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Journal of Psychosomatic Obstetrics & Gynecology
ISSN: 0167-482X (Print) 1743-8942 (Online) Journal homepage: http://www.tandfonline.com/loi/ipob20
A qualitative interview study into experiences
of management of labor pain among women in
midwife-led care in the Netherlands
Trudy Klomp, Anke B. Witteveen, Ank de Jonge, Eileen K. Hutton & Antoine L.
M. Lagro-Janssen
To cite this article: Trudy Klomp, Anke B. Witteveen, Ank de Jonge, Eileen K. Hutton & Antoine
L. M. Lagro-Janssen (2016): A qualitative interview study into experiences of management of
labor pain among women in midwife-led care in the Netherlands, Journal of Psychosomatic
Obstetrics & Gynecology, DOI: 10.1080/0167482X.2016.1244522
To link to this article: http://dx.doi.org/10.1080/0167482X.2016.1244522
Published online: 25 Oct 2016.
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ORIGINAL ARTICLE
A qualitative interview study into experiences of management of labor pain
among women in midwife-led care in the Netherlands
Trudy Klomp
a
, Anke B. Witteveen
a
, Ank de Jonge
a
, Eileen K. Hutton
a,c
and Antoine L. M. Lagro-Janssen
b
a
Department of Midwifery Science, AVAG and EMGO Institute for Health and Care Research, VU University Medical Center
Amsterdam, the Netherlands;
b
Department of Primary Care and Community Care, Women’s Studies Medicine, Radboud University
Medical Center Nijmegen, the Netherlands;
c
Midwifery Education Program, McMaster University Hamilton, Ontario, Canada
ABSTRACT
Introduction: Many pregnant women are concerned about the pain they will experience in
labor and how to deal with this. This study’s objective was to explore women’s postpartum per-
ception and view of how they dealt with labor pain.
Methods: Semistructured postpartum interviews were analyzed using the constant comparison
method. Using purposive sampling, we selected 17 women from five midwifery practices across
the Netherlands, from August 2009 to September 2010.
Results: 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 indi-
cated that midwives should know which method of pain management they need during labor
and arrange this in good time.
Discussion: It may be difficult for midwives to discriminate between women who need continu-
ous support through labor without pain medication and those who genuinely desire pain medi-
cation at a certain point in labor, and who will be dissatisfied postpartum if this need is
unrecognized and unfulfilled.
ARTICLE HISTORY
Received 29 September 2015
Revised 8 September 2016
Accepted 14 September 2016
Published online 24 October
2016
KEYWORDS
Childbirth; coping; labor
pain; midwifery; women’s
health
Introduction
Labor pain is a varied phenomenon not restricted to
the sensory mechanism alone. Emotional, motivational
and cognitive dimensions all contribute significantly to
the way in which labor pain is experienced [1]. Many
pregnant women worry about the pain they will
experience and about how they will deal with it [2].
The management of labor pain includes medicinal and
nonmedicinal pain relief. It is also influenced by factors
such as a woman’s relationship with the health profes-
sional involved [3,4,5,6]. Also midwives’personal char-
acteristics, such as years of professional experience
and number of births to the midwife herself, might
influence the assessment of woman’s pain in labor
and therefore influence the professional’s approach to
deal with labor pain [7,8]. Because of the variable
accessibility of labor pain medication in hospitals and
as a result complaints of women and maternity care
providers about this, the board of anesthesiology
wrote a new guideline in partnership with obstetri-
cians. This guideline on the use of pain medication in
labor was introduced in the Netherlands in 2008. It
states that a women’s request is a sufficient medical
indication for pain medication in labor and that epi-
dural analgesia is the method of choice [9], and all
women have to be informed before birth about their
options for management of labor pain. This guideline,
together with the influence of Dutch and international
media, has probably helped to boost the use of pain
medication in the Netherlands [10,6].
Women’s ability to deal with labor pain is influ-
enced by several inter-related psychological factors
such as self-efficacy [11], pain-related fears [12,13,14]
and pain coping strategies [15]. Recently, cognitive
coping strategies, such as pain catastrophizing where
women only think in a negative way of pain and its
outcome, have gained increasing attention in the
childbirth literature [15]. Pain catastrophizing is a well-
known vulnerability factor in the fear-avoidance model
for the development of pain-related fear in general
[16] and in relation to labor pain specifically [17].
Catastrophizing labor pain was positively associated
with avoiding pain during childbirth, with an increase
CONTACT Trudy Klomp trudy.klomp@inholland.nl Department of Midwifery Science, AVAG and EMGO Institute for Health and Care Research, VU
University Medical Center Amsterdam, Van der Boechorststraat 7, D4-40, 1081 BT Amsterdam, the Netherlands
ß2016 Informa UK Limited, trading as Taylor & Francis Group
JOURNAL OF PSYCHOSOMATIC OBSTETRICS & GYNECOLOGY, 2016
http://dx.doi.org/10.1080/0167482X.2016.1244522
in labor pain intensity and request for pain relief
[17,18,19]. Interestingly, it has also been suggested
that catastrophizing before expected pain sensations
begin is associated with a tendency to underestimate
pain (i.e. fear avoidance) and is used as a way of
reducing anticipatory distress [15,20]. Earlier research
identified different approaches of women towards
dealing with labor pain [6,21], that is, natural prag-
matic, deliberately uninformed and pro medicinal pain
relief approach. Interestingly, women with a deliber-
ately uninformed approach felt more confident in
approaching labor without knowing too much, per-
haps in an effort to reduce anticipatory distress
regarding labor pain.
The Dutch maternity care system is community
based [22]. Midwife-led care is restricted to women
with a low level of risk at the onset of labor, that is,
singleton pregnancy with cephalic presentation, no
previous cesarean sections and no other risk factors
on the Dutch Obstetric Indication List [23]. Those opt-
ing for midwife-led care may choose to give birth at
home, in a birth center or in hospital. If risk factors or
complications arise, the woman is referred to obstet-
ric-led care. Medical interventions such as induction or
augmentation of labor, electronic fetal monitoring and
pain relief only take place in obstetric-led care.
In the Netherlands, around 12% of the population
is of a different non-Western cultural background and
in the cities this percentage is around 20–30% [24],
80% of women start their pregnancy in midwife-led
care and around 55% of women start their labor in
midwife-led care [25]. The relatively high rate of
physiological births (around 82% of all women who
have a vaginal delivery use no medicinal pain relief)
[25] in the Netherlands lends itself to investigate wom-
en’s perceptions of their ability to deal with labor
pain. Midwife-led care systems focus on helping
women to work with their labor pain, unlike many
obstetrician-led care systems that routinely offer medi-
cinal pain relief at an early stage of labor [26].
There have been no previous studies in the
Netherlands of how women receiving midwife-led care
from the onset of labor perceive their ability to deal
with labor pain.
An in-depth exploration of women’s perceived deal-
ing with labor pain in midwife-led care in the
Netherlands may thus generate important insights for
countries that are supporting midwife-led care to
encourage physiological birth [27,28]. This study’s
objective was to analyze women’s perception and
view of how they dealt with labor pain in order to
understand women’s perception and view about this
subject.
Methods
This study was designed as a qualitative interview
study, as we feel that this is well suited to an explor-
ation of women’s perception [29]. The choice of inter-
views over focus groups was driven by the private
nature of the topic of labor pain. Furthermore, this set-
ting allows women to discuss their intimate, personal
experiences with the interviewer, if they so wish.
Participants and procedure
We conducted semistructured postpartum interviews
with clients from five midwifery practices across the
Netherlands, between August 2009 and September
2010.
We selected practices in both rural and urban areas.
Our goal was to include women who varied in terms
of age, parity, level of education, cultural background
and intended place of birth. This was because these
factors are expected to affect women’s experiences of
pain management [30,31]. We included women who
spoke Dutch, were between four and eight weeks
postpartum, and who received midwife-led care at the
onset of labor. Interviews were held at least four
weeks after women had given birth, as we wished to
allow them some time to reflect on their experiences
of labor [32,33]. The final deadline was 8 weeks after
birth, as a woman’s memory may change over time
[34], and we wanted to interview women who still had
vivid memories of their labor pain.
In each of the five participating practices, the mid-
wife or her practice assistant identified eligible preg-
nant women. Initially, convenience sampling was
carried out by the midwives during prenatal care vis-
its (after 36 weeks of gestation), women were asked
if they would consent to a researcher contacting
them around 3-week postpartum. Women who
agreed gave written consent to the researcher. After
some time, during interviewing and data analyzing,
purposive sampling was adopted to achieve variation
in our sample size. The midwives were asked to
invite women with specific, under-represented charac-
teristics, such as women with Surinamese, Antillean
or Moroccan cultural backgrounds, women who had
decided beforehand to use some form of pain medi-
cation during labor, and women who had originally
intended not to use pain medication but who actu-
ally did so in the end. The number of women to be
interviewed was not prearranged. Interviewing was
continued until data saturation was achieved, that is,
the point at which no new information or themes
were detected in additional data [35]. A total of 24
2 T. KLOMP ET AL.
women were asked before childbirth and 20 agreed
to participate, five of these women refused to partici-
pate postnatally mostly due to time constraints and
one participant was not available for the scheduled
interview. Postnatally, another three women were
asked to participate and all of them agreed and gave
their written consent. All interviews were conducted
in Dutch, at the women’s homes, by the principal
researcher (TK); a female Dutch researcher. She
studied midwifery education and science and had
training in qualitative research methods by taking a
master's level course while enrolled at the University
of Humanistics in Utrecht. The researcher explained
to each participant that all information obtained dur-
ing the interview would be strictly confidential and
explained that the interviewer was a former midwife
but would be acting as a researcher in her role as
interviewer. The interviewer kept field notes in a log-
book, about the context of the interview, the inter-
viewee’s circumstances and her own role as the
interviewer. The interview guide was based on the lit-
erature of the theoretical model of “dealing with
labor pain”[36]. This model is based on the two
dealing with labor pain styles of “working with labor
pain”versus “pain relief”.
All interviews started with the same open question:
We would like to know how you dealt with labor
pain, what can you tell me about it?
Additional open questions helped women to talk
freely, describing events in their own words (see
Appendix 1 for details of the interview guide).
Ethical approval
Ethical approval was obtained from the Institutional
Review Board of the VU Medical Center Amsterdam.
Analysis
All interviews were audiotaped and transcribed by
the first author (TK) and an assistant. The transcripts
were coded and analyzed using ATLAS.ti version 5.2
(ATLAS.ti Scientific Software Development GmbH,
ATLAS.ti (Version 5.2) [Computer software], Berlin,
Germany), and further analyzed using the constant
comparison method [37]. The interpretative phenom-
enological analysis (IPA) was used to explore wom-
en’s personal perception of how they deal with their
labor pain experience [38]. The following baseline
information was collected for all study participants:
age, level of education, country of birth of the sub-
ject and of her parents, parity, intended and actual
place of birth. The participant’s level of education
was categorized as follows: (1) no education, (2) pri-
mary school only, (3) secondary school only, (4)
“intermediate”(postsecondary but below university
level) and (5) “higher”or university level. We explored
the data using open coding. The first three interviews
were coded separately by the first author (TK) and
second author (AW). We ensured the reliability of our
results by comparing the results they obtained.
Subsequent interviews were analyzed by TK, three of
which (chosen at random) were reviewed by AW.
When any inconsistencies in coding were found, the
first and second author tried to reach consensus and
consulted the third author (AdJ). The final analyses
were discussed by all of the authors. The second
author is a researcher with a PhD in psychology
working in a Department of Midwifery Science in the
Netherlands. The third and fourth authors are
Professor of Women Health Sciences in the
Netherlands and Professor Midwifery Science in
Canada and the Netherlands. We ensured the validity
of our data through monitoring the research role of
the first author and through a constant search for
disconfirming cases or falsifying evidence that would
refute the emerging themes during data collection
and analysis [37,39]. To avoid socially desirable
answers, the women were told that the interviewer
was a lecturer of midwifery and researcher interested
in improving the quality of care and asked them to
be honest about their labor experiences. The informa-
tion was coded as follows: P
x
¼participant no. x.
Quotes were translated from the Dutch verbatim
transcript into English by a professional translator.
Results
Of the 20 women who agreed to participate before
childbirth, five declined participation postnatally mostly
because of time constraints and one woman was not at
home at the time scheduled for the interview. An add-
itional three women were asked to participate postna-
tally and all of them agreed and gave their written
consent. As shown in Table 1, the seventeen participat-
ing women varied in their background characteristics.
The interviews lasted from 45 to 105 min. Three main
themes emerged from the analyzed interview data:
“control over decision making in labor”,“midwives con-
tinuous support in labor”and “childbirth preparation”.
The themes will be discussed below.
Control over decision-making during labor
Most women were in need of control over dealing
with labor pain and preferred to be informed by their
JOURNAL OF PSYCHOSOMATIC OBSTETRICS & GYNECOLOGY 3
midwife or other hospital staff about options and
expectations. When labor did not proceed as
expected, however, most women expressed very
strong feelings.
…until labor became very stressful and I became very
tired, at which point the hospital staff took action. And
just said ‘we have to arrange something or a drip with
pain medication so you can control the dose slightly
each time or just an epidural’. And we opted for the
latter. When I was connected to all the tubes, I could
not control that part of my body anymore and I think
that this made me feel emotional. That I just could not
follow my original birth plan anymore [planned to give
birth without medicinal pain relief], [P14, parous
woman] .
Some of these women blamed the Dutch maternity
care system’s culture of dealing with and accepting
labor pain for poor accessibility to pain medication in
hospital, while other women expressed their satisfac-
tion with the new policy on the provision of pain
medication, which allowed them to make their own
decisions during labor. One woman pointed out that
the supporting midwives failed to recognize her need
for pain medication and felt unable to control her
labor pain and the decision-making process. The fact
that she thought she was not able to control or toler-
ate the pain and her fear of being overwhelmed by
this pain shows that she was catastrophizing.
I really felt that I had to call out for it [pain medication].
I expected that the midwife would be able to assess how
much pain I had to endure and I expected that she [ …]
would be sympathetic to your plight, thinking ‘she can’t
do this anymore’and that she would transfer you to the
hospital. It was a bit as if she was just looking at me,
no matter how much pain I had. And I find that very
disappointing. [P5, primiparous woman].
Many women described their cognitive coping style
as one that encouraged themselves to work with labor
pain as it occurred and their pragmatic approach to
labor pain helped them to remain in control. Some
women who expected their body to cope with giving
birth naturally, felt disappointed when they realized
that they could not cope with the labor pain anymore
and developed catastrophizing thoughts on the pro-
gress of labor and on labor pain itself.
I thought that all my efforts were for nothing. [ …], I
thought the baby just does not want to come out. So
then, I started to scream for an epidural because I could
not bear it any more. In fact, my body really let me
down during labor. [P5, primiparous woman].
And a few women explained why, during labor,
they changed their mind about how to deal with labor
pain during labor. One woman who during pregnancy
planned to give birth in hospital with medicinal pain
relief followed her midwife, whose support helped her
to continue without pain medication.
Yes, I wanted an epidural but she [midwife] said ‘you
really do not need to do this, I know you’re afraid, you
just have to be patient then everything will be fine and I
was fine [ …], really it was a good decision, I was very
proud of myself. [P13, parous woman].
Midwives’continuous support in labor
Women appreciated the continuous support of their
midwives especially when they had direct access to
the midwife and when a familiar midwife cared for
them from onset of labor until actual childbirth, both
at home and in hospital. Particularly midwives with a
communicative, supportive and proactive attitude
Table 1. Characteristics of study sample.
Resp. Parity
Cultural
background
Level of
education Age
Intended place
of birth
Actual place
of birth
Framework: labor
pain approach
a
01 Primiparous Dutch Intermediate 32 home hospital DU
02 Primiparous Dutch Intermediate 29 home home PN
03 Primiparous Dutch Intermediate 27 home home PN
04 Primiparous Dutch Higher 28 indecisive hospital PP
05 Primiparous Dutch Higher 32 home hospital PN/PP
06 Primiparous Moroccan Secondary 22 hospital hospital DU
07 Primiparous Antillean Secondary 18 hospital hospital DU
08 Primiparous Surinamese Secondary 19 hospital hospital DU
09 Parous Dutch Higher 35 hospital hospital PP
10 Parous Dutch Higher 32 home home PN
11 Parous Dutch Secondary 28 home home PN
12 Parous Dutch Intermediate 36 indecisive hospital PN
13 Parous Moroccan Lower 41 hosp./indec. home PP/PN
14 Parous Moroccan Secondary 33 home home PN
17 Parous Other Eur. Higher 29 home home PN
16 Parous Turkish Lower 27 hospital hospital DU
17 Parous Turkish Intermediate 30 hospital hospital DU
a
Labor pain approaches.
PN: Pragmatic Natural; DU: Deliberately Uninformed; PP: Pro Pain relief.
4 T. KLOMP ET AL.
during labor were well appreciated by the women.
The women trusted their midwives to act as their
advocate if their labor did not proceed as expected.
Yes, I knew her [midwife] from my consultations at the
midwifery practice and that was nice. She stayed very
calm and in control and that calmed me. She kept on
talking to me when contractions came and when she
noticed that I was in severe pain she just said nothing
and waited until the pain was over. Good
communication with your midwife because in the end,
she’s the one you’ll have to trust. [P8, primiparous
woman].
A few women who were transferred from primary
midwife-led care to secondary obstetrician-led care
due to prolonged labor and a request for pain medica-
tion, expressed negative emotions about their birth
experiences. These women felt abandoned by their
familiar midwife who, once being referred, is no longer
responsible and out of the picture and criticized the
Dutch maternity care system for this.
I believe it is just not right that your midwife can’t stay,
that she has to hand you over, I did not like that
because that person knows you very well and I know
her [P12, parous woman].
And then I got another midwife [woman’s face expresses
disappointment]. For a long time, it really bothered me
that three different midwives were looking after me,
which was not OK [P1, primiparous].
Childbirth preparation
Antepartum preparation was evaluated as highly
important to the approach women used during labor.
Great importance was also placed on childbirth stories
by women with experience of labor and on antenatal
classes. Concerning the latter, women often stressed
the importance of breathing exercises, of becoming
familiar with the physical and cognitive aspects of the
labor process and of developing a birth plan in order
to help control pain during labor.
I was very happy with my yoga childbirth classes, they
helped a lot, it meant that I could really control my
breathing so, no matter how much pain I had, my mind
stayed clear; then there is less tendency to panic …,
with fewer stressful moments and I was more in control
[P2, primiparous woman].
Some participants in our study said that they had
used cognitive coping strategies, such as believing
that natural childbirth is positive and special.
I am convinced that, well fear makes your body stiff.
Fear does not allow you to be open to things, so you
always have to try [ …]. And I also said a few times
[during prenatal classes]: yes, wait a minute, just try to
face it in a relaxed manner because it is also beautiful
[birth]. It’s something very special that you are allowed
to do; to try and develop that kind of attitude. [P15,
parous woman].
Although labor pain stories of other women helped
women to prepare for childbirth, too much informa-
tion made women feel unsecure and more fearful
about working with labor pain. Some women who pre-
ferred to see how things turned out said they just
planned to do their best, believing that the birth of
their child would be compensation enough.
I think that all that information about pain relief
actually makes women afraid of giving birth. While
reading the information, I was thinking ‘Gosh, this is all
such scaremongering’.[…] I would prefer to believe
that I can just do it. I have to empower myself. And if
something happens [during birth] that means I cannot
handle the pain any more, then the midwife will know
what to do [P10, parous woman].
Discussion
The findings of our study essentially show that active
involvement in decision making during labor helped
the women in our study to deal with labor pain, as
did their midwives’continuous support and effective,
helpful birth preparation. Within these themes, three
main postpartum approaches to deal with labor pain,
became apparent as described in earlier antepartum
research of Klomp et al. [6]: the “Pragmatic Natural”
approach with women planning to give birth naturally
and without pain medication, provided labor was
straightforward; the “Deliberately Uninformed”
approach with women restraining themselves from
information and preferring to see how things turned
out; the “Pro Pain relief”approach with women who
definitely planned to use pain medication [6]. The
three themes identified in the current study cut across
these approaches to pain management.
Remarkably, the women in our postpartum study
adopted the same approaches during labor compared
to the identified adopted approaches during preg-
nancy, in the studies of Klomp et al. and Haines et al.
[21]. One could argue that approaches of women dur-
ing pregnancy reflect fixed approaches of dealing with
labor pain in general, since postpartum women reflect
similar aspects important for them in dealing with
their labor pain experience.
Additionally, our findings show that feelings of loss
of control during labor particularly emerged when
women’s approach during pregnancy towards labor
pain did not work out as planned, which is in line
with previous studies [2,10]. Moreover, this feeling of
JOURNAL OF PSYCHOSOMATIC OBSTETRICS & GYNECOLOGY 5
uncontrollability might also have a cognitive compo-
nent and essentially shows the presence of catastroph-
izing thoughts about labor and labor pain [15,40,19].
Catastrophizing involves focusing on the significance
of pain in specific circumstances, and a lack of belief
in the ability to work with it [41,42]. Interestingly,
women who catastrophized their labor pain in our
study were also particularly focused on its physical
dimension and had difficulty accepting that their
bodies were unable to deal with labor pain the way
they expected. Interestingly, these women with cata-
strophizing thoughts had a deliberately uninformed or
pragmatic natural approach that might suggest a fear-
avoidant approach towards labor. In line with recent
studies of Whitburn et al. (2013, 2014) and Escott et al.
(2009), we also found that the cognitive coping strat-
egies such as distraction based techniques and use of
empowering thoughts, instilled in women as part of
their childbirth preparation, appeared to help women
to work with labor pain [40,15].
Additionally, our findings show that feelings of con-
trol over labor pain are highly related to the ability of
making shared decisions about pain relief methods
during labor. Similar to other studies, many women
preferred to defer decisions about pain medication
until labor, as they trusted their maternity care profes-
sional to guide them through labor pain with the help
of relevant information and available options [42,43].
On the other hand, feelings of loss of control may
arise when midwives have difficulty assessing whether
pain medication should be provided, as our findings
show. In this respect, it seems important that mid-
wives should help women to have realistic expecta-
tions about dealing with labor pain by antepartum
discussion of potential difficulties that only arise dur-
ing active labor in deciding whether or not to use
pain medication. In other studies, continuous support
from one maternity care professional, has been shown
to have a positive effect on women’s birth experiences
[4,44]. The Dutch guideline of “failure to progress in
labor”recommends continuous support during labor
to facilitate the labor process, to reduce the need for
pain medication and to reduce labor interventions
[45]. In our study, too, women preferred continuous
support from one familiar midwife to deal with labor
pain.
The fact that the previously identified antepartum
framework by Klomp et al. (2013) [6] and our postpar-
tum findings of approaches toward labor pain are
quite similar to the framework identified by Haines
et al. (2012) toward childbirth in general [21], suggests
that women’s approaches to birth are highly
determined by important personal characteristics as
coping and pain-related fear [1,15,19].
Situations arising during pregnancy and labor, how-
ever, may also influence women’s approach to a sub-
sequent pregnancy and labor [46,47]. Interestingly, we
found that some women even changed their approach
early in labor from “Pro Pain relief”to “Pragmatic
Natural”and was often prompted by information from
their midwife. Some women who adopted a
“Pragmatic Natural”approach and changed their
approach to labor pain to a subsequent labor may
have been so focused on natural birth without pain
medication that they failed to take the unpredictability
of birth into account, and were unable to request pain
medication when they actually needed it.
The Dutch culture seems to be an important deter-
minant for women’s approach to labor pain [48,49].
Previous pregnancy study results showed that, most
low-risk women believe in natural childbirth –including
working with labor pain without pain medication –
provided that labor proceeds well [6]. The current study
shows that this “Pragmatic Natural”approach contin-
ued during labor as well. Nevertheless, the change in
Dutch culture and the greater availability of pain medi-
cation is important for many of these women [7].
Our study results might be somewhat limited by
the fact that all women were in midwife-led care, so
the results of our study cannot be generalized to
those in labor in obstetrician-led care. A strength of
our study, however, is that –given the delicate nature
of the subject of labor pain –the women in the cur-
rent study were not interviewed antepartum about
their expectations with labor pain. In some studies,
expectations and experiences of pain are explored in
the same group of participants [2], enabling compar-
ability of women’s ante- and postpartum perception
within subjects. Although comparison of perception of
antepartum expectations with postpartum experiences
in itself is interesting, interviewing the same women
both antepartum and postpartum, might make the
antepartum interview an intervention. Therefore, focus-
ing these women during pregnancy on the subject of
dealing with labor pain and interviewing the same
women again after birth might alter the findings com-
pared to only interviewing women in the postpartum
period.
In conclusion, our study shows that primi- and mul-
tiparous women with a variety of ethnic backgrounds
who gave birth at home or in hospital under midwife-
led care may appreciate clarity about pain manage-
ment options such as requesting pain medication and
midwife support in shared decision making when to
go forth with medicinal pain relief. Women generally
6 T. KLOMP ET AL.
also expected their midwife to be able to provide con-
tinuous support during labor, to enhance the commu-
nication of needs, such as switching approaches to
labor pain. Continuous support was particularly essen-
tial in working with the pain and when women
changed from midwife-led care to obstetrician-led care.
Clinically, these study findings urge maternity care
providers to offer antepartum information about feel-
ings of loss of control during labor and how to (cogni-
tively) cope with these feelings. Furthermore, we
suggest that adequate discrimination could be neces-
sary between women who need continuous support
through labor without pain medication and those who
genuinely desire pain medication at a certain point in
labor. Further research is needed to identify areas for
improvement in working with labor pain in “Pragmatic
Natural”subjects, for example, coping techniques and
the support needed to balance giving birth without
pain medication versus getting medication in time,
when necessary. Similar research is also needed in
obstetrician-led care.
Acknowledgements
We thank all the midwifery practices for recruiting women
for our interviews. We also thank all the women who gave
us their time and were prepared to share their intimate labor
experiences with us.
Disclosure statement
The authors report no conflicts of interest. The authors alone
are responsible for the content and writing of this article.
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8 T. KLOMP ET AL.
äCurrent knowledge on the subject
When women's antenatal approach toward labor pain does not work out as planned, some women feel
lost, not in control and tend to catastrophize labor pain.
The cognitive coping strategies instilled in women as part of their childbirth preparation help them to man-
age with labor pain.
Most women want to wait and see until labor before they decide about the use of pain medication during
labor.
äWhat this study adds?
Some women change their approach early in labor from “Pro Pain Relief”to “Pragmatic Natural”(wait and
see). This change may be prompted by their midwife.
Women may be so focused on natural birth without pain medication that they fail to take the variability of
the birth process into account.
Some women expect midwives to know which method of pain management they need during labor and to
ensure this is arranged in a timely manner.
Appendix
Experiences of management of labor pain among women
in midwife-led care in the Netherlands
Postpartum interviews with women.
Opening question:
We would like to know how you dealt with labor pain,
what can you tell me about it?
Pain
How did you experience pain during the initial stages of
labor?
How did you experience pain during the pushing period
or when actually giving birth?
Pain approach –methods
What are your experiences of labor pain relief methods?
Probes:
How did you perceive the availability of pain relief
methods?
What influenced the method of pain relief used?
Support
What are your experiences of the support provided by
maternity care professionals during labor?
Is there anything else you would like to tell me?
JOURNAL OF PSYCHOSOMATIC OBSTETRICS & GYNECOLOGY 9
