especially low
risk mothers [9]. As a matter of fact, it has been observed that many interventions are being
implemented and the process, more than there should be, and in so many cases in unnecessary
situations and circumstances. Even more, some interventions took place in some cases that are
low risk cases rather than only interfering with the high-risk childbirth cases [9].
Ninety-eight percent of all births in Jordan occur in a health facility with a skilled health
care provider in attendance referenc is needed. Maternity care in Jordan is divided into three
main parts: antenatal care, childbirth care, and postpartum care. Antenatal care is provided in
hospitals and clinics and in the 506 health centers of the Ministry of Health. In Jordan, antenatal
care is almost universal: 98% of mothers receive antenatal care from a skilled health care
providers (doctor, nurse, or midwife) during pregnancy [10]. Little is known about the use of
nonpharmacological pain management interventions during labor and birth in Jordan [11]. Some
reasons were found behind the low usage of nonpharmacological pain management interventions
in Jordan  unclear[11]. Different studies have shown that mothers in Jordan experienced poor
health care support in hospitals during the childbirth experience. According to previous studies,
mothers reported that their respective experiences and labor rooms were somewhat impersonal
[9,11,12].
According to these findings, further studies need to be conducted regarding this issue, and further
recommendations and propositions need to be set forth according to these investigations' results.
Introduction needs to be reorganized
Methodology
Methods Needs to be rewritten
A phenomenological qualitative research design, using a semi structured interview to address
the research question what is the research question??? and meet the study aims and objectives
what they are?? was used. This study helps to elucidate the unknown elements that need to be
investigated further with mothers.
Sample and Sampling
The researchers used purposeful sampling techniques to recruit the study participants. A total
of 18 mothers met the inclusion criteria and agreed to have a physiological childbirth  this is
unclear…. Did you ask the mother to go for normal delivery or their health conditions allows
for that. Please explain this point and to be interviewed after that. We included all low-risk
mothers  what do you mean by this??? with no history of cesarean sections. Additionally, their
current pregnancy must be complication free and naturally conceived. The target population was
all low-risk Jordanian mothers admitted to the Al Zarqa Hospital for childbirth. The accessible
population was low-risk laboring mothers who were admitted to the labor room in an Al Zarqa
Governmental Hospital. Inclusion and exclusion criteria need to addressed clearly, please
Data collection was collected through conducting only one interview???
One to One audio recorded in-depth interviews with eighteen mothers were conducted after
childbirth in a place chosen by the participants. The length of each interview ranged from 40-60
min (in a private room in the same ward a few hours after birth. The primary investigator asked
the mother to describe their experience from admission to the time she left the hospital. Questions
included "could you please describe your experience of your last childbirth?", "Can you tell me
in detail about the care you received in the hospital?" follow up questions such as "can you
explain more?" "What do you think about this?"  were used when necessary.
Different non-pharmacological pain management interventional were used to the participants.
These interventions included breathing exercise, back message, birthing ball, walking. in
addition, they were allowed to drink sips of water.  This is supposed to be your intervention.
More detailed information regarding the intervention needs to be added, and the intervention
done by whom????
Any missing information from the interviews was obtained from the mothers’ medical record.
Setting need rephrasing
Al Zarqa Governmental Hospital is considered one of the largest hospitals in Jordan. Which
is equivalent to and is recently classified as one of the best hospitals in the city who said
that, reference is needed. There is a Department of Neonatology and Prematurity at Al Zarqa
Governmental Hospital. This hospital has passed the requirements for success in the Excellence
Program for the year 2018, thus it deserved the shields for its excellence in providing mothers
and child health services. Is it an accredited hospital either at national or international level???
More information regarding the capacity of hospital and the number of deliveries need to be
added
Ethical Considerations
The study was approved by the Institutional Review Boards of the Hashemite University
(No.5/3/2021/2022) and the Ministry of Health (Moh/REC/2021/234). All research participants
signed a consent form. The interviews were one to one, semi structured, audio recorded, and
conducted by the researcher (PI) herself. Anonymizing individuals’ information and places to
protect their identity was ensured, and all data files were protected by passwords.
Data Analysis
A manual Thematic and Content Analysis Tool (TCAT) was used by the researcher. Following
Braun and Clarke’s (2006) [13] six steps of analysis, (1) the interviews were reviewed multiple
times and transcripts were also read and reread several times to familiarize the researcher with
the data, (2) interesting sentences relevant to the purpose of our study were then systematically
coded by the research team, (3) all data relevant to each other were grouped and an initial theme
was given, (4) then initial themes were checked and rechecked in relation to the coded extracts
and the entire dataset to generate a thematic map, (5) after the thematic map was completed,
final names were given to the themes, (6) vivid and compelling extract examples were selected
and final analysis of the selected extracts was carried out. Final themes were linked back to the
research question and literature to produce the final report [13]. To ensure the accuracy of the
analysis, five random transcripts of the in-depth interviews and the generated themes were sent
back to the participants to read them and to confirm whether they reflected what they said during
the interviews [14].
Results
A total of eighteen mothers agreed to participate in our research study. Their ages ranged
between 22 and 37 with an average of 29.4 years. The age ranges of their husbands were between
26 and 39, with an average of 32.9. At the time of marriage, their ages were between 19 and 26,
with an average of 22.5. The duration of marriage time ranged between two years and 12 years,
with an average of 6.9 years. Three of our participants had a bachelor's degree. Five of them were
high school graduates, while two of them graduated with a diploma. Only three of them were
employed (those who had a bachelor's degree). Six of the husbands were high school graduates,
and three of them had a bachelor's degree, while one of them graduated with a diploma. Most
were employed, and some had their own businesses as drivers, farmers, etc. Their salary ranged
from 250 JD to 700 JD, with a maximum value for family income of 700 JD. Eleven of our
participants live in rented houses, and seven own their homes; eleven of them live with family in
the same building. Regarding the number of pregnancies for the mothers, including the present
pregnancy (G), the maximum number was six, while the minimum number of pregnancies was
two. The maximum number of term births was five, while the minimum was one.
Three major themes emerged from the interviews analysis. These themes were extracted from the
participants own words: “Positive, respectful and satisfying childbirth experience”; “Maintain
mother’s sense of control and cope with childbirth pain”; “Birth outcome”. These themes were
interconnected and influenced by each other.
In general, our findings suggest that our participants were satisfied with their experience
of using non-pharmacological interventions for the management of pain during labor and
birth. Compared to their previous experiences of childbirth, our participants felt relaxed and
autonomous.
Theme One: Positive, respectful, and satisfying childbirth experience
The use of the nonpharmacological intervention for pain management enhanced our participants’
feelings of respect and satisfaction, which resulted in positive feedback about the new
experiences. For example, one of the mothers described her experience as follows: “wonderful
experience, everything was good and less pain, more respect… I am so satisfied” (Mother 9,
Q20). Some of our participants expressed that this birth experience was a wonderful childbirth
experience, and they were very satisfied with the whole birth experience. “This was one of the
most wonderful birth experiences I ever imagined…” (Mother9, Q22). They said that, compared
to their previous childbirth, this time was less stressful, and they felt less fatigue in the labor
room: “this time I felt good, not tired … I was not exhausted after birth…” (Mother, Q17). They
also felt better and safer. “In my previous childbirth, I screamed a lot and cried too… but today
things were different…. I felt safe “(Mother1, Q3)
Our participants’ felt care was more comfortable and respectful during this childbirth. One of
our participants explained that “this baby’s birth was more respectful care and experienced less
fear and stress… its nice new experiences” (Mother 10, Q12).
Involving our participants and the process of childbirth enhanced their feelings of satisfaction.
Respect for the mother’s choice and avoiding unnecessary medical interventions increased the
mother's satisfaction with childbirth. The use of nonpharmacological interventions for them
played an important and essential role in ensuring mothers’ satisfaction and creating a positive
experience and nice childbirth memory for the mother and family: “Breathing exercise and back
massage were very good… could not believe that it will help in calming me down … at the
end I was truly satisfied…” (Mother1, Q1). “This childbirth was amazing. New ways of pain
management, all were nonpharmacological interventions, had used me during my childbirth.
Honest, unexpected, nice experience. I am so satisfied” (Mother7. Q7). The one-on-one care
during childbirth also gave mothers a sense of security: “The nurses were there all the time to
help me, she massaged my back, walked with me around the room and ensured me all the time
that I am doing well…” (Mother 9, Q11)
Our participants expressed positive feelings toward the use of breathing exercises, and the
professional support had a significant effect on reducing their pain level and increasing
relaxation: “in previous childbirth, I had several labor pains, but when the nurse supports
me by drinking water, doing breathing exercise and massaging my back …. My labor pain
decreased” (Mother 2, Q6).
Theme two: Maintain mother’s sense of control and cope with childbirth pain
Compared to their previous experience of childbirth, our participants found that the
nonpharmacological methods were highly effective in managing the childbirth pain. They also
expressed positive feelings toward using breathing exercise and massaging the perineum with
a birth ball. They report that these methods were very effective in reducing pain levels and
increased their sense of relaxation: “compared to my previous childbirth, …… this childbirth is
an experience to remember” (Mother 2, Q6). This time, my childbirth was easier than previous
ones and less painful” (Mother6, Q15).
Theme three: Birth outcome
The last theme emerged from the researcher’s field notes during her stay with the mothers
at the time of childbirth. The researcher wrote some notes about the birth outcome for each
mother. We found that after birth, all our participants and their newborns (n= 18 participants
with 18 newborns) were free of birth complications. Only three mothers (16.6%) requested
analgesics. Episiotomy was performed for only two mothers (3.6%). Amniotic membranes
were spontaneously ruptured for all mothers. Mothers were very cooperative with maternity
staff and coped very well with childbirth. All our participants accomplished their childbirth
vaginally without the need of assistance or cesarean birth. Additionally, all newborns recorded
normal Apgar scores at min 3 and 5, with no need for resuscitation or transfer to the NICU. All
participants experienced early skin-to-skin contact, and breastfeeding was directly initiated.
Discussion
Overall, this research study found a positive childbirth experience for our participants after
conducting normal physiologic vaginal childbirth. We used some nonpharmacological pain
management interventions to reduce the level of childbirth pain. In addition, we provided one-
on-one nursing care for each mother. All participants reported a better experience compared to
previous experiences or to what they expected. They expressed positive emotions, satisfaction,
and feelings of relaxation. Mothers also said that this birth experience will be recorded in their
memories forever. Our participants also showed cooperation with staff and acceptance of care
providers’ orders and comments. On the other hand, our participants felt respected, cared for,
comforted, and experienced less fear.
The same results were reported in a Cochrane review (2011) of 11 studies that found that
relaxation was associated with a reduction in pain intensity during the latent phase and active
phase of labor. They also found evidence of improved outcomes from relaxation instruction
with increased satisfaction with pain relief and lower assisted vaginal delivery and reduced
length of labor when compared to usual care [15]. Another study examined the effectiveness
of combined breathing exercises, foot reflexology, and massage interventions on labor pain,
anxiety, labor duration, stress hormone levels, maternal satisfaction, maternal vital signs,
and newborns’ APGAR scores. The intervention lowered the labor pain intensity after the
intervention, increased the oxytocin level, and shortened the labor duration. Participants who
received intervention during the first stage of labor experienced significantly reduced labor pain,
lowered anxiety (2.9 vs. 4.2, p < 0.001), less fear and labor duration, and improved maternal
outcomes (vital signs, maternal satisfaction, higher oxytocin levels, and reduced cortisol). This
study supports the effectiveness of intervention (breathing, massage). It provides good evidence
for maternity care to consider nonpharmacological interventions in the labor unit [7]
Our participants’ feelings of satisfaction were associated with the use of nonpharmacological
pain relief, and respectful care in avoiding unnecessary medical interventions was effective
in improving mothers’ satisfaction with childbirth. Using non-pharmacological interventions
played an important and essential role in increasing mothers’ satisfaction and comfort. More
participants felt satisfied because she felt supported by the nurse. The presence of the nurse
with participant to serve and help her during childbirth hours. Our findings were also confirmed
by another study that included nine different nonpharmacological interventions for reducing
labor pain. This study demonstrated that the nonpharmacological intervention was effective in
increasing satisfaction and comfort and reducing labor pain among their participants. This study
also demonstrated that nonpharmacological interventions are effective in enhancing satisfaction
and reducing labor pain among participants [2].
I think more recent research studies need to added
Do you think that  the results of your study help the mother in  the initiation of breastfeeding
Conclusions
Childbirth is an important event in the life of every mother. It is often associated with pain,
anxiety, and fear, which has a negative impact on the outcome of childbirth and on the mother
and her newborn. Pharmaceutical methods could quickly relieve pain and a feeling of satisfaction
for the mother, but they can have negative impacts or side effects, such as the inability of the
mother to push the fetus in the second stage and long second stage, with a risk to the fetus and
a negative impact on the respiratory system. Nonpharmacological methods such as breathing
techniques, back massage, birth balls, walking, and changes in position are safe for the mother
and the fetus and ensure the improvement of the outcomes of childbirth. Nonpharmacological
shows coping with childbirth pain, reducing anxiety and fear in childbirth, feeling satisfaction
and respectable care with the staff in the childbirth unit and creating a positive experience of the
birth. They also reduce the need for anesthesia or painkillers and the need for cesarean sections.
Limitations and recommendations of the study should be mentioned