Towards A Feminist Epistemology of Labor Pain
Purpose
We heal our tongues… We give testimony. Our noise is dangerous
(Mirikatani p. 202).
The purpose of this qualitative, phenomenological research proposal is to describe the essential structure of the lived experience of labor pain, as it occurs within the larger context of childbearing in women's lives. The focus of this research will be on generating descriptions of labor pain, which emanate from the narratives of women who have labored in childbirth, so that a clearer picture of the relationship between a woman's experience of pain in labor and the meaning she ascribes to it might emerge. It is anticipated that this information might contribute to a more clearly delineated and comprehensive theory of pain management within midwifery practice.
Context of the Study
For generations, pregnant women have asked their birth attendants to help them cope with pain in labor. In response, birth attendants have endeavored to identify the causes of labor pain, while searching for safe and effective means to alleviate it. Throughout the course of Western history, while women and their caregivers struggled with the immediacy of the problem, the subject of labor pain generated debate and controversy. “Childbirth is an intimate and complex transaction whose topic is physiological and whose language is cultural” (Jordan in Callister, 1995, p. 327). As such, cultural values and norms influence the availability and the desirability of the various methods of pain relief that technology offers.
Biblical injunctions admonished women that God “will increase your labor and your groaning, and in labor you shall bear children” (Genesis 3: 16, New Oxford Study Edition). Pain in childbirth was interpreted to be God’s punishment for Eve’s introduction of “sin” into the world, and it was intimately connected to women’s perceived subordination to men. Women in the Middle Ages could be buried alive if they accepted pain relief (R. Weiss, on-line article), and midwives working during these burning times, were killed as witches because the church feared their knowledge of birth and healing (Rothman, 1982).
During the Victorian era, pharmacological pain relief became accepted after Queen Victoria used medication to ease the pain of birth. During this same period of time in the United States, birth moved into the hospital, doctors replaced midwives as birth attendants, and pain relief was sought through pharmacological means (Rothman, 1982).
During the 1970s, the social movements of natural childbirth, health care consumerism, and feminism all converged in an effort to reform birth (Rothman, 1982; Patterson & Peterson, 1980; Mathews & Zadak, 1991). Some of the modifications that women demanded in the birth environment were the presence of a support person during labor and delivery, to be awake and aware for the delivery, and rooming-in of the baby in a more family-like environment (Hazell, 1975). Concerns regarding the safety of medications during labor and delivery were also raised (Arms, 1975).
More recently, debate has centered on the “epidural epidemic” with epidural use rates approaching 85% in some areas (Richardson, on-line article). Women often welcome the opportunity be pain-free during labor and delivery while remaining awake and aware, but epidural use is not without risk. Risks associated with the procedure include adverse reaction to the medications used, ineffective pain blockade, infection, bleeding, low blood pressure, decreased uterine perfusion resulting in fetal bradycardia, inability to ambulate and urinate without assistance, spinal headache, spinal injury, and rarely paralysis and respiratory or cardiac arrest (Thorpe, J., & Breedlove, G., 1996). In addition some have argued that epidural use increases the risk of instrument deliveries and cesarean sections (Thorpe, J., & Breedlove, G., 1996).
Currently, about four million women give birth in the United States annually (US Census Bureau on-line statistics), and fewer than 1 % of these women report a painless childbirth (Waldenstrom et al., 1996), The debate on pain relief in labor continues.
Research Questions
The general question is: How do women describe the experience of labor pain? More specific questions to be addressed include the following:
1. What words and phrases do women choose to describe their experience of labor pain?
2. What meaning, if any, do women ascribe to pain in labor?
3. How do women interpret labor pain within the larger context of childbearing?
4. Does a woman’s response to pain in labor influence her feelings and attitudes about herself as a woman? As a parent?
Despite widespread acknowledgment regarding the multifactoral nature of labor pain, it remains difficult to find a comprehensive definition of it in the literature that takes into account all these factors. The leading textbook of nurse-midwifery in the United States never defines labor pain in its discussion of pain management (Varney, 1997). This unfortunate shortcoming typifies the professional debate on labor pain, and contributes to the confusion regarding what it is we are trying to measure and manage when we study pain in labor. Most of our knowledge development on the concept of labor pain has concentrated on trying to determine the causes of labor pain intensity, while advancing our skill at reducing its severity for the women who desire such help. This is an important aspect of the pain management services we offer women. However, there remain critical gaps in our understanding about women's experience of labor pain, which limit our ability to respond to women in a comprehensive manner.
We know that women remember giving birth and the care they receive for a long time (Niven, 1995; Simkin, 1991; Slade, 1993), and that over-all satisfaction with giving birth may be important to maternal mental health and adaptation to parenting (Green, Kitzinger & Coupland, 1990). Numerous studies have investigated the experience of pain in labor, and the role it plays in a woman’s over-all experience of giving birth, yet much about the experience remains elusive. Some have hypothesized that the tendency to assume an inverse relationship between negative and positive emotions has contributed to methodological mistakes and problems in interpreting findings, because childbirth is a complex event in which both types of emotional experiences may co-exist (Slade, MacPherson, Hume, & Maresh, 1993). Some researchers have hypothesized that a woman's satisfaction with her pain coping strategies, including her use of medication, may be related to whether or not it contributes to her sense of being in control of the events surrounding her child’s birth (Simkin, 1991; Waldenstrom et al., 1996). Other research confirms these findings (Green, 1993; Halldorsdottir, 1996; Slade, 1993; Waldenstrom, 1996).
First person narratives of pain in labor might illuminate the relationship between the experience of pain, and the need for personal control. Clinicians would then be better able to assist women in selecting pain coping strategies that safely promote a woman’s sense of mastery of this important life event.
Assumptions
This author believes that childbirth is a socially constructed event, possessing social, psychological, sexual and spiritual meaning for individual women that the biomedical model is unable to capture. This assumption guides this research proposal. This author further asserts that the subjective material obtained through the use of qualitative methods represents not only a valid, but also a crucial research strategy, in our endeavors to comprehend the complexity of physiological events imbued with personal and social meaning. It is also the belief of this author, that over-reliance on quantitative methods of inquiry, has hindered our ability to locate apt scientific metaphors for the experience of labor pain.
Definition of Terms
For the purposes of this paper, this author will define labor pain as the sensory and emotional experience associated with uterine contractions leading to cervical dilation, fetal descent, and the birth of a child in human childbearing.
Conceptual Framework
The introductory paragraph of the American Academy of Nurse-Midwives states, “Certified nurse-midwives believe that every individual has the right to safe, satisfying health care with respect for human dignity and cultural variations. ACNM further supports each person’s right to self-determination, to complete information and to active participation in all care. ACNM members believe the normal processes of pregnancy and birth can be enhanced through education, health care, and supportive intervention” (ACNM, 1989). In a 1989 article published in the Journal of Nurse-Midwifery, the need to begin building a descriptive theory of midwifery care based on the ACNM philosophy was addressed. The authors identified seven key concepts in the ACNM philosophy for which they listed the distinguishing components and empirical indicators. The concepts identified include: safe, satisfying, respecting human dignity and self-determination, respecting cultural and ethic diversity, family-centered, and health promoting (Thompson, J., Oakley, D., Burke, M., Jay, S., & Conklin, M., 1989). The concepts most germane to this undertaking are safe, satisfying, and respecting human dignity and self-determination.
Feminism and Connected Knowing
McCool & McCool (1989) presented a historical overview of the relationship between midwifery and feminism. Relevant to this research is the discussion on feminism and nurse-midwifery. The authors note how nurse-midwives are in a “special position to document and study the unique health experiences of women throughout their lifespan” (p. 331). They address the difficulty confronted by researchers attempting to adopt a woman-centered approach while still relying on the perspectives of medicine and nursing. They challenge midwifery to explore feminist research methods, which focus on women’s experience, making women more visible, invalidating the artificial distinction between subject and object in research, and possess an ethical concern for women and their families.
Another contribution from feminist theorists, of particular interest, is the feminist developmental model of mind, first postulated in Women’s Ways of Knowing, by Belenky, Clinchy, Goldberger, and Tarule (1986). These feminist researchers noted that women tended to "ground their epistemological premises in metaphors suggesting speaking and listening” (Belenky, et al 1986, p.18). The relationship to intellect implicit in the metaphor of voice and silence reveals a way of being in the world that is conversational and connected. This contrasts sharply with visual metaphors that implore the subject to maintain clearly delineated boundaries between the self and the object under observation. Despite the fact that this theory was originally intended to help us comprehend the educational implications of gender differences in the development of mind, this author believes this theory has much to offer researchers and clinicians attempting to understand the experience and meaning of labor pain. Qualitative research conducted from within this theoretical framework, has the potential to generate narrative descriptions of labor pain quite different from the data currently being produced from perspectives that encourage objectivity and distance.
The concept of “connected knowing” developed by the same feminists theorists, refers to an approach to learning which values both subjective and objective strategies, while recognizing the social construction of knowledge. Connected knowers recognize that “All knowledge is constructed and the knower is an intimate part of the known” (Belenky, et al, p.137). It encompasses a high degree of tolerance for contradiction and ambiguity. It recognizes the individualistic nature of experience, without succumbing to the epistemological relativism inherent in the subjectivist stance. “It is important to distinguish between the effortless intuition of subjectivism, in which one identifies with positions that feel right) and the deliberate imaginative extension of one’s understanding into positions that initially feel wrong or remote” (Clinsky, p.205). This potential for imaginative extension, inherent in connected knowing, offers us the possibility of healing the mind-body split which has permeated Western medicine since the seventeenth century, and limited our efforts to understand and respond to women’s labor pain.
Literature Review
The wide range of labor pain's expression is recognized by seasoned clinicians; and like all pain, it is believed to be comprised of both sensory and affective components, and these components are in turn are influenced by a variety of physiological and psychosocial variables (Brownridge, 1995; Gabbe, 1996; Hopkin, 1997; Melzack, 1981). The physiological mechanisms responsible for uterine nocioception are not completely understood. Most researchers attribute first stage labor pain to distention of the lower uterine segment and dilation of the cervix during uterine contractions. During the bearing down efforts of second stage labor, pressure of the fetal presenting part on nerves and soft tissues as it passes through the pelvis and birth canal, is considered a pain stimulus. The role of uterine ischemia in labor pain is debated, as myometrial blood flow increases, while intervillous blood flow decreases. Uterine contraction pain in labor resembles other forms of abdominal pain in that it is poorly localized and often referred to the lower back, buttocks and thighs (Brown, 1989; Brownridge, 1995, Green, 1993; Hopkins, 1997; Melzack, 1981, Reading, 1985).
Pain perception results from the transmission of sensory and afferent nerve impulses originating at sites of painful stimuli which then proceed to the dorsal horn of the spinal cord. The dorsal horn receives nerve impulses from the entire body, including descending impulses coming from the brain. The small afferent fibers responsible for the transmission of painful stimuli are slower than the large myelinated fibers responsible for transmitting touch and pressure. These larger, faster nerve fibers transmitting the sensations of touch and pressure, along with descending impulses from the brain compete with impulses transmitting painful stimuli, and help close the "gate " to painful perception. It is believed that the balance of impulses constellates the pain experience. Synthesis and release of endorphins in the dorsal horn is also thought to play a role in the inhibition of pain perception. Other chemical mediators under investigation for their role in labor pain include: bradykinins, leukotrienes, prostagandins, serotonin, lactic acid, and substance P. This physiological model for describing pain perception is referred to as the "gate theory" and was developed by Melzack in the 1970's and 1980's. Although intended as a general model of pain perception, it has been widely applied to the study of labor (Melzack, 1981; Niven, 1984).
A number of studies have attempted to correlate various psychosocial variables with labor pain intensity. Psychosocial variables found to have a consistent association with labor pain intensity include age, parity, and prior experience with pain. Younger women consistently report higher levels of pain than older women, as do primiparous women. Women with histories of non-childbearing pain, report lower levels of pain intensity during labor than do women without such histories (Green, 1993; Halldorsdottir, 1996; Melzack, 1981; Niven, 1984; Reading, 1985; Waldenstrom, 1996). Some investigators have hypothesized that previous pain experience promotes the development of cognitive coping strategies that decrease pain intensity or perception (Niven & Gijsbers, 1984). Others researchers note an association between prenatal fear and anxiety, and increased levels of pain in labor (Wuitchik, Hesson, & Bekal, 1990). Despite research findings suggesting that decreased anxiety, and the development of cognitive coping strategies might contribute to lower levels of pain in labor, studies on whether or not prepared childbirth training is associated with decreased pain intensity, report mixed results. (Green, 1993; Humenik, 1981; Melzack, 1981; Wuitchik, 1990). Demographic factors shown to be associated with increased labor pain in some studies include lower socioeconomic status, less education and unmarried status; however most researchers have not been able to duplicate these findings (Melzack, 1981; Reading, 1985; Waldenstrom, 1996).
The only obstetrical factor shown to be consistently related to increased levels of pain in labor is duration of labor, with longer labors generally being perceived as more painful ( Wuitchik et al., 1990).
The McGill Pain Questionnaire and the Study of Labor Pain
The above studies focused on the identification of variables correlating with labor pain intensity. Melzack, a prominent pain researcher, and a primary scholar responsible for development of the "gate theory" of pain perception, believed language describing pain could be used to assess and measure several dimensions pain. He believed pain was a complex perceptual experience. He stated, "The fact that there are so many words to describe the experience of pain lends support to the concept that the word 'pain' is a label which represents a myriad of different experiences, and refutes the traditional concept that pain is a single modality which carries one or two qualities" (Melzack, 1975, p. 53). In an effort to redress this perceived shortcoming, he developed the McGill Pain Questionnaire (MPQ), an instrument designed to measure the sensory, affective and evaluative qualities of pain, in addition to pain intensity. This tool consists of 78 words or descriptors, representing 20 different categories, all of which have been theoretically derived to correlate with different pain syndromes (1975). Subjects select the word from each category that best describes their pain. One word is scored from each category, and subjects may elect to not choose a word in a category. Words have an assigned intensity ranking in addition to their pain quality ranking. Pain intensity scores are based on the summation of the intensity rankings of chosen words, and the sensory, affective and evaluative rankings are intended to reflect the qualities of a particular pain experience.
A 1990 meta-analysis of the MPQ found five different versions of the MPQ referenced in the literature, with most researchers using the interview method for data
collection, and completion of the MPQ generally taking 10-25 minutes (Wilkie, Savedra, Holzemer, Tesler & Paul, 1990). The authors found considerable documentation that the MPQ has concurrent validity for distinguishing between chronic and acute pain, as well as a variety of different pain syndromes. In addition, test-retest reliability was found to be well documented (Wilkie et al., 1990). Significant to the application of this tool to the study of labor pain, was the observation noted in the discussion section, that the MPQ has not been carefully examined for differences in word selection that may be related to age, gender or ethnicity; and that norms testing for the various pain syndromes is lacking. This is a potentially important limitation of this tool's usefulness to the study of labor pain. In an exhaustive review article on gender differences in clinical pain experience, published in a 1996 issue of the journal Pain, the author draws attention to the fact that "…intensity of pain is important in the appraisal process, but for women has some limitations. It would seem that appraisal of pain for women would incorporate multiple features of pain to assist in the separation of pain due to normal biological processes and pain due to other, potentially pathological sources. In addition, women must make distinctions between manageable, and excessive pain due to normal biological events" Unruh, 1996, p. 157). Despite these potential shortcomings, the MPQ has been widely applied to the study of labor (Melzack, 1981; Niven, 1984).
A 1984 descriptive correlational study by Niven & Gijsbers was conducted to determine if there was a relationship between previous experience with non-childbearing pain, and pain intensity in labor. The MPQ was used to score the dependent variable of pain intensity since it attempts to quantify several dimensions of the pain experience, and also because the researchers were interested in determining if it was a feasible tool for use in labor. This two-fold aim was not apparent from the title, but was clearly defined in the introduction. The review of the literature skillfully communicated the problems inherent in reducing the complex nature of the pain experience to a simple intensity scale, as well as a brief, but adequate description of the MPQ. It did not address the lack of norms testing for labor pain.
A convenience sample of 29 women delivering in a hospital in Scotland was recruited for participation. The researchers tell us that all the women were married, Caucasian, either middle-class or working class, and between the ages of 17 and 38. The homogeneity of the sample and the small N both pose external threats to the generalizability of the findings. We know that women with anticipated complications were excluded.
Data collection involved administration of the MPQ on two separate occasions. The MPQ was administered the first time during active labor. This was the only specific inclusion criterion revealed in the report. Women were asked to select items from the MPQ in- between contractions. The MPQ was administered a second time at 24 to 48 hours post-partum. The Hawthorne effect, and the testing effect, are inherent treats to the validity of the findings posed by this design.
The authors found the MPQ was cumbersome to administer in labor, but well accepted by women. Labor pain levels were noted to be severe. Pearson correlation coefficients appropriately correlated the antepartum, intrapartum and psychosocial factors collected from charts and post-partum interviews with reported pain levels as measured by the MPQ. Two-tailed t-tests were used to compare an individual woman's two MPQ scores.
Duration of labor was found to have a significant association with labor pain intensity, with longer labors associated with greater reported pain (R= 0.4, P < 0.02). Being a primipara was also associated with increased pain in labor, but we are not given R or P values. The authors found that prior experience with non-childbearing pain was associated with decreased pain levels in labor, although again we are not given R or P values. Despite the small sample and the inability to generalize from this study, the authors make a worthwhile clinical recommendation on when they suggest that women be assessed prenatally for prior pain coping history, and that women without such histories be assisted in the development of cognitive coping strategies.
Critiques of Additional Representative Research
It is interesting to note, and important to understand clinically that labor pain intensity does not necessarily correlate with overall satisfaction in childbearing (Green, 1993; Halldorsdottir, 1996; Niven, 1884; Slade, 1993;Waldenstrom, 1996). It has been noted that although labor is generally perceived as very painful by most women, attitudes towards pain in labor are not entirely negative (Waldenstrom et al., 1996).
A widely read qualitative study by Penny Simkin (1991) entitled, "Just Another Day In A Woman's Life? Women's Long-Term Perceptions of Their First Birth Experience" published in three parts, set out to discover which aspects of a woman's first childbirth experience contributed to long-term satisfaction or dissatisfaction. Participants were recruited from the author's childbirth preparation classes during the years 1968-1974. In all, 20 women, ages 19 to 33 years participated. All participants were Caucasian, and all but one was married. This group included women who had short and long labors, vaginal and instrument deliveries, and episiotomies and intact perineums. In addition, the author notes that childbirth preparation classes were not widely available, and represented an unconventional choice at this time. The author gives a brief over-view of typical birth practices of the time, and notes that they differ from what a family can expect on admission to the hospital today. Data collection involved the use of questionnaires, and personal accounts of the birth obtained via open-ended questions during interactive interviews. Participants were asked what they felt was important and what they remembered. Women were interviewed shortly after the birth of their first child, and again 15 to 20 years later. Data was analyzed using techniques borrowed from ethnography, grounded theory and phenomenology, and an ethnographic piece of software was used to aid the researcher in content analysis. A striking observation was the author's note that every single woman contacted agreed to participate, and was eager to discuss her birth. In addition, memories for birth were not only detailed, but vivid, so that the author imagined that many women were "not merely recalling, but reliving" (p. 209) their birth experience. Half of the women cried during the second interview. The themes of accomplishment, personal control, self-esteem, and how a woman was cared for by the doctors and nurses, all emerged as important contributors to long-term satisfaction or dissatisfaction. A closer examination of the theme of control, as it was interpreted by the researcher, may help to identify the ways in which seemingly contradictory pain management strategies may contribute to a woman's over-all satisfaction with her birth experience. The author states,
Self-control, or behaving in a planned, prescribed manner during contractions, was
one dimension. For the women in this study, control meant breathing at a prescribed
rate and depth while staring at a focal point, and remaining relaxed and quiet. They
took great satisfaction not only in avoiding pain medication, but also in appearing not
to be in pain. Control over what was happening to them and the decisions about their
care were important contributors in long-term satisfaction. Women whose doctors and
nurses said and did things that they did not want still feel anger or disappointment
(p. 210).
We know very little about the measures which were undertaken to enhance the credibility and auditability of the study design, and the findings. It would have been helpful to know if the researcher used the same open-ended questions with each participant, and it seems important to know whether or not the participants felt that the themes identified by the author successfully captured what they felt was important about the experience. Triangulation or the use of another researcher during the data analysis phase would have enhanced credibility. The author does shares with us her thought trail during the analysis of data, which increases the auditability. The homogeneity of the sample is a limitation of this study.
'The Complexity of Labor Pain: Experiences of 278 Women" is a descriptive study published in 1996 which was conducted in an effort to understand women's attitudes towards pain in labor. After an exhaustive literature review of labor pain studies, and studies of women's satisfaction with childbirth, the authors hypothesized that women's attitude towards labor pain might not be entirely negative, and might have some positive attributes as well.
A convenience sample of all 385 women, delivering at three Swedish hospitals, over a 2 week period, were selected for inclusion in the study. The exclusion criteria were clearly stated, and reduced the sample size to 334. 88% of the women contacted one day post-partum, completed a questionnaire, resulting in an N of 278. Three seven point scales measuring pain intensity, attitude towards pain, and the relationship of expected pain to pain experienced, were completed. Demographic and obstetrical material was collected from the medical records.
Threats to validity are primarily related to the fact that we know little about the development of the three seven point scales used to measure pain. Seven point scales are generally considered adequate for these purposes, but we do not know if these particular scales were tested prior to use in the study, or whether the phrases used to anchor these scales allowed participants a sufficient range of choices to represent their experiences.
We know from the discussion on data analysis, that odds ratios, and chi-squares were used to analyze nominal data, and that multiple regression was used to explain the variation in the pain intensity and pain attitude scores. These statistical analyses are appropriate.
Findings included an average pain intensity score of 6.1 for primiparas and 5.9 for multiparas, a non-significant difference. Women often underestimated the amount of pain anticipated in labor. Primiparous women had lower anxiety scores than women who had already given birth ( p= 0.001). Only five explanatory variables turned out to be significant after regression analysis and included: anxiety during labor, expected pain intensity, expectations of birth generally, midwife support during labor and duration of labor. However, the authors make the point that these explanatory variables only account for 30% of the variance among their sample. The authors go on to further state that "both linear regression and the ordinal logit model may fail to discover the true form of an association" (p. 224).
The authors conclude their paper with a brief discussion of the mastery model, first introduced by Humenick in 1981. Humenick proposed that the concept of mastery be substituted for the concept of pain management, when trying to explain women’s satisfaction with childbearing. She states, “The weight of evidence is that the long-term benefit to women is greatest when they are able to meet the psychological tasks they set for themselves in labor, and actively participate to the extent that they desire” (Humenick in Waldenstrom, et al., p. 226). The authors go on to hypothesize that mastery may be important for some women, but not for others, and that sensitive clinicians should assess this for this.
Methodology
Design
A descriptive design using phenomenological methods is proposed for this exploratory study. In-depth, open-ended interviews of newly delivered mothers will be conducted to obtain comprehensive descriptions of labor pain. The narratives of these new delivered mothers will provide the raw data for analysis, so that descriptions of labor pain, originating from the lived experience of women will provide "the basis for the reflective structural analysis that portrays the essences of the experience" (Moustakas, 1994, p.13).
This qualitative design has several advantages in meeting the stated purpose of this proposal, and in overcoming some of the limitations of quantitative methods. When we attempt to understand complex, and often times ambiguous, personal and cultural events, we risk losing sight of what is theoretically and clinically important when we focus solely on quantitative methods and what is most easily measured. Qualitative methods offer alternatives to the positivist paradigm of Western science, and provide us with opportunities to elicit descriptions of labor pain that emerge from the context of the childbirth experience, and women's lives. As a result, research designs employing these methods, are more likely to yield data capable of discovering the meaning of the experiences we are attempting to capture (Bergum 1989).
"The language of research methodology is itself sexist in its use of metaphor, 'soft’ having connotations of weakness and unreliability and 'hard' suggesting strength and confidence (Bart 1974, quoted in Webb 1984, p 249). Evaluations of care which include the effects "soft outcomes" are more complete than those that do not (Oakley,1983, p. 106), and the measurement of soft outcomes is compatible with feminism's desire to recover and validate previously missing pieces of information about women's lives and experiences (Bortin).
The philosophy of phenomenology is the theoretical tradition from which the qualitative methods used in this study have emerged. First described by Husserl (1859-1938), phenomenology is the study of how people describe the things and experiences they come to know through their senses. It asserts that we can only know what we experience, and that sensory experience, interpretation, and meaning are intertwined.
Descriptions of experience and interpretations are so intertwined that they often
become one. Interpretation is essential to an understanding of experience and the
experience includes the interpretation. Thus phenomenologists focus on how we put
together the phenomena we experience in such a way as to make sense of the world
and, in so doing, develop a worldview. There is no separate (or objective) reality
for people. There is only what they know their experience is and means. The
subjective experience incorporates the objective thing and a person's reality
(Patton p. 69).
Phenomenology also assumes that there is an essence to shared experiences (Patton 1990).
Setting
The setting for this study is the Family Birthing Center at Dominican Hospital Santa Cruz. The community of Santa Cruz is located on the central coast of California, approximately 70 miles south of San Francisco, and 30 miles southwest of San Jose. There are 242, 637 county residents, with approximately 51,000 individuals residing within the city of Santa Cruz. Primary industries for the county include tourism, agriculture, manufacturing and high tech (visitor's bureau pub).
Dominican Hospital Santa Cruz is a non-profit, privately owned Catholic hospital. It was founded in 1941 and has occupied its present location since 1974. A board of directors comprised of local community members and physicians manages the hospital. In 1986 Dominican Hospital merged with other Catholic hospitals to form the corporation Catholic Healthcare West. This corporation currently operates 35 acute care facilities, and eight medical centers throughout California, Arizona, and Nevada. Catholic Healthcare West estimates that it had 4.4 billion dollars in assets as of June 30, 1996, and that community benefits to the poor totaled 174 million dollars during the same year (on-line stats).
Dominican Hospital has 194 acute beds. In addition, there is a rehabilitation unit, a mental health unit, and a skilled nursing unit, bringing the total number of beds to 270. There are 350 physicians, and 20 allied health professionals on staff. The hospital employs 1300 individuals, 411 of which are registered nurses (DSCH human resources dept.)
Dominican's Family Birthing Center is one of three facilities providing maternity services in Santa Cruz County. It is the facility with the largest number of annual births. It has eight birthing suites where women labor and deliver. After the delivery, barring complications, infants are admitted in the birthing suite with family present. Once medically stable, mother and baby are transferred to a post-partum room on the same floor where rooming-in is encouraged. Women desiring a postpartum tubal ligation may elect to have this procedure performed prior to discharge.
Hospital sponsored childbirth preparation classes are offered through the education department, and are open to the community. Classes are taught in both English and Spanish, and a "refresher course" is available for experienced moms needing to review relaxation and breathing techniques. Childbirth educators employed by the hospital, come from a variety of backgrounds, with both nurses and non-nurses working in this capacity. 15 obstetricians and five certified nurse-midwives deliver babies at Dominican Hospital. In 1996 there were1450 babies born at Dominican Hospital, and 1320 babies were born there is 1997.
Sample and Selection
A purposive sample of women delivering at Dominican Hospital's Family Birthing Center will be solicited for participation in this study. "A sample in a phenomenological study is drawn from a population that has experience with the phenomena of concern. In this respect it is purposive, and participants are chosen to provide as much variability as possible in their responses" (Kennedy p.412). The author hopes that by talking to women with a desire to be interviewed on their experience of labor pain, that she will be maximizing the number of information rich interviews. Interviews will be conducted until the researcher concludes that no new information is being gathered. The point at which this occurs is referred to as saturation. This author estimates that saturation in this study will be reached at a sample size of between six and ten. This estimate is based on a review of phenomenological studies of women's experiences within nursing literature (Kennedy 1995; Beck 1992; Zalon 1997).
Initial contact will be made through the hospital's childbirth preparation classes, in which the researcher will introduce herself and explain the purpose of the study. Women over the age of 18, anticipating a vaginal delivery in the birth center, will be eligible for participation in the study. Expectant mothers will be provided with written material explaining the author's qualifications, as well as information on how participants' anonymity will be assured (Appendix A). Women who continue to express an interest in the study will then be asked to write a birth plan in which they include a statement about their willingness to participate in the study. The birth plan will be forwarded to the hospital with the patient's medical records, and will serve to alert nursing staff to notify the researcher when the woman has delivered. The researcher will be notified by phone. Interviews will be conducted in the mother's room prior to discharge, at 8-72 hours post-delivery.
Exclusion criteria include: planned cesarean section, gestational age less than thirty-seven weeks at the time of delivery, infant admission to the level-two nursery, adoption, neonatal death or stillbirth, and inability to communicate in English. Women with planned cesarean sections will be excluded since they presumably do not have an experience of labor pain. Women with neonatal complications or losses will be excluded because of the possible influence of these events on the perception and re-call of pain, as well as out of respect for the family's need for privacy during such times. The researcher is English speaking, and regrettably, this excludes the possibility of interviewing women who cannot communicate well in English.
This site was chosen for its diversity and accessibility to the researcher. In 1997, 70 percent of birth center families were Caucasian, 25 percent were Hispanic, and the remaining five percent were Asian or African-American. 25 to 30 percent of the families served had Medi-Cal insurance. 15 percent of Spanish speaking clients were monolingual. The cesarean birth rate was 20 percent, and the vaginal birth after cesarean rate was approximately 85 percent. 45 percent of the mothers delivering used epidurals for pain relief, and these figures represent a drop from 55 percent epidural use noted the previous year. 45 percent of the mothers had their labors induced. No relationship was found between women having their labors induced and epidural use. 95 percent of the mothers are breastfeeding at discharge (personal communication, Robin Courtney). The researcher has worked as a registered nurse in the department since 1989, and is well known to the staff at this facility. She continues to work there on a per diem basis while completing her nurse-midwifery education. The department manager, numerous members of the nursing staff, and several providers have expressed interest and support for this research project.
Protection of Informants' Rights
This research proposal will be submitted to the Human Subjects Committee of the University of California at San Francisco. Members of the Dominican Hospital obstetrical staff, the maternal-child health department manager, and the charge nurses of the Family Birthing Center will also be asked to review, and approve this research proposal. Informed consent from prospective participants, will be obtained both verbally and in writing. Written consent forms will include permission to tape record the interview, and they will also explain the procedure by which the informants' anonymity will be assured (Appendix A). Written consent forms will be obtained during the initial contact with prospective participants in prepared childbirth classes. The participant's willingness to participate will be solicited again immediately prior to beginning the interview. Informants will be reminded verbally, at this time, that they may elect to have the tape recorder turned off, or have the interview stopped at any time. Informants will be asked to provide the researcher with an address, so that a transcript of their interview can be sent to them for their review. Return postage will be paid by the researcher. Participants will be offered at copy of any publication that results from this research.
Instruments, Tools, Materials
The primary instrument in studies relying on in-depth interviews for data collection, is the researcher. As a result, the success of this method in collecting important and useful data is directly related to the skill of the interviewer. It is important for the interviewer to be able to establish a rapport with a diverse number of individuals, and also be adept at hearing the subtleties and nuances of what is being expressed (Wilson 1989; Patton 1990; Polit & Hungler 1995). The author will be the sole researcher for this study, and she has a number of diverse experiences that have contributed to the development of her communication skills and her qualifications as researcher. These experiences include: an undergraduate degree in psychology for which she completed several small research projects, including two studies involving the interview process; past employment in several psychiatric settings, both as a mental health worker, and as a nurse intern; previous employment as and childbirth educator; and ten years of work experience as a registered nurse.
A tape recorder will be used to record interviews, so that verbatim transcripts can be obtained for data analysis. Paper and pens will used to make brief notes about those aspects of the interviews that cannot be captured in a recording, such as facial expressions and behaviors. An IBM compatible computer will be used to type the transcribed interviews, and the final manuscript.
Reliability and Validity
The focus of qualitative research is on the development of theory, and as a result these methods are generally non-experimental since they are designed to yield in-depth information about the material under investigation (Polit & Hungler, 1995). As a result, some scholars have suggested we employ different criteria for the evaluation of methodological rigor when critiquing this research (Sandelowski, 1996). Credibility has been suggested as a substitute for internal validity, when attempting to assess the truth value of a qualitative study (Guba & Lincoln in Sandelowski). "A qualitative study is credible when it presents such faithful descriptions or interpretations of a human experience that the people having the experience would immediately recognize it from those descriptions or interpretations as their own" (Sandelowski, p. 30). Credibility in this study will be enhanced in several ways. Intersubjective agreement between the primary researcher, and the assistant will be achieved during the data analysis phase of the study. In addition, the data analysis results will be shared with participants to verify that the portrayals of labor pain have succeeded in accurately describing their experiences.
Guba and Lincoln have proposed that auditability be used in place of reliability as the criterion for evaluating the consistency of qualitative findings. Auditability in this study will be achieved by asking each participant the same, open-ended question (Patton), and by listing the formulated meanings under each theme cluster when writing the research report. This procedure allows other researchers to "follow the 'decision trail' used by the investigator in the study. In addition, another researcher could arrive at the same or comparable but not contradictory conclusions given the researcher's data, perspective, and situation" (Sandelowski, p. 33).
Data Collection
We cannot observe how people have organized the world and the meanings that they
attach to what goes on in the world. We have to ask people questions about those
things. The purpose of qualitative interviewing, then, is to allow us to enter into the
other person's perspective. Qualitative interviewing begins with the assumption that
experience of others is meaningful, knowledgeable, and able to be made explicit
(Patton p. 278).
Data will be collected through in-depth interviews using the following open-ended question, "Please describe to me everything about your experience of pain in labor. Share all your thoughts and feelings about the experience that you can recall, until you have no more to say. " Additional open-ended questions will only be asked if further clarification is needed. Participants may be asked to provide examples that help to describe their experiences. This type of inquiry typifies the format generally used in phenomenological interviewing (Beck, 1992; Kennedy, 1995; Zalon, 1997). Open-ended questions allow respondents to answer in their own words, and have the potential to reveal a "richer and fuller perspective on the topic of interest" (Polit & Hungler p. 276). This is an important advantage when conducting an exploratory study on a complex, and potentially ambiguous phenomenon.
Women will be interviewed prior to hospital discharge, during the first 72 hours post-partum, in an effort to capture the vividness of their experiences. Interviews will take approximately 40-60 minutes to complete, and will be conducted during a period of time that is deemed convenient to family members and hospital staff. This interview time will be arranged by phone during the day the interview is to take place.
Data Analysis
Interviews will be transcribed verbatim prior to coding. The four components to a phenomenological inquiry are bracketing, intuiting, analyzing, and describing. Bracketing is the first step, and refers to process in which the researcher identifies all of his or her preconceived ideas and assumptions about the phenomenon under investigation, and sets them aside. This is done to facilitate a greater appreciation of the empirical reality of the data collected. Ideally, this is process is reviewed prior to beginning each interview. The second step in a phenomenological inquiry is called intuiting, and refers to the researcher's ability to remain open and receptive to the meanings attributed to the phenomenon by the study participants. The third phase in a phenomenological inquiry is the analysis of data. The final step is the description phase in which the researcher utilizes the information garnered from data analysis to generate a definition of the essential structure of the experience (Moustakas,1994; Polit & Hungler, 1995).
The specific method of data analysis used in this study will be Colazzi's method. A brief summary of the steps involved in this method follow:
1. The researcher begins by bracketing her own assumptions and experiences of the
phenomenon, using a phenomenological approach.
2. Each verbatim transcript is read to get a global feeling of an individual participant's
description of the phenomenon. Significant statements pertaining to the experience
of labor pain are extracted. Each non-repetitive statement is listed, and is referred to
as a meaning unit. Meaning units are clustered into themes, and these themes are
used to create a description of the experience. Verbatim examples are used
to illustrate, and to validate the process by which this occurs. Study participants will
be asked to review for accuracy, the descriptions of labor pain resulting from their
transcripts. Revisions will be made in those cases in which a discrepancy occurs.
3. After each transcript has been analyzed in the method described above, the
researcher will construct a composite description of the meanings and essences
of the experience that incorporates all of the individual themes (Kennedy,1995;
Moustakas, 1994; Zalon, 1997).
Another master's prepared nurse-midwife, with experience in qualitative methods, will assist in coding data into meaning units, and clustering meaning units into themes. Resources and Feasibility
The researcher has a well-established, long-term, collaborative relationship with medical and nursing staff at Dominican Hospital, so that access to an adequate number of subjects for the study seems assured. The researcher will conduct two to three interviews per month, so that the projected time frame for data collection is estimated to be five months. Transcription of each hour-long interview will take approximately eight hours, and it is estimated that each interview will yield about 20 pages of raw data. Data analysis is estimated to take an additional six months, with both the primary researcher and the assistant donating their labor. The researcher owns an IBM compatible computer and a printer that can be used for the reproduction of information about the research, consents, and copies of labor descriptions to distribute to participants. There will be no need to purchase any additional software for the purpose of this study. However, it will be necessary to purchase writing materials and a tape recorder. Please see Appendix B for an itemized budget which details the $1,385 estimated costs for conducting this research. In terms of access to participants, time and resource needs, this study seems feasible.
Limitations
Many previous studies of labor pain, both quantitative and qualitative, have focused their investigations on the experience of married women, or heterosexual women living with the fathers of their babies. It is possible that single mothers, lesbian families, and women with other alternative support systems may experience and describe their experience of labor pain differently. It is possible that this limitation is inherent when subjects are solicited from traditional childbirth preparation classes, and this study may suffer from a similar limitation, although this is not known at this time.
There is some quantitative data which suggests that women who birth at home, and don't have the option of using pharmacological methods of pain relief, experience decreased pain in labor (Morse & Park, 1987). These women may ascribe different meanings to the experience of pain in labor as well.
A significant limitation of this study is the lack of non-English speakers represented in the sample. It has previously been documented that different cultural values and expectations, regarding both pain and childbearing, lead to different behaviors and expressions of labor pain cross-culturally (Callister, 1995). This author considers all of these limitations important and interesting directions for further research.
Appendix A
University of California, San Francisco
Consent to be a Research Subject
Thank you for your interest in my research on the experience of pain in labor. I value the unique contribution you can make to my study, and I am looking forward to your participation in it. As a result of your participation, I hope to better understand the essence of the experience of pain in labor.
I am seeking vivid, detailed descriptions of your experience, and I will encourage you to recall and communicate all of your thoughts, feelings and behaviors, as they occurred during labor. You will be asked to provide accurate descriptions, including specific details and events of your experience. The interview will take place in the hospital, prior to your discharge home, and will be take approximately one hour of your time. Interviews will be tape-recorded. You may elect to have the recorder turned off, or the tape erased at anytime. Your name will not be used, but your interview will be assigned a number. All information collected will be treated as confidential. Upon completion of the project, you will be mailed a copy of your interview, and you will be given the opportunity to make corrections, in those instances in which you feel that the researcher has erroneously represented your experience.
It is hoped that this information will be used to provide more comprehensive and compassionate care to laboring women. As a nurse-midwifery student, and as a mother, I want to again thank you for your contribution to this end. Your dated signature at the bottom of this page serves to indicate your voluntary participation in this research.
_______________ _______________________________________
Date Participant's signature
_______________________________________
Participant's name, printed
Appendix B
Research Budget
Transcription Costs:
$6 per page X 20 pages per interview = $120 per interview
$120 X 10 interviews = $1200
total transcription costs = $1200
Materials:
IBM compatible computer- already owned by the researcher
Tape recorder, $100
Paper for copies, notebook for field notes and pens, $50
Postage for copies of reports, $35
Total materials costs = $185
All other labor will be donated by the researcher and her nurse-midwife colleague
Total Budget = $1385
The author will seek funding through the American College of Nurse-Midwives, the Association of Women's Health, Obstetric, and neonatal Nurses, and through Sigma Theta Tau. Costs not covered by these sources will be paid by the author.
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