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Friday
Feb262010

Are we using our brains when it comes to epidurals? 

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

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Reader Comments (104)

Another possible con of an epidural is complications with breastfeeding, should some of the other cons arise. For instance, the women I know who had spinal headaches from epidurals had a lot of trouble breastfeeding b/c they had to lay on their back for weeks while the hole healed (blood patching doesn't always work). We also know that c-sections can cause at best a delay in breastfeeding.

February 26, 2010 | Unregistered CommenterMZ

I have to agree. I was induced with my first (9 days late, so at least over that one week guideline), but with more education I would have really pushed for monitoring and one more day, as I was in light labor already. Probably could have done without the pitocin that lead me to need an epidural if I had known better.

I'd had hopes for my later pregnancies, but the second was an urgent C-section, and the third, a hoped for VBAC turned out to be a C-section for breech. But now I know enough that when I talk to other moms I can help them to consider whether that epidural is really needed.

In Australia (and I'm assuming elsewhere with similar health systems) the c-section rate is higher in private hospitals than the larger public hospitals. I suspect this is at least partly due to higher levels of epidural use in private hospitals. Anecdotally, it can take longer to get am aneasthetist in a public hospital, and labouring women are also more likely to be left alone in the early stages. They are also less likely to be induced because their pregnancy is managed by midwives or a GP instead of an ob/gyn. Women with higher education levels are more likely to have private (expensive) care. So, whilst a greater tolerance of pain and exertion amongst 'blue collar' women may be a factor, I would question whether these women are afforded the same ready access to epidurals in the first place. This might be one case of less access to healthcare actually being a positive for some individuals.

February 27, 2010 | Unregistered CommenterSpilt Milk

I did not have an epidural with either of my babies, but they were both very fast labours. My second child, for instance, was born 45 minutes after I arrived at the hospital - there wouldn't have been time. I was never offered an epidural, again I think because my labours were both fast and I was never induced. So I can't really comment on choosing one.

I wonder if there are other differences in care between the two groups. For example, are more educated women more likely to see one type of care provider over another? Are they more likely to be induced, or experience other interventions that may lead to a higher rate of epidural anesthesia? I think that sometimes the way that care is delivered varies with the patient, because of biases or fears on the physician's part. After all, doctors are people, too. For instance, I understand that doctors often treat other physicians differently when they are patients, or lawyers who they fear may be likely to sue them.

February 27, 2010 | Unregistered CommenterAmber

Split Milk:

This study was done in particular in Canada because that could be excluded as a factor due to our public health care system. There were differences between teaching hospitals and non-teaching hospitals and between rural hospitals and urban hospitals, but they accounted for those factors in the analysis of the data and were comparing apples with apples.

February 27, 2010 | Unregistered Commenterphdinparenting

While I agree that the presumptions are certainly biased, your conclusion is as well.
I had an epidural, at 0cm in preparation for induction, I was able to get up to use the bathroom, I did tear but that was a known risk and I honestly can not blame that on the epidural, as the OB and midwife did perineal stretching throughout labor, and I could still feel that I was having a contraction, but it wasn't painful. I even squatted to deliver, with the help of my husband and midwife. I agree that there are risks and benefits to an epidural, but I think the problem is more in the fact that no one actually agrees on what those risks are. A 2005(?) Northwestern study suggested that the long held belief that epidurals a)increase the length of labor and b)increase the risk of c section are invalid. I recall this from when I was pregnant with my daughter in 2007, so I don't know the current follow up to the study, maybe you have more current information? I think the idea that epidurals are the right choice for everyone is wrong, but the anti epidural movement isn't right for everyone either. Every medical intervention, or lack thereof has risks and benefits.

If both camps could get together to study the REAL risks and benefits it would go a long way in helping mothers make the best choices. Sure, some of the things the doula you cited mentions are possibilities but how much of a risk, and are there other risk factors for those things? ie is a spinal headache more likely in an obese woman? does waiting until 4 cm dilation (the current standard, I believe) make a difference in any side effects? saying it is a risk isn't enough, a mother needs to know if 50% of women have this complaint or less than 1%, who is doing the study? is every woman who had an epidural at a particular hospital surveyed or just those who volunteered to discuss problems with theirs?

February 27, 2010 | Unregistered CommenterRebekah

as an addendum: I was 42 weeks, and had copious amounts of meconium in the fluid as well as a degrading placenta. the induction was medically necesarry.

February 27, 2010 | Unregistered CommenterRebekah

Rebekah:

I'm not familiar with the study you mentioned, but if you find a link please do post it here.

I don't have it with me now, but I found one of the best books for more detailed information on risks and benefits was Henci Goer's http://www.amazon.com/gp/product/0399525173?ie=UTF8&tag=phdinpar-20&linkCode=as2&camp=1789&creative=390957&creativeASIN=0399525173" rel="nofollow">Thinking Woman's Guide to a Better Birth.

February 27, 2010 | Unregistered Commenterphdinparenting

I'm not sure if your assumption that white collar women can't cope with pain is valid at all, though it does seem quite insulting (I've met some incredible stoic blue bloods and some reall whinging miserable deserving poor) .... but socio-economic status aside, all labouring women deserve effective pain relief when required/requested.
Another consideration which might be valid is rates/uptake/availability/quality of pre-partum education between the different groups. Pre natal education does inform about pain relief strategies during labour but also will cover (I hope) analgesia available, pro's and con's, outcomes, delivery, etc. Without this kind of information, the idea of needle inserted into your back for pain relief is terrifying - the much more common needle into the backside seems less so.
One of the many things running thru my mind as my baby ground his way face-first outwards thru my pelvic canal was what kind of pain control was going to be best for us both since the situation was rapidly spiraling out-of-control. On offer were gas-and-air, systemic analgesia e.g. intramuscular narcotics, and an epidural. Epidurals terrified me (maybe something to do with having administered a fair number in my time), but our pre-natal education told us that the epidural was the least invasive in terms of drug getting into the neonatal circulation. Having been a pethidine blue baby at birth myself it's not something I wanted to inflict on my child. The pethidine slowed my respiratory rate leading to seclusion from my mother and a subsequently difficult breastfeeding relationship, formula feeding and all its sequelae.
In summary I chose an epidural precisely because I was educated, in great pain and hoped to deliver an alert, viable baby who would breastfeed/bond ASAP.
Yes, I am white collar; no, I don't have manicured nails; I like shoes; I've worked in both the City (with a capital C) and rural locations; I've seen/experienced adversity but still consider myself comfortably off; I delivered a healthy baby who was alert enough to breastfeed within 30 minutes and build his strength up enough to survive a harrowing 11 days with his own post partum issues. I'm glad I thought of his welfare rather than my own vanity birth plan.

February 27, 2010 | Unregistered Commenterebbandflo aka pomomama

Interesting and thought-provoking as usual, Annie, and I agree that the assumption that epidural is the clever choice bears examination, for all the cogent reasons you cite.

I do, however, also agree with ebbandflo above - I think your language around the pain tolerance of women of higher socioeconomic status is unnecessarily belittling, and equally as unlikely to represent the true picture (no doubt a complex one) as the insouciant idea in the study that "if women are better educated, they'll choose epidural - The Smart Mum's Choice." Furthermore, I'd also suggest that yes, pain tolerance is one reason why some women might choose epidural, but in fact, it is not an invalid one. Despite the popular scorn heaped on individuals with low pain tolerance, the fact remains that ability to cope with pain varies. Little is achieved by trying to push people beyond their thresholds for the sake of an ideal, especially at a time such as birth, which is rife with so many other emotional stressors and delights, and is immediately followed by a period where the mother's reserves will be called upon intensely as she bonds with her newborn.

My personal disclaimer here is that I had three spinal anesthetics (not epidurals - full spinal blocks) to deliver my three daughters via caesarian sections, and while the first two deliveries were emergency c-sections where spinal was the safest and best choice, I deeply regret the third spinal (and third caesarian, in fact), as it caused permanent nerve damage to peripheral nerves in my cervical spine. I was educated, but also afraid - too afraid of uterine rupture to attempt a VBAC last February after two previous c-sections, especially as my second delivery, an attempted VBAC, had failed after 21 hours of (unmedicated, naturally commenced, midwife-supervised, mobile) labour. Third time around, I wasn't afraid of the pain - I was afraid of losing my baby or my own life. I now believe I should have taken the (small) risk and tried. But hindsight is always 20/20, isn't it?

February 27, 2010 | Unregistered CommenterKathy

I agree with many of the others here, Annie. While I understand your arguments against the study you mentioned and agree that assuming education = greater uptake of epidurals is a false dichotomy, the language you use to describe 'white collar' and 'blue collar' women is full of assumptions as well. Being well-educated does not automatically translate into being well-paid, so claiming that all white collar workers are rich is simply false. Unless by 'well-educated' you mean educated to the level of a master's or doctorate degree in a male-dominated field that pays significantly more than those which are care or service-oriented and considerably less well-paid, of course. I have a bachelor's degree so if that's considered 'well-educated' then I don't fit your 'rich' stereotype. Nor do I (or many other women) fit the (rather insulting, frankly) generalisation of the shoe-and-looks obsessed, well-groomed, weak, urban woman who hasn't done a days' "real" work in her life. Similarly, not all blue-collar women are salt-of-the-earth, no-nonsense, vanity-less broads who work with their hands and don't suffer fools gladly. Your breathtakingly prejudicial comments reduce both types of women to their patriarchy-approved stereotypes: the delicate flowers vs. the noble savages. Neither are helpful. I'm disappointed in this post.

February 27, 2010 | Unregistered CommenterNoble Savage

"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."

I think your posts would carry a lot more weight if you didn't lower yourself to these kinds of "too posh to push" statements. This kind of thing is truly insulting, and I think alienates the very people you're trying to reach.

I also take issue with the implication that if everyone knew the risks of epidurals, they wouldn't get them. I knew the risks. I got one because I needed it.

February 27, 2010 | Unregistered Commenterzchamu

ebbandflo:

I’m not sure if your assumption that white collar women can’t cope with pain is valid at all, though it does seem quite insulting (I’ve met some incredible stoic blue bloods and some reall whinging miserable deserving poor).

I was poking fun at my own socioeconomic cohort and my own reasons for choosing an epidural the first time around. I'm sorry if you find it insulting. I was trying to inject a bit of tongue-in-cheek humour into an otherwise serious topic. Choice of words aside, my experience has been that women in my socioeconomic cohort are very likely to opt for an epidural before even getting close to the point of feeling they need one because we get told that if we don't get it early, it might be too late.

Another consideration which might be valid is rates/uptake/availability/quality of pre-partum education between the different groups.

Yes, that was raised in the study as well. They said: "In addition, women in socioeconomically disadvantaged groups were also more reluctant to attend antenatal health education classes.31 Attending antenatal classes could make pregnant women more aware of available pain relief techniques and could result in higher epidural rate as well.32" However, I would question whether the women who do attend antenatal health education classes are getting a balanced view of pain relief options during labour or if they are getting the hospital's view that an epidural is the way to go. Each class is different, obviously, but it seems the majority of women around here go to the classes taught by the hospital, buy books like "What to Expect When You're Expecting" and talk to their OB/GYN about pain relief, which might give a very different perspective than going to a class taught by a doula, working with a midwife, or reading books about natural childbirth.

One of the many things running thru my mind as my baby ground his way face-first outwards thru my pelvic canal was what kind of pain control was going to be best for us both since the situation was rapidly spiraling out-of-control....

It sounds like you made an educated and appropriate choice in your situation (not that you needed me to tell you that, but just in case you think I'm condemning all epidural use, which I'm not). My big objection is the assumption that an epidural is always the smart choice, because I don't think it is. As Penny Simkin says in the article I linked to in my post: "When the mother is managing her pain well and progress is normal, the risks of an epidural outweigh the benefits. If, however, she is exhausted, in extreme pain or requires painful interventions, the benefits may outweigh the risks."

February 27, 2010 | Unregistered Commenterphdinparenting

zchamu:

I didn't say that if everyone knew the risks of epidurals, they wouldn't get them. I do, however, believe that if more people were educated about the risks of epidurals and understood more about pain in childbirth and how to manage it, that fewer epidurals would be requested. Epidurals have a place, but like many things I believe they are being overused.

February 27, 2010 | Unregistered Commenterphdinparenting

Noble Savage:

The study looked at neighbourhood income characteristics and neighbourhood education characteristics. So no assumption was made that highly educated = rich or vice versa. Both were looked at independently and education had a higher influence on epidural use than income did, but both played a role.

Here is a screen capture of that portion of the data:

http://www.phdinparenting.com/wp-content/uploads/2010/02/27-02-2010-9-29-47-AM.jpg

They looked at quintiles, not specific levels of education, so I can't say which quintile refers to bachelor's degree, which one to master's degree, etc.

February 27, 2010 | Unregistered Commenterphdinparenting

Kathy:

I agree that pain is not an invalid one. In my case, I chose an epidural the first time out of fear of pain. I was scared into believing that if I didn't get an epidural right away (I was 6cm when I arrived at the hospital and not in any pain yet), that it would be too late. Not knowing what to expect and being very fearful of the pain that was sure to come, I signed up for an epidural before I was in any pain at all.

February 27, 2010 | Unregistered Commenterphdinparenting

MZ

I agree. My son was 8 weeks old when he latched on for the first time. I know our troubles were partly due to tongue tie, but they were likely compounded by the fact that he was so sleepy after the birth in which they pumped copious amounts of epidural into me (the normal dose wasn't enough and they had to keep upping it until I was finally "frozen").

February 27, 2010 | Unregistered Commenterphdinparenting

Amber:

Those are all good questions and I don't have answers to all of them! But I can answer some. In the study, among women who had an obstetrician as their health provider, 62% had an epidural compared with 43% epidural use among women who did not have an obstetrician (note: they do not say whether the ones who didn't have an OB had midwives, no provider, some other provider). The poorest, least educated women were about 5% more likely to have an OB than the richest, most educated (all groups were in the 74 to 79 percent range for OB use).

February 27, 2010 | Unregistered Commenterphdinparenting

I would venture to guess that women of lower socioeconomic status (especially in rural areas) are more likely to have seen animals give birth, and thus understand birth as a natural process, not a medical condition. I know that's the case for me, and I know if my horse, goats, sheep, cows, etc. can all do it without any pain relief, then so can I.

February 27, 2010 | Unregistered Commenterabbie

I love this comment Abbie. Thank you.

I'm sure exposure to the way things happen in nature certainly does help. It is sad that we view pregnancy and birth as a medical condition (especially when it gets called a "pre-existing condition" and is used as a reason to refuse insurance to women in the United States).

February 27, 2010 | Unregistered Commenterphdinparenting

Though I guess as an adendum I should at that I'm not of a lower socioeconomic status and my level of education is a MS degree, so I guess I would fall into the "white collar" group. But my upbringing (and preference for that matter) is notably blue collar.

February 27, 2010 | Unregistered Commenterabbie

I thought it was interesting that 2/3 of first time cesareans are due to "failure to progress." I didn't have an epidural (I was at home), but my labor was 44 hours and would have probably fit in the "failure to progress" category. I'm glad I was home and patient enough to just wait. Not everyone is going to fit in the 12-hour-average.

February 27, 2010 | Unregistered CommenterTopHat

TopHat:

Yeah...I fit into the 9 day category in my second birth! I was having regular contractions every 2 minutes, went to hospital to get checked and was only 1cm dilated. They didn't want me to go home. Wanted me to stay at the hospital, but not check in yet. I hightailed it out of there and came back 9 days later when I was 6cm dilated.

February 27, 2010 | Unregistered Commenterphdinparenting

I wonder how much the economic part affected the study, from the point of view that the poorer women are less likely to have good health insurance and may have been discouraged from having epidurals because of cost, either in her own mind when calculating rent and groceries, or by the medical personnel. Who knows?

February 27, 2010 | Unregistered CommenterFangedFaerie

FangedFaerie:

That has been a factor in past studies that were referenced in this one. However, this study in particular was conducted because that factor would not play into it. All women in Canada have insurance that covers the use of epidural during birth and as a result a Canadian data set was used to study whether factors other than insurance/cost affects the decision.

February 27, 2010 | Unregistered Commenterphdinparenting

Ah, I see. Interesting, and thanks for the clarification!

February 27, 2010 | Unregistered CommenterFangedFaerie

To be fair, if someone made a joke about "crunchy granola birkenstock-wearing armpit-hairy women with babies in slings" not wanting epidurals because of their obvious assumed beliefs, people would take issue with it too. KWIM?

February 27, 2010 | Unregistered Commenterzchamu

Geez with the typos. Pregnancy brain! I'm 38 1/2 weeks, and I'm guessing I should stop typing anything for a while :)

February 27, 2010 | Unregistered Commenterabbie

I believe in manicured nails and comfortable shoes ;) . At my pre-natal classes I was told I could have any type of birth I wanted. I had a fair idea of the pain that would be involved (I miscarried my first) and I have a good pain tolerance. The other 2 people with me --my cousin and DH, had gone to the same classes, etc.

I started having lovely painful and very irregular contractions at 35 weeks. So when I finally got regular contractions every 5 minutes for 1 hour I was over the moon!

We get to the hospital and I was 8cm! I was was thrilled, in my mind 2more cm meant that it would be a quick labor. I got to the hospital around 12-1am. I was being vocal --the hmming, the low moans (as told to be by my pre-natal classes). The nurse recommended Fentanyl as it would take the "edge off" and not affect the baby.

Things after that get fuzzy. I remember my water breaking and then I remember a nurse talking me through the contractions while they were putting the epidural on (my cousin said it was about 12 hours after I checked in). After that the contractions stopped and I was given Pitocin.

Claudia was born a little before 3pm, using vacuum and me getting an episiotomy. The dr said she would try 3 times with the vacuum and then it was C-section for me. Claudia came out on try #2.

To me looking back, the nurses wanted me quiet but besides monitoring they did nothing else until it was time for the epidural. My cousin and DH were probably in the "deer/headlight" category and could have used a push from the nurses to do what we had learned in the classes. When the nurse came in to help with the contractions I remember thinking, "hey, this is what should have been going on before".

In our first family portrait, DH is holding Claudia and I am in bed. I am completely swollen up, to the point that my eyes are puffy. That was a LOT of IV fluids --that I also had not wanted.

So the point of this comment? yes, I am well-educated, I went to the classes, and I am a SAHM thanks to DH well paying job. I didn't WANT the epidural but I got it anyways. My theory on this is that women in my camp are more likely to sue, thus they get all the interventions. But this is my thought before my morning coffee, and I come from sue-happy USA.

February 27, 2010 | Unregistered CommenterAndy

Oh dear! 9 days! I shouldn't have read that with my due date so soon...

February 27, 2010 | Unregistered Commenterabbie

I think you are generally such a serious & 'textbook' writer that when you tried to be joking/humorous/sarcastic with your comments of the "manicured nails" it just didn't come across correctly!! Definitely do not stop writing for your blog. But maybe you're just not meant to be a tongue-in-cheek writer? And that's okay!

With regards to the topic, the only thing you can really take away from this is if you wanted to spend time or money educating individuals about the risks of epidurals, then you'd target the rich, educated neighborhoods.

February 27, 2010 | Unregistered CommenterAlina

Even if it was the "crunchy-granola" woman herself? I thought the "rules" of comedy were that you can make fun of yourself, but not others (e.g. Jews can make Jew jokes, blacks can make black jokes, lesbians can make lesbian jokes, but people who are not part of those groups cannot make fun of them)?

February 27, 2010 | Unregistered Commenterphdinparenting

The 9 days was frustrating, but the contractions weren't that painful during that time. The way I see it (in retrospect) was that those 9 days were fully preparing my body for the birth, which then happened quickly and fairly easily.

February 27, 2010 | Unregistered Commenterphdinparenting

Alina:

You must be forgetting my post about your United Airlines experience. ;)

http://www.phdinparenting.com/2008/07/29/when-breastfeeding-is-a-safety-hazard/" rel="nofollow">When breastfeeding is a safety hazard

February 27, 2010 | Unregistered Commenterphdinparenting

I am not sure than any of the assumptions that were made are correct at all. At least not in the town that I am from. My husband and I chose to attend the more expensive Natural Birthing Pre Natal classes. The families that attended these classes were definately older and from a higher socioeconomic class. These VERY educated women were choosing to not have interventions and be more educated in the pros and cons of all their options. This being said the women who live in my town are pretty outdoorsy and active, (Not the high heel,manicured type mentioned above). I wonder if it is the lack of adversity faced in life that increases rates??? It makes sense. The whole Outward Bound program is based on this philosophy.

The other thing that I thought may increase the rate of epidural use in higher socioeconomic group women could be that professional women are getting more used to controlling situations and needing to be in control of situations. They are less likely to just deal with things as the come and be able to relinquish themselves to the birthing process than women who do not hold such positions of control in their lives (general workers following instructions Vs. Managment makeing decisions).

Though I was looking to have, and 'planning' for a natural birth free from chemicals, in the end I did take the epidural. I fought the doctor who wanted to induce me instead allowing my daughter to 'cook' until SHE was done. But even with going into labour naturally I got an epidural, not because I was more educated or anything other than the fact that I had a 24 hour labour with 12 hours of it being strong contractions every 2 minutes overnight. By 7am the next morning I did not have anything left to give, I have been puking all night and really needed rest if I was going to deliver at all. Turns out I had a hard time letting go of tension as well and that was part of things, I was not relaxed enough. After 10 hours of 2 minute contractions I was only 2 cm dialated. Once I had the epidural I actually progressed very quickly to 10 cm (within 30 minutes). I did then require other interventions as there was muconium in the fluid so the doctor helped get her out with the vacume. Looking back I wonder what if, but deep down I know that though it was the right decision for me. Maybe next time I will be able to get more rest in the early labour stages so that I have the energy to finish strong. Who knows. We will have to wait and see.

All this being said my daugther is a healthy happy very bright little girl and I think that she is no worse the wear for it. She did not come out with a big bruise or bump on her head and I am pretty sure that they did not need to pull on her to hard to get her 'unstuck'. I think that everyone is different and every labour is different, to paint those who choose an epidural as either 'smarter' or 'unwise', weak or anything else is unfair. There are a lot of active strong intelegent women who choose to have an epidural and there are a lot of active strong intelegent women who choose not to or never get the chance at an epidural because their labour goes too fast. All I say is that Women should look at all their options, the pros and the cons and if they are going to make a birth plan do not be too set in it as nothing ever turns out as you imagine when a baby is involved.

February 27, 2010 | Unregistered CommenterWanted Natural

Wanted Natural:

Those are all very reasonable points. Thank you for your comment.

February 27, 2010 | Unregistered Commenterphdinparenting

Andy:

I was so glad to have my doula there to remind me of the things that we should have remembered from our reading. The "deer in headlight" thing is very real and she provided the balance, calm, and reminders that we needed.

February 27, 2010 | Unregistered Commenterphdinparenting

That study is so frustrating to me. Epidurals are not always the "smart" choice! Sometimes, they do make sense. But not always!

I would argue that women who are fully educated on the natural birth process would be more likely to reject an epidural.

Obviously, having an epidural will cost more money than a birth that doesn't have one. Perhaps women of less means to pay are not offered an epidural (or refuse it) because the money isn't there to pay for one?

February 27, 2010 | Unregistered CommenterKacie

Kacie:

In other countries that might be true. In Canada, however, everyone (rich or poor) has the same government health card that will pay for the epidural. This study was done in Canada for that reason, i.e. to see if factors other than ability to pay affected the reasons why women do or do not use an epidural.

February 27, 2010 | Unregistered Commenterphdinparenting

Oh, and I just saw your response to an earlier comment also discussing the economical impact of this. I didn't realize this was a Canadian study, so that makes sense!

February 27, 2010 | Unregistered CommenterKacie

I personally feel that epidurals are overused. I also believe that there are certain mother's that require it.
My best friend had "back labor" for 24hours. She struggled, and tried to be strong to have a natural birth, but in the end we (including her) knew that she needed the rest and was in far too much pain. She received the epidural and was able to see her birth in a whole other way.

In my case both my kids have been natural. I got to the hospital with my first about two hours before he was born and with my second about 20 minutes before. Although in much discomfort I was able to labor at home for most of the labor.

I'm a nurse at a County hospital in LA and used to work with labor & delivery doctors and nurses. I have heard many stories of them just using the epidural as "routine" so the mom won't be in pain. I think sometimes physicians and nurses push or suggest the epidural right away instead of suggesting she start out trying to labor without meds and comforting and letting her know what a good job she is doing. Another problem is the inability of letting mothers labor in different positions and out of bed. I think if they were able to move around and labor in different positions in the hospital, mom's could find different and personal ways of dealing with their pain. If the mother is truly in an unbearable amount of pain, options can be talked about again and an epidural can be given.

I was kind of going on and on, sorry. Hope this made some kind of sense.

February 27, 2010 | Unregistered CommenterMarcela Beatty

I like all of your points and agree with you. Every labor IS different. Every women in labor IS different.

"All I say is that Women should look at all their options, the pros and the cons and if they are going to make a birth plan do not be too set in it as nothing ever turns out as you imagine when a baby is involved."
^ Excellent point and it rings so true!!

February 27, 2010 | Unregistered CommenterMama in the City

Was there any mention of the race of the poor and less educated women? I don't want to inject racism/discrimination where it is not appropriate, but is it possible that the medical establishment is less likely to offer an epidural to a minority?

February 27, 2010 | Unregistered CommenterAmanda

I so wish I could have had a doula, I didn't even know they existed at the time

February 27, 2010 | Unregistered CommenterAndy

Amanda:

That is a good question. Here is what they had to say about race and culture:

Women from different neighborhood economy and education groups could also have significant differences in race/ethnicity, cultural background, religious background, attitude toward health care, and seeking of perinatal health care. Hispanic, black, and Asian women were less likely than their non-Hispanic white counterparts to have received epidural. 8-10,26 Although similar normal delivery women were equally likely sensitive to pain regardless of their race,27 their culture values may have strong influence on their attitude toward labor pain.28 Asian women considered labor pain to be natural and would like to tolerate it stoically.29 Religious women proved to be less likely to use epidural,15 probably because their religious leaders oppose it. Economically or educationally disadvantaged migrant women could also be less likely to receive epidural, because the language they used or the cultural style in which they expressed pain was unfamiliar to service providers.30

So it doesn't look like they would be less likely to be offered an epidural (unless they were asking for pain relief in a language not understood by the care providers), but other cultural factors may cause women of some cultural backgrounds to refuse an epidural.

February 27, 2010 | Unregistered Commenterphdinparenting

I wanted a natural birth. I ended up with a c-section.

I was a full two weeks overdue so they induced me. It didn't go anywhere and after 20 hours of painful, PAINFUL pitocin induced contractions that came one after the other I ended up with an epi and c-section. It was nowhere near what I'd envisioned for myself or my baby who had complications and ended up with a 3 day NICU stay. (she was the biggest baby in there being 14 days overcooked).

After the whole ordeal I discovered that my mom was 2 weeks overdue with both me and my sister. I bet ya if I was allowed 2 or 3 more days everything would have been just fine. I don't know that they were right on with my due date anyhow.

Now, I wonder what to do for the next one. I'd like to try vbac but at the same time if I'm going to be 2 weeks past due again (who knows right?) then what choice do I have? I'd rather have a scheduled c-section than go through what we went through the last time.

Interesting and insightful post as usual!!

Heather:

Fudge the date of your last period to put your due date forward a bit? (only half kidding!)

Did you have a midwife or an OBGYN? I find OBGYN's are generally more anxious to just get the baby out as soon as you've passed that magic date, whereas midwives are willing to wait longer as long as there are no signs beyond the date itself that indicate a need to deliver.

February 27, 2010 | Unregistered Commenterphdinparenting

It might be that hospital pre-natal classes do "push" their preferred pain relief methods but round here, and we experienced two of them, birthing classes are taught by private groups with no particular influence over what happens in hospital.
... and both (yes, we really went to two - long story!!) emphasised how much safer as a method of pain relief an epidural was (and the drawbacks were also covered as per timing, immobility, lack of push etc.) compared with the systemic administration of drugs to the mother.
Maybe another and equally as insulting conclusion from the study is that posh educated women care more about their baby's welfare, in terms of systemic vs. localised administration of drugs during childbirth, than their own wellbeing?

Sorry, I didn't catch the humour in your writing.

February 27, 2010 | Unregistered Commenterebbandflo aka pomomama

ebbandflo:

There was no discussion of use of other drugs (other than epidural) in the study at all, so I'm not sure I understand where your comment is coming from (re: equally as insulting conclusion). My assumption (perhaps incorrect...not sure) was that most women who did not have an epidural did not use any type of drug to control pain. I saw this is an issue of epidural vs. natural childbirth. I could be mistaken, but there definitely wasn't a discussion of other drugs in the study itself.

February 27, 2010 | Unregistered Commenterphdinparenting

Interesting issue. I wonder if this is similar to vaccine compliance, in which as far as I understand, wealthier and better educated parents vaccinate more than poorer and less educated parents, so it looks like vaccinating is the more educated choice... mainly because the population group who chooses not to vaccinate due to educated concerns about the risks of vaccination is so small as to be statistically insignificant. Similarly, those of us who knew all the pros and cons of the epidural, and chose to skip it for all the reasons you mentioned, may be a statistically insignificant group.
I wasn't convinced by the pain tolerance theory, though, since we also know that wealthier and highly educated women are much more likely to breastfeed than their poorer and less educated counterparts, and that is pretty painful at the beginning for most of us. I personally found it much easier to tolerate six hours of intense drug-free labor than weeks of sore nipples.

February 28, 2010 | Unregistered CommenterChanna

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