Are we using our brains when it comes to epidurals?
Friday, February 26, 2010 A 2009 study called Social disparity and the use of intrapartum epidural analgesia in a publicly funded health care system 
by Ning Liu MB, MSc et al concluded that in Canada "the use of labor epidural analgesia is decreased with decreasing neighborhood economic and education levels." Or, in plain language: rich highly educated women are more likely to get an epidural than poor less educated women. Those are facts which are supported by an excellent data set. I won't argue with the facts [edited to add screen capture of basic results set].
However, I take issue with some of the study's assumptions and the conclusions drawn by some of the researchers involved. From the start, the study presents the use of epidurals as the smart choice, referring to the increased use of epidurals as "1 [sic] of the most significant achievements of modern obstetric practice." The whole study seems to question whether women of lower socioeconomic status are just not smart enough to understand how great epidurals are.
Education level could influence a patient’s acceptance of epidural analgesia.26 We speculate that in our study women from a high-education neighborhood may have had more knowledge about labor epidural and considered that it could alleviate pain more effectively. These women could then be more likely to accept epidural when clinicians recommended it to them, or they request the service themselves.
Despite conceding some cultural reasons for some women refusing epidurals, ultimately, they seem to conclude that if you are educated about epidurals you will make the smart choice and get one. If you are not educated about epidurals, you will not know what a wonderful thing you are missing out on.
The pros and cons of epidurals
I think the first mistake the study's authors made was to assume that getting an epidural is a smarter choice than not getting an epidural. There are both pros ans cons to epidural use during birth. According to Sam Leeson, a doula with babyREADY in Toronto in her post on epidurals:
PROS
May offer pain relief
May offer mom the chance to rest
May be medically necessary
CONS
May not work the way mom wants
Mom will be unable to get up to urinate
Some moms complain of long-term back ache at the epidural site**
May slow labour
May drop mom’s blood pressure (an IV will be administered)
May increase the need for surgical interventions (i.e. vacuum, forceps, episiotomy and/or caesarean section)
Will increase the risk of tearing
May give mom a spinal headache
May affect the baby
May result in an allergic reaction to the narcotic (mom would need more medication)
Is cumulative (results in increasing physical disconnection the longer it is in place)
Limits options of positions for pushing in second stage labour
There is a detailed examination of the pros and cons of epidural use, giving a full explanation of these factors, in Weighing the Pros and Cons of the Epidural by renowned childbirth education expert Penny Simkin. In her article she concludes that:
The childbirth educator's duty is to inform, not to talk women into or out of using an epidural. Many women will choose an epidural, when well informed of benefits, risks and alternatives; others will choose to avoid it if their labor allows.
When women are well informed, they will consider the information, along with other factors - such as their fears, self-perceptions, their goals for their birth experiences, their support system - and make the most suitable decision.
This is a reasonable, balanced conclusion. Assuming that an epidural, which has many risks including increasing the likelihood of need for other birth interventions (each of which carries its own risk), is a better smarter choice is inappropriate. Assuming that the decision to refuse an epidural is something that only uneducated or unaware women do, is insulting.
A brief tangent on inductions, epidurals and c-sections
One of the key risks of epidurals that is mentioned above is the likelihood that an epidural will result in the need for additional interventions, like a c-section. But often the story doesn't start with the epidural. Experts say that a lot of women are induced unnecessarily just because they have passed an arbitrary date by which the obstetrician thought they should have given birth. In an article about Canada's increasing c-section rate, this logic is questioned:
Today in Canada, one in five women who gives birth in hospital is induced.
What doctors fear are stillbirths. But alarmed by the rising rates of inductions, the Society of Obstetricians and Gynecologists of Canada recently urged doctors not to consider an induction until a woman is at least one week past her due date.
Claudia Villeneuve says that women are getting induced "if they're two, three, four days overdue."
"Inductions are rampant," says Villeneuve, president of the International Cesarean Awareness Network of Canada. "You have a perfectly normal mom who comes in with a perfectly normal baby, and now you put these powerful drugs into her system to force labour to start."
The "humane" thing is to offer an epidural, she says. With an epidural, a woman can't feel pain in the lower half of her body. But epidurals slow labour, sometimes so much that labour stops. "Now you have to get this baby out," Villeneuve says. Two-thirds of first-time C-sections are done for "failure to progress."
Interestingly, despite this logical explanation for part of the increase in the c-section rate, one of the authors of the study this post is about (the one about how smart women get epidurals), Dr. Mark Walker, is quoted in the same article as saying that "We don't know what the ideal rate [of c-sections] is. I think it's fair to assume it's lower than where we are now." (note: the WHO says it shouldn't be higher than 15 percent and Canada's c-section rate is 29 percent).
An alternate hypothesis
Back to the epidural study. In addition to rejecting the authors' assumption that an epidural is a smart choice, I also reject their conclusion that education level is what causes women of higher socioeconomic status to have a higher epidural rate.
**WARNING: Evidently from the comments so far my attempt to facetiously poke fun at myself and my socioeconomic cohort in the next paragraph was a complete failure. Please take it with a grain of salt or feel free to join in telling me what a jerk I am while I ponder whether I want to keep writing at all if there is no room for a bit of sarcasm and creative license here and there to make a point (going to keep writing...and keep learning). **
Instead of saying that rich educated women are making the "smart" choice by getting an epidural, I'd be more likely to say that women with perfectly manicured nails, pretty shoes, and a white collar job in the city who have never done a day of manual labour in their lives or endured any type of hardship are more likely to be unwilling or unable to endure the pain of childbirth than rural blue collar working women with practical shoes, callouses on their hands and whose life experience has taught them how to fight and endure. That is, of course, a generalization since not all rich educated women chose to have epidurals and not all poor uneducated women refuse them. However, I think it is a more likely explanation for the difference in epidural rates across socioeconomic groups than the one the authors of the study put forth.
Or, if I am wrong and women of higher socioeconomic status are truly choosing epidurals because they think it is the smarter, safer choice, then we need to seriously reconsider how women are educated about epidurals and find ways to ensure more of them learn about the risks of epidurals and are given the confidence in their body's ability to birth a baby and to endure the pain of childbirth.
My experience: I had an epidural for my first birth because I was "educated" about the "benefits" of the epidural and scared of the pain. I ended up spending a very uncomfortable night, lying on my back, waiting for my baby to be born. I needed a nurse to tell me when to push and for how long. They had to use the vacuum extractor to get my baby out (and I'm very lucky that is all they had to use). For my second birth, I refused the epidural because I was educated about the risks of an epidural. I was able to labour in whichever position was most comfortable for me, which mostly meant standing up and using gravity to help move things along. I was able to feel when it was time to push and knew how long and how hard to push because my body told me and not because a nurse was counting for me.
Image credit: mangpages on flickr
Reader Comments (104)
On that post you totally nailed it! :)
Channa:
That is a very good point (about those making an "educated" choice to avoid something like an epidural or vaccines being statistically insignificant).
With regards to the pain tolerance of birth versus breastfeeding, I agree that a few hours of labour/birth is more tolerable than weeks of sore nipples. However, the epidural is presented to women as a completely safe risk-free option for eliminating the pain of labour, whereas formula is presented to women as an inferior way of feeding their babies. So they may think there is no harm in choosing an epidural and therefore opt out of the pain of birth, but endure the pain of breastfeeding in order to be able to give their child the best. Even at that, we know that there are numerous women who do want to breastfeed but who do end up giving up. There are certainly some who are not able to endure that pain and do turn to an alternative.
Thanks for the info about the education and income levels, that makes more sense. However, I still take issue with your 'alternate hypothesis', which posits that rich, well-educated women are less likely to be (or feel) able to cope with the pain than women from more disadvantaged socioeconomic backgrounds. Though you acknowledge that you are generalising, you say, "I think it is a more likely explanation for the difference in epidural rates across socioeconomic groups than the one the authors of the study put forth." If any part of that was tongue-in-cheek and not a serious 'hypothesis', I'm afraid that was not clear whatsoever. Or do you just mean that your hypothesis was serious but the 'manicured nails, pretty shoes' bit was a joke? Either way, I see some serious stereotyping that concerns me.
Perhaps this was a case of miscommunication, the kind that can easily happen with the written word, but I would hope that you, as a blogger who often speaks out against efforts to pigeon-hole or undermine women, would welcome criticism of what appears to be negative, potentially harmful language in your post. If a statement was sarcastic, perhaps you could make that clearer next time? I hate feeling like someone who is raining on a parade, so to speak, but I really didn't feel that the 'joke' was made clear at all.
Also, if your hypothesis was a joke, what *is* your hypothesis on the disparity between epidural uptake between these groups? Perhaps the idea that rich women shouldn't *have* to endure pain (or aren't able to) while poorer women are stronger and just 'get on with it' is so firmly entrenched in our minds that doctors and nurses don't offer them as readily and quickly to their poorer patients? Also, I wonder if mistrust of the medical community as a perceived authority figure or symbol of elitism has anything to do with poorer women declining their interventions. Perhaps they labour longer at home before going in, making epidurals a less likely option if their dilation is further along, while richer women follow the 'race to the hospital at the first sign of a contraction to be with the trusted doctors' script? Being poor would also make transportation to the hospital and arranging care of other children more difficult, again explaining why they maybe get to the hospital further along in labour? I've no data to back these hypotheses up but I think it's worth thinking about all of the factors that fit into the bigger picture, not just income and education level and what colour one's collar is. It's so much more complex than that.
Noble Savage:
The part of my post that was intended to be facetious was the descriptions of richer/more educated women ("perfectly manicured nails, pretty shoes, and a white collar job in the city who have never done a day of manual labour in their lives or endured any type of hardship") and poorer less educated women ("rural blue collar working women with practical shoes, callouses on their hands and whose life experience has taught them how to fight and endure").
However, my hypothesis that richer/more educated women are more likely to be unwilling or unable to endure the pain of childbirth than poorer/less educated women was not a joke. It certainly was my own experience with my birth and also reflects what I have heard other women in my own socioeconomic cohort say. The women I tend to associate with online, who are from a variety of different socioeconomic backgrounds, are overwhelmingly in the "natural birth" camp. The women I associate with in real life, who are primarily from my socioeconomic cohort, fit much better the "spare me the pain please" camp. So I was describing a trend I have seen with myself and my peers. Before my first birth, I certainly fell into the "avoid pain at all costs" camp because I was not sufficiently educated about the benefits of natural childbirth or the risks of epidurals. By the time I was pregnant with my second, I knew a lot more about these things and made the educated choice to try for a natural birth and the educated choice to have the right type of supports in place to increase the likelihood that I would be successful at it (doula, birth plan, etc.).
However, I certainly did not intend to say that my hypothesis applies to all richer/highly educated women or even to the majority of them. There was a 12% difference in epidural use between the richest and poorest groups and a 21% difference in epidural use between the most educated and least educated groups. As such, my hypothesis would only need to apply to less than 1/5 of the richer/more educated women in order to hold water as a possible explanation.
That said, I thought that your other hypotheses and the hypothesis put forward by Channa are also reasonable. So if each of them applies to, let's say, 5% of the women in that socioeconomic cohort, then together they could explain the difference.
I am, however, interested in understanding why my hypothesis is insulting or inappropriate (once you strip away the facetious language), but yours is okay. Why is it okay to hypothesize that richer/more educated women are racing to the hospital at the first sign of a contraction, but not okay to hypothesize that they might be less willing/able to endure the pain of childbirth? Personally, I don't see myself in your hypothesis (so would be more likely to be insulted by it if I was so inclined), but I do see myself in my own hypothesis (so would be less likely to be insulted by it).
In any case, I agree that the answer is likely to be complex and there are probably a lot of factors involved. But I certainly outright reject the study's assumption that smart women are making the smart choice by getting more epidurals.
I'm a pretty good candidate for your generalization above- PhD, SAHM, white collar, white collar husband with executive job. I wasn't offended by your generalization at all. Because I am the *only* person I knew until recently (having just joined the real life crunchy granola brigade) who had given birth without an epidural (twice). Due to that fact, I am considered in my cohort as unusual, strange and freakishly tolerant to pain, as opposed to normal, as I would have been in my mother's generation ;)
I don't think I agree with the facetious "intolerant to pain" hypothesis (which I wasn't supposed to ;)), but I'd propose the "intolerant to fear" hypothesis. Just about everybody I know IRL is afraid of birth. Some have very good reasons that won't change no matter how much information they have (histories of complications etc.), others are being offered bad information, incomplete information or are encouraged to think by the prevailing view of their cohort that the epidural is a normal way to give birth.
Now, let's not get me started on DH's home country where all his female relatives with normal pregnancies and normal babies are being offered routine (unnecessary) c-sections "because it hurts less". (Again, upper socio-economic cohort, incomplete information is being offered, a wide take-up of the interevention is occuring...)
Oh and for next time, I'm not a buyer of shoes and have never had a manicure, but I do routinely purchase baby carriers that are not strictly necessary as my poison of choice ;)
Steph:
I probably fell somewhere in between at my first birth - I was fearful of pain. Not sure if I was intolerant to it or not because I just wasn't going to let it get that far. I'm used to being in control and not knowing how much it would hurt scared the heck out of me!
But I said "unwilling" (which would include your "intolerant to fear) or "unable" because I have certainly had numerous people tell me that they tried to do it without an epidural, but it just hurt too much. I didn't want to dismiss their experiences as being "unwilling" to deal with the pain of childbirth. Rather, I wanted to recognize it as them being truly unable to deal with it at that point. And as Penny Simking said, if a woman is unable to deal with the pain, then the benefits of the epidural may outweigh the risks.
I agree completely. I know several women who have experienced some pretty profound birth trauma due to the extended, uncontrolled and terrifying pain they experienced in birth trying to hold out *against* an epidural. If they had felt able to ask (rather than feeling like they were "failing"- a good case for your point about being "unable" rather than "unwilling") for one a few hours earlier, their birth experience would have been quite different and, ultimately, I think, far more positive.
Epidurals are undoubtedly an important intervention, the simple fact that they can take a c-section from an out-of-body, terrifying experience to a beautiful birth is another important argument in their favour. My experience of my cohort (and it is just my own experience), however, is that women are afraid of birth. It's no longer perceived as a natural event for which the vast majority of us can complete without major intervention. I think it's that fear that ultimately contributes to the belief that epidurals are a part of making birth "safe". Safe from pain (which, realistically, is significant!), safe from sick or dying babies, safe for ourselves (both understandable fears). For many women, they are necessary, positive and a part of a beautiful birth experience. For others, they lead to our ubiquitous "cascade of intervention" and all that entails. The difference between the two...? As many and varied as the women giving birth, I guess.
I'm going to read through the comments later, partially because people being obtuse about sarcasm is one of my chief pleasures in reading the comments on blogs...so I will leave my comments about the connections with class until then. Though I think you are right that a more likely explanation lies in how we are conditioned to think of birth...or even in how hospitals treat different patients.
In the meantime:
I always use an epidural as an example where I twice, knowingly, made a less than optimal choice. However, since I was educated about the risks and benefits, I don't really regret the choice. Well, perhaps a little with #2 because it went much faster than I thought it would. And I certainly do not feel upset or attacked when presented with evidence that epidurals have side effects.
Birth #1 was over 24 hours. My water had broken early, I accepted pitocin after 8 hours, an epidural after another 4 hours, ended up with a fever, and so on.
Birth #2 took less than 4 hours in the hospital. If I had realized how quick it would be, if I had better support in place to help me try other types of pain relief, I might not have requested the epidural.
At any rate, I can look at studies showing that epidurals have potential risks for mom and baby without feeling personally attacked.
One thing I would add to the plus column is that it can actually allow a mom who is tense and is therefore feeling sensations more as "pain" to relax into the contractions. And that has to of course be weighed against being "stuck" in one position or the potential drawbacks of the drugs.
Another point to make is that some women can still move around under a light epidural. I can. Twice I used the birthing bar towards the end of the labor. If hospitals were more open to how women can move with assistance, even with an epidural, then possibly that would mitigate at least one of the "cons" of an epidural.
Can you get a real midwife? Or is it illegal for a midwife to do a VBAC where you are?
If you are stuck with a doctor, you can still just not allow them to induce. Go in for the tests, make sure everything is okay (check the oil, as I call it), and then just keep putting them off. Or, as Annie says, fudge the date if the confrontational approach is too much.
I was almost two weeks "overdue". They thought my son was over 11 lbs (he ended up being over 10 lbs). They tried to scare me. I did my research, went in for the tests, and put the midwives off (it was a hospital midwife practice).
They like to make you feel like it isn't up to you...but it is. Of course, it isn't easy to resist advice from medical professionals who make it seem like consequences are dire. And it may not be worth the stress, depending on how strongly you believe you are making the right call.
thanks ladies - you've given me some things to think about!
I believe in the "don't go there rule" of comedy. The humor has to strongly outweigh the potential offensiveness. And the potential offensiveness is related to the discrimination the group has faced (and perhaps how recent that is) and the extent to which the persecution or discrimination is part of the joke. So, for example, it is theoretically possible a Jewish person could tell a Holocaust joke so funny that it is okay, most likely that would still be offensive. But Mel Brooks and the Inquisition? Enough time has passed.
At any rate, I think you are safe gently tweaking your own, relatively privileged cohort.
I wasn't thinking anything like a Holocaust joke (nothing to joke about there), but more like a Jew poking fun at certain Jewish stereotypes.
But Mel Brooks, we're okay there, right? Because that's a friendship deal breaker.
Just kidding...mostly.
Here's what I'd like to see the numbers for: What percentage of people who work in hospitals, in particular maternity wards, choose epidurals? Those are the people making informed decisions and I'd guess they tend toward "no" on the needle in the spine, wheelchair, bedpan option.
Women, especially educated, wealthy women who are used to solving and problems and controlling situations, want to believe and are led to believe there is some great medical solution to the problem that childbirth is tough and painful. The truth is, elective epidurals and C-sections really just give you different ways to take your pain.
I think fear and control are big factors - a long recovery doesn't sound as scary as the unknowns of late labor, transition, and pushing even though it may actually be much tougher on your body. I, for one, was ready to take my pain straight up - deal with it on the front end with a natural birth so that I could be done with all things delivery related once my babies were out. Fear and control were factors for me, too, though. I was much more afraid of having someone (probably a student) stick a needle in my spine than any labor pains!
BTW, I appreciate the snark. Maybe you should have a "snarky saturday" so everyone will be ready for it.
This was not about people being 'obtuse about sarcasm.' I get sarcasm. I live in the land that invented it! I just don't think it was used here, at least not effectively. I (and a few others) disagreed with Annie's hypothesis and the language she used to generalise about it -- that's it. I don't feel 'offended' or 'personally attacked' at all. I've never even had a damn epidural so it really has no impact on my life. I'm simply disagreeing with her. Regardless of whether sarcasm/humour/whatever was being employed, I'd appreciate it if my disagreement wasn't met with "Can't you take a joke?" which is a silencing technique.
At any rate, I think I've said all I need to say on this subject so I'm bowing out now.
Honestly? I didn't see it as poking fun. If it was "poking fun", it would have been phrased differently. It came across as a shot. If that wasn't what you intended, then just learn from it and phrase it differently next time.
I'm happy to discuss people's objections to my arguments. I wasn't intending to use a silencing technique, so apologize if it had that effect. I obviously screwed up on the choice of words, but hoped that we (my readers and I) could still have a discussion about the issues despite poor choice of words. That is why I was trying to clarify that I was attempting (again, failed) to poke fun at the stereotypes. I really did want to discuss the issues, my hypothesis, any alternate hypotheses, etc. I did want to hear from people who disagreed with me, especially if they were truly disagreeing with my argument and not just the descriptors I used for the two groups. If I screwed up so badly that we can't even do that, then I'll accept that and just move on.
I was very clear that I hadn't read the comments yet. Therefore I did not call you obtuse.
The rest of my comment about being personally attacked had nothing to do with that either. It had to do with many posts across many blogs where whenever ANYONE mentions risks of c-sections or non breastfeeding or WHATEVER, someone starts taking offense and talking about how in their case it was necessary. The epidural is my example of how *I*, when I'm *personally* involved, can look at the research without taking offense.
When I had my first, I most definitely wanted an epidural. I knew there were some risks but didn't look into those too much, because I was afraid of the pain. But I was shocked when during the hospital class, a dad asked about risks, and the instructor basically laughed it off, implying there were no risks, you silly man! Not being brave, or educated enough to argue, I didn't speak up, but it bothered me she wasn't upfront about the possible issues -- even though I planned to have one myself! I don't know about the other parents there, but I consider DH and I educated, middle-class. We just weren't "educated" about childbirth (despite being in a class about it!)
With my second, I informed myself and also chose m/w care, with the goal of avoiding an epidural (which I was able to do) in part because I almost ended up with a c-section, and had many bf issues at the start. Most women I know though, avoid researching this topic and make the argument that a person wouldn't have a tooth removed without pain relief. These are educated, smart, strong women. But they in many cases make the choice NOT to be educated on this topic (I've gotten more than one crazy look for even suggesting a woman at least hold off as long as possible on getting an epidural). Or, they are taking at complete face value what they are hearing from medical professionals (like one friend who got an epidural at 3 cm, while she was tolerating the pain just fine, because the admitting nurse said "if you are going to get one, may as well get it now" -- no mention that it might slow labour etc. etc.)
Interestingly, the one woman I know who has worked in as a nurse in L&D chose to go med-free as well -- according to her, she didn't want her birth to be managed to suit the schedules of the doctors, something she'd seen time and time again...
Andrea:
Yup - that "if you are going to get one, may as well get it now" is exactly what I was told the first time too. Along with a "before it is too late".
re: use of other drugs
Although the study was focussed on just epidural or not, and historical records were selected on that basis, in that birthing population where the info was drawn from how many women from which socioeconomic background (aka class) selected a directly administered pain relief drug which would pass thru into the baby's circulation? Was there a class bias, and therefore would my proposed conclusion stand? ie. do poorer women care less about the welfare of their babies? We'll probably never know as the study was focused exclusively on epidural yes or no, and seemingly a retrospective records-based collection (though without access to the full article I'm really just guessing here, I don't have an institutional log in for anything more than the abstract). Without it being specifically stated, and it wasn't the focus of the study, I think it is dangerous of you to assume that the women who didn't have the epidural laboured drug-free.
Here is the info on the methodology in case you were interested:
I agree that we cannot assume women who didn't have the epidural laboured drug-free. I hadn't considered the alternative initially, but certainly did after you brought it up, which is why I said my assumption was probably incorrect. But we also cannot assume that they used other types of drugs. The study doesn't provide that info one way or another. It is a good question though.
Yes, one of the reasons I wanted to avoid an epidural the second time was I figured, a day (more or less) of pain would be worth not suffering 8 weeks of pain due to bf start-up problems! But, when I was pregnant with my first, I had no idea bf would be like that -- I knew there could be problems but assumed they wouldn't happen to me :P I was too focused on my fear of the actual delivery to think that far ahead maybe. With my second, of course I had a completely different perspective, and was able to think ahead, to what I wanted AFTER the birth. And while there was still pain in the early days nursing my second, at least he wasn't too sleepy to latch!
Out of curiosity, and sorry if this has already been covered, but did they take into account whether it was the first birth for these moms or not?
To be fair, my own experience was a bit different. When I was having my first I was in such pain (back labour, contractions every 2 minutes from the get-go) that I was convinced I must be on the verge of giving birth, that maybe I was one of those "lucky" women who don't feel early labour. So imagine my surprise to only be 1.5 cm dilated when I got to the hospital -- they would not give me an epidural at that point (at the time I wished they would!) So I can't say *I* was pressured into getting one. But I also can't say the OB or the hospital classes gave me any other coping tools either. And I probably didn't seek any out on my own because I assumed I'd get an epidural, like everyone else I knew!
Excellent question to Candace above. I had an epidural with my first and it was similar to the fear Annie talked about - not necessarily fear of the pain, but of the unknown "will this get worse? how long will I be enduring this?" etc. With the benefit of experience now, I would not do it again. I was very far along when I got to the hospital and had my baby in half a day. If I had realized how far along I was (maybe if someone had told me "you're doing great" instead of "whatever you want" because I requested it - my husband was just as new to it as I was and just wanted me to have what I wanted). I try not to regret it though so that I don't have any bad memories of the experience - I just look at it as it gave me some time to relax and focus on what was going on so I would remember it later better, if that makes sense.
I was also curious if family involvement is a factor - I have no research to back this up, but it seems like lower socioeconomic classes actually have more family involvement, where higher classes may be more about 'individuals' - and maybe having more support or more relatives who have 'been there done that' around, you just get through it together. I'm not stating what I mean very well, but I hope what I'm trying to say makes sense!
I was the same way - severe back labor and contrations 1.5 - 2 minutes apart from the get go. Except I was dilated at like 5 or 6 when I arrived at the hospital. It was so overwhelmingly different from what I expected (slow, long labor) that I was like "I need this now before it's too late" and everyone just went along with it.
Candace:
It appears as though it included all births that met the study's criteria, which would have included first birth and additional births from the same mother.
My thinking is this--educated and wealthy women (statistically) have fewer children. **PLEASE everyone note this is not a judgment, just a statistical correlation** Therefore, unless the study controlled for this, more women from a lower socioeconomic cohort would be more likely to be on a second or third birth. Not sure how much this would skew the study...but just another factor to possibly consider.
I'm also assuming they controlled for age, as well, because usually that is considered in most studies. Otherwise, that could also theoretically skew things, as well.
Candace:
Yes - they controlled for age and there was no statistically significant difference when it came to epidural use across maternal age groups.
Also, turns out they did look at number of children, I just wasn't familiar with the term they used ("parity"). The stats were as follows:
- 1st baby: 71% used epidural
- 2nd baby: 55%
- 3rd or greater: 46%
In the study, they didn't cross-reference parity with the income/education elements. That doesn't mean they didn't look at whether it was a factor (i.e. they may have ruled it out or may not have), but either way it isn't referenced directly as being a contributing factor to the lower use of epidurals among lower income/lower educated women. But they missed other possibilities, so that could be a reasonable hypothesis too.
Great topic and wonderful discussion. I think you and the commentators have done a great job of pointing out the biases and assumptions of such a study. I am of the opinion that how a woman approaches labor and delivery has less to do with academic education and everything to do with what kind of information she is exposed to prior to giving birth.
I was lucky to attend a prenatal class taught by a nurse who clearly outlined the risks and benefits of hospital supplied pain-management and labor inducement. She encouraged her students to consider alternative methods of pain management and emphasized the importance of keeping mobile and trying different labor positions. I am eternally grateful to her for neither sugar-coating the scary side of labor or terrifying couples into automatically asking for epidurals.
As a first time mother, I had no idea what to expect during labor, but I decided that I wanted to do my best to have a natural birth. I read a couple of Ina May's books, which are full of wonderful (if dated) first-person descriptions of natural labor. These powerful accounts gave me much needed confidence in my ability to do what my body was designed to do. Having had a natural birth, I cannot imagine asking for an epidural and numbing such a profound and powerful experience. (I am, of course, speaking only for myself and my experience. I was only in active labor for about 7 hours and I have no idea how I will react in any subsequent labors). I was also lucky to be encouraged and supported by the nursing staff. When I told them I didn't want any drugs, they suggested I go home to labor. Having read that a woman is more likely to accept/request an epidural (or deliver by c-section) the longer she is in the hospital, my husband and I took their advice and high-tailed it back home where I had the privacy of my own bathtub. Anyway, my point is that women of all socioeconomic backgrounds are bombarded with images of labor that cannot begin to approximate the experience of birthing a child. Shows like A Baby Story posit c-sections, pictotin drips and epidurals as not only routine but also as the "smart" or "obvious" way to labor. I'm not sure how socioeconomic background plays into epidural use, but I think that women need to educated themselves so as to make informed decisions about labor, medical intervention, and pain management. Doctors and medical staff should respect those decisions and support women so that they can labor with confidence and not in abject fear.
I have had the pleasure of birthing two children. One with the epidural and one without. I hated the epidural. I hated not being able to feel everything - I couldn't even wiggle my toes. If given the chance I would have a natural birth again. During my first pregnancy, I had a group of well-educated women try to make me feel somewhat idiotic for planning to have a natural birth and for going to prenatal classes to help me and my husband cope with labour. These so-called 'educated' women told me flat out that they weren't even bothering with classes, that as soon as they felt their contractions they were planning on asking for an epidural right away. I walked out of that house that night, not feeling idiotic, but feeling like the MOST educated woman for learning all about birth, and my body's ability to birth a baby. I actually felt sorry for these women. They missed out on so much. The fact that they didn't give their bodies a chance to do what it was meant to do, or to even learn about it only proves that they are, to say the least, not very educated. Having a natural birth has been the best experience of my life, and I try to tell this to pregnant women every chance I get. I've had a doctor cringe at my birth story, and ask me why I just didn't have an epidural. The nurse in the hospital with the birth of my first child, made me feel like I was ridiculous for trying to go natural, and 10 hours of back labour later, with the threat of a c-section on the horizon, I felt that I needed to get an epidural, and after that the nurse was sweet as pie. I regretted it right away. These women who are choosing to have an epidural, without giving natural birth a try, are right up there with women who schedule unnecessary c-sections. They may be educated, but they are doing themselves a great disservice. (sorry for such a long comment!)
I will admit to only having read the abstract, and to only having read the first 25 or so comments to this post, so I don't know if my points have already been covered. That said:
1) The part in the abstract where it says that the difference in rates between rich and poor and more vs less educated are lower in teaching hospitals and higher in community hospitals is interesting. My guess is that those women who expect to get an epidural are going to get it no matter where they labour and birth (assuming it's not an unanticipated homebirth). The more important factor in this is whether the environment itself leads to the "choice" in epidural. In a small community hospital where there isn't 24/7 access to an anesthesiologist, labour and delivery nurses and midwives are possibly more likely to offer a variety of different comfort measures to labouring women before opting to suggest an epidural. In an environment where it's readily accessible, it may be more heavily pushed by hospital staff.
2) Did the researchers take into consideration the women who had been induced for medical indications?
3) Did the researchers study who the care providers were? Women who give birth in community hospitals are more likely to have family physicians as their care providers than women who give birth in teaching hospitals. It's a numbers game: there often isn't a high enough population to support more than one on-call OB (or general surgeon with OB skills training) for emergencies at many Level 1 hospitals in Canada. And midwifery clients have significantly lower rates of epidural use than labouring women in general.
I did have a problem with the marketing of the article in question, as you did. I do have one other thought: are poor or less-educated women offered epidurals less BECAUSE they're poor and/or less educated? Is there a built-in prejudice around poverty and whether some women "deserve" pain relief more than others (which is a problematic thought on so many levels)?
I am (some might consider) overeducated. I did everything I could to avoid an epidural during my first labour, but in the end, my persistently posterior baby triggered contractions that were more like a non-stop uterine spasm that was doing nothing to my cervix and exhausting me. While I grieved and felt a great deal of guilt for months after that birth, I am in retrospect sure that the epidural was what prevented me from having a c-section. There is a time and a place for all interventions, but when I look at the breakdown of epidural rates by LHIN (Google OPSS 2008 Report), and I see that Toronto Central had an almost EIGHTY PERCENT epidural rate in 2006-07, I'm horrified. That is blatant misuse, in my opinion.
plastikgyrl:
Those are good questions....here are some answers:
2) They excluded c-section births, but otherwise did not seem to take into consideration medical indications.
3) They looked at whether the woman had an obstetrician as her antenatal health provider, but didn't go into any more detail than that. They found that 62% of women who had an obstetrician had an epidural and 43% who did not have an obstetrician (which could mean midwife, family physician, etc.) had an epidural.
The whole idea of having to get the epidural now "before it's too late" infuriates me. I specifically asked my maternity doc when it would be too late and she said "when the baby's crowning?" She told me that if anyone is told it's too late to get the epidural, the care provider is not telling them the whole truth - most likely they're just feeding her a line to encourage her to go on without it. Anecdotally, I received my (very light) spinal after 1.5 hours of pushing, 45 minutes before my son was born. I am so glad I held out as long as I did; I feel like I gave it a 100% effort.
natalieushka:
To be fair to those who said it to me, I think the fear was that it may take a while for the anesthesiologist to get there and then a while for the epidural to actually take effect. So if I did wait too long, I might be stuck doing what I was so fearful of (going through transition, crowing, etc.) without the epidural. But I think that giving women more confidence in their ability to birth the baby is a better place to start.
I would likely fall within the generalized cohort as well (at least the highly educated part) and am also somewhat "freakish" amongst my coworkers and friends because I planned and had a natural, drug-free birth. I can't even count how many times someone at work would advise me when in my third trimester to "go for the epidural - it's great!". I definitely think that fear of pain is part of the puzzle but also wonder if any of the following come into play:
1. Increased faith in the medical system and the medical managment of childbirth - most of my peers have absolute faith in their doctors, and the medical model. Most of them do feel that childbirth is somewhat of a medical emergency rather than a natural thing that our bodies were meant to do. Those who "required" medical interventions during childbirth (inductions, c-sections etc.) believe that those interventions were absolutely neccessary or they or their infant would be at risk of serious complications or die (though evidence based practice and statistics suggest otherwise). One coworker went as far as to have an elective c-section (uncommon in Ontario, but her care was through a privately funded fertility clinic) as she felt that it was safer and more controlled. (I do work in health care and wonder if my peers in particular may have more faith in the medical model than the average woman in this cohort or women working in corporate jobs.)
2. Sense of entitlement - e.g. entitled to pain relief/entitled to avoid pain
3. Dissociation from one's body and/or nature in general - along the lines of Abbie's comment above - I wonder if the fact that most women in the higher income/higher education cohorts have not been exposed to anything but portrayals of medically managed childbirth plays a role in creating the fear of pain (usually women are portrayed screaming in pain and cursing their partners). I also wonder if women in this cohort are so used to being in/working with their heads, that they are less connected to their bodies and possibly fear pain more than some one who uses their body in their work. Some of the women I know expressed that they had limited faith in their own ability to deal with the pain, and their own body's ability to birth. A total tangent here, but I wonder if athletes, who are very in-tune with their bodies, are more or less likely to have an epidural?
Anyway, I'm just throwing some ideas out there (and rambling at this point). I'm not even sure why these things might differ between groups (except for the entitlement piece and maybe the working with head vs. body part (assuming that higher income/education = mental work and lower income/education = manual labour which is probably an over-generalization)) - they are just ideas based on discussions I've had with people who would fall within the cohorts with the highest epidural rates. We talk about childbirth at work a lot - I work in a female dominated area of health care (more than 85% of the employees at my workplace are women) where someone is always pregnant or returning from mat. leave, and those who's children are older still love to talk about their experiences. It's definitely educational! And entertaining!
And to add to that - I don't know where you are, but 'term' is classed as different things in different countries. In the UK it's 38 weeks and in France it's 41. The WHO classes full term as up to 42 weeks, so... don't be bullied anywhere before - but do get your checkups if you feel reduced movement.
I guess there are different takes on 'educated' too - I am well educated, but I knew nothing about pregnancy or childbirth till I became pregnant. And since then I've educated myself in PREGNANCY and CHILDBIRTH. I've written a lot about natural birth on my blgo, because seriously, I can't believe how blindly people go in to it. Like someone who went in to hospital in labour and was surprised by a chart on the wall with 'optimal birth positions'. She thought - get this - that you have to use stirrups by law. I had a home water birth and I'd not exchange our beautiful, almost bloodless, beautiful peaceful gentle birth for anything in the world. Great post as always.
It surprises me that you would be shocked by a woman's ignorance, considering that you also knew nothing when you became pregnant. But I guess there's a world of difference between starting the process ignorant and showing up at the delivery room that way.
I can understand going into labor ignorant. We live in a culture that expects doctors to be in charge of our health and to trust them implicitly. This means we can just be "along for the ride" if we want to be. I'm not saying it's a good idea, but it is possible within our system.
What amazes me are some of my friends who seriously had no idea what was done to their newborns after birth - drops, K shot, and Hep B. I remember telling a friend that we refused the Hep B vaccine, and she said, "Oh, I'm not sure my daughter got it." I asked her, "Did you refuse it?" She said no, which means that she got it. There's no way the hospital wouldn't have hounded her and asked her multiple times if she didn't want it (they came in a few times a day with the forms and the vaccine, and we had to say no every time). I think if you choose to vaccinate (and we do as a whole, we've only refused Hep B and the chicken pox vaccine) you should know what they are getting and be aware of the risks.
[...] epidurals, the majority of women in midwife-led units were happy with their pain relief Are we using our brains when it comes to epidurals? | PhD in Parenting www.phdinparenting.com A 2009 study called Social disparity and the use of intrapartum epidural [...]
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I am just reading this now. I haven't read through all the comments, so I don't know if it has been brought up or not so I'm sorry if this is repeated information.
I have serious problems with the conclusion of this study, particularly as a sociologist. Now I haven't actually read it, mind you, just what you have presented here. I do not know how they can use "neighbourhood" statistics to determine whether or not women were coming from high income/education brackets. The only thing that can determine what education and income level a woman has is her actual education and income level!!! So I have a serious problem with using where you live to indicate your education-income. While only an anecdote, I am educated (PhD) and believe to have a high income to boot. As does my husband. However, we live in a neighbourhood that would be considered "working-class." Yes, we could probably live in a place more "educated/rich" but we choose to live here. We have lower mortgage and therefore have more money to save for things we want (vacation, retire, education for our children, etc). We can't be the only ones who live like this - especially since one of our neighbours is an engineer with a master's degree and I know of other friends who are purposely living in areas "below their means" (is that the right expression?) and therefore the "neighbourhood" in which they live does not tell the story of their education or income. Moreover, there has to be lower income/less educated women who live in "better" neighbourhoods. For instance, if one lives with their parents or renting. Again, is it just me that has a problem with this as measure of a woman's education/income level? If the measure is problematic then the conclusions are problematic as well.
By the way - I gave birth - without epidural - at home. And research indicates that women who give birth at home are more likely to be educated (bachelor degree or higher) - and that's *her* education - not the neighbourhood she lives in!
Hi there, it's a late respond but I would lake to share how it's done in the Netherlands. I'm Dutch and a natural birth is 'the normal way' in this country. An epidural is not even possible if you're in a small hospital during the night. A third of all births are at home: if you don't have medical problems, you can chose between at home or hospital. A midwife helps you at home or in the hospital. Most midwives promote the natural birth at home, simply because that's their business. When you're in trouble, a gynaecologist is called onto the case. Twenty percent of the births is with epidural - you can't have an epidural with the midwife, certainly not at home, but in the hospital there has to be a anesthesiologist too and he won't be there in that small hospital in the middle of the night.
I chose to give birth at the hospital. That's only for the last hours by the way, giving birth to my son took 24 hours, only the last 4 hours were in the hospital. My daughter was a bit quicker: 12 hours, of which an hour or less in the hospital. You can call the midwife if: your contractions occur with a pause of 3-5 minutes, AND last more than a minute, AND it has been like this for an hour. Because then it's serious business, then they will come and check you out. And then the midwife tells you if it's time to go to the hospital. So I chose the hospital because I wanted to be more special care around when giving birth. Too many women want to give birth at home and are rushed to the hospital in the latest stage of giving birth - in my opinion, anyway I didn't want that. So I preferred the hospital, and was glad that I did. No epidural, that wasn't even possible. And yeah, I screamed for it. There was no time in between the contraction. (We call that a 'contraction storm'?? so there's no pause, you don't know when a contraction starts or ends.) Luckily I had two darling nurses in the hospital (I wouldn't have had them at home) who motivated me, helped me breathing, prepared the baby's clothing, because, yes darling, you're almost there. Still I would have preferred an epidural, because I didn't know when to push, I didn't have any energy left, I do not recall that whole last hour, I was totally knocked out and I don't think that is the best way (mentally and medically speaking) to give birth. So I talked about this with the midwife during my second pregnancy, and yes, it was possible to have an epidural, but only during the day or in a hospital in another town. I was not heavily traumatized and decided to 'see what would happen'. The second time around was a lot easier. It was nighttime, so no epidural, but I didn't need it anyway, it was a lot easier.
The problem here is: we don't have a choice. There will be in a few years I guess, but right now the epidural is simply not available everywhere. There's a lot of discussion about this and very often we refer to the USA, because 'you girls' have a lot of epidurals and c-sections, even when it's not necessary! Well, that's what they say around here, I think it's not that simple. But I want to be able to do it my own way and I think that's what we all want. Doing it your own way makes it a lot easier, it is as simple as that.
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Rebecca, I am a birth doula and Registered Massage Therapist in New Brunswick, Canada, and I do a lot of work with prenatal clients. In general (both for prenatal work and "general" work), I do find that athletes have not only a higher pain threshold, but are MUCH more in tune with their bodies than the "average" person. That means that they can recognize the difference between pain that says "that's a little intense (spicy is what I call it), but it'll feel so good later!" versus "Uh oh! That's BAD! Leave that ALONE!!". I see a definite "plus" to going through labour with an athletic background! Unfortunately, I don't have any data to back it up with, but I think it's a viable concept.
I agree with the "fear of pain" concept, too, and the dissociation from your body. Our society is constantly teaching us to dissociate from our bodies and "stay in control", and yet, with labour, we NEED to be connected with our bodies! Also, women in labour need to shift from their "modern/thinking" brain into their "primitive/intuitive" brain. If a woman is not used to releasing control, then they're going to have a hard time with letting go enough to make it into their "primitive" brain. If a woman doesn't get (or stay) in her "labour" brain, labour is harsher, pain is felt a lot more, and labour takes longer. That could quite likely push a woman into having an epidural, even if she had all the best intentions in the world of avoiding one. In the end, though, it's all up to the situation, and what's best for the mother and baby. Penny Simkin has a really good say on the difference between pain versus suffering: http://www.youtube.com/watch?v=rlj9ehB-hLc
I think the idea of entitlement is interesting, too. In fact, "modern" obstetrics really started with the advent of "twilight sleep" - basically women were drugged so that they 1) were given memory-wiping drugs and had their memories blanked, 2) were so stoned they had no control over themselves and had to be, literally, tied up, and 3) when it came time for birth, they were tied in the lithotomy position, and had the doctor pull their babies out with forceps. Women went through this, not only willingly, but specifically REQUESTED it, because of the promise of no (remembered) pain. This was before the advent of any form of health insurance, so only well-off women could afford it. It then became a form of a status symbol. At the same time, obstetricians and physicians also put forward a propaganda campaign which portrayed the local midwife as a dirty, uneducated, ignorant woman who was really putting babies and mothers at risk. This combined effort served to practically kill natural birthing in North America. Read "The Birth House" - it gives a very good description of the struggle. I think we are going through something similar with epidurals.
By the way, my personal view of epidurals and all forms of medical pain management is this: They are tools, just like any tool in my "labour toolbox". I promote using support and natural methods first, mostly because they are effective and because they don't have any side effects! If a woman gets to her "breaking point", where the pain is about to turn into suffering and the natural techniques just aren't doing the job, then it is time to look at using other options, and it is totally appropriate to do so.
Oh, and I completely forgive your "online faux-pas", Annie! :)