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Vol. 5, No. 8, August 2024
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P-ISSN: 2723-6595
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Jurnal Indonesia Sosial Sains, Vol. 5, No. 8, August 2024 2041

KEYWORDS ABSTRACT
Birth ball; Labor pain; First
stage of Labor

Childbirth is the process of expelling the fetus to the placenta, the
process of giving birth is identical to pain, while to reduce this pain,
non-pharmacological methods are carried out, one of which is the
Birth Ball method. This study aims to evaluate the effectiveness of
using birth ball as a non-pharmacological complementary therapy
in reducing labor pain in the first stage. The method used was a
narrative literature review by searching for relevant articles on
Google Scholar using keywords such as “Birth ball” and “Labor
pain”. Inclusion criteria included Indonesian-language articles
published between 2021-2023. Of the six studies analyzed, it was
found that birth ball use significantly reduced the intensity of labor
pain. These studies showed that birth balls can accelerate cervical
opening and reduce anxiety of laboring mothers through
movements that increase endorphin release. In conclusion, birth
balls are effective as an alternative method to reduce labor pain in
Stage I, providing the added benefit of increasing maternal comfort
and relaxation during the labor process. This study suggests the
use of birth ball as part of midwifery practice to reduce labor pain
non-pharmacologically.

Attribution-ShareAlike 4.0 International (CC BY-SA 4.0)

1. Introduction

Childbirth is the process of releasing the fetus accompanied by contractions in full-term
pregnancy (37-42 weeks). Labour is a natural process that begins with regular uterine contractions
until the baby and placenta are born (Sutriningsih et al., 2019). Basically, giving birth is a natural
thing. Baby, placenta, and amnion exit the mother's womb (Yuanita & Hartati, 2023). The labour
process begins with contractions, which are characterized by gradual changes in the cervix until the
birth of the placenta (Rufaindah, 2024). Physiologically, the labour passes a period characterized by
regular contractions of the uterus accompanied by pain and increased cervical dilation ranging from
5 to 10 cm in the first and subsequent births (Mulyati & Imaniar, 2023).

The Use of Birth Ball as A Non-Pharmacological
Complementary Therapy in The Reduction of Labor Pain in

Phase 1

Harwin Holilah Desyanti, Sasriawati
Universitas Nurul Jadid, Probolinggo, Indonesia

Email: [email protected], [email protected]
Correspondence: [email protected]*

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According to the World Health Organization (WHO), in 2020, as many as 60 million (28.57%)
women suffer from pain during pregnancy and childbirth. Maternal deaths occurred as many as
295,000, with the majority (94%) occurring in developing countries. Maternal mortality is mainly
caused by postpartum haemorrhage (39%), preeclampsia/eclampsia (23%), infection (17%),
prolonged labour (11%), miscarriage (9%), and embolism. (5%) and others (40%) (Nuraini et al.,
2023).

Maternal mortality is still a significant problem in Indonesia. The cause of childbirth
complications is the increasing maternal and fetal mortality rate, such as long childbirth. Mothers
with prolonged childbirth are more likely to experience bleeding due to uterine atonia (33%), birth
canal tears (26%), infections (16%), fatigue (15%) and shock (10%). At the same time, it increases
the risk of severe fetal asphyxia, brain trauma, and infection (Dirgahayu et al., 2022). The
occurrence of prolonged labour is caused by many factors, such as fetal position, pelvic
abnormalities, histological abnormalities, birth errors, excessive fetal size, congenital abnormalities,
mothers with obesity, and premature rupture of membranes (Nurmaisya & Mulyati, 2022).

Childbirth is synonymous with pain. In the latent phase, the cervix disappears, while in the
active phase, the cervix opens and lowers the lowest area of the fetus (Dewi et al., 2020). Mothers
experience pain during childbirth in the following proportions: 15% experience mild pain, 35%
experience moderate pain, 30% experience severe pain, and 20% experience very severe pain
(Sulistianingsih & Wijayanti, 2022). At the time of one delivery, the mother experienced severe pain
that lasted for a long time (Ulfa, 2021). Phase I of labour is defined as the time from the start of
labour to the complete opening (Anuhgera et al., 2021). If not handled properly, labour will take a
long time; long labour can have a bad impact on the mother and fetus, such as uterine infections and
the formation of fistulas. The pain of maternal labour must be effectively eliminated.

Rupture can lead to fetal death or placental abruption. Pharmacological and non-
pharmacological methods can be used to relieve labour pain (Raidanti & Mujianti, 2021). Non-
pharmacological treatments include massage, maternity balls, relaxation, hot and cold compresses,
aromatherapy, breathing regulation, posture control, music therapy, hypnotherapy, and
acupuncture. However, keep in mind that some mothers are not used to being massaged during
childbirth (Gau et al., 2011). Some maternity mothers prefer the birth ball method to reduce pain
during childbirth.

A birth ball is a physical therapy ball that can be used in a variety of positions to help mothers
facilitate the progress of childbirth. One movement is to sit on the ball and move it using gravity to
help the mother feel comfortable and help the labour progress. At the same time, the elasticity and
curvature of the ball stimulate the receptors in the pelvis, thereby increasing the release of
endorphins (Subagio, 2022). Birth Ball exercises for primipara mothers are carried out for 30
minutes after dilatation of 4 to 7 cm (the first stage of active labour), which can help the delivery
process (Irawati et al., 2020). In the first stage of labour, practice using a maternity ball by sitting on
it and slowly swinging your hips back and forth, right and left, and in circular motions. This exercise
will help the uterus contract more effectively and help the baby descend through the pelvis faster
(Anggraeni et al., 2021).

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From this, the purpose of this study is to evaluate the effectiveness of the use of birth balls as
a non-pharmacological complementary therapy in reducing the intensity of labor pain during the
first active phase. This study aims to determine how significantly the birth ball method can reduce
labor pain and speed up the cervix opening process, as well as to assess its benefits in improving
comfort and reducing maternal anxiety during childbirth. Thus, this study is expected to provide a
safe and effective alternative for labor pain management without the use of pharmacological drugs.

2. Materials and Methods

The method used in this study is a literature review in the form of a narrative review. Writing
is done by searching for articles using a combination of several keywords in the Google Scholar
database. The keywords used in the search are Birth ball, Labor pain, and Period 1 childbirth.

Inclusion criteria for articles taken in the study: 1) publication time range 2021-2023, 2)
Indonesian language articles, 3) Research on the use of Birth Ball as a non-pharmacological
complementary therapy in the reduction of labour pain in phase I. Exclusion criteria in article
selection: 1) all studies that did not meet the inclusion criteria were not included in the writing.

Figure 1 Diagram Flow

3. Result and Discussion
The results of the review of the literature obtained in the search in the database using Digram

Flow that correspond to the inclusions and exclusions are presented in Table 1. Results obtained
from 6 literature (Rahmi mutia ulfa, Ervin Rufaindah & fatimah, Miftakhul Zanah, Oriza Zativa Beru

Journals searched through google scholar ( n = 752 )

Journals screened by title and abstract
(n = 504)

Journals included in the final
assessment (n = 6)

Appropriate journals in full review (n =
11)

Excluded journals ( n = 493 )
Participants are not according to the topic

Result
It is not relevant to the application of the

use of birth balls as a nonpharmacological
complement
Intervention

Does not discuss the use of birth balls as a
nonpharmacological complementary
therapy to reduce pain during labor 1

Journals that were rejected because they
did not meet the inclusion criteria (n = 5)

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Barus, Fera Yuanita & Dwi Hartati, dan Nuraini). Discussing the Use of Birth Ball as a Non-
Pharmacological Complementary Therapy in Reducing Labor Pain.

Table 2 Literature Search Results

Authors and
years

Study design,
Sample, Variable,

Instrument, Analysis

Outcome of
Analysis
Factors

Summary of
Results

(Rahmi mutia ulfa,
2021)

Design: pre and post-
test control group
design
Sample: 26 people
Variable: 2 variables,
namely the
independet variable
using a ball and
related variables to
reduce labor pain
Instrument:
Questionnarie
Analysis: 2 analyzes,
namely univariate
and bivariate

describe the characteristics of
mothers giving birth and
determine the effect of using a ball
on labor pain

The birth ball
method is one of the
alternative methods
recommended to
reduce pain during
childbirth

Rufaindah (2024)) Design: Random
control trial
Sample: 60 people (30
births and 30 control
people)
Variable: The use of
birth balls and
reducing pain in
labour
Instrument:
Questionnaire
Analysis: univariate
and bivariate

The data management uses
intervention, in mothers giving
birth while the results are recorded
on a partograph

The use of birth
balls with
complementary
therapy is very
effective in reducing
pain and
accelerating the
opening of the
cervix.

(Miftakhul Zanah,
2023)

Design: one group
pretest, posttest
design
Sample: 31 mothers
giving birth
Variable: use of birth
balls and reduction of
pain in labor
Instrument:
Questionnaire
Analysis: univariate
and bivariate

Shapiro-Wilk is used to test the
normality of the data, if normal it is
followed by the Paired T-Test
statistical test, if it is abnormal it
uses the Wilcoxon hypothesis test
as an alternative to the Paired T-
Test test.

Using the birth ball
method is very
effective in reducing
labor pain in the 1st
active phase

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(Oriza Zativa Beru
Barus, 2023)

Design: descriptive in
the form of a case
study
Sample: -
Variable: use of birth
balls and reduction of
pain in labor
Instrument: medical
record
Analysis: univariate
and bivariate

To measure pain, numerical
assessment scales (NRS), verbal
assessment scales (VRS), visual
analogue scales (VAS) and facial
assessment scales are used. and
using birth ball therapy

Using the birth ball
method
accompanied by
proper relaxation, is
more effective to
reduce pain and
speed up labor

(Fera Yuanita, Dwi
Hartati, 2023)

Design: One group
pre-posttest design
Sample: 21 mothers
giving birth
Variable: use of birth
balls and reduction of
pain in labor
Instrument:
Questionnaire
Analysis: wilcoxon
statistics

Maternity mothers experience pain
in the first active phase

It is very influential
to use birth balls to
reduce labor pain.
Because of the
enthusiasm and
enthusiasm of
maternity mothers
to apply the birth
ball method, the
uterus can contract
optimally

(Nuraini, 2023) Design: observational
analytics
Sample: 30 mothers
giving birth
Variable: The use of
birth balls and
reducing pain in
childbirth
Instrument:
Kuesioner,
partograph
Analysis: chi square
test.

Birthing balls can activate
endorphin compounds so that the
transmission of pain messages can
be inhibited which can lead to a
decrease in pain intensity.

The use of the
Birthing Ball
method is very
influential in
reducing the
intensity of pain
during childbirth

Discussion

The researcher's results, after selecting from several journals using Flow diagrams, obtained 6
journals suitable for the use of birth balls as a non-pharmacological complementary therapy in
reducing labour pain in the first period. The birth ball method is very influential in reducing labor
pain during active phase I (Adnyani et al., 2022).

The first journal of Rahmi Mutia Ulfa (2021), this study indicated that the use of a Birth Ball
significantly affected pain reduction during the first active phase in primigravida women, with a p-
value of 0.000. Additionally, there was a significant difference in the duration of active phase labor
between the treatment and control groups, also with a p-value of 0.000. However, during the second
stage of labor, the use of the Birth Ball did not show a significant effect, with a p-value of 0.160. The
use of birthing tools has been demonstrated to alleviate labor pain during the active phase and to
shorten the duration of the first stage of labor. The Birth Ball is recommended as an alternative

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method for reducing labor pain in midwifery services. This method involves sitting on the ball and
rocking, which utilizes gravity to enhance the release of endorphins, while the ball's shape
stimulates receptors in the body that promote endorphin secretio (Siregar et al., 2021).

The second journal, Ervin Rufaindah and Fatimah (2023), this study indicates a significant
difference in childbirth progress between the two groups, with a p-value of 0.000. It can be
concluded that complementary therapy using birth balls has an effect on cervical dilation in
pregnant women. It is recommended that expectant mothers engage in complementary therapy
exercises while sitting on a birthing ball, as this can be an effective method to enhance labor
progress. The movement on the birth ball focuses on diverting attention from pain through physical
activity, involving rhythmic movements that promote comfort and relaxation. This approach can
also boost the confidence of the expectant mother in managing the pain she experiences, thereby
reducing the perceived pain (Noviyanti et al., 2020).

The third journal Miftakhul Zanah (2023), this study demonstrates that the use of birth balls
significantly reduces labor pain in pregnant women during the first active phase at BPM Yulinda,
Padang Pariaman Regency, with a p-value of less than 0.05. The average Numerical Rating Scale
(NRS) score decreased from 6.78 before using the birth ball to 3.54 afterward. Thus, it can be
concluded that birth balls effectively reduce pain levels in pregnant women during the first active
phase of labor. Birth ball therapy is beneficial for managing, reducing, and alleviating childbirth
pain, particularly during the initial phase, as it can be utilized in various positions (Tane et al.,
2024).

The fourth journal Oriza Zativa Beru Barus (2023), this study stated that the study subjects
had a pain scale of 4-6 (moderate pain) and after using the birth ball for 2 periods with a time of 30
minutes in each period, there was a decrease in the pain scale to 1-3 (mild pain). There is a decrease
in pain levels in pregnant women during the first active phase after the use of the birth ball. The
effect of the use of Birth balls on reducing pain intensity in pregnant women. The use of a birth ball
is very beneficial if accompanied by good relaxation. It can be more effective in reducing pain so as
to accelerate head dropping, accelerate cervical opening and reduce the intensity of maternal
anxiety (F. M. Lestari, 2021).

The fifth journal of Fera Yuanita, Dwi Hartati (2023), this study is based on the Wilcoxon
statistical test with the use of SPSS version 20 with the result of p-value = 0.000 <0.05, so it can be
concluded that there is an effect of the period I pain intensity on primigravida mothers before and
after the use of the birth ball. The enthusiasm and enthusiasm of the mothers who give birth also
greatly help the mother's psychology in processing pain and creating a positive atmosphere for the
mother so that the uterus can contract optimally. The pelvic rocking movement with a birth ball
carried out by the maternity mother helps the mother adapt to the pain and discomfort she
experiences (N. E. A. Lestari et al., 2023).

The sixth journal, Nuraini (2023), this study states that the pain intensity for those who use a
birthing ball is an average of mild pain with a standard deviation of 68.8, while those who do not use
a birthing ball have an average severe pain with a standard deviation of 71.4. It can be concluded
that there is an effect of the use of the Birthing Ball on the intensity of labour pain where the p-value
is 0.028 (p-value < 0.05). The birthing of the ball can affect the duration of the first active phase in

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primigravida due to the application of an upright position combined with ball movement (Heriyeni
& Wiji, 2023).

4. Conclusion

Based on the results and discussions in the literature review, it was found that 6 articles
showed the use of Birth Ball as a non-pharmacological complementary therapy to reduce the
intensity of labour pain during the first active phase. It has a great effect on maternity mothers; the
effects found are reduced pain, relaxation and worry. This literature review is expected to be a
source and literature material for further research and support the maximum application of the use
of birth balls to maternity mothers.

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