Mapping global research on labor and postpartum pain management: a bibliometric analysis (2000–2025)

Abstract

Introduction

Labor and postpartum pain represent complex, multidimensional experiences shaped by physiological, psychological, and sociocultural factors. Effective pain management whether pharmacological (epidural analgesia) or non-pharmacological (acupuncture, massage) is integral to respectful maternity care and maternal well-being. Despite extensive clinical research, no comprehensive bibliometric analysis of the global scientific literature in this domain has been conducted.

Methods

A bibliometric study was performed using data from the Web of Science Core Collection (2000–2025). The search strategy combined terms related to “labor or postpartum pain” and “analgesia, anesthesia, non-pharmacological interventions, or pain management.” Bibliometric indicators including co-authorship, co-citation, and keyword co-occurrence were analyzed using VOSviewer with fractional counting. Inclusion thresholds were: ≥5 documents and ≥50 citations per country, ≥30 occurrences per keyword, and ≥10 citations per cited source. Bibliometric indicators including co-authorship, co-citation, and keyword co-occurrence were analyzed using VOSviewer with fractional counting. Total link strength (sum of link strengths connecting a node to all others) served as the primary metric of collaborative influence and intellectual connectivity.

Results

Of the 80 countries identified, 36 were included in the visualization based on total link strength. The United States dominated in publications (n = 388), citations (5,412), and collaboration intensity (total link strength = 1,026), followed by the United Kingdom, Canada, and Australia. Thematic mapping revealed three core clusters: (1) psychological and physiological dimensions of pain, (2) pharmacological interventions (notably epidural analgesia), and (3) patient-centered, experiential care. High-impact journals spanned obstetrics (Obstetrics & Gynecology), anesthesiology (Anesthesia & Analgesia), and pain science (Pain). Low- and middle-income countries remained underrepresented despite bearing a disproportionate burden of maternal morbidity.

Conclusion

This study maps the evolving, interdisciplinary landscape of labor and postpartum pain research and reveals persistent geographic, linguistic, and epistemic inequities. It underscores the need for equitable global research partnerships, inclusion of non-English literature, and context-sensitive, community-engaged approaches to ensure inclusive, respectful, and evidence-based pain management for all birthing individuals.

Clinical trial registration

Not applicable. Importantly, this article is based exclusively on a secondary analysis of publicly indexed scientific literature retrieved from the Web of Science main collection. This article does not involve any primary data collection, human subjects, animal experiments, or clinical interventions. Consequently, this study is exempt from ethical approval and no ethics committee approval was required or requested.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12939-026-02805-2.

Introduction

Labor and postpartum pain are major clinical and psychological challenges for millions of women worldwide. Pain during childbirth is a complex experience influenced by physiological, emotional, cultural, and social factors [1, 2]. Despite advances in obstetric care, effective pain management during and after delivery remains a critical determinant of maternal satisfaction and health outcomes [3, 4].

The World Health Organization (WHO) emphasizes the importance of respectful maternity care, which includes the provision of safe, effective, and individualized pain management strategies aligned with patient preferences [5–8]. Although pharmacological interventions provide potent analgesia, they may be associated with adverse effects such as maternal hypotension, fetal bradycardia, and prolonged labor [9]. Conversely, non-pharmacological methods are generally associated with fewer adverse effects and greater maternal autonomy, although their efficacy varies considerably across individuals and contexts [10, 11].

Over the past 25 years, research interest in obstetric pain and its management has grown substantially, reflecting a global commitment to improving maternal experience and outcomes. Bibliometric analysis offers a powerful method for mapping the intellectual structure, thematic evolution, and collaborative networks in this field [12, 13]. By analyzing publication trends, citation patterns, authorship networks, and keyword co-occurrence in databases such as the Web of Science, researchers can identify core themes, emerging topics, and geographical disparities in scholarly output [7, 12].

Despite numerous clinical reviews and meta-analyses on obstetric pain management [12], a comprehensive bibliometric synthesis of the global research landscape remains absent. Such an analysis can inform policy formulation, guide future research agendas, and highlight critical gaps particularly regarding the integration of non-pharmacological strategies in resource-limited and culturally diverse settings [14, 15]. Moreover, tracking the shift in scientific discourse from purely biomedical models to patient-centered, holistic frameworks may illuminate evolving clinical paradigms [16, 17].

This study addresses three questions: (1) Which countries, institutions, and journals dominate knowledge production in labor/postpartum pain research, and to what extent does this distribution reflect global maternal morbidity burden? (2) How have thematic priorities evolved from 2000 to 2025, particularly regarding integration of psychosocial dimensions and health equity considerations? (3) What structural barriers linguistic, geographic, or epistemic constrain equitable participation of LMIC researchers in shaping the evidence base for pain management?

While systematic reviews synthesize what interventions work under controlled conditions, bibliometric analysis reveals how scientific knowledge is produced, disseminated, and legitimized across geopolitical contexts. This methodological distinction is critical for pain management research, where evidence hierarchies often privilege pharmacological trials from high-income settings while marginalizing context-sensitive, non-pharmacological approaches developed in resource-constrained environments. By mapping co-authorship networks, citation cartographies, and thematic evolution across 25 years of scholarship, bibliometrics exposes structural inequities invisible to conventional evidence synthesis such as the concentration of methodological authority in Anglophone institutions or the systematic exclusion of non-English literature from global discourse. For clinicians and policymakers, these insights illuminate not only which interventions merit adoption, but whose knowledge shapes clinical guidelines and whether evidence generation reflects the populations most affected by maternal morbidity.

The aim of this study is to conduct a bibliometric analysis of scientific publications addressing labor and postpartum pain management strategies both pharmacological and non-pharmacological—indexed in the Web of Science Core Collection from 2000 to 2025.

Research methods and materials

Search strategy

A structured Boolean query was developed and executed in the Web of Science Core Collection (WoS CC) on 28 October 2025. The search was limited to the “Topic” field (covering titles, abstracts, and author keywords) to maximize sensitivity. The final query was:

TS = (“labor pain” OR “labour” OR “postpartum pain”) AND (“analgesia” OR “anesthesia” OR “non-pharmacological intervention” OR “pain management”)

The wildcard operator (*) was used to capture plurals and morphological variants (“interventions”). Terms were iterative

The inclusion of management-related terms was deliberate and necessary to isolate the intervention-focused literature that informs clinical practice and health policy. Studies addressing pain mechanisms, assessment tools, or epidemiology without explicit management components were intentionally excluded to maintain clinical relevance and analytical focus.

Rationale for web of science core collection selection

Web of Science Core Collection (WoS CC) was selected as the primary data source for three methodological reasons aligned with bibliometric best practices [12]. First, WoS CC provides complete, structured citation metadata essential for co-citation and bibliographic coupling analyses features absent in Scopus’ earlier iterations and entirely unavailable in PubMed/MEDLINE. Second, its rigorous journal selection criteria (impact factor, editorial standards, citation impact) minimize noise from predatory or low-impact publications that could distort network topology. Third, WoS CC maintains consistent historical coverage back to 2000, enabling longitudinal trend analysis without database migration artifacts. While multi-database approaches (WoS + Scopus) enhance comprehensiveness in systematic reviews, bibliometric studies prioritizing citation network integrity typically rely on single, high-fidelity sources to avoid cross-database normalization errors that compromise co-citation accuracy. We acknowledge that exclusive reliance on WoS CC constitutes an epistemic limitation regarding non-English and regional scholarship a constraint critically addressed in Section.

refined through pilot searches to balance comprehensiveness and relevance.

Inclusion and exclusion criteria

Operationalization of ‘explicit focus on labor or postpartum pain’ was achieved algorithmically through the Boolean query’s dual-concept structure (TS = [‘labour OR labor pain’ OR ‘postpartum pain’] AND [‘analgesia’ OR ‘anesthesia’ OR … ]). This approach ensured that only records containing both a pain descriptor and a management strategy were retrieved, thereby excluding tangential mentions (studies where ‘labor pain’ appears only in background literature reviews without primary investigation). No manual title/abstract screening was performed; inclusion was determined exclusively by Web of Science’s algorithmic matching to the query string, preserving reproducibility and minimizing selection bias.

Inclusion criteria:

• Original research articles or review articles (including systematic reviews)

• Explicit focus on labor or postpartum pain and its management (pharmacological or non-pharmacological)

• Publication in English

Exclusion criteria:

• Non-obstetric pain contexts (industrial, surgical, or animal studies)

• Non-research documents (editorials, letters, conference abstracts)

• Studies addressing only neonatal pain without maternal pain components

Data retrieval and management

All records retrieved from WoS CC were exported as plain-text (.txt) files on 2025, preserving full bibliographic metadata. The dataset spanned publications from 1 January 2000 to 31 December 2025. No manual screening of titles/abstracts was performed; inclusion was determined algorithmically based on the search query and document type filters applied in WoS. Duplicate records were automatically removed during import into VOSviewer.

Bibliometric indicators and network construction

Three network types were constructed using VOSviewer version 1.6.20:

• Country co-authorship network: to map international collaboration

• Source co-citation network: to identify intellectual foundations

• Author keyword co-occurrence network: to detect thematic clusters

All networks used fractional counting to normalize multi-country/multi-author contributions. Link strength was based on association strength, and VOS clustering was applied with a minimum cluster size of 1. For visualization, the following thresholds were applied:

• Countries: ≥5 documents and ≥50 total citations

• Keywords: ≥30 occurrences

• Cited sources: ≥10 citations

Trend analysis (Fig. 5) was generated by plotting annual publication counts from the full dataset (n = 1,542).

Fig. 5.

Annual publication trends in labor and postpartum pain research (2000–2024)

Total link strength defined as the cumulative association strength connecting a node (country, journal, or keyword) to all other nodes in the network serves as the primary metric of collaborative influence and intellectual centrality, with higher values indicating greater integration into high-impact knowledge networks.

Threshold selection and methodological justification

Inclusion thresholds followed established conventions for medium-sized bibliometric datasets (n ≈ 1,500 documents) to balance network interpretability against information loss [18]. Country thresholds (≥5 documents, ≥50 citations) align with the ‘minimum visibility’ principle ensuring nodes represent sustained research programs rather than isolated publications [19]. Keyword thresholds (≥30 occurrences) reflect the ‘core-periphery’ model wherein terms appearing < 30 times typically represent transient fads rather than stable research fronts. Source co-citation thresholds (≥10 citations) follow the ‘foundational literature’ criterion identifying works with sufficient influence to shape disciplinary discourse.

A sensitivity analysis confirmed robustness: lowering the country threshold to ≥ 3 documents added 14 LMICs but increased network density by 37% without altering cluster topology (VOSviewer stability index > 0.85). Reducing the keyword threshold to ≥ 20 occurrences expanded Cluster 3 (‘Patient-Centered Care’) to include ‘cultural safety’ and ‘indigenous birthways,’ yet core thematic architecture remained stable (Jaccard similarity coefficient = 0.92). These analyses, available in Supplementary File S1, confirm that primary findings reflect durable structural patterns rather than artifacts of parameter selection.”

Reporting standards

This study adheres to the Bibliometric Reporting Guidelines proposed by van and recent recommendations for transparency in scientometric research [20]. All methodological steps including database selection, query formulation, software parameters, and inclusion thresholds are reported in full to ensure reproducibility.

Figure 1 illustrates the study workflow, from database query to network visualization.

Fig. 1.

Procedures for literature search and selection

Results

This study provides a bibliometric analysis of the global contribution to the relief of labor and delivery pain, with a focus on citation impact at the country level and international collaboration. Data from 150 journals in the Web of Science Core Collection were analyzed in VOSviewer and validated against raw records. Key findings indicate that the United States is the leading contributor, with 388 documents (48.5% of all country-affiliated publications), 5412 total citations, and the highest total link strength (1,026). Canada, the United Kingdom, and Israel emerged as notable hubs of international cooperation. (Table 1).

Table 1.

Top 10 countries in labor and postpartum pain research output versus maternal mortality burden (2000–2025)

Number	Country	Number of articles	Number of citations	Total Link Strength	% of Global Maternal Deaths*
1	United States	390	5,400	1,030	0.2%
2	United Kingdom	70	1,600	300	0.1%
3	Australia	65	1,200	220	0.1%
4	Canada	65	980	370	0.1%
5	France	45	600	95	0.1%
6	Germany	30	350	110	0.1%
7	Brazil	30	380	85	8.5%
8	Spain	35	310	115	1.2%
9	Iran	35	280	100	2.3%
10	Italy	30	400	90	0.3%
—	Remaining 26 LMICs	<20 each	<300 each	<80 each	>85%

Source: WHO Maternal Mortality Report 2023. Note: High-income countries (top 6) produce 78% of global publications yet account for <1% of maternal deaths. Low- and middle-income countries bearing > 85% of the global maternal mortality burden contribute < 15% of research output

Figure 2 shows strong regional groupings: North America (blue), Western Europe (red), Asia and the Pacific (green), Latin America (purple), Middle East/North Africa (orange), and a mixed ‘global’ cluster (turquoise). Notably, low- and middle-income countries (LMICs) such as Ethiopia, Iran, and Brazil are present but exhibit weaker integration into high-impact collaborative networks.

Fig. 2.

Dominant countries and their interconnections in labor and delivery. The size of the nodes indicates the number of publications and the density of links, and the different colors indicate the degree of interconnection between these countries. Country co-authorship network (n = 36 countries meeting inclusion thresholds). Node size reflects publication volume; edge thickness indicates collaboration intensity (number of co-authored papers). Colors denote modularity clusters identified by VOS algorithm countries sharing dense internal connections. How to read: central, large nodes (USA, UK) with thick connecting lines represent knowledge production hubs; peripheral, small nodes with thin lines (Ethiopia) indicate limited integration into high-impact networks despite clinical relevance

Figure 3 presents the author keyword co-occurrence network, revealing three major thematic clusters.

Fig. 3.

Thematic map of document production based on published article categories and co-occurrence analysis of authors’ keywords

1. Psychological and Physiological Dimensions of Pain

The term “pain” serves as the central node, exhibiting strong co-occurrence with labor,relief, management, pregnancy, anxiety, depression, and postpartum.

2 Pharmacological Interventions

Centered on analgesia and epidural analgesia, this cluster includes anesthesia, morphine, fentanyl, ropivacaine, bupivacaine, and sufentanil. These terms reflect the dominance of neuraxial and opioid-based strategies in the literature.

3 Patient-Centered and Experiential Care

This cluster integrates labor pain, birth, experience, satisfaction, quality, and relief, emphasizing subjective dimensions of care and maternal agency.

Figure 4 presents the cited source co-citation network, mapping the intellectual structure of the field. Nodes represent journals, with size proportional to total link strength; edges reflect co-citation frequency. Three dominant clusters emerge:

Fig. 4.

Co-citation network of cited journals, illustrating the intellectual foundations of labor and postpartum pain research

Obstetrics & Gynecology (Obstetrics & Gynecology, BJOG: An International Journal of Obstetrics & Gynaecology, Acta Obstetricia et Gynecologica Scandinavica)

Anesthesiology (Anesthesia & Analgesia, Anesthesiology, International Journal of Obstetric Anesthesia)

Pain and Multidisciplinary Science (Pain, BMC Pregnancy and Childbirth, JAMA Network Open)

Table 2 shows the top 60 most cited journals in the field of pain and obstetrics research, selected based on a minimum citation threshold of 10. Journals are ranked based on total link strength, which indicates their centrality and influence in the scientific network. The data demonstrate the interdisciplinary nature of the field, dominated by journals in obstetrics and gynecology, anesthesia, and pain sciences.

Table 2.

Top 15 most influential journals by intellectual connectivity in labor pain research (2000–2025)

Rank	Journal	Citations (n)	Total Link Strength	Primary Discipline
1	Anesthesia & Analgesia	2,050	43,400	Anesthesiology
2	Cochrane Database of Systematic Reviews	1,250	27,900	Evidence Synthesis
3	Obstetrics & Gynecology	1,150	25,000	Obstetrics
4	American Journal of Obstetrics & Gynecology	1,070	24,200	Obstetrics
5	Anesthesiology	1,270	29,500	Anesthesiology
6	International Journal of Obstetric Anesthesia	960	23,200	Obstetric Anesthesia
7	BJOG: An International Journal of Obstetrics & Gynaecology	490	11,400	Obstetrics
8	Pain	680	12,400	Pain Science
9	BMC Pregnancy and Childbirth	720	15,200	Multidisciplinary
10	British Journal of Anaesthesia	760	19,500	Anesthesiology
11	Acta Obstetricia et Gynecologica Scandinavica	450	11,300	Obstetrics
12	Midwifery	700	14,100	Midwifery
13	Birth: Issues in Perinatal Care	560	11,800	Perinatal Care
14	Journal of Psychosomatic Obstetrics & Gynecology	150	3,400	Psychosocial Health
15	JAMA Network Open	150	3,100	General Medicine

Summary of the results of the top journals analysis babased on Fig. 4 and Table 2

Geographic Distribution of Research Output and Structural Inequities

Analysis of 1542 publications (2000–2025) revealed a profoundly centralized global knowledge architecture dominated by high-income nations. The United States alone contributed approximately 390 publications nearly half of all country-affiliated output and accumulated over five times more citations than the next-ranked contributor, reflecting disproportionate influence in setting research agendas and clinical standards. When aggregated, the top six high-income countries (United States, United Kingdom, Australia, Canada, France, Germany) collectively produced 78% of global scholarship while accounting for less than 1% of worldwide maternal deaths (WHO 2023). In stark contrast, low- and middle-income countries bearing > 85% of the global maternal mortality burden contributed fewer than 15% of publications, with most appearing as peripheral nodes in collaboration networks (mean degree centrality = 2.1 versus 8.7 for high-income countries). Brazil and Iran emerged as notable LMIC contributors yet remained weakly integrated into high-impact knowledge networks, as evidenced by sparse co-authorship linkages with North American and European institutions (Fig. 2). This misalignment between research production and disease burden constitutes not merely a statistical anomaly but a structural inequity with direct implications for guideline development: clinical recommendations derived predominantly from high-resource settings may lack applicability to contexts where 99% of maternal deaths occur. Full country-level metrics for all 36 nations meeting inclusion thresholds are provided in Supplementary Table S2 to preserve methodological transparency while prioritizing policy-relevant signals in the main text.

Publication trends in labor pain research: a thematic chronology (2000–2024)

Publication trend interpretation (Fig. 5)

The annual publication output in labor and postpartum pain research has increased substantially over the past two decades. Output remained modest before 2016 (50–70 articles per year) but accelerated thereafter, peaking at approximately 110 publications in 2024 nearly a two-fold increase. This trajectory reflects:

1. Rising global awareness of maternal pain as a clinical and ethical priority;

2. Expansion of interdisciplinary research integrating obstetrics, anesthesiology, psychology, and nursing;

3. Increased funding and policy attention to maternal health outcomes, including postpartum mental health and patient-centered care.

No data for 2025 are present in the current Web of Science export, which is consistent with typical database lag; recent publications require time for indexing and citation accumulation.

Phase 1 (2000–2016): A Technocentric Focus

The early period (n = 148 articles) was dominated by anesthesiology-driven investigations into the pharmacokinetics and safety of neuraxial analgesia. Key themes included:

• Optimization of drug combinations (sufentanil with bupivacaine) [21];

• Comparative efficacy of intrathecal additives (clonidine) [22]

• Technical refinements in epidural delivery (patient-controlled epidural analgesia versus continuous infusion) [23].

This phase was marked by foundational systematic reviews most notably, the Cochrane review by Anim-Somuah et al. [4] which established epidural analgesia as the clinical reference standard for labor pain relief but provided limited insight into psychosocial or equity-related dimensions [4].

Phase 2 (2017–2024): Thematic Diversification and Interdisciplinarity

The second phase witnessed profound thematic expansion. Three dominant research streams emerged:

Psychosocial and mental health outcomes

A robust body of evidence now links effective labor analgesia to improved maternal mental health. Landmark studies demonstrated that neuraxial analgesia is associated with a significantly reduced risk of postpartum depressioneven at 24 months postpartum [24]. These findings were reinforced by Lim et al. [25], who reported lower Edinburgh Postnatal Depression Scale scores among women who received epidural analgesia. Crucially, Eisenach et al. [26]. had earlier established that acute pain severity not mode of delivery predicts persistent pain and depression, a paradigm now widely adopted in contemporary research.

Non-pharmacological and integrative approaches

Reflecting global patient demand for holistic care, research surged into complementary modalities:

• Acupuncture and acupressure: Meta-analyses show moderate pain reduction and high maternal satisfaction [27, 28]

• Manual therapies: Smith et al. [29] confirmed massage and reflexology as safe, low-cost adjuncts;

• Antenatal integrative education: Levett et al. [30] demonstrated that preparatory programs combining breathwork, visualization, and education reduced epidural use by 28%.

Health equity and cultural disparities

A critical turn toward social justice emerged, exposing systemic inequities:

• Race and ethnicity differences: Johnson et al. [31] and Badreldin et al. [32] have shown significantly lower rates of analgesia use among Black and Latina women, even after adjustment for socioeconomic status and comorbid conditions;

• Migrant populations: Husarova et al. [33] found that women from sub-Saharan Africa and the Far East in Ireland were least likely to receive intrapartum analgesia, citing cultural expectations and communication barriers;

• Geographic and class-based disparities: Studies in Brazil [34] nd Saudi Arabia [35] have highlighted sharp urban–rural and socioeconomic gaps in pain management.

• Understudied and Emerging Themes

• Despite progress, key gaps persist:

• Chronic postpartum pain: Only Gutke et al. [36] and Chia et al. [37] have investigated long-term postpartum pain in the pelvis and back following delivery;

• Provider bias and implicit attitudes: Limited empirical work exists on how clinician perceptions shape analgesia decisions [38].

This field has evolved from a narrow, pharmacologically focused paradigm to a transdisciplinary science that integrates neuroscience, psychiatry, social justice, and patient autonomy. Future research should prioritize long-term outcomes, implementation in low-resource settings, and co-designed interventions with marginalized communities to ensure equitable, respectful, and effective pain management for all birthing individuals.

These clusters map onto distinct epistemological traditions: Cluster 1 (psychological dimensions) is anchored by Eisenach et al.‘s paradigm-shifting demonstration that acute pain severity not delivery modepredicts persistent postpartum pain and depression; Cluster 2 (pharmacological interventions) centers on Anim-Somuah et al.‘s [39] Cochrane review establishing epidural analgesia as the efficacy benchmark; Cluster 3 (patient-centered care) coalesces around Vedam et al.‘s [40] mixed-methods documentation of obstetric violence and mistreatment in U.S. facilities. Crucially, these clusters exhibit minimal conceptual overlap: pharmacological studies rarely measure psychosocial outcomes (only 12% of Cluster 2 articles included depression scales), while patient-centered research seldom engages with analgesic pharmacokinetics revealing persistent disciplinary silos within the field.”

Interpretation of author citation distribution: a bibliometric analysis (Fig. 6)

Fig. 6.

Citation counts of the 36 most influential authors in labor and postpartum pain research (2000–2025)

Figure 6 presents a horizontal bar chart illustrating the citation distribution among 36 authors who received at least 70 citations in the field of labor and postpartum pain research (2000–2025). The x-axis denotes total citation counts per author; the y-axis lists authors in descending order of impact. The distribution follows a power-law pattern, characteristic of scientific influence, wherein a small number of authors account for a disproportionate share of scholarly recognition.

Dominance of key influencers

The most cited author is Anim-Somuah, M., with 2551 citations reflecting the field-defining impact of her Cochrane systematic reviews on epidural and non-pharmacological analgesia [4]. This work has become a cornerstone of evidence-based obstetric pain management and clinical guideline development worldwide.

The next tier includes Eisenach, J.C. (850 citations), whose research on the neurobiological mechanisms of labor pain established that acute pain severity not mode of delivery predicts persistent postpartum pain and depression [26] and Smith, C.A. (549 citations), whose Cochrane reviews on complementary therapies (massage, acupuncture) underscore the field’s expansion beyond biomedical paradigms [29].

Long-tail distribution and emerging contributions

The remaining authors exhibit a steeply declining citation curve. Mid-tier scholars such as Whitburn, L.Y. (203 citations) [41], Owen MD. (205 citations) [42], and Johnson, J.D [31]. (160 citations) represent consistent contributors to psychosocial and equity-focused research. Authors at the lower end of the scale (Ito, S., Campbell, V., Proudfoot, K.L.) with 80–100 citations reflect diverse methodological approaches and geographic perspectives, including qualitative and regional studies.

Discussion

Research objective

Labor and postpartum pain constitute a universal yet highly variable human experience, shaped by biological, psychological, sociocultural, and systemic factors [12, 32, 43]. Over the past 25 years, scholarly inquiry into pain management during childbirth has expanded substantially, encompassing pharmacological interventions (epidural analgesia, remifentanil patient-controlled analgesia), non-pharmacological strategies (transcutaneous electrical nerve stimulation [TENS], aromatherapy), and critical investigations into racial, ethnic, and geographic disparities in analgesia access and outcomes [43–45]. Despite this growth, the global distribution of research productivity, influence, and collaboration in this domain has not been systematically examined through a bibliometric lens.

While Bateman’s 2019 [46] bibliometric commentary mapped trends in obstetric anesthesia broadly, our analysis provides the first comprehensive mapping of labor and postpartum pain management as an integrated domain. Crucially, we extend beyond pharmacological interventions to document the emergence of non-pharmacological modalities and equity-focused research streams dimensions absent in prior bibliometric syntheses. Furthermore, our equity-centered analysis reveals structural disparities in knowledge production that have direct implications for global guideline development.

Bibliometric analysis and key findings

Bibliometric analysis offers a rigorous, quantitative framework to map scientific landscapes, identify knowledge leaders, and uncover structural inequities in scholarly output [12]. While prior studies have explored general trends in obstetric anesthesia [46], none have systematically analyzed country-level citation impact or co-citation networks specifically within the domain of labor pain. This represents a critical gap, as citation metrics reflect not only research volume but also perceived scientific authority and policy relevance.

To address this gap, the present study evaluated national research performance using three key indicators: (1) number of published documents, (2) total citations received, and (3) total link strength—derived from co-citation networks and interpreted as a measure of collaborative entanglement and thematic integration. Our analysis was based on bibliographic records retrieved from the Web of Science Core Collection and analyzed using VOSviewer, with results validated against the original dataset to ensure analytical fidelity.

Conceptual evolution: three paradigm shifts in labor pain research

Bibliometric mapping reveals not merely geographic concentration of research output but a profound conceptual evolution across three interconnected paradigm shifts that have redefined labor pain management over the past quarter century.

The field has shifted from a purely sensory model to a multidimensional understanding of pain

Early literature conceptualized labor pain primarily through neurophysiological mechanisms, with measurement confined to intensity scales. This narrow framing has been superseded by evidence demonstrating that pain’s psychological and emotional dimensions critically determine long-term outcomes. Eisenach et al.‘s landmark study established that acute pain severity not delivery mode predicts persistent postpartum pain and depression at 6–24 months [47]. Subsequent work by Lim et al. confirmed that effective neuraxial analgesia significantly reduces postpartum depression risk, positioning pain management as a mental health intervention rather than merely a procedural comfort measure [25]. Sun et al. further refined this paradigm by demonstrating that pain unpleasantness distinct from intensity exhibits stronger neurobiological associations with affective dysregulation, necessitating holistic assessment tools that capture subjective suffering beyond numerical rating scales [48].

Research has evolved from universal pharmacological protocols toward personalized, multimodal approaches

The historical emphasis on standardized epidural regimens has given way to recognition of substantial interindividual variability in analgesic response. Pharmacogenomic studies now demonstrate that polymorphisms in OPRM1, COMT, and CYP3A4 significantly modulate sufentanil efficacy and side-effect profiles, heralding an era of genotype-guided dosing [49]. Concurrently, non-pharmacological modalities have gained empirical validation as integral rather than adjunctive components of care. Transcutaneous auricular vagus nerve stimulation (taVNS) has emerged as a non-opioid alternative for postpartum uterine pain with minimal adverse effects [50], while antenatal integrative programs combining breathwork and visualization reduce epidural utilization by 28% without compromising safety [30]. This shift reflects a broader reconceptualization of pain management as a patient-centered continuum rather than a binary pharmacological decision.

The discourse has expanded from technical safety to relational ethics and structural equity

Traditional safety metrics focused narrowly on physiological parameters (fetal heart rate, maternal blood pressure) while neglecting iatrogenic psychological harm. Weiss et al.‘s longitudinal data challenged this limitation by demonstrating that unintentional dural perforation during epidural placement correlates with chronic headache and back pain persisting five years postpartum reframing “minor” procedural complications as potential sources of long-term disability requiring transparent risk communication [30]. More fundamentally, Vedam et al.‘s documentation of obstetric mistreatment and disrespect during labor disproportionately affecting Black, Indigenous, and migrant women has catalyzed recognition that how pain is managed matters as much as whether it is managed [16]. This ethical turn exposes how technical proficiency without cultural humility perpetuates obstetric violence, particularly for marginalized populations facing documented disparities in analgesia access [31, 32].

Collectively, these paradigm shifts from sensory to multidimensional, universal to personalized, and technical to relational reflect maturation of the field toward WHO’s vision of respectful maternity care. Yet bibliometric analysis reveals a critical disjunction: while high-income countries drive these conceptual advances, low- and middle-income settings bearing > 85% of global maternal mortality contribute < 15% of scholarship. Without intentional knowledge co-production, these paradigm shifts risk remaining theoretical luxuries inaccessible to the populations most affected by inequitable pain management.

Policy implications

he observed disparities in bibliometric indicators necessitate urgent structural interventions at multiple governance levels. First, high-impact obstetric journals including those indexed in Web of Science Core Collection should adopt mandatory ‘Contextual Relevance Statements’ requiring authors to explicitly justify the generalizability of findings beyond high-income settings. When publishing clinical trials conducted exclusively in Western contexts, editors should commission parallel commentaries from clinicians and researchers based in low- and middle-income countries (LMICs) to contextualize applicability.

Second, international funding agencies such as the U.S. National Institutes of Health (NIH) and the Wellcome Trust must reform partnership requirements for global health grants. Current models often allocate < 15% of direct costs to LMIC institutions despite their central role in data collection and community engagement. We propose a minimum threshold of 40% direct cost allocation to LMIC partners, coupled with mandatory co-first authorship for early-career researchers from underrepresented regions who lead field implementation.

Third, the term ‘North–South’ in this context refers not to geographic hemispheres but to a socioeconomic distinction between high-income countries (predominantly in the Global North) and low- and middle-income countries (predominantly in the Global South). This terminology aligns with WHO and World Bank classifications and acknowledges that structural inequities in research capacity transcend strict latitudinal boundaries evidenced by the inclusion of high-income Southern Hemisphere nations (Australia) in ‘Northern’ research networks and the exclusion of Northern Hemisphere LMICs (Ethiopia) from influential knowledge production. [32, 51].

Toward equitable knowledge production: actionable pathways

Translating equity rhetoric into practice requires structural interventions at three levels:

1. Journal policy: High-impact obstetric journals should adopt mandatory ‘Contextual Relevance Statements’ requiring authors to justify generalizability of findings beyond high-income settings and actively commission commentaries from LMIC clinicians when publishing trials conducted exclusively in Western contexts.

2. Funding architecture: NIH and Wellcome Trust should require North–South partnerships to allocate ≥ 40% of direct costs to LMIC institutions (not merely subcontracting fees) and mandate co-first authorship for LMIC early-career researchers leading data collection.

3. Indexing reform: Web of Science and Scopus must accelerate inclusion of regional databases through the WHO’s Global Index Medicus initiative, with transparent criteria for journal evaluation that value linguistic diversity and community-engaged methodologies alongside citation metrics.”

Limitations

“Our exclusive reliance on Web of Science English-language publications constitutes not merely a technical constraint but an epistemic limitation that paradoxically reproduces the very inequities we critique. By excluding regional databases (LILACS for Latin America, IMEMR for Eastern Mediterranean), we inevitably undercount LMIC scholarship published in local languages a body of work often more attuned to context-specific pain management strategies (traditional birth attendant practices, community-based psychosocial support). Consequently, our conclusion that LMICs are ‘underrepresented’ reflects not absence of knowledge production but systematic exclusion from Western-indexed knowledge infrastructures. Future bibliometric studies must adopt multilingual search strategies and partner with regional indexing initiatives to avoid reinforcing colonial knowledge hierarchies under the guise of ‘global’ analysis.” Second, citations and link strength show visibility and impact, but do not in themselves measure the quality of science or its clinical benefit. Thirdly, the data set records publications until a specific cut-off date and may not reflect recent advances in emerging fields such as digital therapeutics or decentralized models of pain management.

Future research directions

The following should be priorities for future studies:

Future research priorities should address critical gaps revealed through bibliometric mapping. First, longitudinal investigations into the long-term physical and psychological sequelae of childbirth-related pain remain scarce; our analysis identified only two studies examining chronic postpartum pain beyond six months [36, 37], despite evidence that acute labor pain severity predicts depression at 24 months [26]. Second, patient-centered outcome measures capturing subjective pain experiences and functional recovery require development and validation, as current instruments predominantly assess sensory intensity while neglecting affective dimensions a limitation highlighted by Sun et al.‘s recent demonstration that pain unpleasantness exhibits stronger neurobiological associations with affective dysregulation than intensity alone [47]. Third, bibliometric coverage must expand beyond Web of Science to include gray literature, regional databases (LILACS for Latin America, IMEMR for Eastern Mediterranean), and preprint repositories; our sensitivity analysis confirmed that exclusive reliance on English-language indexed literature systematically underrepresents context-specific pain management strategies developed in LMICs. Finally, machine learning approaches could enhance real-time identification of emerging thematic clusters and prediction of research frontiers, addressing the 12–18 month lag between publication and indexing that constrains contemporary bibliometric analyses.

Conclusion

This bibliometric analysis of 1542 publications (2000–2025) reveals a profoundly centralized global research architecture in labor and postpartum pain management, dominated by high-income nations that collectively produce 78% of scholarship while accounting for <1% of global maternal mortality. Three paradigm shifts characterize the field’s evolution: (1) reconceptualization of pain from a sensory phenomenon to a multidimensional biopsychosocial experience; (2) transition from universal pharmacological protocols toward personalized, multimodal strategies incorporating pharmacogenomics and integrative approaches; and (3) expansion of safety metrics beyond physiological parameters to encompass relational ethics and structural equity. Critically, these conceptual advances remain concentrated in Anglophone institutions, with low- and middle-income countries bearing > 85% of maternal mortality burden contributing < 15% of publications and exhibiting peripheral positioning in collaboration networks. Without intentional knowledge co-production, equitable resource allocation, and inclusion of non-English scholarship, these paradigm shifts risk remaining theoretical luxuries inaccessible to populations most affected by inequitable pain management. Future bibliometric syntheses must adopt multilingual search strategies and partner with regional indexing initiatives to avoid reinforcing colonial knowledge hierarchies under the guise of ‘global’ analysis.

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Author contributions

All authors have made significant contributions to the work reported, whether in conception, design, data acquisition, analysis, interpretation, drafting, or critical revision. All authors have approved the final version for publication and agree to be accountable for all aspects of the work.Saboura Sahebi: Conceptualization, methodology, writing – original draft, writing – review & editing, project administration.Behrang Rezvani Kakhki: Data curation, formal analysis, visualization, writing – review & editing.All authors have made significant contributions to the work reported, whether in conception, design, data acquisition, analysis, interpretation, drafting, or critical revision. All authors have approved the final version for publication and agree to be accountable for all aspects of the work.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Presentation and publication

This manuscript has not been presented at any national or international conference, and no abstracts or preliminary reports derived from this study have been previously published.

Competing interest

The authors declare no competing interests.