Patients who were admitted for confinement in a private nursing home outside and near Puducherry, who had normal vaginal deliveries during one calendar year during 2005 January to December were selected for the study. After obtaining approval from hospital ethics committee and informed consent, 400 parturients were enrolled for the study. Parturients belonged to two groups- group G who were admitted for confinement in a Government hospital and group P, in private hospital. Parturients with dead born babies, multiple pregnancies and instrumental deliveries were excluded from the study. All the parturients filled up a questionnaire during early labour about age, literacy, gravida, socioeconomic status, booking, and the prelabour preparation. The perceived pain scores were elicited from the parturients between 6 to 7 hours after delivery (Reported pain). The use of oxytocics, analgesia offered were noted. Baby weight and the sex were recorded. The observations were made in the Govt. set up by four staff nurses during shifts and by two nurses in the private set up. All the six nurses were educated about the proforma. Socioeconomic status was defined based on the monthly income of the earning member. The literacy status was defined as: 1) Illiterate; 2) Up to fifth standard; 3) Fifth standard to tenth standard; 4) Tenth standard to graduation; 5) Post graduation and professionals.

Booking meant the parturient had visited the same hospital for monthly check up and delivered in the same hospital.

By prelabour preparation we meant that the parturients were explained about the nature of labour pain, its effects and ill effects, methods to decrease it during their monthly visits.

The intensity of labour pain was classified as: 1) Easily tolerable (mild); 2) Tolerate with difficulty (moderate); 3) Distressing (severe); 4) Unbearable (very severe).

(Less severe = 1, 2) (More severe = 3, 4)

The data was analysed using SPSS version 19 and Microsoft Excel 2010. The following statistical tests were used for analysis. Demographic Data: t-Test, Non parametric data by chi-square test and correlation of each factor with pain by logistic regression analysis.

All the 400 patients completed the study. The incidence of severe reported pain (scores 3 and 4) in group G was 43.5% while in group P was 12%. No patient of group G received antenatal preparation and 10 out 200 received the same in Group P. A 134 parturients of 200 in Group G while only 27 in Group P were not given any form of analgesic intervention. Group G patients had 6.548 times more pain than group P patients (p<0.001)*and primigravida experienced 4.358 times more pain compared to Multi (p<0.001)*Patients who has not received analgesics experienced 2.392 times more pain compared to patients who received analgesics (p = 0.006)* Even though patients aged greater than 30 years had 1.58 times more pain compared to patients aged<30 years. Literates and Unbooked patients experienced more pain than the illiterates and booked cases but without statistical significance. Parturients who received oxytocics and had given birth to female kids reported more pain but it was statistically insignificant. Regarding baby weight, there was no difference. * = statistical significance [Table/Fig-1]. Booked patients, literates and patients of higher income group were statistically more in Group P. There were more primigravida in group P than group G. Analgesia was administered more often to patients of group P [Table/Fig-2]. The analgesic intervention was in the form of intravenous tramadol in group P while it was intramuscular pentazocine in group G. Four parturients of group G received electro acupuncture. Only 3 out of 27 patients who did not receive analgesic intervention in Group P had severe pain, but 24 out of the remaining 173 patients who received analgesic intervention had severe pain. It can be inferred that patients of group P received analgesic intervention during labour as a routine treatment and reported less pain after 8 hours on the whole but there was no correlation of pain with intervention possibly because of their literacy. In Group G, out of the 59 parturients who received inj. Pentazocine, 20 had severe pain which means even with analgesics, one third of patients admitted in Govt. hospital suffered from severe pain [Table/Fig-3]. But considering all the 400 parturients, with pain as a fixed variable, a one by one introduction of various factors by logistic regression revealed primigravida, parturients admitted in Govt. hospital and analgesic intervention were the factors which influenced pain than other factors

The overall pain suffering in the Pain Rating Index (PRI) in parturients differs with gravida. Melzack in his study has proved that primigravida experience more pain than multi gravida which goes along with our findings [4,5]. The incidence of severe labour pain is lower in Group P than Group G. The incidence of severe pain even in the Group P itself is 12% which also needs attention. Even though Moron et al., reported longer duration of labour pain in parturients with higher education [6], they have not reported intensity differences. In our study, the intensity of labour pain is less in higher education group probably due to increased incidence of intervention in this group. Even though the literates suffered less pain it is not statically significant. E Ogboli-Nwasor et al., in their study in Nigerian population found out that even though the mothers want pain relief, providers are hesitant to offer the same and there is continual suffering of antenatal mothers during labour [7]. This component was not a part of our study. Group P patients received more analgesic intervention than G patients, which suggests that the pain of patients admitted in the government set up was not taken care of satisfactorily. If we consider results in [Table/Fig-3], we can deduce that patients who had severe pain in spite of demanding and getting analgesic were equal in both the groups (21:22). Out of the 24 patients without analgesic intervention [Table/Fig-3] only four were primigravida. They reported less pain only to establish that gravida may play a lesser role in reported pain than interventions. A patient who didn’t demand analgesic but had severe pain is significantly more in Group G. (66:2). Possibly they are not aware that they can make a demand. Out of the 66 parturients, 62 were illiterate, but 32 were primigravida and 34 were having babies more than 3 kg. The reported pain is severe in illiterate patients which influences the pain more than the gravida and the weight of the baby. Hence literacy plays a major factor to demand and get analgesics. Mothers who delivered male babies had less pain than who delivered female babies. There is a traditional belief in South India to regard male babies as their heirs [8]. As our study involves a reported pain after a few hours, there is an immense happiness about delivery of male babies. This factor accounts for less pain in mothers who delivered male babies which is more in Group P but yet without statistical significance. The more number of literates and better economic status among group P patients is natural. There is no concept about antenatal preparation and discussion about pain in the Group G while it is also minimal in the Group P (0% vs 5%). Nabukenya et al., in his work found out that of the 1293 participants interviewed, only 7% of the participants had knowledge of labour analgesia [9]. This was a study done in the rural population in Uganda. In our study, no patient of group G knew about labour analgesia and 5% knew in group P. Hence it is impossible to study the influence of the same. Shidhaye RV et al., described that majority of women suffered from labour pain and this could be possible because of lack of awareness [10]. Hodnett et al., concluded that the influence of pain, pain relief and medical interventions during labour on later satisfaction are neither as obvious, nor powerful as the influences of the behaviours and attitudes of the caregivers [11]. We did not study this aspect of attitude of caregivers in labour analgesia in our project. Melzack R et al., in their study of factors influencing labour pain have mentioned heavier babies causing more pain [4]. The increasing weight of the baby may cause more pain, but in our study, it was more significant in group P but not in the Group G. Overall, considering two groups, the weight of the baby was not influencing pain in our findings induction with oxytocin was common in the group P and this influenced pain more in Group P. In a study of antenatal women, one third of patients received oxytocin. In our study around 15.5 patients of group G and 44 % of group P received oxytocin which is obviously less than one third of the sample size. Klusman in his study has found out that reduction of anxiety before labour significantly decreases pain [12]. This goes along with our study that unbooked cases had more pain. The study by Lowe et al., showed that less pain is experienced in confident and educated mothers [13–15]. Norr et al., in their study showed that women with higher social status, less traditional attitudes toward sex roles, and greater marital closeness are more likely to prepare for childbirth [16], they had their husband’s help during labour and delivery, which resulted in less pain and more enjoyment during birth. Social support during labour is a critical factor in improving birth experiences. Increasing the availability of preparation classes and encouraging greater support from relatives during birth could improve birth experiences for many women.

The limitation of our study is that it’s more of a qualitative than a quantitative one.

Mothers hailing from peripheral semi urban India suffered from labour pain to a significant extent and there is an urgent need for awareness about labour analgesia. Primigravida, confinement in a Govt. hospital and analgesic interventions were the three factors which influenced pain than others. Overall that literates demanded analgesics, received the same to report less pain. But parturients, who knew that the process of labor would be painful possibly from their elders, admitted in Govt. hospital demanded less analgesics but reported more pain later. Antenatal preparation was minimal in both groups. We suggest a proper booking with counseling about labour pain, modes of its reduction should be explained to parturients in the antenatal period.