Original Article
Effect of Change in
From the *Midwifery Unit, Erbil
General Directorate of Health;
†
Midwifery Department, College of
Nursing, The Center for Research and
Education in Women’s Health,
Hawler Medical University, Erbil City,
Kurdistan Region, Iraq.
Address correspondence to Hamdia
Mirkhan Ahmed, PhD, Midwifery
Department, College of Nursing, The
Center for Research and Education in
Women’s Health, Hawler Medical
University, 60th Street, Erbil City,
Kurdistan Region, Iraq. E-mail:
hamdia76@gmail.com
Received November 4, 2016;
Revised January 27, 2018;
Accepted January 29, 2018.
This research did not receive any
specific grant from funding agencies
in the public, commercial, or
not-for-profit sectors.
1524-9042/$36.00
Ó 2018 by the American Society for
Pain Management Nursing
https://doi.org/10.1016/
j.pmn.2018.01.006
Position and Back
Massage on Pain
Perception during First
Stage of Labor
--- Suad Abdul-Sattar Khudhur Ali, MSc,*
and Hamdia Mirkhan Ahmed, PhD†
- ABSTRACT:
Labor is one of the most painful events in a women’s life. Frequent
change in positions and back massage may be effective in reducing
pain during the first stage of labor. The focus of this study was to
identify the impact of either change in position or back massage on
pain perception during first stage of labor. A quasi-experimental
study. Teaching hospital, Kurdistan Region, Iraq, November 2014 to
October 2015. Eighty women were interviewed as a study sample when
admitted to the labor and delivery area and divided into three groups:
20 women received frequent changes in position (group A), 20 women
received back massage (Group B), and 40 women constituted the
control group (group C). A structured interview questionnaire to
collect background data was completed by the researcher in personal
interviews with the mothers. The intervention was performed at three
points in each group, and pain perception was measured after each
intervention using the Face Pain Scale. The mean rank of the differ-
ence in pain scores among the study groups was as follows after the
first, second, and third interventions, respectively: group A—52.33,
47.00, 49.2; group B—32.8, 30.28, 30.38; group C—38.44, 42.36, 41.21.
There were significant differences between groups A, B, and C after the
first, second, and third interventions (p1 ¼ .011, p2 ¼ .042, p3 ¼ .024).
Back massage may be a more effective pain management approach
than change in position during the first stage of labor.
Ó 2018 by the American Society for Pain Management Nursing
Labor pain is one of the most severe forms of pain women experience during
their lives. It is viewed as a complex physiological phenomenon that encom-
passes psychological, emotional, spiritual, and physical dimensions (Zahra &
Leila, 2013). Continued pain and fear during labor have numerous adverse ef-
fects on the physiological status of the mother and fetus (Melender, 2002), and
may also increase the need for midwifery interventions including assistive
devices and cesarean section. Indeed, labor pain can increase elective cesarean
Pain Management Nursing, Vol -, No - (--), 2018: pp 1-7
2 Abdul-Sattar Khudhur Ali and Mirkhan Ahmed
section; thus, the provision of pain relief in obstetrics
and gynecology is of considerable significance
(Hajiamini, Masoud, Ebadi, Mahboubh, & Matin, 2012).
The management of labor pain is a major goal of
intrapartum care. There are two general approaches
to pain management: pharmacological and nonphar-
macological (Simkin & Klein, 2007). The advantages
of nonpharmacologic pain management strategies are
their simplicity and relatively easy initiation, the sense
of control women feel when they actively manage their
pain, the lack of serious side effects, and the fact that
they do not generally add additional costs to the birth
process (Simkin & O’Hara, 2002). Among the most
important tasks for a midwife and nurse who are
providing obstetric care is support of women during
pregnancy and childbirth and reduction of the inten-
sity of pain or discomfort during labor (London,
Ladewig, Ball, & Bindler, 2003).
Various nonpharmacological techniques have
been proposed for relief of labor pain, such as massage
therapy, change in position, acupuncture, music, warm
bath, relaxation, and aromatherapy. These methods are
often simple and safe, have few adverse reactions, are
relatively inexpensive, and can be used throughout la-
bor (Simkin & Bolding, 2004; Perry, Hockenberry,
Lowdermilk, & Wilson, 2014). Nonpharmacological
approaches to pain management are intended not
only to decrease the physical sensations of pain, but
also to prevent suffering by enhancing the
psychological, emotional, and spiritual dimensions of
care. In this approach, pain is perceived as a side
effect of a normal labor. Research studies reveal that
nonpharmacological measures such as back massage
and frequent changes in position are very effective in
reducing labor pain during the first stage of labor, and
the use of oil makes massage more pleasant (Gallo
et al., 2013; Simkin, 2003; Simkin & Klein, 2007).
In therapeutic massage, the sense of touch is used
to promote relaxation and pain relief. Massage works
as a form of pain relief by increasing the production
of endorphins in the body. Endorphins reduce the
transmission of signals between nerve cells and, thus,
lower the perception of pain. In addition, massage
acts as a distraction from the discomfort. Another non-
pharmacological technique is change in position,
frequently from sitting to lying, kneeling, or walking,
all of which help relieve pain. Changes in position
also may help speed labor through the effects of gravity
and changes in the shape of the pelvis. Continuing
changes in positions frequently facilitate favorable fetal
rotation by altering the alignment of the presenting
part with the pelvis. As the mother continues to
change positions based on comfort, the optimal pre-
sentation is achieved (Ricci, 2013).
It is worth mentioning that antenatal care in Iraq
comprises four visits during which vaccinations are
administered, laboratory tests are performed, and
checking blood pressure is checked. Prenatal educa-
tion is very limited. There are no childbirth classes
for mothers during pregnancy or professional health
care providers (midwives or nurses) trained to deliver
maternal education. As pregnant women in Iraq are
not educated in the primary health care system on
the availability of pain management during labor and
delivery, they are not offered pharmacological inter-
ventions. The lack of these interventions for pain man-
agement allowed for a clearer interpretation of the
nonpharmacological interventions in this study.
Iraqi public maternity hospitals do not implement
nonpharmacological therapy to reduce pain and
discomfort during labor, nor do they offer pharmaco-
logical therapy. Most patients have no opportunity to
receive any analgesic medications, and few receive
only pharmacological analgesia with tramadol or
meperidine. There are no antenatal teaching or child-
birth classes in Maternal and Child Health (MCH) units
of Iraqi primary health care centers, so pregnant
women are not familiar with pain management ap-
proaches during labor and delivery. In addition, our
women consider pain during labor to be an inevitable
component of the labor process. We became inter-
ested in examining the effects of back massage and/
or change in position on pain perception during the
first stage of labor among Kurdish women. The present
study was aimed at determining and comparing the
effectiveness of change in position and back massage
on pain perception during first stage of labor, as
compared with the usual care of patients.
METHODS
A quasi-experimental study was conducted in the deliv-
ery unit of a teaching hospital in the Kurdistan Region,
Iraq, during the period 2014-2015. A convenient, non-
probability sampling method was used to select 80
mothers who were then divided into three groups:
two study groups each with 20 women, and a control
group of 40 women. Group A (study group) received
changes in position. Group B (study group) women
received back massage. Group C (control group)
women received standard care by the staff of the hos-
pital. The rights and confidentiality of the respondents
were respected in all phases of the study. During the
verbal informed consent process, the type and pur-
pose of the study, discussion, issues of confidentiality,
voluntary participation, and free will of withdrawal
from the study were explained, and the women were
 Pain perception in first stage of labor 3

promised that the data would be used for study pur- circle the face that represented how they were feeling
poses only. before the intervention and at the three intervals.
Mothers had to meet the following criteria To be
included in the study, women had to be full-term and
Interventions
carrying a live single fetus in cephalic presentation,
Group A (Change in Position). The positions used
in the active phase of the first stage of labor (cervix
for women in the first stage of labor were sitting,
dilation of at least 3-4 cm), and gravida 1 or 2. Mothers
walking, semi-sitting, hands and knees (all fours), and
with high-risk pregnancies, such as those with
lying on either side. The researcher prepared a
eclampsia, pre-eclampsia, hemorrhage, malpresenta-
pamphlet that described the five appropriate and suit-
tion, contraindication for vaginal delivery, multiple
able positions (including pictures) for the mother and
gestation, gestational diabetes, preterm labor, and post-
the benefits of each position during the first stage of la-
date pregnancy and those who received analgesic
bor, which was translated into the local language. The
drugs were excluded from the study. All groups had
women were asked to begin by choosing the position
the following matching criteria: age <20-35 years, grav-
in which they were most comfortable. Women were
ida 1 or 2. It is worth mentioning that pregnant women
encouraged to remain in each position for 10 minutes
in both study groups and the control group had not
with a 10-minute rest between changes and assumed
received any antenatal teaching regarding pain man-
the five positions during the first stage of labor at 4,
agement during labor, as this type of service is not
7, and 10 cm of cervical dilation. Women completed
included in antenatal care of the Iraqi primary health
the FPS to indicate how they felt before starting the
care system before or during labor.
intervention and at the three intervals during the
Prior to data collection, official permission was
intervention.
obtained from the Hawler College of Nursing, General
Group B (Back Massage). The researcher had pre-
Directorate of Health, and teaching hospital for car-
pared a pamphlet describing the advantages of back
rying out the study. Data were collected from mothers
massage during labor, which was translated into the
who agreed to participate in the study. After explana-
appropriate language. The participants, in a sitting po-
tion of the objectives of the study and intervention pro-
sition, were massaged by the researcher who had
cess it was determined if the women were willing to
learned the technique by reading the literature and
participate. Verbal informed consent was obtained
watching videos. Back massage was performed during
from the mothers, because Iraqi women prefer not to
the first stage of labor at 4, 7, and 10 cm of cervical dila-
sign a written consent or are illiterate. The women
tion for 20 minutes during contractions. Massage was
who presented for delivery were screened to deter-
performed in a circular motion gently, with moderate
mine if they met the inclusion criteria, after which
pushing and rhythmic movements. Jasmine oil was
they were assigned to one of the three groups. Each
used to make the massage easier to perform and to
day, only 2 women were assigned to receive one type
make it more enjoyable for the women. Women
of intervention (study group) or assigned to the control
completed the FPS to indicate how they felt before
group randomly. The women were placed in separate
starting the intervention and at the three intervals dur-
rooms. The researcher spent 4-9 hours with the partic-
ing the intervention.
ipants to complete the data collection.
Group C (Control). The women in the control group
A questionnaire was designed and constructed by
received routine care from midwives in the delivery
the researcher through an extensive review of the rele-
room, which included cannulation, intravenous ther-
vant literature to collect appropriate data. The ques-
apy, and encouragement to urinate during first stage.
tionnaire was completed by the researcher during
The midwives were most involved prior to the second
the interview with the mothers and included sociode-
stage of labor and prior to delivery of the placenta.
mographic characteristics, obstetrical history, and
Most women in the control group did not receive anal-
mother’s status at the time of admission. The Face
gesic medications; some received only pharmacolog-
Pain Scale (FPS) was used as a pain assessment tool
ical analgesia with tramadol or meperidine.
for measuring pain before and after the intervention.
The FPS was developed by Donna Wong and Connie
Baker and consists of a series of faces ranging from a Data Collection and Statistical Analysis
happy face at 0 ¼ ‘‘no hurt’’ to a crying face at A pilot study was conducted on 12 women before start-
10 ¼ ‘‘hurts the most.’’ Participants were asked to ing the main data collection to identify barriers that
choose the face that best described how they might be encountered by the investigator during the
felt. The intervention was performed at three different study process, such as place and time. The knowledge
intervals: 4, 7, and 10 cm. The women were asked to gained from the pilot study was helpful in developing
4 Abdul-Sattar Khudhur Ali and Mirkhan Ahmed

TABLE 1. TABLE 2.
Distribution of the Samples by Obstetrical Characteristics of the Study Sample
Sociodemographic Characteristics
F (%)
F (%)
Group A Group B Group C p Value
Group A Group B Group C p Value Items (n ¼ 20) (n ¼ 20) (n ¼ 40) (c2 Test)
Item (n ¼ 20) (n ¼ 20) (n ¼ 40) (c2 Test)
Gravida
Age group 1 10 (50) 10 (50) 20 (50) 1.000
<20 3 (15) 4 (20) 7 (17.5) 2 10 (50) 10 (50) 20 (50)
20-24 7 (35) 7 (35) 12 (30) Parity
25-29 8 (40) 6 (30) 18 (45) .937 0 11 (55) 10 (50) 21 (52.5) .959
30-35 2 (10) 3 (15) 3 (7.5) 1 9 (45) 10 (50) 19 (47.5)
Educational level Abortion
Illiterate 3 (15) 4 (20) 10 (25) 0 19 (95) 20 (100) 39 (97.5) .599
Read and write 3 (15) 3 (15) 6 (15) 1 1 (5) 0 (0) 1 (2.5)
Primary 1 (5) 1 (5) 2 (5) Gestational age
Intermediate 3 (15) 2 (10) 6 (15) 38 wk 4 (20) 9 (45) 15 (37.5) .560
Secondary 3 (15) 5 (25) 6 (15) .985 39 wk 13 (65) 9 (45) 20 (50)
Institute 3 (15) 4 (20) 2 (5) $40 wk 3 (15) 2 (10) 5 (12.5)
College 4 (20) 1 (5) 8 (20) Time of onset of
Occupation of regular
mothers contractions
Employed 5 (25) 3 (15) 9 (22.5) Day before 7 (35) 5 (25) 8 (20) .789
Housewife 10 (50) 17 (85) 25 (62.5) Night before 9 (45) 11 (55) 22 (55)
Student 5 (25) 0 (0) 6 (15) .129 Same day 4 (20) 4 (20) 10 (25)
Residential area morning
Urban 13 (65) 11 (55) 32 (80) Membranes
Suburban/rural 7 (35) 9 (45) 8 (20) .117 status
Intact 12 (60) 7 (35) 13 (32.5) .107
Group A ¼ change in position; group B ¼ back massage; group C ¼ control. Rupture 8 (40) 13 (65) 27 (67.5)
Group A ¼ change in position; group B ¼ back massage; group C ¼ control.
the procedure for the intervention for the study groups
in the infrastructure of the delivery room.
Data were prepared, organized, and entered into a The majority of the participants had not had a prior
computer program, Statistical Package for Social abortion. There were no significant differences
Science (SPSS Version 21, IBM, Armonk, New York). between the groups with respect to gravidity, parity,
The following statistical methods were used to analyze and prior abortion. There were no statistically signifi-
and assess the results: frequency and percentage, mean cant difference between the groups in gestational age,
and standard deviation, Mann-Whitney U test, Kruskal- time of onset of regular contractions, and membrane
Wallis test, one-way analysis of variance (ANOVA), and status at the time of admission (Table 2). There
c2 test. The score from the FPS, which ranges from 0 to were significant differences in mean ranks of pain
10, was transformed by a factor of 10 so that the pain scores in the three groups between pre-intervention
scores ranged from 0 to 100 for analysis, facilitating the and the first, second, and third interventions
interpretation of results. (p ¼ .011, .042, .024) (Table 3).
The results of the present study revealed that the
mean rank of the difference in pain scores for group A
(changing position) was higher than that for group C
RESULTS
(control), which means that changes in position in-
Values for the study sample (mean  standard devia- crease pain, but the mean rank of the difference in
tion [SD]) were 24  4.437 for group A, pain scores for group B (back massage) was lower
23.9  3.985 for group B, and 24  4.101 for group than that for group C (control), indicating that back
C. There were no statistically significant differences massage decreased pain perception. Comparison of
between the groups with respect to all the character- the two approaches—change in position and back
istics mentioned (Table 1). Half of the mothers in all massage—revealed highly statistically significant differ-
groups were primigravida, and 55% of group A, 50% ences in pain scores between groups A and B after the
of group B, and 52.5% of group C were primipara. first, second, and third interventions (Tables 4–6).
 Pain perception in first stage of labor 5

TABLE 3.
Mean Rank of the Difference in Pain Scores among the Three Study Groups before and after Intervention

Mean Rank
p Value
Group A Group B Group C (Kruskal-Wallis
Pain score difference (n ¼ 20) (n ¼ 20) (n ¼ 40) Test)

First – before intervention 52.33 32.80 38.44 .011*

Second – before intervention 47.00 30.28 42.36 .042*
Third – before intervention 49.20 30.38 41.21 .024*
Group A ¼ change in position; group B ¼ back massage; group C ¼ control.
*Significance at the .05 level.

DISCUSSION pain. This effect presumably could produce a local lateral

The present study examined the effects of frequent
changes in position and back massage as non-
pharmacological methods to decrease pain perception
by women in the first stage of labor. The results indi-
cated that back massage is an effective method, in
contrast to frequent changes in of positions, which in-
crease the perception of pain. The effects of each posi-
tion (sitting, walking, semi-sitting, hands and knees [all
fours], and side lying) on pain perception were not
measured separately so it is unclear if the increasing
pain perception was related to a specific position. The
increase in pain perception after frequent changes in
position may result from changes in the shape and
size of the pelvis, which can help the baby’s head
move to the optimal position during the first stage of la-
bor, and in rotation and descent during the second stage
(Mathew, Nayak, & Vandana, 2012), which result in dila-
tation and stretching of the cervix, pressure on and pull-
ing of pelvic structures (ligaments, fallopian tubes, and
peritoneum), and distention and stretching of the va-
gina and perineum splitting and tearing sensation
(Leifer, 2005). Massage may stimulate large fast nerve fi-
bers (unmyelinated C fibers) and block the smaller,
slower nerve fibers (myelinated A fibers) that detect
inhibition in the spinal cord and explains why touching
the painful area is an effective strategy for relieving pain.
Massage can increase levels of endorphins, decrease
arousal level, and increase parasympathetic response en-
dorphins (Hall, 2016). In comparison, massage affects a
women’s response to pain by decreasing anxiety and
promoting a more secure, comfortable feeling, thereby
increasing satisfaction during delivery. Massage also pro-
motes communication between nurses/midwives and
women during childbirth and serves as a psychological
intervention during childbirth (Pilevarzadeh, Salari, &
Shafei, 2002). Few studies have examined the effect of
frequent position changes and back massage on pain
perception either specifically or combined with other
pharmacological and nonpharmacological methods;
therefore, it was not easy to compare our findings with
those of other studies.
Pain scores after changing positions, in general, re-
vealed an increase in pain perception. In a study by
Adachi, Shimada, and Usui (2003) on 39 primiparous
and 19 multiparous women who alternatively assumed
the sitting and supine positions for 15 minutes during
cervical dilation from 6 to 8 cm, the results indicated
that pain scores for the sitting position were signifi-
cantly lower than those for the supine position.

TABLE 4.
Comparison of the Mean Rank of the Difference in Pain Scores between Groups a and C before and after
Intervention

Mean Rank

Group A Group C p Value

Pain score difference (n ¼ 20) (n ¼ 40) (Mann-Whitney U Test)

First intervention – before intervention 37.43 27.04 .001*

Second intervention – before intervention 32.93 29.29 .005*
Third intervention – before intervention 34.75 28.38 .002*
Group A ¼ change in position; group C ¼ control.
*Significance at the .05 level.
6 Abdul-Sattar Khudhur Ali and Mirkhan Ahmed
TABLE 5.
Comparison of the Mean Rank of the Difference in Pain Scores between Groups B and C before and after
Intervention
Group B
Pain score difference (n ¼ 20)
First intervention – before intervention 27.70
Second intervention – before intervention 24.35
Third intervention – before intervention 24.83
Group B ¼ back massage; group C ¼ control.
*Significance at the .05 level.
In contrast to the present study, Abdolahian,
Ghavi, Abdollahifard, and Sheikhan (2014) looked at
the effect of a combination of changes in position
and massage on pain perception. They randomly as-
signed 60 primiparous women to the dance labor
group or control group to manage active-phase labor
pain. In the dance labor group, women were in-
structed to do pelvic tilts and rock back and forth or
around in a circle while standing upright as their part-
ner massaged their back and sacrum for a minimum of
30 minutes. The results revealed that mean pain scores
in the dance group were significantly lower than those
in the control group.
Fourteen randomized control trials (RCTs)
included in one review failed to report consistent find-
ings regarding changes in position and labor pain. Only
one of the seven RCTs in which women were randomly
assigned to various positions reported a decrease in the
use of analgesia (Simkin & O’Hara, 2002). Two trials of
touch and massage during labor met the criteria for the
systematic review (Leeman, Fontaine, King, Klein, &
Ratcliffe, 2003). In eight trials of the effectiveness of
maternal position changes in reducing pain, none of
the women found the supine position more comfort-
able than other positions. When standing for 30 minutes
TABLE 6.
Comparison of the Mean Rank of the Difference in Pain Scores among Intervention Groups A and B
before and after Intervention
Group A
Pain score difference (n ¼ 20)
First intervention – before intervention 25.40
Second intervention – before intervention 24.58
Third intervention – before intervention 24.95
Group A ¼ change in position; group B ¼ back massage.
*Significance at the .05 level.
Mean Rank
Group C p Value
(n ¼ 40) (Mann-Whitney U Test)
31.90 .012*
33.58 .001*
33.34 .002*
was compared with lying supine or sitting, the women
reported less pain while standing (Simkin & Bolding,
2004). These findings cannot be compared with the
findings of the present study because pain perception
was not assessed after each position change.
In the present study, back massage was found to
be an effective nonpharmacological approach to
decreasing pain perception during labor. In 15 Cochrane
Pregnancy and Child systematic reviews, massage was
found to be one method that may improve management
of labor pain with few adverse effects when pharmaco-
logical and nonpharmacological methods were studied
(Jones, 2012). Brown, Douglas, and Flood (2001), in
their study of 46 women, found that massage was one
of the first four most effective strategies of 10 nonphar-
macological strategies rated by the sample. Almost all
studies on the effects of touch and massage on reducing
pain indicated that women appreciate being touched
and massaged during labor, and these simple interven-
tions may reduce pain and enhance feelings of well-
being (Simkin & Bolding, 2004; Datta, Kodali, & Segal,
2010). Hajiamini et al. (2012), in their quasi-
experimental study on 90 women, concluded that ice
massage reduced pain during labor and provided more
persistent pain relief than acupressure.
Mean Rank
Group B p Value
(n ¼ 20) (Mann-Whitney U test)
15.60 .005*
16.43 .021*
16.05 .011*
 Pain perception in first stage of labor
A limitation of this study is the quasi-experimental
design. The lack of random assignment into test groups
leads to non-equivalent test groups which may limit
general application of the results to a larger popula-
tion. Pre-existing factors and other effects are not
taken into account because variables are less
controlled in quasi-experimental research.
Implications for Nursing Education, Practice,
and Research
The results of the present study indicate the benefits of
massage. For this treatment to be better analyzed, back
massage should be included in the in-service education
of nurses and midwives in both prenatal and hospital
settings. The results are a motivator for health system
stakeholders to improve prenatal education and ante-
natal childbirth classes prior to general application in
the maternal and child health care arena. The use of
effective nonpharmacological methods for pain man-
agement will increase mothers’ satisfaction with the
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