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Abstract

Background:

Theoretical literature suggests utilising relaxation practices during labour can mitigate perceived pain. However, empirical evidence regarding their effectiveness in reducing epidural use remains inconclusive. Investigating women’s experiences with relaxation techniques during labour, alongside their use of epidural, may provide further insights into these conflicting results.

Objective:

To investigate women’s experiences regarding the impact of relaxation practices on labour pain and the utilisation of epidurals, following attendance at an antenatal relaxation class (ARC).

Design:

An exploratory sequential mixed method was used.

Methods:

Phase 1 explored the experiences of women using qualitative interviews. Phase 2 was a prospective longitudinal cohort study using online surveys completed before and after attending ARC and post-birth.

Results:

Of the 17 women interviewed in Phase 1, all 15 who experienced labour reported using ‘relaxation for labour pain’ which enhanced their ability to cope with labour pain, resulting in satisfaction and pride. However, the effectiveness of these practices in influencing epidural use depended on the ‘space for relaxation’ shaped by the physical surroundings, clinical context, and birth attendants. Among the 91 women who participated in Phase 2, both the ‘intended use of epidural’ post-class and the ‘actual use of epidural’ post-birth were significantly lower than the ‘intended use of epidural’ pre-class. Women whose labour started spontaneously reported using relaxation techniques at home to manage pain, and most delayed hospitalisation until labour was established.

Conclusion:

Educating women on relaxation practices can enhance their ability to cope with labour pain and reduce the use of epidural for pain management.

Plain language summary

Effect of relaxation practices on labour pain and choice of epidural

The study looked at how relaxation techniques during labour affect women’s pain and their decision to use an epidural. In the first part, 17 women who took a relaxation class were interviewed after giving birth. Most said the techniques helped them manage pain and feel proud. However, the success of these techniques in reducing epidural use depended on the environment and support they had. In the second part, 91 women completed surveys. The results showed that both their intention to use an epidural after the class and their actual use of it after birth were lower than their initial intention before the class. Women who started labour naturally used relaxation techniques at home, which often delayed their hospital visit until labour was well established. The study concluded that teaching women relaxation techniques can help them handle labour pain better and reduce the need for an epidural.

Keywords

relaxation techniques labour pain epidural use antenatal education

Introduction

The theoretical literature^1–3 along with a limited but growing body of women’s* qualitative accounts^4–6 suggest that relaxation practices such as guided imagery or hypnosis may alleviate perceived labour pain and enhance women’s coping abilities by calming emotional responses such as fear and anxiety, while fostering greater confidence. Relaxation practices are grounded in the psychophysiological stress model,⁷ which suggests that reducing sympathetic nervous system activation can lower perceived pain intensity. These practices promote a sense of control and calm, which directly enhances childbirth self-efficacy defined as the belief in one’s ability to manage pain and cope effectively.⁸ According to Bandura’s Social Cognitive Theory,⁹ higher self-efficacy leads to adaptive coping strategies and reduced pain-related distress. In turn, this cognitive appraisal influences pain perception, as individuals with greater confidence in their coping abilities tend to interpret pain as less threatening, thereby diminishing its subjective intensity.

In the current climate of increasing obstetric interventions,^10,11 such education has attracted interest as a pain management method with the potential to reduce epidural use and the associated medical interventions.^12–16

The first systematic review in the field¹⁷ reported that hypnosis as a relaxation technique may reduce the need for epidural. This review was heavily influenced by the findings of Mehl-Madrona,¹⁸ who conducted the first large multi-centre randomised controlled trial (RCT). This RCT reported that women participating in a comprehensive course of hypnosis (mean of five sessions) had significantly lower epidural analgesia use, caesarean sections, and induction/augmentation of labour.¹⁸ The intervention employed, however, was complex, poorly reported and included as many hypnosis and supportive psychotherapy sessions as desired. Therefore, the external validity of the findings is questionable, and the intervention is difficult to replicate.¹⁹ An observational study conducted by VandeVusse et al.²⁰ reported similar findings by demonstrating that a course of five sessions of antenatal hypnosis resulted in significantly less use of epidural analgesia during labour. This research was an exploratory retrospective study that compared childbirth outcomes of 101 women in 1 obstetrician’s caseload by extracting data from their medical records. Participants in the intervention group, however, were self-selected, thus potentially introducing selection bias to the study.²¹ Interestingly, the hypnosis instructors in both studies accompanied women during labour.

Between 2013 and 2015, three high-quality RCTs were conducted by Cyna et al.,²² Werner et al.,²³ and Downe et al.²⁴ in Australia, Denmark, and England respectively, to investigate the effect of a brief (total of 3 h) antenatal course in group self-hypnosis on epidural use during labour. These studies employed rigorous experimental designs, including randomisation, large sample sizes, comprehensive methodological reporting, and standardised interventions. Unlike earlier studies, these trials excluded the involvement of hypnosis instructors during labour, focusing solely on the antenatal component. Despite their methodological strengths, none of the three trials demonstrated a statistically significant reduction in epidural use or other obstetric interventions among participants in the hypnosis groups.

This contrast with earlier findings raises important questions about the mechanisms and contextual factors influencing the effectiveness of antenatal relaxation education. For instance, the absence of intrapartum support for using relaxation techniques in the latter trials may have contributed to the lack of observed benefit, suggesting that the context in which relaxation techniques are applied could be critical. These inconsistencies have led more recent systematic reviews^25,26 to conclude that there is no clear evidence that antenatal hypnosis education reduces epidural use or improves other clinical outcomes.

Despite growing interest in antenatal relaxation education, the reasons behind inconsistent findings in the literature remain poorly understood. A critical gap lies in the lack of qualitative research exploring how childbearing women perceive, interpret, and engage with such education. Existing studies often assume that instruction alone translates into practice, yet little is known about whether and how women apply relaxation techniques during labour, or how they evaluate their effectiveness in managing pain and supporting coping strategies. Furthermore, the influence of antenatal relaxation education on women’s decision-making regarding epidural analgesia remains underexplored. Contextual factors such as cultural norms, birth environment, and personal expectations that may shape uptake and perceived efficacy of these techniques also warrant investigation.

To address these gaps, this exploratory mixed-method study examines how participation in a single, 3-h group antenatal relaxation class (ARC) influences women’s experiences of labour pain and their decisions about epidural use. While RCTs provide valuable hypothesis-driven evidence, they often overlook the nuanced, context-specific insights embedded in lived experiences. By integrating qualitative and quantitative approaches, this study uses women’s narratives as a foundation for hypothesis generation, ensuring that subsequent quantitative testing is informed by real-world perspectives. This design enhances the relevance, depth, and applicability of findings beyond what RCTs alone can achieve, offering a more comprehensive understanding of how antenatal relaxation education operates in practice.

Methods

Design

An exploratory sequential mixed‑method design was chosen to develop a comprehensive understanding of the phenomena under investigation. The study comprised two phases: Phase 1 employed a qualitative descriptive approach,²⁷ and Phase 2 followed a prospective longitudinal cohort design using online surveys administered pre‑class, post‑class, and post‑birth. Insights from Phase 1 directly informed the development of the hypothesis, research questions, and survey instruments for Phase 2. The qualitative findings indicated that relaxation techniques helped women feel calmer, more confident in managing labour pain, more able to remain at home during early labour, and less inclined to choose an epidural. These insights informed the development of the Phase 2 survey, which explored the extent to which ARC techniques were used during labour, whether women with spontaneous labour remained at home during early labour, and whether ARC attendance was associated with changes in intended and actual epidural use.

Additional qualitative insights regarding shifting expectations and post‑birth reflections informed the decision to collect data at three time points. During analysis, Phase 1 themes also provided a conceptual framework for interpreting quantitative trends, supporting a deeper understanding of behaviours such as epidural uptake despite reported confidence. This sequential approach enabled the qualitative findings to be tested in a larger sample²⁸ while preserving their contextual relevance.

This article reports part of a larger study, and the findings regarding the influence of ARC on childbirth experiences and maternal psychological wellbeing are reported elsewhere.⁷

Setting

The study was conducted in a tertiary maternity hospital within an NHS Health Board in Scotland, with approximately 5000 births per year. This setting was chosen because it already offered the single‑session ARC programme. Although data collection took place during the COVID‑19 pandemic (2020–2021), there is no evidence in the data of restrictions or alterations of key aspects of the intrapartum care environment in this setting.

Antenatal relaxation class

ARC is an established initiative within a Scottish NHS Health Board. This single, face-to-face, 3-h group class was facilitated by two midwives trained in relaxation techniques and offered to pregnant women and their birth partners in the third trimester. Most women attending ARC were referred by their maternity care provider due to expressing anxiety or apprehension about childbirth. In class, after an introduction to childbirth physiology, participants practiced four relaxation exercises including breathing, visualisation, hypnosis, and relaxation in labour. Participants were also given leaflets and audio resources for further practice at home. The class and provided resources were free of charge for participants. Further details on ARC can be found in Tabib et al.²⁹

Research questions

Phase 1

The qualitative phase of the study aimed to address the following question.

‘What are the experiences of childbearing women in using relaxation techniques to manage labour pain and their decisions regarding epidural use?’

Phase 2

Drawing on the qualitative findings from Phase 1, the following hypothesis (H) and research questions (RQs) were formulated for investigation in a larger sample through a quantitative follow-up study conducted in Phase 2.

H1: ‘There will be a relationship between time (pre-class, post-class, and post-birth) and intended/actual use of epidural for labour’.

RQ1: ‘Do women attending ARC widely use the ARC techniques in labour?’

RQ2: ‘Do “women attending ARC whose labour starts spontaneously”, stay at home during early labour and seek hospitalisation in established labour?’

Participants

Phase 1

Purposive sampling was used to recruit 17 women who were interviewed between January and June 2020. Midwives delivering ARC accessed the NHS database system to identify and send invitations to women who were due to attend the class. Inclusion criteria were being over the age of 16, able to read, write and understand English, attending ARC, and receiving midwifery-led care at the point of recruitment. The latter criterion was to ensure the childbirth experiences of a sufficient number of participants with spontaneous labour and birth was captured. Women were excluded if they did not meet the inclusion criteria. The sample size was guided by the ‘information power model’,³⁰ which considers factors such as study aim, sample specificity, theoretical framework, interview quality, and analysis strategy. Participants were aged between 26 and 41 years (mean age = 31.94, standard deviation (SD) = 3.76) and from a range of ethnic groups and educational backgrounds. Three women were multiparous, and the rest were primiparous. Characteristics of Phase 1 participants and processes of care are presented in Table 1. Participants’ identity was protected by using pseudonyms they chose for themselves.

Table 1.

Phase 1 characteristics of study participants and processes of care.

No.	Participants (woman and birth partner)	Parity	Ethnicity	Level of education	Employment	Marital status	Age	Onset of labour/mode of birth/place of birth	Cervical dilatation on admission to the hospital (cm)	Pain management	Had attended private AN classes
1	Lara and Frank	First	White British	MSc	Engineer	Married	32	Spontaneous onset forceps Operating theatre	7	Epidural in theatre	No
2	Rosie	First	White British	MSc	School teacher	Married	33	Induction of labour C-section Operating theatre	Not applicable	Epidural during labour	Yes (hypnobirthing)
3	Louise and James	Second	White British	BSc	Housewife	Married	33	Spontaneous onset SVB Home birth	Not applicable	None	No
4	Charlotte and Amy (Charlotte’s mother)	First	White British	BSc	Marketing	Married	34	Induction of labour/forceps Obstetric-led Unit	Not applicable	Entonox	No
5	Margaret	Second	White Polish	MSc	Charity manager	Married	32	Induction of labour/SVB Labour ward	Not applicable	Entonox for 1 h	No
6	Neave	First	White British	BSc	School teacher	Married	34	Induction of labour C-section Operating theatre	Not applicable	Spinal in theatre	No
7	Zoe and James	First	Mixed raced Asian-British	MSc	Engineer	Married	28	Spontaneous onset SVB Home birth	Not applicable	None	Yes (hypnobirthing)
8	Mavis and Robert	First	White British	College HND	Document certifier	Engaged	32	Spontaneous onset augmentation/forceps Obstetric-led unit	6	Epidural when augmented	No
9	Liz and Jo	First	White British	MSc	Senior accountant	Married	33	Elective C-section Operating theatre	Not applicable	Spinal in theatre	No
10	Angela and Graham	Second	White British	College HNC	Office manager	In relationship	38	Spontaneous onset SVB Obstetric-led Unit	4	Entonox and Morphine	Yes (Yoga)
11	Sandra	First	African	MSc	Entrepreneur	Married	31	Induction of labour SVB Obstetric-led Unit	Not applicable	Entonox, Morphine, Epidural when transitioning	No
12	Summer and Hamish	First	White American	BSc	University admin	Married	27	Spontaneous onset SVB Homebirth	Not applicable	None	Yes (Yoga)
13	Emilia and Oliver	First	White British	PG diploma	Community developing officer	Married	28	Spontaneous onset SVB Midwives Unit	10	None	No
14	Louis	First	White British	PG degree	School teacher	Married	27	Induction of labour Emergency C-section Operating theatre	Not applicable	Epidural in labour	No
15	Mary	First	Asian	PhD	Engineer	Married	41	Spontaneous onset Augmentation/ SVB Obstetric-led Unit	7	Entonox	Yes (Yoga)
16	Silvana	First	Brazil/ South American	BSc in engineering	Housewife	Married	32	Spontaneous onset augmented/forceps Operating theatre	4	Entonox and Morphine in labour Epidural in theatre	No
17	Arlene	First	White British	HNC College	Nursery nurse	In relationship	28	Spontaneous onset SVB Midwives unit	9	Entonox for 1 h	No

HNC: Higher National Certificate; HND: Higher National Diploma; PG: postgraduate; SVB: spontaneous vaginal birth.

Phase 2

Using a convenience sampling strategy, a consecutive sample of 243 women attending ARC were invited to participate in Phase 2 between January and June 2021. All women scheduled to attend ARC were sent invitation emails by the midwives facilitating the class. The Power calculations using G*Power 3.0.10 (G Power; Department of Psychology, Heinrich Heine University Düsseldorf, Germany) indicated a sample size of 57 women was required to detect treatment effects, assuming power = 0.95, significance set to 0.05, and an effect size of d = 0.4 based on similar research.³¹ Considering the attrition rate of 50% from a previous study on a similar population in the same setting, a total number of 114 was estimated to be sufficient. Ninety‑one women (37.44%) completed the pre‑class survey, of whom 85 (93.4%) completed the post‑class survey and 84 (92.4%) completed the post‑birth survey 4–8 weeks after birth, resulting in attrition rates of 6.6% and 7.6%, respectively. Inclusion criteria were consistent with those used in phase 1.

Participants’ age ranged from 21 to 41 years (M = 31.00, SD = 3.6). Mean gestation was 31.7 weeks (SD = 3.2) at pre-class, 34.00 weeks (SD = 3.3) at post-class, and 5.00 weeks postnatal (SD = 2.4) at post-birth. The participants were predominantly primigravida (n = 78, 85.7%) and from a range of ethnicities, with the majority (n = 70, 76.9%) being White British. A large proportion of the participants were either married (n = 56, 61.5%) or cohabiting (n = 29, 32.9%), with the remaining (n = 6, 6.6%) identifying themselves as single. In terms of educational attainment, this varied from secondary school to doctorate, with 79.1% (n = 72) being educated to degree level or higher. Most participants (n = 76, 83.3%) were in full-time employment, 7.7% (n = 7) were in part-time employment, and the rest were unemployed, students, or others. Characteristics of phase 2 participants are presented in Table 2. A potential risk of self‑selection bias is acknowledged, as women who attend relaxation classes may already prefer non‑pharmacological pain relief. However, most study participants were referred by their maternity care providers rather than by self-referral, which likely reduced this effect.

Table 2.

Phase 2 demographic characteristics of participants.

Characteristics	n (%)
Previous births
No previous birth	78 (85.7)
One previous birth	11 (12.1)
Two or more previous birth	2 (2.2)
Ethnicity
White British	70 (76.9)
Other white	10 (10)
Black	0 (0)
Asian	7 (7.7)
Mixed	3 (3.3)
Others	1 (1.1)
Marital status
Married	56 (61.5)
Domestic partnership	29 (31.9)
Single	6 (6.6)
Educational attainment
Secondary school	4 (4.4)
College (HNC/HND)	15 (16.5)
Degree	39 (42.9)
Master’s degree	25 (27.5)
Doctorate	3 (3.3)
Others	5 (5.5)
Employment
Full-time	76 (83.5)
Part-time	7 (7.7)
Unemployed	5 (5.5)
Student	1 (1.1)
Others	2 (2.2)

HNC: Higher National Certificate; HND: Higher National Diploma.

Data collection and analysis

Phase 1

The data were collected using semi-structured interviews between March and June 2020. In total, 64 women were invited to the study of whom 39 gave written consent. Ultimately, 17 responded to the text reminders following birth and took part in the interviews, giving a response rate of 26.5%. Having a new baby seemed to be influential in the low response rate. Seven interviews took place face-to-face, and 10 interviews were conducted via audio (2 women) and video (8 women) phone calls. All interviews were conducted by one of the authors (MT). Birth partners were present in nine interviews; all other sessions involved only the woman and the researcher. An interview question guide was used with the relevant questions (shown in Table 3). The interviews lasted between 40 and 60 min and were digitally recorded and transcribed verbatim. The study was conducted and reported in accordance with the COREQ statement.³² The completed COREQ checklist for this study is available in the supplementary material.

Table 3.

Interview question guide.

Main interview questions
1. Can you tell me about your labour and birth?
2. Can you tell me about your experience of the antenatal relaxation class?

Supplementary and prompting questions
• How did you feel about childbirth immediately after the class?
• What techniques (if any) did you practice during pregnancy? Can you tell me how often you practised?
• How were you feeling about labour and birth before attending ARC?
• How were you feeling about labour and birth following the class?
• Can you describe the moment of practicing the relaxation techniques? Can you tell me what you were thinking and how you were feeling then?
• Can you tell me about your experience when labour started?
• Did you use any of the techniques during labour?
• What influenced the use of relaxation techniques? What helped or hindered the use of the techniques?
• What pain reliefs did you use?
• How did your labour progress?
• What was your experience of labour pain?
• How did the care you received, influenced the use of relaxation techniques?

ARC: antenatal relaxation class.

Reflexive thematic analysis³³ was used as it offers a systematic, rigorous, and transparent approach to data management, analysis, and reporting. Transcripts were not returned for member checking because Braun and Clarke³³ argue that, within thematic analysis, such checks cannot provide objective knowledge in a process inherently shaped by researchers’ interpretations. Three researchers took a collaborative and reflexive approach in coding. The aim was to develop a richer and more nuanced reading of the data, rather than just seeking a consensus on meanings. The overall approach to data coding and analysis was inductive and data-driven.

The research team comprised two PhDs (TH and KFM) and MT, a PhD student. At the time of the study, TH was professor of Midwifery, KFM a senior lecturer in Psychology, and MT a Midwifery lecturer. All researchers were female with formal training and prior experience in qualitative and mixed-method methodologies. No prior relationship existed with participants before the study commenced, although participants were informed of the researchers’ institutional affiliations and the study’s purpose. The team disclosed their interest in the topic and acknowledged potential biases, assumptions, and motivations. To enhance trustworthiness, an audit trail was maintained through records of raw data, field notes, transcripts, and a reflexive journal.³⁴

Phase 2

The quantitative data in Phase 2 were collected using a series of online surveys administered via Novi Online Surveys at three time points: pre-class, 2 weeks post-class, and 4–8 weeks post-birth. The surveys are provided in supplemental material. Data collection occurred between January and June 2021, with participants distinct from those in Phase 1. The study was designed and reported in accordance with the STROBE guidelines for cohort studies.³⁵ The completed STROBE checklist for this study is available in the supplementary material.

The survey instrument was designed specifically for this study, drawing on insights from Phase 1 findings and a review of literature related to antenatal education, pain management, and decision-making in childbirth. To ensure content validity, the survey items were reviewed by a panel of experts in midwifery, and survey methodology. The instrument was then pilot tested with a small group of women (n = 6) who met the study’s inclusion criteria, representing approximately 7% of the final sample. These participants were not included in the main study. Feedback from the pilot was used to refine questions wording and improve clarity.

The final survey included items to assess eligibility, collect demographic data, and examine both the intended and actual use of epidural analgesia. For the hypothesis (H1), participants were asked at pre-class and post-class whether they intended to use an epidural during labour, with response options of ‘yes’, ‘no’, and ‘maybe’. At post-birth, they were asked whether they had actually used an epidural, with response options of ‘yes’, ‘no’, and ‘not applicable’. Responses of ‘not applicable’ were excluded from analysis, and ‘yes’ and ‘maybe’ responses were combined at pre- and post-class to allow for consistent comparison using a binary scale across time points. Post-birth, the use of epidural during labour was measured and those who received an epidural for operative birth or those who did not experience labour (e.g. planned caesarean section) were excluded from the post-birth epidural outcome analysis.

To address research question 1 (RQ1), a binary (yes/no) item asked whether participants used ARC techniques during labour. For research question 2 (RQ2), participants reported the number of hours spent at home during labour and their cervical dilatation (in cm) upon arrival at the hospital, as indicators of coping ability in early labour.

The survey demonstrated acceptable face and content validity, and internal consistency was supported by the logical structure and clarity of the items. The full survey instrument is available in the Edinburgh Napier University repository as per data availability statement.

For statistical analysis, survey data were exported from Novi to IBM SPSS Statistics³⁶ Version 25 for analysis. Descriptive statistics were used to summarise sample characteristics and address the study’s research questions. Cochran’s Q test was conducted to test hypothesis 1 (H1), examining differences in intended epidural use reported at pre-class and post-class, as well as actual epidural use for labour pain reported post-birth.

Results

Phase 1

As shown in Table 4, two main themes and five sub-themes were generated. Women reported using ‘Relaxation for labour pain’ which helped them ‘cope with labour pain’ and led to feelings of ‘satisfaction and pride’. However, their ability to implement these techniques was not solely dependent on personal intention; it was conditioned by the availability of an appropriate ‘Space for relaxation’. This space was shaped by the ‘physical surroundings’, the ‘clinical context’, and the interactions with ‘birth attendants’. When the environment was calm, private, and supportive, women could engage fully with relaxation strategies, enhancing their coping and sense of control. Conversely, when the space was noisy, crowded, or clinically restrictive, relaxation became difficult to sustain, diminishing its effectiveness. Thus, the second theme of ‘Space for relaxation’ functioned as a critical mediator, enabling or constraining the use of ‘Relaxation for labour pain’.

Table 4.

Themes and sub-themes.

Themes	Sub-themes
1. Relaxation for labour pain	• Coping with labour pain • Satisfaction and pride
2. Space for relaxation	• Physical surroundings • Clinical picture • Birth attendants

Theme 1: relaxation for labour pain

After attending ARC, women reported that they felt more confident in their own ability to induce a state of relaxation which was referred to as ‘the zone’. They attributed their ability to cope with labour pain and avoid pharmaceutical pain relief to their skills in taking themselves to ‘the zone’. The participants who experienced labour contractions (15 women), commonly applied relaxation techniques as a pain management method in labour. They believed this helped them to ‘cope with labour pain’ and experience the subsequent feelings of ‘satisfaction and pride’.

Coping with labour pain

Relaxation techniques were used during labour to induce a state of relaxation. Charlotte commented,

‘As soon as I felt it (contractions) came on, that was when I used the techniques to get into the zone’. (Charlotte, P0 (Para 0))

Those who had planned for home birth (three women) succeeded in coping with labour pain and having uncomplicated childbirth at home.

Zoe highlighted how focusing on breathing and body relaxation helped her to cope with the labour at home,

‘The breathing was really; really good you know. . . I just got through it (labour) with breathing and relaxing’. (Zoe, P0)

Women planning for a hospital birth, whose labour started spontaneously at home (seven women) felt confident to spend time at home and apply the learned relaxation techniques before seeking hospitalisation. These women were all admitted to hospital in established labour with a cervical dilatation over 4 cm.

Emilia was a primiparous woman who was admitted to hospital in the second stage of labour. She described her experience of applying the techniques during labour as,

‘I’m a bit of a drama queen, so the labour was uncharacteristic in terms of how calm I was. I genuinely think the slowing down of my breath and checking myself and saying, “okay, breathe slowly, breathe deeply” was what got me to the stage where I was fully dilated’. (Emilia, P0)

Except for one woman (whose labour was augmented), none of the women with spontaneous onset of labour requested an epidural during labour.

Those undergoing induction of labour (five women), however, were more likely to seek pharmaceutical pain relief including epidural (three women), although, some managed without epidural (two women).

Some of these women found the artificially stimulated contractions too strong to cope with. Louis stated,

‘. . . I was finding them (contractions) just excruciating. Really just couldn’t bear much more’. (Louis, P0)

Satisfaction and Pride

The ability to cope with labour pain and avoid using pharmaceutical pain relief was linked to feelings of achievement, satisfaction, and pride in one’s own performance, even for those who eventually had an epidural. Mavis who had eventually opted for an epidural, but managed to cope with labour pain for part of her labour stated,

‘I managed to get to six centimetres on my own (stated proudly), I was on no gas and air, no pain relief, just Paracetamol at home. I was quite happy’. (Mavis, P0)

Overall, women felt attending ARC and learning about relaxation practices increased their coping abilities and had a positive influence on their experiences of labour. However, the effectiveness of relaxation techniques for pain management seemed to depend on external factors such as physical surroundings, the clinical context of the experience and birth attendants.

Theme 2: space for relaxation

It seems for women to be able to use relaxation techniques as effective coping strategies for labour pain, a protected space is required. This space appears to be essential for both entering and remaining in ‘the zone’, particularly for long periods of time. The data indicated physical surroundings, the clinical context of the experience, and birth attendants were the main factors influencing this space and thereby impacting women’s ability to effectively use relaxation techniques.

Physical surroundings

Physical surroundings such as lighting, privacy, or an environment that allowed freedom of movement were frequently highlighted as factors that influenced women’s ability to induce a sense of calmness. Summer who had a successful homebirth commented,

‘We had a birthing pool. . .a very relaxing kind of massage music, like exactly what used in class and then, I mean, it was dark in the room, and lavender’. (Summer, P0)

Being confined to the bed prevented the effective use of the relaxation techniques.

‘I wasn’t really breathing properly when I was lying down in bed’. (Lara, P0)

Women frequently made negative comparisons between the home environment and the clinical environment of the hospital. Mavis whose labour started at home and then spent some time in the triage ward stated,

‘I used it (the techniques) at home more because in hospital was a bit harder, because of just the environment you’re in …’. (Mavis, P0)

She highlighted the lack of privacy in triage as a barrier,

‘Sharing a room with other people, that was quite hard to relax because you were listening to other people’. (Mavis, P0)

Clinical context

The procedures experienced by women such as induction of labour also influenced the birth space and women’s coping abilities. Sandra whose labour was induced, explained the reasons for requesting an epidural as,

‘The contractions were coming quite fast . . . pain was getting more . . . and I had to lie down. . .’.

Some women required an epidural due to undergoing operative births. Silvana who had managed without an epidural for 12 h of labour, said,

‘They thought forceps was a better option, so, I had the epidural. . .’.

Birth attendants

Birth attendants’ presence, their influence on the physical surroundings, and their interactions with the woman during labour appeared to influence the women’s ability to cope with pain. Angela compared the experience of pain in her two childbirths and noted the positive influence of relaxation techniques during the second birth.

‘. . .the whole experience was so positive . . . pain was there, but not nearly as bad as when I first gave birth. Throughout the breathing, I couldn’t believe how much it did help with the pain. The first pregnancy, the pain at the time seemed extreme 10 out of 10. This time, five’. (Angela, P1)

She continued to highlight the enabling role of the midwife in the second birth,

‘. . . my first experience, (the midwife said) lie here, do this, do that, whereas this time was just more, what do you want?, get up, move about . . . it made me so much more confident’. (Angela, P1)

Women also highlighted the importance of support from their birth partners in applying the learned techniques and protecting the birth space. Summer explained the effect of James’s encouragement in using the learned relaxation techniques during labour,

‘His encouragement was pretty much just like an audible breath’. (Summer, P0)

Phase 2

The findings of Phase 2 indicate attendance at ARC was associated with a significant decline in the intended and actual use of epidural for labour pain as reported at post-class and post-birth respectively. The relaxation techniques taught during ARC were widely utilised during labour, and the majority of women who experienced spontaneous labour onset remained at home during early labour, seeking hospital admission only once labour was well established. Phase 2 hypothesis and research questions were addressed as follows.

H1: ‘There will be a relationship between time (pre-class, post-class, and post-birth) and intended/actual use of epidural for labour’.

Table 5 presents the frequency data on intended and actual use of epidural for labour. The number of women who did not intend to use epidural increased from 40 (44.4%) at pre-class to 59 (69.3%) at post-class, with 44 (55.7%) reporting no use post-birth. Some of these women, however, received regional anaesthesia due to operative birth. The proportion intending to use epidural or uncertain about its use declined from 46 (50.5%) pre-class to 25 (29.4%) post-class, with 26 (32.9%) reporting actual use post-birth. Figure 1 presents a comparison in intended/actual use of epidural across three timepoint.

Table 5.

Frequencies of intended/actual use of epidural for labour.

Intended/actual use of epidural for labour	Time
Intended/actual use of epidural for labour	Pre-class, n (%)	Post-class, n (%)	Post-birth, n (%)
No	40 (44.4)	59 (69.3)	44 (55.7)
Yes/maybe (intended use) & Yes (actual use)	46 (50.5)	25 (29.4)	26 (32.9)

Figure 1.

Frequency of intended use of epidural reported at pre-class and post-class, and actual use post birth.

To examine whether there were significant differences in the number of women intending to use/using epidural across three time points (pre-class, post-class, and post-birth), a Cochran’s Q test was conducted. The analysis showed a statistically significant difference across these time points, Q(2) = 40.10, p < 0.001. To identify where these differences occurred, McNemar tests were performed. Results indicated a significant change in the proportion of participants intending to use an epidural between pre-class and post-class (p < 0.01, large effect size, φ = 0.592), and between pre-class intentions and actual use at birth (p < 0.01, large effect size, φ = 0.555). These findings suggest that both the intended use of epidural after the class and the actual use reported post-birth were significantly lower than the initial intention expressed prior to attending ARC, thereby supporting the hypothesis.

RQ1: ‘Do women attending ARC widely use the ARC techniques in labour?’

The results showed that all women (100%) who had experienced labour (n = 74) reported using the relaxation techniques in labour. Breathing techniques were the most frequently used techniques during labour and birth (88%, n = 73) as opposed to visualisation (31.3%, n = 26) or hypnosis (used by 1.2%, n = 1).

RQ2: ‘Do “women attending ARC whose labour starts spontaneously”, stay at home during early labour and seek hospitalisation in established labour?’

This question examined the length of time spent at home during labour and the stage of labour when women sought hospitalisation for birth. Of 84 women who returned post-birth surveys, 44 (55.7%) had spontaneous onset of labour at home. The remaining participants had either a planned caesarean section or their labour was induced. For women with spontaneous onset of labour, the mean time spent at home in labour was 13.7 h (median = 7.5 h). The majority (63.6%) of those with spontaneous onset of labour arrived at hospital in established labour. NICE guidelines³⁷ define established labour as experiencing regular painful contractions and progressive cervical dilatation from 4 cm.

The mean cervical dilatation for this group of women on admission to the hospital was 4.86 cm (SD = 2.66) with 5 (11%) of them being admitted to hospital with a fully dilated cervix (10 cm). It is important to note most of these women were primigravidae (n = 38, 84.4%) with the remaining (n = 6, 13.6%) being multiparous.

Discussion

The findings suggest the relaxation techniques were widely used and viewed as having a positive influence on women’s confidence and ability to cope with labour pain. The majority of those with spontaneous onset of labour stayed at home during early labour and sought hospitalisation only when in established labour. In addition, attending ARC was associated with a significant reduction in both intended and actual use of epidural for labour pain, as reported post-class and post-birth. As indicated by the qualitative accounts, however, the effectiveness of relaxation techniques for pain management in clinical settings seems to depend on the physical surroundings, the clinical context of the experience, and the interactions with birth attendants.

The wide use of relaxation techniques in labour shows a high application of the education, a finding not previously reported in the literature. This has important implications for practice, particularly if such education is to be integrated into mainstream antenatal education. Evidence suggests that successful implementation of health interventions depends on their acceptability to recipients.^38,39 The predominance of breathing techniques over visualisation or hypnosis among participants may reflect differences in class length or content, though this has not been examined in previous research and warrants further investigation.

In Phase 1, women reported increased confidence in their birthing abilities following ARC attendance and described how relaxation techniques helped them cope during early labour at home, delaying hospitalisation until labour was established. Phase 2 confirmed this finding in a larger sample, indicating that ARC may enhance women’s ability to manage early labour at home. The influence of antenatal education incorporating relaxation practices on delaying admission has not been explored in previous research, apart from a service evaluation of ARC⁴⁰ and a recent audit of birth outcomes for 93 ARC participants,⁴¹ which reported similar results. The audit⁴¹ showed that 74% of women with spontaneous onset of labour were admitted with cervical dilatation of 4 cm or more. This finding has significant implications for women and maternity services, as delaying admission in medically low-risk term women until active labour is associated with reduced epidural use, augmentation, instrumental birth, caesarean section, and maternal deaths,^42–44 as well as substantial cost savings⁴⁴. These outcomes highlight the potential value of integrating relaxation techniques into antenatal education. Consequently, access to relaxation practices should be considered a core component of antenatal education. To strengthen this evidence base, further comparative studies are needed to explore the causal relationship between such education and stage of labour at admission to clinical settings.

Attendance at ARC was also associated with a significant decline in intended and actual epidural use for labour pain. Previous research^{18,20,22–26} has not examined the influence of relaxation education on women’s intention to use epidural during pregnancy or their actual choice during labour. Instead, epidural use was typically measured as a binary (yes/no) variable, without distinguishing between elective use and clinical indication. If research aims to assess the impact of educational interventions on coping abilities, it is essential to differentiate between epidural as a personal pain relief choice and when clinically required. This distinction is particularly relevant given the rising rates of obstetric interventions such as caesarean section, instrumental birth, and labour induction worldwide,^45–47 which commonly necessitate epidural anaesthesia. In this study, women reported significant reductions in both intended and actual epidural use, and those who received epidural for clinical indications such as operative births were excluded from the post-birth analysis. This methodological decision ensured a clear distinction between elective and clinically indicated use, strengthening the validity of the findings.

Significant improvements in women’s anxiety and fear of childbirth levels, and their confidence to manage labour pain (childbirth self-efficacy)⁴⁸ corresponded with delayed hospitalisation and a significant decline in their intended and actual epidural use during labour. These findings can be interpreted through the lens of the biopsychosocial model of pain, which conceptualises labour pain as an interaction of biological, psychological, and social factors.⁴⁹ While the physiological processes of labour contribute to pain intensity, psychological factors such as fear, anxiety, and self-efficacy play a critical role in shaping women’s pain experience. According to Bandura’s self-efficacy theory,⁹ confidence in one’s ability to manage labour challenges enhances coping strategies and reduces reliance on pharmacological interventions. Empirical evidence also confirms that childbirth self-efficacy beliefs could reduce perceptions of labour pain⁵⁰ and the likelihood of using epidural analgesia.⁵¹

Although the findings indicate that attending ARC was associated with greater confidence and improved coping with labour pain, the qualitative data suggest that the effectiveness of relaxation practices is also shaped by the physical environment, the wider clinical context, and interactions with birth attendants. These finding also aligns with the biopsychosocial model of pain,^49,52 emphasising that supportive birth environments and positive interactions with birth attenders can enhance women’s confidence and coping strategies, whereas stressful surroundings or unsupportive care may undermine the benefits of relaxation techniques. These insights highlight the need for thoughtfully designed birth settings that provide quiet, privacy, and emotional support to facilitate the use of relaxation practices. Maternity care policies should prioritise investment in such environments, recognising their potential to improve maternal outcomes. Birth practitioners, who have considerable control over the physical environment and clinical decisions, play a pivotal role in either fostering or disrupting conditions conducive to relaxation.^53,54 For example, participants identified induction of labour as a factor that disrupted their ability to remain in ‘the zone’, increasing the likelihood of opting for an epidural; a finding consistent with existing evidence.^55,56 To address these challenges, training programmes for maternity care providers should incorporate the principles of the biopsychosocial model and emphasise continuous emotional support, ensuring women receive consistent assistance in utilising relaxation techniques, particularly in clinical settings beyond the home. Implementation of these changes should be evaluated through outcome measures such as timing of admission, epidural rates, and maternal satisfaction, with feedback informing ongoing improvements. Collectively, these strategies can support a holistic approach that empowers women, reduces unnecessary interventions, and enhances the overall quality of maternity care.

Strengths and limitations

The study appears to be the first mixed-method study in the field to use an exploratory sequential approach. This is important because the study examined the hypothesis and research questions grounded in women’s qualitative accounts. The study has identified new knowledge highlighting contextual factors that could mitigate the effectiveness of relaxation practices for pain management during labour. Previous research in the field seems to have overlooked these factors. Another strength of the study is the diversity of participants in terms of age, ethnicity, educational attainments, parity, employment, and marital status in both phases of the study, which increases the study’s external validity.⁵⁷ Finally, the high retention rate in the quantitative phase strengthened the internal validity of the research and allowed the drawing of valid conclusions.⁵⁸

The study had some limitations. Firstly, the observational design of the quantitative phase means that the findings can only demonstrate associations between attending ARC and reported changes, rather than establish causality.⁵⁹ Secondly, sampling issues may have introduced bias, volunteer participation means the results reflect only the views of those who took part, and self-selection of ARC attendees may have led to positive response bias, as women who choose such programmes are likely more motivated or receptive to non-pharmacological strategies, potentially inflating perceived benefits. Thirdly, the study was conducted at a single site, which limits transferability to other regions in Scotland, the wider United Kingdom, or different care settings. Finally, data collection occurred during the COVID-19 pandemic (2020–2021), when restrictions, changes in maternity care, and heightened anxiety could have influenced recruitment, attendance, and participants’ experiences. These contextual factors should be considered when interpreting the findings.

Conclusion

Providing antenatal education on relaxation practices appears to enhance women’s ability to cope with labour pain and may reduce the likelihood of choosing epidural analgesia. These findings should be considered in the provision of future routine antenatal education. However, the effective use of relaxation techniques during labour is also shaped by the broader ‘space for relaxation’, including the birth environment, the presence and approach of birth attendants, and the clinical procedures undertaken. This underscores the need for maternity care policies that prioritise protected, supportive spaces within clinical settings.

To expand women’s options for pain management and reduce unnecessary obstetric interventions, future research should explore more comprehensive educational interventions that involve childbirth practitioners and address the prevailing technocratic norms of maternity care.

Supplemental Material

sj-doc-1-whe-10.1177_17455057261435178 – Supplemental material for Effect of relaxation practices on labour pain and choice of epidural: An exploratory mixed-method study

Supplemental material, sj-doc-1-whe-10.1177_17455057261435178 for Effect of relaxation practices on labour pain and choice of epidural: An exploratory mixed-method study by Mo Tabib, Tracy Humphrey and Katrina Forbes-McKay in Women's Health

Footnotes

Acknowledgements

The authors would like to express their gratitude to the women who participated in the study during a very busy time in their lives. In addition, the authors are also grateful to the midwives facilitating ARC, particularly Mrs Geraldine Stevenson, who kindly assisted with the recruitment process.

Authors’ note

*Using a gender-inclusive language in perinatal related texts is of paramount importance. However, as in the current study none of the participants identified themselves otherwise, the terms ‘woman’ and ‘women’ have been used throughout the article.

ORCID iDs

Mo Tabib

Katrina Forbes-McKay

Ethical Considerations

Full ethical approval was granted by the National Research Ethics Service (REC reference number: 17/LO/0666). Participation in the study was voluntary, and participants could withdraw from the study at any point prior to the completion of data collection, without giving any reason. Data confidentiality and participant anonymity were maintained by removing all identifiable information from online questionnaires and assigning each participant a unique study ID. In Phase 1, pseudonyms were used for qualitative data, whereas in Phase 2, responses were linked only to the assigned ID number. Participants were assured that their responses would remain confidential unless there was a disclosure of intent to harm themselves or others. There were no breaches of confidentiality.

Consent to participate

The participants in both phases of the study provided informed written consent.

Consent for publication

The study participants provided written informed consent for publication of the collected data.

Author contributions

Mo Tabib: Conceptualisation; Investigation; Writing – original draft; Methodology; Validation; Formal analysis; Data curation; Writing – review & editing.

Tracy Humphrey: Conceptualisation; Writing – review & editing; Methodology; Formal analysis; Supervision.

Katrina Forbes-McKay: Methodology; Conceptualisation; Writing – review & editing; Formal analysis; Supervision.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: MT was supported by the Iolanthe Midwifery Trust.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data availability statement

The data that support the findings of this study are openly available in the Edinburgh Napier University repository.⁶⁰

Supplemental material

Supplemental material for this article is available online.

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