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The Pain of Childbirth: Perceptions of Culturally Diverse Women

yyy Lynn Clark Callister, RN, PhD, Professor,* Inaam Khalaf, RN, PhD, Assistant Professor, Sonia Semenic, RN, PhD(c), Robin Kartchner, RN, BSN, and Katri Vehvilainen-Julkunen, CNM, PhD, Professor

ABSTRACT:

From the *Brigham Young University College of Nursing, Provo, UT; University of Jordan Faculty of Nursing, Amman, Jordan; McGill University, Montreal, Quebec, Canada; Intermountain Health Care, Provo, UT; University of Kuopio School of Nursing, Kuopio, Finland. Address correspondence and reprint requests to Lynn Clark Callister, RN, PhD, Brigham Young University College of Nursing, 136 Kimball Tower, Provo, UT 84602-5544. Tel: 801-422-3227; Fax: 801-422-0536; E-mail: lynn_callister@byu.edu 2003 by the American Society of Pain Management Nurses 1524-9042/03/0404-0000$30.00/0 doi:10.1016/S1524-9042(03)00028-6

The pain experiences of culturally diverse childbearing women are described based on a secondary analysis of narrative data from phenomenologic studies of the meaning of childbirth. Study participants were interviewed in the hospital after giving birth or in their homes within the rst weeks after having a baby. Transcripts of interviews with childbearing women who lived in North and Central America, Scandinavia, the Middle East, the Peoples Republic of China, and Tonga were analyzed. Participants described their attitudes toward, perceptions of, and the meaning of childbirth pain. Culturally bound behavior in response to childbirth pain was also articulated. A variety of coping mechanisms were used by women to deal with the pain. Understanding the meaning of pain, womens perceptions of pain, and culturally bound pain behaviors is fundamental in order for nurses to facilitate satisfying birth experiences for culturally diverse women. 2003 by the American Society of Pain Management Nurses

Every year in the United States over four million women give birth. Childbirth represents a major pain experience that accompanies the normal physiologic process of giving birth. Birth is also a profound psychosocial experience. Childbirth may be viewed as a test of womanhood, a test of personal competence, a peak experience, and the rst act of motherhood. The origin of the word birth is from the Old Norse word burdinr or behr, which seems to imply to bear or to endure. Women interviewed about their memories of pain experiences throughout their lives report that the pain of childbirth was the most memorable pain they had experienced (Niven & Brodie, 1995). Childbirth pain is a unique and complex sensory and affective experience that differs from the acute or chronic pain of disease, trauma, or surgical or medical procedures (Niven & Murphy-Black, 2000; Sittner, Hudson, Grossman, & Gaston-Johannson, 1998; Waldenstrom, 1996; Yerby, 1996). Birth is characterized by pain but also by the most positive of life events[creating] a new life (Niven & Gijsbers, 1996, p. 131). Although childbirth pain is a unique experience for each individual woman, how the woman perceives and makes meaning of her pain, as well as her pain
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TABLE 1. Studies of Culture and Childbirth Pain


Author(s) Chang, et al. (2002) Research Focus Effects of massage on pain and anxiety during labor Sample Method/Tools Results Massage helpful in reducing pain and anxiety

n 60 primiparous Randomized trial PBI Chinese women (Present Behavioral giving birth in Taiwan Visual Analogue Intensity) Scale Fouche, et al. (1998) Psychological needs of n 30 African women Interviews laboring women Green (1993) Expectations and experiences of childbirth pain Pain experiences of Arab women

Harrison (1991)

Lee & Essoka (1998) Cultural differences/ similarities in childbirth pain perception Morse & Park (1988) Cultural differences in childbirth pain perception

Pathanapong (1990) Childbirth pain communicative behaviors Weisenberg & Caspi Effects of culture on (1989) childbirth pain

Culturally appropriate care may reduce anxiety and pain n 700 English Survey (92% return) Anxiety about pain women strong predictor of negative birth experiences Visual Analog Scale Bedouin women no PBI less pain but absence of pain behaviors n 67 Euro-American Visual Analog Scale Signicant differences women Interviews in quality of and n 57 Koreanoverall evaluation of American women pain, no signicant differences in pain intensity Ratings of pain (paired Pain perceptions Western Canadian comparisons) highest in Anglo women women, secong n 191 Anglo among East Indian n 48 Ukranian women, third n 41 Butterite Hutterite women, and n 22 East Indian lowest among Ukranian women n 32 Thai women Observations of Pain expressed subtly behaviors in nonverbal quiet mode Higher pain ratings and n 30 Western Visual Analog Scale more pain behaviors women Observations of pain in Middle Eastern n 53 Middle Eastern behaviors women, no women giving birth in Eysenck Personality signicant Israel Inventory differences in coping Miller Behavioral Style style Scale

related behaviors while giving birth, are culturally dened (Baker, et al., 2001; Moore & Moos, 2003; Schott & Henley, 1996). According to classic studies by Zborowski (1952), each culture has its own language of distress, expressed both verbally and nonverbally. The pain of childbirth is no exception. Women give birth within their sociocultural context, which affects the psychosocial and physiologic perceptions of pain (Bates, 1987; Shilling, 2000). In classic anthropologic studies of childbearing, Kay (1982, p. 17) concluded that, Pain in labor and childbirth is expected by women in all societies, but may be interpreted, perceived, and responded to differently. A strong association was found between cultures and

womens beliefs about and behavior in connection with childbirth pain (Weber, 1996). Pain is a culturally dened physiologic and psychosocial experience.

LITERATURE REVIEW
Few studies have focused specically on perceptions of childbirth pain in culturally diverse women. Crosscultural studies on childbirth pain are summarized in Table 1 (Green, 1993; Harrison, 1991; Lee & Essoka, 1998; Morse & Park, 1988; Pathanapong, 1990; Weisenberg & Caspi, 1989). In a study of three groups of Arab women, among Bedouin women there was an absence of pain behaviors, yet on a visual analog scale,

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pain intensity scores were similar to those of women in the other two groups (Harrison, 1991). Similarities were found in the use of word descriptors of pain across cultural groups, with the word pain used to characterize the most intense discomfort, the word hurt used for less severe discomfort, and the word ache used for the least severe pain. Pain perception is composed of highly interactive emotional, cognitive, as well as sensory components (Gijsbers & Niven, 1993, p. 55). Signicant variances in labor pain have been associated with condence in the womans ability to handle labor, preparation for childbirth, and the physiologic intensity of labor (Brown & Lumley, 1998; Goldberg, Cohen, & Leiberman, 1999; Nichols & Gennaro, 2000). Because studies of childbirth pain depend on retrospective recall, previous emotions and expectations concerning pain may be overshadowed by positive maternal and newborn outcomes. Lowe (2000; 2002) has detailed numerous issues related to self-efcacy, personal control, and pain management in childbearing women. Her landmark work emphasizes the complexity of the multiple variables that inuence the pain of giving birth.

or aggregated narrative descriptions related to the pain of childbirth. Participants described sociocultural experiences with pain, attitudes toward childbirth pain, denitions of the meaning of their pain, coping strategies for dealing with the pain, and culturally proscribed behaviors related to the pain of childbirth. Attitudes, Perceptions, and Meaning of Childbirth Pain Study participants described their attitudes toward, perceptions of, and the meaning of childbirth pain. One woman spoke of the difference between her expectations and the reality of the childbirth experience:
I had a very easy labor. In fact, I remember being surprised that my pain wasnt worse. Because they say its so awful and youre gonna have to have an epidural. Well, the whole idea of an epidural really scared me bad. I mean, I just do not like the thought of someone putting a needle in my spine. And so I realized that it was an option I had, but I was determined that I would only use it if absolutely necessary, and it turned out I got to the hospital so late I didnt have time. But it was not that bad. I remember, even during labor, thinking, Well, this isnt as bad as I expected it to be. Yeah, it hurt a lot. But it wasnt as bad as I had made it out to be. I was expecting it to be this horrible, you know you see on television all the women screaming. I dont remember ever screaming when I was in labor. It was really a lot better than I thought.

PURPOSE AND METHOD


The purpose of this secondary analysis of cross-cultural phenomenologic studies is to report on the perceptions of culturally diverse women regarding the pain experience of childbirth. These data were gathered in a series of phenomenologic studies that focused on the cultural meanings of childbirth (Callister, 1992, 1995; Callister, Lauri, & Vehvilainen-Julkunen, 2000; Callister, Semenic, & Foster, 1999; Callister & Vega, 1998; Callister, Vehvilainen-Julkunen, & Lauri, 1996, 2001; Kartchner & Callister, 2003; Khalaf & Callister, 1997; Semenic, Callister, & Feldman, 2003). Phenomenology is an appropriate method for the study of pain (Madjar, 1998). Following human subjects approval and informed consent, interviews were conducted with childbearing women living in North and Central America, Scandinavia, the Middle East, the Peoples Republic of China, and Tonga (n 100). This secondary analysis answers new questions with existing data from these phenomenologic studies, examines the dimension of childbirth pain, and allows for comparisons among several related phenomenologic studies (Burns & Grove, 2001).

Another woman sought an unmedicated birth after having an epidural with her rst birth because of the lack of personal control she felt.
I had my rst one in a way I view as traditional, where the doctor was in control and he encouraged me to have an epidural. It was such a frightening experience. Afterwards I thought, This isnt childbirth. Theres got to be more to it than just having a numb body.

RESULTS
Content analysis revealed themes (i.e., patterns of linked descriptive meanings), vignettes, and clusters

She changed providers and had an unmedicated second birth. Childbirth was viewed as a bittersweet experience, with paradoxical feelings of love and the challenges of pain culminating in the birth of a child. Word descriptors used by study participants included burning, stinging, cramping, sharp, stabbing, hot, stinging, heavy, aching, throbbing, tiring, exhausting, and intense. Giving birth was seen as a difcult yet empowering experience. Mastering pain may be viewed as an integral part of a self-actualizing experience. Some women described a sense of achievement and feeling of pride in their ability to cope with intense pain, which increased their sense of self-efcacy. For example, Finn-

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ish women felt it was essential to trust themselves and their bodies to give birth, viewing childbirth as an experience of wellness rather than illness (Callister, Lauri, Vehvilainen-Julkunen, 2000; Callister, Vehvilainen-Julkunen, 1996, 2001; Melender, 2002). One study participant said,
The experience of childbirth made me grow up a lot. It really did. Ive learned a lot about my capacity. When I thought I was just too tired to push any more I found another 15 minutes worth of it. I just learned I have a lot more strengths than I thought I did. Childbirth brought me more in tune with my body because I know what my capacities are: My mental capacity, my strength. I just know I could do a lot more than I thought I could.

attaching a sense of coherence or purpose for this last event. A rst time Finnish woman described how she visualized childbirth and put the pain she experienced in perspective:
You dont think about the childbirth process, at least I didnt. I would simply think about the child. The end result of all this is not going through labor; the end result of all this is the baby that you get to hold in your arms. Thats what I visualized. Thats the most beautiful, most wonderful moment, and the labor part of itjust dont think about it because its really bad, and its just what you have to do to get what you get, and its absolutely worth it.

Another participant described the use of the metaphor of strength in adversity to describe her experience: I just kept thinking in my mind, Endure to the end. Endure to the end. I feel really proud of myself that I did. Another woman who had an unmedicated birth following induction related that, My sister said, You always feel like a super hero when you have a baby and I agree! I did better than I thought I would! Religiously motivated women who participated in the study seemed to accept pain as a necessary and inevitable part of the human experience. One participant espousing beliefs of the Church of Jesus Christ of Latter-day Saints framed the pain experience with a spiritual perspective, which lent meaning to her pain:
Right before the baby is born, when his head is pushing up against the perineal tissue, it burns like re. And really, theres no getting away from it, or not feeling it. You just have to go straight through it, and push him through. Its really hard and you cant see that the pain will be over. But there are so many wonderful blessings on the other side.

An Orthodox Jewish mother described the shift in her emotions at the moment of birth:
Once he came out, I felt exhilarated. I couldnt believe that the baby came, that the pain would be over. I was crying and laughing at the same time from happiness. I had this ood of emotions. I didnt believe that it was my son.

Women having medicated births put less emphasis on active participation in childbirth. One Orthodox Jewish woman who had epidural anaglesia/anesthesia said, As long as I was awake, participating, and knowing what was going on, seeing her born and not having to experience the full pain, why not? Pain Related Behaviors Muslim women who gave birth in either refugee camps, at home, or in public hospitals had unmedicated births; of those who gave birth in private hospitals, 50% had medicated births with opioids or epidural anesthesia. In the hospital most women labor alone, with their husbands rarely present at the birth. In contrast, women who gave birth at home were attended by trained midwives and extended female family members or female friends who gave support during labor. Muslim laboring women are verbally expressive, sometimes crying and screaming. During labor devout Muslim women gained their support from their reliance on God and they asked God to help them to give birth safely. Chinese women had unmedicated births in the hospital, most often without the father of the baby present but supported by extended female family members. These women said it was shameful to scream, and also that such actions expended energy needed to give birth. Crying out is believed to deplete the body of energy stores needed for the nal stages of birth. One Chinese mother said, Although it is painful, it is also easy because women have been having babies for thousands of years. Chinese women used

Women described the intense pain associated with giving birth as being temporary in nature and worthwhile. A Muslim mother of six said:
There are no words to describe the pain you have to go through. All I wanted was for [the baby] to hurry up and come out. But you wont remember once its over. Thats why you give birth again.

A Tongan woman with three children expressed her feelings this way:
When I was in labor, the pain was something I had never experienced in the whole world. Right before the baby was born there was more pain than I could think of, but then I saw the baby and there was a happiness more than I could think of.

Becoming a mother was seen as a productive, creative act, articulating a sense of coherence and

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soft voices and demonstrated quiet demeanor while laboring and giving birth. Mayan women living in Guatemala who gave birth at home were attended by village midwives and supported by extended female family members. Those who gave birth in public hospitals were largely unattended and unmedicated; those who gave birth in private hospitals had the option of analgesia/anesthesia. In some instances if an epidural was offered, these women thought that this indicated that there was a worrisome complication. Silence or saying over and over the mantra of aiee, yie yies while laboring and giving birth is considered a sign of strength. This mantra is a culturally appropriate coping mechanism, since saying this several times in succession requires slow, deep breaths. Sometimes they cried out to the Lord, saying, Dios mio! Jnopeudo! Jnoguantomas! or My God! I cant bear it any more! but they accepted pain as an obligation of a womans life, with stoic dignity and courage. Coping Mechanisms for Dealing with Childbirth Pain A variety of coping mechanisms were used by childbearing women. Listening to extended female family members stories of their own births in preparation for their own provided some women with preparatory guidance for their own birth experiences, particularly for Orthodox Jewish women. Other women had observed and assisted with births from adolescence, or followed culturally proscribed behaviors during their pregnancy. One coping mechanism frequently mentioned and used during labor and birth was reliance on God for help, as suggested by a Tongan woman:
When it got to the worst part of the pain thats when you look up to heaven for Gods help. Sometimes during the labor I would cry out in pain and say, Jesus, help me. I felt like God was saving me as I gave birth.

a baby and because of my spiritual support (jingshen zhizhu). Focusing on the hope of a positive outcome sustained one rst-time Tongan mother who expressed her faith, The most difcult part were the contractions. I could barely handle them. You need the help of the Spirit. The fruits of labor are the baby who is a gift from God. Some women described conditioning themselves to give birth as though they were preparing to run a marathon or climb high mountain peaks. They described starting out exhilarated, looking forward with condence to giving birth (nishing the race). As time passed and the intensity of the labor experience increased, women described being exhausted, discouraged, vulnerable, and feeling their condence slip away. This time was when these women described the need for help and support. When empowered by their own attitudes and with the assistance of others, these women felt they met and mastered their birth experience, and some described giving birth as a transcendent experience.

DISCUSSION
Limitations of this study include the differing environmental contexts of birth. Study participants gave birth in varied sociocultural contexts, in different birth settings from home births to giving birth in tertiary care centers, within a wide variety of health care delivery systems, and had varied levels of personal and professional support. However, the universality of expression seems to transcend these limitations. The halo effect of giving birth to a healthy newborn may have superseded the negative aspects of the pain experience of childbirth. Study participants made meaning of their pain experience. This nding is congruent with the social constructionist analysis of making sense of pain, perceived as either malfunction, abuse, or an alien invasion, pain as an opportunity for self-growth or spiritual growth, pain as a coping mechanism and control strategy, pain as a homeostatic mechanism, or pain as power (Aldrich & Eccleston, 2000). Searching for meaning may become a powerful coping mechanism for the woman giving birth (Mander, 2000; Simkin, 2000; 2002). Mastering the pain of childbirth fosters personal growth as articulated by Grainger and McCool (1998, p. 256): Birth is an important emotional and spiritual growth process, and enduring labor pain may be an integral part of that growth. The notion of a woman trusting her intrinsic strengths as well as her bodys ability to give birth is conrmed in the ndings in a

This same reliance was articulated by a Guatemalan woman, I asked God to let childbirth pass quickly because one suffers. I felt closer to God. Another Guatemalan woman suggested that a laboring woman should:
Ask God to help you give birth rst. [Women] should pray before the time to give birth arrives. If they dont pray during pregnancy, they will think of it during labor. It is better to remember God before you are in need of His help. No one can take away the pain only God.

Even women who were not overtly religious used their spirituality as a coping strategy. A Chinese mother said, The most helpful thing to me in giving birth was that I had a strong will and desire to have

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phenomenologic study of Swedish childbearing women (Lundgren & Dahlberg, 1998). Childbirth pain as an expected and normal part of giving birth was described in this study. This nding is exemplied by Chinese childbearing women. A midwife wrote about her clinical observations of Chinese childbearing women, It is expected that [childbirth pain] is within tolerable range, and is something every woman has to go through if she wants to have a baby (Cheung, 1994, p. 215). A proverb often used by Chinese women is, If you wish to be the best person, you must suffer the bitterest of the bitter. Some religious and cultural traditions consider acceptance of ones own pain and suffering as a means of spiritual purication and growth. Such philosophies may inuence whether or not a woman requests pain medication or uses alternative measures to manage childbirth pain. Behavior in response to childbirth pain is observable. As labor progresses, women may exhibit increasing outward signs of pain, such as being doubled over, moaning, groaning, and making facial grimaces (Chapman, 2000). Some women may wish to express their pain in an audible way. Others may respond to pain with stoicism. Other women quietly draw inward as labor progresses, focusing and centering, shutting out noxious external stimuli. Classic work documents that culture inuences the neurophysiologic processes of pain perception and pain tolerance (Bates, 1987). The notion of control was articulated by study participants, dened as the sense a person has of being able to make decisions and be in control of her situation (Mander, 1998, p. 106). A sense of personal control is increased as women have a choice in pain management, participate actively in decision making, use their own personal coping strategies, and feel supported by professionals (Hodnett, 2002; Luckman, 1999; McCrea & Wright, 1999; McCrea, Wright, & Stringer, 2000; Weaver, 1998; Wright, McCrea, Stringer, & Murphy-Black, 2000).

IMPLICATIONS FOR CLINICAL PRACTICE AND RESEARCH


Culture plays a signicant role in attitudes toward childbirth pain, the denition of the meaning of childbirth pain, perceptions of pain, and coping mechanisms used to manage the pain of childbirth. According to Schuiling and Sampselle (1999, p. 77), nurses can provide comfort in the presence of pain. Pain does not have to be eliminated for women to be comforted, and comforting diminishes pain. The signicance of comfort cannot be over emphasized (Jimenez, 2000). Personal and professional support during labor is critical. Womens responses to childbirth pain may be

modied by support received from caregivers and companions (Corbett & Callister, 2000; Enkin, et al., 2000; Hodnett, 2002). Women who are well supported and condent feel less pain. This idea was expressed in the images of these childbearing women comforted by comfort measures, a safe and private environment, reassurance, information and guidance, strengthening of coping resources through encouragement, emotional support, and human presence, able to transcend their pain experience with a sense of strength and profound psychological and spiritual comfort during labor (Lowe, 2002, p. 522). Caring for culturally diverse women is becoming a more common experience for nurses in birthing centers throughout the United States. Thus culturally appropriate strategies should be generated by health care facilities in order to provide multicultural care (Emang, Wojnar & Harper, 2002). Understanding the cultural meaning of pain is a fundamental prerequisite if the nurse is to facilitate a satisfying birth experience. Understanding that there are broad cultural, as well as individual differences in a womans pain experience can lead to more effective and sensitive nursing care for laboring women and their family members. A discussion with the woman to develop an individualized plan of care to manage her childbirth pain enhances the womans sense of control and positively inuences the quality of her birth experience. Control includes active involvement, taking responsibility, the provision of information, and the ability to inuence outcomes (Waldenstrom, et al., 1996). The pain experience of childbirth can provide opportunities for positive growth or may be a negative experience if it is overwhelmingly stressful and the woman has little sense of control or support. It is important to coach the coach in the instance where the father of the baby chooses to be the support person. Nurses should provide support within the family context and according to womens cultural values and belief systems (Simkin & Frederick, 2000). Culturally diverse women giving birth in an unfamiliar and highly technologic environment with routine application of procedures and policies and unknown birth attendants who most likely do not share the womans culture and/or language are at risk for increased anxiety and pain (Maclean, McDermott, & May, 2000). It has been documented that there is often incongruence between nurses rating of pain and the perceptions of the childbearing woman who is experiencing that pain (Baker, et al., 2001; Harrison, 1996; Hoffman & Tarzian, 2001; McCaffery, 1999; McDermott, 2000; Sheiner, et al., 2000). A consensus exists among clinicians that pain should be assessed as the

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fth vital sign (Mayer, Torma, Byock, & Norris, 2001; Phillips 2000). When a cultural and communication gap exists between the nurse and the childbearing woman, there is disparity between what the woman is experiencing and the nurses assessment of that pain (Sheiner, et al., 1999, 2000). The Joint Commission on the Accreditation of Healthcare Organizations has established pain management standards for accredited institutions, and the Maternity Center Association has made specic recommendations for the management of childbirth pain (Maternity Center Association, 2002a; Pasero, McCaffery, & Gordon, 1999). Pain is private data that requires sensitivity to behavioral and verbal cues in order to assess the level of discomfort (Montes-Sandoval, 1999; Sherwood, et al., 2000). It is important that the nurse asks, What is your level of pain? and Is your discomfort being managed at an acceptable level now? The womans score on a pain intensity scale is less important than the womans sense of satisfaction about how her pain is being managed (Mackey, 1998). It has been noted that satisfaction with childbirth is not contingent on the absence of pain (Enkin, et al., 2000, p. 328; Hodnett, 2002), since women in some cultural groups view pain as a necessary and integral part of the birth experience. A painful birth is just as likely to have a positive evaluation as one without pain, depending on the womans feelings of fulllment. What is known about labor pain is not integrated into the information given to women prior to giving birth, nor is information provided about the clinical management of pain. What is not known about childbirth pain is perhaps the most important information that can be given to women to assist them in managing the pain associated with childbirth (Kardong-Edgren, 1999; King, 2002). A need exists for nurses to gain more knowledge about cultural considerations and childbirth pain, and to obtain specic knowledge of certain cultures traditional beliefs, values, and priorities related to pain and its management (Ahman, 2002; Callister, 2001). Gaining linguistic skills is an important strategy, since it has been noted that shared language may increase

the congruence between how laboring women and nurses rate the pain of laboring women (Harrison, 1996; Jimenez, 1996). A recent issue of the American Journal of Obstetrics and Gynecology provides landmark systematic reviews of the nature and management of childbirth pain (Caton, et al., 2002). These published reports are based on the Maternity Center Association Labor Pain Symposium (Maternity Center Association, 2002a). More qualitative studies are needed that describe cultural beliefs, values, perceptions, and responses to pain behaviors and preferences for pain management. (Marmor & Krol, 2002). Comparative studies of pain perceptions of culturally diverse childbearing women would be of value (VandeVussee, 1999). Outcomesfocused research is needed to document the effectiveness of holistic interventions in pain management (Cole & Brunk, 1999; Cook & Wilcox, 1997; Fouche, et al., 1998; Kohn, 2000), such as a recently published Chinese study on the effects of massage on pain and anxiety during labor (Chang, Wang, & Chen, 2002). Englands work (1998), Birthing from Within and Listening to Mothers (Maternity Center Association, 2002b), a report of the rst national United States survey of womens childbearing experiences can increase nurses understanding of the lived experience of childbirth from the perspective of women themselves. It is important to acknowledge womens descriptions of their experiences as legitimate sources of nursing knowledge (Young, 1998). Increasing understanding of the cultural meanings of childbirth pain, coping strategies, and culturally proscribed pain behaviors will assist in the provision of culturally competent nursing care. The quality of the womans birth experience will thus be enhanced.
ACKNOWLEDGMENTS Appreciation is expressed for funding from the Brigham Young University College of Nursing, Ofce for Research and Creative Activity; Kennedy Center for International Studies; Sigma Theta Tau International Iota Iota Chapter; Womens Research Institute; and to the women who participated in these studies.

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