A bias against women in the treatment of pain
The assertion by "natural" childbirth advocates that childbirth is not inherently painful, or that the pain of childbirth is best managed by preparation dovetails quite well with sexist notions about women and pain. A large body of scientific literature shows that women's pain is much less likely to be taken seriously than men's pain.
The Girl Who Cried Pain: A Bias Against Women in the Treatment of Pain, Journal of Law, Medicine & Ethics, 29 (2001): 13–27, provides a disturbing description of the ways in which the pain of women is systematically devalued, disbelieved and undertreated.
Given that women experience pain more frequently, are more sensitive to pain, or are more likely to report pain, it seems appropriate that they be treated at least as thoroughly as men and that their reports of pain be taken seriously. The data do not indicate that this is the case. Women who seek help are less likely than men to be taken seriously when they report pain and are less likely to have their pain adequately treated...
The study by McCaffery and Ferrell of 362 nurses and their views about patients' experiences of pain found that while most of the nurses (63 percent) agreed that men and women have the same perception of pain, 27 percent thought that men felt greater pain than women. Only 10 percent thought that women experienced greater pain than men in response to comparable stimuli. This result has no justification in the literature ... The same study also found that almost half of the respondents (47 percent) thought that women were able to tolerate more pain than men as compared to 15 percent who felt that men were able to tolerate more pain than women...
These erroneous attitudes are particularly prevalent in regard to childbirth:
Bendelow found that "the perceived superiority of capacities of endurance is double-edged for women — the assumption that they may be able to 'cope' better may lead to the expectation that they can put up with more pain, that their pain does not need to be taken so seriously." Crook and Tunks point to the influence of the psychoprophylaxis movement in the United States with its implicit assumption that it is good to experience childbirth without the aid of analgesia. As a result, some women who have "gone through psychoprophylaxis classes, feel guilty if they relent at the last minute and ask for an epidural"; according to the authors, "these attitudes imply that we have a value system endorsed by some parts of our population that suggest women should be encouraged to keep a stiff upper lip."
The authors believe that people discount women's expressions of pain.
A deeper examination of why women are treated this
way is explored by several feminist authors. They attribute it to a long history within our culture of regarding women's reasoning capacity as limited and of viewing women's opinions as "unreflective, emotional, or immature." In particular, in relation to medical decision-making, women’s moral identity is "often not recognized..."
Some researchers have argued that a "bias toward psychogenic causation for disorders in women has occurred even in well defined painful biological processes: 'Despite the well documented presence of organic etiologic factors, the therapeutic literature is characterized by an unscientific recourse to psychogenesis and a correspondingly inadequate, even derisive approach to their management.'" These findings are consistent with studies reporting that female pain patients are less likely than their male counterparts to be taken seriously or are more likely to receive sedatives than opioids for the treatment of their pain.
It is not a coincidence that the philosophy of "natural" childbirth was promulgated by white, male physicians steeped in the ethos that women's pain was not worthy of serious consideration. Their claims that childbirth pain is socially constructed, that women can and should manage pain through psychological means, and that women are "empowered" by pain are simply elaborate justifications for not acknowledging and not treating the pain of women. It is also not a coincidence that the ONLY form of pain thought to be "empowering" is a type of pain that ONLY women can experience.
Those claims can and should be rejected as expressions of sexism. Women's experience of severe pain in labor is real, authentic, and biologically based. Respect for women demands that we acknowledge that pain, not minimize it, and not suggest that it should be psychologically managed. There is no reason take the word of a bunch of middle aged white men, steeped in a medical culture that minimized and ignored pain in women, for what women are "supposed" to feel in labor.
Labels: pain
Why talk about good pain rather than good pain relief?
At the final meeting of my childbirth preparation course, the instructor finally broached the subject of labor pain relief... Even then, in the eleventh hour of the class, all I heard were words like "trust," "empowerment" and "self-confidence." Was this a scout meeting? Trust, empowerment and self-confidence are not anesthetics.
Alexander asks:
This claim by the experts that women become better people, possibly even better mothers, for having successfully given birth without the benefit of medical pain relief, led me to wonder what excruciating physical challenge my husband should triumph over to become a superior father — and would I get to choose?
Even before my own difficult labor, the attempt to reframe the pain of childbirth as "good pain" struck me as a bit of a sham. I found myself wondering why my teachers were talking about good pain rather than good pain relief...
She raises the most important question of all:
Childbirth professionals with a nature-worshipping bias against medical pain relief seem to suggest that only self- indulgent, entitled control freaks — void of spirituality, feminist enlightenment and the ability to bond with their young — would want a pain-free birth. But the wish to avoid pain is not an upper-middle-class whim. It's a basic human instinct, one that has been useful in preserving our species. Since when did childbirth become about having a transformative personal experience rather than about getting a healthy baby and not dying (or wishing you were dead) in the process?
Alexander acknowledges that birth may be over medicalized, but asserts:
... [P]ain relief is not the culprit. These are care issues that have to do with how physicians practice, how legal threats loom and how big institutions can't seem to deliver comfort — even with pretty new wallpaper and lots of big pillows.
Contrary to the suggestion made by its opponents, the epidural is not an unnecessary medical intervention that deprives women of satisfaction and empowerment while giving birth. Moreover, telling pregnant women they should attempt to deal with their pain as an exercise in "plumbing the depths of their inner resources," rather than honoring their choice to give birth on their own terms, without pain, is in itself disempowering.
She sums up with a sentiment that is shared by the vast majority of mothers:
... [F]or me, giving birth was the fulfillment of a lifelong wish to have a baby, not a means of self-actualization.
Labels: pain
Natural childbirth? Why should we?
Alice Miles' opinion piece in The Times of London
Natural birth! Hello? This is the 21st century, Let’s have fewer pious midwives, not more:
A “normal” birth . . . birth without medical intervention: why? Why should we? This is an extraordinary conspiracy against women, a sort of quasi-religious belief in the virtue of pain, which Ms Hewitt is bafflingly encouraging. The more that modern medicine offers, in terms of pain relief and convenience, the more urgent the insistence of this weird sorority that a woman has to give birth "naturally".
Again, why? We are no longer expected these days to die naturally, without the operation that would remove the cancer or the pain relief to help us on our way. We are not expected to have our hips fixed naturally. We are not even expected to endure a mild headache without a paracetamol. Yet somehow the deeply painful and, for some, traumatic experience of giving birth is forced upon woman after woman in the name of some Earth Mother concept.
She concludes:
It is shocking that a feminist Secretary of State for Health in the 21st century should be colluding with the pious missionaries campaigning to keep women’s birth experiences in the 19th. We are modern now. And we are not in the Third World. We do not need to get behind a bush and squat. Let those who want to go natural, choose natural. But let those who don’t, choose drugs. Choose a Caesarean. Choose life — any way they want it.
In light of recent discussions on this blog, the point that I find most interesting is Miles' reference to a "quasi-religious belief in the virtue of pain". Why, exactly, do "natural" childbirth advocates feel that there is a virtue to pain?
Labels: "natural" childbirth, feeling superior, pain
Race, culture and childbirth
Until I started reading in depth about "natural" childbirth, I never realized the prominent role that race has played in the development of contemporary thought about childbirth. Patricia Jasen, in
Race, Culture, and the Colonization of Childbirth in Northern Canada, gives a fascinating overview of the origin of racially based theories of pain in childbirth. Jasen situates claims of painless childbirth firmly within European imperialism:
Theories of racial difference are one of the oldest and most enduring features of European imperialism. They were inspired and perpetuated, in good part, by the desire to assess the level of European civilization and racial progress in comparison with more 'primitive', or less enlightened, peoples, and the history of ideas regarding aboriginal women and childbirth needs to be examined with this context in mind... [T]he notion that women in 'savage lands' were fundamentally different from European women gained a wide following through the myth of painless childbirth... [I]ts increasing acceptance during the nineteenth century, ... makes sense only in light of the fact that this image of the aboriginal woman satisfied a growing preoccupation, in European and Euro-American cultures, with both the anatomy of race and the politics of sexual difference.
Jansen posits that the myth of painless childbirth did important cultural work within European and American culture:
... [T]he myth of painless childbirth acquired an unprecedented following on both sides of the Atlantic around the middle of the nineteenth century and achieved a new level of abstraction from reality. The growing preoccupation with racial hierarchy and degeneracy did not preclude a belief that primitivism and health were somehow linked, and many Europeans and Euro-Americans sought to internalize the qualities of 'wildness'... which would counter the ill effects of civilized life. Outdoor sport would help preserve the qualities of 'natural man', but even more urgent was the quest for the 'natural woman'. There was a common fear that through some accident (or logic) of evolution, women of superior breeding experienced the most pain and debility in childbearing — that civilization, or over-civilization, made them less fit for reproduction. The survival of the race seemed to depend on alleviating this suffering and countering the growing reluctance, on the part of middle- and upper-class women, to undertake the maternal role.
Jasen describes the intellectual climate in which Grantly Dick-Read formulated his theories:
[T]he myth of painless childbirth was useful on a variety of rhetorical fronts. If regular physicians were anxious to establish that, under their care, the terrors of childbirth could be overcome, there were many alternative practitioners, health reformers, and feminists who argued that the process was by nature painless. They argued that if women learned the laws governing their own bodies, adopted sensible dress, and returned in their habits and diet to a more 'aboriginal condition' or 'state of nature', the dangers of childbirth would be removed. Such writers often resorted to the image of the 'Indian woman' who, 'when she feels the signs of coming labour, repairs to the nearest brook, gives birth to her child, it may be amid the snows of winter, washes it and herself in cold water, and is ready to resume her journey',.. They stressed that cultural, not innate anatomical differences, were responsible for women's plight...
So the fundamental premise of "natural" childbirth, that childbirth in nature is painless, is not only a fabrication, but it a fabrication designed to reinforce the idea of differences between inferior indigenous races and the superior white race. Perhaps this accounts for the fact that "natural" childbirth is a preoccupation of white women in first world countries. Women of other races and cultures never believed in the myth of painless childbirth and never accepted the idea of superior and inferior races separated by their reactions to pain.
Labels: "natural" childbirth, pain
"Alternative" methods of pain relief in labor
In case anyone was still wondering if "alternative" methods of pain relief in labor work, they don't. This is not suprising since most "alternative" methods are ineffective for virtually everything they claim to do, treat, cure or prevent. The comprehensive reivew
Complementary and Alternative Approaches to Pain Relief During Labor by Tournaire and Yonneau in the current issue of Evidence Based Complementary and Alternative Therapy provides even more scientifc evidence that the claims of "alternative" providers are unsubstantiated:
"This review evaluated the effect of complementary and alternative medicine on pain during labor with conventional scientific methods using electronic data bases through 2006 were used. Only randomized controlled trials with outcome measures for labor pain were kept for the conclusions. Many studies did not meet the scientific inclusion criteria. According to the randomized control trials, we conclude that for the decrease of labor pain and/or reduction of the need for conventional analgesic methods: (i) There is an efficacy found for acupressure and sterile water blocks. (ii) Most results favored some efficacy for acupuncture and hydrotherapy. (iii) Studies for other complementary or alternative therapies for labor pain control have not shown their effectiveness."
Methods that were evaluated and found to have no scientific evidence of effectiveness included:
biofeedback
herbalism
homeopathy
hypnosis
"natural" childbirth
Interestingly, even for methods that demonstrated some effectiveness, more than 50% or treated patients found the method to be inadequate.
Labels: "alternative" medicine, pain
Labor pain as punishment
I am struck by the fact that throughout history labor pain has been explained as punishment for women who do not behave properly. Regrettably, the philosophy driven ("natural") childbirth movement continues to view the pain of labor not as physiologic, which it certainly it, but as symptomatic of something wrong with women.
The pain of labor was so impressive to our Bronze Age forebears that they felt it necessary to attempt an explanation in their founding religious document, the Bible. Indeed, they were so impressed by the universal nature of agonizing childbirth that the only explanation they could think of was that it was a punishment meted out to Eve and all her descendants for disobeying the will of God. The idea of labor pain as punishment was so powerful that it was harnessed by Grantly Dick-Read for his own ends, and is currently endorsed by the PD childbirth movement, though as punishment for entirely different sins.
| system | who has pain | who has no pain |
| Bible | Eve after sinning | Eve before she sinned |
| Grantly Dick Read | "overcivilized" white women who want more education and independence | "primitive" women who understand that their role is to reproduce |
| PD ("natural") childbirth advocacy | "authentic" women who are "educated" | women who are not "educated" and who have not been brainwashed by the "medical" model |
These systems share two defining characteristics: lack of knowledge or understanding of the physiologic basis for pain in human labor, and the conviction that women who experience pain in labor have brought it on themselves. In the case of the Bible and the system developed by Grantly Dick-Read, the assumption that women had brought labor pain upon themselves was considered justification for believing that women were inherently sinful and that women could not and should not stray from the domestic sphere into the wider world.
PD ("natural") childbirth advocates also deny the physiologic basis for labor pain, positing that it is in a woman's head instead of her pelvis. However, "authentic" women who "educate" themselves do not have to experience labor pain. Hence, labor pain (as always) marks the women who experience it as deficient in some way. Moreover, within the system of PD childbirth advocates, it is critically important to be seen as a woman who did not experience labor pain or found some way to master and control it.
I have long maintained that PD ("natural") childbirth advocacy is just a way for some women to declare superiority over other women. What I had not realized until recently is that PD ("natural") childbirth advocacy is part of a tradition, lasting thousand of years, which places the blame for labor pain directly on the women who experience it.
Labels: pain, philosophy
The painful childbirth movement
There is a big difference between childbirth without interventions and "natural childbirth". Childbirth without interventions is a choice in modern societies, and the only option in most places around the world. On any given day, the majority of women in the world are giving birth without interventions, and many of them would eagerly change places with their first world sisters.
The natural childbirth movement pays lip service to the notion of childbirth without interventions, but the resemblence stops there. There is no good reason for the disingenousness, and occasional dishonesty, that characterizes the natural childbirth movement.
It starts with the very name. Calling it "natural" childbirth is purely a marketing ploy. It is a blatant attempt to co-opt the generally favorable public opinion of all things natural. However, natural childbirth bears little if any relationship to childbirth in nature, and as such, does not deserve to call itself natural.
Natural childbirth as practiced in first world countries virtually always involves prenatal care, blood pressure monitoring , urine dipsticks for protein and sugar, listening to the fetal heartrate, routine weights, measurement of hematocrit, blood type, Rh status, checking for evidence of previous exposure to viral diseases and sexually transmitted diseases, a prescribed diet, prenatal vitamins, etc. etc. etc. None of these things occur in nature; they are not natural. So pregnancy, as managed in the natural childbirth movement (and make no mistake, it is managed) bears absolutely no relationship to pregnancy in nature.
Let's take a look at labor and delivery then. That's not natural either. It always involves the use of technology such as blood pressure measurement and fetal heartrate monitoring. Most midwives carry medication and resucitation equipment, decidely non-natural. In fact, there really isn't much about childbirth that is natural, either. There are only two things that hark back to nature in the natural childbirth movement, the decision to forgo pain medication and the refusal to have an episiotomy. In the case, of the perineum, the expectation is always that any significant tears will be repaired with sutures, so that's not natural either.
Essentially, the movement that touts itself (falsely) as the "natural" childbirth movement is really the childbirth with pain and without episiotomy movement. Calling yourself the "painful childbirth movement" doesn't really sound that great. Natural childbirth sounds so much better. Truth in advertising doesn't count, it's all about marketing.
The problem doesn't end there, though. Not only is the designation "natural" childbirth movement disingenuous, proponents of the movement claim benefits that do not even exist. There is no scientific evidence that painful childbirth is better, healthier or superior in any way.
If you want to have childbirth without pain medication, go right ahead. Many women do it and I have done it myself. Just don't call it "natural" childbirth, because it has nothing to do with childbirth in nature.
Labels: "natural" childbirth, pain
More on voluntary pain
I am struck by the fact that there are few if any comments about the actual topic of the previous thread.
Rev. Cusick is writing specifically for health care providers to alert them to the fact that pain means different things to different individuals. Does the lack of comment indicate a general acceptance of that claim? If so, it has important implications for the natural childbirth movement.
First of all, it suggests that the willingness to endure pain, even extreme pain, stems from the fact that the individual has assigned a personal meaning to the pain. This is what I have argued in regard to natural childbirth.
Grantly Dick-Reid was simply making it up as he went along. There is no evidence that the pain of childbirth is a social construct created by modern obstetrics. There is no evidence that childbirth in nature was painless or even less painful. There is certainly no evidence that "primitive" women feel litle or no pain in labor.
Natural childbirth advocates feel exactly the same pain as every other woman. They simply choose to endure it because of the personal meaning that the pain has for them. It is that meaning which is socially constructed. The idea of pain as a trancendent experience or a competition is social construct created by the natural childbirth movement.
According to the adherents of the movement, the "ideal" woman experiences the pain of labor in this way, (or at least claims to experience the pain in this way). Women who patently didn't experience the pain in this way and cannnot even pretend that they did because they asked for and received an epidural are forced to claim that it was someone else's fault. Therefore, they typically claim that they didn't receive enough support or some similar claim that pushes the blame from themselves to others. This also explains the often made up claim that labor "wasn't really painful". Within the natural childbirth movement, it is very important to be seen as making light of the actual pain.
The second implication is even more important. Because the meaning of pain is personalized by individuals, one person cannot expect another to share her understanding of pain. The willingness of women world wide to ask for pain relief in labor is a reflection of the actual pain and the fact that most women have no socially constructed need to deny that pain. Asking for pain relief in the face of severe pain is what most people do.
I cannot and will not condone women being pushed to have pain medication that they did not intend to have because of their adherence to the principles of the natural childbirth movement. On the other hand, it is easy to see why many health care providers are dismissive of the rationales and birth plans of natural childbirth advocates. Most women having their first baby have absolutely no clue about the real pain of childbirth. They have often been misled by natural childbirth publications that claim that labor pain is made up or the result of "fear". Because other women have not been honest with them, they are utterly unprepared for what is going to happen. It is no surprise that they ask for pain medication, since they are in agony, and then attempt to save face by insisting that the problem was lack of support.
In addition, healthcare providers are hardly likely to be swayed by claims that natural childbirth is better, "healthier" or superior in any way, since they know those claims are made up. For healthcare providers, such claims mark natural childbirth advocates as gullible, not knowledgeable.
It seems to me that natural childbirth advocates would be much more likely to get respect and support if they were more honest about their motivation and (in the case of first time mothers) if they were actually knowledgeable about the real pain of childbirth. Presenting yourself as someone who is well aware that childbirth is agonizing, but determined to avoid pain medication as a personal challenge is much more likely to get respect than the deliberately insulting, false claims about natural childbirth being "healthier" or the equally insulting claims that modern obstetricians exist to ruin your birth "experience".
Labels: pain
Voluntary pain
Rev. Jason Cusick writes about how the social meaning of pain has changed over the past 150 years or so and how different people apply different values to the experience of pain. The article is entitled
Spirituality and Voluntary Pain and appears on the website of the American Pain Society.
Rev. Cusick reviews the debate that occured over the introduction of pain relief in labor:
As recently as the 19th century, James Young Simpson, the founder of obstetric anesthesia, unknowingly fell into religious territory as people of faith debated whether pain relief was a sign of God's grace or modern man's attempt to avoid the natural consequences of original sin ... Those interested in character development argued pain was a door to spiritual and moral growth...
In the end, mainstream religious thought overwhelmingly promoted pain relief with strong theological and religious support. Anesthesia and other approaches to pain management have flourished, especially in Western medicine, but the seeds of doubt, questioning of scientific promises, and deep religious convictions still remain strong, especially among more conservative people of faith. In fact, some have even questioned whether the advent of pain management has given a new, even extreme spiritual meaning to pain - that it is "evil and must be eliminated".
Despite the general consensus among the American public that pain is bad and should be eased whenever possible, there are those who find spiritual meaning in pain. Rev. Cusick discusses five spiritual meanings of pain: pain as punishment, pain as an opportunity for transcendence, pain as test or competition, pain as atonement, and pain as gaining or retaining control. He suggests that the decision to forgo pain medication in labor owes much to the social meanings of pain as transcendence and pain as a test or competition.
Pain as transcendence:
The best example of the use of pain in modern health care is in our labor and delivery rooms. A new mother writes, "I am no masochist; I have been known to cry over cuts, menstrual cramps, and even spilt milk. Childbirth is pain like none of those, nor is it like any other pain I have had...I had no need or desire to end or diminish the sensations of birth. It was exhilaration to be part of a primal experience. I was caught up in the desire to know each moment; to discover the unique progression of events leading to the entrance of a new being - or is it 'exit'? Not only me, but no one else can have that time again. It was an opportunity".
On pain as a test or competition:
Marie, a 28-year-old Vietnamese-American woman, chose natural childbirth to give birth to her son. While intending to give birth "as God intended" (meaning without medical intervention) and later viewing the experience as an opportunity for transcendence, her primary motivation for voluntarily enduring the pain of labor was more to test her own limits and prove to herself and to others that she was not a weak-willed person. "I want to see what I can handle," she said, speaking of the modern world's overemphasis on personal comfort and convenience. For those who choose it, voluntarily enduring pain becomes an opportunity to discover one's own limits and potential and connect with one's self on the most intimate level.
I found the article to be enlightening on several levels. First, it views pain through an entirely different prism: the role of pain in spirituality. Interestingly, there is no suggestion that the people who voluntarily choose to accept pain don't feel much pain. Indeed, it is made clear that the pain of women who choose unmedicated childbirth is exactly the same as those who choose medication. What is different is the
response to that pain, because the response is mediated by the meaning that the woman assigns to her pain.
The meanings of the pain are socially contructed based on the individual's background, philosophy and religious training. Some women experience the pain of labor as an opportunity, and some women (as I have argued all along) view the pain of labor as a test of themselves or a competition with other women. For those who view the pain of labor in this way, the reason why they are so obsessed with other women's choices is obvious. It provides a ready made opportunity to feel superior to women who chose pain medication in labor.
What is important for natural childbirth and homebirth advocates to understand is that their views of pain are simply personal views. Most people do not share these views and there is no reason why they should since the meaning of pain for an individual is shaped by that individual's personal choices.
It seems to me, that some women are not able to accept that the decision to use pain medication in labor is simply a personal preference. Perhaps the fact that most women do not view the voluntary acceptance of pain as an achievement plays a role in this. If a natural childbirth advocate believes that she has achieved something in forgoing pain medication, she may expect validation of that "achievement". Obviously, there is going to be no validation in accepting that different people view pain differently. Hence the extraordinary effort to convince themselves and others that the willingness to forgo pain medication is "healthier" or "better for the baby". It's not, it's simply a personal preference, based on an individual's interpretation of the meaning of pain as shaped by her personal experiences, philosophy and religious training.
Labels: pain
Epidurals: the quality of the evidence
Drs. Murphy and Fullerton have created a new instrument to analyze childbirth. It is called an
Optimality Index. Rather than looking at adverse outcomes, Murphy and Fullerton believe that childbirth can best be analyzed by comparing individual outcomes with optimal outcomes. The prefer this approach because it deliberately incorporates specific beliefs about what constitutes optimal care. For example, traditional medical studies would consider the birth of a healthy baby to a healthy mother the optimal outcome; the Optimality Index would subtract points from a perfect score because, in their view, having an epidural is a non-optimal outcome.
Murphy and Fullerton claim that their choices of optimal vs. non-optimal practices are grounded in scientific research, and are not arbitrary designations. Therefore, they provide multiple studies to substantiate their claims about optimality. It is quite instructive to review the claims and documentation about epidurals.
Not surprisingly, Murphy and Fullerton have concluded that merely having an epidural is a "non-optimal" factor in any labor. They seek to buttress this assertion with no less than 8 separate studies about epidurals. All of the articles are relatively recent, and I assume that Murphy and Fullerton believe that these are the best, most current studies that document non-optimal effects of epidurals. Below I have listed each article and the abstract or conclusion, so you can look at them individually. Let's look at the studies that supposedly show that merely having an epidural, in and of itself is a "non-optimal" factor.
In summary:
None of the studies show an increase in neonatal mortality.
None of the studies show an increase in neonatal morbidity.
None of the studies show an increase in maternal mortality.
None of the studies show an increase in C-section rate.
All the studies showed epidurals to be extremely effective for pain relief.
The one study that specifically addressed neonatal outcomes concluded that "although epidural analgesia may cause maternal hypotension and fever, longer second stage of labour and more instrumental vaginal deliveries, these potentially adverse factors appear to be outweighed by benefits to neonatal acid-base status."
The study cited to show an adverse impact of epidurals on breastfeeding, showed an association, but concluded that prospective studies would be needed to show if there is a causal relationship.
The study cited to show the long term effects of epidurals found no difference in long term side effects between women who received epidurals and those who did not.
Two studies showed that epidurals might increase the length of the first stage of labor.
Three studies showed that epidurals increase the length of the second stage of labor and increase the number of forceps deliveries.
That's it. That's all there is. Murphy and Fullerton claim that merely having an epidural is "non-optimal" despite the fact that there is no increase in neonatal mortality or morbidity, no increase in maternal mortality, no increase in the C-section rate, no evidence of relationship bewteen epidurals and breastfeeding, and no long term side effects for the mother.
The only thing that these studies show is that epidurals can increase the length of labor and can increase the rate of forceps deliveries.
So epidurals provide safe and effective pain relief in labor. They have no short term or long term impact on the baby. They also have no short term or long term impact on MOST women (only a minority experienced longer labors or forceps deliveries). Why, then, do they conclude that merely having an epidural is a "non-optimal" outcome?
I believe that this conclusion reflects their prejudice that any intervention in labor, even one requested by the mother and found very effective by the mother, is wrong. They are certainly entitled to their opinion, but it is very important to realize that it is only their OPINION. At least when it comes to epidurals,
the index does not tell us whether someone had a birth that SHE judged to be optimal. Evidently, HER opinion does not count. It only tells us whether she had a birth that Murphy and Fullerton approve of. If the epidural information is any guide, this is an index that evaluates whether a woman has conformed to the socially constructed notion of what an "optimal" birth should be; in other words, yet another way for natural childbirth advocates to judge other women.
******
Labor course and delivery in epidural analgesia: a case-control
study. Decca L, Daldoss C, Fratelli N, Lojacono A, Slompo M, Stegher C, Valcamonico A, Frusca T. J Matern Fetal Neonatal Med. 2004;16(2):115-8.
Our results confirm that epidural analgesia does not affect the rate of Cesarean delivery, while increasing the use of oxytocin augmentation, the duration of the second stage of labor and the rate of instrumental vaginal delivery.Epidural versus non-epidural analgesia for pain relief in labour. Howell CJ. In: The Cochrane Database of Systematic Reviews, 2003.
Eleven studies involving 3157 women were included.
Epidural analgesia was associated with greater pain relief than non-epidural methods, but also with longer first and second stages of labour, an increased incidence of fetal malposition, and increased use of oxytocin and instrumental vaginal deliveries. With new trial data included, no statistically significant effect on caesarean section rates could be identified. REVIEWER'S CONCLUSIONS: Epidural analgesia appears to be very effective in reducing pain during labour, although there appear to be some potentially adverse effects. Further research is needed to investigate adverse effects and to evaluate the different techniques used in epidural analgesia.
Randomised study of long term outcome after epidural versus non-epidural analgesia
during labor. Howell CJ, Dean T, Lucking L, Dziedzic K, Jones, PW, Johanson RB. BMJ. 2002; 325(7360):357.
After childbirth there are no differences in the incidence of long term low back pain, disability, or movement restriction between women who receive epidural pain relief and women who receive other forms of pain relief.Analgesic efficacy of intramuscular opioids versus epidural analgesia in labor. Jain S, Arya VK, Gopalan S, Jain V. Int J Gynaecol Obstet. 2003;83(1):19-27.
Ninety percent of women rated analgesia as good to excellent in the epidural group as compared with 72% of women in the meperidine group and 65% in tramadol group.
However, epidural caused a significant prolongation of first (P<0.05) and second (P<0.01) stage of labor with an increased number of operative deliveries (27% in the epidural, 7.6% in the meperidine, and 11.4% in the tramadol groups, P<0.05). In the epidural group 40% women had urinary retention and 16% had motor weakness, whereas sedation was the only side effect seen in the meperidine (41%) and tramadol groups (9%). Respiratory depression was noted among three neonates in the meperidine group, two in the tramadol group and none in the epidural group. CONCLUSIONS: The analgesic efficacy and maternal satisfaction is better with epidural analgesia than with opioids. Analgesia provided by meperidine and tramadol is comparable and approximately 50% of women rated the analgesia as good. Meperidine is better in the second stage than tramadol. Hence in developing nations where availability of facilities is the main limiting factor, intramuscular opioids can be considered suitable alternatives.
Epidural analgesia for pain relief in labour and childbirth – a review with a systematic approach. Nystedt A.; Edvardsson D.; Willman A. Journal of Clinical 2004; 13:4, pp. 455-466.A structured question was formulated and used for deriving search terms, establishing the inclusion of certain criteria and retrieving articles, i.e. what are the effects of epidural analgesia for pain relief in labour and childbirth?..
Twenty-four articles were retrieved and systematically assessed. Seven studies were judged as high quality, 15 as moderate quality and two as low quality.
The majority of studies appraised in this review failed to obtain or establish a cause and effect relationship. According to the data, it seems clear that the use of epidural analgesia is considered to be an effective method of pain relief during labour and childbirth from the perspective of women giving birth.
Factors associated with a prolonged second state of labour--a case-controlled study of 364 nulliparous labours. Journal of Obstetrics & Gynaecology, 2003; 23:3. M O'Connell, J Hussain, F Maclennan, S Lindow.
The aim of the study is to identify factors associated with a second stage of labour greater than 2 hours in nulliparous women delivering at term. It a retrospective case-control study of 182 women with a second stage less than 2 hours' duration, matched with 182 women with a second stage greater than 2 hours. Women with a short second stage of labour were significantly younger (mean age 23.2 vs. 24.9 years) and had significantly smaller babies (mean weight 3315 g vs. 3463 g) than women with a long second stage.
Long duration of the second stage of labour was significantly associated with oxytocin and epidural use. The intervention rate did not rise above 50% until the second stage exceeded 5 hours duration. The fetal outcome was good in both groups of patients.
Analgesia in labour and fetal acid–base balance: a meta-analysis comparing epidural with systemic opioid analgesia. BJOG, 2002; 109:1344. F Reynolds, S Sharma, P Seed.
Umbilical artery pH is influenced by maternal hyperventilation. Base excess is therefore a better index of metabolic acidosis after labour. Epidural analgesia is associated with improved neonatal acid–base status, suggesting that placental exchange is well preserved in association with maternal sympathetic blockade and good analgesia. Although epidural analgesia may cause maternal hypotension and fever, longer second stage of labour and more instrumental vaginal deliveries,
these potentially adverse factors appear to be outweighed by benefits to neonatal acid–base status.
Breast-feeding problems after epidural analgesia for labour: a retrospective cohort study of pain, obstetrical procedures and breast-feeding practices. Volmanen P, Valanne J, Alahuhta S. Int J Obstet Anesth. 2004 Jan;13(1):25-9.
Various clinical practices have been found to be associated with breast-feeding problems. However, little is known about the effect of pain, obstetrical procedures and analgesia on breast-feeding behaviour... As many as 44% of the 99 mothers reported partial breast feeding or formula feeding during the first 12 weeks. Older age of the mother, use of epidural analgesia and the problem of "not having enough milk" were associated with the failure to breast-feed fully. Caesarean section, other methods of labour analgesia and other breast-feeding problems were not associated with partial breast feeding or formula feeding. In the sub-sample, 67% of the mothers who had laboured with epidural analgesia and 29% of the mothers who laboured without epidural analgesia reported partial breast feeding or formula feeding (P = 0.003). The problem of "not having enough milk" was more often reported by those who had had epidural analgesia.
Further studies conducted prospectively are needed to establish whether a causal relationship exists between epidural analgesia and breast-feeding problems.Labels: pain
What is "natural" pain relief?
We started talking about this in the previous thread, but I'd like to explore it in more detail.
DEMs claim, and many of their patients agree, that they know natural methods to reduce the pain of labor. I have several questions, though.
In general, the success of pain relief is measured by its ability to reduce pain. While some relief is undoubtedly better than none, we would not judge a pain reliever as particularly effective if it only reduced the pain from excruciating to bearable but agonizing. So my first question is: how effective is natural pain relief?
Second, we all know about the placebo effect. That is the name for the phenomenon that occurs when someone is told they are getting a medication or using a technique that will make them feel better. Up to 30% of the people who are taking the control medication (usually a sugar pill) will claim to feel better. Therefore, simply relying on patient reports is not enough when evaluating a technique. Is there any evidence besides patient reports to show that these techniques work? Specifically, are their any trials that compare natural pain relief to pharmacologic methods?
Third, if something really works, it will work whether the patient expects it to or not. If natural pain relief really works, it will work for people who are not committed to it as well as for people who are. What evidence to we have that natural pain relief techniques provide sufficient pain relief for women who have no commitment to natural childbirth?
Finally, if it turns out (as I suspect it will) that natural pain relief reduces pain slightly, works best in women who are committed to natural childbirth, and provides very little or no relief to women who are not committed to natural childbirth, is it really a method of pain relief, or simply a method to bolster pre-existing willpower to avoid pain medication of any kind?
Labels: "natural" childbirth, pain
"How can a man possibly understand the joy of unmedicated childbirth?"
Sometimes, all you can do is laugh.
I saw this statement on homebirth advocacy website, chastising the author of an
article questioning why women might refuse pain relief in labor, and I have seen it quoted approvingly on other websites within the past day. Doesn't anyone see the irony?
Natural childbirth advocacy is a creation of MEN! Only a man could come up with the idea that labor pain is good thing. Consider:
Grantly Dick-Read
Michel Odent
Fernand Lamaze
Frederick LeBoyer
Robert Bradley
It is not the least bit surprising to me that men could create a theory that pain is good for women. What is more than a bit ironic is that women (natural childbirth advocates) would accept indocrination in what they are "supposed" to feel from people who never have and never could experience labor.
Labels: feeling superior, pain
The function of pain in childbirth
What if pain in childbirth is an unnecessary remnant from human evolution?
Natural childbirth advocates often claim that the pain of childbirth brings a variety of benefits. Indeed, there are some who claim that the pain triggers a hormone cascade that is necessary for maternal infant bonding. Others insist that childbirth is not painful and is actually "ecstatic" and provides sexual pleasure. These varying theories hinge on the notion that the pain of childbirth adds something of value to the experience birth, and that the pain is good and beneficial. However, evidence derived from the study of ancient childbirth suggests that natural childbirth advocates have it precisely backwards. The pain of childbirth is not needed to trigger good things, it is vital to prevent maternal and neonatal death, and is a vestigial response that is no longer needed.
Before we consider ancient childbirth, it makes sense to think about the role of pain in the human body. Pain is almost always a sign that something is wrong, perhaps seriously wrong. Indeed, pain is so important to human survival that it can stimulate reflexive reactions. Put your hand on a hot object and you will actually begin pulling it away before you consciously feel the pain. That's because there are nerve circuits in the spinal cord that allow you to unconsciously perceive the pain and pull away, skipping the step of consciously noticing the pain so as to save time and limit damage.
When you think about it, there is no instance in which pain is not designed to protect against damage. At the level of the skin, pain tells us what is safe to touch and what is dangerous. At the level of bone, the pain of a broken bone is so great that it forces immobility, and that probably helps the bone to heal properly. The pain of disease makes people search for ways to diminish the pain, and perhaps improve survival from the specific problem. So, at the most basic level, there is no reason to believe that the pain of labor is beneficial in and of itself. Unless labor pain is different from all other types of pain of human existence, labor pain exists to warn.
Human childbirth has existed in its present form for millions of years. During that time, the death rate of both mothers and infants was extraordinarily high. Evolution would certainly have favored strategies that lowered the risk of death. Perhaps labor pain, like all other forms of human pain, existed to warn women to seek assistance.
Seeking assistance in childbirth may have lowered infant mortality by having help in situations like breech birth (which usually cannot be accomplished without some manipulation of the baby's body) and may have lowered the death rate from postpartum hemorrhage, because the assistant could massage a woman's uterus after birth. Assistance in childbirth must be very important from an evolutionary perspective because anthrologists report that all human societies have birth attendants.
According to Karen Rosenberg (a paleoanthropologist who studies human birth) and Wenda Trevathan (a biological anthropologist and trained midwife) writing in Scientific American special edition, New Look At Human Evolution, 2003:
... [W]e suggest that natural selection long ago favored the behavior of seeking assistance during birth because such help compensated for these difficulties. Mothers probably did not seek assistance solely because they predicted the risk that childbirth poses, however. Pain, fear and anxiety more likely drove their desire for companionship and security.
Psychiatrists have argued that natural selection might have favored such emotions—also common during illness and injury—because they led individuals who experienced them to seek the protection of companions, which would have given them a better chance of surviving [see “Evolution and the Origins of Disease,” by Randolph M. Nesse and George C. Williams; Scientific American, November 1998]. The offspring of the survivors would then also have an enhanced tendency to experience such emotions during times of pain or disease. Taking into consideration the evolutionary advantage that fear and anxiety impart, it is no surprise that women commonly experience these emotions during labor and delivery.
It would be quite ironic for natural childbirth advocacy if the role of pain in labor was to alert women to the inherently dangerous nature of childbirth, so they would seek assistance. It would also mean that labor pain has outlived its usefulness. Far from being beneficial, labor pain may turn out to have only harmful effects.
Labels: pain
RCM proposal met with widespread anger
Not suprisingly, the Royal College of Midwives' repugnant proposal to make individuals pay for epidurals in labor was greeted with widespread anger throughout the UK.
Mary Newburn, the head of policy research for the
National Childbirth Trust (NCT), said charging was out of the question:
The NCT does not support the proposal to charge women for an epidural. This would be adding insult to injury, when women are often denied access to other options that would help them cope during labour. It is also an impossible judgment call to decide when some women need an epidural for pain relief and others don't. We need to build up women's confidence so that they can cope with the pain of a normal labour, rather than take away one of the choices that they have come to expect.
Those who manage maternity services should be thinking about how they can promote the kinds of maternity care and birth choices that increase straightforward births and women’s sense of well-being and empowerment.
India Jones of the
Times wrote:
Is the RCM suggesting that women who scream for epidurals are just sissies and should up their pain threshold, pronto? Or is it saying — outrageously — that opting to have pain relief is somehow an “unnatural” decision, and one which it’s not up to the mother to make? And what about women who can’t afford to pay and have low pain thresholds — do they just lie there screaming in agony because they are skint?
As a veteran of three C-sections (and three epidurals), I’m bored to tears by the fanatical zeal of institutions like the RCM (and the blimmin’ National Childbirth Trust), with their fixation on natural childbirth. They love nothing better than making you feel like a failure because you didn’t tear from front to back, or leave claw marks on the bed.
The thing about childbirth is this: it doesn’t matter a jot how you get the baby out, as long as it’s out and healthy. Have whatever birth works for you. And shut up about it.
Lowri Turner writing on the
Wales National website:
We mere mothers, the ones who will be affected if this plan comes in, are not to be invited to comment. This tells you a lot about the relationship between mums and some midwives. Yes there are great ones, but there are others who are only a shade off Cruella de Vil.
The worst midwives don't have kids of their own but feel they can tell us exactly how to behave while we are having ours. When you arrive at the labour ward they give you a bored look that says, 'Oh, here comes another one and, oh, God, and she's got a birth plan'. Some even have a sadistic streak. If you express a preference for pain relief, they give you a withering look as if to say, 'What a baby'...
At a stroke, the Royal College of Midwives managed to convince many people that their worst fears about midwives are true. Midwives don't want to empower women, they want sneer at them, belittle them and hurt them, all to preserve the midwives' idea of an appropriate "birth experience".
See original comments here.
Labels: midwifery, pain
Appalling
In an effort to discourage epidurals,
The Royal College of Midwives now proposes that women should pay for them out of pocket!
The RCM education and research committee's motion states that epidurals should be "free to women who have a definite need of it" but says a fee should be "levied for all other women who desire an epidural".
In other words, you can have a free epidural if you need a C-section, but if you want it for pain relief, you have to pay for it. The end result of this, of course, is that rich women would get pain relief and poor women would not.
According to RCM Deputy Secretary Louise Silverton:
Women should be experiencing birth, and although birth is a painful experience, administering an epidural is not always the best thing for the mother.
Really? Isn't the mother supposed to make the choice about what is best for her? Are midwives supposed to support the mother's choice, or do they only support choices they agree with? Who, on earth are they to say what another woman should or should not "experience"?
Sue MacDonald, chairwoman of the RCM's education and research committee said:
Epidurals have become a kind of norm for a lot of women. Sometimes women think 'I just want to get rid of the pain, how fantastic'.
Is that supposed to be a bad thing? How, exactly, is that different than religious fundamentalists who claim that epidurals are wrong because the Bible tells us that women are "supposed" to bring forth their children in pain?
Midwives in Great Britain have a lot more power than they have in the US. Instead of using that power to support all women in their choices for birth, whatever those choices might be, they are using their status to pressure women into adopting
their choices. How is this different from what they accuse doctors of doing? And making the poor pay for their epidurals, that it nothing short of appalling.
See original comments here.
Labels: midwifery, pain
Drugs at homebirth
I just learned something that surprised me. I thought that there were never any medications for pain relief at a homebirth. I was perusing Angela Horn's
Home Birth Reference Site and read the section on pain relief at home:
Entonox [nitrous oxide and oxygen] appears to be a harmless drug which is quickly cleared from the mother's body. It is inhaled by the mother from a mouthpiece or mask. Midwives will routinely bring it to home births in many areas of the UK. The only problems associated with it seem to be if the mother gets too 'high' and cannot push effectively in the second stage, or if she finds herself depending on the drug and then the canister runs out.
It is fairly common for supplies of Entonox to run out at home births and you may have to wait some time for a new canister to arrive from the hospital. It is also fairly common for canisters and mouthpieces to be faulty, so if you feel very strongly that you want to have Entonox available, perhaps your birth partner could ask the midwife to test her stash when she first arrives. The National Birthday Trust study found that Entonox was used at 50% of home births surveyed, and 73% of the hospital births.
I wonder why there is opposition to epidurals. The medications in epidurals do not enter the bloodstream at all or in very small amounts, but nitrous definitely crosses the placenta and affects the baby. It also calls into question the assertion that childbirth at home is less painful than in the hospital, or that natural childbirth techniques make the pain manageable.
Labels: pain
Are natural childbirth advocates honest about pain?
There is a fair amount of antipathy from other women toward advocates of natural childbirth. I think some of this comes from the fact that many women feel betrayed by their natural childbirth educator who downplayed the nature of labor pain. I certainly have had quite a few patients who said "no one ever told me what it would really be like". I wonder why natural childbirth educators are often not honest with the women they teach.
I came across this humorous take on the subject. From
"Natural" Childbirth--the Big Lie:
To my untutored mind, the words "natural childbirth" conjured up visions of the brainwashed masses whose childbirth experiences had been unnatural: distorted and deformed from God's intent by the immoral overuse of pain relief. I saw in my mind's eye hoards of cowardly, superficial crybabies hooked up to IVs and epidurals in chemically sterile tombs. Those women, the unnatural ones, had fled from the miracle that is birth and had sold their souls to the corporate modern devil in order to escape a little bit of temporary discomfort. I had no respect for them and refused to join their ranks. I, the authentic woman, was going to do it the Natural Way.
Oh, they had me all right.
When I got to the class, my instructor was a very lovely, friendly woman who had either given birth multiple times herself or who had seen hundreds of other women do it. She had all the couples sit in a cozy circle and told us how simple it was for strong women to control and enjoy the birth experience, and congratulated us for choosing to be there. "I can tell you really care about your babies," she said. After a few weeks of such treatment, if she had told us all to go rob abank we would have done it and believed it proved how much we loved our babies.
She had a name, but I will call her Liar.
Liar wanted us to believe that her so-called "natural" method would allow us to really experience birth and thereby become closer to our babies. She taught us to breathe in a regular rhythm and stare at some symbolic object, in order to focus our minds elsewhere and take our focus off the discomfort (there was never pain in Liar's class-- only discomfort). Now, years later, I see the contradiction in that. If one can only get through the birth experience by thinking about something else, one is emphatically NOT getting closer to one's baby during the experience. But I digress.
Labels: "natural" childbirth, pain
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?
Labels: feeling superior, pain, philosophy
Is pain empowering?
One of the often touted benefits of natural childbirth in general, and homebirth in particular, is that tolerating the pain of labor without resorting to an epidural is empowering. I wonder about that.
The meaning of pain is culturally mediated. Different cultures and different religions have vastly different ideas about the meaning of tolerating pain. Some see pain as enobling or even cleansing. Most don't apply any positive value to tolerating pain when relief is available.
Of course, if a woman feels empowered by tolerating pain, that's fine. She is perfectly entitled to do that. However, she should not assume that other women share her values. I suspect that the majority of women would rate tolerating labor pain without medication as akin to tolerating a root canal without novocaine. Sure, you could do it, but why would you want to?
Perhaps this is where some of the disconnect arises between advocates of natural childbirth and other women. It may be that other women are not impressed and might even react with disdain (which they shouldn't do because it is rude) to the notion that tolerating labor pain could ever be empowering. That value is simply not a part of their cultural or religious background.
Labels: feeling superior, pain, philosophy
