Tuesday, May 09, 2006

Is natural childbirth an achievement?

It seems that this question follows logically from the notion of pain as empowering. Also, it is a source of much contention between advocates of natural childbirth and other women. Many women complain that natural childbirth supporters judge them and find them wanting. The implication is subtle (or not so subtle) that childbirth without medication is an achievement, and that women who do opt for pain relief have failed in a quest for that achievement.

Let me say emphatically that I am not talking about the notion of reaching a personal goal. Reaching a personal goal is always an achievement whether it is losing weight, quitting smoking or simply running around the block. I am talking about the idea of an objective achievement. In other words, I think we all agree that running a marathon is an achievement because it is very difficult and most people could never do it. On the other hand, while we recognize that running around the block might be a personal achievement for a woman who has never exercised, we would not consider it an objective achievement since it isn't really that difficult and most people can do it if they try.

So can we consider natural childbirth an achievement? We tend to be so embedded in our own culture, that we often forget that things can and often are done other ways. In our culture, many women have pain relief in labor, so it can appear that it is unusual to forgo an epidural. However, anesthesia is only about 150 years old. Over 99.9% of women who have ever existed have had natural childbirth. Right now, at this moment, virtually all the laboring women in a host of countries and on a variety of continents are having natural childbirth. There is simply no other alternative.

Natural childbirth is, essentially, the default mode. It is the rare woman who can and does choose pain relief in labor. Certainly natural childbirth can represent a personal achievement. However, could we or should we consider it an objective achievement?

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21 Old Comments:

"On the other hand, while we recognize that running around the block might be a personal achievement for a woman who has never exercised, we would not consider it an objective achievement since it isn't really that difficult and most people can do it if they try."

I think that's your answer Amy. Drug-free birth really isn't that difficult Out of Hospital, and with appropriate support. In Hospital is another story however. If a woman can have a drug-free birth in a hospital, I consider it quite an achievement. You only have to look at the minute numbers of women who do have drug free labors in hospital to say it's nigh impossible.

I'll repeat a question from another section since it seems pertinant here also. Have you personally, Dr Amy, ever been present with a woman throughout her entire active labor? How about a woman who didn't take drugs? (and I mean drugs of any kind, including pit)
If, by chance you have, did you consider it an achievement?
Cherrie

By Blogger Cherrie, at 11:00 AM  

Cherrie:

"Have you personally, Dr Amy, ever been present with a woman throughout her entire active labor? How about a woman who didn't take drugs? (and I mean drugs of any kind, including pit. If, by chance you have, did you consider it an achievement?"

Well, of course I have: ME.

I have four children, all NSVDs; two with epidurals and two without. And, no, I did not consider it an achievement.

By Blogger Amy Tuteur, MD, at 12:51 PM  

I for one would be very interested to hear about your birth experiences. No doubt this forms the basis for your current views.

By Anonymous Anonymous, at 1:13 PM  

First of all, as a dedicated marathoner, let me say that almost everyone can indeed run a marathon! You may not be able to do it right now, but with a basic training program and about four months of lead time even a fairly sedentary person can prepare themselves to run a marathon in a respectable amount of time. Women have even been known to run them pregnant. One ultra-marathoner ran a fifty-mile ultrathon when she was seven months pregnant. So...no excuses...;-)

Having a baby and raising him or her to be a responsible, caring, productive member of society is an objective achievement. Not just having a baby, but following through for the next twenty-some-odd years. Anyone of childbearing age and with working equipment can have a baby. Not everyone is a good parent.

Making not using pain meds or having an epidural an achievement in itself is dangerous. It's okay to say you need a little help. It's okay to feel that lessening the pain a bit might enable you to focus and concentrate better. Being made to feel that you've failed somehow because you chose pain management instead of being a "real woman" is so very, very wrong.

And for all that the all-natural-all-the-time crowd goes on about how pain medication was never used before childbirth was taken over by doctors and hospitals, you can bet everything you own that, had the women of centuries past had access to the pain meds women have now, they'd have been downing them by the bucketful at the time.

You know, it's all about responsible choices, and the only goal worth bothering over is having a healthy baby. Women shouldn't be made to feel bad that they asked for a little pain medication or even an epidural. It's not a contest. Personally, I think the people who make it a contest are the ones with serious issues, not the women who are willing to stay open to the fact that they might decide to take advantage of what modern medicine has to offer.

~T

By Anonymous Anonymous, at 1:15 PM  

"it's all about responsible choices"

Absolutely! Shall we bring up that elective c-sections increase perinatal mortality rates FOURFOLD? Is that a responsible choice?

By Anonymous Anonymous, at 1:20 PM  

"Well, of course I have: ME."

Excellent. We've all been there at our own births. Kinda hard to get away. I was thinking more about if you'd attended a non-medicated birth in the role of OB, or support person.

"I have four children, all NSVDs; two with epidurals and two without. And, no, I did not consider it an achievement."

I've only had one. It was a drug free labor and birth in a birth center, and I didn't really consider it too much of an achievement either. Of course I intended to labor drug free, so I didn't feel I'd done anything special. I have attended three births as support person, all unmedicated, two in a hospital. And I do consider those two hospital births to be QUITE an achievement.

Maybe in your area it's a little different. In my area hospitals have a 98% epidural rate. (in part because women who don't want one don't go) But it does make it a little difficult for the hospital staff who don't know WHAT to do with a woman going drug free.

One thing that's missing from this discussion are the adverse affects of narcotics/other drugs on the baby. I chose not to take drugs because my birth choices wern't about my experience so much, but my baby's wellbeing. I know you can relate, because you've used the arguement several times.

Cheers,
Cherrie

By Blogger Cherrie, at 1:45 PM  

Anonymous said...
Absolutely! Shall we bring up that elective c-sections increase perinatal mortality rates FOURFOLD? Is that a responsible choice?


No, it's probably not a responsible choice. Nobody has advocated it here, however, which is why it's sort of silly to bring it up.

By Anonymous Anonymous, at 2:43 PM  

Anonymous:

"Shall we bring up that elective c-sections increase perinatal mortality rates FOURFOLD?"

I'd like to see the data for that assertion. I think you may be accidentally misquoting the real statistics.

By Blogger Amy Tuteur, MD, at 2:45 PM  

Cherrie,

"One thing that's missing from this discussion are the adverse affects of narcotics/other drugs on the baby. I chose not to take drugs because my birth choices wern't about my experience so much, but my baby's wellbeing."

This is another axiom of natural childbirth advocacy. However, there are no adverse effects of epidurals on babies. Narcotics can depress neonatal breathing if given too close to delivery, but that can be easily fixed with naloxone which reverses the effects of narcotics.

Where is the data that shows pain relief in labor is harmful to babies?

By Blogger Amy Tuteur, MD, at 2:48 PM  

Amy:

I generally agree with you, but when you say "Narcotics can depress neonatal breathing if given too close to delivery, but that can be easily fixed with naloxone which reverses the effects of narcotics" I think you're in error.

This IS showing that pain relief is "harmful" to babies--at least if you count depressed neonatal breathing as harmful, which it is.

You are also saying the harm can be fixed and managed (which it can, of course; naloxone is a great antiopiate) but that is not the same thing as saying it doesn't occur.

By Blogger sailorman, at 3:10 PM  

The cost of c-sections is in the maternal mortality rate, not the perinatal mortality rate:

Perinatal mortality rate:
4 per 1000 for elective cesarean
7 per 1000 for all births

Maternal mortality rate:
2.4 per 10,000 with an elective cesarean
4 in 10,000 with cesarean
1 in 10,000 with all vaginal births

Sources:
Trends in Cesarean Birth and Vaginal Birth After Previous Cesarean, 1991-1999
National Vital Statistics Reports, Volume 49, Number 13, December 27, 2001
A Guide to Effective Care in Pregnancy and Childbirth, Chapter 38, Labor and birth after previous cesarean, M. Enkin, M.J.N.C. Keirse, J. Nielson, C. Crowther, L. Duley, E. Hodnett, and J. Hofmeyr. Oxford University Press, 2000
Annual Summary of Vital Statistics: 2000, Hoyert DL, Freedman MA, Strobino DM, Guyer B. Division of Vital Statistics, National Center for Health Statistics, Centers for Disease Control and Prevention, Hyattsville, Maryland 20782, USA

By Anonymous Anonymous, at 5:11 PM  

Wow, someone's really bitter about their C-section...

By Anonymous Anonymous, at 6:09 PM  

Sailorman:

"when you say "Narcotics can depress neonatal breathing if given too close to delivery, but that can be easily fixed with naloxone which reverses the effects of narcotics" I think you're in error.

This IS showing that pain relief is "harmful" to babies--at least if you count depressed neonatal breathing as harmful, which it is."

Point taken. However, narcotics are not supposed to be used within the hour prior to delivery. They should only be used when they can be metabolized by the mother well before delivery occurs.

Nonetheless, since some mothers will deliver earlier than anticipated, it does happen that babies are born with narcotics on board. As I said, that can be easily reversed. To my knowledge, this is not considered morbidity, nor does the effect last for longer than a few minutes.

If it did cause a long term impact, that should be reflected in the statistics about hospital birth, so any study comparing homebirth and hospital birth would necessarily take that into account.

By Blogger Amy Tuteur, MD, at 6:47 PM  

"The cost of c-sections is in the maternal mortality rate, not the perinatal mortality rate."

Right. The numbers are small, but they are real. That's why I cannot fathom the reasoning behind ACOG's decision to endorse elective C-section for social reasons (as opposed to elective repeat C-sections).

I feel very strongly that a C-section is a medical decision and must be reserved for situations in which it is medically indicated. To me, an elective C-section makes no more sense than an elective gall bladder removal. You don't get to have an operation simply because you want one.

I'm willing to predict that within the next few years, doctors will begin refusing to do elective C-sections. It is inevitable that there will be a lawsuit following the death of pregnant women as a result of elective C-section. The woman's family will sue claiming that she didn't give informed consent. She really didn't understand that she could die and it was the responsibility of the doctor to refuse her because there was no medical reason for her operation. Her family will probably win. That will be the end of elective C-sections for social reasons.

By Blogger Amy Tuteur, MD, at 6:54 PM  

Oh Dr. Amy so glad to agree on something! It's a conflicting issue for me too, the elective c/section issue. I DO support women's right to informed choice in reproductive health, and this walks that line. I likewise agree that the tidal wave of c/sections will begin to recede once docs start getting sued for problems in subsequent pregnancies.

By Anonymous maribeth, CNM, at 10:29 PM  

Amy, there's too much overlap in the multiple posts. Are we talking about effects of pain meds here or in the other place? Can you try to limit new posts until conversations have time to develop, or just make certain new posts are new topics altogether? Thanks.

By Anonymous maribeth, CNM, at 11:21 AM  

This comment has been removed by a blog administrator.

By Blogger Kaz_Oze, at 9:22 AM  

“Natural childbirth is, essentially, the default mode”

I wonder if anyone else thought of computers when they saw the word default. I must say I couldn’t disagree more with your statement if you rely on the definition of default as “an option that is selected automatically unless an alternative is specified” (wordnet.princeton.edu/perl/webwn). With most hospitals having ridiculously high rates of interventions (inductions, epidurals, episiotomies, c-sec’s to name but a few) it seems to me that the default option for childbirth these days in Western countries could not be deemed “natural”. You certainly seem to enjoy opening up worm cans with your use of subtle yet reasonably inflammatory language. You would have to be pretty naïve to not realise that comparing natural childbirth to a “default option” could be deemed fairly offensive to many people.

By Blogger Kaz_Oze, at 9:24 AM  

Well, I was not using the computer science definition. I was using default to indicate that natural childbirth automatically happens if you don't choose medication or if medication is unavailable.

Natural childbirth is often presented as something that only a very few women can do. Any woman can do it and 99.9% of all mothers who have ever existed have done it.

As I said above, I am beginning to think that the "achievement" is refusing pain meds when they are available as opposed to simply having a baby without pain relief, since anyone CAN have a baby without pain relief, though many women CHOOSE not to do so.

By Blogger Amy Tuteur, MD, at 3:34 PM  

I hope you are not trying to tell me that women make an "informed choice" when it comes to giving birth naturally. What a joke! The level of fear regarding a natural bodily function combined with the lies and deception often perpetrated by the medical profession mean there is no such thing as informed choice with regard to a natural birth vs a highly medicalized one.

By Anonymous Anonymous, at 8:43 PM  

>>"It seems that this question follows logically from the notion of pain as empowering."<<

Only if your logic is specious.

By Anonymous queen of Run On Sentences, at 8:26 PM