Pain not part of the plan

Researchers have warned that “antenatal programmes are giving women an unrealistically rosy view of childbirth”, The Daily Mail says today. The Daily Telegraph also covers the story and says that women often believe they will not need pain relief during childbirth. It adds that "new mothers are often shocked at the ’intensity’ of the agony they experience”.

The newspapers report on a review of a selection of studies that compared women’s initial expectations with their actual experience of pain and its relief during childbirth. The researchers found differences between the two when they looked at four areas: the level and type of pain, access to pain relief, control over decision making and the level of control during childbirth.

Obstetrical practice differs between countries, and it should be considered that of the 32 studies included, 22 were conducted in countries other than England. Although this review indicates that women globally may be unprepared for birthing pain, it does not give a clear picture as to the extent of the problem in England.

Identifying such differences provides some direction for future changes in antenatal education and suggests ways to improve support for pregnant women. As the lead researcher says, “people involved in antenatal care should listen to women's hopes for labour while also preparing them for what might actually happen.”

Where did the story come from?

Joanne Lally and colleagues from the Institute of Health and Society at Newcastle University and at the Royal Victoria Infirmary in Newcastle carried out the research. The main author was the recipient of an MRC training grant and the review was part of her PhD. The study was published in BMC Medicine, an open access (peer-reviewed) medical journal.

What kind of scientific study was this?

This was a systematic review of studies that looked at women’s experiences and expectations of pain and pain-relief in labour.

The researchers searched eight databases of medical literature to identify appropriate studies to include. The search resulted in 346 papers of possible interest, of which 277 were excluded upon reading the abstract because they were irrelevant or too specific for the purposes of the review. A further cull of 37 articles was made upon reading the full text. This left the researchers with 32 articles to include in the final review. Thirteen of the studies used qualitative methods and 19 used quantitative methods.

What were the results of the study?

The 13 qualitative studies (six from England) described results from in-depth interviews and questionnaires on small numbers of women to develop insights and form a framework for understanding their expectations and experiences. From these, the researchers identified four key themes for further analysis: the women’s level and type of pain, pain relief, involvement in decision making and control. Within these themes the researchers reported on the women’s expectations, actual experiences of childbirth and, if the original study had reported it, the differences between these.

For the 19 quantitative studies (four from England), the researchers summarised the results in a narrative description of the women’s satisfaction scores and pain-rating scales. For example, the researchers were able to estimate the proportion of women who expected pain to be bad and those who had actually reported that it had been bad.

What interpretations did the researchers draw from these results?

No overall analysis of the results in numbers was possible. However, from looking at the responses to the interviews with the women, the researchers concluded, “If women are well prepared during pregnancy, then they are more likely to have realistic expectations of the levels of pain, less likely to feel a failure, have increased confidence, which in turn can lead to more a positive experience.”

The researchers suggest, “If we are to improve women’s experience of labour, we need to look at how the expectations of these women can be brought more in line with their actual experience.”

What does the NHS Knowledge Service make of this study?

This review identified a difference between women’s expectations of childbirth and their actual experiences of it. Several aspects of qualitative and quantitative systematic reviews should be considered when assessing this study:

• Small studies are usual in qualitative analysis because the methods require detailed analysis of exactly what is said in interviews and structured questionnaires. The number of participants in these qualitative studies ranged from eight to 202 and the studies varied in their design. This makes it hard to be sure that a summary of the results would apply to all pregnant women. The quality of the studies was assessed by the researchers, but was not reported for all studies. In general, qualitative research is good for generating some insight into areas for further study.
• The number of participants in the quantitative studies ranged from 60 to 6459 and these reported the results from questionnaires and interviews. They were assessed for quality, but it is not clear if any were excluded because they were of low quality; for example if they had unacceptable levels of bias or unclear methods.
• Pregnancy care and childbirth practices differ between countries. It is not clear how the practices and experiences in other countries are relevant to the UK as the details of antenatal care were not provided.

This study has added to the knowledge and provided insight into the experience of childbirth and how women are prepared for it. This insight should inform how antenatal classes are provided and guide areas for future trials that compare different methods of antenatal preparation.