Women experience more severe pain, more recurrent pain, and longer duration of pain than men [15]. Moreover, pain affects a higher proportion of women than men and they are less likely to receive treatment compared to men [16, 17]. Upwards of 20 % of women may suffer from continued severe acute pain after labor and delivery of their children [18]. Since acute pain is a risk factor for chronic pain, it can be postulated that the experiencing the pain of childbirth may shape a woman’s “pain future,” having a profound effect on her life.

Access to pain management is poor for all people in LMIC, gender inequalities contribute to the pain suffered women globally. This can be due to various cultural, economic and political barriers. Pain from menstruation and/or childbirth is diminished by caregivers and deemed ‘natural’. Women are among the most commonly cited vulnerable groups along with children, the elderly, patients living with HIV/AIDS or other chronic diseases, those with mental or physical disabilities, ethnic minorities, and socioeconomically disadvantaged groups [19, 20]. A large percent of the female population are potential mothers, and the detrimental effect of maternal death on household income, household productivity, and household disintegration has been widely described [21]. During and after a disaster, women have to assume the role of head of household. This may include management of household finances and food supply, in addition to childcare and other responsibilities [20].

Pregnancy may be the defining period of a women’s life. In most parts of the world pregnancy can also be a life threatening condition. Access to safe and pain free surgical care during pregnancy is a critical prerogative for all women. The ability to provide quality analgesia is likely an indicator of the level quality of care facility can deliver. In the opinion of the authors, the rate of death of women in LMIC could be improved by providing them with access to quality health services such as analgesia. However, in reality, most women experience serious barriers to accessing services. Even if they do reach them, the services themselves are often of insufficient quality or effectiveness. The main components are the health professionals within their ‘enabling environment’ that comprise a functioning health care system including effective transportation, drugs, equipment and supplies [21]. A lack of trained surgical providers is among the most significant barriers to essential surgical and postsurgical care. LMIC have a crisis of human resources where the workforce of surgeons, obstetricians, and anesthesiologists is severely depleted [22]. This scarcity is due in part to a paucity of education, training, and economic opportunities for physicians and other health care workers.

In the advocacy of pain management as a human right, the Declaration of Montreal states that it is the right of all people to have access to pain management for acute pain caused by trauma, disease, or terminal illness without discrimination. The pain of pregnancy is not caused by any of these injuries described but by the physiological preparation of the uterus and cervix to expel the fetus through the vagina. Labor causes severe pain for most women. The pain of labor for nulliparous women was similar to the trauma of having a digit amputated [23]. There is no other circumstance where it is considered acceptable for an individual to experience untreated severe pain, amenable to safe intervention, while under a physician’s care [24]. The American College of Obstetricians and Gynecologists together with the American Society of Anesthesiologists have stipulated that in the absence of a medical contraindication, a women’s request is a sufficient medical indication for pain relief during labor [24].

In China, most women in labor are primigravidas whose fear of labor pain leads them to request cesarean deliveries rather than risk labor without effective analgesia; their fears may be justified as less than 1 % of women in labor are given analgesia [25]. As a result, the rate of cesarean deliveries is as high as 50 % in many hospitals in China. In these situations, more available labor analgesia may reduce the rate of cesarean deliveries and resulting morbidity and mortality by reducing fear of labor pain.

The logistics of pain management during labor are complex. There is the physiology of both mother and fetal circulation to consider and the choice of drug and delivery may have impact one or both parties. Some methods of pain management, such as labor analgesia, can be costly and labor intensive. Neuraxial labor analgesia is the primary modality in high-income countries. However, epidural analgesia uses numerous disposables and large volumes of medications. The ability to supply the medications and disposable equipment must be considered when planning to provide a labor analgesia service. All classes of drugs used traditionally on labor units for pain management of labor are listed in the WHO List of Essential Medicines. This includes opioids, naloxone, local anesthetics, and nitrous oxide [26]. Providing pain relief during labor is both necessary and feasible in developing countries.

Neuraxial analgesia is a highly effective method of providing pain relief during labor [27, 28]. Regardless of economic situation, some women in labor wish to have analgesia for childbirth. Unfortunately, access to epidural analgesia during labor is limited in LMIC [29]. In a survey of women in LMIC, 85 % of respondents indicated they would request labor analgesia if available but only 40 % received any form of analgesia during childbirth [30]. Costs of staffing and supplies associated with providing neuraxial analgesia can be prohibitive in LMIC [13, 31]. With limited resources for epidural analgesia, spinal analgesia may be a useful alternative for relief of labor pain [32, 33].

Pain management during labor permits a calm and stable environment for the infant’s delivery. It will offer the workers the ability to demonstrate compassion and empathy instead frustration. Perhaps the learned behavior of pain and its needed endurance will be recognized as unnecessary and bring these women to a supervised skilled setting for delivery. Skilled delivery would offer the women greater chances of survival and perhaps even reduce the complications affecting the neonate leading to longer-term survival of both mother and child.

To truly promote women’s rights and the right to pain relief, a greater investment in education and health, including reproductive health and family planning must be made [4]. Beyond difficult accessibility, women have limited access to health care in LMIC because of traditional beliefs surrounding religion and ethnicity into which modern medical care does not fit [34]. The authors postulate that exposure and education of women may have women ignore traditional beliefs and choose safe labor pain relief over cesarean delivery. The next section describes in more detail the international efforts to advance the health of women in the context of the Millennium Development Goals.

When women are treated as objects and not as fully human, they have few or no rights and their health suffers. Basic human rights generally include a right to: (a) respect as a person of value or worth, (b) security of person (safety), (c) privacy/confidentiality, (d) food, nutrition, and housing, (e) freedom from any form of discrimination, (f) information and education, (g) benefits of scientific progress, (h) freely informed consent, (i) reproductive choices, and (j) equitable access to health services of good quality [4].

To galvanize purpose and organize efforts toward the achievement of basic human rights for all people, at the turn of the twenty-first century, the United Nations (UN) created an ambitious set of eight goals to be achieved by 2015 (see Table 14.2).

Although there have been great strides made to improve conditions for the marginalized minorities, for women and children under five in developing countries, the objective deadlines of the MDGs will not be met. Still more than 1 billion people live in extreme poverty, with a total of 385 million still living on less than 1.25 dollars a day. There is still a huge gender gap for those employed, with the gender-employment ratio resting at almost 30 % in Africa [35]. Women still fill positions of lesser employment [36]. Primary school education in developing countries has reached 90 % [37]. A child under five is twice as likely to die if her mother has not had a primary school education [36]. For this reason, the UN is in the process of setting a post-2105 agenda for continued work [38].

The survival of children under five (MDG 4) and the reduction in maternal mortality (MDG 5) may be key pain related goals. Reducing by almost half, the child mortality incidence has fallen 12.4 million in 1990 to 6.6 million in 2012 [39]. Despite this fall in the child mortality rate, the rate of neonatal deaths is increasing [39]. Asphyxia is the cause of 9 % of the neonatal deaths. In dealing with the pain of the laboring woman, a reduction in some of the complications of labor can result in successful instrumental delivery allowing those infants to be delivered without serious morbidity or complications which would result in lower infant mortality rate [39, 40].