It’s good to suffer pain

I have given birth twice (in the states, in the hospital, attended by nurse midwives and nurses, no doctors). The first time I had no pain medication, the second I did have some (synthetic morphine). While the pain medication did rid me of some pain, it did not decrease the levels significantly, nor did I have an easier labour. Plus both the baby and I had the drug in our systems, we had a more difficult time after the birth than I did with my first child.

I guess I feel compelled to write to say that while giving birth has been the most painful thing that’s ever happened in my life, the use of drugs during labour didn’t make a big difference. I think we use too many drugs in the US, as well as too much intervention during childbirth. I don’t know anything about Dutch culture, but I do know American culture and the pain of childbirth is something that seems greatly exaggerated in the US. Not that it doesn’t hurt like hell, but it’s a pain with purpose, and at some point it ends. I wonder if that pain story comes out of a place of both scaring women (younger, curious ones) and keeping shame alive…

That said, it is always bad when people are more concerned about their positions than they are about their patients, who ostensibly should come first.

The childbirth class my wife and I attended prior to the birth of our daughter shoveled out exactly the kind of crap that Ingrid is complaining about (and that Lavalady seems to be endorsing). Fortunately, our midwife was open-minded enough to recognize when my wife had had enough, and needed an epidural. When our reunion class was held, it turned out that every single woman had opted for an epidural, and at least half ended up having C-sections for one reason or another. Needless to say, there were no regrets about the anasthesia.

I strongly suspect that the same “the more the mother suffers, the better off the child” ethos is at work in the fanatical breastfeeding culture that has grown up in the US. Breastfeeding is extremely difficult and taxing for most mothers, and formula is so easy and convenient by comparison that many people have apparently concluded that it must be much, much worse for the baby than the exhausting natural alternative. (Hence, for example, the wide credence given the myth that babies absorb crucial antibodies from mother’s milk.)

If you are going to have an emergency C-section (and C-sections are common for many reasons, including, preumably, because anaesthesia is now very safe thus changing the balance of risks between C-sections and vaginal birth, women have children later in life than they once did, and they are less fit than they used to be and more prone to high blood pressure, etc) there’s a huge benefit to already having the epidural in effect.

I don’t know about pain. The worst pain I’ve ever experienced is gout, which is like having your toe smashed with a hammer constantly for hours on end. I watched my wife in labour for 30 hours prior to her first C-section. She seems to have a higher pain threshold than I do, in normal circumstances, and I’d have said that she was in more pain than I was in during my worst gout attack (though not for as long). Very few women of childbearing age get gout, but if any are reading: which is worse?

Those wondering whether to breastfeed or not should ask for a second opinion besides Dan Simon’s. The Slate piece he links to is interesting, but far more temperate than Simon’s mini-rant. And frankly, Slate itself is mostly a contrarian source on whatever.

oh yeah, and agreeing with John Emerson about Dan Simon–

I think breast-feeding is a whole different order of issue. Sure, it suffers from some of the same mythologizing and brow-beating.

But 1) the benefits of breast-feeding are not mythical (even if the antibody story is).

2) There are no women for whom childbirth is not at least somewhat painful. There are many women for whom breast-feeding is completely unpainful, and indeed pleasurable. And the hassle of breast-feeding just does not compare with the excruciating agony of labor.

3) If you get into labor and change your mind about pain-meds, you are in a really bad position to persuade people to act on your new decision. Time is short, contractions are moving fast, and ten other factors are conspiring to deprive you of choice. By contrast, if breast-feeding doesn’t work out, you have all the time in the world to change your mind. You don’t need to ring up an anaesthesiologist and get a referral and three prescriptions. You just go down to the store for some formula. You have a lot more control.

So there may be *some* comparison between the two issues, but I really think they are of a completely different order of gravity.

dan simon’s comments don’t strike me as a rant, even though, indeed, breatfeeding is quite different from childbirth. Its true that it is unproblematic for many perhaps most women, and enjoyable for many, but for some women, with some children, it is intensely difficult and often painful. For them the performance anxiety which is the accompaniment of a very strong cultural message that if you don’t breastfeed you don’t really love your kid at best doesn’t help, and at worst worsens, postpartum depression for example. Lots of bottle-fed kids are well loved and do fine in life — there does seem, to me, to be a kind of ideology of self-sacrifice around breatfeeeding (or, sometimes worse, a denial that it can be a problem for anyone).

It seems better for mothers to be exhausted and unable to enjoy their babies right at birth — the kid has to learn sometime that the whole world doesn’t revolve around them. “Mommie’s tired, honey, shut the hell up.” Think how much more pleasant the average trip to the grocery store would be if more children had that experience at birth!

Two exceptionally difficult births, two deliveries that would have been way beyond excruciating, but for the epidural. I’ll spare the details, but only share what turned out to be a sure-fire way to get the meds, the first time:

I started out, as the Lamaze course had instructed, with all the breathing stuff. Did nothing at all for me. (Perhaps I should have been tipped off by the fact that the Lamaze instructor had had three deliveries…all Caesarian.)

So there I am trying to find SOMETHING that will work… and, it turns out, singing does. Who knew? (Really just a tune-y kind of hum.) Well, the nurses, whose station was right outside, couldn’t stand the sound, bouncing off the tile walls & floor of the delivery room. (What, labor nurses who don’t like the sound of labor? Ever think of getting a new job?) The epidural came post-haste. Try it: It works.

As irony would have it, I was cleaning up around the house today and came across the copy of The Gift of Motherhood: Your Personal Journey through Prepared Childbirth that was given to my wife and I (ok, mostly her) about a year ago when we were getting ready to become parents.

You would think that if anyone was anti-anethesia, it would be people who write things with titles like The Gift of Motherhood: Your Personal Journey through Prepared Childbirth. But sure enough, there it is on p. 55: “Do not set yourself up for failure just because your labor did not go like you though or because you chose to take medication when you planned not to. You need to feel good about the choices you make for yourself when you are in labor” (emphasis most definitely in original). A little euphemistic, but clear enough.

When I had my babies, during the ’80s “natural childbirth” was all the rage, home births with midwives were considered the ne plus ultra in political correctness, and breast feeding was de rigeur. All this was supposed to be–can you f-ing believe this–a feminist response to the high-tech male medical establishment: women–mothers and midwives–taking control of the “birthing” process. I had three kids and no epidurals. I almost treated you all to a technicolor account of my birthing stories but I’ll refrain. Two things though I want to note.

(1) Breast feeding is not a hassle if you’re reasonable about it. My idea was to do it the easy way. When I was at work they got formula. They slept with us and I fed them through the night–I never missed any sleep. It was easy and cheap though my kids’ baby teeth rotted out from snacking all night. But the literature and advice from “childbirth educators” was bananas. It suggested that one swig of formula from a bottle and the baby would be ruined forever and breast feeding would be conclusively over. The moral: take (at least) 6 months off from work to be a full-time Earth Mother. It’s rather interesting that in the ’50s when most new mothers didn’t work and bottle feeding was a time-consuming hassle–mixing formula from scratch, sterilizing bottles and nipples, bottle feeding was de rigeur. In the ’80s when premixed formula was available and you didn’t have to cook bottles and nipples, and when more women worked outside the home, the establishment promoted breast feeding and the whole program of pumping and freezing that made it difficult for women to go back to work after having babies. The moral: to be a good mother you’ve got to do whatever is least convenient and most disruptive to your life.

(2) The midwives/doctors issue is really fascinating. The received view when I had my kids was that midwifery was a Feminist Statement. Midwives were doing a great job until MALE ob/gyns took over, medicalized “birthing,” made it a MALE high tech affair and squeezed women out. There may be something in this but by the time I had my kids women were doctors and were approaching parity with men in medical schools. You’d think that women would have inferred that this was great (as I did): now women get to be doctors, supervise “medicalized birthing” and do all the high tech stuff that guys used to monopolize. But not. The received view when I was “birthing” my babies was that women doctors had sold out and that real feminists should “birth” their babies naturally, without drugs or epidurals, without high tech, under the auspices of midwives, and that women who were doctors and embraced high-tech had sold out.

Generalize from this: women have traditionally done A using technique x; men do A using technique y and lock women out of using technique y. But, wow, now women get to use technique y. What shall we say? Good: let’s see to it that more women get to use y or bad: women who use technique y have sold out–let’s promote the use of technique x. Try this: women use hoes–men use tractors. What should we do: promote the use of hoes because it’s women’s traditional way of doing agriculture and affirms women’s way of going things or promote the use of tractors and see to it that women get to drive them? Traditionally women have been midwives–men have been ob/gyns. What should we do: promote midwives because it’s women’s traditional way of birthing babies or promote ob/gyns and see to it that women get to be ob/gyns.

This is the bottom line dispute in feminism across the board. Is the aim to promote and confer prestige on traditionally female-identified activities or enable women to get into traditionally male-identified activities? Both are important but also potentially in conflict and, just IMHO when the crunch comes, getting women the opportunity to to guy stuff trumps getting woman stuff more highly valued.

Do you actually have figures for the rest of Europe or are you just guessing? I know of only two women among my friends in the UK who have had spinal puncture anaesthesia. Both hated it. They said it made them feel dead from the waist down.

I also don’t recognise your image of mid-wives. All the UK midwives I know are down to earth, sensible people who say things like “For god’s sake, have painkillers if it hurts”.

Unlike with anaesthetics in other procedures, there are possible medical benefits in not having an epidural. I’ve seen scientific articles arguing that epidurals tend to slow down labour (because of less muscle strength available) and given that failure of labour to progress is one of the main reasons for emergency caesarians, that’s a good argument for not having an epidural if you can avoid it. There’s also the issue that it restricts the possible positions for giving birth, which may also make labour harder. And I think there’s also more general concern about a ‘domino effect’: once you start intervening medically in one particular labour, you tend to have keep increasing the interventions (again, often ending with a caesarian), because of side-effects from the earlier interventions.

Having said that, what you really want is flexible midwives/doctors who can respond to a woman’s changing needs in labour. The current emphasis on having birth plans is misleading because there are so many variables outside your control. I’d have ticked any boxes on pain relief beforehand, but I was lucky and had an easy labour and only needed gas and air. Meanwhile some enthusiasts for natural childbirth end up having to have emergency caesarians.

What does annoy me in discussions about childbirth (at least in the UK) is all the condemnation of women who have elective caesarians and claims made about them being ‘too posh to push’. A woman in my prenatal class had her baby in a breech position. The obstretician recommended that she have a caesarian. She was told she did have the choice of a natural birth, but there were increased risks to the child. Under the circumstances, it’s not surprising that she had a caesarian. But to what extent was that really her choice? I’d like to see statistics on elective caesarians broken down in terms of how many are actually on doctors’ advice. (I’d bet a large percentage).

I upset my wife’s midwife when she argued that we should try and avoid pain relief as “birth is a natural process, not an illness”. I responded that in nature humans can expect about a 20% neo-natal mortality rate and a 3% maternal mortality rate.

Being bipedal and having big brains (hence having large newborns with massive heads) gives us tremendous advantages, but it has a downside – it makes the mechanics of human birth inherently difficult.

As a card carrying member of the American Academy of Pediatrics I have to respond to Dan Simon. You seem to misunderstand the importance of mucosal protection, meaning the prevention from penetration of microorganisms conferred by antibodies and other substances (anti-attachment molecules)in breastmilk. If some physicians mistakenly think the antibodies are absorbed they should be better informed, but your criticism is nothing but a quibble. The benefits of breastmilk are not a myth. We have good outcome data on infection rates (controlling for other variables) and we have bench research supporting the biological plausibility of the mechanisms. While the effect size is smaller than some breastfeeding zealots might portray, the benefits to a population are quite significant. Besides the well-documented reduction in diarrheal diseases, I have included some data on the effect of breastfeeding on ear infections.

Breastfeeding > 3 mos reduced acute otitis media (ear infection) risk (RR 0.87 CI 0.79-0.95)
Uhari, Clin Infectious Disease 1996;22(6):1079

Exclusive breastfeeding reduced the cumulative incidence of acute otitis media
at: 6 mos 25 % vs 54 %
12 mos 51 % vs 76 Duffy, Pediatrics 1997;100(4):E7

Dan, I read your Slate link, and a couple of the links in the Slate link, and even the Slate link doesn’t say what you’re claiming it does — and the other links still less so. There are health benefits to breastfeeding, though they’re different and somewhat lss than some claim.

I have the same kind of anecdotal information that Dan does, and it’s much more mixed and generally more positive. The mothers I knew and their midwives were mostly in the pro-natural-childbirth camp, and the reports were mostly good. It did hurt, though. And I don’t remember any reports at all about dogmatic, bullying midwives. My sister-in-law wanted a natural-childbirth home-delivery both times, and both times the midwife sent her to the hospital for Caesarians because there were special medical problems.

My ex-wife had a 28 hour labor, and a friend had a 50+ hour labor, and neither spoke badly of it. Long labor isn’t constant high-intensity pain, but widely spaced (but yes, painful) contractions. There are weird hormones in their systems — after 28 hours my ex-wife slept five hours and then got up full of energy and went out to chop firewood.

Harry-In the Duffy study they control for gender, ethnicity, history of OM, smoke exposure, daycare and number of siblings. The other study is a meta-analysis with studies that use a variety of covariates. By the way, the effect size of number of siblings is much greater than breastfeeding or smoking. If you want to protect the middle ears of your other kids, better to smoke than have a third kid. :-)

On the breastfeeding issue, people seem to focus on the high-probability, low-impact effects, which are hard to pick out from all the politicized background noise. Our decision had a lot more to do with the high-impact tails of the bell curve, like this tragedy.

Sure, what are the odds? And do you drive without a baby seat?

derrida derida@26: Those figures sound like utter bunk to me. I remember looking this stuff up about a year ago & in countries with little to no modern health care but with a well-nourished population the figures were nowhere near those you quote.
The only places even approaching a 20% infant mortality rate are the completely failed states like Angola or Liberia or those with major famine problems like Ethiopia.

Most third world countries with otherwise decent infrastructure appear to have an infant mortality rate of around 2-3%. See http://en.wikipedia.org/wiki/List_of_countries_by_infant_mortality_rate for a list taken from the CIA world factbook.

Your estimate of maternal death rate is similarly overblown. There’s a WHO report with some figures available: http://www.who.int/reproductive-health/publications/maternal_mortality_2000/mme.pdf

Both my kids were born in Amsterdam – the first in the hospital with an epidural (because she was 2 weeks overdue and had to be induced), the second at home without painkillers. As an American man with a Dutch wife, it was interesting to encounter this whole debate, which was on doubly alien ground: I could enter into both the pain and the cultural argument only by sympathy.

We wound up with an ambivalent attitude towards the whole Dutch birthing structure. On the one hand, my wife certainly shared the irritation Ingrid expresses towards the vestigial Calvinistic pain-is-good attitude which seems to at least partially underpin the infrequency of epidurals in Holland. On the other hand, the determination to treat birth not as an illness but as a normal occurrence within the everyday familial and social sphere is responsible not just for the midwife system, but for an integration of birth and early childhood medical care into the national social fabric which I found marvellous.

For example: the midwife system, as far as I understand, is a national registration system; you are assigned to a rotating set of midwives in your neighborhood, who are in turn in contact with an OB/GYN in the neighborhood. That system is then connected both to the prenatal care system and to the postnatal and early childhood system, so that the same doctors and midwives you see for prenatal care will (most likely) be the ones you see during birth; and your baby’s first checkups will be at the neighborhood clinic where the same docs work.

At least a month before the due date, you go down to any pharmacy to pick up the “birth packet”. This is a kit including plastic sheeting for your mattress and everything else which you and the midwife will find necessary for the delivery. Also, if your bed is below a certain height, you rent from some bureau whose name I forget a set of risers to elevate it an extra several inches off the floor, so that the midwife will be able to work comfortably during the delivery. You’re also given a little green booklet in simple, clear language which explains all the medical concerns you might have leading up to and shortly after delivery, plus vaccination schedules, breastfeeding and bottlefeeding and bathing tips…

Anyway – I’m rambling way too long. But what I wanted to say was that I do think that this determination to integrate birth and early childhood into the communal social fabric is not unconnected to the determination to treat birth as a family event, rather than a medical event. So while I can see how irrational the latter is in many ways, I also hope that if the Netherlands turns towards a more medicalized model, it doesn’t lose the communal aspect. Because that communal and social strength is the great power of the Dutch model – a model which the Dutch themselves have lost much confidence in over the past five years, but which has tremendous strengths in ways they often take too much for granted.

h. e. baber–

your #20 and #37 are right on the money. Exactly what I would have said (i.e. what I have learned from my wife).

In a way, that’s the problem that goes even deeper than medicalization vs. anti-medicalization or OB vs. midwife or pain meds vs. no pain meds: the problem of blowing up birthing and breastfeeding into Big Deals that Define a Woman’s Life. (The most meaningful day of your life. The day you’ve waited all your life for. etc. etc.)

If we could get a little more perspective on what’s at stake, we might find it easier to allow women to make pragmatic, individualized decisions.

(Actually there are probably two main strands to the Big Deal problem: over-inflating the significance to Your Life as a Woman, and over-inflating the significance to Your Child’s Well-Being and Chances of Getting Into Harvard. Yeah, I’m all in favor of breast-feeding, and my wife did with both kids. But the idea that if you can’t breast feed then you are ruining your child’s life–that’s where the nonsense creeps in. None of the differences in outcome are significant enough to make yourself crazy about, or make yourself miserable about.)

Also–can I say that it still gets my hackles up when people say that some women just “tolerate” or “manage” pain better than others do? Yes, there’s some truth to that, but it makes it sound as though every labor is intrinsically as painful as every other, and some women just “tolerate” or “manage” that amount of pain better than others (i.e. the ones who are just wimps).

Look, there are differences *in the labor itself*. My wife’s second labor was less painful than the first one, because the first one was a brow presentation that got lodged in the birth-canal. You’re not going to ‘manage’ that away, nor the C-section after 20 hours. Number two had his head screwed on right and came out in a fraction of the time, with a fraction of the pain.

So I’m all for saying that different women have different experiences in labor. But it’s not merely, or even primarily, a difference in “managing” or “tolerating”. Some labors are more painful than others, full stop.

Birthing babies isn’t—it’s just a painful physiological process and I don’t see why we should be looking for an “experience” of some sort, or resist it’s being medicalized, any more than we should look for an “experience” in getting dental work done.

Tolerating avoidably bad dental experiences for the sake of the dentist’s golf schedule is the lip of a slope some of us are determined to resist. Let it slide, and one day we will end up dying very expensively in unfamiliar beds, with bedside companions who beep instead of holding our hands. That a woman’s ownership of her own sexual machinery is at the nexus of so many highly charged power issues in our society makes childbirth a specially marked case. (When a doctor reaches into my chest, deliberately stops my heart, fails to start it again, and yet hasn’t committed a felony, she is enjoying a remarkable license that should be grudgingly entrusted and jealously watched; the consequences of her entertaining delusions that she acts by right are too dire for us all. When a doctor reaches into my wife’s vagina, that too is politics.)

Empowering women doesn’t mean making a hobby out childbirth and breastfeeding or giving women the option of squatting over birthing stools or having babies underwater—it means seeing to it that women can break glass ceilings in business and public life etc.

It can be two things.

As for midwives, I think going to them is pretty crazy (yes, I am biased). Sure, most births are uncomplicated and a midwife can handle them but the unexpected in medicine is commonplace and no one (dr., midwife, etc.) can predict with complete certainty who is and who is not going to need medical care.

Yet you, who have delivered a baby fewer times than I’ve changed my own engine oil, think my wife would be crazy not to entrust this uncertain process to you (as a med student) and OB backup, in preference to a midwife with fifteen years of clinical experience and the same OB backup? For how many of those deliveries had you discussed the mother’s expectations with her in detail, say four months before delivery and again a month before? How many of them would you even have been able to greet by name in street clothes without checking a chart, for that matter?

I don’t remember her advocating that OB’s should entertain delusions that they act by right—did I miss that part?

See my notes at #32. The power relationship as between midwife and mother, midwife and hospital, hospital and patient, all profoundly influenced our two (objectively similar, uncomplicated) deliveries. I contend that a strong midwifery, inevitably backed by a few judgmental earth-mother crazies to counterweight the malpractice-shy crazies in hospital and insurance back offices (and 3rd-year-med-student-as-Aesculapius crazies on the obstetrics floor), is a crucial ingredient in maintaining a sane power structure in which the mother’s voice can be heard. For us, the trickle-down effect from faraway RI vs. IL lobbyists we would never meet made an unforgettably sharp difference.

The idea that somehow the character of the procedures surrounding birth can be either “empowering” to women or otherwise is seriously disturbing.

Talk to a first-time marathon runner (who has typically prepared less than nine months for a race-day effort less prolonged, less draining, less painful and far less life-altering than the birth of a child) about whether the experience was empowering, and whether the role of the supporting cast made a difference. If we let the race organizers move the cheering family 100 feet back behind glass (on legal advice) and put overworked nurses and green medical students in charge of the water and blister stations, would as many of us finish?

I’ve been out all day, visiting my family in Belgium, and upon return read the comments — very interesting, thanks all!

I think the pain relief and breastfeeding thing need to be discussed seperately. Perhaps one day someone will write a post about it, with links to some good background studies. I am in general very suspicious about anything that is culturally imposed on women, but I have to say when I was breastfeeding and wondering how long I had to go on (since it was draining and difficult), I looked at some survey studies by the WHO, and there are good reasons to breastfeed for at least 6 monhts. But it is very hard to find good argument in the ‘popular’ literature (e.g. websites) – and this is upsetting, because the first thing women need is *objective information*.

I also agree with those who write that epidurals are not a panacea; but what I would like is that (1) women receive the information they ask, also from midwives (in my case, I asked on 3 different visits, and didn’t get any), (2) and know that if they will ask for an epidural, they will get one (again, in general not possible in the Netherlands if you don’t have this thing called ‘medical indication’, though a few hospitals are a bit more relaxed about it). Hence, the bottomline is: give women information and real choices. I think that would empower them much more than all this nonsense about running a marathon and being proud of yourself of how much pain you’ve been able to cope with. Knowing that it’s available, even if you don’t use it, can really help and make one more relaxed or feel under controle.

tribald ozgevir (# 38) writes some interesting things about the Dutch system which are in large part also my experience (though the midwife I had at childbirth was not the midwife I had during the pregnancy, and that’s the case for many women, and I haven’t seen my midwife since, nor has my son been checked by anyone who was present at the birth or checked him during the pregnancy). I also do hope that the communal aspects of childbirth will be kept in the Netherlands. But I can’t see any reason why we can keep the good aspects of the current system, while changing those aspects which I find repulsive – the fact that women are effectively denied the option of epidurals except under very specific circumstances (e.g. C-sections).

Are there statistics on the average length of labour (particularly for first births) in different countries? It seems as if the Americans who’ve discussed this with me have been up towards that length of time, but I’d like to get beyond anecdote.

Part of the problem is that it’s hard to define the onset of labor. That 26 hours I mentioned above included about 15 hours of regular but relatively mild contractions, not that much worse than the intermittent Braxton-Hicks contractions that she’d been experiencing earlier, but enough to disturb her sleep (and the sleep deprivation made it much harder toward the end). Some people might not start counting until it’s time to go to the hospital.

Re never being seen agian by pre-natal doctors/nurses: My wife says that the one fantastic thing about having a child in the UK (as opposed to the US where the first was born) was being visited at home, several times, by nurses, some of whom helped with breastfeeding, and also by our family doctor (who visits all new mothers). I talked to my doctor about it because, although I thought it was great, it seemed a bit inefficient – -and she said that she’s nosy so she likes to do it, but also that visiting the home helps her and the nurses enormously in figuring out what’s really going on with the newborns and the mothers. She reckons that it helps catch serious post-natal depression in particular.

Just to clarify my use of the word “empowerment”. I was referring to the choice that a woman can make about how to manage pain. I don’t agree that pain is empowering. Also, the toleration of pain varies between people not because of bravery but simply as a function of physiological differences.

Many women, including me, view their child birth experiences as something positive not because of pain, but because of the intense effects of the new child, rushes of endorphins and oxytocin, the presence of happy family and friends, the joy at a normal baby, and the none to early relief from a miserable pregnancy. The perception of pain tends to diminish quickly.

I was raised in the Netherlands and I know of the paradoxically patriarchal attitudes that persist in a country that seems enlightened in so many ways. Not allowing pain relief during uncomplicated child birth is medieval.

didn’t mean to strike that stuff out, by the way.

Are doctors advising against pacifiers with the same vigor that they devote to steering mothers away from formula? And if not, why not?

Father of an 11-month-old here. Yep — we got lots of advice not to use a pacifier. So we didn’t. No apparent ill effects; hard to imagine he could be more cheerful than he is.

Re dan simon’s comment (#59 at present but these numbers do change): I think there’s a general reluctance in the culture (on the part of parents as well as the medical establishment whatever that is) to acknowledge that there really are trade offs between parent’s and children’s interests, because there is an ideology that parents should pursue the child’s best interests (and it would be very incovenient to portray what parents have to do in pursuit of that sacrifices). This problem bedevils discussions of divorce and daycare (proponents go to great lengths to claim that divorce doesn’t harm children and that childcare in the first couple of years is absolutely fine) because otherwise people divorcing and using daycare are tarred with the brush of selfishness. If, like me (and, judging by his last comment, dan simon), you think that parents are NOT obliged to pursue the best interests of the child, only to pursue their interests pretty well, then you can acknowledge that sometimes divorce is not in the best interests of the child but is nevertheless ok (I’ll add, though, that I think it is sometimes very bad for the child, and therefore not ok even if it is better for the parents). Back to breastfeeding (which is NOT ingrid’s topic — sorry ingrid someone seems to have derailed you, and I’m colluding): if bottle feeding is fine for the child, and breastfeeding is really a cost to the mother, I see no problem with the mother giving it up.

joshua burton on extreme risks: sure, I drive with my kids in car seats, responding to the risks at one end of the curve. But I drive with them, thus exposing them to risk of death daily, much greater risks, even in a car seat, than if I refrained from driving. I do so even when I could just as easily, though with more expense, fly with them, which would be much safer for them and me. I bet you do too. (As ingrid knows, this is a rather live issue with me right now!)

Mark: thanks for the clarification of the studies. I guess I want to know if they control for the socio-economic status and education level of the mother.

Sorry but it’s also irritating that rich women like me can make a fuss about managing the ideal, empowering birthing experience, an ‘alternative birthing centers’ with pretty curtains on the windows when 15 year old girls are sent home with a few samples of baby formula and coupons, and infants who need care, without any instruction, support or follow up.

In our classes at that pretty birthing center in Rhode Island was one married couple, ages 16 and 15, both still in school, no parents in sight. (White ethnic Catholic, if anyone’s prurient interest runs in that direction.) They got the same four at-home nurse-midwife visits postpartum that we did, under the same HMO plan; God knows if they stayed covered through the baby’s first year, much less to their own majority. “Affordable” is another criterion of empowerment on which I think there may be wide agreement here.

Derrida: My understanding is that prior to the invention of agriculture most humans were fairly well fed, on average. It was agriculture that led to a general decline in the nutrition available to the average person & that’s too recent to have had much impact in evolutionary terms.

If you’ve got some references which disagree, then please do post them!

(I’ve found what might be the ideal reference, http://www.amazon.co.uk/gp/product/0521402166 but will have to make a trip into Oxford to see if I can track down a copy.)

breastfeeding is in many ways much easier tha bottlefeeding.

For many women this is true. For some women, it is absolutely not true.

Perhaps you need to go through the experience to appreciate, but there really is a lot of pressue on women that makes them feel like absolute failures if they cannot breastfeed for whatever reason.

I went through this experience with my first child. After several weeks of breast pumps, lactation consultants, cracked bleeding nipples, low milk supply, angry hungry baby, angry tired depressed mother, etc., we finally decided to bottle feed the baby exclusively – for own sanity.

Read this thread for other stories:

http://www.babycenter.com/comments/baby/formulafeed/1399223

In certain situations, it is a perfectly reasonable decision to bottlefeed. Yet the breastfeeding industry rarely tells this to mothers. They are made to feel like miserable failures, and their is always something else the mother should be doing to try to breastfeed successfully. This is taken to quite absurd lengths in many cases.

They’re just trying to line their pockets by selling you breasts and so on.

Have you ever used a lactation consultant? It is an industry, and they make money by selling their services.

Ok, “industry” was the wrong word.

philosophers’ question but I’m serious and puzzled here: what do you mean by “breast feeding”? Breast feeding exclusively–no bottles ever? Breast feeding + bottles but only with expressed breast milk? Or breast feeding + bottles with formula as need be?

If the first, or even the second it seems to be setting the bar too high. Surely, the baby gets all those good antibodies if you just breast feed some of the time, and that isn’t such a big deal. Not arguing, just wondering what’s at stake in this discussion.

I’m a father of two, I’m Dutch, and I’m a doctor (though not a gynaecologist). Perhaps I can elucidate the murky state of Dutch birthgiving somewhat.

First some medical background:

The problem with epidurals is not the epidural itself. It is the rare complication where the dura is punctured and the anaesthetic gets directly into the cerebrospinal fluid. When this happens, the paralysis (and anaesthesia) is more complete, and there is a chance that the lidocaine creeps upwards blocking the nerves that activate the muscles we need to breathe. This can even happen with a correctly placed epidural.

Scary stuff, but luckily quite rare (and, for those of you who want to know, the heart doesn’t need input from the nervous system to keep beating). But it does mean that it is necessary to monitor the mother for at least half an hour in a place where you can immediately intubate and ventilate her should things go wrong.

The most obvious place is the recovery room of the OR. The necessary skills and equipment are already there. Except at night. Then the necessary skill may very well be busy. Or at home, sleeping.

To get an epidural for every woman who wants one requires that the gynaecologists learn how to do them. And learn how to intubate (with frequent refresher courses as they will only have to do this in rare emergencies). And have all this expensive equipment on stand-by in the delivery room. I know there are hospitals in the US which have this arrangement, but they tend to have an epidural delivery rate of >80%, making it more worthwhile.

Another course is to have fewer, but much larger, ob-gyn wards (or even dedicated women’s hospitals), so the anaesthesiologists know they have to stay at night just for procedures that aren’t a strict medical necessity. This might become a reality in the future (gynaecology is really night-shift intensive work, so most starting gynaecologists prefer large hospitals with lots of colleagues to share the burden). On the other hand, it might be incompatible with home deliveries supervised by midwives if it means the difference between getting to a hospital just in time or getting there too late, so midwives will probably be opposed. Also, the pediatricians may not like it, as having fewer, bigger ob-gyn wards means having fewer-bigger incubator wards.

My wife will agree wholeheartedly when I state that she has a low pain threshold. Personnally, I find witholding pain medication to people in pain a rather barbaric practice. That’s why, with our first child, my wife and I decided right at the beginning of the pregnancy that we both wanted her to have an epidural. I knew this would be difficult, so we stated our intentions at the very first check-up by the midwife.

The midwife responded by rattling off her little list of horrors and by saying my wife could always wait-and-see during the delivery.

We told her I was a doctor, we were well informed and that we were quite adamant nonetheless.

She went “Oh” and said we could still always wait-and-see, but she would make arrangements to transfer care to the gynaecologists in the last trimester.

Because midwives work in shifts and you never get to see the same one twice, we had this same conversation during every check-up. At the end of the second trimester my wife’s chart was filled to the brim with “wants epidural” notes, but each midwife still decided to try one last pitch for good ole’ natural birth at home. Maybe they can write but not read.

Then the gynaecologists took over.

“You know there is a higher chance of adverse outcomes with epidurals?”

Every gynaecologist we saw (and it was always a different one), right up to the delivery, was a card-carrying member of the VPINEGC. My wife was brought to tears several times because the gynaecologists were peddling the same lines as the midwives, and time was running out. Mind you, this was in the hospital where I work. (A big university hospital so they don’t know me personnally, but still.)

In the end they got the message and relented.

Unfortunately, a big car crash prevented the anaesthesiologist on duty to administer the epidural. For the entire night. So my wife only had her epidural for the second half of the delivery. And, of course, she got an episiotomy with a vacuum even though our son started life with a 9/10 Apgar score.

That is why, for the second pregnancy, my wife knew what to do. Instead of crying in the car after seeing the doctor, she started crying during the first visit. The doctor didn’t even have the chance to tell her the second delivery usually goes smoother than the first. My wife got herself an elective caesarian on “psychological grounds”.

My advice for pregnant women trapped in the Dutch VPINEGC: get what you want and don’t accept anything less.

wow–Jasper emmering–

thanks so much. Real information. Informed opinion. Well-written, too.

I’m only sorry you got here so late that your views won’t be read by many of the original participants.

And I like your final conclusion, sc. giving women the choices they want.

But do you make any provision for people who like to eat placentas that have been marinated in lidocaine first?

I’m pretty sure that when you sauté the platenta in garlic and oil, it boils off any residual lidocaine.

Early in my research career I would harvest fetal stem cells from umbilical cords. I had to secure placentas because the only umbilical cord section that was decent was the part attached to the placenta. The peculiar smell is still with me, 20 years later.