Journal of Midwifery & Women’s Health www.jmwh.

org
Original Research

Effect of Birth Ball Usage on Pain in the Active Phase of Labor:

A Randomized Controlled Trial
Simin Taavoni, MSc, Somayeh Abdolahian, MS, Hamid Haghani, PhD, Leyla Neysani, MSc

Introduction: Anxiety can be a contributor to labor pain, which is known to be multifactorial. Because there is little information available on the
efficacy of birth ball use for labor pain management, this study aimed to evaluate the effectiveness of use of a birth ball on labor pain, contractions,
and duration of the active phase of labor.
Methods: In this randomized controlled trial, 60 primiparous women aged 18 to 35 years were divided into birth ball and control groups. Pain
scores were measured by a visual analogue scale.
Results: Mean pain scores in the birth ball group were significantly lower than the mean pain scores in the control group (P ⬍ .05). There were
no significant differences between duration of the active phase of labor or the interval between uterine contractions in the 2 groups (P ⬎ .05).
Discussion: Although the use of a birth ball had no effect on the duration of the active phase of labor, the duration of uterine contractions, or the
interval between contractions, this complementary treatment could reduce the intensity of pain during the active phase of labor.
J Midwifery Womens Health 2011;56:137–140  c 2011 by the American College of Nurse-Midwives.

Keywords: birth ball, duration of labor, labor pain management, uterine contraction

INTRODUCTION breathing techniques, positioning/movement, massage, hy-

Labor pain is natural, unique, complex, and multifactorial, 1,2 drotherapy, water immersion, hot/cold therapy, music, guided
and management of labor pain is an essential aspect of obstet- imagery, acupuncture,6 acupressure, aromatherapy,8 transcu-
ric care and a major goal of intrapartum care.3 The percep- taneous electrical nerve stimulation,2,8 hypnosis,8 and use of a
tion of labor pain might be better tolerated by women who birth ball.10 These nonpharmacologic techniques can be com-
do not have excessive fear.4 Cultural, social, and environmen- bined or used sequentially to increase their overall effect.
tal factors may influence the experience. In addition, personal One popular nonpharmacologic technique is movement
experiences, expectations about support from family, and re- and change of position during the first stage of labor.11 The
lationship with caregivers influence women’s perceptions of supine position is purported to adversely affect heart rate and
labor pain.5 blood flow to the fetus and may raise levels of maternal stress
It is noteworthy that childbirth educators have focused on hormones, thereby reducing uterine contractility and progress
teaching women about reduction of pain during labor6 via 1 of labor.12 In addition, ambulation or upright positions during
of 2 general approaches, pharmacologic and nonpharmaco- labor have several potential mechanical advantages, including
logic methods.7 Pharmacologic approaches aim to eliminate the effect of gravity and increased pelvic dimensions, which
the physical sensation of labor pain, but nonpharmacologic might decrease the need for instrumental births.13
methods are largely directed toward prevention of suffering Research on the effect of maternal position during labor
via improvement in the psychological/emotional and spiritual has reported conflicting results. Molina et al14 found that less
components of labor.8 Although pharmacologic approaches pain occurred during the first stage of labor with participants
such as intravenous or intramuscular opiates, regional nerve in horizontal positions compared with vertical positions. An-
blocks, and anesthetics may be associated with various risks,9 drews and Chrzanowski15 compared pain during the active
these are the methods predominately used in most hospitals. phase of labor with participants in upright versus recumbent
However, there may be a place for complementary therapies as positions and found no differences in pain for the 2 posi-
well.10 The purpose of this study was to evaluate the effects of tions. Walking and maintaining an upright position in the
birth ball use on pain, contractions, and duration of the active first stage of labor also can reduce the length of labor and do
phase of physiologic labor. not seem to cause negative effects on the health of mothers
There is a wide variety of nonpharmacologic pain re- and newborns.12 In summary, data regarding the efficacy of
lief techniques6,8 that not only address the physical sensation such interventions are limited, and most of the available stud-
of labor pain, but also attempt to prevent suffering by en- ies have small sample sizes and wide variations in participant
hancing the psychological/emotional components of care.6,7 populations.16
In this approach, pain is perceived as a side effect of a The birth ball is a relatively new tool for improving the ex-
normal labor process.8 These techniques include relaxation, perience of labor. Use of the birth ball incorporates both rock-
ing and movement, which, theoretically, helps the fetus find a
better fit through the pelvis as labor progresses.17 Chang et al18
Address correspondence to Somayeh Abdolahian, MS, P.O. Box 13185- developed a set of birth ball exercises for labor and evalu-
1678, Tehran, Iran. E-mail: swt [email protected] ated the acceptability of a video description of the exercises

1526-9523/09/$36.00 doi:10.1111/j.1542-2011.2010.00013.x c 2011 by the American College of Nurse-Midwives

 137
with 30 pregnant women in the fifth month of pregnancy and ball to participants before and during the study. Also, the in-
3 women in the active phase of labor. The results showed that dividual responsible for data analysis was masked to the study
performing birth ball exercises during labor may reduce labor purposes to minimize any bias that might arise from knowl-
pain.18 Our research group decided to evaluate the effective- edge about the participants. This ensured us that, as far as pos-
ness of the use of a birth ball on labor pain, contractions, and sible, differences came only from the effect of birth ball usage.
duration of the active phase of physiologic labor. Because there is not enough space in most Iranian
birthing environments, women are usually restricted from
walking or moving freely. In the control group, the partici-
METHODS
pants received routine care during labor, which consists of the
In this randomized controlled trial using convenience sam- parturient reclining on the bed without ambulating or any in-
pling, 60 volunteer primiparous women were recruited from tervention. Usual clinical examination (station, dilatation, ef-
one of the large general public hospitals of Iran University of facement) is done every 2 hours, and fetal heart rate monitor-
Medical Sciences, in Tehran, Iran. The study protocol was ap- ing is done every 30 minutes throughout the active phase of
proved by the ethics committee of Iran University of Medical labor.
Sciences, Tehran, Iran, and ethical permission was obtained We compared the pain scores, contractions (interval and
from this committee. length), and duration of the active phase in the birth ball user
The determination of sample size was accomplished by group and control group by using the t test in SPSS version
use of a formula with a significance level of 0.05 and a power 14. The demographic characteristics were analyzed by t test
level of 0.80, with an anticipated effect size d = difference of and chi-square test. A P value less than .05 was considered
means/standard deviation = 2.5. The minimum sample size significant.
for this study was 26 in each group.
The study included primiparous women aged 18 to 35 RESULTS
with singleton pregnancies, cephalic presentation of fetuses,
Sixty-two primiparous women were enrolled in the study. Two
38 to 40 complete weeks of gestation, anticipation of a normal
women from the birth ball group were excluded, one with-
birth, and no history of infertility. After describing the aim of
drew because she was dissatisfied with sitting on the ball dur-
the research and obtaining informed consent, we randomized
ing birth ball movements, and the other underwent a cesarean
those in the first stage of active-phase labor with cervical di-
birth because of lack of descent of the fetal head. The major-
latation between 4 and 8 cm into 2 groups. Randomization was
ity of the participants were aged 18 to 24 years (55%), were
accomplished with a table of random numbers. If the number
housekeepers (81.6%), and had finished high school educa-
was even, the woman was assigned to the birth ball group, and
tion (48.3%). The mean (SD) age of participants in the birth
if the number was odd, the woman was assigned to the control
ball group was 23.73 (4.07) years, and in the control group,
group. Group 1 consisted of birth ball users, and group 2 was
the mean age was 24.80 (3.30) years. There was no significant
the control group who received usual care.
difference in terms of age of participants between the group
If there was a need for analgesic medication, or if obstet-
(P = .731). The average gestational age in both groups was
ric complications occurred, the participant was immediately
between 39 and 40 weeks.
referred to an obstetrician and other professionals as needed,
There were significant differences between the pain scores
then excluded from the study.
of the women in the birth ball group after 30-minute
Demographic characteristics such as age, education level,
(P = .001), 60-minute (P ⬍ .001), and 90-minute interven-
gestational age, and occupation were obtained from the med-
tions (P = .001) when compared with the pain scores of the
ical records of participants. The investigator, who was an MSc
women in the control group. The mean score of pain severity
student of midwifery, performed a clinical examination to
in the birth ball group was significantly less than that of the
record dilatation, effacement, station, position, duration and
control group (Table 1).
interval of uterine contractions, and fetal heart rate. The pain
There was no significant difference in the duration of
score was recorded by the participants using a visual analogue
uterine contractions between the 2 groups or the intervals
scale (VAS) of 0 (lack of pain) to 10 (most severe pain they had
between uterine contractions. Also, this study showed no
experienced). Pain scores were measured in both groups be-
fore labor and then obtained every 30 minutes in both groups
until cervical dilation reached 8 cm.
Table 1. Mean Pain Scoresa in Control and Intervention Groups
In the birth ball group, women were instructed to sit on
Control Birth Ball
the ball and rock their hips back and forth or around in a cir-
cle for a minimum of 30 minutes. During these movements, Time of Intervention Mean (SD)a Mean (SD)a P Value
while the participants were sitting upright on the ball, they Before intervention 7.80 (2.31) 8.57 (1.43) .128
were instructed how to sit while their arms rested extending Min after intervention
to their sides and then start to rock their hips back and forth
30 8.50 (1.83) 6.93 (1.61)
or around in a circle. Although participants should have been .001
able to maintain their balance on the ball during these exer- 60 8.92 (1.31) 6.97 (1.58) ⬍.001
cises, the professional attending the session gave the women 90 9.29 (1.10) 7.57 (1.69) .001
support.
Abbreviations: SD, standard deviation; min, minutes.
To further reduce bias, researchers were instructed not to a
The pain visual analogue scale tool is scored from 0 to 10, with 0 being no pain
give verbal information about the possible effects of the birth and 10 being the worst pain.

138 Volume 56, No. 2, March/April 2011

 Table 2. Mean Duration and Interval of Uterine Contractions and/or the effect of different social and cultural backgrounds,
and Duration of Active Phase of Labor According to Intervention by which could influence study results. Also, it must be noted
Group that the sample selection method was not accessible for the
Duration and Control Birth Ball Chang study. Our findings are unlikely to be the result of ex-
Interval Mean (SD) Mean (SD) P Value perimental bias because the cases were selected by random
sampling.
Duration of uterine 46.40 (14.23) 48.94 (12.64) .863
Other more rigorously designed studies have found that
contraction, sec women who remain upright (standing, walking, sitting up-
Interval between 158.38 (40.78) 159.11 (39.10) .537 right) use less narcotic or epidural analgesia, have shorter first
uterine stages of labor, and need less oxytocin to augment labor when
compared with women who remain supine.20,21 It might be
contractions, sec
concluded that maternal positioning during labor generally is
Duration of active 1.67 (0.98) 1.78 (0.58) .605 a useful method for decreasing labor pain, but because there
phase, h are different findings about the influence of positioning on la-
bor duration, future investigations are recommended.
Abbreviations: h, hours; SD, standard deviation; sec, seconds.
In recent decades, the importance of measuring satisfac-
tion with health care has been recognized.5 Patients’ views are
being used by health care managers in assessing the quality of
significant difference in the duration of the active phase of
care and by policy makers in making decisions about the orga-
labor between groups (Table 2).
nization of health services.22 Because childbearing is the most
common reason for accessing health services, assessments of
DISCUSSION
women’s satisfaction with their care during labor and birth are
This study found that pain scores reported by women who relevant to health care providers and policy makers. In this
used the birth ball for a minimum of 30 minutes during the study, although satisfaction was not measured objectively, the
active phase of labor were lower than the pain scores of the majority of the women liked to sit and move on the birth ball,
women in the control group during the active phase of la- which is in agreement with other studies that found laboring
bor. This finding is consistent with the results of Chang and women willingly walk, sit, bathe, kneel, rock, sway, stand, lean,
Meeiling,18 which showed that performing birth ball exercises squat, and lie down when they are encouraged to move about,
during labor reduced labor pain, facilitated a positive birth ex- and where a variety of furniture and plenty of space are avail-
perience, and promoted comfort.18 This is also in agreement able. Also, many women will move if allowed, but, unless in-
with the findings of Adachi et al19 that indicated that women structed to try an upright position, they are likely to remain in
who underwent the early stage of labor in the upright position bed. Although the influences of pain and pain relief on sub-
(sitting or standing) had less pain. sequent satisfaction are neither as obvious, nor as direct, nor
Adachi et al19 proposed that the sitting position offers an as powerful as the influences of the attitudes and behaviors of
effective method of relieving lower back labor pain during cer- caregivers,5 we recommend that a mother’s satisfaction after a
vical dilation from 6 to 8 cm.19 The decrease in lumbar pain birth using the birth ball can be measured in future studies.
that occurs in the sitting position might be attributed to de- Comparing the results of this study with those of others,
creased pressure on nerve filaments that lie over the iliosacral we can conclude that the use of a birth ball during the first
joint and its immediate surrounding area. This hypothesis is stage of the active phase of physiologic labor and the birth pro-
supported by other studies that have found that some women cess reduced the perception of labor pain. Our results suggest
feel an uncontrolled level of lumbar pain in the supine posi- that midwives and obstetricians can incorporate using a birth
tion and report feeling a controlled level of pain in the sitting ball as part of labor pain management.
position; despite no decrease in abdominal pain while in the Limitations of our study should be considered. Labor pain
sitting position.19 was measured for 120 minutes during the maximum slope
These findings differ from those of Molina et al,14 who phase, hence not permitting the determination of the effect
found that pain was not influenced by maternal position dur- of the sitting position during all the stages of labor. Although
ing the early stage of labor and that there was less pain in the this study took place in a single obstetrics clinic in an Iranian
horizontal position when compared with the erect position society with a homogeneous population, it was hoped that by
in the latter first stage of labor. Unfortunately, although the choosing and randomizing participants from a public hospital
Molina study included sitting, standing, and walking as erect we could achieve an equal distribution of any cultural differ-
positions and supine and side lying as horizontal positions, ences that might exist between the 2 groups. It must be stated
the intensity of pain was not recorded, making it difficult to that mothers’ attitudes about birth might be different in dif-
apply those findings to effective labor pain relief. ferent populations.
In our study, there were no differences in the duration Although the use of a birth ball did not have any ef-
of the active phase of labor or the duration and intervals be- fect on the duration of the active phase of labor or uterine
tween uterine contractions when the 2 groups were compared. contractions or their intervals, this complementary treatment
This is in contrast with the Chang and Meeiling18 study that could reduce the intensity of pain during the active phase of
found that birth ball exercises caused acceleration of labor and physiologic labor. Use of a birth ball is a low-cost intervention
significant improvement in the labor process. This difference that does not require complex training and could be of value
might be attributed to the small sample size in the Chang study in low-resource settings. Future additional research might

Journal of Midwifery & Women’s Health r www.jmwh.org 139

evaluate its effectiveness during pregnancy and the postpar- 6.Brown ST, Douglas C, Flood LAP. Women’s evaluation of intrapartum
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Simin Taavoni, MSc, Medical Education, and Midwifery, Se-
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Pain Member. Tehran, Iran. tegrative Medicine. Philadelphia: Saunders; 2003:339-347.
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Somayeh Abdolahian, MS, is a graduate student of midwifery, tary therapies for laboring women. MCN Am J Matern Child Nurs.
Iran University of Medical Sciences, Tehran, Iran. 2006;31:364-370.
11.Storton S. The Coalition for Improving Maternity Services: Evidence
Hamid Haghani, PhD, is an assistant professor of biostatistics, basis for the ten steps of mother-friendly care. Step 4: Provides
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CONFLICT OF INTEREST
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ACKNOWLEDGEMENTS
bor: relationship with the patient’s position. J Pain Symptom Manage.
This study was supported by grant 771 P 2009 to S. Abdol- 1997;13:98-103.
lahian and S. Taavoni from the Research Department of Iran 15.Andrews CM, Chrzanowski M. Maternal position, labor, and comfort.
Appl Nurs Res. 1990;3:7-13.
University of Medical Sciences. We appreciate the kind help of
16.Smith Ca, Collin Ct, Cyna AM, Crowther CA. Complementary
Ching-Yi Chang for providing some articles for us and M. Os- and alternative therapies for pain management in labour. Cochrane
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Technology for technical assistance. vent or alleviate dystocia in labor. Clin Obstet Gynecol. 1987;30:83-
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