Perception of Pain in Hospital vs. Home Birth

By Jill Christianson

In my career as a birth doula and midwife's assistant, I have attended approximately 70 homebirths. Of those births, not one mother transferred to the hospital because she wanted pain medication. Contrast that with the conversation I had with a labor and delivery nurse at one of our local hospitals: I asked her what she thought the epidural rate at her hospital was, and she replied, "Probably about 98%." Even if that was a slight exaggeration, why the vast difference? Are the women who birth at home fundamentally different?

Part of the answer may lie in recent research of elite athletes. Scientists attempt to measure athletes' ultimate limits with tests like lactate threshold and VO2Max, but come up against a problem: the athlete who performs the best on the test is not always the athlete who wins the race. Why? The reason, according to the researchers, is that our brains have too much say in what our bodies can and can't do.

So is it the environment that changes the perception of pain? Or the woman herself who perceives and handles the pain differently? Any experienced birth worker will tell you it's both.

I read a fascinating article a few years back about a midwife who had the privilege of watching a prize-winning racehorse give birth. The foal was already worth about $3 million, so it was imperative that the birth go as smoothly and safely as possible. To that end, there was total privacy and silence. The veterinarian was crouched in the corner with his eyes averted, ready to intervene only if necessary. The midwife passing by was able to observe only as long as she kept quiet and peered over a wall where the horse couldn't see her.

Contrast that with a typical hospital birth: lights are bright. The laboring woman is surrounded by people she's probably never met. The first thing that usually happens is an invasive procedure (the cervical exam). The next thing that happens is answering a battery of questions. After she's finally checked in and left alone to labor, continuous fetal monitoring means there's usually lots of fussing with the equipment. There seems to be a premium placed on speed rather than safety with the frequent use of Pitocin to induce or augment labor. And some care providers pay little attention to the mood of the room or whether the birthing woman is contracting before barging in to the middle of things.

Certainly there are some key differences between horses and humans, but we often forget how primal birth really is. Midwife Ina May Gaskin strongly believes that birth happens best when a mother is able to turn off her brain, and the best environment in which for that to happen is dark, private, quiet, and intimate. In other words, the environment for getting a baby out should be pretty similar to the environment that likely got the baby in there in the first place.

I was reminded again recently of the vulnerability a laboring woman can feel. I was assisting a mom at the hospital, and her provider came in to discuss a possible intervention. He was very respectful, and in my (non-laboring) mind, I believed he came in to state what hospital policy was, and then left in order to let the parents make a decision for themselves. Talking to the mother after the birth, that same conversation left her feeling pressured to comply with hospital policy. After all, she was on their turf, and the provider was an authority figure. The slightest whiff of time pressure caused her anxiety and stress to increase, which in turn affected the way her body labored and her perception of pain.

The Birthing Woman

Here's where the studies on endurance athletes come in. Regardless of the circumstances or the intensity of the experience, both the athlete and the birthing woman have incredible power over their perception of pain. In an article in Bicycling Magazine entitled "The Transcendent Pain", pro cyclists described various methods of coping with, ignoring, or embracing pain, including:

• Coming up with a mantra: cyclist Jens Voigt likes to repeat to himself, "Shut up, legs!" I've heard mothers repeat things like "down baby, down baby," "down and out," "come on, [baby's name]," and "Open, open, open."
• Visualization: one cyclist pictured himself as a superhero while racing; another visualized himself folding up his pain and sticking it in his back pocket. Some common childbirth visualizations are the wave (picturing yourself riding the wave of each contraction and gliding down the other side) and the flower (picturing your cervix as a flower that's opening up with each contraction).
• Emptying your head: Gaskin calls this "letting your monkey do it." For this, you must turn your thinking brain off, ignore your surroundings, and find peace and quiet within yourself, even if your surroundings are less than peaceful and quiet.

Of course, women who are planning to birth at home also have the added benefit of knowing going into it that they will be making it all the way through birth without pain medication if they wish to remain at home. This can lead her to do additional research, stay in shape, take a natural childbirth class, and/or hire a doula to assist her. In fact, research on the benefits of doulas strengthens the argument of "mind over labor": researchers have found that the presence of a doula means the birthing woman actually feels less pain.

Is medication-free childbirth possible in the hospital? Certainly. But it can take a little more preparation beforehand, and some serious vetting of potential care providers to determine how much they strive to create a peaceful, calm birthing environment. The extra work is often worth it in the end, though: like endurance athletes many women describe feeling that same "runner's high" after childbirth. Not a bad state of mind in which to enter another marathon of sorts: parenthood.

Resources:

Ina May's Guide to Childbirth by Ina May Gaskin

"The Transcendent Pain" by Bill Gifford, Bicycling Magazine

"Safer Birth in a Barn", Midwifery Today