The January 11, 2012 Slate.com article “The Truth About Epidurals: Are they really so bad?” by Melinda Wenner Moyer concludes with this paragraph:

“Women shouldn’t cave to pressure from either side.” [Of the 'mommy wars' between natural birth advocates and pro-epidural advocates] “They should make informed decisions based on their goals and priorities. I aspired to have a comfortable birth even if it meant being surrounded by nurses and doctors and tubes and incessant beeps; other women may trade pain for a more intimate birthing experience. Each choice comes with its own benefits and unpleasantries. My unnatural childbirth left me with a memory that does not involve intolerable pain, and that’s exactly what I wanted.”

I’m concerned about this piece for a number of reasons, but the most significant are summed up in this paragraph, so I’d like to start here.

I agree that women should make their own best and informed decisions. I object to the continued polarization of “us” and “them.” I also disagree with the characterization of the options as choices between benefits and “unpleasantries.”  This minimizes the fact that we must weigh benefits and risks when considering birthing options. This includes risks to babies as well as ourselves. Thus, while the decisions very well may be based on “goals and priorities” I would argue that the highest priority must be the health and well-being of the mother-baby dyad. Reducing the choice to that of comfort vs. an “intimate” experience ignores that many women choose natural birth not because of the “experience” but to minimize risk.

Intervention was introduced for a valid reason and, when used appropriately, has the potential make a difficult birth better. That does not mean every intervention is appropriate for every situation. When used inappropriately, every intervention has the potential to also cause problems. This includes epidurals and other labor drugs. To suggest otherwise is disingenuous and a huge disservice to those trying to make an informed decision.

Wenner Moyer mentioned studies in her article, but failed to cite them. I did not find her references, but she was correct in her assertion that the evidence is “inconclusive.” The vast majority of studies do say that rates of surgical deliveries increase due to a multitude of reasons involving epidurals. A handful suggested otherwise.

The Cochrane Collaboration, the largest independent collection of available medical studies, encapsulated in A Guide to Effective Care in Pregnancy and Childbirth, states:

“In women with epidural analgesia, both the first and second stages of labor are longer, and oxytocin use, malrotation and cesarean sections are more frequent.” (Enkin, et al p. 291)

The Cochrane Collaboration last updated in 2011 states:

“The review identified 38 randomised controlled studies involving 9658 women. All but five studies compared epidural analgesia with opiates. Epidurals relieved labour pain better than other types of pain medication but led to more use of instruments to assist with the birth. Caesarean delivery rates did not differ overall and nor were there effects of the epidural on the baby soon after birth; fewer babies needed a drug (naloxone) to counter opiate use by the mother for pain relief. The risk of caesarean section for fetal distress was increased. Women who used epidurals were more likely to have a longer delivery (second stage of labour), needed their labour contractions stimulated with oxytocin, experienced very low blood pressure, were unable to move for a period of time after the birth (motor blockage), had problems passing urine (fluid retention) and suffered fever. Long-term backache was no different. Further research on reducing the adverse outcomes with epidurals would be helpful.” (Anim-Somuah, Smyth & Jones, 2011)

Cesarean rates did not increase overall, but the risk of cesarean section for fetal distress was increased. The experience of very low blood pressure often leads to fetal distress which leads to surgical birth. If a complication can be directly attributed to the epidural, and it leads to emergency surgery, is the surgery then considered due to a medical complication instead of the epidural, even though the complication would not have occurred in the absence of the epidural? If a study does not compare natural birth to medicalized birth, how can any conclusions be drawn about how the interventions impact a birth?

And does it matter if the research is possibly tainted by special interests anyway?

Dr. Marcia Angell, the Editor of the New England Journal of Medicine, said in 2009:

“It is simply no longer possible to believe much of the clinical research that is published, or to rely on the judgment of trusted physicians or authoritative medical guidelines. I take no pleasure in this conclusion, which I reached slowly and reluctantly over my two decades as an editor of The New England Journal of Medicine.” (Angell, 2009)

When looking at the evidence in trying to make a decision as important as that regarding the long term health of our children, this should lead consumers to ask: Where is the funding for a coming from and who is performing it?

Who loses revenue if tools like epidurals are used sparingly? I hear a lot of disparaging remarks about natural birth advocates, but what do they have to gain by questioning the safety of labor drugs?

Wenner Moyer suggests that we compare the objective evidence with “…the reassuring words of obstetricians and anesthesiologists who tout epidurals as being completely safe.” What makes her think that her doctor or anesthesiologist is making a recommendation on scientific evidence anyway? Reading the summary of ACOG recommendations for suspected fetal macrosomia (big baby) 2/3 of obstetrical recommendation not evidence-based. (Chatfield, 2001) A Guide to Effective Care in Pregnancy and Childbirth reveals this is hardly unusual.

If we are only asking “Do epidurals effectively reduce or eliminate pain?” and “Is there 100% consensus on safety?” Wenner Moyer’s article addresses those questions. That is also providing that the only thing one is concerned about is whether the mother will end up with a surgery that has a 5 times greater mortality (death) rate than natural birth. But what about other consequences of epidurals, like the increased risk of maternal fever, slowed labor, augmentation, vacuum or forceps assisted delivery, and perineal tearing? (Childbirth Connection, 2011.)

If the debate is framed in such a way as to present the only choice as excruciating pain or “completely safe numbness”, it would seem illogical to opt for natural birth as opposed to “risk-free” drugs. Except that isn’t being honest, there is no such thing as a “risk-free” drug, and these extremes aren’t our only options.

When women are confident that they are fully capable of making the best decisions for themselves, because they made their decisions on the actual events specific to them and not an imagined potential reality, they tend to feel good about their choices. Becoming a mother comes with enough challenges without having to deal with ones that might have been avoided. One of the best ways to avoid the pitfalls is to take an independent childbirth class and educate yourself fully on your options.

References:

AIMS. (Alliance for the Improvement of Maternity Services): Drugs not FDA approved for obstetrics http://www.aimsusa.org/ObstetricDrugs-NotApproved.htm

Angell,M., 2009. Drug Companies & Doctors: A Story of Corruption. The New York Review of Books. http://www.nybooks.com/articles/archives/2009/jan/15/drug-companies-doctorsa-story-of-corruption/

Anim-Somuah M, Smyth RMD, Jones L., 2011. Cochrane Supparies: Independent high-quality evidence for health care decision making. Epidurals for pain relief in labour. http://summaries.cochrane.org/CD000331/epidurals-for-pain-relief-in-labour

Chatfield, J., ACOG Issues Guidelines on Fetal Macrosomia, Am Fam Physician. 2001 Jul 1;64(1):169-170. Retrieved from http://www.aafp.org/afp/2001/0701/p169.html

Simkin, Penny. “Best Evidence: Labor Pain | Labor Pain :: Childbirth Connection.” Childbirth Connection: helping women and families make decisions for pregnancy, childbirth, labor pain relief, the postpartum period, and other maternity care issues.. N.p., 30 June 2008. Web. 7 Feb. 2012. http://www.childbirthconnection.org/article.asp?ck=10183#epidural.

Enkin, M., Keirse, M., Neilson, J., Crowther, C., Duley, L., Hodnett, E., Hofmeyr, J., A Guide to Effective Care in Pregnancy and Childbirth, 3rd edition, 2000. Oxford University Press, USA.

Wenner Moyer, M., 2012. The Truth About Epidurals: Are they really so bad?  Posted Jan. 11, 2012, at 3:28 PM http://www.slate.com/articles/health_and_science/medical_examiner/2012/01/the_truth_about_epidurals.html