For want of a better word: childbirth beyond pain

When out with friends at a reading of Hollie McNish's newly released book "Nobody Told Me" recently, (1) I found myself faced with familiar challenge. The chances are, if you are pregnant, work in maternity support or have pregnant friends, it's one you may be able to relate to. 

One of our number, Sarah*, is soon to give birth for the third time. Her two previous experiences hadn't quite matched her hopes. This time, she has been preparing for birth a little differently in the hope of maximising her chances of a positive experience. One of the strategies she’s applying in preparation for the birth is to limit her exposure to fear inducing birth related words and images. I’ll explain the basis for this below.

fear, pain and words

In 1942, in the book ‘Childbirth without Fear,’ (2) (then ‘The Revelation of Childbirth’) Grantly Dick Read proposed the fear - tension- pain model to explain the relationship between mental state and pain. 

"The fear of pain actually produces true pain through the medium of pathological tension. This is known as the Fear-Tension-Pain Syndrome"                                    - Grantly Dick Read

 He asserted that a fearful woman enters the birthing process in a state of danger arousal. Her body automatically responds to the perceived threat to her own and her baby’s safety by engaging her sympathetic nervous system and producing adrenaline in readiness to flee from the threat. This impedes the production both of oxytocin (the hormone which governs contraction of smooth muscle and social processes such as bonding) and endorphins (the pain relieving hormones that soothe the experience of the aforementioned contraction); diverts energy away from the uterus to the limbs where it’s needed for getaway; and creates tension in the cervix. 

In short: it’s built into the process of birth that being fearful disrupts it. This disruption results in pain. 

Building on Dick-Reads work, centred around the assumption that pain is undesirable, many childbirth education heavyweights and preparation methodologies today (examples include Ina May Gaskin 3, and hypnobirthing respectively 4,5) ascribe language crucial responsibility for creating feelings of either fear or confidence about birth.  

So arises the recommendation to purge the birth lexicon of words steeped in medical, pathology based, fear triggering connotations. ‘Contraction’ is replaced by ‘surge’, ‘pulse’, ‘wave’ or ‘rush’. The word ‘pain’ is omitted for fear that it may be made manifest through suggestion.  Exposure to negative stories is avoided. 

Whilst evidence (6,7,8) demonstrating the influence of language on pain in clinical settings may be viewed as supportive of approaches filtering birth talk exposure, the more complex appreciation of emotion's role in pain (9) gives cause to question the validity both of taking the emotional content of words for granted and interpreting the effect of words in isolation of the context in which they are delivered.  

Ideals versus reality

Back to me and my friends' evening out. "Nobody Told Me" is a collection of Hollie's diary entries and poetry from the period of her pregnancy through her first few years of motherhood.

Please do check out ‘Nobody told me’ for one really lovely and funny woman’s visceral evocations of the highs and lows of supporting a new life whilst navigating an identity shift in a culture not always friendly to the transition.

““I don’t think I cried because of overwhelming motherly love. I think I cried because no one was telling me to push a bowling ball through my arse anymore and I was no longer worried my ribs would break, lungs burst or face explode.””

— Hollie McNIsh

By my side in the audience, in her carefully crafted bubble of fear free positivity, sat Sarah. 

On stage, wielding a sharpened pin of raw, from-her-guts prose  stood Hollie. 

The inevitable pop. And here the familiar quandary: being with pregnant woman as she struggles to find a foothold in the no man's land of theory versus practice/ ideals versus reality, searching for the right material to hand her with which she could build a bridge to span the two. 

The inadequacy of the language of pain to communicate experience

Pregnant people, with their bump shaped advertisement of potential interest in birth, frequently find themselves audience to birth veterans recounting their stories, whether they willingly purchase a ticket to a spoken word event promoting a birth and early motherhood book or not.

On one side of the coin are those frequently labelled horror stories: the tellers' focus on impressive hours-in-labour numbers, blood, gore and agony.

On the flip side, for example in the Positive Birth Movement group I co-facilitate, most attendees dwell on an entirely different set of details when sharing their stories.

You can find similar examples of this online. These: most extreme descriptions of sensation I could find in the first handful of positive birth story results that google returned me, are pretty typical of the form:  “surges becoming uncomfortable” “I was starting to feel them by now” “tightenings growing closer together” “rather a powerful surge”. They don’t give much away about the visceral sensations of birth, do they?

I think there may be two things at play for the positive group here. Given how modulated perception of pain is by other factors of experience, for some of those women, the other factors are simply enough to remove the label for their concept of pain from the shelf they'd reach to when filing the memory or describing the physical sensations of their births. For others, the conspiratorial whispers in my ear along the lines of ‘it didn't half smart a bit’ after sharing self proclaimed life affirmingly positive stories might suggest that the omission is informed by the prevalent 'pain-tension-fear' discourse (in that either they are being careful not to give rise to fear in others; or that by the F-T-P model, their pain in their positive birth was aberrant and confusing so not to be mentioned; or both.) 

For the pregnant women unable to control all language and stories incoming from those around them, reduction of birth experience to the physical on one side can turn pain into the elephant in the room on the other. I wonder if the polarity here contributes to the red herring that physical experience is the significant part of the story in birth.

I think this illusion has endured because fuller understanding has been curtailed by the medium of communication here: limitations both of expression and of interpretation.  Regarding expression, further to Virginia Woolf’s lament on the “poverty of the language of pain.” (10) (which, given the lack of colour in the descriptions of positive birth we could arguably extend out to physical sensation generally) we could consider the inadequacy of language concerned with physical sensation to convey entirety of experience. In birth at least, there’s a mismatch between the enormity of what’s to be communicated and the scope of the tool at our disposal with which to do it.  

The importance of recognition and narrative

I don’t think it’s a coincidence that the poem above all others which elicited the strongest response (loudest sniffs, most eye/nose wipes) - certainly from our cluster of mothers - in the audience of Hollie McNish’s set was ‘Opposite man,’ about her boyfriend; support and cheerleader through her birth. Here’s an excerpt: 

“I feel the pain is soothed by praise
you brag about my strength today
The things I really wanna shout
but am told a ‘lady’ wont let out

As woman undermine themselves
Underplay the pain they felt
We need more men like you
To tell the tale of what we all go through

You’re the opposite of what the article said
That ‘men shouldn’t be at the hospital bed’
‘Cos you calmed me, laughed through a room full of pain
And now you shout out the strengths that I’m not meant to claim”

She went on to describe how following the birth he rang up all the mothers he knew and congratulated them. In bearing witness to her metamorphic transcendence of birth, he was able to acknowledge and celebrate the significance of their experiences.

For me, what's striking about the poem is her joy and gratitude for the recognition of her strength, not the degree of physical sensation she endured.

Strength, incidentally, that may just be the only factor common to all births: whether 3 hours or 93; pain free or pain filled; peaceful spontaneous vaginal; induced rollercoaster or planned caesarean, one thing is universal: the transition into motherhood requires strength.

I still get the tingles thinking about the power of that recognition. Recognition that, as Joanna Bourke, author of ‘The Story of Pain: From Prayer to Painkillers’ reflects, may in itself be transformative (11): “When I was in the hospital, I told a visiting friend that my pain was “beyond language,” only to have him remind me that I had been speaking about my suffering for the past hour. Perhaps, he mildly remarked, the problem is not that people in pain cannot communicate, but that witnesses to their pain refuse to hear. For a few moments, his empathy overcame my suffering.” 

Could it be that this empathy and recognition is what women are desperately seeking when, whenever they sense the possibility of ears open to it, they reach to whatever inadequate language they have at their disposal to communicate what they transcended and the impact it had on them the day/s they gave birth?  Perhaps this is where the limitation of our bias in interpretation has had us misled. That what we've been hearing as horror stories all the while were attempts to tell the same secret as Laura Stavoe when she wrote, “There is a secret in our culture. It is not that childbirth is painful, but that women are strong.” (12)? 

If so, in closing our ears to them for caution of what damage the language might do, what are we achieving? Is it possible that we may create a taboo that perpetuates its own hype and misunderstanding? And in modelling this, set the next birthing woman up not to be heard when by being so she may find her experience soothed or validated? With ears fully open to the nuance of the individual's narrative, we can learn more about what distinguishes a positive experience from a negative one, whether that experience involved perceived pain or not.

How to help: shifting the focus to positive birth 

Whether or not you agree that the focus on the physical experience of birth has arisen from inadequacy of communication and understanding, for many women now, that focus needs addressing in a way that can bridge the poles of the discourse.

Penny Simkin suggests that we think about the physical sensations of labour in the same way we might those which arise through other positive and chosen physical exertion: mountain climbing, athletics, recovery from planned surgery, for example. She labels this "pain" which illustrates again the breadth of meaning that 4 letter word is used to cover.  Acknowledging that some people use the word pain to mean this more positive category of sensation may help diversify its connotations and distinguish pain from suffering and trauma.

She also reminds caregivers to be mindful of their influence over factors that govern how a woman perceives her experience. If we convey to a woman that we believe she isn’t coping and that the pain will rule the labour and overwhelm her (for example with unsolicited offers of pain relief) we are exerting our influence and may cause her to lose faith in her own ability and experience her sensations as suffering. (13,14)

Sheila Kitzinger also acknowledged the power of this influence, emphasising the importance of love and support in the difference between the perception of pain “as constructive” and “something that implies you’re going to die any moment” (15)

Penny and Sheila's wisdom feed neatly into what much research, discussion and a growing global movement has defined as positive birth. (16,17,)

Milli Hill, founder of the Positive Birth Movement: "A positive birth means a birth in which a woman feels she has freedom of choice, access to accurate information, and that she is in control, powerful and respected." (18)

In her book ‘A Good Birth: Finding the Positive and Profound in Your Childbirth Experience’ Dr Anne Lyerly broadly agrees, asserting that 5 key factors (19) cover the bases of a positive birth:

1. Agency
2. Personal security
3. Connectedness
4. Respect
5. Knowledge

If we accept this definition,  we can use it to:

• move past the problems that preoccupation with physical experience of birth in the discourse has created
•  guide our listening to all language used to describe birth
• aim to avoid suffering rather than pain.

Suggestions for action 

In antenatal preparation:

Antenatal preparation has a key role to play in shifting the focus from pain and fear to how to plan for a positive birth to avoid suffering. 

• Distinguish pain/ physical sensation from suffering, using common sense analogies and resources such as the wisdom of Penny Simkin and Sheila Kitzinger.
• Explore what constitutes a good birth and how those factors can prevent pain interacting with emotion to equate to suffering
• Talk about how to achieve a good birth in a chosen birth setting. 

In the wider world:

Acknowledge the roles of communication and emotion in the complexities of birth and of pain.

• Really listen when women want to tell you their birth story and encourage them to do the same when others want to share with them. Our vocabulary to communicate the depth and breadth of the experience and impact of birth is limited so the entire narrative is crucial to understanding the experience. Applying the knowledge of what constitutes a good birth may be useful to decode the story, redress assumptions that pain=negative experience and aid empathy. 
•  In all areas of your conduct with pregnant and birthing women,  aim that the circumstances the woman finds herself in, your words, body language and behaviour don't combine to undermine, disempower, depersonalise, alienate or coerce. [references 20,22,23,24,25,];
• By making respectful treatment, kindness, free exchange of knowledge and regard to agency and personal security your standards, you'll sow the seeds for positive birth beyond the considerations of pain.

*name changed to protect privacy.

References

1.  ‘Nobody Told Me’ Hollie McNish 2017 https://www.amazon.co.uk/Nobody-Told-Me-Poetry-Parenthood/dp/0349134359
2. ’The revelation of childbirth’ Grantly Dick-Read, 1945 

3. “Spiritual Midwifery” Ina May Gaskin, Fourth edition, 2002 https://www.amazon.co.uk/Spiritual-Midwifery-Ina-May-Gaskin/dp/1570671044

4. ‘The Hypnobirthing Book: An Inspirational Guide for a Calm, Confident, Natural Birth’ Katharine Graves, 2014 https://www.amazon.co.uk/Hypnobirthing-Book-Inspirational-Confident-Natural-ebook/dp/B00AQ3LGAE
5. ‘Hypnobirthing: The Mongan Method: A Natural Approach to a Safe, Easier, More Comfortable Birthing’ Marie Mongon, 2008 https://www.amazon.co.uk/Hypnobirthing-Natural-Approach-Comfortable-Birthing/dp/0757302661
6. ‘Pain Affect Encoded in Human Anterior Cingulate But Not Somatosensory Cortex’ Pierre Rainville, Gary H. Duncan, Donald D. Price, Benoı̂t Carrier, M. Catherine Bushnell, 1997 http://science.sciencemag.org/content/277/5328/968
7. ‘Effect of communication on pain during intravenous cannulation: a randomized controlled trial’ J. Dutt-Gupta, T. Bown, A. M. Cyna, 20007 https://academic.oup.com/bja/article-lookup/doi/10.1093/bja/aem308
8. ‘Pain vs comfort scores after Caesarean section: a randomized trial’ C. S. L. ChooiA. M. WhiteS. G. M. TanK. DowlingA. M. Cyna, 2013 https://academic.oup.com/bja/article/110/5/780/330168/Pain-vs-comfort-scores-after-Caesarean-section-a
9. 'Pain and Emotion: A Biopsychosocial Review of Recent Research' Mark A. Lumley, Jay L. Cohen, George S. Borszcz, Annmarie Cano,Alison M. Radcliffe, Laura S. Porter, Howard Schubiner, and Francis J. Keefe https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3152687/#R74
10. ‘On being ill’ Virginia Woolfe, 1926
11. ‘How to talk about Pain’ Joanna Bourke, 2014 https://www.nytimes.com/2014/07/13/opinion/sunday/how-to-talk-about-pain.html?ref=opinion&_r=0
12. ‘Laura Savoe speaks- why she wrote: “There is a secret in our culture and it is not that birth is painful but that women are strong.”’ Laura Stevoe, 2011 https://birthtraumatruths.wordpress.com/2011/06/06/laura-stavoe-speaks-why-she-wrote-there-is-a-secret-in-our-culture-but-it-is-not-that-women-are-strong/
13. ‘Pain, Suffering, and Trauma in Labor and Subsequent Post-Traumatic Stress Disorder: First of Two Posts’ Penny Simkin, 2011 https://www.scienceandsensibility.org/blog/pain-suffering-and-trauma-in-labor-and-subsequent-post-traumatic-stress-disorder-first-of-two-posts-by-penny-simkin-pt-cce-cddona
14. Penny Simkin on Pain, Suffering and Trauma, 2009 https://www.youtube.com/watch?v=rlj9ehB-hLc]
15. Sheila Kitzinger on facing the pain of labour, 2015 https://www.youtube.com/watch?v=Pcje8TMIzkU
16. ‘The meaning of a very positive birth experience: focus groups discussions with women’ Annika KarlströmEmail author, Astrid Nystedt and Ingegerd Hildingsson, 2015 http://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/s12884-015-0683-0
17. ‘Factors Influencing Positive Birth Experiences of First-Time Mothers’  Lena Nilsson,1 Tina Thorsell,2 Elisabeth Hertfelt Wahn,1 and Anette Ekström, 2013 https://www.hindawi.com/journals/nrp/2013/349124/
18. ‘What is a positive birth?’ Milli Hill, the Positive Birth Movement 2017 http://www.positivebirthmovement.org/what-is-positive-birth.html
19. ‘A Good Birth: Finding the Positive and Profound in Your Childbirth Experience’ Dr Anne Lyerly, 2014
20. ‘Watch your language.’ Andrea Robertson, 1999 https://birthinternational.com/article/childbirth-education/watch-your-language/
21. ‘The words we use.’ Sara Wickham, 2002 http://sarawickham.com/wp-content/uploads/2011/10/tpm1-the-words-we-use.pdf
22. ‘Mind your language- exploring positive communication skills.’ Bernadette Matus and Belinda Phipps, 2004 https://www.rcm.org.uk/news-views-and-analysis/analysis/normal-birth-%E2%80%93-is-it-possible-in-the-21st-century
23. ‘Childbirth and the Language we use: does it really matter?’ Sheena Byrom, 2013 http://www.sheenabyrom.com/blog/2013/04/12/childbirth-and-the-language-we-use-does-it-really-matter 
24. ‘Midwives: 17 Words and Phrases to consider stopping using… please?’ 2015 Mark Harris https://birthingawareness.com/2015/08/05/midwives-17-words-phrases-to-stop-using-please-%F0%9F%98%83/