ABSTRACT - Objective: to discuss suffering as a meaning assigned to pain by women who experienced vaginal delivery in hospital. Methodology: Descriptive and qualitative study carried out in a public maternity ward in Rio de Janeiro, Brazil. The informants were ten mothers admitted to hospital who had just experienced vaginal delivery. Data were obtained by semi-structured interviews. Ethics Research Board approved this study. Findings: It was identified three dimensions of suffering related to pain in childbirth, “redemptive suffering”, where childbirth pains are deemed to be a means of cleansing Eve’s sin; “heroic suffering”, when woman signifies this suffering as a heroic act which makes her feel stronger, with enough power for overcoming pain; and “useless suffering”, influenced by technocratic model and which removed any vestiges of cultural or social meaning from the pain in childbirth. Conclusion: To experience pain in childbirth is real and makes women aware of the arrival of their children. This pain is bearable and does not cause any permanent injury to women. Therefore, it does not need to be treated. Nurse midwives, being together with women, could help them to rescue the senses of pain in childbirth and experience it without suffering and without medical interventions.
Keywords: Labor pain; childbirth; pain relief; natural childbirth; nurse midwifery
RESUMO - Objetivo: discutir o sofrimento como um significado atribuído à dor por mulheres que tiveram parto vaginal em hospital. Metodologia: estudo descritivo e qualitativo realizado em uma maternidade pública no Rio de Janeiro, Brasil. Os informantes foram dez mulheres internadas em hospital, que tiveram parto vaginal. Os dados foram obtidos por meio de en-trevistas semi-estruturadas. Este estudo foi aprovado por Comitê de Ética em Pesquisa. Resultados: foram identificadas três dimensões do sofrimento relacionado à dor durante o parto, “sofrimento redentor”, onde as dores de parto são consideradas um meio de purificação do pecado de Eva; “Sofrimento heróico”, quando a mulher significa esse sofrimento como um ato heróico que a faz se sentir mais forte, com poder suficiente para superar a dor; e “sofrimento inútil”, influenciado pelo mod-elo tecnocrático e que removeu todos os vestígios de significado cultural ou social da dor no parto. Conclusão: experimentar a dor no parto é real e faz com que as mulheres estejam conscientes da chegada de seus filhos. Essa dor é suportável e não causa nenhum dano permanente para as mulheres. Por conseguinte, não necessita de ser tratada. A enfermeira obstétrica, estando junto com as mulheres, poderia ajudá-las a resgatar os sentidos da dor no parto e experimentá-la sem sofrimento e sem intervenções médicas.
Palavras-chave: dor do parto; parto; alívio da dor; parto natural; enfermeira obstétrica.
RESUMEN - Objetivo: discutir el sufrimiento como un significado atribuido al dolor por mujeres que tuvieron un parto vaginal en el hospital. Metodología: Estudio descriptivo y cualitativo realizado en una maternidad pública de Río de Janeiro, Brasil. Los informantes fueron diez mujeres ingresadas en el hospital que fueron por vía vaginal. Los datos fueron recolectados a través de entrevistas semiestructuradas. Este estudio fue aprobado por el Comité de Ética en Investigación. Resultados: se identifi-caron tres dimensiones del sufrimiento relacionado con el dolor durante el parto, “sufrimiento redentor”, donde las dolores de parto se consideran un medio de purificación del pecado de Eva; “Sufrimiento heroico,” cuando una mujer reconoce este sufrimiento como un acto heroico que la hace sentirse más fuerte, con poder suficiente para superar el dolor; y “sufrimiento innecesario”, influenciado por el modelo tecnocrático y donde se eliminan todos los rastros de importancia cultural y social del dolor durante el parto. Conclusión: experimentan dolor durante el parto es real y hace que las mujeres sean conscientes de la llegada de sus hijos. Este dolor es soportable y no causa ningún daño permanente a las mujeres. Por lo tanto, no necesita ser tratada. La enfermera obstétrica, que se une con las mujeres, podría ayudarlas a rescatar los sentidos del dolor de parto para que la vivan sin sufrimiento y sin intervención médica.
Palabras clave: dolor del parto; entrega; el alivio del dolor; parto natural; enfermera obstétrica.
Pain in childbirth and suffering: perspectives of Brazilian women
Dor no parto e sofrimento: perspectivas de mulheres brasileiras
El dolor en el parto y el sufrimiento: perspectivas de mujeres Brasileñas
Octavio Muniz da Costa Vargens1; Priscila de Oliveira Macedo2; Alexandra Celento Vasconcellos da Silva3; Jane Márcia Progianti4
1RN; RNM; PhD; Professor. Faculty of Nursing, Rio de Janeiro State University (UERJ). Brazil. E-mail: [email protected] 2RN; RNM; Master in Nursing Science. Casa de Parto David Capistrano Filho. Rio de Janeiro. Brazil. E-mail: [email protected] 3RN; RNM; Substitute Professor. Faculty of Nursing, Rio de Janeiro State University (UERJ). Brazil. E-mail: [email protected] 4RN; RNM; PhD; Associate Professor. Faculty of Nursing, Rio de Janeiro State University (UERJ). Brazil. E-mail: [email protected]
Enfermagem Obstétrica, 2015; 2(1):15-20
Introduction
Psychosocial and cultural factors are quite influential in the way women experience pain in childbirth. These expe-riences may evolve into short and mid-term consequences in maternal healthcare and the mother’s relationship with
her child1-3. In Brazil, the biomedical assistance model adopted by the medical practice since the mid-20th century, which takes pregnancy and delivery into account under the perspective of disease and intervention, instilled in both the
professionals and women the idea of employing actions of intervention as a very necessary step towards the safety of the parturition process4,5. In this conception, the pain in childbirth was one of the most highly debated issues in the medicalization process, considered one of the worst types of pain to be endured. For this reason, this process started being thought of as a problem that should be abolished.
Therefore, in order to solve this pain in childbirth “prob-lem”, doctors caring for pregnant women started counseling women regarding certain therapies6, offering elective caesar-ians, analgesia, and acceleration of the childbirth process by use of exogenous oxytocin. In this perspective, the meeting between the pregnant woman and the medical professional produced the idea of the unbearability of the pain based on the culturally shared medicalization language and medical practices that were associated with political and ideological components grounded on the relations of power5,7.
Specifically in the case of caesarians, the medical justi-fication leans on the fact that the fear of pain in childbirth is due to a lack of psychological preparation of the woman2,8,9. Women began desiring this surgery after the institutionali-zation of the procedure. A fundamental fact in the caesarian institutionalization process was the assignment of a “labor” status to the surgery. Such a fact symbolically implies that the Brazilian woman who has undergone a caesarean totally believes that she has given birth.
On the other hand, in the case of pain reducing medical therapies used in Brazilian obstetrics, an intriguing fact is that they are considered as invasive interventions because they are externally applied to the female body’s physiology. Considering that the woman and her child are naturally able to undergo the physiologic delivery, invasive interventions towards the childbirth physiology represent a higher demand on the body than the natural capacity of response from both mother and baby, thus becoming a potential source of trauma7,10-12. If, on the one hand, the analgesia reduces pain, it also decreases the woman’s sensations. Whenever a pain reducing process in childbirth is thought of as a problem solving action, the chosen therapy is usually exogenous oxytocin. Such a policy imposes the enhancement of uterine contractility, and in our medicalized culture the contraction is the pain itself.
Nonetheless, contradictions regarding the manage-ment of pain in childbirth have been continually stimulating the idea of employing the woman’s own psychology as a satisfactory resource towards relieving painful childbirth sensations, as well as enhancing the respect the woman pays to the meaning of such pain2,13. Brazilian women in general assign different meanings to the pain in childbirth. Among these, we highlight “suffering” as having a remark-able meaning. Bearing that in mind, the present article has the purpose of discussing the idea of suffering as a meaning assigned to pain by women who experienced vaginal deliv-ery in a hospital of a large urban center in Brazil.
The debates around these meanings will certainly contribute to the reflections of healthcare professionals on their obstetric practices, aimed at valuing the evidence women themselves show us as protagonists of the social event of delivery.
Methodology
This descriptive, qualitative-based study approached suffering as one of the meanings attributed by mothers to the pain experienced during childbirth. The qualitative method proved to be the most adequate approach to the objectives of the research, since it unveils the universe of meanings, reasons, aspirations, beliefs, values, and atti-tudes towards phenomena that can not be reduced to the operationalization of variables14.
Setting
The study was carried out in a public maternity ward in the city of Rio de Janeiro, Brazil. The population of Rio de Janeiro more than includes 6,000,000 inhabitants liv-ing in a territorial area of 1,182 km215. The municipality’s territorial area is subdivided into five programmatic areas composed of a group of neighboring districts. The City Hall plans and implements healthcare policy actions intended to meet specific needs in each area.
Sample
The informants were ten mothers admitted to hospital who had just experienced vaginal delivery. The research ex-cluded the women who arrived at the unit already in the fi-nal stages of labour, those who underwent a caesarean, and women experiencing a high-risk pregnancy. All who were included in the study experienced pain during childbirth. Data Collection
Data were collected by semi-structured interviews, starting from an open question regarding the delivery pro-cess, followed by an approach of the women’s experience with pain in childbirth, its several meanings, their feelings towards pain, and the strategies they developed to tackle it.
Data were analyzed according to the thematic analy-sis content method16. Interviews were transcrbed and all portions of the reports that presented common meanings were highlighted. These highlighted portions composed the registration units. Registration units were grouped together and formed the study’s thematic issues.
Ethical considerations
According to the Brazilian and international ethics recomendations, this study was submitted to and approved by the Ethics Resewarch Board. The informants were en-lightened on the study’s objectives and the preservation of their identities, and then signed a consent form.
Results and Discussion
Data analysis allowed us to identify three dimensions of suffering and their essential meanings related to pain in childbirth. We decided to name them as: “redemptive suf-fering”, “heroic sufsuf-fering”, and “useless suffering”. The pain in childbirth as redemptive suffering
According to their statements, women understand that the pain is necessary in the baby’s delivery process. For these mothers, to experience childbirth pain equates
with suffering, described by adjectives like “bad”, “worst”, and “a calvary”. However, they also employed expressions such as “the best moment in anyone’s life”, followed by the adjective “rewarding”, thus reflecting their joy at the end of the process, which points out a redemptive perspective of childbirth pain:
It is hard to explain, but it’s quite exciting [...] there’s a child inside you, and he wants to come out; it’s a very strong feeling […] And we are there, undergoing that process […] it’s very bad but very rewarding at the same time […] It’s bad because you feel the pain […] that’s the best moment in anyone’s life […] it’s the worst part […] very difficult. Coming to the climax, the zenith, looks like calvary […] It’s worth it! (Daisy)
In the statement above, the expression “And we are there, undergoing that process ... it’s very bad” conveys the idea of punishment. In this context, suffering is a necessary step towards the woman’s glory of giving birth to a child. By means of this glory, she can be redeemed of all guilt she’s been carrying for millennia of subservience. These ideas take us back to the Roman Catholic Church’s conceptions, in which childbirth pains are deemed to be a means of cleansing Eve’s sin.
The apostolic letter “Salvifici Doloris”, written by Pope John Paul II in 198417, affirms that suffering is expressed as a punishment by God so that committed sins can be justi-fied. Such argument is based upon the idea of justice, in which God is the “Supreme Legislator”17. The Bible teaches us that the woman suffers with childbirth pain due to the original sin.
However, Daisy’s declaration, for instance, is con-cluded with the expression “It’s worth it!”. In this way, interviewees affirmed that their suffering had reached the “climax”, or the “zenith”. In other words, she signified the end of her suffering. The “Salvifici Doloris”17 makes clear that the redemptive value of suffering is followed by the joy of reaching its salvific meaning. Hence, a sense of “re-demption” is established whenever the woman compares her suffering with Christ’s calvary. On the other hand, being exempt from any guilt, Christ frees man from sin and death.
In the redemption realm, “salvation means freedom from evil; that’s why it is closely connected with suffer-ing”17:7. Due to a lack of a better term, “suffering” was defined as “evil”. Following the insertion of the verb “to suffer”, suffering is not anymore directly identifiable as evil, “but expresses a condition in which man feels the evil, and by feeling it, becomes the subject of suffering”17:3.
The pain in childbirth is signified as suffering. In this context, pain allows the woman to partake of Christ’s suf-fering towards the cleansing of her own sins. In the same apostolic letter, suffering is addressed as being essential to human nature, and the pain of childbirth is taken from an ex-ample in the Bible in the epistle of Romans, chapter 8, verse 22: “We know that the whole creation has been groaning as in the pains of childbirth right up to the present time”18. The sense of redemptive suffering was also mani-fested as a “beautiful feeling” towards others.
It’s not a question of being good [...] it’s a beautiful thing … I mean, in some aspects … it’s a beautiful feeling … to say: hey, I felt pain for my child! (Fleur-de-lis).
The pain of childbirth resembles the suffering of Christ who died for the salvation of every man. Christ’s death and resurrection “revealed the glory, the eschatological glory that was completely overshadowed by the immensity of suffering on the cross”17:14.
The suffering for the benefit of others, expressed by the excerpt “I felt pain for my child” and the unique suffering of the childbirth pain observed in the statement “The pain is one of a kind” transports us to the realm of “marianism”, in which the Christian married woman is inserted into a model of a “suffering and worthy” mother. This sacrificing woman is the one “who died in childbirth, and spends her whole life putting charges on her children over what she has done for them”19,20. Some of the interviewees indicated that women do not feel that they are able to bear the pain, but when the time of delivery comes, they discover that that sensation can be overcome by God’s strength.In this sense, the woman overcomes the pains of childbirth by trusting her God.
I had all that I wanted [...] it was everything the way I desired, thank God! I think that I surely deserved it […] I thought I would not make it, I thought I was going to die […] I really thought I could not do that, I thought I was not able to do that […] And I … will I make it? […] Will I finally make it? […]; I thought that the baby could have any number of physical problems because I am a smoker. But thank God, he showed me quite the opposite […] (Pansy).
We realize that several excerpts of the women’s statements can be associated with ideas of punishment, redemption, trial and trust in God. This dimension of suffer-ing the pain of childbirth reveals the Church’s influence in the formation of the “redemptive” meaning of pain felt by women. In this way, women feel a strong sense in suffering in experiencing pain in childbirth as a way towards redemption. Pain in childbirth as heroic suffering
The suffering produced by pain in childbirth is clearly pointed out by the expression “worst of all”. However, the interviewees believe that delivery necessarily demands that suffering. The suffering generated by childbirth pain is also denoted by the word “best” in the sense that it is good for the woman to feel pain in childbirth, since it is her responsibility to manage the childbirth’s process and climax. The woman signifies the suffering of childbirth pain as a heroic act when undergoing it makes her feel stronger. She compares her power of overcoming pain in childbirth with the virtues of a goddess.
[The contraction] is the worst of all. You know that it is for a good purpose, but it’s the worst part […] I feel stronger […] We feel stronger […] So, I’m feeling like a goddess (Camellia).
Some excerpts in the history of humanity lead us to reflect on maternity as a demonstration of female strength and power. All cultures revered goddesses and these super-natural entities were connected to childbirth, thus reflecting the appraisal of the female21.
Goddess Gaia was one of the first entities to be worshiped by people. She is the great mother, the per-sonification of the ancient motherhood power of the old Indo-European culture. Her history reveals that she suffered excruciating pains for being unable to give birth to her chil-dren, who had been imprisoned in her womb by Uranus22, 23. A study performed in 201024 elaborates on the main characteristics of the goddesses in history. In Iran, goddess Aditya gave birth to seven children who are the deities of space. Bachue, the Inca goddess, gave birth to the first human beings. The gods of nature were born from the separation of Papa, Mother Earth, and Rangi, Father Sky, in the Maori’s myth of creation. Juno, the Roman goddess, was the guardian of women and childbirth. She was the goddess of the obscure, hidden and female things. Her equivalent in Greek mythology was Hera. Juno was deemed to be the Queen of the Sky after the conquest of Britain by the Romans, a title that was conferred to Brigit. According to one of the tales of the Hebrides islands, Brigit was the midwife in the creation of Jesus Christ. The inhabitants of these islands asked Brigit to provide them with successful deliveries. Goddess Ajysyt held dominion over the birth of babies in eastern Siberia. The Egyptian goddess Meskhenet was considered a sacred midwife.
Therefore, womanliness is valued in the figures of goddesses who, as women, give birth to children and even suffered the pains of the parturition process.
Some reflections made on poet Rilke’s works com-pares childbirth to combat. The parturient who dies while giving birth is compared to a hoplite warrior dead in the battlefield25. In this way, women who have the capacity to bear the pains of childbirth, even when they die as a result of these pains, are praised. The woman who suffers in the childbirth process is associated with the strength of male warriors.
Childbirth pains, on the one hand, relate the woman to the warrior male, and on the other, cause woman to feel superior and stronger than man. Women undergo exclusive pains, such as those of childbirth. When they experience those pains, they are made more resistant than men26.
Although pain and suffering often occur together, one may suffer without pain or have pain without suffering5. Furthermore, one can have pain coexisting with satisfac-tion, enjoyment, and empowerment. Loneliness, ignorance, unkind or insensitive treatment during labor, along with unresolved past psychological or physical distress, increase the chance that the woman will suffer.
More recently, a study showed that teenage girls who silently bore the childbirth pains were described using ad-jectives such as “incredible”, “strong”, “self-controlled” and “victorious”. The authors referred to the expression “heroi-cally resisting pain” to imply that isolation was one method those young girls used to face their childbirth pains27.
This concept of suffering via childbirth pain indicates that the parturition process, in distinct times of the history of mankind, was bound to a female status of power and strength. The goddess woman is one who owns the power of giving birth to life. A woman experiencing travail is as
strong as a warrior. A woman that experiences the parturi-tion process is stronger than a man. In this sense, the pain in childbirth is signified as a heroic suffering.
The childbirth pain as useless suffering
A number of interviewees assign a meaning of intense suffering to the childbirth pain, as expressed by the term “bad”. It is worth observing that there are no contradictions in these statements. In other words, the “useless” sense is revealed when only the negative value of suffering is attrib-uted to the pain of childbirth, with no rewards whatsoever connected to the process, as previously presented in this study. These ideas are reinforced when the statements add the adverb “quite” to the adjective “bad”, and also when women use the expression “quite bad”, repeating it several times throughout their statements.
It’s quite a bad pain [...] It’s quite bad to keep feeling that pain (Violet).
The worst pain, the worst pain of all is the pain of childbirth, because for all other pains you can take a medicine and the pain just goes away, but what about the pain of childbirth? (Rose).
This piercing pain is associated with the childbirth pain-reducing medical model due to the biological charac-teristics of the uterine muscle. This model teaches women that uterine contractions in the process of delivery cause too much pain, and that labor is not dependent upon their will; in this way28.
Therefore, this model instructs women that contrac-tions have different funccontrac-tions during their period, labor, and the birthing process, as well as the puerperium. In the delivery process, the uterine contractions origin, propaga-tion and coordinapropaga-tion processes explains the woman’s complaints of pain during uterine contractions11.
The interviewees in this study also associated the pain they felt during the parturition process with an intense suffer-ing, similar to the definition of pain in the biomedical model. When addressing labor pain, words or expressions such as “sensorial and emotional experience”, “affection”, “suffering”, “distress”, “discomfort”, “anxiety”, “thoughts”, “emotions”, “culture”, “ethnicity”, and “raised feelings” are often applied29.
Being a physiological process, the labor was trans-formed into a naturally painful phenomenon, thus contra-dicting the initial definition of pain, in which pain was con-sidered as a disease-related symptom. A study performed in 2011, sheds light on this idea when refers to Medicine having the power to turn physiologic events into diseases4.
Once uterine contraction was associated with pain, the labor became a purely painful process. Thus, the child-birth pain was transformed into a pathologic symptom subject to medical treatment, and the conception of the professionals concerning the relief of such sensation tends to be restricted to pharmacologic methods12,30. That is why women refer to the caesarian as a painless delivery, and to the normal process of labor as one in which women feel strong pain.
I mean, the pain [...] I thought it was time for the baby to come […] they would find a way […] because there are so many painless ways […] Caesarean would be another option […] and there are some alternatives by which you don’t even feel the caesarian (Fleur-de lis).
In the opinion of women, the major advantage of the caesarian is to avoid the contraction/pain sensation30. Medicalization causes pain to lose its personal sense when it is reduced to a technical problem, or a diagnostic signal6. Hence, medicalization removed the pain of labor and wiped out all the meanings assigned to it. In this conception, the pain in childbirth was thought of as a useless suffering. The medicalization contributed to the women’s lossed capacity to accept and to cope with the pain in childbirth. When they begin to perceive it as unnecessary suffering, they reject it4,12.
As a consequence, many women affirm that they should not feel pain in order to bring their children to life. For these women, the prospect of waiting for the time to bring their babies into the world makes the childbirth pain the worst pain of all, since there are efficient painkillers for all other types of pain. This is why the interviewees agree that medical interven-tion is necessary in order to relieve their pain and provide them with compassionate care. That means that they do not need to suffer or fell this useless pain. A major portion of pain is relieved by the uneventful use of conventional obstetric interventions, which provides no other alternative to women but to demand the means for artificial relief12,30. Women’s statements clearly express that useless suffering.
I think that bearing a child should happen differently, not with these strong pains. That’s how a baby should be born […] coming out with no pain. No woman should feel any pain. (Rose).
Women, therefore, have learned to desire medical interventions in order to be rid of the childbirth pain. In the history of the childbirth medicalization process in Brazil, it is clearly observable that the position of middle-class women was favorable towards sophisticated medical assistance in relieving pain in childbirth5.
Women have learned that childbirth pain is a deficien-cy of their body and that they are not capable of bearing it. They also know that Medicine has developed interventions in order to help them relieve the childbirth pain problem. Therefore, as it is viewed as an intense and useless suffering, women wish not to feel the pain of childbirth ever again. In this dimension of suffering, we see that the technocrat model removed any vestiges of cultural or social meaning from the pain in childbirth. That’s why women are not will-ing to undergo it again. In this context, childbirth pain was signified as a useless suffering.
Conclusion
Suffering was one of the meanings assigned to child-birth pain by women who experienced a vaginal delivery. Suffering and pain are not synonyms. It was possible to identify three meanings for suffering: the “redemptive”, the “heroic” and the “useless” suffering. The recognition of these meanings and feelings should be the first step towards
care. Whenever those meanings and feelings are respected and valued, women are made active participants in their own labor process. The childbirth pain is real and necessary to make women aware of the arrival of their children, signi-fying a tremendous change in the direction of their lives, and of the changes that their bodies experienced in such a short period of time. This pain is bearable and surmountable and does not cause any permanent injury to women. Therefore, it does not need to be treated. Whenever women are cared for in that perspective, she can resignify and transcend the pain of childbirth.
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