By Margaret Jowitt
NICKY LEAP'S articles on midwives' attitudes to pain in labour in the September 1999 and March 2000 issues of MIDIRS have inspired me to report some of my own research into mothers' experience of pain and their attitudes to it. Nicky's research originated from trying to answer two accusations laid at the feet of 'cruel' midwives: first, "Why should women suffer pain in childbirth in the 1990s?" and second, "Why on earth would you not offer pain relief?". She found that she could divide midwifery thinking about pain broadly into two schools of thought, first the 'pain relief' paradigm and second the 'working with pain' paradigm. Initially, I assumed that the midwives ascribing to the second paradigm enabled mothers to work with the pain but on closer inspection it seemed to be midwives working with women in pain.
What do mothers think about pain in labour? Do they have comparable attitudes to midwives? Are there two types of mothers, those who want pain relief willy nilly, and those who will 'grin and bear it', or work with it?
The very next abstract in the March issue of MIDIRS gave perineal trauma rates after epidural; the hospital concerned had a 70.9% epidural rate (which itself carried a higher risk of episiotomy and operative delivery which was associated with increased perineal trauma). This high epidural rate must be the result of a wide acceptance of the pain relief paradigm on the part of service providers, albeit readily accepted by many women.
Recent newspaper articles also seem to be pushing the pain relief paradigm, deriding women who wish to do without it. Already some midwives are qualifying without ever having seen a woman labouring without an epidural; they have had no chance to discover whether there are any benefits of 'working with pain'.
But is labour always painful? The ARM ukmidwifery internet mailing list was discussing 'white coat hypertension' and the subject of pain came up (see page 36). The possibility of naturally pain free labour was ridiculed. The 'pain relief' paradigm is gaining ground relentlessly.
Pain is a subjective experience - only the person suffering can know what it feels like. Thus our own attitudes to pain and pain relief are highly subjective. Midwives' attitudes will be coloured by what they have been taught, the experience of being with many women in labour and, for those who are mothers, their own experience of childbirth. And we must not forget other experiences of pain, for example toothache, and dental treatment - the one physiological and the other related to treatment. These are different types of pain - some of us are willing to endure the latter in order to avoid the former while others require anaesthesia for dental work. Pain is not a single entity, it has different qualities according to its origins and it also has different meanings attached to it.
I have been interested in the possibility of painfree childbirth ever since reading Grantly Dick Read's Revelation of Childbirth (1933). Rayner Garner, a contributor to the UK Midwifery email list, seems to share my opinion that a relaxed environment will help to prevent pain. I have to admit that my opinion is based on subjective experience. I have had four babies with labours lasting from one and a half hours to 12 hours and in all those labours I remember only two contractions which were really painful, both in my first (induced) labour, an OP presentation in hospital, they occurred when I experimented with resting on the bed. The pain was excruciating, I soon reverted to my previous position. Some of the other contractions were very fierce but none of them was actually painful. Second stage does have pain but I remember it as mental pain rather than physical pain - not wanting to finish the job, wanting to put it off for another day. This seems to be a common reaction to second stage. Perhaps it relates to a fear of being split open - we all know how big a baby's head is and how small the opening through which it must be born. How can we find the courage to inflict such injury on ourselves?
Perhaps I have a different definition of pain? Anyway, after the third, perfect, painless, labour at home, I decided to do some research and approached my old university with a research proposal to look at women's experience of birth at home and in hospital. I wanted to discover whether home birth mothers were simply more stoical about pain than hospital birth mothers or whether they reported less pain, and if so why labour should be less painful at home.
This article is based on clinical notes and interviews with 63 women, 26 of whom, at the onset of labour at term, had been intending to give birth at home (H) and 37 who had intended to give birth in hospital, either in the GP unit (GP, 22) or the consultant unit (CU, 15). Six of the home birth women were transferred to hospital during labour but were analysed under the home birth group (this method of analysis is known to most researchers as 'intention to treat'), thus the home birth group included women who ended up in hospital with an epidural. With the help of the hospital computer and computer staff I tried to match intended home birth women with intended GP unit mothers and consultant unit mothers by age, parity and social class. We never did manage to match all the home birth mothers to GP unit and CU mothers but the three groups did not differ significantly from each other.
I must point out that the women I interviewed were not typical of the childbearing population as a whole since 48 of 63 had chosen not to labour in a consultant unit. Nevertheless, I hope that their experiences will cast light on pain in childbirth. For those of you who are interested, only one seemed to me to fit the NCT stereotype (as I perceive it) and one other was an NCT teacher. One third of the mothers came from social classes III(Manual), IV and V, the 'working' class (surely as much an insult to those in classes I, II and III(Non-Manual) as it is to the latter). Please forgive the unPC nature of the classification, but this is how formal research has to be conducted, social class is related to many outcomes in childbirth and it would be foolish to ignore it. (Incidentally, I found that 'working class' women were just as articulate in recounting their childbirth experiences as middle class women.) I have quoted women's own words liberally in this article - we need to hear their voices strongly through the sometimes turgid academic writing!
Even when looking at women's experiences of childbirth, asking questions about the quality of their experience rather than quantitative factors such as the length of labour, it is possible to use statistics to compare one group with another; these are known as non-parametric statistics. I used a technique known as grounded theory to pick out themes and concepts mentioned by women in answering each interview question. Sometimes women's responses could be ranked in a meaningful order (e.g. intensity of pain) and sometimes they had categories to themselves (e.g. a particular word used or not used).
While it is patently ridiculous to estimate, for example, that 'severe pain' is ten times worse than 'painful', we can order women's responses into a reported pain scale from 'no pain', through 'painful' and 'severe pain' to 'unbearable/agony', and give them a number (a 'rank') and we can then say confidently that women ranked low report less pain than women ranked high. Then if we divide women into groups, for example, intended home birth, intended GP unit birth and intended consultant unit birth, we can add up the rank numbers in each group and find an average rank and then use standard statistical tests to see if any difference is likely to have happened by chance, or whether the two things are likely to be related.
The usual tests of significance give a 'p' value and if this value is 0.05 or less then the chances are that the two things are related (not necessarily through cause and effect). The lower the value of p, the more likely it is that the two things are related. A p value of 0.005 is likely to reflect a strong association between two variables.
While the main purpose of my study was to compare the experience of women labouring in different places, I was also able to divide women into two groups: those who mentioned a particular concept (for example, saying something like 'contractions are like period pains') and those who did not mention the concept, and then compare the average ranks of each group on the reported pain scale and find out which group reported less pain.
I used an ordinal scale of physical invasiveness of pain relief method for analysis of pain relief given: nil; TENS; Entonox; pethidine; epidural, this appears comparable to the 'hierarchical menu of pain relief' referred to in Nicky's article.
As was expected, mothers intending to give birth at home tended to use the least invasive pain relief methods; half of them used nothing. Only those transferred to hospital used anything more powerful than Entonox. A fifth of the CU mothers used nothing, but all of the GP mothers used something (p < 0.0001).
Before I mentioned the word 'pain' in the interview I asked mothers how they would describe a first stage contraction to a first time mother and based on their actual words I created the pain scale described above. Nearly all women mentioned pain, and those that did not were asked if contractions were painful.
When analysed by three groups: home, GP unit and consultant unit the groups did not differ significantly but when analysed by intended home birth and intended hospital birth (GPU and CU groups combined) intended home birth mothers reported contractions as significantly less painful than intended hospital birth mothers (p < 0.02). Thus the hypothesis that mothers labouring at home tend to report less pain was supported.
However, pain was not the only sensation reported. The following ideas were also mentioned and most of these had a statistical association with reported pain.
23 women referred to rhythm and timing, to wave-like sensations, pauses between contractions and an end in sight. Describing contractions as coming in waves was very significantly associated with reporting contractions as less painful (p < 0.005). A selection of responses is given below; letters in brackets indicate intended place of birth. (Some responses fall into more than one category.)
Just a wave of period pain, swift, that comes and goes very quickly, easy to cope with (H)
Comes from the side, builds up to the middle, rock hard, a wave, and back (H)
They creep up on you, they rise like a Slendertone which you put on and build the power up. First contractions only build up so far, the later ones go round the dial (CU)
Each one lasts longer and is more severe (CU)
In my case a dull pain, later on much more pain, intense, build up then ease off till the next one comes (GP)
Pain that goes to a crescendo then tapers off again. Contraction, rest, contraction. When there's 20 minutes between them you can cope (GP)
14 women mentioned tightening and muscle tension in their descriptions. This was also associated with reporting contractions as less painful (p < 0.005).
Something pulling muscles in your stomach (H)
A gradual build up, a tightening round my stomach, not unpleasurable in the beginning, quite exciting, not painful (H)
Strong tightenings of the vagina, come over the hips and down to the front (CU)
Not worth trying to describe [but she does!] like a really strong tight muscle pull (GP)*
21 women described where the pain was felt, sometimes adding how it moved. These women were also less likely to describe contractions as painful (p < 0.02)
A kind of pain, a heat inside you at the bottom of your back and stomach (H)
A build up of tension round your stomach, mine go into my back as well (CU)
Ache travels over hips (CU)
It spreads across the top then vanishes (GP)
Starts in the bottom of the back, comes round to front (GP)
Don't know how to describe a contraction
Conversely, the 7 women who did not know how to describe a contraction (apart from pain, and apart from the woman who said she couldn't but did, see * above) reported them as more painful (p < 0.002)
I don't know, just painful, takes your breath away (CU)
I wouldn't know, don't know how to (CU)
I wouldn't know where to start, I did find them painful (GP)
Not worth trying to describe (GP)
Like period pains
The 26 women who reported a resemblance to period pains were no more or less likely to report contractions as painful:
A severe period pain (H)
A dull ache like a period pain (CU)
A very, very strong period pain that does not go away (CU)
Very, very painful, worse than period pains (GP)
Like a really bad period pain, quite mild at first, then cramps (GP)
Seven home birth mothers and six hospital mothers gave a coping strategy:
It only hurts if you worry about it (H)
Be positive, this one is one less (H)
The pain's there but as long as you know what's happening, emotionally, you can get over that (H)
There's a time limit, a rhythm, breathing helps (H)
Acknowledge it's there, not ignoring it. Don't tense up, nice sensation, nothing to be frightened of. It's more painful if you're tense (H)
Pretend that each one is the only one. I leant on something. Try not to fight it - it's hard not to fight it (H)
As long as you understand what's happening, what's going on, then you can cope with it (GP)
I could control it with gas and air (GP)
This remark was made by the only woman to mention the effect of pain relieving treatment in her description of a contraction.
Several women remembered and reported the advice of a midwife from a community antenatal class:
One more is one less
Pain is gain
But perhaps this is most pertinent for a written account:
Whatever you've read, your experience is different, don't get a fixed idea of what it will be like for you (H)
While I agree that every woman's experience will be different, and that it does not help to have a fixed idea of what labour will be like, I feel that, whether they laboured at home or in hospital, these women have something to teach us, and through us, women who are preparing for their next labour. From my own experience I could personally endorse each of the coping strategies given above (including the gas and air, which was enough for me to cope with an A.R.M. induced OP labour).
I think we could perhaps add more to our advice to pregnant women in antenatal classes. Those women who were able to describe a contraction in terms of their wave-like qualities, the place where they are felt, and the sensation of muscle tightening, reported less pain.
Antenatal teachers might do well to highlight the physical sensations of contractions in addition to informing women of methods of pain relief. Similarly, midwives working in labour wards could encourage women who are in early labour to describe to them the sensations they are experiencing so that women could then concentrate on the physical sensations rather than the pain. This cognitive approach to labour could enable women to cope better with later, fiercer contractions. If nothing else, highlighting positive aspects of contractions might distract women from pain.
In this study there was no statistical evidence to support the view that women who have period pains are likely to experience bad labour pain. My own view is that period pains are probably the result of the uncoordinated contractions of a uterus that is failing efficiently to expel menstrual products and that painful contractions in labour (such as the two I experienced in my first labour) are likewise the result of a uterus that is not being allowed to do its job properly.
The next questions in the interview were designed to elicit women's attitudes to pain in labour.
"If there was a drug that stopped pain with absolutely no side effects on the baby would you have used it?" followed by, "If not, why not?" I will refer to this as a 'wonder drug' .
Many women doubted whether such a drug existed - "There'll always be something ." said one. Some women pointed out that they would be worried about side effects on themselves and others seemed to assume that the question referred to epidurals (9, all hospital mothers).
Two thirds of the women (42, of whom 23 were in the home birth group) said they would not use such a drug and one third said they would. These figures will not be typical of the childbearing population as a whole because intended home birth mothers were significantly less likely to say they would use a pain relieving drug (p < 0.01); nevertheless half the GPU mothers were also against using a 'wonder drug' (11 for, 11 against) and just over half the CU mothers were against using a 'wonder drug' (8 against, 7 for).
If more than half the women would choose not to use a completely safe drug to eliminate pain it must mean one of three things: they did not want to risk their own or their child's health; they did not experience the type of pain that needed to be relieved; or that the pain of childbirth is not necessarily something to avoid.
I suggest that the following responses are the mothers' equivalent to Leap's pain relief paradigm:
There's no point in having pain, its not spiritual (H)
Yes, I don't believe in having pain if there's something to take it away (GP)
Yes, why suffer, but it must be completely safe before I'd contemplate it (GP)
I'm not one for natural childbirth (GP)
I can do without that sort of pain (GP)
If they've got the technology they can use it on me. I just want the end result (CU)
I don't believe in having pain if there's something to take it away (GP)
Yes, but not an epidural (6 mothers, mostly citing knowledge of the side effects of epidurals)
Yes, an epidural (2 mothers)
However, even those mothers saying they would use a 'wonder drug' didn't want all the pain taken away:
Yes, but not [the pain to be taken away] completely (GP)
Not for the birth itself (GP)
Nothing is simple, however. A few of the mothers said that they might use such a drug, but only in certain circumstances - it would depend on the labour itself, the type of pain, severity of pain and how long it lasted.
Not for my second birth, I felt I coped well with Entonox. I had 75-100 mg of Pethidine for the first, it knocked me for six and led to forceps (H)
With back labour you'd do anything (GP)
If labour was worse than mine was, yes, but by the time you need it it's too late. (GP)
It depends how long the labour is. (GP)
Yes because the pain's that bad but I'd want to feel the birth itself (GP)
Just knowing that unbearable pain can be relieved may be enough for women to do without pain relief.
I would want a drug available (H)
Play it by ear (H)
Only two of the women mentioned 'work'in connection with pain which suggests that, for women, the concept of 'working with the pain' is not very meaningful, at least in first stage. The work involved in first stage is more a passive 'putting up with the pain' rather than active work (although it might take mental work to avoid giving in to the pain, to actively tolerate it).
You've worked for what you've got, you'd feel cheated without pain (H)
You wouldn't have to put any effort in to having a baby, put work in to having the baby (CU)
11 mothers (9 home, 2 hospital). For these mothers the question was academic and therefore largely unanswerable. The difference between the home and hospital mothers is apparent in this case.
There's always going to be something (H)
I wouldn't/couldn't believe the lack of side effects (H) (CU)
Side effects put me off (GP)
It is not surprising that women took the question with a pinch of salt; all the way through pregnancy they are told of the dangers of drugs including nicotine and caffeine and if these drugs can damage the baby then anything powerful enough to prevent pain must have side effects.
14 mothers (7 home, 7 hospital)
Pain doesn't bother me (H)
I can put up with it for that length of time, everyone's different (H)
I used personal distraction techniques - breathe rythmically and deliberately, blow on things, very effective (H)
It's not horrible, not even the hospital one [her last birth], labour isn't worse than period pains, I haven't wanted pain relief (H)
Pain is short lived, I could take it (CU)
The way I cope with it I felt more in control, I preferred to stand it my own way, yoga techniques, no problem (CU)
You can cope with it on your own if you are confident and happy (GP)
Labour is not a bad experience really (H)
Pain is not that unbearable, I just enjoyed it. I was lucky (GP)
Included in this section are three subcategories: labour is not painful; drugs are not the only way to deal with pain; and pain is bearable/can be coped with without drugs.
18 mothers (9 home, 9 hospital).
Pain is meant to be, it makes it all worth it (H)
It's the way things are meant to happen (H)
It's a mother's pain, you're built to fight that kind of pain (H)
It's all part of the experience (H)
Pain is there for a reason (H)
You've to go through the pain to have a child, recovery is instant (CU)
It's all part of giving birth, all part of going through the process, pain is supposed to be (GP)
You're built to give birth, if you were built to have pain free childbirth you'd have it. It's against nature (CU)
I never moan about pain. Pain is all part of childbirth, I wouldn't have anything to stop the pain completely; you've got to have the pain otherwise you might as well have a caesarean (GP)
It's all just part of giving birth, you've got to suffer pain, you know why you're getting the pain (GP)
15 mothers (9 home, 6 hospital):
I want to feel my baby being born, want to feel it, experience it (H)
I want to experience is unless it gets too bad, it's the giving part of giving birth
I want to feel the birth itself, that's how it should be, no local anaesthetic for the birth
I wanted to know what it was like, and then I wanted to experience it (H)
Not an epidural, I don't feel I've somehow felt I've been through labour, something I haven't done, felt you'd had a child (CU)
Practical reasons:
It would make it difficult to know where you were in labour, you need the sensations (GP)
[with a drug] you don't know when a contraction's coming on and when it's faded away (GP)
You can feel what you're doing, can feel what's happening, pain is there for a reason (H)
6 mothers (3 home, 3 hospital).
You're not in control any more, you might as well be dead (H)
A positive being in charge (H)
The way I cope with it I felt more in control (H)
I enjoyed labour so much, being in control of pain (CU)
Once you're on a drip it's out of your control (CU)
You don't feel in control then (GP)
I'm pleased, proud (H)
A worthwhile pain, an achievement, you've worked for what you've got (H)
You need to feel after you've given birth, I've done it, this is my achievement (GP)
Pain is meant to be, it makes it all worth it. Pain is there but as long as you know what's happening, emotionally you can get over that (H)
Result is worth the pain and discomfort (GP)
I cope with it on my own, if you are confident and happy, the result is worth the pain and discomfort (GP)
A 'pain is acceptable' label seems to describe these women's attitudes. The reasons why pain is acceptable seem to fit the following categories:
1. No safe drugs to relieve the pain of childbirth exist - pain must be accepted for the baby's sake (and/or the mother's sake)
2. The pain is not bad enough to require relieving - it is relatively easy to accept the pain
3. Pain is part of a natural process and therefore acceptable. (Pathological pain, however, may need to be relieved)
4. Women want to experience the good aspects of labour and therefore will accept the bad aspects
5. Women accept pain as a price to pay for staying in control
6. Pain is an acceptable price to pay for a sense of personal achievement
One final word about the no 'wonder drug' group - I hope it goes without saying that when no pain is perceived by the mother, no pain relieving treatment is necessary.
Why should women suffer pain in childbirth in the 1990s?
This question is of course rhetorical; we are not expected to reply. It goes without saying that labour is painful, that women suffer, that pain relief prevents suffering and that women ought to take up the offer - one is tempted to add, if only for the sake of the people caring from them. However, the women in my study made a good shot at answering the real question, and the answer, somewhat conveniently for me, lies in the archaic meaning of the word 'suffer' which means simply 'to go through with, to accept, to tolerate'. But the 1990s sanitised version of birth does not suffer these fools gladly - nor the midwives who are prepared to suffer their suffering. The first, modern, definition in the OED, 'to experience ..', tells us why many women are prepared to suffer labour, labour is seen as part of the process of life and they want to live it, one woman even put this into words, "You might as well be dead". The women refusing pain relief in my study were not preparing for martyrdom in the childbirth stakes, they were asserting a human right to be allowed to feel.
Why on earth would you not offer pain relief?
The romantic in me makes the glib reply, "to allow women to experience a little bit of heaven," but at the same time women must be able to choose not to feel - we cannot uninvent the epidural and there is no doubt that it has made labour a bearable experience for many women, including a few in this study. The art of midwifery may well lie in knowing when to offer pain relief: one GP unit woman in this study was disappointed at being offered pain relief, "half an hour before I needed it." (How many readers are wondering whether the very offer of pain relief made the pain unbearable?) Midwifery education is lacking if it does not attempt to teach midwives how to accept, to work alongside, women's pain. It is substandard if it produces midwives who are unable to distinguish bearable from unbearable pain, to distinguish midwives' suffering from mothers' suffering.
And to cap it all there is another invidious thread which is threatening women's autonomy as birth givers - the prospect of fetal pain is rearing its head. Will this become another pain which 'ought' to be relieved because, in our present state of ignorance about the development of the mind, we think it serves no useful purpose? How long will it be before pain relief is forced upon women with the words that it is, 'for the good of the baby,' when the maverick in me suspects that, like many developments in childbirth, it is for the convenience of the caregivers?
Margaret Jowitt
Dick Read, G (1933). Revelation of Childbirth, Heinemann.
Leap N (1999). 'A fresh approach to pain in labour', MIDIRS, 9, 3, 339-341.
Leap N (2000). 'Pain in Labour: Towards a midwifery perspective', MIDIRS, 10, 1, 49-53.
This article was originally published in Midwifery Matters ISSUE 85 Summer 2000, p10-11
LW updated February 4, 2005