The Effect of Positive Mental Imagery on Labor Pain Tolerance in Primiparous Women Referred to Atieh Teaching-Medical Center of Hamadan, Iran, 2018

Background: Childbirth is an important experience in the woman's life; and its quality has short- and long-term effects on them. The present study aimed to determine the effect of positive mental imagery on the labor pain tolerance in primiparous women referred to Atieh teaching-medical center in Hamadan. Method: The present clinical trial study was conducted on 90 primiparous mothers referred to Atieh Hospital of Hamadan in interventional (n= 45) and control (n= 45) groups. Data collection tools included demographic information forms, Behavioral pain scale, Visual analogue scale (VAS), and the birth registration checklist that were responded by both groups through interviews and observation during labor. The intervention group participated in 4 weekly counseling sessions in groups of 5 to 7 participants, but the control group received only routine care. Finally, the obtained data from above questionnaires was analyzed using SPSS 21 and analysis of covariance (ANCOVA), Independent t-test and chi-square test and the significance level of tests was considered to be at the level of 5%. Results: The research results indicated that the mean age of control and intervention groups was 25.98±4.82 and 25.32± 4.85 respectively. The mean scores of Visual analogue scale (VAS) and the Behavioral Pain Scale significantly decreased compared to the control group (P <0.001). The mean scores of behavioral changes in the intervention group were 1.77 ± 0.68, 2.39± 0.54 and 3.09±0.60 in 4-5 cm, 6-7 cm and 8-10 cm dilatations respectively. That was statistically significant decrease compared to the control group (P=0.005). Conclusion: Positive mental imagery counseling reduced the visual analogue intensity and behavioral pain intensity in primiparous women. It seems that continuing education and counseling and empowering control themselves and learn

The labor pain always raises concerns for pregnant women and is sometimes a major concern for women and their families (3). Dick Read (1930) found that fear of unknown phenomena such as childbirth caused muscle contraction and, consequently, increased the labor pain intensity (4). This in turn has complications for mother and fetus. Therefore, all maternity care units aim to alleviate this pain and make it a pleasant experience with the minimal pain (5).
To reduce these interventions, the anxiety of labor pain should be directed towards pleasant emotions and experiences. The applied methods for alleviating the labor pain are divided into pharmacological and non-pharmacological groups. The use of nonpharmacological approaches has been considered due to adverse effects of medications such as hypoxia, hypotension and maternal cardiac arrhythmia and neonatal respiratory failure. Non-pharmacological practices are superior to pharmacological methods because of their cheapness, simplicity of implementation, non-invasiveness, creation of selfesteem, clients' participation, non-interference with the delivery way, no adverse effects, and being pleasant for mother and fetus (2, 6). Nowadays, taking care of mothers during 4 labor and relieving their pain are major goals of the health system. Studies indicate that the progress of childbirth is facilitated in women who feel more secure and their pain is well controlled (7). The applied techniques for increasing the pain relief and tolerance, such as avoidance of generalization and catastrophizing, positive self-talk and imagery, distraction, use of alternative experience, desensitization and relaxation affect the selfefficacy and increase the ability to cope with labor pain. Studies indicate that relaxation and imagery affect the autonomic nervous system (ANS) and cause relaxation both during pregnancy and labor. Labor support includes ongoing attendance and psychological support such as mother reassurance, encouragement and guidance, physical comfort such as cooperation to perform touch, massage, cold, heat and hydrotherapy techniques, position change and movement, woman and wife information, facilitation of communication to help women to express their needs and demands (1, 2).
Mental imagery or creative visualization is an easy ways to remove stressful thoughts and replace them with relaxing images and it is extremely effective. Mental imagery is the simulation or recreation of a perceptual experience among sensory moderators (8). Since psychological factors play critical roles in the onset, severity, or persistence of pain; and the resulting pain can cause significant discomfort or loss of function, and as the message, which are sent through organs, are perceived by the cerebral cortex after passing through the spinal cord and receiving the brain (9), the stress management and physical relaxation and mental imagery techniques are non-pharmacological methods that are used to control pain. Recent studies indicate that this technique is an effective way to deal stressors. It can eliminate undesirable physiological effects of stress and prevent its symptoms (10,11). In imagery, people are trained to visualize positive images of vague information; and participants need positive scenarios and images to create positive mental images. In particular, higher levels of optimism are reinforced by the ability to imagine future positive events (12). Midwifery staff provides, maintains and promotes social health through counseling and provision of midwifery services at various stages of life to promote reproductive health and enhance women's health indices. A midwife plays an important role in counseling and reproductive health education not only for women, but also for the family and society. Therefore, all women should have access to midwifery care models. Therefore, the present study investigated the effect of positive mental imagery counseling on labor pain tolerance in primiparous women. Mental imagery may reduce labor pain by reducing fear of childbirth and distraction from labor pain. According to the World Health Organization, the labor pain relief by non-medicinal methods is a principle that should be included in the mother-friendly hospital protocol.

Study design, setting:
A randomized clinical trial was conducted on 90 pregnant mothers in the delivery preparation class at Atieh Hospital of Hamadan in 2017. After obtaining the necessary permission from Hamadan University of Medical Sciences and submitting it to Atieh Hospital, and coordinating with the delivery officer, Subjects were included in this study based on informed consent and having required inclusion criteria.

Participants:
The researcher explained research objectives and methods for them, and provided a list of people who were willing to participate in the study and included in the study at the gestational age of 23-33 weeks. Inclusion criteria were: age 18-35 years; primiparous women; tendency to normal vaginal delivery; gestational age of 32-33 weeks; singleton pregnancy with head view; attending physiological delivery training courses during pregnancy at Atieh Hospital; having low risk pregnancy; and not using specific and invalid medications (alcohol and smoking) during pregnancy; normal placental and fetal status; 6 lack of infertility and chronic diseases; and history of thyroid diseases; lack of familial history of depression; depression in pregnant women; and giving birth at Atieh Hospital, and explained the research goals and methods and prepared a list of people who had a willingness to participate in the study. Exclusion criteria included complications during pregnancy (preterm labor, preterm rupture of membranes, etc.), the absence in at least a counseling session, emergency cesarean section during labor due to fetal or maternal reasons (placental abruption, fetal distress), painless delivery or use of Entonox, and use of analgesics in labor.

Sampling Methods:
According to the data from Bolbol-haghighi et al. (2016), The sample size was 37 peoples based on the information below and following formula: The sample size for each group was 45 persons with 20% loss in sampling (13).

Randomization procedure and Randomization allocation concealment:
Simple randomization method was used in this study with red and blue balls. Women were divided into intervention and control groups (Fig. 1).

Blinding:
Due to the content of counseling sessions, there was no possibility of blindness in this study.

Instrument tools:
1-demographic questionnaire: Includes questions about age, weight, height, marital status, job, education level, family income level. represented "too much pain and unbearable pain," and the other extremity represented "absence of pain" The participants were asked to rate the degree of pain by making a mark on the line. The validity and reliability of this tool has been proven in previous studies (15). Demographic information was completed by two groups at the beginning of the study. And the next two scales for both groups were completed during childbirth. After the completion of sessions, follow-up was conducted until the pregnant woman was hospitalized for delivery. In the active phase of labor with the onset of 3-4 cm dilatation, the researcher was present at the mother's bedside and the training, which was presented before the birth, was reviewed. Positive mental imagerytechnique were again taught to each individual during the labor stages as well as the labor pains. The pain assessment was then performed using the visual analogue scale (VAS) and behavioral pain scale at 4-5 cm, 6-7 cm and 8-10 cm dilatations at the peak of contraction. The same stages without counseling was done in the control group. It should be noted that the researcher as accompanying midwife was present alongside all members of intervention. There was no other accompanying midwife in the mother's bedside in the control group.

Data analyses:
The obtained data from above questionnaires was analyzed through SPSS 21 and analysis of covariance (ANCONA), independent t-test), and chi-square test. Significance level was considered less than 0.05.

Comparison of demographic characteristics between the two groups:
The findings of this study revealed no statistical differences between the two groups. Data were normal and the two groups were homogeneous in terms of demographic characteristics (P>0.05) According to the results of Table 2,  Results indicated that there was a significant difference between two groups in mean pain scores at three time points (p = 0.02) (Fig. 2). Bonferroni post hoc test indicated that there was a statistical significant difference between pain score in 4-5cm dilatation and pain score of 6-7cm dilatation, and also between pain scores in 4-5cm dilation and pain score in 8-10cm dilatation. (p = 0.02, F = 5.20) This difference was also found between pain scores of 6-7cm and 8-10cm dilatations. Mean pain scores of control and intervention groups were compared using the independent t-test and the results indicated that there was no significant difference between two groups in 4-5 cm dilatations (P = 0.29), but the differences were significant in 6-7 and 8-10 cm dilatations (P = 0.005 and P = 0.01 respectively) ( Table 3).
According to results, the mean scores of pain behavioral changes were significantly different between two groups at three time points (p = 0.04) (Fig. 3). Bonferroni post hoc test indicated significant differences between mean scores of behavioral changes in 4-5 cm dilatation and 6-7 cm dilatation, and also between mean scores of behavioral changes in 4-5 cm dilatation and 8-10 cm dilatation (p = 0.007). This difference was also observed between mean scores of behavioral changes in 6-7cm and 8-10cm dilatations. Comparison of mean scores of behavioral changes between intervention and control groups was done by independent t-test and the results showed that there was a significant difference between two groups only in 4-5 cm dilatation (p = 0.007), while these differences were not significant in 6-7cm and 8-10cm dilatations (p = 0.08 and p = 0.53 respectively) ( Table 4).

Discussion
The present study aimed to investigate the effect of mental imagery on labor pain tolerance in primiparous women. The results indicated that the visual analogue scale and pain behavioral changes by relaxation with positive mental imagery were significantly decreased compared to the control group. In a study by Orch et al. (2015) with the aim at "Comparing immediate effects of two methods, advanced muscle relaxation and mental imagery, on physical and psychological indices in pregnancy", it was found that mental imagery was significantly effective in increasing level of relaxation compared to relaxation, and it was associated with a significant decrease in maternal heart rate and anxiety and a decrease in the visual intensity of pain; hence, it was consistent with the present study (16). Stressful life events, such as fear of labor pain, are associated with an increase in pain, but psychological support and a constant presence of midwife besides mother partially overcome fear and reduce stress and subsequently reduce pain. Hess and Maddi (1992) found that among people, who were faced with important anxiety issues, those who had high levels of psychological hardiness, were less likely to become ill than those with less hardiness and higher loathing or those who were mentally and physically damaged after changes or accidents (17). The above cases are also true for delivery and its pain. In our study, the severity of labor pain was reduced by applying a positive mental imagery. In general, the research results indicated that positive mental imagery counseling decreased the labor pain in the active phase. Unlike other pains, labor pain has no constant intensity and it gradually increases to promote birth. And with the mental imaging consultations, women's perceptions of pain have been affected. And the pain tolerance is increased. In our research the imaging counseling had the highest effect on labor pain in 4-5 cm and 6-7 cm dilatations. The results were consistent with findings of similar studies that used non-pharmacological methods to reduce labor pain (18,19).
The results of our study showed that the mean score of pain behavioral changes indicated that cognitive behavioral therapy was effective in reducing pain intensity and improving pain coping strategies (20). Given that pregnancy is a major and stressful period of women's life, the women's psychological status and stress during pregnancy can directly or indirectly affect the health of mother and fetus. The positive effect on psychological pain control is an effective non-pharmacological method in this regard (21).
In a study by Chesli et al. (2006) the results indicated that mean pain tolerance score of the imaging group was significantly higher than the control group, and even higher than other evaluated methods. Furthermore, they considered the use of distraction or imaging in increasing pain tolerance as the most effective strategy that was consistent with the present study19 (22).
In fact, more relaxation in intervention group resulted in more pain control. Pain has been the most common clinical complaint of pregnant women in labor; and its reduction or elimination has always been the demand of most patients and medical staff (22). Goliyan Tehrani study results (2006) indicated a decreased duration of active phase of labor and 12 pain intensity after application of transcendental meditation effects. Pain intensity was higher in the control group and the results were consistent with the present study (23). In general, it is stated that due to the continuous support of mother during childbirth and her relaxation, she can have greater pain tolerance. Our findings also indicated that having a support person like midwife at delivery had a positive effect on behavioral changes and Learning and implementing non-pharmacological pain methods is an effective step in reducing number of elective cesarean sections.

Limitation of the study:
One of the limitations of this study was the exclusion of women during labor due to the use of other non-pharmacological methods to control their labor pain. There are few number of similar papers. Further studies on the use of positive mental imagery or other psychological approaches, with long-term evaluation of the psycho prophylaxis method, and with more samples, are needed.

Conclusion
The overall results indicated that positive mental imagery counseling reduced the pain intensity and pain behavioral changes in primiparous women during labor. It seems that 13 continuous education and counseling during pregnancy and chilbirth and empowering mothers to control themselves and training mental imagery techniques to women and midwives can be effective in enduring labor pains. And encouraging mothers to practice this method during pregnancy and childbirth can help mothers to be more relaxed and have lower labor pain intensity.  Tables   Due to technical limitations, all Tables are only available