The Effect of Birth Ball Therapy on the Intensity of Spontaneous Labor Pain

Background: Labor pain is physiological, with different intensities in each individual, and intermittent. Birth-ball exercises are more comfortable and safer in labor. The birth ball promotes maternal delivery by assisting the mother's posture and assisting the fetus's position to be optimal in order to facilitate the birth process under normal circumstances. This study aimed to define the effect of birth ball therapy on reducing pain intensity in spontaneous labor. Methods: The method of determining the framework uses PICO. Google Scholar, Pubmed, Science Direct, and Sage Journal were used to search for literature. The inclusion criteria were an original experiment study published in English in 2017–2021. The terms "birth ball" and "labor pain" were used. The database was filtered using the PRISMA method until the relevant articles were obtained, then a content review and discussion were carried out. Results: There were a total of 5 articles regarding the effect of birth ball therapy on spontaneous labor pain. This article mainly carried out birth ball therapy in first-time mothers. The assessment process used to measure pain intensity in this study used the Visual Analog Scale (VAS). Conclusion: Giving birth ball therapy for 10–20 minutes three times a week can lower pain intensity in mothers with spontaneous labor.


INTRODUCTION
Labor is the process of birthing the fetus that occurs at term (37-42 weeks).Physiologically, pregnant women experience contractions that result in the thinning and opening of the cervix.In a normal delivery, the pain is intermittent.Attacks of pain begin at the peak of the contraction and disappear when the uterus relaxes (Isye et al., 2017).
Labor pain is a process of protection from the mother's body in childbirth to notify the mother of danger signs.It will increase sympathetic nerve activity and then cause changes in heart rate pressure, respiratory disorders, muscle tension, and stress (Rotenstein et al., 2022).Labor pain can also cause hyperventilation, increasing oxygen demand and blood pressure, and decreasing bowel and bladder motility.These conditions can stimulate an increase in catecholamines that cause uterine inertia, prolonged labor, fetal distress, and maternal or fetal death (Solehati, 2018).
In the early stages of normal labor, the pain felt is driven by involuntary contractions of the uterine muscles.At the beginning of the labor process, the contractions felt by the mother tend to be in the lower back.The more advanced the labor process, the more pain the mother feels in her abdomen and back.Labor contractions generally last about 45 to 90 seconds.When labor progresses, the intensity of contractions increases, making the pain stronger (Reeder, 2011).
Pain management in labor can be done pharmacologically or nonpharmacologically. Non-pharmacological methods are easier and safer, one of them is birth ball therapy.Birth ball therapy is one of the non-pharmacological methods that can be used to reduce labor pain without using drugs.
A birth ball is a therapy carried out by the mother sitting on the ball during delivery.The birth ball encourages the mother's intense energy.They help the mother's posture to be upright to allow the fetus to be in an optimal position for childbirth under normal conditions (Sutriningish et al., 2019).
According to the description of the background above and several journals that discuss birth ball therapy, few literature reviews still examine the effect of a birth ball on pain in spontaneous birth.Thus, this study aimed to analyze the impact of birth ball therapy on spontaneous labor pain.

MATERIALS AND METHOD
This article is a systematic literature review concerning the Preferred Reporting Items for Literature Review and Meta-Analyses (PRISMA).The systematic review was carried out according to the PICO model, namely: P (patient, population, problem), I (intervention, prognostic factor, exposure), C (comparison, control), and O (outcome).The PICO formulations in this article are P (mother giving birth), I (birth ball therapy), C (articles reviewed without using a comparison intervention), and O (reducing labor pain).
Search for primary articles using an electronic database that aims to provide relevant articles.The databases used include Google Scholar, Science Direct, Pubmed, and Sage Journal.The keywords in the search for evidence-based research in this literature review are "birth ball" and "labor pain".The selected article is an article the author can download or open access to.The inclusion and exclusion criteria for the reports that the authors compiled in this literature review are presented in Tables 1 and  2.
The article search flow begins with collecting articles according to keywords from various databases.After checking for duplication of titles, the same title is eliminated from the article search process.The search is continued by eliminating articles with titles not relevant to the topic to be reviewed.
The selection is then followed by abstract screening according to the predetermined inclusion criteria, and pieces that do not match have been eliminated from the search process.Furthermore, articles were screened up to this stage and then rescreened through full-text screening.Reports that have met the inclusion criteria and have no problems with the research methodology are involved in the review process for further article evaluation.

RESULTS
Based on search results in Google Scholar, Science Direct, Pubmed, and Sage Journal with the keywords "birth ball" and "labor pain", the author found as many as 380 articles.The screening was completed, and 14 journals were obtained.A feasibility assessment of 31 full-text journals was carried out.However, because the journals did not follow the intervention and methodology, only five journals were reviewed according to applicable regulations (Figure 1).After assessing the quality of articles using The Joanna Briggs Institute (JBI) checklist for quasi-experimental studies (Tufanaru et al., 2020) and the checklist for randomized control trial studies (RCT) (Moola et al., 2017).The assessment process involves answering the question points contained in the questionnaire in accordance with the contents of the article in question using yes/no/unclear/not applicable answers.There are 13 question items for quasi-experimental research (nonrandomized).
The answer "yes" will get a value of 1 and the other answers will get a value of 0, then the result is divided by the total number of questions and multiplied by 100%.Good quality if the score is 80-100%, sufficient quality is 50-79%, and less quality <50%.The results of the article quality assessment are that the five articles have good quality, with a value of 92% for articles 1, 3, and 4, a value of 85% for article 2, which is an RCT-type article, and a value of 100% for article 5, which is a quasi-experimental article (Table 3).The next position is the squat position (leaning on the ball on the wall).After this teaching session, respondents were instructed to do birth ball therapy for an early stage of labor every hour for at least 10-20 minutes up to 10 cm dilatation.
The women in the control group just receiving the routine care of the hospital.
In the fifth article, the results of the pain level during the first stage of labor showed no difference between the two groups before the intervention p = 0.07 and 0.09.However, after the intervention during the active and transition phases, the intervention group experienced less pain with a statically significant difference compared to the control group.

DISCUSSION
This study consisted of five articles on birth ball exercises to reduce labor pain.Labor pain is a pain that all pregnant mothers feel.When the delivery mother focuses her attention on the pain, felt, it will affect her perception of pain, which will make the pain felt will increase.
Pain in this process needs good treatment and does not cause trauma and complications that interfere with childbirth (Sintya Dewi et al., 2020).Several studies mention interventions to reduce labor pain, one of which is birth ball therapy (Henderson, 2006).A birth ball is a ball therapy that helps mothers in the first stage of labor, and mothers can use various positions (Kurniawati et al., 2017).
Giving birth ball therapy in the first study Aktaz et al., (2021), the second Taavoni et al., (2018), the third Jothirathne & Rathnasiri, (2021), and the fifth (Farrag, 2018).The birth ball therapy program includes four types of positions with eight exercises taught, including standing (leaning forward on the ball and leaning on the ball against the wall, up and down), sitting (pelvic rocking, forward and backward, hula-hula, side to side, and rocking), squatting (leaning against the ball and wall), and kneeling (hugging the ball and swinging the hips).Birth ball exercises are carried out once a week, with a duration of 20-25 minutes in each session of the initial training program.
Then proceed with the activity at least three times a week for 20 minutes for 6-8 weeks.Meanwhile, in the fourth study Jothirathne & Rathnasiri, (2021), the birth ball intervention was given by instructing the respondent to sit on the birth ball and move in a circle for at least 15 minutes.While the second article Taavoni et al., (2018) added intervention after birth ball therapy, followed by giving 2.5 teaspoons of honey syrup in 150 ccs of water every 30-60 minutes to provide energy.
The intervention group respondents also heard natural sounds such as ocean waves, rain, and soothing birds through headphones to prevent distraction from the surrounding environment.For the volume of natural sounds to be heard, the respondents set their own according to their respective comfort levels.Those interventions continued from the active phase to the transitional phase.
From the research results of each journal, it was found that birth ball therapy can help pregnant women, especially primigravida and nulliparous women, reduce the intensity of spontaneous labor pain, especially during the first stage.One of the movements of birth ball therapy is to sit on the ball and rock to feel comfortable and help the improvement of labor using gravity while raising the curvature of the ball, stimulating the receptors of the hip that are responsible for producing endorphins (Kurniawati et al., 2017).Using a birth ball during labor prevents the mother from continuously being in a supine position and contributes to improving maternal selfefficacy during delivery, and reduces pain.
As much as 60% reported decreased pain levels after using birth balls, 8% said more pain than before, and 26% reported no change in pain levels (Gau, 2011).Mothers who can rest in time with uterine contractions will feel comfortable during the delivery process.In addition, the birth ball is handy for powerfully pushing the mother's energy needed during childbirth, and the fetus's position feels optimal, making it easier for normal birth.
Mothers sit as comfortably as possible, and the form of the ball that can alter the mother's body shape creates relaxation.In addition, ligaments and muscles, especially those in the pelvic area, become loose, reducing pressure on the sacroiliac joints, bladder, back, waist, tailbone, and perineum (Irawati et al., 2019).Based on this theory, using a birth ball is one of the interventions to devastate pain during labor.
Besides relieving pain during the opening in the first stage, the birth ball also reduces the incidence of the prolonged first stage by revving the cervical opening, facilitating uterine contractions, enlarging the diameter of the pelvis, and revving the descent of the fetal head.So, it is recommended that pregnant women use the birth ball in labor (Maryani, 2016).

CONCLUSION
Based on the results and discussions described in the previous section, it can be concluded that birth ball therapy effectively reduces the intensity of pain in mothers who give birth spontaneously.Of the five articles that have been reviewed, the most common birth ball therapy interventions are sitting, standing, kneeling, and squatting.The intervention was performed for approximately 10-20 minutes, three times a week.The Visual Analog Scale (VAS) can use the pain assessment technique.
As for suggestions for other scientific writing related to the same topic, namely the effectiveness of birth ball therapy with other types of non-pharmacological treatment in lessening spontaneous labor pain.So that the advantages and disadvantages of each intervention can be seen and which intervention is more effectively used with a more profound and precise discussion.

Figure 1 .
Figure 1.The Stage for Article Selection

Table 3 .
Randomized Controlled Trial Article Assessment

Table 4 .
Quasi Experimental Article Assessment

Table 5 .
Results of Article Quality Assessment

Table 6 .
Summary of Article Review