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Contents lists available at ScienceDirect

Women and Birth

journal homepage: www.elsevier.com/locate/wombi

Perceptions of paternal involvement and labour pain management in

Chinese couples during childbirth: A qualitative study
Fei-Wan Ngai* ,1, Xiao Xiao
School of Nursing, The Hong Kong Polytechnic University, HKSAR

A R T I C L E I N F O A B S T R A C T

Article history: Background: Labour pain is an individual experience embedded in a socio-cultural context. In childbirth,
Received 3 October 2019 the father’s involvement provides important support to the mother during labour. However, few
Received in revised form 22 February 2020 published studies have evaluated couples’ experiences of paternal involvement and labour pain
Accepted 3 March 2020
management in the Chinese context.
Available online xxx
Aim: This study aimed to understand the experience of labour pain management and the father’s
involvement in childbirth from the perspectives of women and their partners in Hong Kong.
Keywords:
Methods: An exploratory qualitative design was adopted. A purposive sample of 45 Chinese parents was
Childbirth
Father’s involvement
recruited at the postnatal unit of a regional hospital. Data were collected through semi-structured face-
Labour pain management to-face interviews within 1 month after birth. The data were subjected to content analysis.
Qualitative Findings: The findings revealed six major themes: the mothers’ experience of labour pain, effectiveness of
pain relief measures, mothers’ perceptions of support from their partners, mothers’ perceptions of
support from healthcare professionals, fathers’ experience of involvement in childbirth and suggested
improvements to maternity services.
Discussion: Chinese mothers experienced intense labour pain and used various pain relief measures. Both
parents considered the involvement of fathers and support from healthcare professionals to be highly
significant during childbirth.
Conclusions: This study highlights the need for a family-centred model of care during childbirth that
involves both parents in the decision-making process. Chinese maternity services should implement
individualised birth plans that acknowledge both parents’ expectations and preferences, thus promoting
a positive childbirth experience for the parents.
© 2020 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.

explored couples’ experiences of paternal involvement in

Statement of significance childbirth, particularly in the Chinese context.

What this Paper Adds

Problem or Issue
Labour pain is considered one of the most severe types of
pain experienced by women during childbirth.
What is Already Known
Fathers can offer important emotional and practical support
to women during childbirth, however, few studies have
The present findings highlight the importance of father’s
involvement and support from healthcare professionals in
promoting a positive childbirth experience for the parents. A
tailor-made birth plan that acknowledges the parents’
expectations and involvement of parents in the decision-
making process during childbirth, should be implemented
by maternity services.

Introduction

* Corresponding author. Labour pain is a unique but normal physiological phenomenon

E-mail addresses: vivian.ngai@polyu.edu.hk (F.-W. Ngai),
that occurs during normal labour progression [1]. Although labour
xiaory.xiao@connect.polyu.hk (X. Xiao).
1
Address: FG427, School of Nursing, The Hong Kong Polytechnic University, Hung
pain is considered one of the most severe types of pain experienced
Hom, Kowloon, HKSAR. by humans [2], studies have indicated that women actually

http://dx.doi.org/10.1016/j.wombi.2020.03.003
1871-5192/© 2020 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.

Please cite this article in press as: F.-W. Ngai, X. Xiao, Perceptions of paternal involvement and labour pain management in Chinese couples
during childbirth: A qualitative study, Women Birth (2020), https://doi.org/10.1016/j.wombi.2020.03.003
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2 F.-W. Ngai, X. Xiao / Women and Birth xxx (2019) xxx–xxx
experience a higher than expected level of pain during childbirth
[3,4]. Persistent pain and the associated fear have numerous
adverse effects on the psychological and physiological status of the
mother and foetus [5]. These effects may also increase the need for
obstetric interventions such as assisted delivery and caesarean
section, which have considerable implications for the quality,
outcome and cost of intrapartum care [6,7].
The experience of labour pain is a subjective and multidimen-
sional response to sensory stimuli during childbirth and is
embedded within specific social and cultural contexts [8]. In a
qualitative study of 14 women in West Africa at 2 months
postpartum, some women described the pain as bearable, while
others reported the most severe and agonising pain [9]. Moreover,
some women coped with the pain by crying, shouting and asking
God for help, while others concealed their pain and exhibited no
outward signs [9]. In a qualitative study of seven postpartum
women in Indonesia, Rachmawati [10] found that the women had
experienced intense labour pain, with scores approaching 10.
Some women coped with pain by screaming, while others
withstood the pain by remaining calm and clenching their hands
[10].
In Chinese culture, women perceive pain as an expected part of
childbirth, which is a short, painful but necessary step on their
journey to motherhood [11]. A qualitative study of 10 primiparous
Chinese women within 5 months of giving birth revealed that the
women were expected to bear their labour pain and remain stoic
while giving birth [11]. The evidence suggests that labour pain is a
highly individual experience and that responses to pain may vary
greatly among different cultural groups.
Labour pain management includes both pharmacological and
non-pharmacological options [12–14]. In a Cochrane review of 310
trials, Jones et al. [13] concluded that pharmacological pain
management, such as epidural, combined spinal epidural and
inhaled analgesia, could effectively manage labour pain but may
cause adverse effects. The administration of opioids during
childbirth may also cause undesirable effects, such as maternal
nausea, drowsiness and respiratory distress, and could potentially
compromise the baby 14]. Additionally, women receiving epidural
analgesia were more likely to experience hypotension, motor
blockage, fever or urinary retention and a greater likelihood of
instrumental vaginal birth and caesarean section for foetal distress
[13]. In contrast, non-pharmacological pain management options,
such as immersion in water, relaxation, acupuncture, massage,
hypnosis, biofeedback and aromatherapy, are non-invasive and
appear to be safe for the mother and child. However, the efficacies
of these approaches are unclear [13]. In a meta-analysis of 57
studies, Chaillet et al. [12] found that non-pharmacological
approaches were associated with the reduced use of oxytocin
and epidural analgesia, a shortened duration of labour, reductions
in instrumental and caesarean delivery and increased maternal
satisfaction with childbirth. The authors concluded that tailored
non-pharmacologic approaches, based on continuous support,
could most effectively reduce the need for obstetric interventions
[12].
In a survey of 1382 women in the United States, Kozhimannil
et al. [15] found that 85% of women used pharmacological pain
relief, such as epidural (75.3%), narcotics (25%) and nitrox oxide
(1.5%), while 70% of women used non-pharmacological pain relief,
such as breathing techniques, position changes, birth ball, and
doula support. Half of women (58.6%) used both pharmacological
and non-pharmacological approaches to manage their labour pain,
and 12% used the non-pharmacological pain relief only [15].
Women view continuous support as an alternative to pharma-
cological pain relief, given their concerns about the adverse effects
of the latter on labour progression and birth outcomes [14]. The
‘natural childbirth’ movement [16] has led to a dramatic increase in
Please cite this article in press as: F.-W. Ngai, X. Xiao, Perceptions of paternal involvement and labour pain management in Chinese couples
during childbirth: A qualitative study, Women Birth (2020), https://doi.org/10.1016/j.wombi.2020.03.003
the attendance of fathers during childbirth, and this factor was
shown to provide important support to mothers during labour
[17]. In a study of 50 first-time parents in Turkey, Gungor and Beij
[18] found that women whose partners attended the labour and
delivery process viewed their experience more positively, com-
pared to women who remained alone. In a study of 30 women of
Chinese, Malay and Indian ethnicities in Singapore [19], women
described their husbands as their main source of support during
childbirth, who played an important role in reducing their anxiety
and facilitating a smooth delivery.
Similarly, Chinese societies are also experiencing an increase in
the participation of fathers at birth [20]. In a qualitative study of 69
women in China, the majority were accompanied by their
husbands during childbirth, and this helped women to face their
fears and manage labour pain [20]. In a survey of 403 fathers in
China, most held a positive attitude regarding their presence
during labour and birth and understood that their attendance
could empower their partners and provide psychological support
[21]. The evidence suggests that fathers can offer important
emotional and practical support to women during childbirth.
However, in China maternal health services are much more
focused on the health of the mother and infant and often exclude
men and their needs as parents. Furthermore, few published
studies have explored couples’ experiences of paternal involve-
ment in childbirth, particularly in the Chinese context. The
emerging importance of the father’s involvement in childbirth
and the promotion of ‘natural childbirth’ [16, 21], have under-
scored the need for an insightful understanding of the lived
experiences of women’s ability to cope with pain during childbirth,
as well as their partners’ involvement. This study aimed to
understand the experience of labour pain management and the
father’s involvement in childbirth according to the perspectives of
women and their partners. This information could promote the
development of individualised interventions to support women
and their families during childbirth.
Methods
Design and participants
The study used an exploratory qualitative design. Participants
were recruited via purposive sampling at the postnatal units of a
regional public hospital between January and December 2017. The
inclusion criteria were parents who were married and aged 18
years or older, a medically uncomplicated singleton pregnancy,
vaginal delivery at full-term, and the ability to speak and
understand Chinese. Parents who were mentally ill or unable to
articulate their experiences fully were excluded from the study.
Data collection
The study protocol was approved by the Clinical Research Ethics
Committee of the university and the study hospital. The research
assistant approached eligible parents at the postnatal units. All
participants were given study information leaflets, and all
provided written consent to participate. Data were collected
through in-depth, semi-structured face-to-face interviews. A semi-
structured interview guide had been developed, which covered the
parents’ experience during childbirth, their perceptions and
management of labour pain and their experiences with the
father’s involvement during childbirth and maternity services. The
mothers were asked open questions such as: ‘Tell me about your
experiences during childbirth.’, ‘How did you cope with pain
during childbirth?’, ‘How did your partner assist you in coping with
childbirth?’ and ‘How did healthcare professionals assist you in
coping with pain during childbirth?’ The fathers were asked
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F.-W. Ngai, X. Xiao / Women and Birth xxx (2019) xxx–xxx 3

questions such as: ‘Tell me about your experience with accompa- Table 1
Characteristics of participants (N = 90).
nying your partner during childbirth.’, ‘How did you assist your
partner in coping with childbirth?’ and ‘How did healthcare Characteristics Mothers (n = 45) Fathers (n = 45)
professionals assist you and your partner during childbirth?’ n (%) n (%)
All interviews were conducted by a research assistant trained in Age, mean (SD) 33.2 (4.2) 35.2 (4.1)
the use of the semi-structured interview guide. The interviews
Education
were conducted within 1 month after birth at the postnatal units or
Secondary 13 (28.9) 11 (24.4)
the parents’ home, according to their preference. The mother and Tertiary or university 32 (71.1) 34 (75.6)
the father were interviewed together. The duration of each
interview was approximately 30–60 min. All interviews were Employment status
audio-recorded and transcribed verbatim, and field notes about Unemployed 12 (26.7) 0
Employed 33 (73.3) 45 (100)
the parents’ non-verbal behaviours were used to support the
interpretation of data. Interviews were conducted until data Monthly household income
saturation was reached. A final sample of 45 pairs of parents was <HK$20,000 2 (4.4)
achieved. HK$20,000 – HK$30,000 7 (15.6)
HK$30,001 – HK$40,000 7 (15.6)
HK$40,001 – HK$50,000 11 (24.4)
Data analysis >HK$50,000 18 (40.0)

The data were subjected to a content analysis that focused on Parity

the participants and context and emphasised variation by Primipara 26 (57.8)
Multipara 19 (42.2)
analysing both manifest (descriptive) and latent (interpretative)
content [22,23]. The analysis began after the first interview and
continued during data collection, thus allowing emerging themes
to be explored in later interviews. The verbatim transcripts were
read several times to obtain an overview of the data. The units of USD 5885. The characteristics of the participants are presented in
meaning were identified, condensed and labelled with codes Table 1.
representing different aspects of labour pain, pain management
and the father’s involvement as experienced by the women and Main themes
their partners during childbirth. The codes were read several times
and compared with the context. Similar codes were grouped into Six major themes emerged in the analyses: the mothers’
categories to analyse the emerging themes. NVivo 12 software was experiences of labour pain, effectiveness of pain relief measures,
used to sort and retrieve the data for analysis and compare themes mothers’ perceptions of support from their partners, mothers’
across the data set. The authors read and coded all transcripts perceptions of support from healthcare professionals, fathers’
independently and met regularly to discuss the coding decisions experiences of involvement in childbirth and suggested improve-
and reach consensus about emerging themes. ments to maternity services (Table 2).

Trustworthiness Mothers’ experience of labour pain

The trustworthiness of the data was verified by the establish-
ment of credibility, dependability, confirmability and transferabil-
ity [22]. Independent parallel coding was adopted, and all authors
read the condensed material and discussed the abstraction to sub-
themes and themes to reduce the risk of a researcher-biased
interpretation of the data. Reflexive journaling was used to reflect
and record the researchers’ personal thoughts and feelings and
thus bracket their perceptions and subjectivity. This measure was
adopted to prevent the researchers’ biases from affecting the
neutrality of the findings. For member checking, the participants
were asked to verify the main themes identified by the researchers
as reflective of their childbirth experiences. Forty-five pairs of
parents were interviewed, at which point saturation of the
thematic categories was achieved. The findings were audited by
a qualitative researcher who was not associated with the study. An
audit trail highlighting every step of the data analysis was
constructed.
Mothers perceived labour pain as severe pain. Almost all mothers
described labour pain as severe and unbearable and beyond their
expectation. This was particularly true for first-time mothers.
‘I think the pain must have been a 10. I never expected pain like this,
it really hurt me . . . nothing was helpful . . . the pain was so
intense that nothing could be done at that moment . . . my only
hope was that it would be gone as soon as possible . . . all I could
count on was myself.’ (P36)
‘It was extremely painful . . . (Laughs) the degree of pain was not
10, I think it was 100 . . . 1–10 is not enough . . . ’ (P39)
One mother described the labour pain as so intense and
agonising that she would rather have died:
‘At that time [during childbirth] . . . it was so painful that I wanted
to die . . . I wanted to give birth, but the nurse told me the cervix
had not yet fully dilated . . . I had to bear the pain, it was
torture . . . ’ (P17)

Most first-time mothers described their pain as ‘out of control’.

Results
They tried in vain to control this pain and felt that they had no
control over their own bodies.
Participants
‘When the contraction was coming, it came up gradually from the
bottom. I felt pain during the contraction, I could feel it . . . I went
Fifty parents were approached and 45 (90%) were interviewed.
mad . . . since the pain was so severe that it was out of my
Of the latter, 26 (57.8%) were first-time parents. The mean ages of
control . . . ’ (P6)
the mothers and fathers were 33.2 (SD = 4.2) and 35.2 years (SD
= 4.1), respectively. All parents had a secondary school or higher
level of education. The majority of mothers (73.3%) and all fathers Differences in the expressions of labour pain. The mothers reacted
were employed, and the median monthly household income was differently toward labour pain when they felt out of control. Some

Please cite this article in press as: F.-W. Ngai, X. Xiao, Perceptions of paternal involvement and labour pain management in Chinese couples
during childbirth: A qualitative study, Women Birth (2020), https://doi.org/10.1016/j.wombi.2020.03.003
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Table 2
Themes and subthemes of the findings.
Themes
Mothers’ experience of labour pain
Effectiveness of pain relief measures
Mothers’ perceptions of support from their partners
Mothers’ perceptions of support from healthcare professionals
Fathers’ experiences of involvement in childbirth
Suggested improvements to maternity services
mothers coped with the pain by crying and screaming and calling
for help, while others concealed their pain and kept silent.
‘It was really painful . . . (Laughs) I kept screaming and had a sore
throat after birth . . . ’ (P31)
‘I went mad [during childbirth] . . . I was crying . . . it was so
painful that I cried out because the pain was a hundred times more
severe than dysmenorrhoea.’ (P12)
However, a second-time mother said:
‘I kept silent, same as the previous birth . . . I lay on the bed . . . I
didn’t make any sound . . . then it was like going to the toilet . . . I
gave birth quickly.’ (P20)
Effectiveness of pain relief measures
Mothers used both pharmacological and non-pharmacological
methods to cope with the labour pain. Nitrous oxide was the most
common pharmacological pain relief measure used by the mothers
(n = 28, 62.2%), followed by epidural analgesia (n = 7, 15.6%) and
intramuscular opioids (n = 1, 2.2%). The mothers also used a wide
variety of non-pharmacological methods, including a birth ball (n
= 11, 24.4%), massage (n = 9, 20%), transcutaneous electrical nerve
stimulation (TENS) (n = 8, 17.8%), aromatherapy (n = 5, 11.1%),
breathing (n = 4, 8.9%), positioning (n = 2, 4.4%), imagination (n = 1,
2.2%) and music therapy (n = 1, 2.2%). These non-pharmacologic
techniques were used in different combinations with (e.g., massage
and nitrous oxide) or without pharmacological methods (e.g.,
aromatherapy and TENS). Fifteen mothers (33.3%) used only non-
pharmacological pain relief methods. However, the effectiveness of
these pain relief measures varied. Five subthemes were identified:
increased sense of control, enhanced relaxation and comfort,
reduced labour pain, useless and side effects of medication.
Increased sense of control. Among the mothers who used nitrous
oxide, nine (15.5%) found that the nitrous oxide helped to regulate
their breathing and enhanced their sense of control.
‘The nitrous oxide was helpful, but it depended on the individual’s
pain tolerance . . . I could tolerate the pain with the assistance of
nitrous oxide, which enhanced my self-control and ability to cope
with the pain . . . I became more focused . . . I didn’t cry out.
Normally I would cry out when I felt pain. I felt relaxed mainly
because of the inhaled nitrous oxide and guidance from the
midwives.’ (P34)
‘Frankly speaking, the nitrous oxide didn’t help much (Laughs), but
it was a kind of psychological support . . . which made me stay
calm by regulating my breathing . . . because it was difficult to
keep breathing.’ (P39)
Please cite this article in press as: F.-W. Ngai, X. Xiao, Perceptions of paternal involvement and labour pain management in Chinese couples
during childbirth: A qualitative study, Women Birth (2020), https://doi.org/10.1016/j.wombi.2020.03.003
Subthemes
Mothers perceived labour pain as severe pain
Differences in the expressions of labour pain
Increased sense of control
Enhanced relaxation and comfort
Reduced labour pain
Useless
Side effects of medication
Psychological support
Instrumental support
Tangible support
Intangible support
Complex feelings
Sense of responsibility
Sense of helplessness
Individualised care and shared decision making
Continuous support from healthcare professionals
Another mother shared her successful use of the imagination
and breathing techniques to cope with labour pain.
‘It was totally natural, no opioids and no nitrous oxide . . . I knew
nitrous oxide was useless, that’s why I refused each time they asked
me to inhale . . . I used imagination to control myself. How could I
say, I had to imagine that . . . the foetal head was there, I had to
control and relax myself. Then I counted on breathing. In fact, I was
frustrated at that time (Laughs), so I had to give myself more space
for imagination. It was really a difficult time . . . ’ (P37)
Enhanced relaxation and comfort. All mothers who used the birth
ball gave positive feedback and stated that it helped them to relax,
distracted their attention from pain and accelerated their labour
process.
‘I asked the health professional if any methods could speed up my
labour process . . . then she introduced me to the birth ball . . . I
had heard about sitting on a birth ball from others . . . so it was
true . . . I sat for a while and my cervix soon dilated to 3 cm.’ (P12)
Some mothers found that the essential oils used in aromather-
apy were refreshing, helped to distract their attention and made
them feel relaxed, though it did not effectively relieve their labour
pain.
‘The health professionals had tried different methods to help me
cope with the labour pain. For example, they asked me to smell the
aroma . . . I felt comfortable and relaxed with the fragrance, but it
did not help to relieve my pain. It simply distracted my attention
and refreshed me a little bit!’ (P13)
Most mothers appreciated a massage by their partner. This gave
them psychological comfort, although it could not relieve pain.
‘My husband administered a massage to me, and the healthcare
professional also helped to administer massage, but it was
useless . . . yes (Laughing) . . . it did not alleviate my pain . . .
but it helped provide comfort . . . it comforted me.’ (P5)
‘He [my partner] tried to massage me . . . I would touch my
abdomen to check whether the baby had moved to his correct
position . . . but the massage . . . the pain was so severe that it
couldn’t be stopped by anything that I did.’ (P31)
A second-time mother highlighted that the effectiveness of
massage was influenced by the implemented technique. She found
that a massage provided by healthcare professionals during her
previous delivery was more helpful, compared to the massage
provided by her partner during the most recent delivery.
‘Actually, I want to say that the massage was helpful during my
previous delivery . . . I think maybe my partner’s technique was
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not correct or maybe he was nervous . . . The massage given by
healthcare professionals was fantastic. If they had taught my
partner the proper skills, I think the massage would have been
OK . . . It relieved my pain at that time [previous childbirth].’ (P18)
Reduced labour pain. Seven mothers (15.6%) used epidural
analgesia and reported that it effectively relieved the labour
pain by helping them to remain calm and rest after excessive pain
and fatigue. The fathers also witnessed the changes in their
partners’ facial expressions and communication after the epidural
analgesia was administered.
‘I felt much better after the epidural analgesia. The feeling was
totally different before and after. I could feel the contractions, I
mean I knew that my uterus was tightening but I did not feel the
pain.’ (P26)
‘She looked peaceful after receiving the epidural. It helped to relieve
the pain and she could take a nap. She slept for a few hours and she
could even talk with me actively . . . ’ (Husband of P26)
One mother shared her experience with the use of breathing
techniques to help her cope with the labour pain. She learnt the
breathing skill in an antenatal class and implemented it during her
delivery. From her perspective, breathing was the most effective
way to manage labour pain.
‘Breathing helped [relieve the pain]. I learnt the skill in antenatal
classes. I took a shallow breath, followed by a deep breath. When
the contraction came, I breathed rhythmically . . . it was like
following the ‘beat’. It was useful, the most useful one.’ (P12)
‘I think it’s the easiest one.’ (Husband of P12)
‘Yes, it saved my life.’ (P12)
Useless. Among mothers who used nitrous oxide, 11 (39.3%) found
that it did not provide pain relief. This was probably due to the
discomfort and difficulty associated with the apparatus.
‘The nitrous oxide could not help relieve my pain . . . maybe
because it was the first time I used it. I didn’t know how to use
it . . . maybe it was my poor technique . . . I felt extreme pain and
it couldn’t help.’ (P33)
‘I used the nitrous oxide, but it was useless . . . I used the nitrous
oxide during my previous delivery, which was also useless . . . I
held the facemask but could not inhale anything . . . it was even a
burden to me.’ (P19)
TENS was found to be helpful at the beginning of labour.
However, its effect was overridden by the intensity of pain during
the later stages of labour. One mother said:
‘The healthcare professional applied TENS to both sides of my lower
back . . . I could feel the release of an electric current to stimulate
my nerves . . . when I felt pain I could turn it up. Actually, it
worked at the beginning, but when I had excessive pain, it was
useless. I had already turned it up to the maximum intensity, but I
still could not tolerate the pain . . . ’ (P13)
Side effects of medication. Several parents (n = 7, 12.7%) worried
about the side effects of medication that might harm the mother
and baby and did not choose pharmacological pain relief methods.
‘I knew the possible side effects of opioid injections and epidural
analgesia, so I did not use any of them.’ (P16)
‘I didn’t know how many side effects [of epidural analgesia] there
were. The healthcare professional gave me a pamphlet. After
reading the information, I realised that there were serious side
effects [of the epidural]and decided not to use it.’ (Husband of P44)
Although the mothers found the epidural analgesia effective in
relieving the labour pain, more than half of the mothers (n = 4,
57.1%) who had used the epidural complained of side effects of
drowsiness, poor sensation and prolonged labour, which required
instrumental assistance with delivery.
‘After receiving the epidural, I still felt the contractions . . . the
doctor then increased the dosage of medication . . . it was helpful
at the time . . . However, I could not feel the contractions when
giving birth . . . therefore, I needed the vacuum to assist with
delivery of the baby . . . which probably caused the pain I now feel
during urination and the muscle pain over my lower back.’ (P43)
Mothers’ perceptions of support from their partners
Psychological support. All mothers were accompanied by their
partners during childbirth, and most (95.6%) appreciated the
psychological support given by their partners, who simply held
their hands and made them feel assured and comforted.
‘My husband was great! Although he could do nothing except
witness my craziness during labour, he gave me his hand to bite
and hold . . . It was much better that he was there, it was really
good because I knew someone was there to share my feelings . . .
he could share with me and I felt much more comfortable.’ (P13)
The presence of a familiar person, particularly their partner,
also gave the mothers a sense of security.
‘It [my partner’s presence] gave me a sense of security . . . the
healthcare professionals were very busy, I was very anxious and
was better to have someone accompanying me.’ (P2)
‘I felt much better with a familiar person accompanying me. Believe
it or not, I could not hear the midwives talking to me when I
delivered the baby, but I could hear him [my husband]. I didn’t
know why. Somebody said: “Keep relaxed, do not stop . . . then
hold on, do not push.” I thought it must be my husband. I did not
hear the healthcare professionals’ voices, but only his voice.’ (P35)
Instrumental support. The fathers also helped to relieve the
mothers’ stress and pain by providing practical support. For
example, the fathers assisted the mothers with the use of nitrous
oxide, coached the mothers to regulate their breathing,
administered massages and talked with the mothers to distract
their attention from the labour pain.
‘It was much better to have my husband, he reminded me to
breathe . . . It was so painful that I was disoriented. I was lucky to
have him, I didn’t know what would happen without him. He
helped me stay calm, he held my hand and taught me how to
breathe although he was nervous too (Laughs).’ (P30)
Mothers’ perceptions of support from healthcare professionals
Tangible support. The mothers (n = 12, 26.7%) appreciated the
guidance and support provided by the healthcare professionals to
help them to cope with the labour pain and delivery.
‘The midwife was very nice . . . She taught me like this . . .
um . . . imagine there were candles in front of me. When I felt the
pain, I would breathe out . . . so I breathed in and out . . .
imagined I was blowing out the candles when I breathed out . . .
then the picture in my mind made me concentrate on breathing but
not on pain . . . ’ (P11)
‘There were so many healthcare professionals, midwives and
obstetricians to help me in the delivery room . . . They provided
me with so much support. I felt that I was supported . . . They were
very important, they told me how to manage my strength and push

Please cite this article in press as: F.-W. Ngai, X. Xiao, Perceptions of paternal involvement and labour pain management in Chinese couples
during childbirth: A qualitative study, Women Birth (2020), https://doi.org/10.1016/j.wombi.2020.03.003
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and about the correct method to deliver the baby. Their support
was the most important during the whole labour process.’ (P16)
Intangible support. The mothers (n = 11, 24.4%) also appreciated the
empathetic care and emotional support provided by the healthcare
professionals, particularly during the second stage of labour.
‘The midwives were very nice. The one who took care of me during
delivery was very supportive throughout the whole process. She
told me how to breathe. I mean, I knew she was there to accompany
me. She was so nice. All the mothers in the next room had successful
deliveries, but I was not able to push my baby out . . . then all the
healthcare professionals came to my room and encouraged me . . .
They praised me and raised my spirits . . . I could hear them telling
me: “We can see the baby’s head now, come on . . . come on . . . ”’
(P12)
Fathers’ experience of involvement in childbirth
Complex feelings. Fathers experienced complex feelings about
their involvement in the birth process. They were excited but
experienced both physical and psychological stress while their
partners gave birth. They worried about the mother and baby and
were physically exhausted.
‘The birth process was torture (Laughs) . . . My feelings were
mixed, full of worry and uncertainty, because I didn’t know what
would happen next and I was very tired at that moment . . . I went
to bed late that night and had only slept for a while when she felt
the pain. I hadn’t slept for 2 days since . . . So my feelings were
complex, anxious and tired.’ (Husband of P12)
Six fathers (13.3%) were happy to be involved when the
healthcare professionals asked them to assist in various aspects of
the birth process, such as administering a massage to their partner,
holding their partner’s leg during delivery and cutting the cord.
‘The massage was wonderful. I pressed on both sides of her waist.
Since the baby had not turned his position, I could see his body
raised from the abdomen. Then the midwife taught me how to
massage. I followed her instructions and massaged slowly.
Gradually, I could see that the raised body of the baby moved
down . . . this must have been the most effective pain relief
measure I had known, the most impressive and useful method that
was helpful to her . . . ’ (Husband of P31)
Another father shared his joy about his involvement in cutting
the cord:
‘It’s exciting [cutting the cord]. I was anxious at the beginning
(Laughs) . . . because I was afraid that I would injure my baby. I
followed the midwife’s instruction . . . she told me the right
position to cut, and then I felt relaxed because the midwife gave
very clear instructions.’ (Husband of P35)
Sense of responsibility. Most fathers were concerned about their
partner’s suffering during the labour process and tried different
methods to help the mothers.
‘I knew it was torture for her, I wanted her to be safe . . . I kept
encouraging her, I tried different methods. For example, when she
said she wanted to drink water, I encouraged her: “Hold back for a
while, I will give you sips of water soon.”’ (Husband of P37)
Sense of helplessness. Seven fathers (15.6%) felt helpless while
they witnessed their partner’s suffering caused by severe labour
pain.
‘There was nothing I could do to help her . . . Although I had
attended all the antenatal classes provided by the hospital, it was
Please cite this article in press as: F.-W. Ngai, X. Xiao, Perceptions of paternal involvement and labour pain management in Chinese couples
during childbirth: A qualitative study, Women Birth (2020), https://doi.org/10.1016/j.wombi.2020.03.003
different in the real situation . . . I tried to think about measures
that could help her . . . such as putting pillows underneath her [to
relieve her pain].’ (Husband of P26)
‘I did nothing . . . I was anxious (Laughs) . . . I couldn’t help
much. All I could do was encourage her: “Keep on! Keep on!”, but it
seemed useless.’ (Husband of P31)
‘He thought he was useless.’ (P31)
Suggested improvements to maternity services
Individualised care and shared decision making. The parents
expressed a wish for greater involvement in decision making
during the labour process. They hoped that healthcare
professionals would provide more information and explanations
regarding the pain management to facilitate their decision making.
However, some parents felt that the advice they were given was not
always tailored to them.
‘Actually, during the labour process, I needed to make many
unpredictable decisions. I did not know that beforehand, such
as . . . when to have the epidural . . . because people gave
different advice [on pain relief methods] . . . the midwives
preferred those with a low risk . . . the lower the risk, the better.
But my partner’s situation was different, she was already out of
control. I could see her suffering . . . ’ (Husband of P26)
‘Actually, I had no idea how to make the right decision . . . but I
knew I wanted the most comfortable one [pain relief method]. The
one that could comfort me . . . It was my own decision, I had to
know what was best for me.’ (P26)
One mother stated that she would have liked more pain relief
options:
‘I encountered a nurse who was very good about performing
massages for me when I was in pain . . . whereas some nurses
ignored me and let me cry out . . . However, not every mother
could tolerate the pain . . . Some mothers might need more
attention and care . . . or more options for pain relief. The hospital
had the birth ball. The only option for me was the use of the birth
ball, whereas I could not make decisions about other pain relief
methods, such as the opioid injection or others. The hospital made
its own decisions about pain management, so I had to suffer the
pain. My only choice was to sit on the birth ball.’ (P32)
Continuous support from healthcare professionals. Some parents
felt that their experience of childbirth had been compromised by a
lack of manpower and suggested the availability of more
healthcare professionals to provide continuous support during
labour and delivery.
‘My husband was with me during labour, which made me feel
secure because if he was not there, no one was in the delivery
room . . . the health professionals seldom came in . . . Maybe
they did not have enough staff because it was Sunday. The hospital
had a shortage of manpower. Only one midwife was walking
around. She walked into the next room . . . and shortly to another
room . . . ’ (P21)
Discussion
To our knowledge, this was the first study to explore couples’
perceptions of labour pain management and the father’s involve-
ment during childbirth in the Chinese context. The present findings
highlight the individuality of the perceptions and expressions of
labour pain. Consistent with previous studies [9,10], the mothers in
this study regarded labour pain as severe and unbearable and
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F.-W. Ngai, X. Xiao / Women and Birth xxx (2019) xxx–xxx
beyond their expectations and control. This was particularly true
for first-time mothers. The evidence suggests that the response to
pain may vary greatly among different cultural groups as a result of
learned patterns of expected behaviour [8]. Although the
traditional Chinese culture places a high value on the control of
strong emotions [24], no strict pattern of beliefs regarding the
expression of labour pain expressions was identified among
Chinese mothers in Hong Kong, which is characterised by a
blended eastern–western cultures. The mothers in this study
expressed a wide range of reactions toward labour pain. They were
free to express their emotions in their own way and considered it
normal to cry out when they experienced excessive pain during
labour. Compared with first-time mothers, the second-time
mothers in this study tended to remain silent while enduring
pain. This decision was probably based on their previous childbirth
experiences and a wish to reserve their energy for a faster and
smoother delivery.
The mothers in this study used both pharmacological and non-
pharmacological methods to cope with labour pain. However, the
effectiveness of these measures varied. Nitrous oxide (62.2%) was
commonly used for labour pain management both in Hong Kong
and in western countries [25]. However, 39.3% of mothers found
that nitrous oxide was useless for pain relief, while 15.5% reported
that it helped to regulate their breathing and enhance their sense
of control. These findings are consistent with a previous systematic
review that demonstrated the inferiority of nitrous oxide inhala-
tion relative to other pharmacological pain relief methods, such as
epidural analgesia [25]. Nevertheless, nitrous oxide seemed to
enhance the women’s ability to cope during childbirth [26]. The
effectiveness of nitrous oxide seemed to be hindered by the
difficulty of use of the apparatus, as identified in a previous study
[26]. Although nitrous oxide is advantageous because it is self-
administered and thus allows women to control the amount they
need, some mothers in this study found that the requirement to
hold the facemask and inhale properly seemed to add another
burden to the experience of intense labour pain. Previous study
suggested that timing is crucial to the successful relief of pain via
intermittent nitrous oxide analgesia [27]. Providing better training
and practice opportunities for women to learn the proper
technique and effective timing of using the nitrous oxide during
the most painful contraction may be necessary in the antenatal
classes.
Although pharmacological pain relief was found to relieve
labour pain effectively [13,14], only seven mothers (15.6%) in this
study chose to receive epidural analgesia and one (2.2%) used
intramuscular opioids, which are lower than those reported in the
United States (75.3% epidural and 25% narcotics) [15]. These low
rates were probably attributable to concerns about the adverse
effects on both the mother and baby. More than half of the mothers
who used epidural analgesia in this study experienced side effects
such as drowsiness, backache and a prolonged labour process,
which necessitated vacuum-assisted delivery. These results are
consistent with previous findings that epidural analgesia may
increase the durations of the first and second stages of labour and
the rate of assisted vaginal births [14,28].
The number of mothers who opt for pharmacological pain relief
during childbirth in Hong Kong has tended to decrease in recent
years, probably due to the promotion of ‘natural childbirth’ [16].
Health professionals and maternity service providers have begun
to recognise the long-term physical and psychological benefits of
‘natural childbirth’ for the mother and baby [29]. Advocacy for
childbirth without pharmacological pain management in Hong
Kong has led to increases in the numbers of women who select
various forms of non-pharmacological pain relief, including a birth
ball, massage, TENS, aromatherapy, positioning and breathing
techniques, as reported by the mothers in this study. Moreover, one
Please cite this article in press as: F.-W. Ngai, X. Xiao, Perceptions of paternal involvement and labour pain management in Chinese couples
during childbirth: A qualitative study, Women Birth (2020), https://doi.org/10.1016/j.wombi.2020.03.003
7
third of mothers in this study used the non-pharmacological pain
relief only to manage their labour pain, which is comparatively
higher than the mothers (12%) in the United States [15]. Similar to
previous studies [12], most mothers in this study perceived non-
pharmacological pain relief as helpful for distracting their
attention from labour pain and promoting relaxation and comfort,
rather than actually reducing pain.
All mothers in this study were accompanied by their partners
during childbirth, and most reported that the psychological and
practical support provided by their partners made them feel secure
and comforted, which is similar to the findings reported by
mothers in Singapore [19]. Consistent with Confucian philosophy,
which emphasises harmonious family relationships, Chinese
people value strong and cohesive bonds among family members
[30]. Most mothers in this study treasured the companionship of a
familiar person, particularly their partner, during childbirth. These
findings are in line with those of previous studies which found that
a supportive social environment, such as the presence of a
preferred caregiver or support person, was a particularly important
factor in a woman’s experience of pain during labour [8]. This
support gave the women a sense of safety and an increased ability
to cope with the pain [8,19,31].
Although the father is generally considered to be the most
appropriate person to support the mother during the natural
process of childbirth [17], not all fathers appear to be well
prepared and ready for their involvement in childbirth. Consis-
tent with previous studies [32,33], the fathers in this study
expressed overwhelming feelings of helplessness and stress while
witnessing their partners under the influence of intense labour
pain, despite adopting various supportive behaviours intended to
help their partners. Participation in the birth process was more
demanding than the fathers had expected, and most felt
unprepared to participate in decisions related to pain manage-
ment and other unpredictable processes, such as vacuum-assisted
delivery. A previous study suggested that fathers often felt
excluded during childbirth and found themselves in situations
where they did not know how to help their partners, which may
have hindered their ability to support the mothers during
childbirth [34]. Healthcare professionals should therefore design
childbirth preparation classes that involve both members of a
couple and discuss their expectations regarding the father’s role
during birth and the positive shared aspects of childbirth. These
discussions will help the couple to support each other throughout
the birth process.
Support from healthcare professionals has a positive and
highly significant effect on the childbirth experiences of labouring
women [35]. Although most parents in this study felt supported
by healthcare professionals during childbirth, they wished to be
seen as individuals and to be included in the decision-making
process during labour, particularly with regard to pain manage-
ment. Importantly, healthcare professionals can advocate for
their patients and thus help new parents to achieve their desired
birth event [35]. An individualised birth plan that addresses pain
management and comfort measures should be introduced. This
will help parents to express their expectations and preferences
and may thus promote their sense of control and satisfaction with
the childbirth experience [36]. Consistent with previous study
[37], parents in this study identified the constant presence of
healthcare professionals as another important aspect of care
during childbirth. Given the shortage of manpower in the Hong
Kong healthcare system [38], healthcare professionals should
reassure the parents that they are readily available and should
frequently monitor the woman if they are unable to remain
present continuously. These practices may foster a sense of
support and improve the overall childbirth experience for the
whole family.
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8 F.-W. Ngai, X. Xiao / Women and Birth xxx (2019) xxx–xxx
Strengths and limitations
A major strength of the present study was the use of qualitative
research to explore couples’ perceptions of labour pain manage-
ment and the father’s involvement during childbirth. These data
provide a broad scope with which to understand the couples’
experiences and interactions during the process of birth. However,
the study was conducted at a single public hospital in Hong Kong
and only targeted parents with a full-term singleton baby delivered
vaginally. Therefore, the results may not apply to parents with
multiple pregnancies or preterm labour and may not be transfer-
able to other healthcare systems. Future studies on similar topics
should be conducted in other contexts with more diverse groups of
parents. Moreover, the data relied on the parents’ reflections of
past events and thus may have been subject to recall bias.
Conclusions
The findings from this study replicated many previously reported
central concepts, which suggests important cross-cultural similari-
ties in couples’ experiences of labour pain and pain management. The
study findings indicate that healthcare professionals could signifi-
cantly affect both the mothers’ and fathers’ experiences of childbirth.
Fundamental changes in maternity care policies and delivery, such as
the ability of women to select a companion of their choice during
labour and delivery, preparation for the father’s involvement in
childbirth, involvement of parents in the decision-making process
during childbirth and a tailor-made birth plan that acknowledges the
parents’ expectations and preferences, should be implemented by
maternity services. These measures will support the parents and
improve their overall childbirth experiences.
Conflict of interest
The authors declare that they have no conflict of interest.
Ethical statement
The study was approved by the Clinical Research Ethics
Committee of the Hong Kong Polytechnic University in June
2017 (Reference No. HSEARS20170525001).
CRediT authorship contribution statement
Fei-Wan Ngai: Conceptualization, Data curation, Methodology,
Investigation, Validation, Visualization, Formal analysis, Writing -
original draft, Writing - review & editing. Xiao Xiao: Formal
analysis, Writing - original draft.
References
[1] L.Y. Whitburn, L.E. Jones, M.A. Davey, et al., The nature of labour pain: an
updated review of the literature, Women Birth 32 (1) (2019) 28–38.
[2] C. Junge, T. von Soest, K. Weidner, et al., Labor pain in women with and without
severe fear of childbirth: a population-based, longitudinal study, Birth 45 (4)
(2018) 469–477.
[3] E. Gibson, Women’s expectations and experiences with labour pain in medical
and midwifery models of birth in the United States, Women Birth 27 (3) (2014)
185–189.
[4] H. Aksoy, B. Yücel, U. Aksoy, et al., The relationship between expectation,
experience and perception of labour pain: an observational study, Spring-
erPlus 5 (1) (2016) 1766.
[5] S. Garthus-Niegel, C. Knoph, T. Soest, et al., The role of labor pain and overall
birth experience in the development of posttraumatic stress symptoms: a
longitudinal cohort study, Birth 41 (1) (2014) 108–115.
[6] E. Wang, Requests for cesarean deliveries: the politics of labor pain and pain
relief in Shanghai, China, Soc. Sci. Med. 173 (2017) 1–8.
[7] C. O’Donovan, J. O’Donovan, Why do women request an elective cesarean
delivery for non-medical reasons? A systematic review of the qualitative
literature, Birth 45 (2) (2018) 109–119.
Please cite this article in press as: F.-W. Ngai, X. Xiao, Perceptions of paternal involvement and labour pain management in Chinese couples
during childbirth: A qualitative study, Women Birth (2020), https://doi.org/10.1016/j.wombi.2020.03.003
[8] L.Y. Whitburn, L.E. Jones, M.A. Davey, et al., The meaning of labour pain: how
the social environment and other contextual factors shape women’s
experiences, BMC Pregnancy Childbirth 17 (1) (2017) 157.
[9] L. Aziato, A.K. Acheampong, K.L. Umoar, Labour pain experiences and
perceptions: a qualitative study among post-partum women in Ghana, BMC
Pregnancy Childbirth 17 (1) (2017) 73.
[10] I.N. Rachmawati, Maternal reflection on labour pain management and
influencing factors, Br. J. Midwifery 20 (4) (2012) 263–270.
[11] R. Kartchner, L.C. Callister, Giving birth: voices of Chinese women, J. Holist.
Nurs. 21 (2) (2003) 100–116.
[12] N. Chaillet, L. Belaid, C. Crochetière, et al., Nonpharmacologic approaches for
pain management during labor compared with usual care: a meta-analysis,
Birth 41 (2) (2014) 122–137.
[13] L. Jones, M. Othman, T. Dowswell, et al., Pain management for women in
labour: an overview of systematic reviews, Cochrane Database Syst. Rev. (3)
(2012).
[14] M. Anim-Somuah, R.M.D. Smyth, A.M. Cyna, et al., Epidural versus non-
epidural or no analgesia for pain management in labour, Cochrane Database
Syst. Rev. (5) (2018).
[15] K.B. Kozhimannil, P.J. Johnson, L.B. Attanasio, et al., Use of nonmedical methods
of labor induction and pain management among U.S. Women, Birth 40 (4)
(2013) 227–236.
[16] B. Mansfield, The social nature of natural childbirth, Soc. Sci. Med. 66 (5)
(2008) 1084–1094.
[17] L. Plantin, A.A. Olukoya, P. Ny, Positive health outcomes of fathers’ involvement
in pregnancy and childbirth paternal support: a scope study literature review,
Fathering 9 (2011) 87–102.
[18] I. Gungor, N.K. Beji, Effects of fathers’ attendance to labor and delivery on the
experience of childbirth in Turkey, West. J. Nurs. Res. 29 (2) (2007) 213–231.
[19] E. Naser, S. Mackey, D. Arthur, et al., An exploratory study of traditional
birthing practices of Chinese, Malay and Indian women in Singapore,
Midwifery 28 (6) (2012) e865–e871.
[20] J. Raven, N. van den Broek, F. Tao, et al., The quality of childbirth care in China:
women’s voices: a qualitative study, BMC Pregnancy Childbirth 15 (1) (2015)
113.
[21] H.G. He, K. Vehviläinen-Julkunen, X.F. Qian, et al., Fathers’ feelings related to
their partners’ childbirth and views on their presence during labour and
childbirth: a descriptive quantitative study, Int. J. Nurs. Pract. 21 (S2) (2015)
71–79.
[22] U.H. Graneheim, B. Lundman, Qualitative content analysis in nursing research:
concepts, procedures and measures to achieve trustworthiness, Nurse Educ.
Today 24 (2) (2004) 105–112.
[23] H.J.S. Speziale, D.R. Carpenter, Qualitative Research in Nursing: Advancing the
Humanistic Imperative, 5th ed, Philadelphia: Lippincott Williams & Wilkins,
2011.
[24] E. Davis, E. Greenberger, S. Charles, et al., Emotion experience and regulation in
China and the United States: how do culture and gender shape emotion
responding? Int. J. Psychol. 47 (3) (2012) 230–239.
[25] F.E. Likis, J.C. Andrews, M.R. Collins, et al., Nitrous oxide for the management of
labor pain: a systematic review, Anesth. Analg. 118 (1) (2014) 153–167.
[26] M.G. Richardson, B.L. Raymond, C.L. Baysinger, et al., A qualitative analysis of
parturients’ experiences using nitrous oxide for labor analgesia: it is not just
about pain relief, Birth 46 (1) (2019) 97–104.
[27] S. Collins, Nitrous oxide for the management of labor analgesia, AANA J. 86 (1)
(2018) 72–80.
[28] A. Shmueli, L. Salman, S. Orbach-Zinger, et al., The impact of epidural analgesia
on the duration of the second stage of labor, Birth 45 (4) (2018) 377–384.
[29] L. Jansen, M. Gibson, B.C. Bowles, et al., First do no harm: interventions during
childbirth, J. Perinat. Educ. 22 (2) (2013) 83–92.
[30] M. Park, C. Chesla, Revisiting confucianism as a conceptual framework for
asian family study, J. Fam. Nurs. 13 (3) (2007) 293–311.
[31] N. Van der Gucht, K. Lewis, Women‫׳‬s experiences of coping with pain during
childbirth: a critical review of qualitative research, Midwifery 31 (3) (2015)
349–358.
[32] J. Fenwick, S. Bayes, M. Johansson, A qualitative investigation into the
pregnancy experiences and childbirth expectations of Australian fathers-to-
be, Sex. Reprod. Healthc. 3 (1) (2012) 3–9.
[33] H.L. Poh, S.S.L. Koh, H.C.L. Seow, et al., First-time fathers’ experiences and
needs during pregnancy and childbirth: a descriptive qualitative study,
Midwifery 30 (6) (2014) 779–787.
[34] C. Bäckström, E.H. Wahn, Support during labour: first-time fathers’
descriptions of requested and received support during the birth of their
child, Midwifery 27 (1) (2011) 67–73.
[35] E.D. Hodnett, S. Gates, G.J. Hofmeyr, et al., Continuous support for women
during childbirth, Cochrane Database Syst. Rev. (7) (2013).
[36] S.C. Kuo, K.C. Lin, C.H. Hsu, et al., Evaluation of the effects of a birth plan on
Taiwanese women’s childbirth experiences, control and expectations fulfil-
ment: a randomised controlled trial, Int. J. Nurs. Stud. 47 (7) (2010) 806–814.
[37] S.E. Borrelli, H. Spiby, D. Walsh, The kaleidoscopic midwife: a conceptual
metaphor illustrating first-time mothers’ perspectives of a good midwife
during childbirth. A grounded theory study, Midwifery 39 (2016) 103–111.
[38] Department of Health, Report of the Strategic Review on Healthcare
Manpower Planning and Professional Development, Hong Kong: Department
of Health, HKSAR, 2019.