Childbirth in Kuwait: The experiences of three groups of Arab mothers

466 Journal of Pain and Symptom Management Vol. 6 No. 8 November I991

Childbirth in Kuwait: The Ex eriences of Three Groups of Arab Ann Harrison, PhD Faculty of Medicine, Kuwait University, Kuwait

Abstract The aims of the pesent study wc1.e to characterize the childbirth experiences of three groups of Arab mothers delivering in Kuwait and to evaluate the use of visual analog scales (VAS) for assessing their pain (N = 301). Kuwaiti, Palestin,itln, and Bedouin women who were expected to have an uncomplicated vaginal deliver) were studied. 73% of the women described their aaximum labor pain as “unbearably painful,” and more than one-half reported that they were “very frightened” or Wrrified. ” The deliveries of Bedouin mothers were remarkable for the absence of pain behaviors; yet their VAS reports indicated that they experienced no less pain. Painful menstruation and fear of childbirth emerged as risk factors for a painful labor. Among the issues discussed are the validity of the VAS data, the dz#iculties of managing Bedouin mothers’ pain, and the importance of excluding physical factors before cultural dqferences in pain perception are assumed. J Pain Symptom Manage 1991;6:466-475.

Delivery, pain, fear, stress, cross-cultural, visual analog scale

Introduction

Most women in Western societies report that

vaginal delivery is an extremely painful experi-

ence, and many sources of noxious stimulation

have been identified.lm5 It is no longer accepted

that women from underdeveloped societies ex-

perience only minor discomfort during child-

birth or that all women who have been “prop-

erly prepared” can expect a drug-free, pain-free

delivery.3,6 During the past decade, emphasis has shifted away from the effort to explain why

the labor pain reports of Western women are

exaggerated, toward a search for abnormalities

Address reprint requests to: Ann Harrison, PhD, Faculty

of Medicine and Health Sciences, University of the United Arab Emirates, P.O. Box 17666, Al Ain, U.A.E. Accepted fm publication: June 13, 199 1.

0 U.S. Cancer Pain Relief Committee, 1991 Published by Elsevier, New York, New York

in women who experience relatively painless la-

bor.’

Various factors place a woman at risk for a

painful labor, including a history of severe men-

strual pain, primiparity, youth, being over-

weight, and delivering a heavy baby.3*4** Moth-

ers who are anxious about the health of their

baby, mothers who doubt their capacity to cope

with labor pain, and mothers who lack family

support and enthusiasm for their pregnancy

also tend to report more painful labor.5sg Low

socioeconomic status and limited education

have emerged as risk factors in some studies.‘.’

Precisely how such psychological and social fac-

tors affect the woman’s perceptions and re-

sponses to pain stimuli, and the contributions of

physical correlates (such as the mother’s general

health, age, panity history, or use of prenatal

services), have yet to be established. Biochemi-

cal and physiological mediators that link the

0885-3924/91/$3.50

Vol. 6 No. 8 November 1991 Childbirth in Kuwail 467

psychological status of the mother to the type of

labor she experiences are being sought. In a

recent study, high pain and high anxiety during

the latent phase of labor were associated with

protracted labor and fetal distress, and the ex- planation offered was in terms of excessive cat-

echolamine and cortisol release. lo*’ ’ Most of the existing empirical work on labor

pain was carried out in Europe and North

America, but a recent study did compare the childbirth experiences of women with Western

and with Middle Eastern backgrounds deliver-

ing in Israel. I2 The authors assumed that a

Middle Eastern background is “conducive to

greater expression of feelings and emotions,”

and thus predicted that Middle Eastern mothers

would express greater pain. Middle Eastern

mothers did display more pain behaviors, but

the difference was only reliable for mothers with

less than 12 years of education. Participatior! in

childbirth preparation classes was associated

with lower pain behavior scares, and a higher

proportion of Western mothers had attended

such classes. From the results presented, it is

not possible to assess how far the ethnocultural

differences described could be accounted for in

terms of the age and preparation differences of

the two groups. Furthermore, two pain indices

were used, observers’ ratings of the mothers’

pain behaviors and mothers’ visual analog scale

(VASj ratings of their pain, and these furnished

different results. Participation in preparation

classes was associated with lower pain behavior

scores, but not lower VAS ratings; and the eth-

nocultural groups differed in their pain behav-

iors, but not their VAS reports. The authors

argue that pain behavior reflects the amount of

“self-control” a mother shows when she is in

pain, while the VAS rating is mainly an index of

the sensory component of her pain experience.

Finally, the Middle Eastern group in this study

included women whose mothers were born in

“Asia, North Africa, or one of the other Middle

Eastern countries,” and with such diversity it is

questionable to what extent they shared a com-

mon ethnocultural heritage. The present study investigated the childbirth

experiences of three stable Arab population

groupings living in Kuwait, namely Kuwaitis,

Bedouins, and Palestinians. Exploitation of oil

in the 1950s triggered the rapid expansion and

modernization of Kuwait.13 Before this the YP;-

jor occupations of urban Kuwaitis were as fish-

ermen, seafarers, merchants, traders, and pearl divers. The Bedouins have their roots in the

wandering tribes of the Arab peninsula. Even

today, some Bedouins live in the desert and

maintain flocks of animals, b;rt the majority are urban dwellers. Many Palestinian families have

lived in Kuwait for over 40 years. Although

these groups share many important features including country of residence, religion, and tan-

guage, sociocultural diversity is also apparent.

The behavior of Bedouin mothers during child-

birth is strikingly different from that of the

other two groups. Bedouin mothers consider it

very shameful to display pain, and their labors

are remarkable for the absence of facial expres-

sions, verbalizations, and body movements that denote pain.

Kuwait provides free medical care including comprehensive prenatal and delivery services for all residents,13 and over 980/o of all deliveries take place in a hospital. Kuwait, thereftire, provided an opportunity to compare mothers from diverse rociocultural backgrounds delivering in the same medical facilities, in a situation where low income was no bar to obtaining comprehensive perinatal care. Women were interviewed both before and after delivery in order to assess the impact of factors such as the mother’s age, birth record, menstrual pain, pregnancy pain, fear nf de!Ivery, duration of labor, and disap- pointment with the sex of the baby on the severity of labor pain reported.

The VAS ratings have proved reliable and valid tools for evaluating clinical pain,14 and have been used for a variety of pain studies in Kuwait.“*16 Mothers were asked to rate their pains using a &point VAS on which 0 was labeled “no pain” and 5 was labeled “unbearable pain. “” Intermediate levels were not labeled because of the lack of empirical data for selecting Arabic adjectives which denote equal incre- ments of pain intensity.” The ramifications of selecting inconsistent numericai and verbal la- bels were thereby avoided.lg Pain intensity var-

ies considerably during labor,4a20 and mothers

were asked to rate both the maximum and the

average pain they had experienced. The aim was to monitor uncomplicated vaginal deliver-

ies, and mothers who were expected to experience complications or a cesarean section were

excluded.

468 Harrison Journal of Pain and Symptom Management

Method Ethical clearance for the study was received

from the Ministry of Health, State of Kuwait.

Convenience samples of Kuwaiti, Bedouin, and

Palestinian women admitted for delivery to two government hospitals were interviewed. The

protocol set was to interview at least 100 women

in each group. The only other selection crite-

rion adopted was that a vaginal delivery with no

complications was predicted by the attending

physician. Potential subjects were informed

about the purposes of the study, and their co-

operation was requested. It was made clear that

participation was voluntary and could be cur-

tailed at any time. Mothers were interviewed

during the first stage of labor before they were

admitted to the delivery room and again after

the birth when they had been moved to a ward.

The first interview collected demographic data

from the mother, VAS evaluations of her men-

strual and pregnancy pain experiences, and her

reported fear of labor. After delivery, the

mother was asked for VAS evaluations of the

average and maximum pain that she had expe-

rienced during labor, and about her own and

her family’s reactions to the sex of the baby.

Information about duration of the labor, any

medications administered, and the baby’s birth

weight and status were taken from medical

records. Subjects were not followed for the sec-

ond interview if the mother or the baby was sick,

or if the baby was stillborn or had died.

Nonparametric tests which assume ordinal,

but not interval, measurements were used for

analyzing the VAS and rating data.

Results

Only 2 of the women approached refused to

participate, blaming their current discomfort;

15 mothers completed only the first interview (9

discharged themselves before the second inter-

view was undertaken, 6 were ineligible because

of illness or the death of their baby). A total of

311 mothers (103 Kuwaitis, 107 Bedouins, 101

Palestinians) completed both interviews. Of

these, 36 had a cesarean section (6 Kuwaitis, 14

Bedouins, and 16 Palestinians), and their data

are presented separately. On average, the first

interview took place 5 hours before delivery and

the second 22 hours after.

&mographic Charactitics The three sociocultural groups (Table 1) did

not differ significantly in terms of current age

(Kruskal-Wallis one-way analysis of variance,

P > .05), but they did in age at marriage

(Kruskal-Wallis one-way analysis of variance, x2

Table 1 The Dewogr2phk Characteristics of the Sub&t Groups

Age (yr)

Characteristic Kuwaitis N = 97

Bedouins N = 93

Palestinians N = 85

Mean (SD) Range

Age at marriage (yr) Mean (SD) Range

Education (%) Illiterate Did not complete high school Completed high school Completed degree or diploma Completed graduate studies

Employed (%) Primiparas (%)

Multiparas-number of previous children Mean (SD) Range

26.4 (5.6) 27.0 (5.9) 26.9 (6.1) 17-53 17-40 1643

19.9 (3.8) 16.6 (3.1) 19.5 (3.6) 13-41 11-26 lo-30

11 80 14 43 16 42

7 4 25 24 0 14 14 0 5 35 1 15 ?7 10 25

2.7 (1.9) 4.6 (2.6) 3.5 (2.2) l-10 l-10 l-9

--___-.

Vol. 6 No. 8 h’wember 1991 Childbirth in Kuurrrit l69

= 47.56, P -C .0001) and number of previous

children (Kruskal-Wailis one-way analysis of

variance, x2 = 32.16, P < .OOOl). Bedouin

mothers tended to have married younger and to

already have more children. Only IO%, of Be-

douin women were primiparous, compared

with one-quarter of the Kuwaitis and Palestin-

ians, respectively (x 2 = 10.0. dj- = 2, P < .Ol).

The three groups also differed significantly in

terms of their literacy and educational attain-

ments (x2 = 146.6, df = 8, P < .OOOOl). Of the

Bedouins, 80% were illiterate, and a further

16% had not completed high school. Less than

15% of the Kuwaitis and Palestinians were illit-

erate, and nearly one-half had completed high

school. The vast majority of Bedouin and Pal-

estinian women were not working outside the

home, but over one-third of Kuwaitis were em-

ployed. About one-quarter of mothers reported

having experienced a miscarriage, and 7% had

experienced a stillbirth. Most mothers (96%)

reported that they had complied with prenatal

checks, and the groups did not differ significantly in this regard (x2 test, P > .05). None of

the mothers had attended childbirth prepara-

tion classes.

BirthIkzta The births included eight pairs of twins. In

these instances, the data for the first child deliv-

ered were analyzed. The three groups differed

significantly in terms of duration of labor


= 9.30, P < .Oi): those of Bedouin mothers

were generally longer (mean, 11.2 hr, SD, 7.3)

than those of Kuwaitis (mean, 10.3 hr, SD, 11.9)

and Palestinians (mean, 9.4 hr, SD, 6.6). Twice

as many multiparas (63%) as primiparas (29%)

received no medication (.y2 = 21.26, ckp = I,

P < .OOOl). The vast majority of babies (95%)

were judged to be fullterm including 89% of

first babies. The overall male-female ratio was

50-50. The mean weight of the babies was 3.5

kg (SD, 0.6). The three age groups differed sig-

nificantly in terms of their babies’ weights


= 8.79, P < .05), with mothers under 20 yr of

age delivering lighter (mean, 3.2 kg, SD, 0.5)

babies-the three sociocultural groups did not

differ significantly in this regard (Kruskal-Wallis

one-way analysis of variance, P > .05).

VAS ratings indicated that labor was generally a very painful experience (Tab

mothers selected an intensity level of 4 or 5 to characterize their average pain. Mild pain rat-

ings (level 2 or less) were selected by only 2% of

respondents. The sociocultural groups differed

significantly in their average pain selections


= 13.44, P < .005), with Bedouin mothers re-

porting more painful deliveries and Kuwaitis

the least pain. The three groups did not, how-

ever, differ reliably in their maximum labor

pain reports (Kruskal-Wallis one-way analysis of

variance, P > .05), although the same rank or-

dering was apparent. The three age groups differed significantly in their average labor pain

selections, with older mothers reporting !c;s

pain (Kruskal-Wailis one-way analysis of vari-

ance, x2 = 6.26, P < .05). Very young mothers

(18 yr old or less) did not report consistently

higher levels of pain than older women (Mann- Whitney U test, P > .05).

Over one-half of the mothers reported that

they were frightened or terrified by the prospect

of labor, and less than 20% reported not being

worried (Table 3). The sociocci:ural groups

differed significantly in their anticipatory fear (Kruskal-Wallis one-way analysis of variance, x9

= 10.5, P < .Ol). Bedouin mothers were gen-

erally more afraid. The ‘three age groups did not differ cons;:tently in this regard (Kruskal-

Wallis one-way analysis of variance, P > .05).

Tht mother’s fear of labor correlated signifi-

cantly with the average (Spearman.s rank order

correlation coefficient, IS = 0.26, P < .OOl) and

maximum labor pain (Spearman’s rank order

correlation coefficient, TS = 0.26, P < .OOl) she

reported. Most (81%) of the mothers who were

te+fied reported level 5 average labor pain,

compared with only 55% of women who re-

ported no more than a little anticipatory fear.

Terrified mothers reported significantly longer

labor than mothers who were less frightened

(Mann-Whitney U test, 21 = 6825, z = 2.06,

P -c .05) and greater average (Mann-Whitney U

test, u = 6147. z = 3.79. P < .0005) and max-

imum (Mann-Whitney U test, ZI = 6570, z =

3.18, P -c .0005) labor pain. Terrified mothers

did not differ reliably in age or number of pre-

vious children (Mann-Whitney U test, P > .05).

470 HatiOn Journal of Pain and Symptom Management

Table 2 Visual Analog Scale (VAS) Ratings of Labor Pain (in %)

VAS level Sociocultural group Parity Age group Birth

Average labor pain 0 0 1 3 2 0 3 17 4 2s 5 53

Maximum labor pain 0 0 1 2 2 0 3 9 4 21

0 0 0 0 0 0 0 0 0 0 2 0 2 0 2 5 2 3 1 0 0 1 0 1 1 0 6 9 9 11 1‘) 13 11 14 12 28

13 18 27 1S 17 20 P”r 20 25 77 71 63 68 71 67 59 67 39

0 0 0 0 0 0 0 0 0 0 2 0 2 0 1 5 2 3 1 0 1 1 1 1 0 0 3 9 7 11 8 13 7 18 8 33

11 19 23 15 8 18 14 17 25 (2::) 79

(24)

When the sociocultural groups were considered The median duration of labor was 8 hours. separately, all three demonstrated a trend for Labors were divided mto those lasting 8 hours terrified mothers to report longer and more or less (shorter labors) and those lasting longer. painful deliveries. In the case of Bedouin moth- Shorter labors were reliably less painful, both in ers, terrified women reported significantly terms of average (Mann-Whitney U test, u = greater average (Mann-Whitney U test, u = 18756, z = 2.50, P C .05) and maximum pain 808, z = 2.67, P < .Ol) and maximum (Mann- (Mann-Whitney U test, u = 18474, z = 2.13, Whitney U test, u = 848, z = 2.34, P < .05) P < .05). Mothers who experienced a shorter labor pain. labor reported less anticipatory fear (Mann-

Table 3 Fear of Labor (in %)

Question: “Some ladies are very frightened when they think of labor and delivering their baby, while others are relaxed and very confident. How would you describe your own feelings?”

Response Sociocultural group Parity Age group Birth

Not worried 12 21 24 21 18 21 18 23 19 A little worried but.

confident I can cope 8 1 11 14 5 4 7 5 7 A little frightened 10 2 13 9 8 4 9 5 8 Frightened 18 7 14 11 13 17 14 0 13 Very frightened 27 26 14 13 25 8 23 32 23 Terrified

(N) (Z:, (Z) (2::) (2;:)

Vol. 6 No. 8 November 1991 Childbirth in Kuwait 471

Whitney U test, u = 18653, z = 1.98, P < .O5)

and less menstrual pain (Mann-Whitney !_I test,

u = 19307, z = 3.04, P < .005). But mothers

who experienced shorter deliveries did not dif-

fer reliably in age, weight of baby delivered, or

number of previous children (Mann-Whitney ?J test, P > .Ot;).

A significant correlation was found between a

mother‘s fear of labor and its reported duration I” \3pearnlalr 3 lyLl.l ---‘- -3m.t order correfatior, coefficient,

rs = 0.13, P < .05). Duration of labor also cor-

related significantly with average pain (Spear-

man’s rank order correlation coefficient, rs =

0.14, P < .Ol), maximum pain (Spearman’s

rank order correlation coefficient, rs = 0.15,

P -=z .Ol), and weight of baby (Spearman’s rank

order correlation coefficient, rs = 0.10,

I’ C .05). The three age groups did not differ

reliably in terms of duration of labor (Mruskal-

Wallis one-way analysis of variance, P > .05).

Only 6 of the 3 11 mothers interviewed before

delivery reported knowing the sex of the child

they were carrying; this was based on ultra-

sound findings. Very few mothers (6%) inter-

viewed after delivery reported that they or their

family were disappointed by the sex of the baby

delivered. When there was chsappointment

mothers reported more painful labor. Of moth-

ers who were personally disappointed, 93%

characterized their average pain as VAS level 5,

compared with 63% of those who were pleased.

Mothers who were disappointed reported con-

sistently greater average labor pain (Mann-

Whitney U test, u = 1345, z = 1.99, P < .05).

The family’s degree of contentment with the sex

of the baby, as perceived by the mother, correlated significantly with average (Spearman’s rank order correlation coefficient, rs = 0.15,

P < 305) and maximum labor pain (Spear- man’s rank order correlation coefficient, rs = 0.10, P < .05).

About one-half of the mothers interviewed re-

ported minimal menstrual pain (Table 4), but

over one-quarter reported vAS levels of 4 and

5. Indeed, the distribution of menstrual pain

reports had two peaks (levels 1 and 4). The so-

ciocultural groups differed significantly in their

menstrual pain reports (Kruskal-Wallis one-way

analysis of variance, x2 = 13.19, P < .005), with

Kuwaiti mothers generally reporting lower lev-

els. But in all three sociocultural groups, two

peaks are apparent. The three age groups did

not differ consistently in their menstrual pain

ratings (Kruskal-Wallis one-way analysis of vari-

ance, P > .05). A significant positive correla-

tion was found between women’s ratings of their

menstrual pain and average (Spearman’s rank

order correlation coefficient, rs = 0..28, P c .001) and maximum labor pain (Spear-

man’s rank order correlation coefficient, rs =

0.22, P < .OOl). Of mothers who reported a

menstrual pain levc! sf 4 or 5, 82% reported ap. average labor pain level of 5, compared with

56% of those reporting a menstrual pain level of

Table 4

VAS level Sociocultural group Parity Age group Birth Y;

L ?.

x .” 2

4 6

E .Z

.s

2

Z 3

c

2 .z ‘3

2 G ?. 2

Z 8

.n

.; ‘3 .% 9

4 4 .G 3

5 4 2

f Z Z ti ; a”

‘C a LZ s

& 4 B !j 0I

0 22 8 18 11 17 4 17 18 16 II

1 44 37 31 46 35 42 35 55 38 58

2 4 2 6 7 3 4 4 9 4 6

3 12 17 8 7 14 8 14 3 I3 -

4 14 32 31 21 27 33 26 9 26 1:

4 7 8 0

(93) (85, (56) (24) (22:) (27:) (36)


0 or 1. A significant association was found between mothers’ estimates of their menstruaI pain and average (x2 = 39.1, df = 20, P < -01) and maximum labor pain (x2 = 32.6, df z 20, p < .Ol), but not duration of labor (x2 test, p > ~5). When mothers who reported minimal menstrual pain (level 0 or 1) were compared with those reporting the highest levels (4 or 5), significant differences emerged in terms of average (Mann-Whitney U test, u = 4413, z = 4.05, P < .OOOl) and maximum labor pain (Mann-Whitney U test, u = 4830, z = 3.23, P < .005) and duration of labor (Mann-Whitney U test, u = 4534, z = 3.17, P < ,005). Mothers who had experienced minimal menstrual pain reported less painful and shorter labors. Most of the women interviewed reported minimal pain during pregnancy. A pain intensity of 1 or less was reported by 88% of women for the first trimester, 87% for the second, and 75% for the third. High pain (level 4 or 5) was reported by only 2% of women during the first two trimesters, and by 8% during the third.

Parity and Birth Weight Comparisons of primiparous and multipa-

rous women revealed no differences in their reports of pain during menstruation, pregnancy or labor, their fear of labor, or the duration of labor (Mann-Whitney U test, P > .05h. Primip- arous mothers delivered significantly lighter babies (Mann-Whitney U test, u = 4894, z = 2.61, P < .Ol). Heavy babies (weight of 5 kg or more) were not associated with more painful deliveries (Mann-Whitney U test, P > .05).

Cesarean Sections When cesarean section and vaginal deliveries

were compared, no differences were found in terms of the mother’s age, her anticipatory fear level, or the weight of the baby delivered (Mann-Whitney U test, P > .05). Labors termi- nated by cesarean section (mean duration, 14.3 hr, SD, 7.1) lasted longer (Mann-Whitney U test, u = 2951, z = 3.95, P < .005) and had less average (Mann-Whitney U test, x = 3388, z = 3.59, P < .005) and maximum pain (Mann- Whitney U test, u = 2932, z = 4.87, P < .oOl) (Table 2). The rates of cesareas section among primiparas (8%) and multiparas, (12%) were not significantly different (x2 test, P > AX); more

boys (15%) than girls (8%) were delivered by cesarean section (x2 = 3.62, df = 1, P = .057).

A major aim of the present study was to in- vestigate the pain reports of Arab mothers delivering in Kuwait. The majority reported that vaginal delivery was extremely painful: 90% of mothers selected one of the two highest. ratings (VAS levels 4 or 5) to signify their m,aximum pain; 73% described their maximum labor- pain as “unbearably painful,” whereas 67% d’escribed their average pain in this way. These pain reports are consistent with reports from Eu-ope and North America and an earlier study from the Middle- East. ‘* In the Israeli study,i2 molth- ers with Middle Eastern backgrounds averaged 88 on a O-100 scale, and Western-background mothers averaged 82 (these correspond to 4.4 and 4.1 on the current O-5 VA’?); mothers in Kuwait recorded a mean average pain of 4.5. Mothers in the current study cannot be characterized as high pain complainers. Less than one-third of the mothers chose VAS levels 4 and 5 when describing their menstrual pain and less than 10% reported such intense pain during pregnancy. Over one-half of the mothers interviewed in Kuwait reported being “very frightened” or “terrified” at the prospect of labor. Mothers who had experienced childbirth before were no less afraid.

The three sociocultural groups did not differ in their reported use of prenatal services, and they delivered in shared medical facilities. The groups did not differ in terms of current age, or the weight and status of the babies they delivered. Clear differences were apparent, however, in terms of other characteristics including age at marriage, family size, formal education, and employment. Bedouin mothers were less well educated and less likely to be employed; they tended to have married earlier and to already have more children. Palestinian mothers were comparable to the Kuwaitis in terms of high school education, but fewer had proceeded beyond this level. This is consistent with the admissions policy of higher education institu- tions in Kuwait which give priority to Kuwaiti applicants. The aim of studying three demo- graphically diverse Arab groups being served by a single medical care service was, therefore, re- alized.

Bedouin Mothms The relatively high levels of fear and pain re-

ported by Bedouin mothers in the current study

Vol. 6 No. 8 November 133i Childh?h in Kuwait - 473

must be of concern. There is no suspicion that

this group contained a higher proportion of

mothers who had opted for a hospital deli:clI.

because they were expecting complications. Most babies (98%) born in Kuwait are delivered

in hospital facilities; indeed, home births are ac-

tively discouraged. Most of the Bedouin women

interviewed had delivered successfully before,

and yet they ulere particularly fearful. Many

factors (physical, psychological, medical car<,

cultural, etc.) could be responsible for their

greater fear and pain, and their protracted Ia-

bors. At this stage, it is only possible to specu-

late on what these might be. Bedouin women

may find the hospital a more alien environment

and may find it harder to accept the exclusion of

family and friends from the birth. They are

probably less successful at communicating their

needs to nurses and doctors. Their lack of pain

behaviors would certainly seem to place them at

risk for a more painful delivery because staff are

less likely to be aware of their needs and so less

likely to administer drugs.*‘**” Previous studies

have found that women with minimal education

and iow socioeconomic status sometimes expe-

rience more painful labors.3*g in trying to find

ways of helping Bedouin mothers it is vital to

identify the factors that may be playing a role in

their behavior. Do Bedouin women differ in

their use of medical services, neglect of physical

problems, misconceptions they harbor, stresses

they face, or strategies for coping? Physical fac-

tors certainly should not be overlooked.’ Ku-

waitis and Bedouins practice consanguine mar-

riage, and so physical risk factors could even

follow sociocultural divisions. Whatever the or-

igins of the excessive fear and pain expressed by

Bedouin mothers, it is vital to try and discover

ways of countermg these. Reducing fear is de-

sirable in itself and might also lead to shorter

and less painful deliveries.‘0*2’*“’

is no possibility of the woman being heard, but

still the tradition persisis. It is important that

the Bedouins who took part in the current study

are among the first generation to experience Western natal services.

It is fascinating that Bedouin mothers did not consider it shameful to report high levels of

pain using the VAS. It may be that the VAS is

unfamiliar and so does not elicit a response that is checked for social acceptability. Or it may be

that in Bedouin tradition the shame lies not in

feeling the pain, but in exhibiting it, that what

Bedouin mothers are expected to do is practice

“self-control.” Other research has shown that

“self-control” can lead to an uncoupling of pain

evaluation and pain expression, creating a situ-

ation in which the mother’s behavior belies her

assessment of her labor as “unbearable.“‘” In

the earlier study, “self-control” was attributed to

the individual psychological preparation of the

mother, whereas in the case of Bedouin mothers

we believe that the origin is cultural. Whatever

the cause, health care workers need to be aware

that pain behaviors do not always offer a reliable

index of the amount of pain the mother is ex-

periencing. The VAS does appear to provide

an index of the mother’s pain which is not bi-

ased by education, preparation, or culture. It would be valuable to search for pain behav-

iors that are not prone to “self-control.” The

facial expressions of infants in pain might pro-

vide a useful starting point. It is also worth ex-

ploring whether Bedouin mothers exhibit pain

behaviors that are oni); recognized by people

from within their community. The aim of such

research would be to provide medical workers

with more sensitive ways of assessing these pa-

tients’ pain and so improve the management

they can provide.

R&k Factors Although Bedouin mothers displayed very Mothers with a history of severe menstrual

few pain behaviors during labor, their VAS rat- pain proved to be at risk for a more painful

ings indicate that the pain they experienced was labor, as has been found in previous studies.

every bit as intense as that reported by Kuwaiti The existence of two peaks in the menstrual

women, Palestinian women, and women in pain reports of all three sociocultural groups is

Western societies. 1-5 Bedouin women are consistent with the presence of two underlying

brought up in a culture in which it is considered distributions. It may be speculated that these

shameful to exhibit pain during child.birth. two peaks represent women with normal pros-

When women give birth in a tent in the desert, taglandin production and women with excessive

any vocalizations they make are audible :o the production respectively.” Primiparous mothers

waiting family. Family members are excluded did not report more painful labors than muiti-

from the delivery area in hospitals, and so there paras but fewer completed childbirth without


medication. This suggests either that medical

intervention was effective in forestalling the higher pain levels reported by primiparous mothers elsewhere or that medical staff were not SO responsive to the pain complaints of experienced mothers.

Analyses revealed that the more fearful a mother was, the more painful she reported labor to be. Fear could exacerbate pain, either by serving as a stressor or by increasing the atten- tion given to pain signals.*’ Primiparous

women reported being unafraid more often

than multiparas did. Primiparas are sometimes

unrealistic in how mild they expect painful labor

will be, supposing that it will resemble men-

strual discomfort. Indeed, health care person-

nel have been warned against using terms such as “cramps” and “discomfort” when describing

childbirth because these understate the pain

most women -wiii ~cJ.~ The problem is that this

may lead the mother to doubt her own adequacy or the medical care provided when she experi-

ences more pain than she was expecting.” Women who were disappointed by the sex of

their baby tended to report more painful labors,

and it could be argued that such circumstances

foster pain complaining. Alternatively, such

mothers may be more stressed during labor be-

cause of worries about the outcome and may

experience greater pain for purely physical rea- sons. One of the shortcomings of the present

study is that mothers were not asked about any sex preference before the birth, and their post

hoc reports may not be valid.*’ To place the matter in perspective, however, very few moth-

ers (less than 7%) expressed any disappoint- ment.

Women who have experienced significant pain outside of childbirth tend to report less

painful labors, 24 but the present study showed

that previous exposure to childbirth pain does

not have a comparable effect; it probably should not be expected unless the mother benefited by having previous fears allayed or by acquiring more effective coping strategies. In the current study, memory of previous deliveries more often seemed to prime fear than provide reassur- ance. Research is needed to explore what types of preparation and what types of care during childbirth would moderate the fear and pain of mothers delivering in Kuwait, and whether

these would make subsequent deliveries easier.

An experience of high levels of menstrual pain

was associated with greater, rather than less, labor pain; this adds credence to the idea that there is a physiological link between the high levels of pain experienced during menstruation and 1abor.s

Th VAS Tool VAS ratings have proved effective for sum-

marizing the pain experience and for isolating

risk factors.5 There are encouraging pointers

concerning the validity of the VAS data pro-

vided by mothers in Kuwait. The pain assess-

ments recorded for the trimesters, for average

and maximum pain, and for menstrual and la-

bor pain are rank ordered as expected. The

replication of previously described associations

between fear and labor pain and between men-

strual and labor pain are particularly encourag-

ing. Average labor pain proved the more sensitive index for monitoring the impact of variables simply because so macy mothers (90%) chose levels 4 and 5 when rating their maximum pain. Mothers who had a cesarean section reported less pain, which is consistent with the medications administered. The VAS tool proved useful for comparing the pain reactions of women with very different educational and social backgrounds.

When Swedish mothers were asked to report

their labor pain at the time of childbirth and

again 2 days later there was a significant reduc-

tion in the VAS levels selected after childbirth.*’

Swedish mothers seemed unwilling to associate

pain with an event that had a very positive out-

come. Mothers in Kuwait, however, reported

high levels of pain retrospectively. This may

reflect the fact that mothers in Kuwait were in-

terviewed sooner after delivery or that the VAS

was less familiar. It is also possible that child-

birth and labor pain have different connotations

in Sweden and Kuwait.

A number of factors (including menstrual pain, labor pain, pregnancy pain, and fear) correlated significantly, but usually these accounted for only a small proportion of the variance. This suggests the need for a multifac-

torial model in which physical, medical manage-

ment, and psychological factors all play a role in determining the intensity of labor pain re-

ported. It is possible that a higher proportion of

variance would have been accounted for had

only the affec:ivc componenlt of the pain expe-

rience been considered,“5 but appropriate Ara-

bic language pain tools are not cllrrently avail-

able. ”

The existing literature offers a conflicting pic-

ture of the relationships between fear, pain, and

duration of labor. Some authors believe that the

option is between a short, painful delivery or

one which is longer and less painful.” In other

studies, however, high fear and pain were asso-

ciated with a protracted labor. “I Relationships

could vary depending on the exact stage of the

chi:/bir:h process investigated or the precise

context provided by other variables. In the

present study, anticipatory fear, pain, and du-

ration were positively correlated.

The present study represents a beginning in

trying to characterize the childbirth experiences

of Arab mothers in Kuwait; but disentangling

the contributions and interactions of physical,

medical,, psvcholcgical, and cuiturai f~tors wi!l

require more focused studies and more sophis-

ticated measures. Stratified sampling, for exam-

ple, is needed to distinguish age and parity con-

tributions. One important finding to emerge

from the current study is that when proper pain

management is being compromised by the pa-

tient actively blocking pain behaviors, visual an-

alog scaling may well provide medical care per-

sonnel with a way of accessing accurate pain

intensity information.

The work was supported by Kuwait L’niver-

sity Grant MUC07 1.

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Documents

Childbirth in Kuwait: The experiences of three groups of Arab mothers