Vol. 4 No. 1 March 1989 Journal of Pain and Symptom Management 13

Or&baa1 Article

Cultural and Educational Influences on Pain of Childbirth Matisyohu Weisenberg, PhD and Zahava Caspi, MS Department of Psychology, Bar-Ran University, Ramat-Can, Israel

Abstract This study investigated the effects of sociocultural family of origin and educational level on the verbal ratings of pain and pain behavior during childbirth fm 83 women. Coping style and extroversion were also measured. It was found that all women rated the pain of childbirth as high. Overall, women from a Middle-Eastern compared with a Western background gave higher ratings of pain and showed more pain behavior. This was found especially for Middle-Eastern women of a low educational background. Overall, low compared with high educational level resulted in higher ratings of pain and more pain behavior. No dajerences were obtained as ahnction of extroversion. Middle-Eastern and Western women did not d@er in coping style. However, women who had higher monitoring scores rated the pain as less even though no d@rences were obtained for pain behavior. Sociocultural group of origin as well as other relevant reference groups, such as educational level, are important in determining pain perception and behavior. Combining this information with coping style could lead to an instructional intervention for preparing women for childbirth. J Pain Symptom Manage 1989;13-19

Key Words Pain, childbirth, sociocultural group, edcuation, peparation for childbirth, coping style

Introduction Group norms and membership have been

shown to influence the reaction to pain.‘-lo Most studies have defined group membership on the basis of cultural and ethnic grouping.1*4 Other groupings, however, have also been shown to be important. Lambert and col- leagues” and Poser’* have shown that differ- ences between religious groups in the response to pain can be demonstrated when subjects are challenged by statements like “Jews (Christians) cannot tolerate pain as well as Christians

Address rejwiknt requests to: M. Weisenherg, PhD, Bar- Ilan University, Department of Psychology, Ramat- Gan 52100, Israel. Accepted fm fmblication: September 20, 1988.

(Jews).” Buss and Portnoy13 demonstrated that the stronger the identification a person has with his or her group, the more willing he or she is to tolerate pain of electric shock to conform to the group norm under challenge, e.g., “Russians have a greater tolerance for pain than Ameri- cans.”

Theoretically, Weisenberg’ has viewed cul- tural and ethnic differences as based upon mod- eling l4 observing how others react under simi- lar circumstances, and social comparison processesr5,t6 socially testing the validity of one’s judgments under ambiguous circum- stances. Because pain is a private ambiguous situation, comparison with others helps to de- termine what reactions are appropriate.” One of the most important and primary groups used

0 U.S. Cancer Pain Relief Committee, 1989 Published by Elsevier, New York, New York

14 Weiwnberg and Caspi Journal of Pain and Symptom Management

as models and as a source of social comparisons is the family of origin that teaches the person appropriate behavior.

However, pain behavior and reactions need not be fixed and determined only by group of origin. Recently, Barak and Weisenbergis have shown that attitudes toward pain and patient anxiety were more strongly related to socioeco- nomic grouping than to cultural group of ori- gin. The setting was a dental clinic where peo- ple are quite willing to discuss openly their feelings regarding dental pain. What is not clear, however, is whether the same results would be obtained for the pain of childbirth. Here there may be less willingness to openly talk of the events of childbirth and thus less peer influence might occur. Perhaps child- birth, as a more private event, may show a strong influence of the family of origin and be less influenced by other social groupings as found in the dental setting. Consistent with this idea, Edwards and colleagues1g have shown in a questionnaire study how family members serv- ing as models influence pain reaction, especial- ly among female family members. In the case of childbirth it is likely that the mother’s atti- tudes and behavior would influence the behav- ior of her daughter. Thus, one of the aims of this study was to test the influence of cultural group of origin on the reaction to childbirth pain. An attempt also was made to translate cultural differences into sociological (education) and psychological terms (extroversion, coping style).

One of the psychological variables that po- tentially could account for group differences in reaction to pain is extroversion. As used by Ey- senck and Eysenck*O high scorers on the extro- version scale tend to be outgoing and gregari- ous, with high energy levels. Eysenck*l reported that extroversion correlated with greater recall of painful labor in childbirth. The conclusion was that high scorers on extro- version tend to exaggerate their feelings more than low scorers. Similarly, Bond and Pear- son** reported that among women suffering from cervical cancer, the tendency to complain of pain was associated with high scores on ex- troversion.

This study examined the reactions to pain of childbirth among women from a Middle-East- ern as opposed to a Western family of origin. In general, the Middle-Eastern background has

been viewed as conducive to greater expression of feelings and emotions.23 It was thus felt that extroversion might be an appropriate psycho- logical construct into which to translate greater expression of feelings and rated pain. It was predicted that women of a Middle-Eastern background would score higher on extroversion and that these higher scores would be associat- ed with greater expressions of pain.

On the other hand, extroversion has also been associated with the reducer style of cop- ing. 24 It would thus follow that women who are extroverted might tolerate pain better and rate it as lower. To test these apparently contradic- tory notions a measure of coping style was also included. Barak and Weisenberg’* found that patients who came from a lower socioeconomic grouping and those who were from a Middle- Eastern background tended to endorse items more in the direction of denying, wanting to be rid of, and not willing to cope with pain. It was thus expected that in terms of coping style women from a Middle-Eastern as opposed to a Western background would be more likely to endorse use of denial or emotion reducing strategies of coping as opposed to an active, more direct style of coping.

Methods

The study sample consisted of 83 women ages 19 to 38 who gave birth in one of the major hos- pitals in Israel. Two other women refused to participate in the study. The Western group (N = 30) consisted of women whose mothers were born in Europe, the United States, or one of the other English-speaking countries. The Middle- Eastern group (N = 53) consisted of women whose mothers were born in Asia, North Africa, or one of the other Middle-Eastern countries. The Western group was significantly older [F(1,78) = 8.60, p < 0.011 than the Middle- Eastern group, (M = 30.7, M = 27.2 for the Western and Middle-Eastern groups, respec- tivel y) .

Women were also classified according to level of education. The low education group consist- ed of women with 12 yr or less of schooling (N = 45). The high education group consisted of women with more than 12 yr of schooling (N = 38). Among the Western group, 66.6% (20 of 30) had higher education, while in the Middle-

Vol. 4 No. 1 March 1989 Pain of Childbirth 15

Eastern group only 33.9% (18 of 53) were so classified.

Out of the group as a whole, 20.5% (N = 1’7) of the women were having their first child, while 79.5% (N = 66) already had given birth at least once. For 24.1% (N = 20), this was the fourth or more birth. Number of births did not differ significantly as a function of cultural or education group. The husband was present for 55.4% (N = 46) of the women. Presence of the husband did not differ as a function of cultural or education group. The majority of women (73.5%, N = 61) had not participated in a prep- aration for childbirth course.

Measures Pain Perception. A visual analogue scale was used to obtain ratings of labor pains. The scale ranged from 0 to 100, in which 0 was labeled “no pain whatsoever” and 100 was labeled “in- tolerable pain.” Each woman was asked to rate her labor pain on three separate occasions: (1) at the end of stage one with complete dilation of the cervix; (2) during stage two when she was told she could push; (3) at expulsion of the child. Each of the three points was determined by the midwife on duty at the time.

Behavioral Ratings. Each woman’s behavior was rated for a period of 20 min from the time she entered the delivery room. A structured observational system was used based on Mei- sels-Iticksohnz5 in which each of 16 different verbal and nonverbal categories was rated from 0 to 4, in which 0 means “no such behavior was observed,” and 4 means the behavior “was ob- served a great deal.”

Categories reflected the various types of be- haviors possible in the delivery room including crying, cursing, twisting and turning in bed, hair pulling, and loss of control. Each woman was given a score that could range from 0 to 64. A subsample of eight women was used to assess interjudge reliability, which was found to be high (r = 0.96).

Extroversion. The Eysenck Personality Inven- tory*O was used to measure extroversion. It consists of 24 “Yes-No” items. It has been translated into several languages and has re- tained a high level of reliability. A person’s test score consists of the total number of items an- swered in the direction of extroversion. The

higher the score, the higher the person’s rating on extroversion.

The Miller Behavioral Style Scale. To assess cop- ing style the Miller Bahavioral Style Scale (MBSS)s6 was used to divide women into moni- tors or blunters. When individuals are faced with a threat, some will seek out additional in- formation and actively attempt to cope with the situation (monitors), whereas others will try to deny the situation or distract themselves from it (blunters). Four stress-evoking situations were presented. Each situation has eight statements (four monitoring and four blunting) that de- scribe ways of dealing with the problem. The person was asked to rate which of the described statements she would follow in the given situa- tion. Higher scores represent more monitoring behavior.

Procedure Patients who participated in the study were

met in the labor and delivery area and asked to consent to rating the labor pain, having an ob- server present and to filling out questionnaires a day or two following delivery. Women were told that the process of labor and delivery was being studied with an aim toward finding ways of matching intervention strategies to the per- sonality and background of the woman.

The observational phase took place in the de- livery room for a period of 20 min. Each woman was attached to a fetal monitor so that it was possible to see clearly when labor pains oc- curred. Between pains, the rating scale was ex- plained.

During the delivery process each woman was asked to rate her pain at the three points men- tioned earlier.

The measures of extroversion and MBSS were obtained on the ward a day or two after delivery. In addition, each woman filled out a biographical questionnaire that included her and her mother’s country of origin, her occupa- tion and that of her husband, her educational level and that of her husband, number of births, and participation in a preparatory course.

Results The four major dependent variables, pain

ratings, pain behavior, extroversion, and coping

16 Weisenberg and Caspi Journal of Pain and Symptom Management

style were examined in a 2 (cultural grouping) x 2 (educational level) multivariate analysis of variance. Significant differences were obtained for cultural grouping [F(4,75) = 2.48, p = 0.051 and for educational level [F(4,75) = 3.89, p C 0.051. Separate analyses were done to fur- ther clarify the results.

Pain Ratings. For each cultural group, the mean pain ratings were high (M = 81.50, N = 30; M = 88.28, N = 53 for Western and Mid- dle-Eastern groups, respectively). Since the dis- tribution of scores was highly skewed (skewness = - 1.39; kurtosis = 3.10) with 23 of 83 women (27.7%) giving the maximal rating of 100, it was felt that the assumptions of paramet- ric statistics were violated. Thus, pain ratings were examined by the Mann-Whitney non- parametric test. Results indicated a significant difference between cultural groups (Z = 1.68, P < 0.05) with the average ranking of the Middle- Eastern group higher than that for Western women (M = 45.10, N = 53; M = 36.15, N = 30 for Middle-Eastern and Western groups, re- spectively).

Similarly, the results indicated that women from the low education group yielded signifi- cantly higher average ranks of pain ratings (Z = 2.54, p < 0.01) than women from the high education group (M = 48.11, N = 45; M = 34.76, N = 38 for the low and high education groups, respectively).

To test the interaction of cultural group and educational level, separate Mann-Whitney tests were conducted for each cultural group. For Western women, the rankings of pain rat- ings did not significantly differ for low and high education groups (M = 18.15, N = 10; M = 14.17, N = 20 for Western low and high educa- tion groups, respectively).

For the Middle-Eastern group a significant difference (Z = 1.78, p < 0.05) was obtained in which the low compared with the high educa- tion group yielded higher rankings of pain rat- ings (M = 29.66, N = 35; M = 21.83, N = 18 for low and high education groups, respective- ly). High Western and high Middle-Eastern ed- ucation groups did not differ significantly. For the low education subjects, Western and Mid- dle-Eastern groups also did not differ signifi- cantly on pain ratings.

Pain Behavior. The ratings of pain behavior also were skewed, albeit in a downward direc- tion (M = 9.88, M = 4.20 for Middle-Eastern and Western groups, respectively). The mini- mal score of 0 was given to 16 of 83 women (19.3%) resulting in skewed distribution (skew- ness = 0.793, kurtosis = 0.17). Pain behavior ratings were thus also analyzed by the Mann- Whitney test. Results indicated a significant difference between cultural groups (Z = 3.35, p < 0.01) for pain behavior ratings, with the aver- age ranking of the Middle-Eastern higher than that of the Western group (M = 48.65, N = 53; M = 30.25, N = 30 for the Middle-Eastern and Western groups, respectively).

Similarly, the results indicated that women from the low compared with the high education group yielded significantly (Z = 3.46, p < 0.01) higher pain behavior rankings (M = 50.39, N = 45; M = 32.07, N = 38 for low and high education groups, respectively).

No significant differences in pain behavior ratings were obtained for Western women be- tween low and high education groups (M = 16.20, N = 10, M = 15.15, N = 20 for low and high Western education groups, respectively). However, for the Middle-Eastern groups, women from the low compared with the high education group obtained significantly higher rankings of pain behavior (M = 31.64, N = 35; M = 17.97, N = 18 for low and high education groups, respectively). Although high education Middle-Eastern and Western groups did not significantly differ, low education groups did (Z = 2.61, p < 0.01) with the Middle-Eastern group obtaining the higher rating (M = 25.73, N = 35; M = 13.45, N = 10 for Middle-East- ern and Western low education groups, respec- tively).

Extroversion. No significant differences were obtained on ratings of extroversion as a func- tion of cultural or educational group. Similarly, when the study population was divided at the median score of extroversion, no significant dif- ferences were obtained for either pain ratings or pain behavior.

Coping Style. No significant differences were obtained on MBSS scores as a function of cul- tural group. However, significant differences

Vol. 4 No. 1 March 1989 Pain of Childbirth I7

[F(l, 80) = 5.31, p < 0.051 were obtained for education. Higher monitor scores were ob- tained for the high as compared with the low education group (M = 6.05, N = 38; M = 4.04, N = 45 for high and low education groups, respectively).

When MBSS scores were divided at the medi- an, a significant difference (Z = 1.67, p < 0.05) between high and low groups was obtained for ratings of pain, but not for pain behavior (M = 36.58, N = 36; M = 45.35, N = 46 for high and low MBSS pain ratings groups, respective- ly).

Participation in a Preparation for Childbirth Course. More Western (N = 14 or 46.7%) than Middle-Eastern (N = 8 or 15.1%) women par- ticipated in a preparation for childbirth course (X2 = 8.24, df = 1,p < 0.01). Similarly, more women in the high (N = 15 or 39.5%) than in the low education group (N = 7 or 15.6%) par- ticipated in such a course (X2 = 4.88, df = 1, p < 0.05).

Course participation did not yield any signifi- cant difference on pain ratings. However, pain behavior scores were significantly (t = 2.16, df = 8 1, p < 0.05) less for women who did as op- posed to those who did not participate in a childbirth course (M = 4.72, N = 22; M = 8.95, N = 61 for women who did not take part in a course).

Relationships Among Pain Rating, Pain Behavior, MBSS, and Extroversion. A correlation analysis indicated a significant moderate correlation be- tween pain ratings and pain behavior (r = 0.41, N = 83, p < 0.01). Pain ratings also yielded a low but significant negative relationship with MBSS monitor score (r = - 0.21, N = 82, p < 0.05). No other significant relationships were obtained.

L?iscussion Consistent with other reports*‘, the results of

this study indicated that pain of childbirth is rated as high by most women. Differences both in pain ratings and pain behavior were obtained as a function of ethnocultural grouping. How- ever, as reported earlier with dental patientsls, pain of childbirth shows a marked influence of

family of origin for women in the low education groups. It is possible, as hypothesized, that a more intimate situation, such as childbirth, is more subject to familial influence. However, the influence of family of origin need not be considered immutable. The strongest influ- ence of family of origin on pain ratings and pain behavior was found in the low education group. The Middle-Eastern and Western high education groups did not suffer. It is likely that educational influences can change the original contribution of family of origin on the reaction to pain.

Similarly, it was shown that participation in a preparation for childbirth course led to a signif- icant reduction of pain behavior. Pain ratings, however, were not affected by course participa- tion. Bonnel and Boureau*s found that al- though pain ratings and pain behavior are moderately correlated, they still measure some- what different aspects. Bonnel and Boureau postulate that pain behavior may be more of an index of self-control. It is sensitive to anxiety. Anxiety reduction could be achieved by ad- vanced course preparation. Pain ratings, in turn, reflect a cognitive activity that is in- fluenced by the instructions provided to the rater and by the level of sensory input which, in the case of childbirth, is high in most instances. It is, thus, less influenced by course preparation unless the course provides coping strategies that affect the sensory component of pain.

Perhaps ability to achieve sensory change was reflected by the MBSS score. Whether or not a woman chooses to acquire advanced informa- tion concerning the process of childbirth should be partially influenced by coping style. As Mil- ler26 has shown, persons high in monitoring (or low in blunting) will choose to expose them- selves to information even if such exposure re- sults in an increase in tension. In this study, there were no significant differences between Middle-Eastern and Western women on the monitoring-blunting dimension. However, women who had a higher monitoring score did rate the pain as less. As was found with repres- sion-sensitization2g~30, when it is hard to ignore pain, as in childbirth, blunting becomes an inef- ficient coping strategy. However, it is likely that with training even blunters could be taught to become actually involved in coping. This is

18 Wekenberg and Caspi Journal of Pain and Symptom Management

consistent with the higher monitoring scores obtained for the high education group of this study.

In contrast to the work of Eysenck*l the present study found no differences as a func- tion of extroversion. Reading and Coxs’ simi- larly did not find extroversion to be relevant to childbirth pain. It is possible that Eysenck’s ear- lier work cannot be replicated. It is also possi- ble that instruments developed in one cultural setting cannot be readily applied in a different cultural settings*.

In general, the findings do confirm the clini- cal importance of considering social ethnocul- tural groupings as having relevance under some circumstances, such as in childbirth. However, these groupings are not fixed. Other reference groups to be considered include educational and socioeconomic groupings. It is likely that training in coping skills could help patients deal with pain, regardless of the cultural group of origin. It would be worthwhile to invest some effort in more effective training in coping, tak- ing into account a starting point defined by so- ciocultural group of origin, as well as by the predominant coping style. Such an effort could lead to a reduction in suffering.

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