Summary of findings
The data from this study suggest that a determining factor of a woman’s experience of pain during labour is its meaning. When women interpret the pain as productive and purposeful, it is associated with positive cognitions and emotions, and they are more likely to feel they can cope. Alternatively, when women interpret the pain as threatening – to either their physical or emotional wellbeing – it is associated with negative cognitions and emotions. When this is the case they tend to feel they need help from external methods of pain control.
The context of the experience influences the meaning of the pain to the woman. Despite the fact that in all cases the process is the same, i.e. the woman is proceeding through labour, for different women this can have different meanings. For some, the pain experience associated with being in labour is acceptable and the pain is seen as necessary (i.e. purposeful). For others, being in labour and the associated experience of pain is not embraced and may be associated with fear or catastrophising thoughts (i.e. threatening). Throughout labour the context of the pain is dynamic and its meaning is changeable – a woman can associate the pain with progression of labour and a sign that she is nearing the birth, or it may be associated with apparent lack of progression, or with artificial progression, or even with progression towards a surgical birth. In each of these cases, the meaning of the pain then changes.
The social environment seems particularly important in shaping a woman’s experience of pain during labour. The people around her can influence her interpretation of the context of the pain, and in doing so can change its meaning. The presence of certain people can influence a woman’s sense of feeling safe or of feeling vulnerable, as well as the thoughts she has towards the pain. She may use the words, actions or expressions of those around her to help her understand the context and thereby construct the meaning of her pain. As the social environment changes throughout her labour, so too can her interpretation of the meaning of the pain. The pain can become more threatening or be seen as more productive, based on a woman’s reaction to variations to the social context she is labouring in.
Ultimately, it is the meaning of the pain that matters to the woman and will influence her ability to cope. An intense pain that is purposeful and that the woman associates with her labour progressing (i.e. it’s productive) is very different to an intense pain that the woman is interpreting as a threat to her baby or herself.
Interpretation in light of the literature
The individual meaning of a pain experience is a dimension of pain that has not been greatly explored in the existing pain literature, and yet it is an implicitly accepted dimension. The placebo effect – a phenomenon that is routinely controlled for in much clinical research – is a striking example of how context can change a person’s pain experience [32]. Moseley and Arntz [17] demonstrated experimentally that a change in the context of a noxious stimulus resulted in a change in the perceived intensity and unpleasantness of the subsequent pain experience. This correlates with the findings from the present study where the context of a woman’s labour experience reflects the perceived intensity and the qualitative characteristics of pain. Our previous work demonstrated that women describe their labour pain experience using either positive, negative or ambivalent terms [3] suggesting that not all labour pain feels the same. This relates to Lundgren & Dahlberg’s [2] findings that labour pain can be a contradictory experience, i.e. both positive and negative, because its context is a desirable one (giving birth to a child). The data from the present study have demonstrated the complexity of pain experiences due to the varied personal meaning of the pain to the individual. Labour pain is a unique experience where a woman can derive a positive meaning of the pain that enhances her capacity to cope.
The data in this study suggest that the people around the labouring woman can shape her pain experience. It is well known that the continuous presence of a known caregiver can improve labour and birth outcomes for women, including a reduction in the use of analgesics [25]. A review of qualitative literature examining women’s experiences of coping with pain during childbirth reported that support from known, trusted caregivers to whom a labouring woman feels emotionally connected makes her feel safe and enhances her ability to cope with pain during labour [33]. The data from the present study may help us understand how this effect is taking place. The data demonstrate that caregivers can influence the woman’s pain experience by influencing her cognitions and emotions towards the pain and, in doing so, can change the meaning of the pain to the woman. This subsequently affects her sense of her ability to cope. By facilitating a state of focus and calm, as well as cultivating positive cognitions about the pain, caregivers can tacitly reassure her that the pain is productive and purposeful. This state of mind is akin to a ‘mindful acceptance’ state that has previously been demonstrated to allow the labouring woman to accept the pain as non-threatening and to work with it [3]. Conversely, a ‘distracted and distraught’ state of mind is associated with pain catastrophising and a sense of helplessness. The data from the present study show that when caregivers explicitly or inadvertently suggest to the woman that something is wrong or that she is not progressing at the expected rate, it changes her cognitions and emotions towards the pain and leads to a state of mind with similar qualities to a ‘distracted and distraught’ state. This suggests that the social environment may be a key regulator of a woman’s state of mind and, in doing so, can change her pain experience.
The data in this study also demonstrate that women can derive a sense of safety or of vulnerability from the people around them during labour and that this seems to be linked to their interpretation of the pain as productive and purposeful, or threatening. Pain science now recognises pain to be the output of a threat-response system [34] that has been activated by implicit or explicit threats to one’s safety [35]. Pain is a homeostatic emotion that motivates the individual to do something about it – specifically, actions that are associated with enhanced chances of survival and thus a sense of safety [36, 37]. The data from this study suggest that the pain a woman feels during labour will be influenced by her sense of safety, or of vulnerability, influenced by the social environment. If the people and the interactions going on around her trigger a sense of vulnerability, it makes evolutionary sense that a woman’s pain experience will change to a more threatening feeling that will then motivate further safety-seeking behaviours.
Notably, one purpose of labour pain may be as a trigger to elicit social support in a time of urgent need [38]. The response to the woman’s call for help is facilitated by the experience of empathy for her pain in the caregiver. A meta-analysis by Lamm et al. [39] has revealed that the empathy networks in the brain overlap with the areas of the brain seen to be involved in a pain experience. Social connections between the labouring woman and others may serve her an important purpose in eliciting a response in her caregivers through their deep inner understanding of her pain. Through the empathic response she receives, her pain experience is validated and she is emotionally and cognitively supported to understand, accept and cope with her pain. Further, Eisenberger [15] demonstrated that the neurophysiology of physical and emotional pain overlap and that emotional pain can heighten physical pain (and vice versa). In this regard, it may be that the social pain of being alone or feeling vulnerable during labour contributes to the woman’s physical pain experience.
The findings of this study identified a further value of labour pain: some women use their pain during labour to self-monitor their progression. Changes in the temporal properties such as an increase in frequency of contractions, and/or an increase in intensity, can signal to women that they are getting closer to the birth and thus influence their interpretation of the pain to mean that it is productive. This is an empowering feeling to have and may contribute to a sense of control that many women seek during labour [40]. Caregivers should also be aware of the potential to negatively influence the pain experience by reporting a woman’s degree of cervical dilation. The data in this study suggest that being told about the degree of dilation can suddenly shift a woman’s state of mind from one of coping with the pain to not being able to cope with the pain and requesting analgesia. The woman may interpret that measurement to mean that she is not progressing at the desired rate and therefore her pain is not productive or if she is already feeling challenged by the pain, it may lead her to predict that she will not have the capacity to cope as labour progresses. If in fact the woman is experiencing a slow progression of labour, caregivers may need to take care to ensure the reports of cervical dilation are accompanied by strategies to help the woman remain confident and promote the progress of her labour, to help prevent her experiencing pain as threatening.
Finally, we would like to acknowledge that while it is now clear that each woman’s unique cognitions, as well as her social environment during labour, are key determinants of her pain experience, she must also work with her body. There are some women who may have long, challenging and exhausting labours for various anatomical and physiological reasons. These women may have ‘ideal’ cognitions and social support to have a positive experience of labour, however the physical contribution to their labour pain makes the process difficult and their pain may become unmanageable. It is here that known, trusted caregivers who are tuned into her cognitively and emotionally, may be better able to offer the right type of support at the right moment.
We hope that the findings of this study inform the development and refinement of interventions to support women and their pain experience during labour. The results of this study suggest that interventions that encourage positive cognitions and emotions about labour pain, and promote labour pain as a productive and purposeful pain, may improve women’s pain experience and, importantly, her capacity to cope. The social environment is a key influencer and the findings of this study may be useful to all carers and support people of labouring women.
Strengths and limitations
We believe that this study investigates important and under-researched concepts relating to labour pain. We have chosen a research strategy that enables us to seek a more complete understanding of the experiential phenomenon of labour pain and have interpreted the findings in light of modern pain science. Through this more sophisticated understanding of labour pain, better strategies to support women during labour and birth may be developed.
The findings of this study should be interpreted taking into account that the demographic factors of participants are not representative of all women giving birth. Despite women being recruited from two different maternity hospitals in various models of care, as well as differing pregnancy risk levels, this study focussed only on nulliparous women’s experiences. Over half of these women had completed tertiary level education.
In addition, the interview relied on recall up to 3 weeks after women’s labours. Previous work, however, has demonstrated that women’s recall of their labour experiences is surprisingly accurate even years after the event (see Niven & Murphy-Black [41] for review).
Finally, because of the limited research that has focussed on the cognitive processes that shape a woman’s pain experience during labour, it is important that these findings be used to as foundation for further research.