The effect of music on pain and anxiety of women during labour on first time pregnancy: A study from Turkey

The effect of music on pain and anxiety of women during labour on

first time pregnancy: A study from Turkey

Sule Gokyildiz Surucu

, Melike Ozturk, Burcu Avcibay Vurgec, Sultan Alan, Meltem Akbas

Cukurova University Faculty of Health Sciences, Midwifery Department, Adana, Turkey

a r t i c l e i n f o

Received 8 August 2017 Received in revised form 12 December 2017 Accepted 14 December 2017 Keywords: Pain Anxiety Labor Music

a b s t r a c t

Objective: This study aims at analyzing the effect of music on pain and anxiety felt by women in labor during theirfirst pregnancy.

Method: When the pregnant women in the experimental group progressed into the active phase of the labor, they were made to listen to music in Acemasiran mode with earplugs for 3 h (20 min of listening with 10-min breaks).

Findings: It was observed that after thefirst-hour women indicated that their pain was statistically less in the experimental group. Trait anxiety scores of the women in labor were similar for experimental and control groups. Following the practice, state anxiety average scores became lower in favor of the experimental group and the correlation was statistically significant.

Conclusion: In order to facilitate women's coping with labor pain and improve their wellbeing with the activity during the labor, musicotherapy, a non-pharmacological method, is an effective, simple and economical method.

© 2017 Elsevier Ltd. All rights reserved.

1. Introduction

Labor is one of the most intense pain sources that is known, especially uterine contractions in primigravidas and labor. Pain is the primary symptom that motivates people to seek professional help [5].

Labor pain, both a universal phenomenon and a subjective experience, differs from other serious pain. Labor pain is a part of a normal process. While other forms of pain imply an abnormal state such as injury or disease, labor pain is completely usual. It moti-vates the pregnant women to make an effort to overcome the sit-uation and enables the baby to progress during the process. Pregnant women have time to ready themselves for the labor and can develop skills to achieve pain control within this time period. Labor pain is not continuous, but intermittent. Labor pains are less discomforting at the beginning of labor; as time progresses, the pain becomes more frequent, and the resting period between contractions becomes shorter. Women play an important role in pain management and cooperation with the health professionals. A pregnant woman's concern for her baby motivates her to tolerate

the pain she experiences during the labor [24].

Despite the expectation of pain during labor, irregular pains that exceed women's tolerance may result in adverse physiological and psychological effects on both the mother and the fetus [5,6,24].

Non-pharmacological and pharmacological methods are used in controlling labor pain. Essential criteria for the eradication of labor pain are the provision of good analgesia, securing the safety of the mother and baby, continuous and predictable effects, simple methods and mother's control over the process. Pharmacological methods are invasive andfinancially costly. It was found that the use of epidural anesthesia and narcotic agents prolong the labor duration and increase the need for oxygen and oxytocin. Non-pharmacological methods, on the other hand, do not need medi-cal rules and are harmless for mother and baby. They do not slow down the labor and they affect the progression of the labor posi-tively. Moreover, they do not cause side effects or allergy [5,6,11,24]. Music plays an important role in people's life. It has been used to help people's well-being and provide pain relief since antiquity. Directly or indirectly, it affects physiological and clinical symptoms. Music and musicotherapy can provide direct physiological, psy-chological and socio-emotional bene_{fits for the patients. In} addi-tion, by affecting attitudes and behaviors of care providers, it can affect the patients indirectly. Carefully selected music can reduce stress, improve comfort, provide relaxation, ease the intensity of

* Corresponding author. Cukurova Universitesi Saglik Bilimleri Fakultesi, Balcali Kampusu, 01330 Saricam, Adana, Turkey.

E-mail address:sgokyildiz@cu.edu.tr(S. Gokyildiz Surucu).

Contents lists available atScienceDirect

Complementary Therapies in Clinical Practice

j o u r n a l h o m e p a g e : w w w . e l s e v i e r . c o m/ l o ca t e / c t c p

https://doi.org/10.1016/j.ctcp.2017.12.015

pain and improve the performance of clinicians [5,6,24]. In a review on therapeutic effects of music on nursing practices, it is stated that music is used widely in variousfields such as intensive care units, surgical operations, dental clinics, mental health, pain control, anxiety control and relaxation [2].

Musicotherapy is one of the non-pharmacological methods used during labor [2,3,11,12]. While the exact effect of music is not known, it is believed that it is effective as it causes relaxing or draws one's attention away from the pain. Music affects the painful stimuli the women experience and results in relief by increasing the secretion of endorphin [6,7,12]. Another way that music directly represses pain is by the aural stimulus. The studies indicate that music reduces anxiety, pain and the problems of women during labor [6,7,14,19_e21]. However, there are not enough evidence-based studies that investigate the effects of music on labor. Only one study was found that took place in Turkey. It was conducted in western part of the country and a different music genre was used [6]. The present study is thefirst in Turkey to investigate the effects of Acemasiran mode music on the pain and anxiety of women during labor in theirfirst pregnancy. In their studies, researchers used the various genre of music during labor. In a study conducted in Turkey, Ersanli (2007) [6] used music in Rehavi (Turkish music) mood. In their study, Hosseini et al. (2013) [10] played classical music in Iran. Labrague et al. (2013) [13] played a calming music in their study conducted in the Philippines. Their study which aimed at analysing the effect of music on anxiety and pain during labor and included 60 primipara pregnant women, Liu et al. (2010) [14] asked the participants to choose amongst 5 types of music: classical music, light music, pop music, traditional Chinese music, crystal child music. 20% of the participants chose classical music, 16.7% pop music, 30% crystal child music and 20% traditional Chinese music.

An analysis of music theory studies on Turkish music moods reveals that Acemas¸iran mood wasfirst spotted in the works of Dimitrius Kantemir. It is a compound mode. Pes¸revi (introduction) by Tamburi Emin Aga and compositions by Dede Efendi may be examples of musical pieces in Acemas¸iran mode [9].

In the literature, it is underlined that Acemasiran mode provides a feeling of creativity and inspiration, and eases labor. Acemasiran mode has features for pain and spasm relief, it gives pleasure and facilitates relaxation [4,8].

As a consequence, the present study was conducted as a rand-omised controlled trial to identify the effects of Acemasiran mode music on pain and anxiety of women during labor on their_first pregnancy.

The research hypotheses were:

Music in Acemasiran mode listened during the active phase of labor is effective in reducing labor pain.

Music in Acemasiran mode listened during the active phase of labor is effective in reducing anxiety during labor.

2. Method

The research population consisted of pregnant women who consulted a maternal and children hospital located in the southern part of Turkey. The sample consisted of healthy pregnant women who complied with the research criteria. The research was con-ducted with 50 primipara women (25 for experimental, 25 for the control group). Coinflipping method was used in randomization. Heads were for experimental and tails were for the control group. The participants were not informed about the randomization pro-cess of the groups. In the hospital where the study took place, each labor unit was for one person and the pregnant women in both experimental and control groups were in separate rooms. The

participants in different groups did not see or communicate with each other during the experiment. The pregnant women in the experimental group were asked whether they would like to listen to music and their participation was voluntary. None of the par-ticipants refused to listen to music.

Criteria for inclusion in the research:

 Voluntary participation

 Being in term pregnancy (37e41 pregnancy week)  Being primipara

 Pregnancy without risk Criteria for exclusion:

 Having hearing problems  Inducing labor

 Using analgesia/anesthesia during labor  Delivery by C-section

 Delivering while listening to music 2.1. Confirmation of ethics committee

The confirmation of Çukurova University Ethics Committee for Non-invasive Clinical Trials was obtained in order to conduct the research.

2.2. Data collection tools

In data collection,“Pregnant Introductory Form” was used for identifying socio-demographic features of pregnant women, “Evaluation Form on Labor” for evaluating progression of the labor, “Visual Comparison Scale” for identifying perceived level of pain, “STAI I-II State-Trait Anxiety Scale” developed by Spielberger et al., “Faces Anxiety Scale” for identifying anxiety levels and “Post-De-livery Evaluation Form” for evaluating the practise after delivery. 2.3. Pregnant introductory form

The form developed by the researchers consisted of 31 items on pregnant women's socio-demographic features, their state of fear, the information they had received about pregnancy, their knowl-edge level of non-pharmacological methods in coping with labor pain and their music listening habits.

2.4. Evaluation form on labor

The form developed by the researchers evaluated the labor process. The data looked at the babies' heart rate, blood pressure, body temperature, pulse, respiration, dilation, effacement, the po-sition of the babies' head and the length and frequency of contracts were recorded on the form.

2.5. Visual analogue scale

Visual Analogue Scale (VAS) is a simple and effective measure-ment method that requires minimal equipmeasure-ment and can be repeated to measure the intensity of pain. In cases where the in-tensity of the pain needs to be measured quickly in clinical and laboratory conditions, VAS is often used. VAS consists of a 10 cm line that is drawn horizontally or vertically. Two defining sets of words for the subjective category are written on two ends of the line as“no pain” and “most intense pain possible” or “unbearable pain”. The patients are instructed to draw a mark on this line in accordance with the intensity of the pain. The distance from the

lowest point on VAS to the patient's mark is measured with a ruler in cm or mm, and numerical pain index of the pain intensity is obtained [1].

2.6. State-trait anxiety inventory

The state-trait anxiety inventory was developed by Spielberger, Gorsuch, and Lushene in 1970. Spielberg enabled the measurement of acute anxiety thanks to the state-trait anxiety inventory. Thus, it became possible to analyze the influence of anxiety stemming from temporary stressful situations such as an operation. The inventory was translated by Oner and Le Compte (1985) into Turkish and was adjusted for Turkish society. The average points obtained in the studies conducted by Oner and Le Compte (1985) on patients in surgery services ranged between 30 and 41. Oner and Le Compte's reliability study indicated that the reliability coefficiency ranges between 0.83 and 0.87 for the trait anxiety scale and 0.94e0.96 for the state anxiety scale [17].

2.7. Faces anxiety scale

The faces anxiety scale was developed by McKinley, Coote, and Stein-Parbury. The scale is a single item scale with five possible responses ranging from a neutral face to one showing extreme fear. When patient scores were three or above, their anxiety was determined to be medium to high [15].

2.8. Post-delivery evaluation form

The form developed by the researchers wasfilled out when the women felt comfortable following the delivery. The form included 13 items on the effects of music on labor pain and the process.

2.9. Application

The procedures were followed by the women included in the study. All questionnaire forms werefilled by the pregnant women at the beginning of the research. The women in the experimental group were made to listen to music in Acemasiran mode for 3 h (20 min listening, 10 min resting) with earphones(dilation 4 cm) when they progressed into the active phase of labor. 30 min after they started listening to music and with 1-h intervals during the labor, pain perception of the pregnant women was measured with VAS and the labor process was examined with the evaluation form on labor. 30 min after completing the music session, anxiety level was examined by the state anxiety scale and the faces anxiety scale. No additional practices were followed for the control group other than the routine. In parallel with the experimental group, 30 min after the beginning and with 1-h intervals during the labor, pain perception of the pregnant women were measured with VAS and the labor process was examined with evaluation form on labor; 30 min after completing the music session, anxiety level was examined through the state anxiety scale and the faces anxiety scale. All of the women in the experimental and control groups filled out the post-delivery evaluation form after the delivery when they felt comfortable (around 1 h later).

2.10. Data analysis

The data were analyzed using SPSS (Statistical Program for So-cial Science) 19 for Windows package program. Categorical mea-surements were expressed using numbers and percentages while numerical measurements were displayed using means and stan-dard deviations. Comparison of the categorical variables between the groups was performed with the chi-square test. Independent group's t-test was applied when the hypotheses were met in the comparison of the numerical measurements. Level of significance was taken as 0.05 in all tests [18].

Table 1

Socio-demographic characteristics of the participants.

Characteristics Experimental Control c2 _p

n % n % Education Illiterate 2 8.0 2 8.0 0.420 0.936 Literate 3 12.0 2 8.0 Primary School 13 52.0 15 60.0 High School 7 28.0 6 24.0 Education of Partner Literate 7 28.0 4 16.0 5.198 0.074 Primary School 11 44.0 6 24.0 High School 7 28.0 15 60.0 Economic Status Minimum 3 12.0 3 12.0 2.071 0.355 Middle 19 76.0 15 60.0 Good 3 12.0 7 28.0 Planning of Pregnancy Yes 22 88.0 21 84.0 0.166 0.684 No 3 12.0 4 16.0 Table 2

Distribution of participants' fear regarding labour and the reasons of their fear.

Fear Regarding Labour and The Reasons of Their Fear Experimental Control c2 _p

n % n %

Fear Regarding Labour

Yes 25 100.0 23 92.0 2.083 0.149 No e e 2 8.0 Reasons of Fear Pain 5 20.0 10 40.0 5.733 0.220 First pregnancy 10 40.0 5 20.0 Labor 6 24.0 4 16.0 Birthing chair 4 16.0 4 16.0 Table 3

Distribution of pregnant Women's status for receiving information and their sources of information. Experimental Control c2 _p n % n % Receiving Information Yes 14 56.0 13 52.0 0.081 0.777 No 11 44.0 12 48.0 Sources of Informationa Friend 13 52.0 7 28.0 3.000 0.083 Internet 8 32.0 9 36.0 0.089 0.765 Health Professional 5 20.0 7 28.0 4.140 0.064 Mother 1 4.0 5 20.0 3.030 0.082 TV-Radio 1 4.0 2 8.0 2.083 0.149

3. Results

No statistically significant difference was found between average ages of participants. The average age for the experimental group was 22.08± 2.32 (min:17-max28) and for the control group was 21.04± 3.06 (min:16-max26).

The data on socio-demographic characteristics of the partici-pants are presented inTable 1. The socio-demographic character-istics of experimental and control groups are similar to each other. An analysis of work status for the pregnant women and their husbands reveal that none of the pregnant women were employed (100%) and all the husbands worked (100%).

Table 2includes the distribution of participants' fear regarding labor and the reasons for their fear. An analysis of the pregnant women's fear indicates that both of the groups have very high levels of fear. All of the experimental group and 92% of the control

group stated that they were very afraid of labor. No statistically significant difference was found between experimental and control groups about their fear of labor.

Table 3 demonstrates pregnant women's status for receiving information and the source of this information. More than half of the women in both groups received information regarding labor and there is no statistically significant difference between them. The pregnant women in the experimental group received infor-mation mostly from their friends (52%), while the women in the control group received information online (%32). The sources for receiving information are alike for the women in experimental and control groups. Receiving information from health professionals is low for both groups. In addition, all of the pregnant women stated that they did not hear about non-pharmacological methods used in labor and thus they did not have any information about them.

The distribution of participants' relation with the music is pro-vided inTable 4. All of the pregnant women stated that they like listening to music. The distribution of music types that participants enjoy listening indicates that the folkloric music is the favorite music type for the experimental group at 36%, while pop music is preferred by the control group at 40%. No statistically significant difference was found between the experimental and control groups about the music types they enjoy listening to. The analysis of when the participants listen to music revealed that the women in both the experimental and control groups listen to music mostly while doing work. When they were asked what kind of music is relaxing for them, more than half of the women in both groups stated that they relax while listening to slow music. It was found that the women in experimental and control groups have similar charac-teristics about when they listen to music and the kind of music that helps them relax. None of the participants or their husbands received any musical education or was able to play a musical instrument.

When the pain of pregnant women in experimental and control groups are analyzed according to the visual analogue scale (VAS), it was found that the average score for pain was similar for both of the groups at the beginning and during the first 30 min of labor. However, statistically significant difference was observed between the experimental and control groups' average scores on VAS after the 1st hour of labor (p_{< .05). Listening to music reduced the} feeling of pain for the pregnant women in the experimental group (Table 5).

When the pregnant women in experimental and control groups are analyzed in terms of their anxiety level, it was found that their trait anxiety scores were similar, and the state anxiety average scores changed in favor of experimental group after the practice. This difference between the groups was statistically significant (p< .05). While there was no difference between experimental and control groups in terms of the faces anxiety scale before the prac-tice, after the practice the faces anxiety scale score of the experi-mental group became lower and the difference between the groups

Table 4

Distribution of participants' relation with the music.

Experimental Control c2 _p

n % n %

Like listening to music

Yes 25 100.0 25 100.0

Enjoy listening music types

Folkloric music 9 36.0 4 16.0 6.593 0.159

Pop music 3 12.0 10 40.0

Arabesque music 4 16.0 2 8.0

Hymn 3 12.0 4 16.0

It doesn't matter/All of them 6 24.0 5 20.0

Time the listening to music

Doing work 11 52.4 10 47.6 0.990 0.610

Rest 9 36.0 7 28.0

When I am sad/bored 5 20.0 8 32.0

Kind of music is relaxing for them

Slow music 16 64.0 13 52.0 0.801 0.670

Folkloric music 5 20.0 6 24.0

Pop music 4 16.0 6 24.0

Table 5

Findings of visual analogue scale.

Time of VAS Experimental Control t p

X±SD X±SD Beginning 4.32± 0.476 3.72± 1.595 27.616 .078 First 30 min 4.32± 0.476 3.96± 1.620 24.877 .292 1. Hour 3.28± 0.458 4.56± 2.083 36.028 .004 2. Hour 2.64± 0.952 5.32± 1.909 18.340 .000 3. Hour 2.60± 0.577 5.76± 2.260 38.637 .000 4. Hour 3.24± 0.436 6.68± 2.410 57.464 .000 5. Hour 3.76± 0.831 7.40± 2.179 50.097 .000 6. Hour 4.04± 1.020 7.40± 2.887 15.190 .000 7. Hour 4.52± 0.510 7.96± 3.434 17.437 .001 8. Hour 4.60± 2.102 7.40± 3.841 7.253 .002 Table 6

Findings about scales anxiety of participants' and scores for difficulty level of the labour.

Experimental Control t p

X±SD X±SD

Trait Anxiety 43.52± 4.91 43.76± 5.27 0.137 .868

State Anxiety

Before listening to music 56.96± 10.48 52.44± 11.96 0.003 .162

After listening to music 43.20± 6.91 66.48± 7.81 0.134 .000

Face anxiety scale

Before listening to music 4.24± 0.66 3.44± 1.35 18.698 .111

After listening to music 5.60± 1.82 8.40± 1.52 3.427 .000

was statistically significant (p < .05). After listening to music, the anxiety level of pregnant women in the experimental group was reduced significantly. The participants were asked to evaluate the difficulty of their labor by grading it between 0 and 10, 0 referring to the easiest labor and 10 referring to the most difficult. The average score for the difficulty of their labor was 8.12 ± 1.24 for the participants in the experimental group and it was 8.12± 1.24 for the control group. There was a statistically significant difference between the experimental and control groups about their average scores for the difficulty level of the labor (p < .05). The pregnant women in the experimental group stated that their labor was easier (Table 6).

Table 7presents the data regarding the labor process and vital signs of the participants in experimental and control groups. The analysis of dilation and effacement findings of the pregnant women reveal that no statistically significant difference was found between experimental and control groups at the end of the 1st hour of labor, while dilation and effacement were found to be more for pregnant women in control group when compared with experimental group in the 3rd, 5th and 7th hours (p< .05). The labor process progressed faster for the women in the experi-mental group. When the pregnant women in the experiexperi-mental and control groups are analyzed in terms of contraction periods, no significant difference was found between the groups in the 1st and 7th hours. The contraction period was found to be longer for the participants in the experimental group when compared with the control group in the 3rd and 5th hours (p_{< .05). The analysis} of diastolic blood pressure measurements reveals that the dia-stolic blood pressure of the participants in the experimental group was lower in comparison to the control group in the 1st, 3rd and 5th hours and the difference was statistically significant (p < .05). No statistically significant difference was found between the participants in experimental and control groups in terms of fetal heart rate, pulse, and respiration rate.

Table 8includes data regarding experimental group's evalua-tion of the music following delivery. The pregnant women in the experimental group responded to the question “Can you claim that the music you listened to had an effect on your pain?” as “partially effective” at 88% and “not effective” at 12%. 88% of the pregnant women stated that listening to music helped them relax. 88% also stated it helped them adjust to the environment, while 72% stated it provided tranquility as well as a sense of trust and 64% stated it helped them reduce their level of pain. 36% said they would like to listen to a different genre of music. While 4 women wanted the music to be religious, 5 women wanted upbeat music. 56% of the women stated they would like to make their babies listen to the music; 7 of them said they would like their babies to listen to the music when they have pain, while 7 said they would like their babies to listen to it when they cannot fall asleep.

At the end of the study, it was found that the women who listened to music in Acemasiran mode during labor expressed their level of pain was lower, had lower anxiety levels, evaluated the labor as easier, had longer periods of contraction and their labor progressed faster.

4. Discussion

Cultures have produced music throughout history and incor-porated music into life cycles from cradle-songs to lament songs. Each culture developed their own genre of music [23]. In a study which aimed at analyzing the effects of light music on pain during the active phase of the labor of primipara Thai women, Phum-doung and Good (2003) [19] included a total of 110 pregnant women in their study; 55 in the experimental group and 55 in the

control group. At the end of the research, 98% of the women stated Table

7 Findings about labor pro cess and vitals of participants. 1. Hour 3. Hour 5. Hour 7. Hour Exp a Cont b t Exp a Cont b t Exp a Cont b t Exp a Cont** t X ± SD X ± SD p X ± SD X ± SD p X ± SD X ± SD p X ± SD X ± SD p Dilatation 4.00 ± 0.00 3.86 ± 0.65 121.121 6.00 ± 0.00 4.68 ± 0.85 118.409 7.44 ± 0.51 6.28 ± 0.89 3.789 8.88 ± 1.01 8.08 ± 1.15 .053 .068 .000 .000 .012 Effacement 58.80 ± 13.34 62.40 ± 10.91 5.822 85.60 ± 5.07 74.00 ± 10.41 16.208 98.00 ± 4.08 83.20 ± 12.49 16.798 100.00 ± 0.00 92.00 ± 7.07 5 3.720 .301 .000 .000 .000 Fetal Hearth Rate 146.64 ± 4.71 146.96 ± 6.14 2.375 145.44 ± 3.24 144 .96 ± 3.70 .414 143.44 ± 2.12 142.16 ± 4.86 12.725 139.60 ± 6.76 137.04 ± 7.74 .374 .837 .628 .234 .219 Period of contraction (second) 11.60 ± 6.28 12.96 ± 5.16 .129 30.00 ± 0.12 25.36 ± 6.42 100.724 43.80 ± 2.18 39.00 ± 11.09 46.219 75.20 ± 7.14 68.60 ± 21.14 5 5.983 .066 .001 .039 .146 Frequency of contraction 1.56 ± 0.44 1.44 ± 0.51 7.438 2.06 ± 0.51 1.88 ± 0.60 2.571 3.64 ± 0.81 2.92 ± 0.70 3.003 4.64 ± 0.76 4.40 ± 1.78 9 .292 .124 .248 .002 .538 Pulse 75.20 ± 2.45 77.68 ± 2.81 .848 80.16 ± 2.58 81.04 ± 2.01 8.998 84.16 ± 2.70 83.68 ± 3.68 1.623 89.12 ± 1.01 89.28 ± 1.62 4 .226 .002 .185 .602 .677 Breath 17.92 ± 1.35 18.32 ± 1.49 1.261 20.40 ± 0.82 20.40 ± 1.41 2.000 22.40 ± 0.82 22.08 ± 1.78 21.297 24.00 ± 0.22 23.12 ± 1.30 8 5.338 .325 1.000 .417 .001 Systolic tension arteria l 104.00 ± 8.16 108.80 ± 7.81 .002 104.40 ± 5.07 110 .00 ± 5.77 3.241 112.00 ± 4.08 112.00 ± 6.45 4.527 112.40 ± 4.36 109.60 ± 6.76 .803 .039 .001 1.000 .088 Diastolic tension arterial 62.00 ± 4.08 66.40 ± 8.60 27.034 64.40 ± 5.07 69.20 ± 6.40 .311 62.00 ± 4.08 70.00 ± 5.77 3.218 72.40 ± 4.36 70.40 ± 7.35 2 .571 .025 .005 .000 .248 a Experimental. b Control.

that the music they listened to helped them and 92% stated they liked the music. In a thesis study which aimed at analyzing the effect of training and music on the labor process for primipara pregnant women who had induction, Ersanli (2007) [6] found that after the delivery 92.5% of the pregnant women in the experimental group stated that the music helped their pain. 30.2% of the women in the experimental group stated that the music helped them relax, 26.9% stated it gave them tranquility and assurance, 23.8% said it reduced the feeling of pain and 14.3% claimed it helped them adjust to the environment. The study by Ersanli (2007) [6] found that the pregnant women listened to music while working and when they had problems. In our study, 88% of the pregnant women stated that listening to music helped them relax, 88% stated it helped them adjust to the environment, while 72% stated it provided tranquility as well as a sense of trust and 64% stated it helped them reduce their level of pain. The results of our study are in line with this literature. Listening to music helps women relax during labor.

In line with the other studies [22e24], it was found that women who participated in our study also had a fear of pain during labor. In a study conducted by Phumdoung and Good (2003) [19], it was found that the pregnant women's pain perception was lower in the group that listened to music and that there was a significant dif-ference between this group and the control group. In their study, Liu et al. (2010) [14] found that the average scores of pregnant women for anxiety and pain were significantly lower in the experimental group in the latent phase of labor, while there was no difference during the active phase. In their study on the effects of music on labor and the baby, Tabarro et al. (2010) [21] found that the participants' pain, anxiety, and fear lessened during contrac-tions, and they adjusted to the hospital more easily. In Fulton's study (2005) [7], which aimed at identifying the effects of music on physiological measurements, pain and fatigue perception at the early phase of labor (less than 6 cm dilated), 20 pregnant women were included in the experimental group and 20 in the control group. It was found that the perceptions of pain and anxiety were lower for the pregnant women in the experimental group and the difference between the two groups was statistically significant. In addition to lower pain perception for the participants in experi-mental group when compared with the control group, it was also found that the uterine contraction intensity was higher. No statis-tically significant difference was found between fetal heart sounds. In their study which aimed at identifying the effects of music on

pain perception and anxiety levels of primipara women in thefirst phase of labor, Nayak et al. (2014) [16] found a significant decrease in pain perception and anxiety level of women after listening to music. In their studies on the effect of music on pain and labor processes of primipara women during the active phase of the labor, Hosseini et al. (2013) [10] included 30 people in their study; 15 for the experimental and 15 for the control group. The study indicated that pain levels of women in the experimental group were signif-icantly lower and their labor progressed more effectively after listening to music. In their study on the effect of music on the perception of labor pain during the latent phase of labor, Labrague et al. (2013) [13] found that the perception of pain of women in the experimental group was significantly lower after listening to music. Thefindings in our study are in line with this literature. Our study indicated that the pregnant women who listened to music in Ace-masiran mode during labor stated that their level of pain was lower, evaluated their anxiety levels as lower, the labor as easier, had longer contraction periods and their labor progressed faster.

The type of music listened to during labor was selected by The Group for the Research and Promotion of Turkish Music, and the pregnant women were not asked which type of music they would like to listen to. This can be considered a limitation of the study. In upcoming studies, the music that pregnant women enjoy can be played during labor and its effect on labor pain and anxiety can be analyzed. Moreover, the study was conducted only on healthy primiparas. The study can be repeated by including multipara and at-risk pregnancies as well.

Funding statement

This study was funded by Cukurova University Department of Scientific Research Project with ASYO2012BAP7 number.

Conflict of interest

The authors declared no con_{flicts of interest with respect to the} authorship and/or publication of this article.

Acknowledgements

We would like to thank all the women who volunteered to participate in the study.

Table 8

Findings about experimental Group's evaluation for the music following the delivery.

n:25 %

Can you claim that the music you listened had an effect on your pain? Partially effective 22 88.0

Not effective 3 12.0

What do you think about musictherapy on your labor?

Helped me relax Yes 22 88.0

No 3 12.0

Helped me adjust to the environment, Yes 22 88.0

No 3 12.0

Provided peace and trust Yes 18 72.0

No 7 28.0

Helped me reduce my feeling of pain Yes 16 64.0

No 9 36.0

Would you like to listen to a different music? Yes 9 36.0

No 16 64.0

What kind of music would you like to listen? Hymn 4 44.0

Upbeat 5 56.0

Would you like to make your babies listen to the music? Yes 14 56.0

No 6 24.0

I don't know 5 20.0

When would you like to make your babies listen to the music? When they cannot fall into sleep 7 50.0

Appendix A. Supplementary data

Supplementary data related to this article can be found at

https://doi.org/10.1016/j.ctcp.2017.12.015.

References

[1] F.E. Aslan, Pain assesment and measurement, in: F.E. Aslan (Ed.), Nature of Pain and Control, Europe Medical Publishing,, Istanbul, 2006, pp. 68e99. [2] F.C. Biley, The effects on patient well-being of music listening as a nursing

intervention: a review of the literature, J. Clin. Nurs. 9 (2000) 668e677. [3] M.S. Cepeda, D.B. Carr, J. Lau, H. Alvarez, Music for Pain Relief (Review), 2010.

The Cochrane Collaboration and published in The Cochrane Library. [4] F.C. Cetin, A. Tan, Y.D. Merih, The effects of Turkish music on pregnancy and

newborn, Med. Bull. Zeynep Kamil 48 (3) (2017) 124e130.

[5] A.B. Ergin, Physiology of labor pain, in: N. Komurcu (Ed.), Labor Pain and Management, Nobel Medical Publishing, Istanbul, 2014, pp. 22e26. [6] C. Ersanli, Effects of Musical Therapy and Labor Education on First Pregnancy

with Induction, Master Thesis, Marmara Istanbul University Institutes of Health Sciences, _Istanbul, Turkey, 2007.

[7] K.B. Fulton, The Effects of Music Therapy on Physiological Measures, Perceived Pain, and Perceived Fatigue of Women in Early Labor, 2005. Electronic Theses,

Treatises and Dissertations. Paper 4376,http://diginole.lib.fsu.edu/etd/4376.

[8] R.O. Guvenc, History and Present Situation of Mental Therapy with Music in Turks and World, Istanbul University Cerrahpasa Faculty of Medicine Philos-ophy of Doctorate Thesis, Istanbul, Turkey, 1985.

[9] B.I. Harmanci, Is sed maqam or performance? Rast Music. J. 1 (1) (2013)

22e77.https://doi.org/10.12975/rastmd.2013.01.01.0003.

[10] S.E. Hosseini, M. Bagheri, N. Honarparvaran, Investigating the effect of music on labor pain and progress in the active stage offirst labor, Eur. Rev. Med. Pharmacol. Sci. 17 (2013) 1479e1487.

[11] L. Jones, M. Othman, T. Dowswell, Z. Alfirevic, S. Gates, M. Newburn, S. Jordan,

T. Lavender, J.P. Neilson, Pain Management for Women in Labour: an Over-view of Systematic ReOver-views (ReOver-view), 2012 (The Cochrane Collaboration and published in The Cochrane Library).

[12] K.J. Kemper, S.C. Danhau, Music as a therapy, South. Med. J. 98 (2005) 282e288.

[13] L.J. Labrague, R.A. Rosales, G.L. Rosales, G.B. Fiel, Effects of soothing music on labor pain among Filipino mothers, Clin. Nurse Spec. 1 (2013) 35e42. [14] Y.H. Liu, M.Y. Chang, C.H. Chen, Effects of music therapy on labour pain and

anxiety in Taiwanesefirst-time mothers, J. Clin. Nurs. 19 (2010) 1065e1072. [15] S. Mckinley, K. Coote, J. Stein-Parbury, Development and testing of a Faces Scale for the assessment of anxiety in critically ill patients, J. Adv. Nurs. 41 (2003) 73e79.

[16] D. Nayak, S. Rastogi, O.K. Kathuria, Effectiveness of music therapy on anxiety level, and pain perception in primipara mothers duringfirst stage of labor inselected hospitals of Odisha, OSR J. Nurs. Health Sci. 3 (2014) 7e14. [17] N. Oner, A. Lecompte, State-trait Anxiety Inventory, second ed., Bogazici

University Publishing, Istanbul, 1998.

[18] K. Ozdamar, Biostatistics with SPSS,fifth ed., Kaan Publishing, Eskisehir, 2003. [19] S. Phumdoung, M. Good, Music reduces sensation and distress of labor pain,

Pain Manag. Nurs. 4 (2003) 54e61.

[20] S. Phumdoung, S. Youngvanichsate, W. Jongpaiboonpatana, R. Leetanaporn, The effects of the PSU cat position and music on length of time in the active phase of labor and labor pain, Thai. J. Nurs. Res. 11 (2007) 96e105. [21] C.S. Tabarro, L.B. Campos, N.O. Galli, N.F. Novo, V.M. Pereira, Effect of the music

in labor and newborn, Rev. Esc. Enferm. USP 44 (2010) 441e448.

[22] J. Toohill, J. Fenwick, J. Gamble, D.K. Creedy, A. Buist, E.L. Ryding, Psycho-Social predictors of childbirth fear in pregnant women: an Australian study, Open J.

Obstet. Gynecol. (2014) 531e543.https://doi.org/10.4236/ojog.2014.49075.

[23] L. Wolf, T. Wolf, Music and Health Care, Carnegie Hall and WolfBrown, Copyright, 2011.

[24] G. Yildirim, The Effects of Breathing and Tactile Stimulation Techniques on the Pain Perception of Pregnant Women during Labor, Istanbul University In-stitutes of Health Sciences Master Thesis, Istanbul, Turkey, 2001.