MS CHING HUI CHUANG (Orcid ID : 0000-0001-8366-8986)

PROFESSOR CHUNG-HEY CHEN (Orcid ID : 0000-0003-4976-7571)

Accepted Article
Article type : Review

Music Intervention for Pain and Anxiety Management of the Primiparous Women During Labour:
A Systematic Review and Meta-Analysis

Ching-Hui CHUANG1,2*, Po-Cheng CHEN3*, ChihChen Sophia LEE4, Chung-Hey CHEN5, Yu-Kang TU6
,Shih-Chung WU7

1
Department of Nursing, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan.

2
Department of Nursing, National Cheng Kung University, Tainan, Taiwan.

3
Department of Physical Medicine and Rehabilitation, Kaohsiung Chang Gung Memorial Hospital and
Chang Gung University College of Medicine, Kaohsiung, Taiwan.

4
Department of Music Therapy, Southwestern Oklahoma State University, Weatherford, Oklahoma,
USA.

5
Institute of Allied Health Sciences & Department of Nursing, National Cheng Kung University,
Tainan, Taiwan.

6
Institute of epidemiology and preventive medicine, college of public health, National Taiwan
University, Taipei, Taiwan.

7
Department of Surgery, Chang Gung Memorial Hospital-Kaohsiung Medical Center, Chang Gung
University College of Medicine, Kaohsiung, Taiwan.

This article has been accepted for publication and undergone full peer review but has not been
through the copyediting, typesetting, pagination and proofreading process, which may lead to
differences between this version and the Version of Record. Please cite this article as doi:
10.1111/jan.13871

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 *Ching-Hui CHUANG and Po-Cheng CHEN contributed equally to this work and shared the role of
first author.
Accepted Article
Running head: music Intervention for labor pain.

Author affiliations:

Ching-Hui Chuang, MSN, RN

Department of Nursing, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan; Doctoral
Student, Department of Nursing, National Cheng Kung University, Tainan, Taiwan

Email: helen.ch.chuang@gmail.com

Po-Cheng Chen, MD

Department of Physical Medicine and Rehabilitation, Kaohsiung Chang Gung Memorial Hospital and
Chang Gung University College of Medicine, Kaohsiung, Taiwan.

Email: b9302081@cgmh.org.tw

ChihChen Sophia Lee, PhD, LPMT, MT-BC, Professor

Department of Music Therapy, Southwestern Oklahoma State University, Weatherford, Oklahoma,

USA

Email: sophia.lee@swosu.edu

This article is protected by copyright. All rights reserved.

 Chung-Hey Chen, PhD, RN, Professor

Institute of Allied Health Sciences & Department of Nursing, National Cheng Kung University, Tainan,
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Taiwan

Email: chunghey@mail.ncku.edu.tw

Yu-Kang Tu, DDS, PhD, Professor

Institute of epidemiology and preventive medicine, college of public health, National Taiwan
University, Taipei, Taiwan.

Email: yukangtu@ntu.edu.tw

Shih-Chung Wu, MD

Department of Surgery, Chang Gung Memorial Hospital-Kaohsiung Medical Center, Kaohsiung,

Taiwan.

Address correspondence to: Chung-Hey Chen

No. 1, University Road, Tainan City 70101, Taiwan

TEL: +886 (6) 235-3535 ext. 5846 FAX: +886 (6) 2377550

Email: chunghey@mail.ncku.edu.tw

Conflict of Interest statement

No conflict of interest has been declared by the authors.

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 Funding Statement

This research received no specific grant from any funding agency in the public, commercial, or
Accepted Article
not-for-profit sectors.

ABSTRACT

Aims

To determine the effect of music on the management of pain and anxiety in primiparous women

during labour.

Background

Music is cost-effective intervention in clinical practice to reduce pain, stress and anxiety. However, a

systematic review with meta-analysis for investigating its effects during labour is still lacking.

Design

A systematic review with meta-analysis

Data sources

MEDLINE, EMBASE and CINAHL databases.

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 Review methods
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Randomized controlled trials or quasi-experimental trials concerning the effects of music among

primiparous women who were expected to give normal spontaneous delivery were searched and

screened up to 31 July 2017. The recruited trials for this review were compliant with the standards of

the Cochrane Handbook for Systematic Reviews of Interventions.

Results

A total of 392 primiparous pregnant women (197 in the music intervention group and 195 in the

routine care group) from 5 studies were included in this review. Music as an intervention seemed to

lower the pain scores for primiparous women during labour, but the effect was not statistically

significant. However, there was a significant benefit of music intervention compared with routine care

for primiparous women during labour. In the sensitivity analysis, music intervention showed

significant effect on the improvement of pain and anxiety for primiparous women during labour.

Conclusion

Music intervention may be an effective intervention for the management of pain and anxiety for

primiparous women during labour.

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 Keywords: music, nursing, pregnancy, labour pain, anxiety, systematic review, meta-analysis
Accepted Article
SUMMARY STATEMENT

Why is this review needed?

 Labour pain is inevitable and may have adverse effects on the physical and psychological

outcomes of labour.

 Labour anxiety commonly increases the sensation of pain during labour.

 Music is a promising but underestimated non-pharmacological approach to relieving labour pain

and anxiety.

What are the key findings?

 Music intervention is useful and easy to administer.

 Music is an effective intervention for the relief of labour pain and anxiety.

How should the findings be used to influence policy practice/research/education?

 Music intervention reduces the labour pain and anxiety of primiparous women during labour.

Music protocols should be developed and used in clinical practice.

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 INTRODUCTION
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Pain beginning during the latent phase of the first stage of labour (the interval between the onset of

labour and full cervical dilatation) is inevitable and may have adverse effects on the physical and

psychological outcomes associated with the birthing process (Boryri, Noori, Teimouri, & Yaghobinia,

2016). The rise in physical parameters such as the respiratory rate, oxygen consumption,

catecholamine levels, cardiac output and blood pressure may have harmful effects on both the

pregnant women and their foetuses (Stott, Papastefanou, Paraschiv, Clark & Kametas, 2017; Su et al.,

2015). Labour pain can disturb the emotional control during ongoing childbirth (Sandall, Soltani,

Gates, Shennan, & Devane, 2016; Simavli, Gumus, Kaygusuz, Yildirim, Usluogullari, & Kafali,

2014) and postpartum mental health. All of the above can lead to anxiety in regard to future labour

and mother-infant bonding (Goodman, Mackey, & Tavakoli, 2004). Cervical expansion and uterine

contractions (Whitburn, Jones, Davey, & Small, 2017) are the primary causes of pain during labour.

Due to the potential adverse effects of analgesic drugs on mothers and their new-borns (Girit et al.,

2017; Cadavid, 2017), many pregnant women therefore choose complementary and alternative

therapies to control labour pain and anxiety (Dehcheshmeh & Rafiei, 2015). Several preliminary

studies suggested that music intervention, a modality broadly accepted by pregnant women, decreased

their anxiety, psychological stress and depression during pregnancy, as soon as after two weeks of

intervention (Chang, Chen & Huang, 2008; Chang & Chen, 2004) and increased the satisfying

experience for women undergoing caesarean delivery (Chang & Chen, 2005). It also significantly

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 reduced diastolic blood pressure, systolic blood pressure and heart rates of pregnant women with
Accepted Article
pre-hypertensive symptoms (Sundar, Ramesh & Anandraj, 2015), which were also biological markers

of anxiety.

Background

Labour is a challenging process and labour pain is usually accompanied by anxiety during the birthing

process (Boryri et al., 2016). Anxiety enhances the sensation of pain during labour; it can be modified

through psychological and physiological approaches (Christiaens & Bracke, 2007). Among the

options of complementary and alternative therapies for pain management during labour, music

intervention is emerging with increasing popularity as an additional treatment to routine obstetric

nursing practices. Music intervention via active listening (accompanied with breathing and imagery

exercises guided by the music) has been applied to manage labour pain and anxiety among pregnant

women (Liu, Chang, & Chen, 2010). Auditory stimulation may hinder the pathways of pain

transmission by diminishing the reaction to pain stimuli, thus blocking pain perception (Nilsson,

Unosson, & Rawal, 2005; Simavli et al., 2014), especially during the active phase (Phumdoung &

Good, 2003).

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 Pregnancy for primiparous women may trigger additional diverse emotions, including uncertainty
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about pregnancy, fear of, or concerns about, pregnancy and maladaptation to pregnancy (Boryri et al.,

2016). Music can improve anxiety among primiparous women during their pregnancy. Listening to

participant-preferred music from three categories (Western classical, Pleasant Music and Chinese

Folk Music) for 2 hours after lunch for 30 minutes per day decreased anxiety levels and improved the

physiological performance of pregnant women (Yang et al., 2009). Music can also reduce the prenatal

anxiety of pregnant women with preeclampsia (Toker & Kömürcü, 2017).

Music is a promising but underestimated non-pharmacological treatment employed to relieve labour

pain and anxiety. Although there are many alternative and complementary therapies for ameliorating

labour pain, music intervention is one of the safest and easiest therapies to administer in healthcare

settings. A Cochrane review (Laopaiboon, Lumbiganon, Martis, Vatanasapt, & Somjaivong, 2009)

found only one study (Chang & Chen, 2005) reporting the effect of music intervention on women’s

satisfaction and anxiety during cesarean delivery and the result was statistically significant. One

Cochrane review (Smith, Levett, Collins, & Crowther, 2011) found the effect of music intervention on

pain intensity and anxiety during labour, but the effect was not statistically significant. Some clinical

trials thereafter evaluated the effect of music during labour. Therefore, we planned to perform a

systematic review with meta-analysis to investigate the effects of music intervention on the

management of pain and anxiety among primiparous women during labour.

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 THE REVIEW
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Aims

The aim of this review was to determine the effect of music on the relief of labour pain and anxiety

for primiparous women during labour.

Design

This was a systematic review with meta-analysis regarding music intervention for pain and anxiety

among primiparous women during labour. We conformed to the standards of the Cochrane

intervention review (Higgins & Green, 2011).

Search methods

The purpose of this systematic review with meta-analysis was to gather evidence describing the music

intervention for pain and anxiety of the primiparous women during labour; quantitative studies

fulfilling the inclusion criteria were included. We defined the techniques of music intervention as

active listening accompanying with breathing or imagery exercises guided by the music. We planned

to include randomized or quasi-experimental controlled trials. There were no limitations in

publication dates or languages.

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 Inclusion criteria
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1. Primiparous women with term pregnancy who were expected to give normal spontaneous

deliveries.

2. No cardiovascular diseases, underlying kidney diseases, gestational diabetes, chorioamnionitis,

cephalo-pelvic disproportions, pre-eclampsia, or any psychiatric disorders.

3. No medical records of abnormal patterns of uterine contractions with cephalic presentation of

infants or fetal heart rates.

Electronic publications from MEDLINE, EMBASE and CINAHL databases were searched using a

combination of subject headings and text words. The PICOS search is listed in Table 1. The subject

headings, text words and keywords for inclusion in the search strategy were discussed and agreed

with two authors (C.-H. C. & P.-C. C.). Additional searches for the ongoing trials in the

ClinicalTrials.gov and meta-analyses listed in the database of PROSPERO and Cochrane database

were also conducted. All the registries and databases were searched up to 31 July 2017.

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 Search outcomes
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Two authors (C.-H. C. & P.-C. C.) independently reviewed the titles, abstracts and contents to assure

that the recruited studies for analysis met the inclusion criteria. We included trials evaluating the

effects of music intervention on the relief of pain and anxiety for primiparous women receiving

perinatal cares. The primary outcomes were the improvements of pain and anxiety.

Quality appraisal

Two authors (C.-H. C. & P.-C. C.) independently reviewed the selected trials based on the principles

listed in the Cochrane Handbook for Systematic Reviews of Interventions to evaluate the quality of the

methodology (Higgins & Green, 2011). The domains for assessing the risks of bias included:

allocation concealment, randomization sequence, participant blinding, specialist outcome blinding,

other biases, incomplete data and selective report. The quality of each domain was classified as low

risk, high risk, or unclear. We assessed each outcome pooled in the meta-analysis with the quality of

evidence by using the GRADE approach, according to the presence of the following five factors: risk

of bias, inconsistency, indirectness, imprecision and publication bias (Guyatt et al., 2011). We

employed data from GRADEprofiler GDT (GRADEpro GDT 2015) to produce Summary of Findings

tables for the comparisons: music intervention versus routine care for pain and anxiety management

of the primiparous women during labour.

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 Data abstraction
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After appraising the recruited literature, the two authors discussed the inter-observer differences for

consensus. If a consensus was not achieved, a third author (C.-H. C.) was consulted. The

characteristics of the analysed studies were in a format of the authors, publication year, study location,

intervention, number of participants and outcome measures. The outcome measures were presented as

the mean with 95% confidence interval (CI). When the mean value was unavailable, the median value

was instead adopted for the meta-analysis. The standard deviations (SD) could be imputed from the p

values according to guidance given in the Cochrane Handbook for Systematic Reviews of

Intervention (Higgins & Green, 2011). If only means and SD for the baseline and follow-up

measurements of each group were reported, we calculated the change of means and SD for each group

(Tu, Baelum, & Gilthorpe, 2005; Egger, Davey Smith, Schneider, & Minder, 1997) according to the

following mathematical formula:

Change in mean =

Change in SD =

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 and are the mean and SD for the baseline measurement, respectively and
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and are the mean and SD for the follow-up measurement, respectively. r was the correlation

between the matched pairs of baseline and follow-up measurements and we set r = 0.5 for each group.

Synthesis

Random-effects models were used for the meta-analysis due to the various participant groups and

treatment protocols (DerSimonian & Laird, 1986). Continuous data were expressed as mean

differences (MD) with 95% CIs or as standardized mean differences (SMD) if the outcomes were

conceptually the same in the different studies but measured in different ways. The I2 statistics were

calculated for evaluating the heterogeneity. Sensitivity analysis was performed when substantial

heterogeneity was recognized. If there were 10 or more studies in the meta-analysis, we planned to

investigate reporting bias using funnel plots (Egger et al., 1997). All the statistical analyses were

conducted using Revman (Review Manager (RevMan) [Computer program], Version 5.3.

Copenhagen: The Nordic Cochrane Centre, The Cochrane Collabouration, 2014).

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 RESULTS
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Characteristics of the included studies

A flow diagram of included studies is shown in Figure 1. Five published studies (Hosseini, Bagheri, &

Honarparvaran, 2013; Karkal, Kharde, & Dhumale, 2017; Liu et al., 2010; Phumdoung & Good,

2003; Simavli et al., 2014) were included in this systematic review. Table 2 describes the

characteristics and major outcomes of these studies. All the study locations were in Asia. Although

the outcomes were measured before and after receiving either routine care or additional music

intervention during labour, the time periods of data collection were inconsistent in the included

studies. Two studies (Hosseini et al., 2013; Phumdoung & Good, 2003) collected the data during the

active phase, while 2 studies (Liu et al., 2010; Simavli et al., 2014) collected the data in the latent and

active phases. The follow-up time was unknown in one study (Karkal et al., 2017). All the studies

applied visual analog scale for the evaluation of pain. Only 4 studies (Karkal et al., 2017; Liu et al.,

2010; Phumdoung & Good, 2003; Simavli et al., 2014) reported the outcome of anxiety, where three

studies (Liu et al., 2010; Phumdoung & Good, 2003; Simavli et al., 2014) used visual analog scale

and 1 study (Karkal et al., 2017) used Zung’s self-rating anxiety scale.

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 Methodological quality
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Figure 2 shows a graphical summary of the risk of bias assessment made by the authors. Overall, the

risk of bias was low on two out of six domains (incomplete outcome data and selective reporting).

There was no blinding of participants and personnel in all the included studies. In other domains of

risk of bias assessment, the risk of bias was high. The study by Hosseini et al. (2013) was a

quasi-experimental design, so there was a high risk of bias resulting from the lack of randomization,

allocation and blinding. There was no description of random sequence generation in 2 studies (Karkal

et al., 2017; Liu et al., 2010), no description of allocation concealment in 3 studies (Liu et al., 2010,

Phumdoung & Good, 2003, Simavli et al., 2014) and no description of blinding of outcome

assessment in 2 studies (Phumdoung & Good, 2003; Simavli et al., 2014). Because the protocols of

music intervention varied among these studies, bias in the treatment effect might exist and the domain

of other bias was recorded as unclear for all the included studies. The quality of evidence included the

pain and anxiety outcomes in the GRADE summary table (Table 3). There was moderate evidence

that music intervention could improve pain and anxiety of the primiparous women during labour.

Effects of music intervention

The outcomes were synthesized in the forest plots in Figure 3. Music intervention seemed to lower the

pain scores for primiparous women during labour, but the effect was not statistically significant (MD

-1.80, 95% CI -4.12 - 0.52, 392 participants, 5 studies, I2 statistic = 99%). However, music

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 intervention could reduce anxiety scores more compared with routine care for primiparous women
Accepted Article
during labour (SMD -3.22, 95% CI -4.98 - -1.47, 362 participants, 4 studies, I2 statistic = 98%).

Sensitivity analysis

Pooled results were of high heterogeneity for both outcomes of pain and anxiety, so sensitivity

analysis was performed for each outcome. We excluded one study (Karkal et al., 2017) in the

sensitivity analysis to rule out the outlier effect (Figure 4). Music intervention could significantly

reduce the severity of pain for primiparous women during labour (MD -0.92, 95% CI -1.33 - -0.51,

332 participants, 4 studies, I2 statistic = 45%). For the change of anxiety scores, the pooled result was

presented as MD with 95% CI because the remaining 3 studies used the same outcome measurement

(visual analog scale for anxiety). Like the previously pooled result, music intervention could reduce

anxiety scores more compared with routine care for primiparous women during labour, but the

heterogeneity was lower (MD -0.96, 95% CI -1.15 - -0.76, 302 participants, 3 studies, I2 statistic =

0%).

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 DISCUSSION
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To the best of our knowledge, this is the first systematic review with meta-analysis discussing the

effect of music intervention for primiparous women during labour. Our review procedure was based

on the guidelines of Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)

(Moher, Liberati, Tetzlaff, & Altman, 2009). Music intervention is a welcome option for pain control

in primiparous women during labour (Liu et al., 2010). One Cochrane review (Smith, Levett, Collins,

& Crowther, 2011) found the effect of music intervention on pain intensity and anxiety during labour,

but the effect was not statistically significant. In this systematic review, the included studies showed

that music intervention could relieve labour pain and reduce the level of anxiety for primiparous

women, but the pooled results were of high heterogeneity and not statistically significant regarding

the changes of the pain scores. In the sensitivity analysis, one study (Karkal et al., 2017) was excluded

and the heterogeneity of both pain and anxiety results obviously decreased. In addition, a significant

improvement in both pain and anxiety during labour was also observed.

The protocols of music listening experiences varied in each study, ranging from the choices of (1) 2

cycles of 30-minute Babane Eshgh via headphone + 30 minutes of break (removing headphone for

assessment) (Hosseini et al., 2013), (2) "most relaxing/distracting" soft European music by

synthesizer, harp, piano, orchestra, jazz arrangement with no lyrics, 60-80 bpm, no strong rhythm or

sustaining notes for 3 hours via earphones with 10 min break per choice of women (Phumdoung &

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 Good, 2003), (3) European Classical/Light/Popular/Crystal (glass armonica) Children/Chinese
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Religious music for two 30-minute sessions: first during the latent then again active phase of Stage 1

with or without headphone (Liu et al., 2010) and (4) European Classical/Turkish Art/Turkish

Folk/Turkish Classical/Turkish Popular Music throughout the labouring process: cycles of (i) 40

minutes of chosen music + 20 minutes of break in each hour during the latent and the first 2 hours of

active phase of 1st stage, (ii) 30 minutes of louder and more rhythmic music + 10 minutes of break

from the late active phase of Stage 1 to the end of 2nd stage; music (with no detailed description)

continued into the 3rd stage (Simavli, et al, 2014). Karkal et al. (2017) did not include the details of

the music protocol. The findings suggested that future trials investigating music intervention among

pregnant women should be designed according to the guidelines of the risks of bias appraisal

instrument to minimize the effects of bias.

Although previous trials have recommended that music intervention may be effective in labour pain,

other alternative therapies for labour pain relief such as massage therapy, antenatal education, group

prenatal care, acupuncture, mindfulness-based intervention were also proposed (Smith, Collins, Cyna,

& Crowther, 2006). The lack of network-meta-analysis to verify the efficacy of these alternative

therapies challenges the music recommendation. Massage therapy seemed to be the most helpful

approach in labour pain relief for pregnant women in one study (Kimber, McNabb, Court, Haines, &

Brocklehurst, 2008); however, readers should be mindful of its small study effect when incorporating

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 its results. A meta-analysis (Fontein-Kuipers, Nieuwenhuijze, Ausems, Budé, & De Vries, 2014)
Accepted Article
indicated that music intervention did not find a significant effect of reduction of antenatal maternal

distress; nevertheless, the study combined pooling data from original different intervention effects

(e.g., music intervention, antenatal education, group prenatal care, acupuncture, mindfulness-based

intervention) and did not include sufficient data for the efficacy of music intervention in labour

anxiety of primiparous women for meta-analysis. This present study includes a construct of maternal

anxiety (VASA) in our search strategy for the consistency and precision in the search results. Further

randomized studies are required to examine these appropriate intervention outcomes trials and the

applicability of music intervention. A study (Toker & Kömürcü, 2017) indicated that using music

minimalized blood pressure with pre-eclampsia. Further studies evaluating the effects of music

intervention on the maternal anxiety of primiparous women may also consider incorporating

participants with such pre-existing physiological concern.

There were still too few well-designed randomized controlled trials to fully evaluate the effect of

music intervention for pain and anxiety management during labour despite the increasing use of

alternative and complementary therapies. Most studies were of small sample size, poor

methodological quality, or inadequately reported. The insufficient reporting also made the assessment

of methodological quality and data extraction difficult.

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 After the initial meta-analysis, there was high heterogeneity in the results of both pain and anxiety.
Accepted Article
The results of pain and anxiety from one study (Karkal et al., 2017) were a prominent outlier. After

reviewing this study, the timing of the outcome assessment was unknown. Since the pain intensity

changed dramatically during the active phase, the timing of the assessment was important when

evaluating the treatment effects. If the follow-up time was unclear in the study design, assessment bias

would eventually occur. While 2 studies (Liu et al., 2010; Simavli et al., 2014) applied music

intervention following the latent phase and evaluated the pain and anxiety scores in the active phase,

the outcomes were not highly heterogeneous. The probable explanation might be that the change of

pain and anxiety intensity was not as obvious from the latent phase to the initial active phase as that

during active phase.

Limitations

The present systematic review with meta-analysis still has some limitations. First, the participants did

not receive the same protocols of music intervention among the included studies. Treatment effect

bias might exist and physicians should keep this in mind when applying music intervention in clinical

practice. Second, music intervention was administered by nurses and physicians instead of certificated

music therapists in the included studies. Certificated music therapists can use proper techniques when

applying music intervention to help participants relieve stress more efficiently than nurses and

physicians do during labour. Researchers in future studies may consider music intervention by music

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 therapists for primiparous women during labour. Third, the sample size of included studies was small,
Accepted Article
with only 2 studies (Liu et al., 2010; Simavli et al., 2014) describing sample size estimations in the

part on study design. Insufficient sample size might underestimate the true effects of music

intervention for primiparous women during labour. Besides, the study results should be interpreted

cautiously because of the small study effect. Fourth, methodological quality was not high in the

included studies, which would lower the validity of the evidence of this systematic review. Future

studies should focus on improving study designs to increase credibility for clinical practice. Fifth, the

impacts of covariates, such as age, duration of labour, or treatment time, would influence the clinical

outcomes of music intervention. However, it was difficult to examine the impact of covariates in this

meta-analysis due to the small number of included studies and the outcome variables in the included

studies were mostly self-reported. For more objective outcomes, physical findings (i.e. Heart rate,

blood pressure, respiratory rate and temperature) should be considered in future studies. Finally, all

included studies were from Asian countries, thus the results may not be applicable to the clinical

setting in Western countries.

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 CONCLUSION
Accepted Article
Music intervention may prove an effective intervention for the management of pain and anxiety for

primiparous women during labour. Future randomized controlled trials with good methodological

quality and adequate power are necessary to strengthen this conclusion.

Author Contributions:
All authors have agreed on the final version and meet at least one of the following criteria
(recommended by the ICMJE*):

1) substantial contributions to conception and design, acquisition of data, or analysis and

interpretation of data;

2) drafting the article or revising it critically for important intellectual content.

* http://www.icmje.org/recommendations/

References

Boryri, T., Noori, N. M., Teimouri, A., & Yaghobinia, F. (2016). The perception of primiparous

mothers of comfortable resources in labour pain (a qualitative study). Iranian Journal of

Nursing and Midwifery Research, 21(3), 239-246. doi: 10.4103/1735-9066.180386

Cadavid, A. P. (2017). Aspirin: The mechanism of action revisited in the context of pregnancy

complications. Frontiers in Immunology, 8, 261. doi: 10.3389/fimmu.2017.00261

This article is protected by copyright. All rights reserved.

 Christiaens, W., & Bracke, P. (2007). Assessment of social psychological determinants of satisfaction
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with childbirth in a cross-national perspective. BMC Pregnancy Childbirth, 7, 26. doi:

10.1186/1471-2393-7-26

Chang, M. Y., Chen, C. H., & Huang, K. F. (2008). Effects of music therapy on psychological health

of women during pregnancy. Journal of clinical nursing, (19), 2580-2587.

Chang, S. C., & Chen, C. H. (2004). The application of music therapy in maternity nursing. Journal of

Nursing, 51(5), 61-66.

Chang, S. C., & Chen, C. H. (2005). Effects of music therapy on women's physiologic measures,

anxiety and satisfaction during cesarean delivery. Research in Nursing & Health, 28(6),

453-461. doi: 10.1002/nur.20102

Dehcheshmeh, F. S., & Rafiei, H. (2015). Complementary and alternative therapies to relieve labour

pain: A comparative study between music therapy and Hoku point ice massage.

Complementary Therapies in Clinical Practice,21, 229-232. doi:10.1016/j.ctcp.2015.09.002

DerSimonian, R., & Laird, N. (1986). Meta-analysis in clinical trials. Controlled Clinical Trials, 7(3),

177-188.

Egger, M., Davey Smith, G., Schneider, M. & Minder, C. (1997). Bias in meta-analysis detected by a

simple, graphical test. British Medical Journal, 315(7109), 629-634.

This article is protected by copyright. All rights reserved.

 Fontein-Kuipers, Y.J., Nieuwenhuijze, M.J., Ausems, M., Budé, L., de Vries, R. (2014) Antenatal
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interventions to reduce maternal distress: a systematic review and meta-analysis of

randomised trials. International Journal of Obstetrics and Gynaecology Gynecologic

Oncology, 121(4), 389-397. doi: 10.1111/1471-0528.12500

Girit, N., Tugrul, I., Demirci, B., Bozkurt, O., Dost, T., Birincioglu, M., &Tanriverdi, H. A. (2017).

Drug exposure in early pregnancy might be related to the effects of increased maternal

progesterone in implantation period. Journal of Psychosomatic Obstetrics & Gynecology, 15,

1-4. doi: 10.1080/0167482x.2017.1289370

Guyatt, G., Oxman, A.D., Akl, E.A., Kunz, R., Vist, G., Brozek, J., Norris, S., Falck-Ytter, Y.,

Glasziou, P., DeBeer, H., Jaeschke, R., Rind, D., Meerpohl, J., Dahm, P., Schünemann, H.J.

(2011). GRADE guidelines: 1. Introduction-GRADE evidence profiles and summary of

findings tables. Journal of Clinical Epidemiology, 64(4), 383-394. doi:

10.1016/j.jclinepi.2010.04.026

Goodman, P., Mackey, M. C., & Tavakoli, A. S. (2004). Factors related to childbirth satisfaction.

Journal of Advanced Nursing, 46(2), 212-219. doi: 10.1111/j.1365-2648.2003.02981.x

Hosseini, S. E., Bagheri, M., & Honarparvaran, N. (2013). Investigating the effect of music on labour

pain and progress in the active stage of first labour. European Review for Medical and

Pharmacological Sciences, 17(11), 1479-1487.

This article is protected by copyright. All rights reserved.

 Higgins, J.P.T., & Green, S. (2011). Cochrane Handbook for Systematic Reviews of Interventions
Accepted Article
Version 5.1.0 [updated March 2011]. The Cochrane Collaboration, 2011. Available from

www.cochrane-handbook.org

Karkal, E., Kharde, S., & Dhumale, H. (2017). Effectiveness of music therapy in reducing pain and

anxiety among primigravid women during active phase of first stage of labour. International

Journal of Nursing Education 9(2), 57-60. doi: 10.5958/0974-9357.2017.00036.8

Kimber, L., McNabb, M., Mc Court, C., Haines, A., Brocklehurst, P. (2008) Massage or music for

pain relief in labour: a pilot randomised placebo controlled trial. European Journal of Pain

12(8), 961-969. doi: 10.1016/j.ejpain.2008.01.004

Laopaiboon, M., Lumbiganon, P., Martis, R., Vatanasapt, P., & Somjaivong, B. (2009). Music during

caesarean section under regional anaesthesia for improving maternal and infant outcomes.

Cochrane Database of Systematic Reviews(2). doi: 10.1002/14651858.CD006914.pub2

Liu, Y. H., Chang, M. Y., & Chen, C. H. (2010). Effects of music therapy on labour pain and anxiety

in Taiwanese first-time mothers. Journal of Clinical Nursing, 19, 1065-1072.

doi:10.1111/j.1365-2702.2009.03028.x

Moher, D., Liberati, A., Tetzlaff, J., Altman, D.G. & Group, P. (2009) Preferred reporting items for

systematic reviews and meta-analyses: the PRISMA statement. Journal of Clinical

Epidemiology, 62(10), 1006-1012.

This article is protected by copyright. All rights reserved.

 Nilsson, U., Unosson, M., & Rawal, N. (2005). Stress reduction and analgesia in patients exposed to
Accepted Article
calming music postoperatively: A randomized controlled trial. European Journal of

Anaesthesiology, 22(2), 96-102.

Phumdoung, S., & Good, M. (2003). Music reduces sensation and distress of labour pain. Pain

Management Nursing, 4(2), 54-61.

Stott, D., Papastefanou, I., Paraschiv, D., Clark, K., & Kametas, N. A. (2017). Longitudinal maternal

hemodynamics in pregnancies affected by fetal growth restriction. Ultrasound in Obstetrics &

Gynecology, 49(6), 761-768. doi: 10.1002/uog.17340

Sandall, J., Soltani, H., Gates, S., Shennan, A., & Devane, D. (2016). Midwife-led continuity models

versus other models of care for childbearing women. Cochrane Database of Systematic

Reviews, (4). doi:10.1002/14651858.CD004667.pub5

Su, Q., Zhang, H., Zhang, Y., Ding, D., Zeng, J., Zhu, Z., & Li, H. (2015). Maternal Stress in

Gestation: Birth Outcomes and Stress-Related Hormone Response of the Neonates. Pediatrics

& Neonatology, 56(6), 376-381. doi: 10.1016/j.pedneo.2015.02.002

Simavli, S., Gumus, I., Kaygusuz, I., Yildirim, M., Usluogullari, B. & Kafali, H. (2014) Effect of

music on labour pain relief, anxiety level and postpartum analgesic requirement: a

randomized controlled clinical trial. Gynecologic and obstetric investigation 78(4), 244-250.

doi: 10.1159/000365085

This article is protected by copyright. All rights reserved.

 Smith, C.A., Collins, C.T., Cyna, A.M., Crowther, C.A. (2006) Complementary and alternative
Accepted Article
therapies for pain management in labour. Cochrane Database of Systematic Reviews 18(4),

CD003521. doi: 10.1002/14651858.CD003521.pub2

Smith, C.A., Levett, K.M., Collins, C.T. & Crowther, C.A. (2011) Relaxation techniques for pain

management in labour. Cochrane Database of Systematic Reviews 7(12), CD009514. doi:

10.1002/14651858.CD009514

Sundar, S., Ramesh, B., & Anandraj, R. (2015). Effect of relaxing music on blood pressure and heart

rate in hospitalized pre-hypertensive women in the third trimester of pregnancy: A randomized

control study. Asian Journal of Pharmaceutical and Clinical Research, 8(5), 186-188.

Toker, E., & Kömürcü, N. (2017). Effect of Turkish classical music on prenatal anxiety and

satisfaction: A randomized controlled trial in pregnant women with pre-eclampsia.

Complementary Therapies in Medicine, 30, 1-9. doi: 10.1016/j.ctim.2016.11.005

Tu, Y.K., Baelum, V. & Gilthorpe, M.S. (2005). The problem of analysing the relationship between

change and initial value in oral health research. European Journal of Oral Sciences, 113(4),

271-278.

Whitburn, L. Y., Jones, L. E., Davey, M. A., & Small, R. (2017). Supporting the updated definition of

pain. But what about labour pain? Pain, 158(5), 990-991. doi:

10.1097/j.pain.0000000000000841

This article is protected by copyright. All rights reserved.

 Yang, M., Li, L., Zhu, H., Alexander, I. M., Liu, S., Zhou, W., & Ren, X. (2009). Music therapy to
Accepted Article
relieve anxiety in pregnant women on bed rest: A randomized, controlled trial. The American

Journal of Maternal Child Nursing, 34(5), 316-323.

doi:10.1097/01.NMC.0000360425.52228.95

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 Table 1. The terms used in the PICOS search.

PICOS tool Search terms

Accepted Article
MEDLINE EMBASE CINAHL
P (exp labor OR labor.tw) (exp labor OR labor.tw) (MH labor) OR (MH
OR (exp labour OR OR (exp labour OR labour) OR (MH
labour.tw) OR (exp labour.tw) OR (exp obstetric*)
obstetric* OR obstetric$ OR
obstetric*.tw) obstetric$.tw)
I (exp music* OR (exp music$ OR (MH music*) OR (MH
music*.tw) OR (exp music$.tw) OR (exp “music therapy”) OR
“music therapy” OR “music therapy” OR (MH song*) OR (MH
“music therapy”.tw) OR “music therapy”.tw) singing)
(exp song* OR OR (exp song$ OR
song*.tw) OR (exp song$.tw) OR (exp
singing OR singing.tw) singing OR singing.tw)
C n/a n/a n/a
O (exp pain* OR (exp pain$ OR (MH pain*) AND ((MH
pain*.tw) AND ((exp pain$.tw) AND ((exp anxiet*) OR (MH
anxiet* OR anxiet*.tw) anxiet$ OR anxiet$.tw) anxious))
OR (exp anxious OR OR (exp anxious OR
anxious.tw)) anxious.tw))
S (randomized controlled (random*:ab,ti) OR (MH "Clinical Trial*")
trial.pt) OR (placebo*) OR ((double OR (PT “Clinical trial*”)
(randomized.mp) OR next/1 blind*):ab,ti) OR OR (TX “randomi*
(placebo.mp) ((single next/1 control* trial*”) OR
blind*):ab,ti) (MH "Random
Assignment") OR (TX
placebo*) OR ((MH
"Placebos")

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ccepted Articl
Table 2. Summary of included studies and participants

Study Year Study location Intervention N Pain1 Anxiety2

Baseline Follow-up Baseline Follow-up
Mean SD Mean SD Mean SD Mean SD
Hosseini et al. 2013 Iran G1: MT 15 3.93 1.162 5.67 1.397 － － － －
G2: RC 15 4.20 1.265 7.60 1.121 － － － －
Karkal et al. 2017 India G1: MT 30 9.45 0.7 4.16 0.75 61.58 1.46 28.26 2.24
G2: RC 30 9.55 0.69 9.68 0.55 61.87 1.46 61.87 0.55
Liu et al. 2010 Taiwan G1: MT 30 6.43 2.57 9.17 1.02 6.38 2.98 8.22 2.26
G2: RC 30 6.60 2.34 9.35 1.02 5.20 2.15 7.68 2.10
Phumdoung et al. 2003 Thailand G1: MT 55 5.915 1.617 7.053 2.027 4.929 1.675 5.909 2.366
G2: RC 55 5.909 1.484 8.005 1.442 5.602 1.774 7.627 1.739
Simavli et al. 2014 Turkey G1: MT 67 2.75 0.37 8.55 0.63 3.30 0.45 8.47 0.66
G2: RC 65 2.72 0.39 9.40 0.71 3.28 0.49 9.41 0.71
Abbreviations:

N, number of participants; MT, music therapy; RC, routine care; SD, standard deviation.

1
Visual analog scale was used in Hosseini et al., Karkal et al., Liu et al., Phumdoung et al., Simavli et al.

2
Zung’s self rating anxiety scale was used in Karkal et al.; Visual analog scale was used in Liu et al., Phumdoung et al., Simavli et al.

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ccepted Articl
Table 3. GRADE summary of findings of music therapy vs routine care for pain and anxiety management of the primiparous women during labour.

Certainty assessment № of patients Effect

Certainty Importance
№ of Study Other Relative Absolute
Risk of bias Inconsistency Indirectness Imprecision music therapy routine care
studies design considerations (95% CI) (95% CI)

Change of pain scores

⊕⊕⊕○
a b c
5 randomised serious very serious not serious serious 197 195 - MD 1.8 CRITICAL

trials lower MODERATE

(4.12

lower to

0.52

higher)

Change of anxiety scores

⊕⊕⊕○
a b
4 randomised serious very serious not serious not serious 182 180 - SMD 3.22 CRITICAL

trials lower MODERATE

(4.98

lower to

1.47

lower)

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ccepted Articl
Abbreviations: CI: Confidence interval; MD: Mean difference; SMD: Standardised mean difference

Explanations:

a. The items of unclear risk of bias and high risk of bias accounts for over half of these items.

b. The I-square is high.

c. The pooled mean difference crosses the midline.

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 Figure 1. Flow diagram of included studies
Accepted Article
Identification

Studies identified through Additional studies identified

database searching through other resources
(n = 80) (n = 14)

Studies after duplicates removed

Screening

(n = 82) Studies excluded

(n = 77)
1. Inadequate study
design
Studies screened 2. Not related to the
(n = 82) topic
3. Not included music
intervention
Eligibility

Studies evaluated for

eligibility
(n = 5)
Included

Studies recruited in
quantitative synthesis
(n = 5)

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 Figure 2. Risk of bias graph and summary: review authors’ judgements about each risks of bias item.

(a) Risk of bias graph

Accepted Article
Random sequence generation (selection bias)

Allocation concealment (selection bias)

Blinding of participants and personnel (performance bias)

Blinding of outcome assessment (detection bias)

Incomplete outcome data (attrition bias)

Selective reporting (reporting bias)

Other bias

0% 25% 50% 75% 100%

Low risk of bias Unclear risk of bias High risk of bias

(b) Risk of bias summary

Blinding of participants and personnel (performance bias)

Blinding of outcome assessment (detection bias)

Random sequence generation (selection bias)

Incomplete outcome data (attrition bias)

Allocation concealment (selection bias)

Selective reporting (reporting bias)

Other bias

Hosseini et al. 2013 – – – – + + ?

Karkal et al. 2017 ? + – + + + ?

Liu et al. 2010 ? ? – + + + ?

Phumdoung et al. 2003 + ? – ? + + ?

Simavli et al. 2014 + ? – ? + + ?

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 Figure 3. Forest plot of the meta-analysis for (a) change of pain scores (b) change of anxiety scores
during labor.
Accepted Article
Abbreviations: IV, inverse variance; CI, confidence interval; SD, standard deviation.

(a) Change of pain scores

Music therapy Control Mean Difference Mean Difference

Study or Subgroup Mean SD Total Mean SD Total Weight IV, Random, 95% CI IV, Random, 95% CI

Hosseini et al. 2013 1.74 1.295584 15 3.4 1.1995 15 19.8% -1.66 [-2.55, -0.77]
Karkal et al. 2017 -5.29 0.726292 30 0.13 0.631744 30 20.3% -5.42 [-5.76, -5.08]
Liu et al. 2010 2.74 2.241406 30 2.75 2.032043 30 19.5% -0.01 [-1.09, 1.07]
Phumdoung et al. 2003 1.138 1.856276 55 2.096 1.463452 55 20.1% -0.96 [-1.58, -0.33]
Simavli et al. 2014 5.8 0.548361 67 6.68 0.615873 65 20.3% -0.88 [-1.08, -0.68]

Total (95% CI) 197 195 100.0% -1.80 [-4.12, 0.52]

Heterogeneity: Tau² = 6.88; Chi² = 522.64, df = 4 (P < 0.00001); I² = 99%

-10 -5 0 5 10
Test for overall effect: Z = 1.52 (P = 0.13)
Favours [music therapy] Favours [control]

(b) Change of anxiety scores

Music therapy Control Std. Mean Difference Std. Mean Difference

Study or Subgroup Mean SD Total Mean SD Total Weight IV, Random, 95% CI IV, Random, 95% CI

Karkal et al. 2017 -33.32 1.969467 30 0 1.277145 30 12.8% -19.81 [-23.52, -16.11]
Liu et al. 2010 1.84 2.693177 30 2.48 2.125441 30 28.9% -0.26 [-0.77, 0.25]
Phumdoung et al. 2003 0.98 2.107257 55 2.025 1.756762 55 29.2% -0.53 [-0.92, -0.15]
Simavli et al. 2014 5.17 0.584038 67 6.13 0.629524 65 29.2% -1.57 [-1.96, -1.18]

Total (95% CI) 182 180 100.0% -3.22 [-4.98, -1.47]

Heterogeneity: Tau² = 2.72; Chi² = 121.07, df = 3 (P < 0.00001); I² = 98%

-20 -10 0 10 20
Test for overall effect: Z = 3.60 (P = 0.0003)
Favours [music therapy] Favours [control]

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 Figure 4. Sensitivity analysis for (a) change of pain scores (b) change of anxiety scores during labor.

Abbreviations: IV, inverse variance; CI, confidence interval; SD, standard deviation.
Accepted Article
(a) Change of pain scores

Music therapy Control Mean Difference Mean Difference

Study or Subgroup Mean SD Total Mean SD Total Weight IV, Random, 95% CI IV, Random, 95% CI

Hosseini et al. 2013 1.74 1.295584 15 3.4 1.1995 15 15.1% -1.66 [-2.55, -0.77]
Karkal et al. 2017 -5.29 0.726292 30 0.13 0.631744 30 0.0% -5.42 [-5.76, -5.08]
Liu et al. 2010 2.74 2.241406 30 2.75 2.032043 30 11.3% -0.01 [-1.09, 1.07]
Phumdoung et al. 2003 1.138 1.856276 55 2.096 1.463452 55 24.1% -0.96 [-1.58, -0.33]
Simavli et al. 2014 5.8 0.548361 67 6.68 0.615873 65 49.5% -0.88 [-1.08, -0.68]

Total (95% CI) 167 165 100.0% -0.92 [-1.33, -0.51]

Heterogeneity: Tau² = 0.08; Chi² = 5.44, df = 3 (P = 0.14); I² = 45%

-10 -5 0 5 10
Test for overall effect: Z = 4.43 (P < 0.00001)
Favours [music therapy] Favours [control]

(b) Change of anxiety scores

Music therapy Control Mean Difference Mean Difference

Study or Subgroup Mean SD Total Mean SD Total Weight IV, Random, 95% CI IV, Random, 95% CI

Karkal et al. 2017 -33.32 1.969467 30 0 1.277145 30 0.0% -19.81 [-23.52, -16.11]
Liu et al. 2010 1.84 2.693177 30 2.48 2.125441 30 2.6% -0.64 [-1.87, 0.59]
Phumdoung et al. 2003 0.98 2.107257 55 2.025 1.756762 55 7.4% -1.04 [-1.77, -0.32]
Simavli et al. 2014 5.17 0.584038 67 6.13 0.629524 65 90.1% -0.96 [-1.17, -0.75]

Total (95% CI) 152 150 100.0% -0.96 [-1.15, -0.76]

Heterogeneity: Tau² = 0.00; Chi² = 0.31, df = 2 (P = 0.85); I² = 0%

-4 -2 0 2 4
Test for overall effect: Z = 9.54 (P < 0.00001)
Favours [music therapy] Favours [control]

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