The Pain of Childbirth: Perceptions of Culturally Diverse Women

Lynn Clark Callister, RN, PhD; Inaam Khalaf, RN, PhD; Sonia Semenic, RN, PhD(c); Robin Kartchner, RN, BSN; Katri Vehvilainen-Julkunen, CNM, PhD


Pain Manag Nurs. 2003;4(4) 

In This Article

Implications for Clinical Practice and Research

Culture plays a significant role in attitudes toward childbirth pain, the definition of the meaning of childbirth pain, perceptions of pain, and coping mechanisms used to manage the pain of childbirth. According to Schuiling and Sampselle (1999, p. 77), nurses can provide comfort in the presence of pain. Pain does not have to be eliminated for women to be comforted, and comforting diminishes pain. The significance of comfort cannot be over emphasized (Jimenez, 2000).

Personal and professional support during labor is critical. Women's responses to childbirth pain may be modified by support received from caregivers and companions (Corbett & Callister, 2000; Enkin, et al., 2000; Hodnett, 2002). Women who are well supported and confident feel less pain. This idea was expressed in the images of these childbearing women "comforted by comfort measures, a safe and private environment, reassurance, information and guidance, strengthening of coping resources through encouragement, emotional support, and human presence, able to transcend their pain experience with a sense of strength and profound psychological and spiritual comfort during labor" (Lowe, 2002, p. 522).

Caring for culturally diverse women is becoming a more common experience for nurses in birthing centers throughout the United States. Thus culturally appropriate strategies should be generated by health care facilities in order to provide multicultural care (Emang, Wojnar & Harper, 2002). Understanding the cultural meaning of pain is a fundamental prerequisite if the nurse is to facilitate a satisfying birth experience. Understanding that there are broad cultural, as well as individual differences in a woman's pain experience can lead to more effective and sensitive nursing care for laboring women and their family members.

A discussion with the woman to develop an individualized plan of care to manage her childbirth pain enhances the woman's sense of control and positively influences the quality of her birth experience. Control includes active involvement, taking responsibility, the provision of information, and the ability to influence outcomes (Waldenstrom, et al., 1996).

The pain experience of childbirth can provide opportunities for positive growth or may be a negative experience if it is overwhelmingly stressful and the woman has little sense of control or support. It is important to "coach the coach" in the instance where the father of the baby chooses to be the support person. Nurses should provide support within the family context and according to women's cultural values and belief systems (Simkin & Frederick, 2000).

Culturally diverse women giving birth in an unfamiliar and highly technologic environment with routine application of procedures and policies and unknown birth attendants who most likely do not share the woman's culture and/or language are at risk for increased anxiety and pain (Maclean, McDermott, & May, 2000).

It has been documented that there is often incongruence between nurses' rating of pain and the perceptions of the childbearing woman who is experiencing that pain (Baker, et al., 2001; Harrison, 1996; Hoffman & Tarzian, 2001; McCaffery, 1999; McDermott, 2000; Sheiner, et al., 2000). A consensus exists among clinicians that pain should be assessed as the fifth vital sign (Mayer, Torma, Byock, & Norris, 2001; Phillips 2000). When a cultural and communication gap exists between the nurse and the childbearing woman, there is disparity between what the woman is experiencing and the nurse's assessment of that pain (Sheiner, et al., 1999, 2000). The Joint Commission on the Accreditation of Healthcare Organizations has established pain management standards for accredited institutions, and the Maternity Center Association has made specific recommendations for the management of childbirth pain (Maternity Center Association, 2002a; Pasero, McCaffery, & Gordon, 1999).

Pain is "private data" that requires sensitivity to behavioral and verbal cues in order to assess the level of discomfort (Montes-Sandoval, 1999; Sherwood, et al., 2000). It is important that the nurse asks, "What is your level of pain?" and "Is your discomfort being managed at an acceptable level now?" The woman's score on a pain intensity scale is less important than the woman's sense of satisfaction about how her pain is being managed (Mackey, 1998). It has been noted that "satisfaction with childbirth is not contingent on the absence of pain" (Enkin, et al., 2000, p. 328; Hodnett, 2002), since women in some cultural groups view pain as a necessary and integral part of the birth experience. A painful birth is just as likely to have a positive evaluation as one without pain, depending on the woman's feelings of fulfillment.

What is known about labor pain is not integrated into the information given to women prior to giving birth, nor is information provided about the clinical management of pain. What is not known about childbirth pain is perhaps the most important information that can be given to women to assist them in managing the pain associated with childbirth (Kardong-Edgren, 1999; King, 2002).

A need exists for nurses to gain more knowledge about cultural considerations and childbirth pain, and to obtain specific knowledge of certain cultures' traditional beliefs, values, and priorities related to pain and its management (Ahman, 2002; Callister, 2001). Gaining linguistic skills is an important strategy, since it has been noted that shared language may increase the congruence between how laboring women and nurses rate the pain of laboring women (Harrison, 1996; Jimenez, 1996).

A recent issue of the American Journal of Obstetrics and Gynecology provides landmark systematic reviews of the nature and management of childbirth pain (Caton, et al., 2002). These published reports are based on the Maternity Center Association Labor Pain Symposium (Maternity Center Association, 2002a).

More qualitative studies are needed that describe cultural beliefs, values, perceptions, and responses to pain behaviors and preferences for pain management. (Marmor & Krol, 2002). Comparative studies of pain perceptions of culturally diverse childbearing women would be of value (VandeVussee, 1999). Outcomes-focused research is needed to document the effectiveness of holistic interventions in pain management (Cole & Brunk, 1999; Cook & Wilcox, 1997; Fouche, et al., 1998; Kohn, 2000), such as a recently published Chinese study on the effects of massage on pain and anxiety during labor (Chang, Wang, & Chen, 2002).

England's work (1998), Birthing from Within and Listening to Mothers (Maternity Center Association, 2002b), a report of the first national United States survey of women's childbearing experiences can increase nurses' understanding of the lived experience of childbirth from the perspective of women themselves. It is important to acknowledge women's descriptions of their experiences as legitimate sources of nursing knowledge (Young, 1998). Increasing understanding of the cultural meanings of childbirth pain, coping strategies, and culturally proscribed pain behaviors will assist in the provision of culturally competent nursing care. The quality of the woman's birth experience will thus be enhanced.

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