Now it's time for the epidural

Giving birth: a woman’s choice between nature and medicine

Anna K. Stelling-Germani

Anna K. Stelling-Germani

Anna is a half German half Italian scientist who grew up in a small town near Vienna, Austria. She is working in the field of cancer research at the University of Zürich. Currently she is facing a new challenge in her life by becoming a mom in June 2018. Anna has lived in Italy, Austria, England, Sweden and Switzerland and loves to travel the world and experience new cultures.

The number of women giving birth without methods of pain-relief are low. Women are experiencing great fears about the pain of giving birth, making them want to exploit all medical pain relieving possibilities. A lack of trust in the body’s natural pain relieving mechanisms and an excessive supply of medical interventions is putting women in the dilemma of having to choose between modern medicine and nature.

There is a widespread fear among women when they think about giving birth. More than once I have heard that women really want to have children one day, but the only thing they are scared of is the pain of giving birth. But why so? One would think that giving birth should be the most natural thing on earth. If women are so scared of labour pain, it makes you wonder how nature was meant to make humans reproduce.

Unfortunately, nowadays giving birth is not as natural as it was initially intended. Giving birth without any method of pain relief is not very common anymore. In 2018, a study was published showing that around 71 percent of women in the US received an epidural when giving birth (1). During an epidural, an anaesthetic is injected directly into the epidural space surrounding the spinal cord, delivering pain relief continuously to the lower part of the woman’s body. Many women already decide to have an epidural when planning the birth of their child, before even having experienced any pain. This is only the start of a long list of pain relief options for women in labour, which ranges from drastic methods like having a planned C-section without any medical indication (in order to circumvent the pain completely) to less drastic methods like inhalation of nitrous oxide (also known as laughing gas) or the administration of opioids.

Before we started using such drastic pain relief methods, women’s biology actually had everything under control. Women produce a set of hormones that should guide them through childbirth. During labour, there is mainly one hormone involved in controlling the pain. Endorphin levels are constantly rising during childbirth, and they are known to be calming and stress-releasing. Endorphins are believed to induce the euphoric feeling after birth, thereby strengthening the mother-child relationship. The same hormones are believed to be responsible for the described feeling of “forgetting” the labour pain after the baby is born. If you ask women who gave birth, many will tell you that they do not remember the actual pain or they remember it but do not recall it as a painful memory (2). The body’s hormonally mediated processes are complex and intertwined with the physical processes of giving birth, and research is lacking to show how interference with this evolutionary conserved process affects mothers and their children (3).

Now it's time for the epidural
Now it’s time for the epidural. Cartoon @ Nadia Pulvirenti for Culturico (copyright).

Studies have shown that women who received an epidural as a pain-relief method do not have natural levels of endorphins in their blood (4,5). This implies that there might be important post-partum hormones missing if the pain of birth has actually not been felt. Of course, having an epidural does not mean that a woman will not feel the same happiness and joy about her new-born baby. Scientific evidence on the matter is contradictory, with some studies even linking increased risk of postpartum depression to natural birth whilst others report the exact opposite. Considering the published literature, it becomes evident that when it comes to childbirth there are too many physical and psychological variables that are difficult to control for by scientists. Ultimately, the consequences of interfering with a woman’s nature remain unknown.

This whole situation is putting women who are preparing for labour in a very difficult position. On the one hand, women can be scared of the pain, which is indeed documented as being perceived as extremely strong pain (6). On the other hand, women can decide to trust their biology and let the hormones do the job. The fear of pain and the excessive availability of pain relief methods lead to the inevitable decision to use pain relief during childbirth often before labour has begun. After all, every woman experiences birth very differently and birthing experiences vary both with and without medical pain relief. Though, it is obvious why many women decide not to take the risk.

The fact that the dilemma came this far is clearly a problem of our current healthcare system. I believe that scientists and medical doctors especially should occasionally question ways of interfering with nature. As an example, there are huge ethical debates about genetically modified babies for obvious reasons, in which many scientists have raised serious questions and doubts. However, not many people would question if labour pain should be artificially decreased because if it makes a woman’s life easier, why not? Is it undebated because the possible negative consequences aren’t too bad at all? Even though given the medical and biological background discussed previously, there are several reasons why one should reconsider the ease with which medical interventions are offered to women in labour. (Obviously, excluding the cases in which medical intervention is needed due to complications).

It lies once again in the responsibility of scientists and healthcare professionals to consider what the world needs and what it does not. In 1996 the WHO commented on natural childbirth as follows:

“epidural analgesia is one of the most striking examples of the medicalization of normal birth, transforming a physiological event into a medical procedure” (7).

Scientists should constantly reflect and decide if the advances made truly benefit our species (also discussed here). In 2002 the obstetrician Richard Johnson and his colleagues already raised the question if the medicalization of birth has gone too far, concluding that true teamwork will be needed in order to halt the ongoing medicalization. The goal was to make childbirth without fear a reality for women, midwifes and doctors (8). Given the current situation, hopefully the trend towards medicalization will eventually halt. After all, giving birth is not a disease that requires treatment.

 

Anna K. Stelling-Germani

 

References:

  1. Alexander J. Butwick, Maternal Body Mass Index and Use of Labor Neuraxial Analgesia: A Population-based Retrospective Cohort Study, Anesthesiology, 2018
  2. Morgan BM et al., Analgesia and satisfaction in childbirth (the Queen Charlotte’s 1000 mother survey), The Lancet, 1982
  3. Sarah J. Buckley, Executive Summary of Hormonal Physiology of Childbearing: Evidence and Implications for Women, Babies, and Maternity Care, The Journal of Perinatal Education, 2015
  4. Abboud TK et al., Effects of epidural anesthesia during labor on maternal plasma beta-endorphin levels., Anesthesiology, 1983
  5. R. Jouppila et al., Maternal and Umbilical Venous Plasma Immunoreactive Beta-Endorphin Levels During Labor With and Without Epidural Analgesia, American journal of obstetrics and gynecology, 1983
  6. Simona Labor and Simon Maguire, The Pain of Labour, Reviews in Pain, 2008
  7. World Health Organization. Care in Normal Birth: A Practical Guide. Report of a Technical Working Group., Birth, 1996
  8. Richard Johanson et al., Has the medicalisation of childbirth gone too far?, BMJ,  2002
Received: 07.05.19, Ready: 29.05.19, Editors: XZ, RG.

 

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