The experience of pain in the context of childbirth for Hong Kong Chinese women: a longitudinal cohort interview study Lee Lai Yin, Irene A thesis submitted in partial fulfillment for the requirements for the degree of Doctor of Philosophy at the University of Central Lancashire. July 2017 1 Student Declaration I declare that while registered as a candidate for the research degree, I have not been a registered candidate or enrolled student for another award of the University or other academic or professional institution. I declare that no material contained in the thesis has been used in any other submission for an academic award and is solely my own work. Signature of Candidate: Type of Award: Doctor of Philosophy School of Community Health and Midwifery 2 Abstract Childbirth, the biggest life event for a woman, is a complicated process. Childbirth pain not only involves physiological sensations, but also psychosocial and cultural factors. In addition, the way the woman handles the pain is affected by the meaning she attributes to it. In order to understand the experience of Hong Kong Chinese women in terms of childbirth in general and childbirth pain in particular, and to learn the meanings attributed, a longitudinal qualitative descriptive study was conducted with the aim of exploring the experience and meaning of pain in the context of childbirth for Hong Kong Chinese women. The study was informed by a systematic review and metasynthesis of existing relevant literature. Since people’s attitudes, beliefs and behaviours may change over a period of time, data were collected from the participants at 4 different time points: around 36 weeks of pregnancy; on postnatal day 3; 6-7 weeks after birth; and 10-12 months after birth. Purposive sampling was employed and a total of 10 Hong Kong Chinese women (5 primiparous and 5 multipararous women) were recruited for the study. The data were collected via semi-structured interviews, informed by phenomenological principles. The resulting data were described using thematic analysis The results from the metasynthesis together with the four interviews yielded 5 meta-themes: The cultural norms; The trajectory of pain sensation; Facing or escaping the pain; Someone to be with me; and Achievement and growth through the unforgettable experience. 3 For these participants, satisfaction with their childbirth experience was not related to the pain they experienced, but to the care they received from their husbands and midwives, as well as to their own sense of achievement. Although the women remembered the fact of their pain over time, their affective noxious memories decreased as their concentration was on their mothering and parenting experiences. Finally, the meta-themes were interpreted in the light of Maslow’s hierarchy of needs, and a model was proposed to help women to handle childbirth pain in the future. 4 Table of Contents Student Declaration…………………...………………………….…… 2 Abstract…………………………..………………………………..…... 3 Acknowledgements……………………………….……………..…..… 15 Guide to abbreviations and terminology………...……………….……. 16 Section One: Background……………………………………..…... 17 Chapter One: Overview of thesis……..…………………………… 18 1.1 Introduction……………………..………………………….……. 18 1.2 Conclusion………………………………………………….……. 25 Chapter Two: The nature of pain in general and of childbirth pain in 27 particular………………………………………………………………. 2.1 Introduction……………………………………………….… 27 2.2 Overview of the nature of pain…………………………………... 27 2.3 Theories of pain…………………………………………….…. 28 2.3.1 Specificity theory………………………………….….. 29 2.3.2 Patterning theory…………………………………….. 30 2.3.3 Gate Control Theory………………………………..…. 31 2.4 Hormonal theories relating to pain…………………………..… 34 2.5 Pain thresholds and pain tolerance…………………………..… 35 2.6 Psychological and cultural perspectives on pain………………... 36 2.6.1 Emotional, cognitive and psychological factors………. 37 2.6.2 Cultural factors……………………………………….…. 39 2.7 Childbirth pain………………………………………….…... 41 2.8 Meaning of childbirth pain for Hong Kong Chinese women…… 42 2.8.1 Historical aspects……………………………….….. 42 2.8.2 The current situation……………………………….……. 47 2.9 Pain relief methods used in Hong Kong…………………….… 48 2.10 Conclusion………………………………………………..…. 51 Section Two: Methods and metasynthesis……………….... 53 Chapter Three: Aims, objectives, theoretical perspectives, methodology and methods…………………………….. 54 3.1 Introduction………………………………………………….… 54 3.2 Development of the research focus for the study………………... 54 5 3.2.1 My initial idea….………………………………….….. 55 3.2.2 The revised research focus….…………………….…... 57 3.3 The theoretical perspective for the study……………...………… 59 3.3.1 Ontology……….……………………………….….. 60 3.3.2 Epistemology..….………………………………….….. 61 3.3.3 Interpretivism (constructionism and constructivism)..… 64 3.4 The study methodology………...………………….… 72 3.5 The study methods……………………….………………….… 75 3.5.1 Initial systematic review of relevant current qualitative 75 research……………………………………………….. 3.5.2 Longitudinal interview study………………………..….. 76 3.5.3 Recruitment of respondents………………….….….. 77 3.5.4 Data collection procedures………………………..….…. 82 3.5.5 Ensuring the quality of the research –Trustworthiness..... 84 3.6 Methods of analysis…………………………….… 89 3.7 Ethical consideration……………………..………………….… 91 3.8 Reflexive Section 93 3.9 Conclusion………….…………...………...………………….… 97 Chapter Four: A meta-synthesis of women’s views on childbirth and pain relief in labour………………..……………….. 99 4.1 Introduction……………………………….…………………… 99 4.2 Background……………………………………………… 99 4.3 Methodology…………………………………………………... 100 4.4 Design………………………………………………..... 101 4.4.1 Search Strategy……………………………………… 101 4.5 Results……………………………..………………….. 107 4.5.1 Included papers…………………………………….. 107 4.5.2 The selected studies……………………………… 110 4.6 Findings…………………………………………………………. 114 4.6.1 Synthesized finding and themes…………………….... 115 4.6.1.1 The need for support from the midwife..……... 115 4.6.1.2 The need for a supportive husband…...... 126 4.6.1.3 The experience of Childbirth pain…....…… 128 4.6.1.4 Self-actualization in childbirth………....…... 134 4.7 Discussion…………………………………………………...... 137 4.7.1 Support helps women go through the childbirth process.. 138 4.7.2 Experience with childbirth pain…………………………. 139 6 4.7.3 Self-actualization in childbirth………………….. 140 4.8 Conclusion……………………………………………….. 140 Section Three: Findings from the qualitative study………….. 142 Chapter Five: Introduction of the findings………………………….. 143 5.1 Introduction..…………………………………………………. 143 5.2 Setting for the study………………………………. 143 5.3 Undertaking the interview…………………………………. 148 5.4 Timing of data collection and demographics of participants...…. 149 5.5 Issues with the focus of the antenatal interview schedule (particularly the gender of the baby)…………………………. 150 5.6 Interview length and the switch from phenomenological to thematic analysis.………………………………………..……. 151 5.7 Transcription and translation……….……………………. 154 5.8 Analytic process…………..…….…………. 155 5.9 Note on presentation of the interview data in the findings chapters…………………..……………………………… 157 5.10 Summary themes, by chapter...………………………. 158 5.11 Conclusion…………………………………………... 159 Chapter Six: Findings from Antenatal Interviews………………….. 160 6.1 Introduction..………………………………………. 160 6.2 Overview of themes and subthemes…………………….. 160 6.3 Detailed review of themes and sub-themes…………………... 162 6.3.1 Theme One: Cultural changes regarding continuing the family line. 162 6.3.2 Theme Two: Commitment to their babies………….. 165 6.3.3 Theme Three: Feelings about the pregnancy…………. 169 6.3.4 Theme Four: Concerns about childbirth and childbirth 172 pain…………………………………………………… 6.3.5 Theme Five: Expected ways of coping with pain……….. 176 6.4 Summary of key themes……………………………………….. 181 6.4.1 Changes in traditional Chinese culture regarding continuing the family line……………………………….. 182 6.4.2 Commitment to their babies…………………………... 182 6.4.3 Feelings about the pregnancy……………………….... 183 6.4.4 Concerns about childbirth and childbirth pain………... 183 6.4.5 Expected ways of coping with pain……………… 184 6.5 Conclusion……………………………………………... 186 7 Chapter Seven: Women’s views in the early postnatal period…………. 188 7.1 Introduction………………………………………………………. 188 7.2 Results……………………………………………………………. 189 7.2.1 Labour outcomes and use of pain relief………………. 189 7.3 Findings……………………………………………………….. 192 7.3.1 Theme one: Feelings about the childbirth process…….. 193 7.3.2 Theme two: Response to childbirth pain……………. 202 7.3.3 Theme three: Need for support during the childbirth process… 206 7.3.4 Theme four: Handling of childbirth pain……………. 212 7.3.5 Theme five: Consequences of the childbirth experience. 221 7.4 Summary of main findings……………………………. 226 7.4.1 Feelings about the childbirth process……………... 226 7.4.2 Response to childbirth pain………………….. 227 7.4.3 The need for support in the childbirth process………. 228 7.4.4 Handling of childbirth pain…………………….. 228 7.4.5 Consequences of the childbirth experience………….. 229 7.5 Conclusion……………………………………………... 230 Chapter Eight: Women’s views at two to three months after birth……. 232 8.1 Introduction………………………………………………. 232 8.2 Results………………………………………………. 232 8.2.1 Theme one: Memories of the childbirth process……… 234 8.2.2 Theme two Handling of childbirth pain………………… 238 8.2.3 Theme three: The benefit of support during childbirth…. 243 8.2.4 Theme four: Consequences of the childbirth experience.. 248 8.3 Summary of main findings…………………………..………….. 253 8.3.1 Memories of the childbirth processes………………..…. 253 8.3.2 Response to childbirth pain……………………………… 254 8.3.3 The benefit