Pain Childbirth

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The Pain of Childbirth:Perceptions of CulturallyDiverse Women

yyy Lynn Clark Callister, RN, PhD, Professor,*

Inaam Khalaf, RN, PhD, Assistant Professor,

Sonia Semenic,RN, PhD(c), Robin Kartchner, RN, BSN,and

Katri Vehvilainen-Julkunen, CNM, PhD, Professor

y ABSTRACT:The pain experiences of culturally diverse childbearing women are

described based on a secondary analysis of narrative data from phe-

nomenologic studies of the meaning of childbirth. Study participants

were interviewed in the hospital after giving birth or in their homes

within the first weeks after having a baby. Transcripts of interviews

with childbearing women who lived in North and Central America,

Scandinavia, the Middle East, the Peoples Republic of China, and

Tonga were analyzed. Participants described their attitudes toward,

perceptions of, and the meaning of childbirth pain. Culturally bound

behavior in response to childbirth pain was also articulated. A variety

of coping mechanisms were used by women to deal with the pain.

Understanding the meaning of pain, womens perceptions of pain,

and culturally bound pain behaviors is fundamental in order for

nurses to facilitate satisfying birth experiences for culturally diverse

women.

2003 by the American Society of Pain Management Nurses

Every year in the United States over four million women give birth. Childbirthrepresents a major pain experience that accompanies the normal physiologicprocess of giving birth. Birth is also a profound psychosocial experience.Childbirth may be viewed as a test of womanhood, a test of personal compe-tence, a peak experience, and the first act of motherhood. The origin of the

word birth is from the Old Norse word burdinrorbehr, which seems to implyto bear or to endure. Women interviewed about their memories of painexperiences throughout their lives report that the pain of childbirth was the

most memorable pain they had experienced (Niven & Brodie, 1995). Childbirthpain is a unique and complex sensory and affective experience that differs fromthe acute or chronic pain of disease, trauma, or surgical or medical procedures(Niven & Murphy-Black, 2000; Sittner, Hudson, Grossman, & Gaston-Johannson,1998; Waldenstrom, 1996; Yerby, 1996). Birth is characterized by pain but alsoby the most positive of life events[creating] a new life (Niven & Gijsbers,1996, p. 131).

Although childbirth pain is a unique experience for each individual woman,how the woman perceives and makes meaning of her pain, as well as her pain

From the *Brigham Young

University College of Nursing,

Provo, UT; University of Jordan

Faculty of Nursing, Amman,

Jordan; McGill University,

Montreal, Quebec, Canada;Intermountain Health Care,

Provo, UT; University of Kuopio

School of Nursing, Kuopio,Finland.

Address correspondence and reprint

requests to Lynn Clark Callister, RN,

PhD, Brigham Young University

College of Nursing, 136 Kimball

Tower, Provo, UT 84602-5544. Tel:

801-422-3227; Fax: 801-422-0536;

E-mail: [email protected]

2003 by the American Society of

Pain Management Nurses

1524-9042/03/0404-0000$30.00/0

doi:10.1016/S1524-9042(03)00028-6

Pain Management Nursing, Vol 4, No 4 (December), 2003: pp 145-154


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related behaviors while giving birth, are culturally de-

fined (Baker, et al., 2001; Moore & Moos, 2003; Schott& Henley, 1996). According to classic studies byZborowski (1952), each culture has its own languageof distress, expressed both verbally and nonverbally.The pain of childbirth is no exception.

Women give birth within their sociocultural con-

text, which affects the psychosocial and physiologicperceptions of pain (Bates, 1987; Shilling, 2000). Inclassic anthropologic studies of childbearing, Kay(1982, p. 17) concluded that, Pain in labor and child-birth is expected by women in all societies, but may beinterpreted, perceived, and responded to differently.

A strong association was found between cultures and

womens beliefs about and behavior in connection

with childbirth pain (Weber, 1996). Pain is a culturallydefined physiologic and psychosocial experience.

LITERATURE REVIEW

Few studies have focused specifically on perceptions

of childbirth pain in culturally diverse women. Cross-cultural studies on childbirth pain are summarized inTable 1 (Green, 1993; Harrison, 1991; Lee & Essoka,1998; Morse & Park, 1988; Pathanapong, 1990;

Weisenberg & Caspi, 1989). In a study of three groupsof Arab women, among Bedouin women there was anabsence of pain behaviors, yet on a visual analog scale,

TABLE 1.

Studies of Culture and Childbirth Pain

Author(s) Research Focus Sample Method/Tools Results

Chang, et al. (2002) Effects of massage onpain and anxietyduring labor

n 60 primiparousChinese womengiving birth in Taiwan

Randomized trial PBI(Present Behavioral

Visual AnalogueIntensity) Scale

Massage helpful inreducing pain andanxiety

Fouche, et al. (1998) Psychological needs oflaboring women

n 30 African women Interviews Culturally appropriatecare may reduceanxiety and pain

Green (1993) Expectations andexperiences ofchildbirth pain

n 700 Englishwomen

Survey (92% return) Anxiety about painstrong predictor ofnegative birthexperiences

Harrison (1991) Pain experiences ofArab women

Visual Analog ScalePBI

Bedouin women noless pain butabsence of pain

behaviorsLee & Essoka (1998) Cultural differences/

similarities inchildbirth painperception

n 67 Euro-Americanwomen

n 57 Korean-American women

Visual Analog ScaleInterviews

Significant differencesin quality of andoverall evaluation ofpain, no significantdifferences in painintensity

Morse & Park (1988) Cultural differences inchildbirth painperception

Western Canadianwomen

n 191 Anglon 48 Ukraniann 41 Butteriten 22 East Indian

Ratings of pain (pairedcomparisons)

Pain perceptionshighest in Anglowomen, secongamong East Indianwomen, thirdHutterite women, andlowest amongUkranian women

Pathanapong (1990) Childbirth paincommunicativebehaviors

n 32 Thai women Observations ofbehaviors

Pain expressed subtlyin nonverbal quietmode

Weisenberg & Caspi(1989)

Effects of culture onchildbirth pain

n 30 Westernwomen

n 53 Middle Easternwomen giving birth inIsrael

Visual Analog ScaleObservations of painbehaviors

Eysenck PersonalityInventory

Miller Behavioral StyleScale

Higher pain ratings andmore pain behaviorsin Middle Easternwomen, nosignificantdifferences in copingstyle

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pain intensity scores were similar to those of womenin the other two groups (Harrison, 1991).

Similarities were found in the use of word de-scriptors of pain across cultural groups, with the word

pain used to characterize the most intense discom-fort, the word hurt used for less severe discomfort,and the word ache used for the least severe pain.Pain perception is composed of highly interactiveemotional, cognitive, as well as sensory components(Gijsbers & Niven, 1993, p. 55).

Significant variances in labor pain have been as-

sociated with confidence in the womans ability tohandle labor, preparation for childbirth, and the phys-iologic intensity of labor (Brown & Lumley, 1998;Goldberg, Cohen, & Leiberman, 1999; Nichols &Gennaro, 2000). Because studies of childbirth paindepend on retrospective recall, previous emotions and

expectations concerning pain may be overshadowedby positive maternal and newborn outcomes.

Lowe (2000; 2002) has detailed numerous issues

related to self-efficacy, personal control, and pain man-agement in childbearing women. Her landmark workemphasizes the complexity of the multiple variablesthat influence the pain of giving birth.

PURPOSE AND METHOD

The purpose of this secondary analysis of cross-cul-tural phenomenologic studies is to report on the per-

ceptions of culturally diverse women regarding thepain experience of childbirth. These data were gath-ered in a series of phenomenologic studies that fo-cused on the cultural meanings of childbirth (Callister,1992, 1995; Callister, Lauri, & Vehvilainen-Julkunen,2000; Callister, Semenic, & Foster, 1999; Callister &

Vega, 1998; Callister, Vehvilainen-Julkunen, & Lauri,1996, 2001; Kartchner & Callister, 2003; Khalaf &Callister, 1997; Semenic, Callister, & Feldman, 2003).

Phenomenology is an appropriate method for thestudy of pain (Madjar, 1998). Following human sub-

jects approval and informed consent, interviews were

conducted with childbearing women living in Northand Central America, Scandinavia, the Middle East, thePeoples Republic of China, and Tonga (n 100). Thissecondary analysis answers new questions with exist-ing data from these phenomenologic studies, exam-ines the dimension of childbirth pain, and allows for

comparisons among several related phenomenologicstudies (Burns & Grove, 2001).

RESULTS

Content analysis revealed themes (i.e., patterns oflinked descriptive meanings), vignettes, and clusters

or aggregated narrative descriptions related to the painof childbirth. Participants described sociocultural ex-

periences with pain, attitudes toward childbirth pain,definitions of the meaning of their pain, coping strat-

egies for dealing with the pain, and culturally pro-scribed behaviors related to the pain of childbirth.

Attitudes, Perceptions, and Meaning of

Childbirth Pain

Study participants described their attitudes toward,perceptions of, and the meaning of childbirth pain.One woman spoke of the difference between herexpectations and the reality of the childbirth experi-

ence:

I had a very easy labor. In fact, I remember being

surprised that my pain wasnt worse.

Because they say its so awful and youre gonna have

to have an epidural. Well, the whole idea of an epidural

really scared me bad. I mean, I just do not like the

thought of someone putting a needle in my spine. And so

I realized that it was an option I had, but I was deter-

mined that I would only use it if absolutely necessary,

and it turned out I got to the hospital so late I didn t

have time. But it was not that bad. I remember, even

during labor, thinking, Well, this isnt as bad as I ex-

pected it to be. Yeah, it hurt a lot.

But it wasnt as bad as I had made it out to be. I was

expecting it to be this horrible, you know you see on

television all the women screaming. I dont remember

ever screaming when I was in labor. It was really a lot

better than I thought.

Another woman sought an unmedicated birth af-ter having an epidural with her first birth because ofthe lack of personal control she felt.

I had my first one in a way I view as traditional,

where the doctor was in control and he encouraged me

to have an epidural. It was such a frightening experi-

ence. Afterwards I thought, This isnt childbirth. Theres

got to be more to it than just having a numb body.

She changed providers and had an unmedicatedsecond birth.

Childbirth was viewed as a bittersweet experi-ence, with paradoxical feelings of love and the chal-lenges of pain culminating in the birth of a child. Worddescriptors used by study participants included burn-ing, stinging, cramping, sharp, stabbing, hot, stinging,heavy, aching, throbbing, tiring, exhausting, and in-

tense. Giving birth was seen as a difficult yet empow-ering experience.

Mastering pain may be viewed as an integral partof a self-actualizing experience. Some women de-scribed a sense of achievement and feeling of pride intheir ability to cope with intense pain, which in-creased their sense of self-efficacy. For example, Finn-

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ish women felt it was essential to trust themselves andtheir bodies to give birth, viewing childbirth as an

experience of wellness rather than illness (Callister,Lauri, Vehvilainen-Julkunen, 2000; Callister, Veh-

vilainen-Julkunen, 1996, 2001; Melender, 2002). Onestudy participant said,

The experience of childbirth made me grow up a lot. It

really did. Ive learned a lot about my capacity. When I

thought I was just too tired to push any more I found

another 15 minutes worth of it. I just learned I have a lot

more strengths than I thought I did. Childbirth brought

me more in tune with my body because I know what my

capacities are: My mental capacity, my strength. I just

know I could do a lot more than I thought I could.

Another participant described the use of the met-aphor of strength in adversity to describe her experi-

ence: I just kept thinking in my mind, Endure to theend. Endure to the end. I feel really proud of myselfthat I did. Another woman who had an unmedicatedbirth following induction related that, My sister said,You always feel like a super hero when you have a

baby and I agree! I did better than I thought I

would!

Religiously motivated women who participated inthe study seemed to accept pain as a necessary andinevitable part of the human experience. One partici-

pant espousing beliefs of the Church of Jesus Christ ofLatter-day Saints framed the pain experience with aspiritual perspective, which lent meaning to her pain:

Right before the baby is born, when his head is push-

ing up against the perineal tissue, it burns like fire. And

really, theres no getting away from it, or not feeling it.

You just have to go straight through it, and push him

through. Its really hard and you cant see that the pain

will be over. But there are so many wonderful blessings

on the other side.

Women described the intense pain associatedwith giving birth as being temporary in nature andworthwhile. A Muslim mother of six said:

There are no words to describe the pain you have to go

through. All I wanted was for [the baby] to hurry up andcome out. But you wont remember once its over. Thats

why you give birth again.

A Tongan woman with three children expressedher feelings this way:

When I was in labor, the pain was something I had

never experienced in the whole world. Right before the

baby was born there was more pain than I could think

of, but then I saw the baby and there was a happiness

more than I could think of.

Becoming a mother was seen as a productive,creative act, articulating a sense of coherence and

attaching a sense of coherence or purpose for this last

event. A first time Finnish woman described how she

visualized childbirth and put the pain she experienced

in perspective:

You dont think about the childbirth process, at least Ididnt. I would simply think about the child. The end

result of all this is not going through labor; the end result

of all this is the baby that you get to hold in your arms.

Thats what I visualized. Thats the most beautiful, most

wonderful moment, and the labor part of itjust dont

think about it because its really bad, and its just what

you have to do to get what you get, and its absolutely

worth it.

An Orthodox Jewish mother described the shift in

her emotions at the moment of birth:

Once he came out, I felt exhilarated. I couldnt believe

that the baby came, that the pain would be over. I wascrying and laughing at the same time from happiness. I

had this flood of emotions. I didnt believe that it was my

son.

Women having medicated births put less empha-

sis on active participation in childbirth. One Orthodox

Jewish woman who had epidural anaglesia/anesthesia

said, As long as I was awake, participating, and

knowing what was going on, seeing her born and

not having to experience the full pain, why not?

Pain Related BehaviorsMuslim women who gave birth in either refugee

camps, at home, or in public hospitals had unmedi-

cated births; of those who gave birth in private hospi-

tals, 50% had medicated births with opioids or epi-

dural anesthesia. In the hospital most women labor

alone, with their husbands rarely present at the birth.

In contrast, women who gave birth at home were

attended by trained midwives and extended female

family members or female friends who gave support

during labor. Muslim laboring women are verbally ex-

pressive, sometimes crying and screaming. During la-

bor devout Muslim women gained their support from

their reliance on God and they asked God to help them

to give birth safely.

Chinese women had unmedicated births in the

hospital, most often without the father of the baby

present but supported by extended female family

members. These women said it was shameful to

scream, and also that such actions expended energy

needed to give birth. Crying out is believed to deplete

the body of energy stores needed for the final stages of

birth. One Chinese mother said, Although it is pain-

ful, it is also easy because women have been having

babies for thousands of years. Chinese women used

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soft voices and demonstrated quiet demeanor whilelaboring and giving birth.

Mayan women living in Guatemala who gave birthat home were attended by village midwives and sup-

ported by extended female family members. Thosewho gave birth in public hospitals were largely unat-tended and unmedicated; those who gave birth inprivate hospitals had the option of analgesia/anesthe-sia. In some instances if an epidural was offered, these

women thought that this indicated that there was aworrisome complication. Silence or saying over and

over the mantra of aiee, yie yies while laboring andgiving birth is considered a sign of strength. Thismantra is a culturally appropriate coping mechanism,since saying this several times in succession requiresslow, deep breaths. Sometimes they cried out to theLord, saying, Dios mio! Jnopeudo! Jnoguantomas!

or My God! I cant bear it any more! but they ac-cepted pain as an obligation of a womans life, withstoic dignity and courage.

Coping Mechanisms for Dealing with Childbirth

Pain

A variety of coping mechanisms were used by child-bearing women. Listening to extended female familymembers stories of their own births in preparation fortheir own provided some women with preparatoryguidance for their own birth experiences, particularlyfor Orthodox Jewish women. Other women had ob-

served and assisted with births from adolescence, orfollowed culturally proscribed behaviors during their

pregnancy. One coping mechanism frequently men-tioned and used during labor and birth was reliance onGod for help, as suggested by a Tongan woman:

When it got to the worst part of the pain thats when

you look up to heaven for Gods help. Sometimes during

the labor I would cry out in pain and say, Jesus, help

me. I felt like God was saving me as I gave birth.

This same reliance was articulated by a Guatema-lan woman, I asked God to let childbirth pass quicklybecause one suffers. I felt closer to God. Another

Guatemalan woman suggested that a laboring womanshould:

Ask God to help you give birth first. [Women] should

pray before the time to give birth arrives. If they dont

pray during pregnancy, they will think of it during

labor. It is better to remember God before you are in

need of His help. No one can take away the pain only

God.

Even women who were not overtly religious usedtheir spirituality as a coping strategy. A Chinesemother said, The most helpful thing to me in givingbirth was that I had a strong will and desire to have

a baby and because of my spiritual support (jing-

shen zhizhu).

Focusing on the hope of a positive outcome sus-tained one first-time Tongan mother who expressed

her faith, The most difficult part were the contrac-tions. I could barely handle them. You need the helpof the Spirit. The fruits of labor are the baby who is

a gift from God.

Some women described conditioning themselvesto give birth as though they were preparing to run amarathon or climb high mountain peaks. They de-

scribed starting out exhilarated, looking forward withconfidence to giving birth (finishing the race). Astime passed and the intensity of the labor experienceincreased, women described being exhausted, dis-couraged, vulnerable, and feeling their confidence slipaway. This time was when these women described the

need for help and support. When empowered by theirown attitudes and with the assistance of others, these

women felt they met and mastered their birth experi-

ence, and some described giving birth as a transcen-dent experience.

DISCUSSION

Limitations of this study include the differing environ-mental contexts of birth. Study participants gave birthin varied sociocultural contexts, in different birth set-tings from home births to giving birth in tertiary care

centers, within a wide variety of health care deliverysystems, and had varied levels of personal and profes-sional support. However, the universality of expres-sion seems to transcend these limitations. The haloeffect of giving birth to a healthy newborn may havesuperseded the negative aspects of the pain experi-ence of childbirth.

Study participants made meaning of their painexperience. This finding is congruent with the social

constructionist analysis of making sense of pain, per-ceived as either malfunction, abuse, or an alien inva-sion, pain as an opportunity for self-growth or spiri-

tual growth, pain as a coping mechanism and controlstrategy, pain as a homeostatic mechanism, or pain aspower (Aldrich & Eccleston, 2000). Searching formeaning may become a powerful coping mechanismfor the woman giving birth (Mander, 2000; Simkin,2000; 2002).

Mastering the pain of childbirth fosters personalgrowth as articulated by Grainger and McCool (1998,p. 256): Birth is an important emotional and spiritualgrowth process, and enduring labor pain may be anintegral part of that growth. The notion of a womantrusting her intrinsic strengths as well as her bodysability to give birth is confirmed in the findings in a



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phenomenologic study of Swedish childbearingwomen (Lundgren & Dahlberg, 1998).

Childbirth pain as an expected and normal part ofgiving birth was described in this study. This finding is

exemplified by Chinese childbearing women. A mid-wife wrote about her clinical observations of Chinesechildbearing women, It is expected that [childbirthpain] is within tolerable range, and is something every

woman has to go through if she wants to have a baby(Cheung, 1994, p. 215). A proverb often used byChinese women is, If you wish to be the best person,you must suffer the bitterest of the bitter. Somereligious and cultural traditions consider acceptanceof ones own pain and suffering as a means of spiritualpurification and growth. Such philosophies may influ-ence whether or not a woman requests pain medica-tion or uses alternative measures to manage childbirth

pain.Behavior in response to childbirth pain is observ-

able. As labor progresses, women may exhibit increas-

ing outward signs of pain, such as being doubled over,moaning, groaning, and making facial grimaces (Chap-man, 2000). Some women may wish to express theirpain in an audible way. Others may respond to pain

with stoicism. Other women quietly draw inward aslabor progresses, focusing and centering, shutting outnoxious external stimuli. Classic work documents thatculture influences the neurophysiologic processes ofpain perception and pain tolerance (Bates, 1987).

The notion of control was articulated by study par-ticipants, defined as the sense a person has of being ableto make decisions and be in control of her situation(Mander, 1998, p. 106). A sense of personal control isincreased as women have a choice in pain management,participate actively in decision making, use their ownpersonal coping strategies, and feel supported by profes-sionals (Hodnett, 2002; Luckman, 1999; McCrea &

Wright, 1999; McCrea, Wright, & Stringer, 2000; Weaver,

1998; Wright, McCrea, Stringer, & Murphy-Black, 2000).

IMPLICATIONS FOR CLINICAL

PRACTICE AND RESEARCHCulture plays a significant role in attitudes towardchildbirth pain, the definition of the meaning of child-birth pain, perceptions of pain, and coping mecha-nisms used to manage the pain of childbirth. Accord-

ing to Schuiling and Sampselle (1999, p. 77), nursescan provide comfort in the presence of pain. Pain doesnot have to be eliminated for women to be comforted,and comforting diminishes pain. The significance ofcomfort cannot be over emphasized (Jimenez, 2000).

Personal and professional support during labor iscritical. Womens responses to childbirth pain may be

modified by support received from caregivers andcompanions (Corbett & Callister, 2000; Enkin, et al.,

2000; Hodnett, 2002). Women who are well sup-ported and confident feel less pain. This idea was

expressed in the images of these childbearing womencomforted by comfort measures, a safe and privateenvironment, reassurance, information and guidance,strengthening of coping resources through encourage-ment, emotional support, and human presence, ableto transcend their pain experience with a sense ofstrength 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 birthingcenters throughout the United States. Thus culturallyappropriate strategies should be generated by healthcare facilities in order to provide multicultural care

(Emang, Wojnar & Harper, 2002). Understanding thecultural meaning of pain is a fundamental prerequisiteif the nurse is to facilitate a satisfying birth experience.

Understanding that there are broad cultural, as well asindividual differences in a womans pain experiencecan lead to more effective and sensitive nursing carefor laboring women and their family members.

A discussion with the woman to develop an indi-vidualized plan of care to manage her childbirth painenhances the womans sense of control and positivelyinfluences the quality of her birth experience. Controlincludes active involvement, taking responsibility, the

provision of information, and the ability to influenceoutcomes (Waldenstrom, et al., 1996).

The pain experience of childbirth can provideopportunities for positive growth or may be a negativeexperience if it is overwhelmingly stressful and the

woman has little sense of control or support. It isimportant to coach the coach in the instance wherethe father of the baby chooses to be the supportperson. Nurses should provide support within the

family context and according to womens cultural val-ues and belief systems (Simkin & Frederick, 2000).

Culturally diverse women giving birth in an unfa-

miliar and highly technologic environment with rou-tine application of procedures and policies and un-known birth attendants who most likely do not sharethe womans culture and/or language are at risk forincreased anxiety and pain (Maclean, McDermott, &May, 2000).

It has been documented that there is often incon-gruence between nurses rating of pain and the per-ceptions of the childbearing woman who is experienc-ing that pain (Baker, et al., 2001; Harrison, 1996;Hoffman & Tarzian, 2001; McCaffery, 1999; McDer-mott, 2000; Sheiner, et al., 2000). A consensus existsamong clinicians that pain should be assessed as the

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fifth vital sign (Mayer, Torma, Byock, & Norris, 2001;

Phillips 2000). When a cultural and communicationgap exists between the nurse and the childbearing

woman, there is disparity between what the woman is

experiencing and the nurses assessment of that pain(Sheiner, et al., 1999, 2000). The Joint Commission onthe Accreditation of Healthcare Organizations has es-tablished pain management standards for accredited

institutions, and the Maternity Center Association hasmade 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 levelof discomfort (Montes-Sandoval, 1999; Sherwood, etal., 2000). It is important that the nurse asks, What is

your level of pain? and Is your discomfort beingmanaged at an acceptable level now? The womansscore on a pain intensity scale is less important than

the womans sense of satisfaction about how her painis being managed (Mackey, 1998). It has been noted

that satisfaction with childbirth is not contingent onthe 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 birthexperience. A painful birth is just as likely to have apositive evaluation as one without pain, depending on

the womans feelings of fulfillment.What is known about labor pain is not integrated

into the information given to women prior to givingbirth, nor is information provided about the clinicalmanagement of pain. What is not known about child-

birth pain is perhaps the most important informationthat can be given to women to assist them in managingthe 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 tra-ditional beliefs, values, and priorities related to pain

and its management (Ahman, 2002; Callister, 2001).

Gaining linguistic skills is an important strategy, sinceit has been noted that shared language may increase

the congruence between how laboring women andnurses rate the pain of laboring women (Harrison,

1996; Jimenez, 1996).A recent issue of the American Journal of Ob-

stetrics and Gynecology provides landmark systematicreviews of the nature and management of childbirthpain (Caton, et al., 2002). These published reports arebased on the Maternity Center Association Labor PainSymposium (Maternity Center Association, 2002a).

More qualitative studies are needed that describecultural beliefs, values, perceptions, and responses to

pain behaviors and preferences for pain management.(Marmor & Krol, 2002). Comparative studies of painperceptions of culturally diverse childbearing women

would be of value (VandeVussee, 1999). Outcomes-focused research is needed to document the effective-ness of holistic interventions in pain management

(Cole & Brunk, 1999; Cook & Wilcox, 1997; Fouche,et al., 1998; Kohn, 2000), such as a recently publishedChinese study on the effects of massage on pain and

anxiety during labor (Chang, Wang, & Chen, 2002).Englands work (1998),Birthing from Within and

Listening to Mothers (Maternity Center Association,2002b), a report of the first national United Statessurvey of womens childbearing experiences can in-crease nurses understanding of the lived experienceof childbirth from the perspective of women them-selves. It is important to acknowledge womens de-scriptions of their experiences as legitimate sources of

nursing knowledge (Young, 1998). Increasing under-standing of the cultural meanings of childbirth pain,coping strategies, and culturally proscribed pain be-haviors will assist in the provision of culturally com-petent nursing care. The quality of the womans birthexperience will thus be enhanced.

ACKNOWLEDGMENTS

Appreciation is expressed for funding from the Brigham

Young University College of Nursing, Office for Research

and Creative Activity; Kennedy Center for International Stud-

ies; Sigma Theta Tau International Iota Iota Chapter; Wom-

ens Research Institute; and to the women who participatedin these studies.

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