Before analysing pain across cultures, a definition of the notion is required.

The
Merriam Webster Dictionary (2015) defines pain as an unpleasant sensation that
sensory neurons transmit to the brain. It signals a potential injury or a
malfunction of the body. Pain perception is highly individualised, being
susceptible to a collection of external and internal stimuli. More than the
variations in the function of the cerebral cortex (concerned with the recognition
of pain), the way one feels is bound to ones cultural background (Narayan, 2010:
39). Wolff (in Wolff, B. and Langley, 1968: 494) argued that ones culture and
class can have a significant impact on the way pain is perceived and dealt with;
the reaction to the stimuli is pre-conditioned by cultural expectations.
Being an important indicator of ones physical state, pain assessment is a
universal health care concern. Sufferers are often asked to rate their pain on a
scale from 1 to 10. Emoticon faces are sometimes added for more accuracy.
Nevertheless, cultural differences present a challenge, the most obvious being
the language barrier. Words as stabbing or aching do not mean the same
thing everywhere. Ones worldview greatly influences the description of pain. For
example, many doctors are perplexed by descriptions of pain in terms of natural
elements (lighting, spider webs analogies, tones of drums, etc.). Moreover, the
attitudes people have towards treatment may differ, as well as the way they
respond to the physician. One example would be stoicism in Japan. A dignified
behaviour is considered crucial; complaining to the doctor, a person of a high
status would be proof of poor social skills (Carteret, 2011).
Pain can be classified in a variety of ways. The most common one is according to
duration, in which case the International Association for the Study of Pain
recognises acute and chronic pain. Chronic pain is longer-lasting and is
associated with long-term illnesses, being often resistant to medical treatment.
Acute denotes physical suffering precipitated by traumatic injuries, surgical
interventions, tissue damage or short-termed medical disorders. If the stimulus is
removed, the pain usually fades away (The Free Dictionary, 2015).

One example of pain that can be classified as acute is childbirth pain. Onwards,
this essay will analyse the manner in which pain is assessed, perceived and
managed, as well as how the choice of relief seems to fluctuate across several
cultural settings. It will begin by investigating reasons for the presence of pain at
birth, from the idea of it being socialised into our minds to a more biological
frame. It will then examine types of labour behaviour across cultures as well as
who holds authority over pain management at the birthing scene. Subsequently,
it will compare ideas about modern and traditional birth in the Western hospitals

and it will analyse the eventuality of a clash between cultures in a bio-medical

setting.
Childbirth Pain - causes
Pain seems to be an intrinsic component in the childbirth scene. History speaks of
its danger and religion dictates to the woman In sorrow thou shalt bring forth
children (Genesis 3:16) 82-83. Many theories have arisen concerning the true
causes of labour pain. The biological explanation is that during labour, the cervix,
vagina and the encircling tissues are overstretching to allow the baby to pass
through. The muscles in the pelvis are abundant with pain receptors; ergo, the
stretching gives way to unpleasant sensations called contractions (Sears and
Sears, 2015). However, if the purpose of pain is protection, why does a natural
process feel bad? Many doctors refer to this pain as psychological; women feel it
because they have been socialised to think it is there (Beels, 1978: 83). Suzanne
Arms sums up the situation bluntly:
After centuries of ingrained fear, expectations of pain and obeisance to male
domination, she cannot come easily to childbirth a changed woman after a
few classes in natural childbirth or a heavy dose of womens liberation. What
we bring to childbirth is nothing less than our entire socialisation as women
(cited in Beels, 1978: 84).
Nevertheless, there are other reasons childbirth can prove to be a dangerous and
painful affair. Poor sanitary conditions, various complications before, during and
after childbirth, inexperience, etc constitute a part of the issues that can
intervene. One cultural example is Female Genital Circumcision. The World Health
Organization (2014) defines it as total or partial removal of the female external
genitalia or other injuries to the female genital organs for cultural and religious
purposes. Immediate effects include shock, pain, haemorrhage and sepsis. Long
term complications affect childbirth, sexual activity and can cause cysts, urinary
infections and the need for later surgeries.

Labour and pain behaviour across borders; who has the authority of decision?

As ideas of what constitutes a home and kin differ from culture to culture, so does
the perception of pain. Pain behaviour during childbirth is easily influenced by
external factors. For example, in particular areas in Asia, the way in which labour
is carried out greatly reflects upon the womans family reputation. It is expected
from her to be dignified and not complain excessively. In the Mediterranean
areas, people tend to be more expressive with their emotions. This is seen in the

way a labouring woman clearly expresses her thoughts and feelings. In the West,
many women like to be in control during labour. Here, pain relief (ex: epidurals) is
seen as ambivalent: some patients feel that it gives control to the medical staff
while others believe that less pain allows more focus (Akinc, 2013). Another
example is of two Norwegian health workers who helped deliveries in Somalia.
They expressed their amazement at the stamina and stoicism shown by Somali
women during their silent labour, without any pain relief. However, many Somali
women interviewed after a delivery in Norway articulated their relief at being
able to scream their pain freely. This illustrates how divergent the pain behaviour
can be depending on the setting (Elise and Johansen, 2006: 535)
Pain management also depends greatly on ones cultural background. A relevant
example is given by traditional Inuit birthing practices. For a pain-free labour, the
women were encouraged to be as active as possible during pregnancy and to
respect and obey the elders. A long and painful birth would be a form of
punishment from the spirits for not behaving (Kaufert and O'Neil, 1990: 430).
Another example of pain-management is that of midwife-practices in south-east
Asia. Massage and reassurance are the main methods used by midwives to
relieve pain. Pain is a natural part of the process and they would only intervene
with local narcotics (ex. betel leaf) in extreme cases, when the labour is too long
or if the woman is in absolute agony (Priya, 1992: 82- 83).
Having considered several aspects of childbirth pain and its management across
cultures, it is also reasonable to look at who holds the authority in a birthing
setting. Authoritative knowledge of doctors and midwives can be located in their
scholarly training, their status, the quality of their work, etc. These usually imply
some sort of compulsion over the patients to trust and obey their directions
(Sargent and Bascope, 1996: 214).
In terms of pain management in a traditional setting, the midwife might allow an
experienced mother to decide for herself what is needed. For example in Yaxuna
Maya, a young, inexperienced mothers opinion is secondary to the midwifes,
who in turn decides if any pain relief or Oxytocin is needed to aid the birthing
process. The more experienced the mother, the more authority she gains to have
a say in the labour process (Sargent and Bascope, 1996: 221- 222). Here, the
midwifes status comes from previous successful births, her position in the family,
her age and her role in community.
In a modern setting, the doctors are often seen as the absolute authority in
taking the best decisions. Research shows that the majority of women submit
themselves willingly to medical authority. Patients seem to find technology
reassuring and in their best interests (Jordan in Sargent and Bascope, 1996: 215).
One relevant example is given by the hospitals in Texas. Some women had

limited understanding of the English language and participated very little in the
decisions concerning the birthing method or the pain relief choices (Sargent and
Bascope, 1996: 223). However, they recognised absolute authority in the hands
of the medical staff. In this case, the authoritative knowledge is constituted by
status and scientific training, rather than position in the family or age.
It is important not to assume that this is the case everywhere. If women want to
control the process, they can make requests to the physician according to their
personal beliefs. In this situation, the woman herself compels authority. Decisions
are influenced by a number of factors. Some are biological, depending on the
progress of labour, and some are social. Research has proven that decisions
concerning pain relief are often based on womens mother, sister, or friends
experiences. Birth classes also have a say in influencing reactions. For example,
hospital childbirth classes tend to encourage epidurals while many private ones
focus on natural childbirth (Sargent and Stark, 1989:44).
Modern versus traditional cultural clash?
When talking about birthing methods, the decision is influenced by several
factors. If there is choice between a modern hospital setting and the aid of pain
relief, or a natural birth accompanied by a midwife, it depends on the economic,
social, cultural and religious background. In the western countries, it is seldom
nowadays for a woman to give birth without any kind of drug in her system
(Priya, 1992: 84). Nevertheless, more attention has been focused lately on a
preference for natural childbirth, as to allow the woman to come into contact with
her inner femininity and bond with her child (Priya, 1992: 86). A contrast between
these two options can be seen between the views on childbirth in Belgium as
compared to Netherlands. In the first, the risks of childbirth are counterbalanced
by a belief in the biomedical model. Pain is a distraction and is removed with
medication. In the later, the midwifery model emphasises natural birth; pain is
accepted and seen as an ally indicator in the process of labour (Christiaens,
Nieuwenhuijze and De Vries, 2013: 3).
Each of these positions makes an important contribution to our understanding of
pain, pain behaviour and pain management across cultures. However, a question
worth exploring is what happens when two different worldviews clash? In this
case, when women who are accustomed, expect or desire a natural birth have no
choice but labour in a bio-medical setting. Two relevant examples are constituted
by the District of Keewatin, Canada and the situation of Somali women who give
birth in Western hospitals (in Norway and Canada).
First, in Keewatin, around the early 1980s, native women were allowed to give
birth in their homes attended by a midwife. The choice has now been rescinded
and childbirth is only allowed in a hospital setting (Kaufert and O'Neil, 1990: 428).

This move from the Canadian Governments part was and is seen as a way of
exercising authority over the Inuit population. Protests arose and many women
complained about being forced to give birth alienated from their culture and
family. Pain relief was not an easy choice in their culture and the usual relaxation
methods were being dismissed by the medical staff (Kaufert and O'Neil, 1990:
432).
The case of Somali women giving birth in Western settings delineates another
growing problem that of miscommunication between patient and doctor/ nurse.
In Canada, many Somali women who have been infibulated (a form of FGC
otherwise known as total circumcision) feel that their needs are not addressed
and have often found themselves victims of discrimination. The practice of FGC
leads to pre-conceived ideas and many patients felt blamed for what happened
to them. This leads to several complications during childbirth, which can become
painful and embarrassing for them (Chalmers and Omer-Hashi, 2010: 267) (ex: I
was in pain. I could not even move to my side. But the nurse insisted that I move.
I fainted and fell on the floor; They were not knowledgeable. We tried to explain
but they were very rude ). Due to what appears to be lack of interest from the
nurses side, many women experienced extreme post-partum pain which
prevented their immediate bond with their baby (Chalmers and Omer-Hashi,
2010: 270- 275).
The situation is different in Norway. The problem of miscommunication exists yet
it inclines in another direction. Health workers are trained to keep the birthing
process as natural as possible. Pain is seen as a natural part of childbirth and
medication is kept low. However, infibulated women need special consideration.
The seal of damaged skin from the vagina needs to be broken surgically in order
for the birth to proceed smoothly (Elise and Johansen, 2006: 518). Many doctors
are uninformed about what being infibulated means in the Somali culture and
they do not dare to ask in consideration for the patient. This points to a
combination of taboo subjects, limited information and often, silence. It leads to
difficulties in labour, for sometimes doctors are reluctant to cut the cultural seal
and they also seldom give medication to aid with the pain. Assuming that the
woman is accustomed to it due to her culture, emotional and traumatic pain is
often disregarded (Elise and Johansen, 2006: 516).
In conclusion, pain perception and management in childbirth depend greatly on
several factors, the main of which are not biological but cultural. The way one
feels, reacts to and manages physical pain is influenced by religion, worldviews,
cultural and social expectations. Language also plays a part in the manner in
which pain is expressed. The authority of knowledge and decision-making in
terms of pain-relief management is seemingly influenced by the same array of
factors. Recently, a trend towards the incorporation of more traditional methods

in labour pain and birth management seems to arise. More attention is given to
the cultural needs of people, as in the case of Norwegian doctors attitudes
towards Somali immigrant women; their uneasiness came from their wish to
respect the womans cultural values. Nowadays, more options in terms of pain
relief are given in Western hospitals as well as ore freedom of choice and
information to women themselves.

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