Effect of Social Support During Labor

Introduction The labor process occurs in four successive stages. The first stage begins with regular uterine contractions until full dilation of the cervix. The second stage ends with the delivery of the baby, during which the uterine walls contract to push the it out through the cervix. This stage includes "intense engagement, descent, flexion, internal rotation, extension, external rotation, and expulsion" (Hutchison \& Mahdy, 2019, p. 122). The third stage spans from the birth of the baby to the delivery of the placenta, and the fourth (final) stage extends from the delivery of the placenta to two hours postpartum (Hutchison \& Mahdy, 2019).

The amount of pain and the associated psychological stress emphasizes the need for psychosocial and spiritual support for women during childbirth. Gaskin (2010) highlights that spiritual midwives play a key role in helping women cope with the intense challenges of labor. Similarly, several studies have reported that social support in the labor room enhances the delivery process, increases woman's comfort and satisfaction, improves the newborn's Apgar score, decreases the need for analgesia, shortens the duration of labor, and reduces the need for medications used to accelerate delivery (Kabakian-Khasholian et al., 2018; Khamehchian et al., 2020; Lunda, Minnie and Benade, 2018; Gizachew et al., 2021).

Although many research studies have pointed out the benefit of social support during childbirth, there was evidence reporting various factors might influence its positive impact. For example, Al Ahmar and Tarraf (2014) revealed that higher levels of satisfaction with the childbirth experience were significantly associated with factors such as age, multiparity, higher education, high monthly income, unemployment, childbirth preparation, strong personal control and self-efficacy, fulfilled expectations, shorter labor duration, and instrumental delivery. In addition, the World Health Organization (WHO, 2018) recommended that every woman has to be offered the option of having a support person a Unfortunately, in Jordanian government hospitals, family members are not allowed in the labor ward. A qualitative study examined Jordanian women's experiences and perceptions of labor and birth in different settings and found that women who gave birth in government hospitals complained about being alone in the labor room and not being allowed to have any family members stay with them (Hussein et al., 2020). On the other hand, due to a shortage of staff in these hospitals, there is limited opportunity to provide one-to-one nursing care. As a result, laboring women are often left alone, especially during the first stage of labor (Khresheh, 2010).

Previous studies in Jordan have not provided sufficient evidence in this area over the past years. Only one survey conducted by Hijazi et al. (2021) evaluated the association between the perceived social support during pregnancy and anxiety levels among postpartum women, using an anxiety-specific screening instrument in northern Jordan. The study revealed that social support during pregnancy, childbirth, and postpartum period helps reduce anxiety among women in labor wards.

Therefore, this study seeks to investigate the effect of the presence of a social support person with a woman during the first and second stages of labor on her levels of satisfaction, anxiety, and pain at a governmental hospital in Jordan. Furthermore, the study aims to examine the influence of women's sociodemographic factors on the levels of pain, anxiety, and satisfaction during the first and second stages of labor.

Materials and Methods Design A randomized controlled trial (RCT) was utilized in this study. This design was selected as it is considered a powerful approach for testing cause-and-effect relationships due to control, manipulation, and randomization (Polit \& Beck, 2017). Moreover, RTCs contribute to translating research findings into clinical practice, provide strong evidence for medical treatments, and support the evaluation of the effectiveness of clinical interventions.

Setting The study was conducted at al-Basheer Hospital, a governmental hospital in Amman, the capital of Jordan. The hospital was established in 1954 by the late His Majesty King Hussein Bin Talal under the name Al-Ashrafieh Hospital, and was later renamed Al-Basheer Hospital in 1977. This site was chosen because it reflects a typical setting where the presence of family members during labor is generally not permitted. Therefore, women often experience labor alone. However, each shift typically includes two resident physicians and three to four midwives.

Sample A total of 150 pregnant women were conveniently recruited from the designated hospital and randomly assigned into two groups of 75 participants each, forming the interventional and control groups. Researchers used a statistical power of 0.8, a medium effect size of 0.5, and a significance level of 0.05 were used to calculate the sample size. Although the required sample size was initially determined to be 120 participants, a 20% attrition rate was anticipated. Thus, the final sample size was increased to 150 women to ensure sufficient statistical validity.

The inclusion criteria were as follows: woman in the active phase of labor, low-risk pregnancy as determined by obstetrician, term pregnancy, carrying a singleton fetus, aged between 15 and 49 years (reproductive age), and with the ability to read and write (at least at a primary education level).

Ethical considerations Ethical approval was obtained from The Hashemite University Institutional Review Board, IRB (NO3/3/2021/2022). In addition, permissions were gained from Al-Basheer Hospital and the Ministry of Health prior to conducting the study. Approval to use the study instruments was also received from the original author. Before data collection, written informed consent was obtained from all participants, ensuring their voluntary participation and the right to withdraw from the study at any time without any consequences.

Moreover, the study ensured the privacy of all participants and other women present in the labor room. Detailed information about the purpose of the study, as well as the potential risks and benefits of participation, was provided to the participants. Participation was entirely voluntary, with no coercion exerted by the researcher. All collected data kept confidential, and identification numbers were used to link participants' responses to their questionnaires instead of using real names. Furthermore, no invasive procedures were involved in the study.

Data collection instruments Data were collected using five structured questionnaires: a demographic sheet for the women and her support person (if present), an obstetrical data questionnaire, the Satisfaction with Childbirth Experience Questionnaire, an anxiety scale, and a numeric analog scale for pain assessment. Prior to the actual data collection, a pilot study was carried out on a sample of 20 participants to test the instrument's reliability. The Cronbach's alpha values indicated high internal consistency, with 0.92 for the satisfaction questionnaire and 0.83 for the anxiety scale.

The demographic sheet gathered information on each woman's age, income, marital status, religion, occupation, and education level. Regarding the support person, data collected included age, marital status, relationship to the women, and educational level.

The obstetrical data questionnaire gathered detailed information on the health of both the mother and her baby. This included the number of antenatal clinic visits, gestational age of fetus at birth, type of healthcare provider present during delivery, complications during the intrapartum, baby's birth weight, mode of delivery, use of Pethidine, neonatal complications, any interventions performed on the baby, duration of first stage of labor; and baby's Apgar score at 1 and 5 minutes after delivery (Chunuan, 2010).

The Satisfaction with Childbirth Experience Questionnaire (SCEQ) consisted of 20 items was developed to evaluate the laboring women's experience during childbirth. Nineteen items stressed on satisfaction with different aspects of care, including physical and emotional support, medical treatment, pain management, and health education, while one item measured overall satisfaction with the childbirth experience. Each item was worded as a statement requesting a response that ranged from 1 = lowest level of satisfaction to 5 = highest level of satisfaction. The items were summed, resulting in a possible range of scores from 20 to 100. A higher score indicated greater satisfaction. The questionnaire demonstrated high reliability, with a Cronbach's alpha coefficient of 0.92 (Chunuan et al., 2010).

The Anxiety Scale included 19 items that addressed feelings of anxiety during intrapartum. Five of the items are stated in a positive manner; thus, they require reverse scoring (items 1, 2, 4, 6, and 10). Each item in the scale is worded as a statement that requires a rating from 1 = never to 5 = most of the time. The range of possible scores is from 19 to 95. The higher the score, the higher the level of anxiety. The original scale was developed by Boonpongmanee and Sopen Chunuan (2005) and later modified in 2010 by Sopen Chunuan. In this study, we used the modified version. The alpha coefficient was 0.83, which means good reliability for this scale. (Chunuan et al., 2010).

The pain scale was a numeric rating scale consisting of ten levels of pain (0 to 10) marked on a horizontal line. The line was divided into equal sections, numbered from 0 = no pain to 10 = strong pain. Participants rated their labor pain on the analog pain scale by placing an "X" near the number that best represented the level of pain they were experiencing (Chunuan et al., 2010).

All questionnaires were translated into Arabic to make them understandable by the participants, then back-translated into English to ensure their validity. The Arabic version of the questionnaire was reviewed by three experts in the field of midwifery and maternal health to confirm content validity, and the Content Validity Index (CVI) was calculated at 0.97. Further, the Arabic version was modified based on the experts notes, which mainly involved simple language adjustments.

Data collection procedure At the onset of labor, both the laboring woman and her support person were given sufficient information about the labor process. The support person was a female relative chosen by the laboring woman to accompany her throughout labor. The support persons were guided on how to support the laboring women and were careful to fulfill their role. The role of the support person in the labor room included providing a continuous presence, reassurance and praise, comforting touch, and overall continuous labor support from their birth partner until the end of the first stage, and continuing to provide assistance throughout the second stage of labor. Finally, after two hours and at the end of the fourth stage of labor, each woman was interviewed face-to-face by the researcher and completed the questionnaire for both groups.

Data Analysis Statistical analysis of the data was performed using SPSS version 25.0. Both descriptive and inferential statistics consisting of frequencies, percentages, means, standard deviations, and independent t-tests to analyze the data. The significance level was set at (p = < 0.05).