Midwifery ∎ (∎∎∎∎) ∎∎∎–∎∎∎
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Women's experiences of labour pain and the role of the mind: An exploratory study Laura Y. Whitburn, BPty (Lecturer in Anatomy/Doctoral Student)a,b,n, Lester E. Jones, BBSc, BAppSc(Physio), MScMed(PM) (Senior Lecturer in Physiotherapy)a,c, Mary-Ann Davey, DPH, MEpi, BEd, RM (Senior Research Fellow)a, Rhonda Small, BA, DipEd, GradDipEpid, PhD (Professor)a a b c
Judith Lumley Centre, Faculty of Health Sciences, La Trobe University, Melbourne, Australia School of Public Health and Human Biosciences, Faculty of Health Sciences, La Trobe University, Bundoora 3086, Australia School of Allied Health, Faculty of Health Sciences, La Trobe University, Bundoora, Australia
art ic l e i nf o
a b s t r a c t
Article history: Received 19 December 2013 Received in revised form 23 February 2014 Accepted 19 April 2014
Objective: labour pain is unique and complex. In order to develop a more sophisticated understanding of labour pain this exploratory study aimed to examine women's experiences of labour pain within the perspective of modern pain science. An improved understanding of labour pain will assist in informing and enhancing pain management approaches. Design: a qualitative study was performed using phenomenology as the theoretical framework. Data were collected from telephone interviews. Thematic analysis of transcripts was performed. Setting: Melbourne, Australia. Participants: a diverse sample of 19 women who gave birth in a large maternity hospital was interviewed in the month following labour. Findings: the data suggest that a woman's state of mind during labour may set the stage for the cognitive and evaluative processes that construct and give meaning to her pain experience. Women's descriptions of their pain experiences suggested two states of mind. The first was characterised by the mind remaining focussed, open and accepting of the inner experience, including pain. This state tended to be accompanied by a more positive reporting of the labour experience. The second was characterised by the mind being distracted and thought processes featured pain catastrophising, self-judgment and a negative evaluation of pain. Although these two mind states appeared to be distinct, women could shift between them during labour. Women's evaluations of their pain were further influenced by their personal beliefs, desires, the context and the social environment. Key conclusions: women's state of mind during labour may set the stage for the cognitive and evaluative processes that construct and give meaning to their pain experience. Implications for practice: developing interventions for labour pain that promote positive evaluative processes and cultivate a state of mind focussing on the present may improve women's experiences of labour pain. & 2014 Elsevier Ltd. All rights reserved.
Keywords: Labour pain Childbirth Mindfulness Catastrophising
Introduction The pain experience associated with labour is unique. Although typical experiences of pain tend to indicate injury or disease, labour pain emerges during a normal physiological process where increases in intensity are associated with normal labour
n Corresponding author at: School of Public Health and Human Biosciences, Faculty of Health Sciences, La Trobe University, Bundoora 3086, Australia. E-mail address: [email protected] (L.Y. Whitburn).
progression (Corli et al., 1986; Lowe, 1991). Labour pain is also complex because it is highly variable and multidimensional; evaluations of labour pain range from excruciating to pleasurable in different women or on different occasions (Melzack et al., 1984; Lundgren and Dahlberg, 1998). Labour pain can be a paradoxical experience – one that is both excruciating and desirable in its ultimate outcome of having a child (Lundgren and Dahlberg, 1998). Notably, the intensity of pain experienced does not correlate with women's satisfaction with labour (Hodnett, 2002). Thus, labour pain is a complex phenomenon to understand and, consequently, challenging to manage.
http://dx.doi.org/10.1016/j.midw.2014.04.005 0266-6138/& 2014 Elsevier Ltd. All rights reserved.
Please cite this article as: Whitburn, L.Y., et al., Women's experiences of labour pain and the role of the mind: An exploratory study. Midwifery (2014), http://dx.doi.org/10.1016/j.midw.2014.04.005i
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There is, however, an urgent need to better understand labour pain in order to enhance approaches to supporting women through this experience, to promote physiological birth and positive experiences for women. In developed countries around the world the use of analgesia during labour is escalating (Khor et al., 2000; Declercq et al., 2011; Osterman and Martin, 2011; Australian Institute of Health and Welfare et al., 2012) with a cascade of intervention that follows (Anim-Somuah et al., 2011; Petersen et al., 2013). Although epidurals are recognised to be highly effective for pain relief (Jones et al., 2012) they paradoxically do not enhance women's labour experiences (Anim-Somuah et al., 2011) and are implicated in a cascade of intervention (Tracy et al., 2007). In addition, women's fear of labour pain (Eriksson et al., 2006) is contributing to the rising use of interventions (Bussche et al., 2007), including caesarean sections (Dehghani et al., 2013). There is a need for more diversity in the pain management strategies for women during labour that ideally do not impede their chances of a normal birth. In order to do this we must first better understand this complex pain experience. Pain science literature recognises the complex role of cortical processes in the experience of pain (Elsenbruch et al., 2012; Melzack and Katz, 2013). Pain is understood to be the conscious correlate of the implicit perception that the body is in danger (Moseley and Arntz, 2007) and this process is highly influenced by its meaning (Avila, 2013) and by the social context in which it occurs (Montoya et al., 2004). Over the past decade research has revealed important clues regarding the role of cortical processes in the experience of labour pain. Key predictors of a woman's labour pain experience include her prior self-efficacy for labour (Berentson‐Shaw et al., 2009), her tendency to catastrophise pain (Ferber et al., 2005; Flink et al., 2009; Veringa et al., 2011) and her anxiety sensitivity (Lang et al., 2006; Beebe et al., 2007). A woman's interpretation of the social environment will also influence her experience; labouring women who are accompanied by a continuous carer with whom they feel emotionally connected have a more positive experience (Leap et al., 2010; Hodnett et al., 2012) and use less analgesia (Hodnett et al., 2012). In addition, the cultural environment, such as the philosophies towards childbirth and labour pain of her place of care, will influence a woman's experience of labour and use of analgesia (Christiaens et al., 2010). The unique meaning of the pain to the individual woman seems ultimately to determine the experience she has (Lundgren and Dahlberg, 1998; Callister et al., 2003; Flink et al., 2009) and this evaluative process is influenced by prior experiences, expectations, the social and cultural environment and most likely other factors yet to be identified (Lowe, 2002; Fenwick et al., 2005; Lally et al., 2008). Thus labour pain is a complex phenomenon, an embodied subjective experience that comes about through an interaction between the woman's brain, her body and the labour environment (Whitburn, 2013). This exploratory study aimed to examine women's labour pain experiences within the perspective of modern pain science in order to better understand its complexity, prior to the development of a larger study examining labour pain in a representative sample of childbearing women.
Methods Phenomenology is a research method that allows researchers to explore phenomena in great depth. This is appropriate when investigating complex human experiences such as pain. As we experience the world through our conscious minds, the study of a human experience such as labour pain needs to be accessed through the subjective experience itself (Whitburn, 2013). In addition, pain is a multidimensional construct that is shaped by
its essential meaning to the person within a contextual framework. The phenomenology method involves the study of things as they appear in order to understand the essence of human consciousness and experience (Valle and Halling, 1989). Analysis of the subjective experience uncovers the dimensions and essential meaning of the phenomenon and subsequently leads to a deeper explanation of how and why the phenomenon exists (Hesse-Biber and Leavy, 2010).
Participants The women participating in this study were recruited through a large maternity hospital in Victoria, Australia. Recruitment took place in the hospital antenatal settings while women waited for their appointments. Women not booked for a planned caesarean section and who were expecting a normal vaginal birth at the time of recruitment were invited to participate. Stratified, purposive sampling was used in order to represent both primiparous and multiparous women in the sample, as well as women who were planning to give birth in both the hospital birthing suites and the Family Birth Centre (a midwifery-led model of care at the hospital for women at low risk of complications).
Procedure Women participated in a pre- and post-birth interview conducted by LW. The pre-birth interview was designed to explore women's expectations, fears and ideals regarding the labour and the birthing environment and additionally allowed women to build a rapport with the researcher. The post-birth interview was designed to capture women's experiences of labour pain and this forms the focus of this paper. The post-birth interview was conducted over the phone within four weeks of giving birth at a time chosen by the women and lasted between 30 and 45 minutes. Interviewing over the phone allowed women to break up the interview if they needed to attend to the infant or other necessary tasks. Women were asked to reflect on the birth and describe their memories of the experience from the onset of the 1st stage of their labour through to the completion of the delivery of the placenta. Prompts were given when necessary to encourage women to explore and describe their pain experience from sensory, affective and cognitive perspectives.
Analysis The interviews were transcribed and imported into NVIVO 10 software for data management. The analysis process first involved reading transcripts to gauge a general sense of the whole experience. Meaning units were then identified and organised into categories. Related categories allowed for the emergence of the themes of the text and finally allowed for a meaningful description of the investigated phenomenon. Coding was performed by LW and LJ, and checked by RS and MD. Agreement was reached with all coding and interpretation.
Ethics approval Ethics approval for the research was obtained from Mercy Health and La Trobe University Human Research Ethics Committees (R11/51), and all women gave their written consent prior to data collection.
Please cite this article as: Whitburn, L.Y., et al., Women's experiences of labour pain and the role of the mind: An exploratory study. Midwifery (2014), http://dx.doi.org/10.1016/j.midw.2014.04.005i
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Findings
Table 1 Participant characteristics by recruitment location/planned location of birth.
Participants Participant characteristics are presented in Table 1. Of the 20 women who consented to participate in the study, 19 completed the post-birth interview. Four of the 19 women had an emergency caesarean section. One woman could not be contacted for an interview. Overview of findings The data demonstrated how women construct and interpret pain, and how they relate to the pain and to their bodies. A major theme that emerged from the data was the influence of the women's state of mind on their experience of labour pain. The data demonstrated how women's state of mind influenced their relationship with the pain and the interpretation of it. The meaning women associated with their pain experience was influenced by their personal beliefs, desires, the context and the social environment. The experience of labour pain and women's state of mind Women's state of mind influenced their relationship with the pain and with their bodies, thereby influencing their response to, and interpretation of, their experience. Two states of mind were identified, each consisting of a number of characteristics. State 1: Mindful acceptance This state of mind was characterised by women describing their minds remaining in the present moment. This was associated with focus and concentration. In this state, women attended to bodily sensations, and yet were non-reactive to this inner experience. Actions were performed with awareness and thought, and without judgment of the experience or of themselves. Women's minds remained in the present moment: When a contraction would pass I was never worried about the next one (Participant 12) …to breathe through and focus on the one right now (Participant 18) I had no sense of time (Participant 20) The mind was in a zone of concentration where women were focussed on their bodies and bodily sensations: I was just focusing on each contraction (Participant 9) I was putting a lot of attention to my breath (Participant 12) I would try to concentrate on the walking or whatever movement I was doing (Participant 15) Attention was given to sensations, including pain, without judgment: This is it; this is what it will feel like (Participant 10) It's ok; this is the uterus contracting so I can meet my baby (Participant 11) I started to feel the sensation that my body wanted to start to push (Participant 12) I wasn't trying to ignore the pain (Participant 15) The relationship between having a focussed mind and attending to sensations in the body was articulated thus by one woman: If I wasn't so focused I think I would have just felt a blanket of pain (Participant 12)
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Age, M (SD)
Hospital birthing suites (n ¼9)
Family Birth Centre (n ¼10)
34.8 (3.8)
33.1 (3.1)
Parity, number Primips Multips
5 4
5 5
Level of education, number School less that year 12 Year 12 or vocational equivalent Tertiary
2 0 7
0 2 8
5 0
9 1
4
0
Birth outcomes, number Vaginal birth Vaginal birth with extraction/ forceps Emergency caesarean sections
There was an aspect of open-mindedness and acceptance of the pain, without judgment and without magnification: I knew I was in labour and wasn't going to die (Participant 8) You can't control it (Participant 10) I knew it (the pain) was all normal (Participant 13) …an uncomfortable feeling but that I was glad to be having because it meant things were happening…feeling like it was starting to do some good work (Participant 18) The mind was non-reactive to the inner experience and to the pain sensations: The midwife saying ‘don't be afraid of it really helped…me relax my body and let my body do what it needed to do (Participant 6) I never had any negative thoughts or worrying thoughts…I was also no longer fearful of pain (Participant 12) I wasn't worried about the pain (Participant 13) I wasn't scared of the pain (Participant 15) I remember thinking ‘this hurts, but it also feels awesome’ (Participant 15) Actions were performed with a purposeful awareness: I could focus the pain and the contraction and all of your attention on pushing (Participant 4) I was using the pain (Participant 15) State 2: Distracted and distraught The second category was characterised by women's minds not being present in the moment. This was associated with distractions – either internally or externally generated. The woman did not attend to direct sensations in her body. Rather, she reacted to the experience and her thought processes featured judgment and catastrophising. Women's minds did not remain in the present moment, but rather were concerned with how much time had passed or how much time was still to go: I was looking at the clock and it felt like every minute was an hour. It made me think ‘it's been an hour, why isn't he out yet!?’ (Participant 5) I've been labouring for a day and a half and…I'm only 1.5 cm dilated! (Participant 7) I was focused on not having seen my daughter for 2 days…I got distracted and out of my zone (Participant 8)
Please cite this article as: Whitburn, L.Y., et al., Women's experiences of labour pain and the role of the mind: An exploratory study. Midwifery (2014), http://dx.doi.org/10.1016/j.midw.2014.04.005i
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L.Y. Whitburn et al. / Midwifery ∎ (∎∎∎∎) ∎∎∎–∎∎∎
I was getting frustrated about why it was taking so long (Participant 9) I've got another lot of intense pain coming (Participant 10) I kept looking at the clock and thinking ‘now it's been 5 hours… this could go on forever…by 2.30 pm it should be over…I might still be here tonight’ (Participant 18) Distractions drew women's minds away from the present moment or from their bodies: Had to have the monitor on the whole time and it was really restrictive…The last thing you want when you're in pain or trying to focus is to have to think of something else (Participant 8) The gas was taking my focus away (Participant 9) Women were not attentive to direct sensations and this was linked to a loss of focus: I was focusing on all the outside stuff instead of what was going on inside me (Participant 12) You don't feel the head come out, you just feel the pain (Participant 19) As soon as I lost my focus I started getting pain (Participant 12) Women were judgmental of themselves and the pain, and described a sense of helplessness in relation to the pain: It's not going to go away…it's staying for too long…please do something (Participant 2) I'm so weak, I have no pain threshold…I can't do this (Participant 5) I felt frightened by the pain…when watching the monitor and the numbers going up I would think ‘no, no, no!’…why do I have to go through this pain? (Participant 11) How am I going to cope? (Participant 12) I can't do this, this hurts so much (Participant 17)
They (contractions) felt good because I wanted a natural labour (Participant 8) It didn't feel like a sick pain, it felt like a productive pain (Participant 15) A negative mindset was related to a negative expression of pain and an inability to accept it: Frustrating pain…this is more like chronic pain (Participant 2) I couldn't embrace the pain or work with it because it felt wrong to me (Participant 12) One woman described a monumental moment during her experience that shifted the meaning of the pain: When I found out I'd need a caesarean section it felt more painful because I knew that it wasn't working towards giving birth (Participant 16) Some women did not describe their sensations as painful but they had great difficulty in finding an alternative label for their sensations: …they are the most challenging physical thing I've ever been through but I don't like to use the word pain because I think of pain as being something unnatural happening in my body whereas the labour is something my body is meant to be doing. They are really intense sensations that are quite difficult to deal with but I try not to think of them as painful…it's so hard to find the right word to describe (Participant 6) They were really strong sensations, but I wouldn't have called them painful…I didn't relate it to something bad that I would have to stop (Participant 12) For these women the word ‘pain’ was associated with an undesirable, threatening experience and this did not befit their personal interpretation of the sensations of labour.
Women had catastrophising thoughts about the pain: I realised pretty soon that I had no pain threshold because the contractions hadn't even started yet and I was like ‘oh my God oh my God’ (Participant 5) I was thinking ‘oh my God let it end, will it be over?’ (Participant 11) Oh my God I've got another lot of intense pain coming (Participant 10) …worrying if it (the pain) would be the same as the last, or worse (Participant 11) It wasn't even that bad a pinch, but it was the fear, it felt like a bad pain (Participant 15) Although these two categories of states of mind are distinct, women often shifted between them during labour. The meaning of labour pain and women's state of mind From women's descriptions of pain the underlying meaning that they associated with the experience can be inferred. They described pain in the context of positive, negative or ambivalent mindsets. The meaning of the pain was influenced by women's beliefs about labour pain, their desires for a normal birth, the situation/circumstances at the time and words spoken by their caregivers. A positive mindset was characterised by positive words and associations with the pain: It's positive pain (Participant 3) Once she told me this, the pain was probably still as intense but it was more purposeful (Participant 4)
Discussion Summary of findings The interview data suggest that a woman's state of mind during labour influences the relationship she has to her body and to her pain experience. Two different states of mind emerged from the data, defined by where the mind's attention was – whether it was focussed in the present moment or whether it was distracted away from the present moment. A woman's state of mind was not static during her labour, but rather could shift. When women were focussed on the present moment they appeared to be in tune with their bodies and could attend to direct experiences, such as pain. Although attending to pain they did so without reacting negatively or judging critically – the pain was accepted as one component of their overall experience. The women's physical and social environment could facilitate their ability to sustain this state. Women could, however, be pulled out of the present moment as a result of distractions in the environment. The sounds or display from monitors, bright lighting, the clock on the wall, the actions of those around them, or their own thought processes in response to the events of labour, all could divert their attention. Women became more reactive to physical sensations, leading to worry about impending moments in the labour and about the pain. Negative self-appraisals could lead to a sense of helplessness in relation to the pain and to their ability to cope. In effect, when women's attention was diverted away from the present moment their pain became more threatening.
Please cite this article as: Whitburn, L.Y., et al., Women's experiences of labour pain and the role of the mind: An exploratory study. Midwifery (2014), http://dx.doi.org/10.1016/j.midw.2014.04.005i
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The meaning of labour pain varied amongst women. Their descriptions of pain suggested a mixture of positive, negative and ambivalent feelings. This evaluative process was influenced by women's beliefs about labour pain, their desires for a normal birth, the circumstance at the time and what was said to them by their caregivers. Interpretation in light of the literature To our knowledge this is the first study to describe cognitive processes that are related to the experience of pain in labouring women. We have attempted to incorporate modern conceptualisations of pain to reach a deeper understanding of the experience of labour pain. Women's descriptions of being focussed on the present moment can be usefully linked with the concept of mindfulness (Baer, 2003; Kabat-Zinn, 2003). Mindfulness is a particular state of mind that involves moment-to-moment attention and observation of external and internal experiences in a non-judgmental and nonreactive way. In such a state of mind women could notice pain and accept it as part of their experience. Thus, although pain may be emerging from an active threat-response system (Chapman et al., 2008), pain did not re-enter as a subsequent threatening input. Women could accept that they could not control the sensations elicited by, or even the movements within, their body and, thus, were not reacting negatively to the experience. Mindfulness has a long history with traditions such as Buddhism and is now recognised by Western medicine as an effective treatment strategy for certain conditions, including pain (Zeidan et al., 2011). Training in mindfulness is also emerging as an intervention during pregnancy to assist with psychological well-being (Vieten and Astin, 2008; Duncan and Bardacke, 2010; Dunn et al., 2012). It would seem that this state of mind may be ideal for facing challenging tasks accompanied by a significant degree of pain, such as giving birth. Women's focussed attention appeared to allow them to act with awareness and purpose and may have enhanced their abilities to produce the physical and emotional effort required in response to the demands of labour. By maintaining focus it may be that their threat-response systems are able to place more emphasis on mobilising motor and stress-regulation responses that will assist in the progression to giving birth (Chapman et al., 2008). There is evidence in the literature that positive, coping-related thoughts during early labour are associated with shorter labours and reduced interventions (Wuitchik et al., 1989). Remaining in the present moment may also have great value between contractions when women can remain calm, enabling rest, instead of ruminating about the impending pain. This state of mind appears to promote a positive approach to coping with labour pain. The construct of the mind not in the present moment features key elements of a concept known as pain catastrophising. Catastrophising is described as a tendency to focus on and exaggerate the threat value of pain and negatively evaluate one's ability to deal with it (Sullivan et al., 2001; Lumley et al., 2011). Catastrophising has been identified as a key cognitive indicator of the pain experience (Vlaeyen and Linton, 2000; Keefe et al., 2004) emphasising that a pain experience is more defined by how the mind responds to the experience, than by its sensory dimension. Pain catastrophising in labour has been directly associated with labour pain severity and postpartum physical recovery (Flink et al., 2009), and has been reported to be an indicator for the request for pain relief during labour (Veringa et al., 2011). According to the communal coping model, catastrophising serves a social communicative function to help elicit assistance and social support from others (Sullivan, 2012). Catastrophic thought processes help to increase the person's attention to pain
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and their subsequent display of pain behaviour (Sullivan et al., 2001). By communicating their pain, an individual maximises the probability that they will attract and maintain the attention and proximity of potential caregivers (Sullivan et al., 2000). In labouring women, assistance from others is vital to the health and safety of both themselves and their babies. Thus, the catastrophic thought processes displayed by the women in this study can be seen as communicating their need for ongoing assistance from others during the labour and the impending birth. If this ‘social call’ is met, women may feel safe and engage a focussed and mindful state where their pain ceases to be threatening to them. If, however, they feel a degree of isolation or social disconnect (Eisenberger, 2012), their threat-response system may be primed to detect and respond to perceived threats thereby increasing the adversity of their pain experience (Sullivan et al., 2001). The cognitive appraisal model is an additional theoretical framework used to describe the relationship between catastrophising and pain. This model demonstrates that judgments about whether a potential stressor is irrelevant or potentially threatening (primary appraisals) interact with beliefs about coping options and how effective these options may be (secondary appraisals) (Thorn et al., 1999). The ‘magnification’ and ‘rumination’ components of catastrophising are associated with the primary appraisal process in which the individual may focus on and exaggerate the threat value of a sensory input. The ‘helplessness’ component of catastrophising is associated with the secondary appraisal processes in which the individual negatively evaluates their ability to cope with the painful experience. It appears from the data that helplessness featured in the thought processes of women in this study. This suggests that during labour women's minds may be more focussed on evaluating whether they are able to cope with the experience – both the psychological experience associated with labour and the physical effort of giving birth. Whether or not they are able to cope, or whether they need extra assistance, is of vital importance to women's sense of safety and the safety of their child. Thus, a degree of this element of catastrophic thinking may be appropriate in generating a level of hypervigilance to the women's ability to cope with, and successfully accomplish, labour and birth. Sustained catastrophic thinking, however, can heighten the degree of suffering with increasing pain severity and can undermine women's sense of coping. In addition, the heightened pain experience can be detrimental to cognitive task performance (Eccleston and Crombez, 1999) thus interfering with women's ability to control thoughts and focus their minds on the task at hand. The data in the present study suggest that catastrophising occurred when women's minds were distracted from their purpose. While distraction methods have been used in various settings for pain management (Malloy and Milling, 2010), our data suggest that not focussing on the present (un-mindfulness) may set the stage for unhelpful thought processes such as catastrophising and critical self-judgment. Other studies have also identified the inverse relationship between mindfulness and catastrophising in relation to pain experiences (Schütze et al., 2010; Cassidy et al., 2012). The data from this study also suggest that women's pain experiences were shaped by their personal interpretation of the pain. The meaning of the pain was influenced by its context, such as whether women felt the pain experience was progressing them towards a normal birth or whether they were about to be administered an epidural, as well as by the social environment where the words spoken by the midwife could influence women's interpretation of the pain. Labour pain shares these influences and determinants with other human pain experiences (Moseley and Arntz, 2007) but
Please cite this article as: Whitburn, L.Y., et al., Women's experiences of labour pain and the role of the mind: An exploratory study. Midwifery (2014), http://dx.doi.org/10.1016/j.midw.2014.04.005i
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differs in that it is part of a normal physiological process. The data suggest that some women are very aware of this difference and find it difficult to talk about their experience of labour and birth as a pain experience. Strengths and limitations We believe that this study explores important and underresearched concepts relating to women's experiences of labour pain. In an attempt to better understand this pain experience this study has applied the knowledge of modern pain science and a focus on cognitive processes to women's descriptions of labour pain. The findings provide the foundation for future research. There are some limitations of this study. The study was small and exploratory in nature, though the participants included both primiparous and multiparous women from two different models of care. The interview relied on recall up to four weeks after women's labours, but previous work (Simkin, 1991) has demonstrated that women's recall of the events of childbirth is surprisingly accurate even many years after the event. Finally, because this is the first study to our knowledge to describe cognitive processes that are related to the experience of pain in labouring women, it is important that subsequent research explores these concepts further. The authors are currently designing a large longitudinal study with this aim.
Conclusion This investigation into women's experiences has helped to deepen the understanding of labour pain. Women's state of mind during labour may set the stage for the cognitive and evaluative processes that construct and give meaning to their pain experience. Developing interventions for labour pain that promote positive evaluative processes and cultivate a state of mind focussing on the present may improve women's experiences of labour pain.
Conflict of interest statement The authors declare that no conflicts of interest exist.
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Contents lists available at ScienceDirect
Midwifery journal homepage: www.elsevier.com/midw
Women's experiences of labour pain and the role of the mind: An exploratory study Laura Y. Whitburn, BPty (Lecturer in Anatomy/Doctoral Student)a,b,n, Lester E. Jones, BBSc, BAppSc(Physio), MScMed(PM) (Senior Lecturer in Physiotherapy)a,c, Mary-Ann Davey, DPH, MEpi, BEd, RM (Senior Research Fellow)a, Rhonda Small, BA, DipEd, GradDipEpid, PhD (Professor)a a b c
Judith Lumley Centre, Faculty of Health Sciences, La Trobe University, Melbourne, Australia School of Public Health and Human Biosciences, Faculty of Health Sciences, La Trobe University, Bundoora 3086, Australia School of Allied Health, Faculty of Health Sciences, La Trobe University, Bundoora, Australia
art ic l e i nf o
a b s t r a c t
Article history: Received 19 December 2013 Received in revised form 23 February 2014 Accepted 19 April 2014
Objective: labour pain is unique and complex. In order to develop a more sophisticated understanding of labour pain this exploratory study aimed to examine women's experiences of labour pain within the perspective of modern pain science. An improved understanding of labour pain will assist in informing and enhancing pain management approaches. Design: a qualitative study was performed using phenomenology as the theoretical framework. Data were collected from telephone interviews. Thematic analysis of transcripts was performed. Setting: Melbourne, Australia. Participants: a diverse sample of 19 women who gave birth in a large maternity hospital was interviewed in the month following labour. Findings: the data suggest that a woman's state of mind during labour may set the stage for the cognitive and evaluative processes that construct and give meaning to her pain experience. Women's descriptions of their pain experiences suggested two states of mind. The first was characterised by the mind remaining focussed, open and accepting of the inner experience, including pain. This state tended to be accompanied by a more positive reporting of the labour experience. The second was characterised by the mind being distracted and thought processes featured pain catastrophising, self-judgment and a negative evaluation of pain. Although these two mind states appeared to be distinct, women could shift between them during labour. Women's evaluations of their pain were further influenced by their personal beliefs, desires, the context and the social environment. Key conclusions: women's state of mind during labour may set the stage for the cognitive and evaluative processes that construct and give meaning to their pain experience. Implications for practice: developing interventions for labour pain that promote positive evaluative processes and cultivate a state of mind focussing on the present may improve women's experiences of labour pain. & 2014 Elsevier Ltd. All rights reserved.
Keywords: Labour pain Childbirth Mindfulness Catastrophising
Introduction The pain experience associated with labour is unique. Although typical experiences of pain tend to indicate injury or disease, labour pain emerges during a normal physiological process where increases in intensity are associated with normal labour
n Corresponding author at: School of Public Health and Human Biosciences, Faculty of Health Sciences, La Trobe University, Bundoora 3086, Australia. E-mail address: [email protected] (L.Y. Whitburn).
progression (Corli et al., 1986; Lowe, 1991). Labour pain is also complex because it is highly variable and multidimensional; evaluations of labour pain range from excruciating to pleasurable in different women or on different occasions (Melzack et al., 1984; Lundgren and Dahlberg, 1998). Labour pain can be a paradoxical experience – one that is both excruciating and desirable in its ultimate outcome of having a child (Lundgren and Dahlberg, 1998). Notably, the intensity of pain experienced does not correlate with women's satisfaction with labour (Hodnett, 2002). Thus, labour pain is a complex phenomenon to understand and, consequently, challenging to manage.
http://dx.doi.org/10.1016/j.midw.2014.04.005 0266-6138/& 2014 Elsevier Ltd. All rights reserved.
Please cite this article as: Whitburn, L.Y., et al., Women's experiences of labour pain and the role of the mind: An exploratory study. Midwifery (2014), http://dx.doi.org/10.1016/j.midw.2014.04.005i
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There is, however, an urgent need to better understand labour pain in order to enhance approaches to supporting women through this experience, to promote physiological birth and positive experiences for women. In developed countries around the world the use of analgesia during labour is escalating (Khor et al., 2000; Declercq et al., 2011; Osterman and Martin, 2011; Australian Institute of Health and Welfare et al., 2012) with a cascade of intervention that follows (Anim-Somuah et al., 2011; Petersen et al., 2013). Although epidurals are recognised to be highly effective for pain relief (Jones et al., 2012) they paradoxically do not enhance women's labour experiences (Anim-Somuah et al., 2011) and are implicated in a cascade of intervention (Tracy et al., 2007). In addition, women's fear of labour pain (Eriksson et al., 2006) is contributing to the rising use of interventions (Bussche et al., 2007), including caesarean sections (Dehghani et al., 2013). There is a need for more diversity in the pain management strategies for women during labour that ideally do not impede their chances of a normal birth. In order to do this we must first better understand this complex pain experience. Pain science literature recognises the complex role of cortical processes in the experience of pain (Elsenbruch et al., 2012; Melzack and Katz, 2013). Pain is understood to be the conscious correlate of the implicit perception that the body is in danger (Moseley and Arntz, 2007) and this process is highly influenced by its meaning (Avila, 2013) and by the social context in which it occurs (Montoya et al., 2004). Over the past decade research has revealed important clues regarding the role of cortical processes in the experience of labour pain. Key predictors of a woman's labour pain experience include her prior self-efficacy for labour (Berentson‐Shaw et al., 2009), her tendency to catastrophise pain (Ferber et al., 2005; Flink et al., 2009; Veringa et al., 2011) and her anxiety sensitivity (Lang et al., 2006; Beebe et al., 2007). A woman's interpretation of the social environment will also influence her experience; labouring women who are accompanied by a continuous carer with whom they feel emotionally connected have a more positive experience (Leap et al., 2010; Hodnett et al., 2012) and use less analgesia (Hodnett et al., 2012). In addition, the cultural environment, such as the philosophies towards childbirth and labour pain of her place of care, will influence a woman's experience of labour and use of analgesia (Christiaens et al., 2010). The unique meaning of the pain to the individual woman seems ultimately to determine the experience she has (Lundgren and Dahlberg, 1998; Callister et al., 2003; Flink et al., 2009) and this evaluative process is influenced by prior experiences, expectations, the social and cultural environment and most likely other factors yet to be identified (Lowe, 2002; Fenwick et al., 2005; Lally et al., 2008). Thus labour pain is a complex phenomenon, an embodied subjective experience that comes about through an interaction between the woman's brain, her body and the labour environment (Whitburn, 2013). This exploratory study aimed to examine women's labour pain experiences within the perspective of modern pain science in order to better understand its complexity, prior to the development of a larger study examining labour pain in a representative sample of childbearing women.
Methods Phenomenology is a research method that allows researchers to explore phenomena in great depth. This is appropriate when investigating complex human experiences such as pain. As we experience the world through our conscious minds, the study of a human experience such as labour pain needs to be accessed through the subjective experience itself (Whitburn, 2013). In addition, pain is a multidimensional construct that is shaped by
its essential meaning to the person within a contextual framework. The phenomenology method involves the study of things as they appear in order to understand the essence of human consciousness and experience (Valle and Halling, 1989). Analysis of the subjective experience uncovers the dimensions and essential meaning of the phenomenon and subsequently leads to a deeper explanation of how and why the phenomenon exists (Hesse-Biber and Leavy, 2010).
Participants The women participating in this study were recruited through a large maternity hospital in Victoria, Australia. Recruitment took place in the hospital antenatal settings while women waited for their appointments. Women not booked for a planned caesarean section and who were expecting a normal vaginal birth at the time of recruitment were invited to participate. Stratified, purposive sampling was used in order to represent both primiparous and multiparous women in the sample, as well as women who were planning to give birth in both the hospital birthing suites and the Family Birth Centre (a midwifery-led model of care at the hospital for women at low risk of complications).
Procedure Women participated in a pre- and post-birth interview conducted by LW. The pre-birth interview was designed to explore women's expectations, fears and ideals regarding the labour and the birthing environment and additionally allowed women to build a rapport with the researcher. The post-birth interview was designed to capture women's experiences of labour pain and this forms the focus of this paper. The post-birth interview was conducted over the phone within four weeks of giving birth at a time chosen by the women and lasted between 30 and 45 minutes. Interviewing over the phone allowed women to break up the interview if they needed to attend to the infant or other necessary tasks. Women were asked to reflect on the birth and describe their memories of the experience from the onset of the 1st stage of their labour through to the completion of the delivery of the placenta. Prompts were given when necessary to encourage women to explore and describe their pain experience from sensory, affective and cognitive perspectives.
Analysis The interviews were transcribed and imported into NVIVO 10 software for data management. The analysis process first involved reading transcripts to gauge a general sense of the whole experience. Meaning units were then identified and organised into categories. Related categories allowed for the emergence of the themes of the text and finally allowed for a meaningful description of the investigated phenomenon. Coding was performed by LW and LJ, and checked by RS and MD. Agreement was reached with all coding and interpretation.
Ethics approval Ethics approval for the research was obtained from Mercy Health and La Trobe University Human Research Ethics Committees (R11/51), and all women gave their written consent prior to data collection.
Please cite this article as: Whitburn, L.Y., et al., Women's experiences of labour pain and the role of the mind: An exploratory study. Midwifery (2014), http://dx.doi.org/10.1016/j.midw.2014.04.005i
L.Y. Whitburn et al. / Midwifery ∎ (∎∎∎∎) ∎∎∎–∎∎∎
Findings
Table 1 Participant characteristics by recruitment location/planned location of birth.
Participants Participant characteristics are presented in Table 1. Of the 20 women who consented to participate in the study, 19 completed the post-birth interview. Four of the 19 women had an emergency caesarean section. One woman could not be contacted for an interview. Overview of findings The data demonstrated how women construct and interpret pain, and how they relate to the pain and to their bodies. A major theme that emerged from the data was the influence of the women's state of mind on their experience of labour pain. The data demonstrated how women's state of mind influenced their relationship with the pain and the interpretation of it. The meaning women associated with their pain experience was influenced by their personal beliefs, desires, the context and the social environment. The experience of labour pain and women's state of mind Women's state of mind influenced their relationship with the pain and with their bodies, thereby influencing their response to, and interpretation of, their experience. Two states of mind were identified, each consisting of a number of characteristics. State 1: Mindful acceptance This state of mind was characterised by women describing their minds remaining in the present moment. This was associated with focus and concentration. In this state, women attended to bodily sensations, and yet were non-reactive to this inner experience. Actions were performed with awareness and thought, and without judgment of the experience or of themselves. Women's minds remained in the present moment: When a contraction would pass I was never worried about the next one (Participant 12) …to breathe through and focus on the one right now (Participant 18) I had no sense of time (Participant 20) The mind was in a zone of concentration where women were focussed on their bodies and bodily sensations: I was just focusing on each contraction (Participant 9) I was putting a lot of attention to my breath (Participant 12) I would try to concentrate on the walking or whatever movement I was doing (Participant 15) Attention was given to sensations, including pain, without judgment: This is it; this is what it will feel like (Participant 10) It's ok; this is the uterus contracting so I can meet my baby (Participant 11) I started to feel the sensation that my body wanted to start to push (Participant 12) I wasn't trying to ignore the pain (Participant 15) The relationship between having a focussed mind and attending to sensations in the body was articulated thus by one woman: If I wasn't so focused I think I would have just felt a blanket of pain (Participant 12)
3
Age, M (SD)
Hospital birthing suites (n ¼9)
Family Birth Centre (n ¼10)
34.8 (3.8)
33.1 (3.1)
Parity, number Primips Multips
5 4
5 5
Level of education, number School less that year 12 Year 12 or vocational equivalent Tertiary
2 0 7
0 2 8
5 0
9 1
4
0
Birth outcomes, number Vaginal birth Vaginal birth with extraction/ forceps Emergency caesarean sections
There was an aspect of open-mindedness and acceptance of the pain, without judgment and without magnification: I knew I was in labour and wasn't going to die (Participant 8) You can't control it (Participant 10) I knew it (the pain) was all normal (Participant 13) …an uncomfortable feeling but that I was glad to be having because it meant things were happening…feeling like it was starting to do some good work (Participant 18) The mind was non-reactive to the inner experience and to the pain sensations: The midwife saying ‘don't be afraid of it really helped…me relax my body and let my body do what it needed to do (Participant 6) I never had any negative thoughts or worrying thoughts…I was also no longer fearful of pain (Participant 12) I wasn't worried about the pain (Participant 13) I wasn't scared of the pain (Participant 15) I remember thinking ‘this hurts, but it also feels awesome’ (Participant 15) Actions were performed with a purposeful awareness: I could focus the pain and the contraction and all of your attention on pushing (Participant 4) I was using the pain (Participant 15) State 2: Distracted and distraught The second category was characterised by women's minds not being present in the moment. This was associated with distractions – either internally or externally generated. The woman did not attend to direct sensations in her body. Rather, she reacted to the experience and her thought processes featured judgment and catastrophising. Women's minds did not remain in the present moment, but rather were concerned with how much time had passed or how much time was still to go: I was looking at the clock and it felt like every minute was an hour. It made me think ‘it's been an hour, why isn't he out yet!?’ (Participant 5) I've been labouring for a day and a half and…I'm only 1.5 cm dilated! (Participant 7) I was focused on not having seen my daughter for 2 days…I got distracted and out of my zone (Participant 8)
Please cite this article as: Whitburn, L.Y., et al., Women's experiences of labour pain and the role of the mind: An exploratory study. Midwifery (2014), http://dx.doi.org/10.1016/j.midw.2014.04.005i
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L.Y. Whitburn et al. / Midwifery ∎ (∎∎∎∎) ∎∎∎–∎∎∎
I was getting frustrated about why it was taking so long (Participant 9) I've got another lot of intense pain coming (Participant 10) I kept looking at the clock and thinking ‘now it's been 5 hours… this could go on forever…by 2.30 pm it should be over…I might still be here tonight’ (Participant 18) Distractions drew women's minds away from the present moment or from their bodies: Had to have the monitor on the whole time and it was really restrictive…The last thing you want when you're in pain or trying to focus is to have to think of something else (Participant 8) The gas was taking my focus away (Participant 9) Women were not attentive to direct sensations and this was linked to a loss of focus: I was focusing on all the outside stuff instead of what was going on inside me (Participant 12) You don't feel the head come out, you just feel the pain (Participant 19) As soon as I lost my focus I started getting pain (Participant 12) Women were judgmental of themselves and the pain, and described a sense of helplessness in relation to the pain: It's not going to go away…it's staying for too long…please do something (Participant 2) I'm so weak, I have no pain threshold…I can't do this (Participant 5) I felt frightened by the pain…when watching the monitor and the numbers going up I would think ‘no, no, no!’…why do I have to go through this pain? (Participant 11) How am I going to cope? (Participant 12) I can't do this, this hurts so much (Participant 17)
They (contractions) felt good because I wanted a natural labour (Participant 8) It didn't feel like a sick pain, it felt like a productive pain (Participant 15) A negative mindset was related to a negative expression of pain and an inability to accept it: Frustrating pain…this is more like chronic pain (Participant 2) I couldn't embrace the pain or work with it because it felt wrong to me (Participant 12) One woman described a monumental moment during her experience that shifted the meaning of the pain: When I found out I'd need a caesarean section it felt more painful because I knew that it wasn't working towards giving birth (Participant 16) Some women did not describe their sensations as painful but they had great difficulty in finding an alternative label for their sensations: …they are the most challenging physical thing I've ever been through but I don't like to use the word pain because I think of pain as being something unnatural happening in my body whereas the labour is something my body is meant to be doing. They are really intense sensations that are quite difficult to deal with but I try not to think of them as painful…it's so hard to find the right word to describe (Participant 6) They were really strong sensations, but I wouldn't have called them painful…I didn't relate it to something bad that I would have to stop (Participant 12) For these women the word ‘pain’ was associated with an undesirable, threatening experience and this did not befit their personal interpretation of the sensations of labour.
Women had catastrophising thoughts about the pain: I realised pretty soon that I had no pain threshold because the contractions hadn't even started yet and I was like ‘oh my God oh my God’ (Participant 5) I was thinking ‘oh my God let it end, will it be over?’ (Participant 11) Oh my God I've got another lot of intense pain coming (Participant 10) …worrying if it (the pain) would be the same as the last, or worse (Participant 11) It wasn't even that bad a pinch, but it was the fear, it felt like a bad pain (Participant 15) Although these two categories of states of mind are distinct, women often shifted between them during labour. The meaning of labour pain and women's state of mind From women's descriptions of pain the underlying meaning that they associated with the experience can be inferred. They described pain in the context of positive, negative or ambivalent mindsets. The meaning of the pain was influenced by women's beliefs about labour pain, their desires for a normal birth, the situation/circumstances at the time and words spoken by their caregivers. A positive mindset was characterised by positive words and associations with the pain: It's positive pain (Participant 3) Once she told me this, the pain was probably still as intense but it was more purposeful (Participant 4)
Discussion Summary of findings The interview data suggest that a woman's state of mind during labour influences the relationship she has to her body and to her pain experience. Two different states of mind emerged from the data, defined by where the mind's attention was – whether it was focussed in the present moment or whether it was distracted away from the present moment. A woman's state of mind was not static during her labour, but rather could shift. When women were focussed on the present moment they appeared to be in tune with their bodies and could attend to direct experiences, such as pain. Although attending to pain they did so without reacting negatively or judging critically – the pain was accepted as one component of their overall experience. The women's physical and social environment could facilitate their ability to sustain this state. Women could, however, be pulled out of the present moment as a result of distractions in the environment. The sounds or display from monitors, bright lighting, the clock on the wall, the actions of those around them, or their own thought processes in response to the events of labour, all could divert their attention. Women became more reactive to physical sensations, leading to worry about impending moments in the labour and about the pain. Negative self-appraisals could lead to a sense of helplessness in relation to the pain and to their ability to cope. In effect, when women's attention was diverted away from the present moment their pain became more threatening.
Please cite this article as: Whitburn, L.Y., et al., Women's experiences of labour pain and the role of the mind: An exploratory study. Midwifery (2014), http://dx.doi.org/10.1016/j.midw.2014.04.005i
L.Y. Whitburn et al. / Midwifery ∎ (∎∎∎∎) ∎∎∎–∎∎∎
The meaning of labour pain varied amongst women. Their descriptions of pain suggested a mixture of positive, negative and ambivalent feelings. This evaluative process was influenced by women's beliefs about labour pain, their desires for a normal birth, the circumstance at the time and what was said to them by their caregivers. Interpretation in light of the literature To our knowledge this is the first study to describe cognitive processes that are related to the experience of pain in labouring women. We have attempted to incorporate modern conceptualisations of pain to reach a deeper understanding of the experience of labour pain. Women's descriptions of being focussed on the present moment can be usefully linked with the concept of mindfulness (Baer, 2003; Kabat-Zinn, 2003). Mindfulness is a particular state of mind that involves moment-to-moment attention and observation of external and internal experiences in a non-judgmental and nonreactive way. In such a state of mind women could notice pain and accept it as part of their experience. Thus, although pain may be emerging from an active threat-response system (Chapman et al., 2008), pain did not re-enter as a subsequent threatening input. Women could accept that they could not control the sensations elicited by, or even the movements within, their body and, thus, were not reacting negatively to the experience. Mindfulness has a long history with traditions such as Buddhism and is now recognised by Western medicine as an effective treatment strategy for certain conditions, including pain (Zeidan et al., 2011). Training in mindfulness is also emerging as an intervention during pregnancy to assist with psychological well-being (Vieten and Astin, 2008; Duncan and Bardacke, 2010; Dunn et al., 2012). It would seem that this state of mind may be ideal for facing challenging tasks accompanied by a significant degree of pain, such as giving birth. Women's focussed attention appeared to allow them to act with awareness and purpose and may have enhanced their abilities to produce the physical and emotional effort required in response to the demands of labour. By maintaining focus it may be that their threat-response systems are able to place more emphasis on mobilising motor and stress-regulation responses that will assist in the progression to giving birth (Chapman et al., 2008). There is evidence in the literature that positive, coping-related thoughts during early labour are associated with shorter labours and reduced interventions (Wuitchik et al., 1989). Remaining in the present moment may also have great value between contractions when women can remain calm, enabling rest, instead of ruminating about the impending pain. This state of mind appears to promote a positive approach to coping with labour pain. The construct of the mind not in the present moment features key elements of a concept known as pain catastrophising. Catastrophising is described as a tendency to focus on and exaggerate the threat value of pain and negatively evaluate one's ability to deal with it (Sullivan et al., 2001; Lumley et al., 2011). Catastrophising has been identified as a key cognitive indicator of the pain experience (Vlaeyen and Linton, 2000; Keefe et al., 2004) emphasising that a pain experience is more defined by how the mind responds to the experience, than by its sensory dimension. Pain catastrophising in labour has been directly associated with labour pain severity and postpartum physical recovery (Flink et al., 2009), and has been reported to be an indicator for the request for pain relief during labour (Veringa et al., 2011). According to the communal coping model, catastrophising serves a social communicative function to help elicit assistance and social support from others (Sullivan, 2012). Catastrophic thought processes help to increase the person's attention to pain
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and their subsequent display of pain behaviour (Sullivan et al., 2001). By communicating their pain, an individual maximises the probability that they will attract and maintain the attention and proximity of potential caregivers (Sullivan et al., 2000). In labouring women, assistance from others is vital to the health and safety of both themselves and their babies. Thus, the catastrophic thought processes displayed by the women in this study can be seen as communicating their need for ongoing assistance from others during the labour and the impending birth. If this ‘social call’ is met, women may feel safe and engage a focussed and mindful state where their pain ceases to be threatening to them. If, however, they feel a degree of isolation or social disconnect (Eisenberger, 2012), their threat-response system may be primed to detect and respond to perceived threats thereby increasing the adversity of their pain experience (Sullivan et al., 2001). The cognitive appraisal model is an additional theoretical framework used to describe the relationship between catastrophising and pain. This model demonstrates that judgments about whether a potential stressor is irrelevant or potentially threatening (primary appraisals) interact with beliefs about coping options and how effective these options may be (secondary appraisals) (Thorn et al., 1999). The ‘magnification’ and ‘rumination’ components of catastrophising are associated with the primary appraisal process in which the individual may focus on and exaggerate the threat value of a sensory input. The ‘helplessness’ component of catastrophising is associated with the secondary appraisal processes in which the individual negatively evaluates their ability to cope with the painful experience. It appears from the data that helplessness featured in the thought processes of women in this study. This suggests that during labour women's minds may be more focussed on evaluating whether they are able to cope with the experience – both the psychological experience associated with labour and the physical effort of giving birth. Whether or not they are able to cope, or whether they need extra assistance, is of vital importance to women's sense of safety and the safety of their child. Thus, a degree of this element of catastrophic thinking may be appropriate in generating a level of hypervigilance to the women's ability to cope with, and successfully accomplish, labour and birth. Sustained catastrophic thinking, however, can heighten the degree of suffering with increasing pain severity and can undermine women's sense of coping. In addition, the heightened pain experience can be detrimental to cognitive task performance (Eccleston and Crombez, 1999) thus interfering with women's ability to control thoughts and focus their minds on the task at hand. The data in the present study suggest that catastrophising occurred when women's minds were distracted from their purpose. While distraction methods have been used in various settings for pain management (Malloy and Milling, 2010), our data suggest that not focussing on the present (un-mindfulness) may set the stage for unhelpful thought processes such as catastrophising and critical self-judgment. Other studies have also identified the inverse relationship between mindfulness and catastrophising in relation to pain experiences (Schütze et al., 2010; Cassidy et al., 2012). The data from this study also suggest that women's pain experiences were shaped by their personal interpretation of the pain. The meaning of the pain was influenced by its context, such as whether women felt the pain experience was progressing them towards a normal birth or whether they were about to be administered an epidural, as well as by the social environment where the words spoken by the midwife could influence women's interpretation of the pain. Labour pain shares these influences and determinants with other human pain experiences (Moseley and Arntz, 2007) but
Please cite this article as: Whitburn, L.Y., et al., Women's experiences of labour pain and the role of the mind: An exploratory study. Midwifery (2014), http://dx.doi.org/10.1016/j.midw.2014.04.005i
L.Y. Whitburn et al. / Midwifery ∎ (∎∎∎∎) ∎∎∎–∎∎∎
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differs in that it is part of a normal physiological process. The data suggest that some women are very aware of this difference and find it difficult to talk about their experience of labour and birth as a pain experience. Strengths and limitations We believe that this study explores important and underresearched concepts relating to women's experiences of labour pain. In an attempt to better understand this pain experience this study has applied the knowledge of modern pain science and a focus on cognitive processes to women's descriptions of labour pain. The findings provide the foundation for future research. There are some limitations of this study. The study was small and exploratory in nature, though the participants included both primiparous and multiparous women from two different models of care. The interview relied on recall up to four weeks after women's labours, but previous work (Simkin, 1991) has demonstrated that women's recall of the events of childbirth is surprisingly accurate even many years after the event. Finally, because this is the first study to our knowledge to describe cognitive processes that are related to the experience of pain in labouring women, it is important that subsequent research explores these concepts further. The authors are currently designing a large longitudinal study with this aim.
Conclusion This investigation into women's experiences has helped to deepen the understanding of labour pain. Women's state of mind during labour may set the stage for the cognitive and evaluative processes that construct and give meaning to their pain experience. Developing interventions for labour pain that promote positive evaluative processes and cultivate a state of mind focussing on the present may improve women's experiences of labour pain.
Conflict of interest statement The authors declare that no conflicts of interest exist.
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