DE GRUYTER Journal of Complementary and Integrative Medicine.

2019; 20180022

Zahi Arnon1,2 / Asnat Dor1,8 / Hadar Bazak3 / Samuel Attias2,4 / Shlomi Sagi6 / Shoshana Balachsan7 /
Elad Schiff2,5

Complementary medicine for laboring women: a

qualitative study of the effects of reflexology
1 Department of Behavioral Science, The Max Stern Yezreel Valley College, Yezreel Valley, Israel, E-mail: [email protected]
2 Integrative Medicine Service, Bnai Zion Medical Center, Haifa, Israel
3 Outstanding Students’ Program – Department of Behavioral Science, The Max Stern Yezreel Valley College, Yezreel Valley,

Israel
4 School of public Health, University of Haifa, Haifa, Israel
5 Faculty of Medicine, Technion – Israel Institute of Technology, Haifa, Israel
6 Department of Obstetrics and Gynecology, Bnai Zion Medical Center, Haifa, Israel
7 Labor and Delivery, Bnai Zion Medical Center, Haifa, Israel
8 Department of Education, The Max Stern Yezreel Valley College, Yezreel Valley, Israel, E-mail: [email protected]

Abstract:
Background: Despite pharmacological interventions, labor pain and anxiety still remain a challenge, and can
carry long-term psychological complications. The goal of this study was to assess the effect of reflexology on
these symptoms and to explore the physical and psychological components of women’s experience associated
with this treatment.
Methods: This qualitative study was conducted in an Israeli university hospital that offers integrative medicine
services. Reflexology was offered to laboring women in the hospital, by the medical staff. In-depth, open in-
terviews were conducted with 36 women, still in hospital, who consented to be interviewed, within 48 h after
delivery. Questions referred to their labor experience with reflexology treatment.
Results: Of the 36 participants, 34 (94%) described a positive and empowering experience. They reported re-
duced pain and anxiety, and an increased sense of self-efficacy brought about by the ability to become active
and manage labor.
Conclusions: Using reflexology as one of the complementary medicine treatment available can contribute
greatly to the entire labor experience as it empowers women and increases self-confidence and ability to self-
manage labor and delivery.
Keywords: childbirth, complementary medicine treatment, qualitative study, reflexology, self-empowerment,
women’s experience
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DOI: 10.1515/jcim-2018-0022
Received: February 20, 2018; Accepted: May 28, 2018

Introduction
A woman’s memory of birthing may affect her postpartum adjustment [1]. However, objective circumstances
alone cannot be related directly to a pleasant or an unpleasant birth experience [2]. Severe labor pain can lead
to long-term psychological complications, disrupt the mother’s mental health, and have a negative effect on
mother–infant relationship [3]. Research [4] has shown that post-traumatic stress disorder is becoming increas-
ingly recognized as a possible consequence of childbirth, especially following birth difficulties.
Delivering a baby can provoke anxiety, and studies have been conducted to understand the physical and
psychological mechanism of this anxiety and its effects. The professional literature [5] has described broad re-
search, showing that anxiety associated with over-activation of the sympathetic nervous system and its accom-
panying vascular constriction can lead to a restricted blood flow between the uterus and placenta, which in turn
can bring about a lack of nourishment for the fetus. In addition, the activation of the sympathetic nervous sys-
tem produces higher levels of adrenaline, which could impair muscle contraction during labor. Furthermore,
increased anxiety and an associated impairment in breathing can lead to muscle tension, impeding cervical
dilation, and tightening pelvic-floor muscles [5]

Asnat Dor is the corresponding author.

© 2018 Walter de Gruyter GmbH, Berlin/Boston.
This content is free.

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The long-lasting symptoms of pain and anxiety should be targeted for intervention, as they can affect a
woman’s functioning, the development of the relationship with her infant, and the care she provides for her
baby [6, 7]. To minimize a woman’s negative experience of childbirth, it is important to gain knowledge of
factors affecting maternal satisfaction, as well as those affecting pain relief and reducing anxiety levels. For this
reason, effective control of delivery pain, as is control of other acute pain, is the most important social and
health challenge [3].
Despite the many pharmacological solutions to relieving pain during labor, not all can be administered to
every woman, either for medical reasons or for lack of the laboring woman’s consent. One solution is to turn
to noninvasive and non-pharmacological complementary methods [8], among them psychological treatment
during labor [9] and relaxation or visualization [10]. Other treatments include homeopathy and aromatherapy
[11] and reflexology [12]. The support that such an intervention can provide, could reduce the need for pharma-
cological analgesia and increase birth satisfaction [13]. Using these treatments could empower laboring women
to make individual choices for managing labor discomfort and pain, supporting them to see labor pain not as
a problem to be solved, but as a process to be worked through [14]. According to Carvalho and Cohen [15],
the psychosocial ramifications of maternal sense of control and satisfaction with pain management are of high
value, and can have wide-ranging and long-lasting effects on maternal wellbeing as well as on the wellbeing of
the wider family.
The current study focuses on the experience of laboring women who received reflexology as one of the
available complementary medicine treatments, and was the treatment selected based on the availability of the
hospital complementary treatment stuff at the time of the study. Reflexology is a special type of foot and hand
massage and is non-pharmacological. Applying pressure on certain reflex points of the sole and palm breaks
calcium crystals and uric acid accumulated in nerve endings. The pressure opens blocked nerve pathways, and
improves blood flow in the entire body.
Studies have shown that reflexology reduces peri-procedural anxiety [16] and improves pain management
and overall wellbeing [17]. Reflexology also showed positive effects on the management of chronic back pain
[18, 19], and on reducing nausea, vomiting, and pain in patients with cancer [20, 21]. Reflexology for preg-
nant women has been found effective for treatment of nausea and vomiting, constipation, edema, fatigue, and
headache, and, postpartum, enhanced lactation [22–24].
In their qualitative exploratory research on reflexology, Embong, Soh, Ming, and Wong [25] noted that most
research on the subject has been quantitative. However, they claimed that qualitative studies gather beliefs and
values from the respondent that are “not normally conveyed in quantitative survey study” [26, p. 330). The few
qualitative studies which examined women’s experience with complementary and alternative medicine during
pregnancy showed a positive effect on women experience [26, 27].
The goal of this study is to explore the physical and psychological components of laboring women’s expe-
rience with reflexology. The findings may contribute to adequately assess outcomes of reflexology treatment
during labor, not only as a means to alleviate pain and anxiety, but to enhancing the laboring woman’s con-
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fidence in her ability to manage her labor. Based on the finding, reflexologists will be able to fine-tune their
treatment strategy to better meet the needs of laboring women.

Methods
This qualitative research was designed to seek out the meanings of the participants’ central themes, aiming to
provide a broad understanding of their experiences. The research was conducted in Bnai Zion Medical Cen-
ter, Haifa, Israel in 2016 . Bnai Zion is a university hospital with an integrative medical service that provides
complementary medicine treatments (e.g. hypnosis, guided imagery, acupuncture, and reflexology) to inpa-
tients. These treatments are conducted with the full cooperation of the medical and paramedical staffs and in
coordination with them [28].

Participants

The research was conducted on 36 laboring women from northern Israel, 29 (8%) Jews and 7 (19%) Arabs who
received reflexology. The women ranged in age from 19 to 43 (M=31.42, SD=5.87); most (88.9%) were married,
58.66% had an academic degree, 25% were high-school graduates. For 16 women (44%) this was the first child,
for 13 (36%) the second, and for 7 women (19%) their third child or more. Of the 20 women for whom this was
a second or more birth, 14 had previously delivered vaginally, 5 by cesarean sections, and 1 had an assisted
delivery. Two participants had previous experience with reflexology during labor.

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Research tool

An in-depth interview (in Hebrew) was conducted with each participant up to 48 h postpartum. The researcher
asked focused questions about the women’s labor experience, leading them to refer to the treatment they had
received. At the beginning of each interview, demographic data were collected. The interview had three core
questions, and these enabled the researcher to add questions according to the development of each interview:
(1) Can you describe what you remember from the treatment you received during labor? (2) Did you feel any
physical and emotional change during and after the treatment? (3) In general, what was your impression of this
treatment and would you consider a reflexology treatment when you are in labor again?
The interviews were analyzed according to Sabar Ben-Yehoshua’s [29] protocol for qualitative data analysis.
The analysis aimed to derive distinct themes regarding each of the questions, and began with a search for sys-
tematic, repetitive, visible, and direct content. Next, the researchers referred to the contents seeking frequency
of appearance, and for the researchers’ subjective interpretation of its significance to the interviewees. Interpre-
tation entailed dividing the contents into groups and identifying prominent themes, each of which was then
given a title. A major theme, categories and subcategories derived from the interviews are presented in figure
1.

Figure 1: Major theme, categories, and sub categories derived from the interviews.

Procedure and ethical consideration

Prior to conducting the interviews, an ethical approval by the institution’s Helsinki committee was adminis-
trated for the research (ethical approval no. 0041-09-BNZ).
Reflexology treatment was offered to the women by the medical staff – midwives and physicians – prior to
their entering the birthing room. Two female reflexology therapists came to the laboring women and treated
those who were interested. The treatment was given during latent and active labor, and as delivery approached,
the therapists were asked to leave the room. The researcher received from the medical staff the names of the
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women who had consented to be interviewed and asked them to be interviewed about their treatment expe-
rience. Each laboring woman who was treated and who agreed to be interviewed signed a letter of consent
regarding the participation in this study. Participation was voluntary, and participants’ anonymity and con-
fidentiality were guaranteed. The women were assured that the data collected would be used for research
purposes only, and were told that they were free to withdraw from the study at any time.
The interviews took place 24–48 h after delivery, when the women were still hospitalized. The interviewees
consented to have the interviews recorded and the recordings were later transcribed. The interviews, conducted
in Hebrew (for the seven Arab women, Hebrew was a second language), lasted about 40 min, according to the
women’s general feeling and ability to cooperate. In three cases, the interviews were interrupted (and then
resumed) by relatives’ visits or a physical examination.

Results
Content analysis of the interviews yielded a major theme – Sense of self-empowerment in which we identified
four major categories and subcategories: Personal attention, trust and confidence, from passive to proactive,
and self-management of pain.

Personal attention

The women sensed that unlike most of the medical staff who were mostly occupied with monitoring measurable
progress and changes (e.g. dilation and fetal heartbeat), the reflexology therapists were focused on them and on

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their overall feelings, including their emotional and physical state. It was apparent that they were encouraged
to see that the therapists’ top priority was that they have a positive labor experience.
I felt that the therapist did everything in her power to help me and to make it easier for me, I was her
top priority.
She devoted time to me. Saw me and the problem I had that moment and did everything she could to
help.
The participants felt that they meant a lot to the therapists, that the therapists wanted them to have a positive
experience, and that they used their full toolkit to achieve this goal.
The therapist focused on me. She was there for me. It was really inspiring. She treated me according to
my special needs and when I needed it. It wasn’t about the fetus’ position. It wasn’t about dilation, and
not about the monitor. Just me.

Trust and confidence

The participants mentioned that the therapist was someone they could trust and really talk to during the treat-
ment while they laid in the birthing room. They could reveal their feelings and fears, share what bothered
them, ask for clarification regarding the procedure. Their conversation with the therapists during the reflexol-
ogy treatment made them feel less pressured and better prepared for the delivery.
I was so nervous. I cried, everything was so tense. Her talks really met my fears. I cried during the time
she was talking. She was fine with it. I’m even starting to cry right now (smiles). She understood my
fears, and as it was my third birth, she said that my fears are understandable since I knew what’s ahead
of me. I got her full permission to be afraid and unexpectedly I felt much more confident in myself.
Another woman, for whom this was second labor, described a high level of anxiety, along with a feeling of
confidence:
The fact that she was with me, explaining everything that happened to me, was really reassuring … She
kept explaining exactly what she was doing and how it might help me.

From passive to proactive

Unlike other interventions during labor (such as repeated vaginal examinations, intrusive assisted labor deliv-
ery, and cesarean section), which are made by the medical staff according to the progress of labor, the decision
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to receive a reflexology treatment is entirely up to the laboring woman. She is the one in charge of the whole
process, and it was she who decides whether to receive treatment, the duration of treatment, and whether she
wanted the session to end.
The fact that I was offered a treatment which I could try and see for myself if it suits me, was really good
for me. I felt I was in charge. It was entirely my decision. It was different from all the other procedures I
had to cooperate with, in the delivery room.
The combination of touch and talking with the therapist also encouraged the women to be active, to take more
responsibility for the labor process.
The reflexology helped me help myself and try to lead the whole process in the direction I wanted.
The power of the therapist’s words was another issue raised by the participants as an influence, the participants
referred to a feeling of self-control that her words gave them:
She made me believe in myself that I can influence the whole process.
She made me realize that the stress I was under, held me back. She taught me how to let go.
I really felt that I can control my body, it responded to me as I wanted it to. As labor progressed, I felt
more and more secured, it’s like a snowball.
The fact that it is was the woman who decided to receive this treatment was also experienced as something
that speeds up labor, and made the whole process shorter and more intense. Some of the women said that right
after treatment they reached complete dilation, some said that they believe that their treatment certainly relates
to the fact that the baby was out only a few minutes after the treatment. In their opinion, their own decision to
receive reflexology treatment was related to the good results they experienced.

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Self-management of pain

The ability to control and manage the pain was another aspect of which the women were aware. They described
the treatment as a holistic experience, in which they learned a few techniques that made it possible for them to
relax also after the therapist had left the room.

While she touched a certain point on my feet the therapist told me to breathe deep and slow when I had
a contraction. She also told me to think about positive things. I responded to it, it helped. I was in charge.

It’s not that suddenly I had no pain. The pain was there but I felt it differently, like I was floating.

I could breathe into my pain, I felt the contraction and it was painful, but I kept on breathing and felt
that I’m in control.

She taught me how to relax. I felt her also after she left. I continued to breathe as she taught me, I felt I
could help myself.

The combination of touch, talk, and being listened to, encouraged the women to focus on their body and on
their labor. Consequently, they felt more aware of their body and more empowered to manage the pain.

Summary of research findings

Of the 36 participants, 34 reported having had a positive and empowering experience. They felt that the labor
was less painful, accompanied with lower anxiety levels, and with an increased ability to become active and
manage delivery. Two mentioned that the treatment was pleasant, but they were not sure whether it had actually
helped them. The significance of these finding is detailed in the Discussion.

Discussion
The aim of the current qualitative study was to learn about the way women experience foot reflexology as one
of the available complementary medicine treatments during labor.
Our findings reveal an empowering experience for most of the participants. The women associated the
treatment with lower pain levels and lower anxiety levels, and with an increased ability to become active and
manage the entire birthing process. Our findings clearly indicate that while describing their experience, the
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women made a strong connection between their experience of the treatment and their own increased ability to
manage the pain, emphasizing their self-trust and feelings of confidence, faith in their own power to handle
the challenge of the birthing process. Turning to complementary medicine as part of an effort to maintain and
control health condition, also discussed in other studies [30, 31].
While describing their own experience, the women referred to the holistic experience they had with the ther-
apists, including the conversations they had with them, the touch and the special connection that was created
between them. Previous studies have already demonstrated that during labor, reflexology was found to lower
pain, anxiety, and stress [12, 18]. The participants in the present study referred to the therapy they received
in a more holistic manner, emphasizing emotional wellbeing, not only the alleviation of physical symptoms.
This lead us to conclude that the special and personal interaction between a therapist and a patient is unique
and original. The fact that the therapist responded to the woman’s feelings and state of mind and did not focus
mainly on their body, strongly impacted the entire experience. Women described their interaction with the ther-
apist as empowering and as one that enhanced their ability to manage their pain. Even after the therapist had
left the room, the women retained their self-confidence and experienced less anxiety during delivery. In other
words, and in line with Mitchell [27], the fact that the women in labor felt that there was someone who was there
for them, fully attentive and dedicated to them in these crucial hours, had power and efficacy, both physically
and emotionally. This insight led us to wonder whether the short-term relationship with the complementary
medicine therapist differs from that with the midwife or midwives who attend the birthing woman throughout
labor and delivery. Researchers [27, 32, 33] have found that there is indeed a special connection created between
a therapist and a woman in labor, a connection that is usually not likely to evolve with a midwife. However,
we must bear in mind that while the therapist has only one duty – to tend to the laboring woman, the hospital
midwife has multiple responsibilities, many of which are to be carried out simultaneously, often hindering her
ability to reach a profound and meaningful connection with a woman during labor. According to Mitchell [27],
“When midwives work within systems constrained by obstetric ideology and risk dominated policies they find

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it impossible to develop connecting relationships with women. They no longer have the option or the time to
provide individualized care” (p. 5).
Therapists use special strategies and behaviors to create an environment that improves client trust and
communication, allowing people to feel safe to discuss their worries and concerns [34]. A recent study [35] of
massage therapists also referred to the importance of clear communication and a comfortable treatment envi-
ronment. These two factors were related to a positive treatment experience where patients felt that the therapist
meets their needs. The participants in the current research expressed this component in the unique connection
with the therapist. However, as mentioned above, the therapist had one task, and one task only. Given the con-
straints of a modern health system, the therapist took part of the traditional role of the midwife, being hands-on
and supportive, while the midwives were working according to a demanding hospital protocol that often deters
from their ability to spend time with the laboring woman.

Research limitations
The present study is qualitative, and hence the sample (36 laboring women), is relatively small. Also, due to
hospital routine (doctors’ visitation, nurses who take measurements, presence of family members) some inter-
views were interrupted or lacked privacy. It is also possible that a day or two after delivery was not the optimal
time to conduct the interviews – perhaps a few additional days would have given the women an opportunity
to process their experience more profoundly and more perceptively.
Furthermore, no attempt was made here to qualitatively compare the experience of women who received
reflexology with those who received standard pharmacological treatment. It might be interesting to conduct
this comparison, and also to investigate whether they would seek such treatment in labor if they were to have
another child.
Another limitation lies in the notion that based on the current study the specific contribution of reflexol-
ogy to the positive impact on women’s ability to manage the labor process, is not clarified – it is impossible to
separate the influence of the reflexology itself (touch and pressure) from the influence of therapist–patient in-
teraction with its associated psychodynamics. To reach an accurate understanding of each of these components
of the treatment, more research is required, where each component will be examined by itself, preferably with
two types of groups – research and control groups.

Conclusions
This study led us to conclude that the interaction created between a complementary therapist and a patient is
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unique and original, especially when the treatments require constant presence and interaction (unlike acupunc-
ture that enables the therapist to leave the room after needle insertion). The therapist’s holistic approach to the
therapy enables reflexology during labor to improve the physical and the emotional wellbeing of the women.
It is highly recommended to policymakers therefore, to enable an inclusion of complementary methods in
birthing rooms The way the therapist responded to the women’s feelings and state of mind, empowered the
women and strongly impacted their entire experience in a positive manner.

Author contributions: All the authors have accepted responsibility for the entire content of this submitted
manuscript and approved submission.
Research funding: None declared.
Employment or leadership: None declared.
Honorarium: None declared.
Conflict of interest: The authors declare that there is no conflict of interest of any kind (financial, personal or
professional) in connection with this manuscript. The authors declare they take full responsibility for the entire
content of the manuscript.

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