Hi, everyone. In this video we’re going to talk about the evidence on painless birth and pain perception during childbirth.

My name is Rebecca Dekker, and I’m a nurse with my Ph.D. I’m the founder of Evidence Based Birth.

If you haven’t already, I recommend that you go back and look at the first video we did about pain management called “An Overview of Pain Management During Childbirth”. The information in that video provides really good background info on this topic.

When we were sharing our videos about pain management during childbirth, some people commented and messaged me asking me if I could talk about the concept of pain not necessarily being part of childbirth because anecdotally some people experience what they would consider to be painless birth.

How many people experience painless birth?

We found a 1998 article in the American Journal of Nursing that suggested that 1% of people, or 1 in 100, do not experience pain during labor or childbirth. Where they got that number from wasn’t cited in the text, but when we went through the reference list we did find a paper published in 1996 where the authors found that 1% of women reported no pain at all during childbirth.

This was a study done in Sweden where they asked women to fill out a survey after their birth experience about their pain. The survey was filled about 45 hours on average after the birth. However, most people in this study had medications for pain management including nitrous oxide or epidurals. Non-drug methods of pain management were also common in this study. The most common methods of non-drug pain management were taking a bath or a shower, using massage, and using deep breathing or relaxation techniques. Forty-one percent of the participants rated their pain as the worst imaginable pain and 1% reported that they did not experience pain at all. Unfortunately, we don’t know anything about what pain management techniques those 1% were using. It’s possible that they were medicated. It’s possible that they were unmedicated. We just don’t know.

Debate over the promise of painless birth

We went back to the 1970s and 1980s to learn about painless birth because this was a hot topic back then. Lamaze’s popular 1970s booked called “Painless Childbirth” suggested that preparing for childbirth could eliminate or drastically reduce the pain you experience during an unmedicated birth. Other researchers disagreed. They thought that this promise was overblown. They thought that childbirth education might lessen or reduce your pain, but it couldn’t eliminate it entirely.

We did a lot of searching and digging trying to find numbers or percentages or other studies that looked at painless birth, and we didn’t have much luck. However, anecdotally there are a lot of reports online of women who say they experienced a very comfortable childbirth, even sometimes unmedicated. A lot of these anecdotes come from families who use the Hypnobabies technique or the Hypnobirthing technique. We’re going to cover hypnosis for pain management during childbirth in a separate video.

State of mind and pain perception

For the rest of this video I want to talk about how your state of mind could influence how you perceive pain during labor and birth.

Common beliefs about pain

In the Netherlands, only about 22% of mothers give birth with an epidural compared with 61% in the United States. Researchers there recently conducted indepth interviews with 40 women post-partum to try and understand how those who experience a natural labor perceived their pain.

Some of the women gave birth at home and others were in a hospital setting. They found that these women who choose to have a natural labor without pain medications shared some common beliefs. They believed that birth is a normal and natural process. They trusted in their body’s abilities to give birth. They believed that medicines for pain are best avoided unless they become necessary, and that pain is a manageable, acceptable, and normal part of the birth process. They believed that epidurals take away some of your control over the birth process, and having a sense of control during childbirth was very important to them.

“Mindful Acceptance” versus “Distracted and Distraught”

In 2017, researchers in Australia did face-to-face interviews and written surveys to understand how people’s state of mind related to how they experienced labor pain. The first part of their research was published in 2014. They discovered that there were two distinct states of mind that women might experience during labor.

One was called mindful acceptance. This meant that a woman was focused on staying in the present moment. She might say something like, “When a contraction would pass I wasn’t worrying about the next one,” or “I lost sense of time.” The other potential state of mind was being distracted and distraught. This state of mind was linked to higher levels of pain. Examples of this might be, “I was looking at the clock and it felt like every minute was an hour,” or “I was dreading the next contraction,” or “I was distracted by the people in the room.”

Later in 2017, they published their findings that when mother’s interpreted their pain as productive and having a purpose that this was linked to positive emotions and that they were better able to cope. In contrast, if they interpreted the sensations they were feeling as threatening, this was linked to negative emotions and the feeling that they needed medical help to relieve the pain.

This reminds me of the TV series of Victoria. Queen Victoria was one of the first to use medication to be sedated during labor. On television when they depict her first birth leading up to it, as soon as labor started, you could see that she was very frightened and she felt very threatened and afraid that she would die. They showed her as experiencing severe pain along with that fear.

Social environment

Your social environment, including your care providers, family, and hospital staff can greatly influence your pain perception. In other words, the social interactions you have during labor can affect your state of mind, which then affects your thoughts and emotions, which then leads to influencing how you interpret your pain. Social interactions might leave you interpreting your pain as manageable and productive, or unmanageable, scary, and threatening. This means that the words and actions of individuals who interact with laboring people has the power to influence how they perceive their pain.

Nocebo effect (preconcieved ideas)

Researchers have also described something called the nocebo effect. Most of you are probably familiar with the placebo effect, which is when you take something and you anticipate a good outcome, so you experience good effects. In contrast, the nocebo effect leads you to anticipate a bad effect, and then you go on to experience a bad effect. In terms of pain with labor, it means that on some level you experience the amount of pain that you expect to experience.

With so much cultural focus and fears about pain and childbirth, we can really be setting people up to expect to experience more pain in childbirth, thus leading them to experience more pain in childbirth.

Stressors in the birth environment

How does the birth environment influence how we perceive pain during labor?

There was a really interesting study where researchers interviewed 300 first-time mothers and 300 experienced mothers who were giving birth at a hospital in Iran. They used a scale to measure pain during labor, and then after labor the women completed surveys about the environmental stressors that they experienced or didn’t experience.

First-time mothers most often reported that a crowded delivery room and restrictions on movement were sources of environmental stress. Experienced mothers reported that noise in the delivery room and restrictions on drinking oral fluids were sources of environmental stress.

Their findings showed that environmental stressors may aggravate birthing people’s anxiety and pain levels. Loud noise increases fear, which can make a person more sensitive to pain. The temperature in the room, the brightness in the room, and the feeling that you’re being observed can also stimulate the brain to release stress hormones which can influence the perception of pain.Care providers can help to reduce pain by reducing the stress levels in the room.

Home birth setting

Interestingly, a study of about 17,000 planned home births in the United States found that only 281 people, that’s less than 2%, transferred to the hospital for additional pain relief during labor. This suggests that as many as 98% of people are able to cope with labor pain in their home environment; however, a minority will still require additional pain relief from medication.

Relationship between pain relief and satisfaction

Finally, I want to talk about the relationship between pain relief and childbirth satisfaction. A common belief in our society is that effective pain relief during childbirth leads to high satisfaction with your birth experience. However, the relationship between labor pain and satisfaction is surprisingly complex. Researchers have found that for some people, effective pain relief is an essential component of their satisfaction, but other people place a higher priority on other aspects of their birth experience.

In one study, researchers surveyed women post partum about their pain management experience and their satisfaction after the birth. They found that people who had epidurals reported effective pain relief and high levels of satisfaction. However, surprisingly, people who used nitrous oxide had varying levels of success with their pain relief, but almost all of them had high satisfaction with their childbirth experience.

Another study looked at women planning an unmedicated childbirth. They found that women who wanted and achieved an unmedicated birth were highly satisfied. Those who planned a natural childbirth but had an epidural, reported effective pain management but less satisfaction.

Basically, people are happy when they get what they want

A way to summarize all of this is that people are generally happiest when they get what they want. If people want the high quality of the pain relief that goes with an epidural and they get it, then they’re happy. But if for some reason their epidural doesn’t work or isn’t effective enough, they probably won’t be happy.

At the same time, if someone wants to avoid medications for pain relief, and they’ve prepared for it and they have supportive care, then they’re usually pretty happy too if they’re able to get it, despite not having medications for pain management.

This is a critical point for healthcare workers. To understand that some mothers can be highly satisfied with their birth experience even if they report having less effective pain relief.

Hodnett 2002 Review

There was a classic study published by Hodnett in 2002 where they looked at 137 studies on childbirth satisfaction. She concluded that there are four factors that influence how satisfied you are even more than pain relief does.

The most important predictors of how satisfied you are with your birth include your personal expectations going into the birth and how they were met, the amount of support you got from your caregivers, the quality of the caregiver and patient relationship, and whether or not the mother felt like she was involved in decision-making.

Conclusion

In summary, it’s not clear how often painless birth occurs. One percent is the number that is most frequently cited in books and blogs and websites, but that estimate comes from a 1996 study in which most people received pain medications. However, there are a lot of anecdotes and stories shared online from people who report experiencing a painless natural childbirth.

We did find research evidence that there’s a lot of different things that can influence how you perceive pain during labor.

Factors that influence pain perception

Research shows that pain is highly subjective. People actually experience less pain when they interpret the pain as more positive or productive, and they experience more pain when they perceive it as threatening or serving no purpose. Labor is also perceived as less painful when the mother is able to focus on her breath and just take each contraction as it comes without worrying about the next one. In contrast, labor can be perceived as more painful when the laboring person is focused on the time, distracted, fearful, or not able to focus because of internal or external stressors.

Environmental stressors can cause anxiety which can increase perceived pain levels. Commonly cited sources of stress in the labor room include crowding, noise, restrictions on movement, restrictions on drinking, and bright lights. The good news is that all of these things are fixable if we just pay attention to them and eliminate them when possible.

Factors that influence maternal satisfaction

Hodnett claims that the most powerful influences on childbirth experiences and satisfaction are how the caregiver interacts with the laboring mother. When mothers feel supported, they’re more likely to feel safe and be able to cope well with labor pain.

Research shows that people can be highly satisfied with their childbirth experiences whether or not they felt like their pain was effectively managed. In other words, effective pain relief is an influence but not a requirement for high maternal satisfaction with the birth experience.

That’s it for this video. Thanks so much for watching. Feel free to check out our other videos all about pain management during childbirth. You can also catch us on our podcast, “The Evidence Based Birth Podcast,” and listen to all of those videos there as well. Thanks everyone and bye.

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