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Natural childbirth vs. epidurals: the Babble.com dispatch.

At the final meeting of my childbirth preparation course, the instructor finally broached the subject of labor pain relief. It was a topic that, up until that point, had not been discussed with much gusto. 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.

I was pregnant for the first time at 37. Having coped with Motrin-defying menstrual cramps since adolescence, I felt I had a reasonable pain threshold. But as my due date approached, I grew increasingly concerned about the physical experience that awaited me. I wanted more concrete information about how painful childbirth would be. I kept hearing a response from my caregivers that was vague and patronizing: “Childbirth is different for everyone.”

Surely they were kidding? After several thousand years of women bringing forth life, that’s all we know about the experience? Is it really so different for everyone that no general body of knowledge exists that could tell me more explicitly how much pain I was most likely going to experience? I honestly wanted to know. Generally speaking? For most women?

My good friend Maureen, a nurse jaded by years of treating patients in pain, reluctantly gave in to my plea to describe exactly how labor felt. She told me that until she was given an epidural, her labor felt like “a living hell.” Darkly, she repeated “a living hell,” then caught herself and said, “I hope that doesn’t scare you.” Noooo, don’t be silly.

Meanwhile, my birthing teacher and all the books I’d picked up (including the popular Easing Your Labor, by Adrienne Lieberman, and the ubiquitous Natural Childbirth The Bradley Way,which came out in 1984 and was revised in 1996) insisted labor pain was “good pain.” In the chapter titled “The Myth of the Painless Birth,” Lieberman attempts to persuade her pregnant readers that “the experience of pain may actually help you to feel a deeper pleasure.” She concludes, “with adequate preparation for childbirth, you can give up the self-indulgent and disappointing fantasy that your labor should be painless and replace it with a more realistic and ultimately more rewarding commitment to working with your pain.” (italics hers)

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. What had been overlooked was how to deal with the type of pain I would rather live (and birth) without, and that was: any type of pain. I was skeptical that the distinction between pains would still be important to me when my uterus began contracting.

Marci Lobel, Ph.D., director of the Stony Brook Pregnancy Project at Stony Brook University, says, “Popular books written for pregnant women may overstate the effectiveness of childbirth preparation in reducing pain.” Glossing over the severity and intensity of labor pain, and emphasizing the use of non-medical forms of pain management such as breathing and relaxation techniques (the cornerstone of most childbirth preparation methods) leads women to underestimate the pain involved in childbirth, and to overestimate their own ability to cope with it without the help of modern medicine.

In the early 1980s, a Canadian researcher, Dr. Ronald Melzack, and his team from McGill University, conducted studies that attempted to measure the pain level of women in labor. Using a pain-measurement scale called the McGill Pain Questionnaire (MPQ) to assess the nature and intensity of labor pain in first-time mothers, You begin to understand why euphemisms are popular among childbirth professionals.the researchers found that labor pain was rated as “severe” by 30 percent of the mothers, and 38 percent of the group rated their labor pain as “very severe.” Add to this the 28 percent of laboring first-time mothers who chose the words “horrible” or “excruciating” to describe their pain, and you begin to understand why euphemisms are popular among childbirth professionals.

More than 2.5 million of the 4 million of us who give birth each year in the U.S. opt for an epidural, so why was it assumed in my class that the goal was to attempt to cope with as much pain as possible for as long as possible, rather than to eliminate the pain as soon as possible through the use of modern medicine? I was puzzled by the fact that, at the world-renowned teaching hospital where I was to give birth, modern medicine was presented merely as a backup to non-medical techniques.

In my class, I was warned that an anesthesiologist might not be immediately available, or that some physicians were concerned with possible risks that may be associated with early placement of an epidural; specifically, the risks of increase in length of labor, or increased likelihood of a cesarean delivery. This concern, I was told, may lead to my having to wait hours until my cervix was sufficiently dilated to the magic number of 4 to 5 centimeters before I would be considered “ready” for an epidural. These potential glitches in my ability to receive timely relief sounded ominous to me, but the casual tone of the instructor’s precautionary statements suggested that the possibility of my having to endure extreme pain for a period of time was seen as a reasonable part of any woman’s birth experience.

Recent research has concluded that early placement of an epidural – or epidural on demand – does not increase the length of labor, or the likelihood of women ending up with a cesarean delivery. At Chicago’s Northwestern University, Pam England tells pregnant women that birth is an “adventure.” Cynthia Wong, M.D. and her colleagues studied the effects of the timing of epidurals on over 700 first-time moms in a landmark study, published in 2005 in the New England Journal of Medicine. Half of the women received narcotic pain relief injections, but not epidurals, until they were more than 4 centimeters dilated. The other half received the epidural much earlier in labor. The study concluded that there was no difference in the incidence of cesarean deliveries among the early versus later group. In fact, the women who received the earlier epidurals actually had a shorter labor – on average 90 minutes shorter – than those who were given the epidural at 4 centimeters.

Commenting on this study in an editorial published in the New England Journal of Medicine, Dr. William Camann, Director of Obstetric Anesthesia at Boston’s Brigham and Women’s Hospital and Associate Professor of anesthesia at Harvard Medical School, said, “. . . safe and effective pain relief. . . should not be withheld simply because an arbitrary degree of cervical dilation has not yet been achieved.” Even the American College of Obstetricians and Gynecologists (ACOG) say, in an official bulletin issued in 2006, “Recent studies have shown that epidural analgesia does not increase the risks of cesarean delivery. The fear of unnecessary cesarean delivery should not influence the method of pain relief that women can choose during labor.”

In spite of this, many popular childbirth professionals suggest women should “try” to labor and give birth without medication – and that we should want to. Since when did childbirth become about having transformative personal experience rather than about getting a healthy baby?

In her wildly popular book titled Birthing From Within, Pam England tells pregnant women that birth is an “adventure” and states that “many childbirth teachers and healthcare professionals unwittingly have misguided mothers by reinforcing the hope that pain can be avoided, and by supporting our natural childlike tendency to look outward for comfort and relief.” She goes on to warn us that ” . . .adopting a passive stance to dealing with pain has its consequences,” and asks, “Is the reassuring option of analgesics or an epidural keeping you from plumbing the depth of your own resources?”

Not only is the book used widely by childbirth professionals throughout the country, the concept has become a phenomenon. England has courses, workshops and a gift shop on her website, where shoppers can find CDs, videos, “birth art” and other items, including tiny tee shirts for the newborn, emblazoned with the words “My Mama’s a Birth Warrior.”

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?

Well, starting in the mid-1960s. At that time, women began to revolt against depersonalized maternity care characterized by the routine use of pain relief that rendered women unconscious or close to it. By rejecting these medications, women hoped to take back control of their birth experience. Birth philosophies that promoted the use of breathing and relaxation techniques, such as Lamaze and the Bradley Method, took hold as the way to achieve a rewarding birth experience.

It’s hard to deny that birth is over-medicalized. In the 1980s, women who enjoyed more social, political and economic power than any previous generation decided breathing techniques (and painful birth) were not for everyone, and the newest pain relief method, the epidural, began to replace natural birth for most American women. During this time, roughly 22 percent of American women used an epidural during childbirth. By 1992, that rate more than doubled. Today, on many busy maternity units, 80 to 90 percent of women choose an epidural for pain relief. According to a recent study in the journal Anesthesiology, only 6 percent of women in large hospitals and 12 percent in small hospitals opted for drug-free births.

In other words, there is a significant gap between how women are

It’s hard to deny that birth is over-medicalized. Our nation’s C-section rate is 30 percent and rising. Labor induction (artificially starting labor before it begins on its own) has doubled since 1989. And I don’t care how much of your hospital’s budget was spent revamping their maternity unit to look like your favorite small luxury hotel, just try to help yourself to something in the fridge when you feel hungry during labor; you will quickly be reminded you are in an institution.

But pain 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.

It was not until the torture ended that I was able to connect with the joy. It is true that if you want an epidural, or a narcotic drip, or any other form of medical pain relief during labor, you will wind up hooked up to a lot of wires: most likely an IV, a Foley catheter and two belts around your waist – one to monitor the baby, one to monitor your contractions. Your blood pressure may dip. You may feel itchy. You may spike a fever. But, here is the great big On The Other Hand: You will not be experiencing mind-blowing pain.

Ultimately, I found Maureen’s description of childbirth as “living hell” to be similar to my own (only when I describe it, I use more expletives). I walked, squatted, used hydrotherapy and massage, but labor was an agony that wrenched my body for hours until I was finally “ready” for the relief provided, almost instantly, by an epidural. It was not until the torture ended that I was able to connect with the joy and excitement of knowing I was about to finally meet my daughter.

I don’t doubt that, for some women, natural childbirth provides an emotional boost that is powerful and gratifying. But for me, giving birth was the fulfillment of a lifelong wish to have a baby, not a means of self-actualization. The real adventure began when I became a parent.

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