It’s good to suffer pain

by Ingrid Robeyns on August 26, 2006

I recently heard some figures about the number of Dutch women who receive spinal puncture anaesthesia when giving birth. The figure would be around 15 percent. This is probably the lowest percentage among all affluent countries. According to the same newspaper article, in Belgium the figure would be 70%, as it is probably also in many other European countries.

The exact figures don’t matter: this post is about the remarkable low percentage of women who receive spinal puncture anaesthesia in the Netherlands. I think these low figures are a scandal. Why? Because in the Netherlands most women have effectively no choice to give birth with effective painkillers. The figures are not low because there is no demand; rather, the figures are low because there are so many barriers,  that it is effectively impossible for most women to choose to give birth without suffering immense pain.

The Dutch always praise themselves to be one of the few countries where women can give birth at home, and they have a relative high percentage of women giving birth at home. However, increasingly women give birth in hospitals, but not with the help of gyneacologists, but with midwives only. In the hospital in which my son Aaron was born, the midwives rule on the third floor, whereas the doctors are on the second floor. When I asked what pain relief was available on the third floor, I got the response: “there is a shower.”

The Dutch health care system makes it virtually impossible for healthy women to choose for anaesthetics. Pregnant women are divided in two categories: those who have healthy pregnancies, and those who have a so-called ‘medical indication’, which means that there is an increased risk for some medical problem, or when one knows that there is something non-standard going on (e.g. in case a previous pregnancy was problematic, or if one knows in advance that a C-section will have to be performed).

Why do so few women in the Netherlands have anaesthetics at birth? I can see three reasons. First, women who do not have a ‘medical indication’ have to give birth under the guidance of the midwives. They cannot choose to give birth under a gynaecologist. You can only go to a gynaecologist if you have a medical indication. If a woman receives spinal puncture anaesthesia, she needs to be supervised by an anaesthetist and a gynaecologist, and the midwives lose their authority. Hence it is clearly not in the interest of midwives to have more women who receive anaesthethics when they give birth: it basically means they have less work, and the remaining work is assistant work for a doctor, not work in which they are in controle.

Second, since many women give birth at night, making the option of spinal anaesthethics available to every woman would imply that many more anaesthetists would have to work during the night—something they are not eager to do, especially not wihtou a significant wage increase.

Thirdly, the Dutch health care system is a complicated mixture of private insurance and public subsidies; but it is extremely unlikely that making spinal anaesthethics genuinly available to all women would not imply higher costs for the government. And this at a moment when the health care costs are already increasing rapidely due to an aging population.

So, you probably ask, why don’t women revolt? Surely part of the explanation is that there is a collective action problem. But many Dutch women also ‘buy’ the idea that it is much better for the child and for the delivery process if it is all ‘natural’, that is, without pain killers. Pain relief is simply not discussed in most pregnancy courses, and many midwives de facto refuse to talk about it, or to give objective information to the women who ask questions. Some pregnancy books written by midwives try to glorify the power that women have over the process, and how proud they will feel afterwards. They even go so far to argue that it’s good to suffer pain, since it speeds up the dilatation and would lower the chance for complications. Women should embrace the pain for their own benefit, and for the benefit of their child.

But even the more mainstream books have explanations that stay clear from the political-economy explanation scetched above. They play the culture card.  And who are made the bad guys? Here’s my translation of the answer in a mainstream book (Ouders van nu, Zwanger van je eerste kind, p. 216)

The way people give birth differs according to culture. For American women, giving birth is often experienced as the most horrible experience of their life becaus of the pain. Pain relief is then a logical choice. It is possible to regard childbirth as surgery, which implies that one uses pain relief, but it is also possible to see it as a marathon, where you suffer pain, but you constantly try to push your boundaries. Many Dutch women see the pain as an additional effect of the most beautiful experience in their life.

What can one say?

{ 84 comments }

1

John Emerson 08.26.06 at 4:44 pm

If goddamn women didn’t want to suffer during labor, they goddamn well shouldn’t have brought sin into the world.

2

lavalady 08.26.06 at 5:33 pm

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.

3

dsquared 08.26.06 at 5:45 pm

Lavalady: Ingrid’s post refers specifically to spinal puncture anaesthesia, which turns the pain off like a switch. Pethidine isn’t nothing, but it is very much the light divisions of pain relief compared to epidurals.

4

Dan Simon 08.26.06 at 5:58 pm

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.)

5

vivian 08.26.06 at 6:31 pm

In my childbirth prep class in the states, there was a definite bias towards minimizing pain relief, discussing the disadvantages of epidurals (the 45 minute procedure, you can’t eat after, etc.) and such. The instructor gave us a checksheet asking on a scale of -10 to 10 how much pain relief we wanted. My husband and I and another woman joked that we really wanted the “knock her out in the parking lot, wake up in a couple of weeks” option.

Friends who had midwives also had the option of meds, however, in hospital settings – I gather the anesthesiologist leaves the room and midwives aren’t demoted. If midwives in the Netherlands are worried about authority, they could simply lobby for changes that left them in charge, and save the rhetoric. There is something about pregnancy that brings out the “remove women’s autonomy and decisionmaking” strain in lots of people. In the states we see it around women’s diet as much as around breastfeeding (which is onerous for some, easier for others).

6

harry b 08.26.06 at 6:32 pm

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?

7

jeevwoman 08.26.06 at 6:41 pm

Having just recently endured labor, I cannot image why someone would opt not to have painkillers. But, to each his own. I do find it repulsive that women are not given this choice at the most stressful and scary time of their entire life. A suffering mother is absolutely useless to a newborn and I cannot in any way understand how no option of an epi, etc is better for the baby if the mother is too overwhelemed, exhausted or in agony to give birth, or enjoy the child once it arrives.

dan simon, you said it perfectly about both pain options during birth and breastfeeding.

Although my epidural did NOT turn the pain off like a switch, sadly. It just took the edge off. Just thought I would add that.

8

John Emerson 08.26.06 at 6:46 pm

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.

9

kid bitzer 08.26.06 at 6:55 pm

ingrid–

excellent post. Like Dan Simon & his wife, we had the same experience from a mid-wife here in the States who effectively withheld pain meds from my wife when she really needed them.

I don’t want to get all down on mid-wives; I’m sure many of them do a better job than many OB’s. But the profession seems to select for people (women) who think that childbirth should be the most magical mystical meaningful moment in a woman’s life.

Well, actually for a lot of women it’s utter agony that could have been avoided. And there’s no way that men would put up with being told some equivalent horse-hooey about the wonders of having open-heart surgery without anaesthetic.

Furthermore, many mid-wives approach childbirth with the view that it has been overly “medicalized” by the MD profession–treated too much like a disease. There’s probably some truth to that. But I suspect that the taboo against pain meds in labor is connected to the idea that we have to treat labor as something totally different from a medical/disease condition. That’s just a mistake, and one that causes a hell of a lot of misery for women.

Question. You write:

“it is extremely unlikely that making spinal anaesthethics genuinly available to all women would not imply higher costs for the government.”

Are you sure about that? Anything that slows down recovery is going to increase hospitalization time. Pain is bad for the body; it slows healing time, it increases stress.

Of course the question is entirely empirical, but it seems to me perfectly possible that spinal anaesthetics are a very cheap way for the government to save a lot of money associated with the indirect consequences of making labor agonizingly painful.

Can I also say. This crap about women forgetting how painful labor was: maybe true for some women out there, but is definitely not true for my wife. She remembers, very clearly, to this day.

10

kid bitzer 08.26.06 at 7:03 pm

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.

11

dsquared 08.26.06 at 7:14 pm

in labour for 30 hours

jesus wept, did you run over the doctor’s cat or something?

12

harry b 08.26.06 at 7:21 pm

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).

13

kid bitzer 08.26.06 at 7:42 pm

harry b–

yeah, fair enough. No dissing of Dan Simon intended on my part, more like qualified agreement.

14

Adam Kotsko 08.26.06 at 7:44 pm

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!

15

Tom Hudson 08.26.06 at 8:10 pm

Dan Simon may have a point, but I couldn’t see it around “breastfeeding is extremely difficult and taxing for most mothers, and formula is so easy and convenient by comparison.” My better half counsels breastfeeding mothers, and neither the “*most*” nor the “*so*” has any relation to our experience.

Ingrid seems to be seeing in the Dutch system the opposite of what we see here in the US, which to me supports the whole “mean between the extremes” idea. Here in our corner of the south, birth is medicated, and midwifery is discouraged legally, but a significant fraction of women who manage to get care from midwives do give birth without drugs and have experiences they’re happy with.

(My wife had labor #1 without any pain medication. She tried to go through #2 the same way, but got exhausted during labor and in the end accepted an epidural to try to deliver without c-section.)

16

dr. mama 08.26.06 at 8:22 pm

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.

17

harry b 08.26.06 at 9:37 pm

My favourite nursing story — a friend of mine who’s a (coeducational) high school teacher was told at a La Leche League session that you have to massage your breasts in preparation to pump (for subsequent use). She pointed out that she had only 5 minutes between classes — barely enough time to pump, let alone massage.

“Oh that’s ok, you can just do the massaging during class”
“But I’m teaching my students during class — they’re all watching me”
“That’s ok — they won’t mind”
“But they’re teenagers”
“They know that babies have to be fed with breastmilk. Just explain why you are massaging your breasts.”

At which point my friend stopped trying to reason.

18

eweininger 08.26.06 at 9:56 pm

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.

19

eweininger 08.26.06 at 10:00 pm

That should be “thought,” of course (typo not in original).

20

H. E. Baber 08.26.06 at 10:19 pm

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.

21

bemused 08.26.06 at 10:39 pm

It is certainly not the case that “breastfeeding is extremely difficult and taxing for most mothers”. It is difficult at first for some first-time mothers, especially if they haven’t got the support of an experienced breast-feeder to show them how it’s done. It is taxing for the first few weeks as the baby’s appetite gets in synch with the mom’s milk supply. A few moms can’t breast feed. Fanaticism is out of place regarding other peoples’ decisions in this regard, both in making a mom feel guilty about choosing to bottle feed and in making it hard or impossible for a mom to breast feed.

As for epidurals — it sounds as if they’re underused in the Netherlands, but they aren’t a panacea…the pain of childbirth usually ends with the birth, and there is definitely a down side to the after effects of anaesthesia then, not least to the ability to begin breast feeding.

22

fjm 08.27.06 at 12:17 am

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”.

23

Dan Simon 08.27.06 at 1:32 am

For the record:

1) My claim about breastfeeding being difficult and painful for “most” women is second-hand from my wife’s circle of new-mother friends and acquaintances, almost all of whom breastfeed. I haven’t seen any hard statistics, of course–in either direction. Anybody got some?

2) I obviously don’t know for sure that breast milk isn’t superior to formula. But every testimonial to the former that I’ve ever heard–including from my daughter’s pediatrician, who you’d think would know better–started with, and prominently featured, the supposed ability of its antibodies to strengthen the baby’s immune system. The other arguments (breast milk is more “natural”; breastfeeding seems to be correlated with various other positive traits, although causation is far from proven, given the significant demographic differences between breastfeeders and formula feeders) are utterly unconvincing by comparison.

24

magistra 08.27.06 at 2:44 am

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).

25

Tim Worstall 08.27.06 at 4:36 am

You’ll need to hunt for the articles but this blog:
http://nhsblogdoc.blogspot.com/
by a GP in the UK is most upset with midwives for exactly the reasons given above: they seem to refuse not just pain relief but other interventions as they are not “natural”.

26

derrida derider 08.27.06 at 6:52 am

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.

27

Matt McIrvin 08.27.06 at 7:58 am

Wow.

I’d say that at the American hospital where we had our daughter, the bias was just a little too much toward traditional hyper-medicalized care for our liking (e.g. the default is to keep the new babies in the hospital nursery for most of your post-natal stay unless you explicitly opt for them to room in, and sometimes you have to go out of your way to remind them).

But when it comes to pain relief, I have no complaints. Toward the very end of the process, after toughing it out for many hours, my wife asked for an epidural and got it.

It was late enough that many obstetricians even in the US might have deemed it too late to be worthwhile. I’m convinced that it did prolong her labor by a few hours, it made it harder to push, and it certainly did create the need for more drugs and intervention to keep the contractions going and get the baby out alive and healthy. Once the doctors take control of the process, they can’t give it up again.

But I still think it was the right decision for her at that moment. Seeing what she was going through and how she behaved before and after getting the epidural, I don’t begrudge her the epidural at all, and had it been me, I would probably have asked for one earlier. Mother and baby are healthy and my wife was spared some intense suffering for a little while.

That’s not to say that everyone must get them; the tradeoffs are real, and some people have an easy enough delivery or high enough pain tolerance that they end up feeling it’s worthwhile to go without. But I think that effectively withholding the option of spinal anesthesia is inhumane if it exists and is reasonably safe.

28

Mark 08.27.06 at 8:43 am

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

29

sn 08.27.06 at 8:53 am

“…it is also possible to see [labor] as a marathon, where you suffer pain, but you constantly try to push your boundaries.”

Seems like a bad analogy to me: the point of labor is the birthing of a child, right, not the ‘pushing of boundaries’? Maybe pain is the point when it comes to marathons, or maybe pain is an unavoidable element of the goal (finishing the race?); not so childbirth, at least as I see it.

I recently gave birth in the States, and my impression was that the “give birth drug-free and be so proud of yourself” mindset is part of a larger package: breast (and only breast) – and, moreover, “fresh is best”; carry baby always, everywhere, mom – preferably in a sling, for constant breast access; respond lovingly throughout the night, indefinitely – sorry, no good sleep for perhaps a couple of years… etc. etc.

The no-epidural mandate thus appears to be there partly to ensure that mother is clear on the fact that it’s going to be hard hard hard to do the right thing for baby – so hard, in fact, that there really won’t be time or energy for anything else.

Oh, and apropos of the “massage your breasts in class story”: Dr. Sears helpfully recommends, in “The Baby Book”, that women who wish to continue to work should “wear” their babies in the workplace. Example: if you worked as a salesperson in a baby store, think of how much the customers would enjoy seeing your baby strapped to your chest! (Of course, this advice comes after a section in which you are asked, over and over: do you REALLY want to keep working now that you’re a mother? and much helpful advice is offered on how to jettison that pesky job and live a blissfully child-focussed life.)

Gah.

30

John Emerson 08.27.06 at 8:59 am

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.

31

harry b 08.27.06 at 9:43 am

mark — I have an immediate interest in this (thrid kid coming in a month, hopefully not after a 30 hour labour and emergency C-section) and my wife had hel breastfeeding both previous kids. So her inclination is to breastfeed until there’s a major problem, then stop. I have basically heard the case for breatfeeding only from zealots who can’t substantiate their case (same with vaginal childbirth over C-sections); though I realise that most people who believe in natural selection similarly can’t substantiate the case (and that doesn’t make me doubt evolution). So the main question is really what other variables the studies control for and how well they do the controlling. When the benefits are significant but not huge this really matters; do they control eg for sociological as well as medical factors?

32

Mark 08.27.06 at 10:10 am

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. :-)

33

Joshua W. Burton 08.27.06 at 10:14 am

The US experience varies significantly from state to state. In Rhode Island, my wife delivered our first child at a natural birthing center in a major research hospital, under the care of a midwife from a practice of six, all of whom she had seen repeatedly during the pregnancy. The center was on the ground floor with a window and a garden outside, and resembled a comfortable motel room with a queen-size bed and a good big whirlpool tub. Full-on medical intervention was five steps and a two-story elevator ride away, and epidural anesthesia was available on demand in the birthing center, neither encouraged nor discouraged by the pragmatic, capable midwives. It was a place for my wife to take charge of her own birthing experience; we were told again and again that there are many opinions and many choices leading to good outcomes.

In the event, my wife had an intense but brief labor and delivery (first contraction to full dilation about two hours, and another hour of pushing) and described the process as similar to pain/endurance management in her fairly hard-core sports experience. She declined the epidural, and is convinced that staying closely “in touch with the pain” enabled her to manage the birth. She suspects she’d have pushed longer and less effectively, and is convinced she’d have torn, under a block. And she places a high value on the unexpectedly wide-eyed alertness of my daughter, when they met face to face five seconds after birth, before the midwife even had me cut the cord.

Our second experience was in Illinois, home turf of the AMA. We had a choice of two nearby facilities (one a major university hospital, the other a small suburban outpost of a large private research hospital). Both imposed so many arbitrary hurtful rules on midwives and their patients that we seriously contemplated home delivery; the state obviously cannot outlaw home births, but midwives who participate in them are barred from any hospital practice, so that route would have meant a 911 call and leaving the midwife at the hospital parking lot, in the event of complications. We didn’t want to be minutes from a hospital anyway; we just wanted to (for example) not have my wife wired down to the bed continuously (as opposed to intermittent Doppler or wireless fetal heart monitoring), and to have one of us remain physically with the baby at all times after birth. The latter was a dealbreaker at the university hospital: they need to take the baby away for up to four hours to perform five minutes of tests, and having the husband accompany them would interfere with the efficiency of the process.

The little hospital tolerated two independent midwives, one of whom was my wife’s cup of tea (the other being a bit earth-motherish and judgmental, in the sense people have outlined above). We got done in a couple of hours, again with intense quick pain after our midwife broke her water with a finger; walking around and changing position and extreme-sport breath control seemed to work for my wife as before, and the midwife only once had to yell at the hospital nurses on our behalf. So objectively the experience wasn’t too different from our first, although the setting was much less pleasant. But where the RI hospital had given us both five hours of quiet sleep together in a comfortable bed with our daughter immediately after birth, the IL hospital had a single hospital bed, a hard chair for me to sleep in, and no chance to sleep because the staff forgot everything they had promised and woke us (to try to take away the baby, to bring an unwanted meal, and I swear to heaven to weigh my postpartum wife in the middle of the night!) several times. And if our lone midwife had not been available that evening, all bets were off, and we’d have wound up with a random physician and no way to own the process at all. The second time around, my wife knew how her body works; all she wanted was backup.

It sounds as if my wife would have done well in the Netherlands, but obviously people’s needs differ. Can’t everyone agree that giving the mother more choices is desirable?

34

Joshua W. Burton 08.27.06 at 10:34 am

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?

35

eudoxis 08.27.06 at 10:39 am

I’m sorry you had such a bad experience at the hospital, Ingrid. I hope that the in-home aftercare made up for some of it.

I agree with the posters above who find pain relief during child birth not a panacea. I’ve delivered both with and without pain relief and I felt much more connected and in control with my delivery when I did not have pain relief. Women are all different in their tolerance for pain, however, so the choice for pharmaceutical intervention should be left to the woman. This may seem strange, but among my group of friends there was a sense of empowerment to be offered pain relief and to refuse it. We all breastfed, too, for years. As working moms.

36

Phil Armstrong 08.27.06 at 11:20 am

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

37

jayann 08.27.06 at 11:20 am

I know of only two women among my friends in the UK who have had spinal puncture anaesthesia.

it’s used in 35% of births in the UK (according to an account, in _The Times_, of the Royal College of Midwives proposal to charge for non-essential epidurals)

38

tribald ozgevir 08.27.06 at 11:48 am

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.

39

H. E. Baber 08.27.06 at 11:54 am

Maybe what I found repugnant about the whole natural childbirth movement was the Earth Mother cult that surrounded it, the romanticization of “birthing” and breast feeding and the idea that somehow making a fuss about one’s “birthing experience” was “empowering” to women.

Having children, bringing them up, teaching them, forming their values and watching them turn into independent individuals, with distinctive personalities, goals and projects is a big deal. 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.

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

40

kid bitzer 08.27.06 at 12:14 pm

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.

41

v 08.27.06 at 12:17 pm

Basically of the 20 babies that I have delivered (while a medical student), only 4 of the mothers chose not to have an epidural. They did agree to morphine and the relative difference in pain they experienced seemed (i admit this is very subjective) enormous. I don’t understand why they would make that choice but then I am limited by very obvious biases (male, in the medical profession, job involves treating pain not standing by and mythologizing it).

On the issue of breastfeeding, it really is one of the few unarguably significant things mothers can do to affect their children’s lives positively (the nature-nurture debate has thankfully not injected itself here). Every study examining it has shown its positive impact and considering the trouble and hassle most parents take over much less important aspects of their children’s lives, I don’t think overemphasizing its importance is happening.

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. Moreover, one takes enough risks involuntarily in a traumatic process like pregnancy and childbirth (or i suppose in life in general) so adding risks voluntarily in the name of being ‘natural’ or being a ‘feminist’ strikes me as ridiculous…

42

Joshua W. Burton 08.27.06 at 12:21 pm

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.

43

kid bitzer 08.27.06 at 12:32 pm

joshua barton–

uh…I hate golf, too, and I hate MD’s who think they’re all that (in my line of work, getting an MD is what happens to the stupid kids that wash out of the program). But how was that first paragraph a response to what h.e. baber had said?

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

44

Joshua W. Burton 08.27.06 at 12:35 pm

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?

45

nick s 08.27.06 at 12:40 pm

jesus wept, did you run over the doctor’s cat or something?

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.

On the general point: the ‘medicalisation’ of childbirth may have provoked a backlash and a desire to give midwives a greater role, but it has to be weighed against the decrease in stillbirths and infant mortality. I still remain convinced that human childbirth is a damned unnatural process (and the word ‘birthing’ even more so) and that epidurals are no less unnatural.

46

Joshua W. Burton 08.27.06 at 12:45 pm

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.

47

mythago 08.27.06 at 12:56 pm

And I don’t remember any reports at all about dogmatic, bullying midwives.

They certainly exist. There’s a large wing of frowny, authoritarian types who see childbirth as a kind of extreme sport, where the closer you can get to the Platonic ideal of the Mother Goddess gently birthing the first of humanity, the better. There’s a deep and hateful anti-scientific vein in that philosophy. It has nothing at all to do with empowering women; it’s all about empowering these advocates’ view of what they think is best for women.

As for pain relief, labor hurts. Of course it’s wise for a woman to be informed of the risks and benefits of the various options available to her, and to be aware of non-medical things she can do to cope with the pain (anesthetic doesn’t always work, or work perfectly). That’s quite different than using scare tactics to suggest that not only is pain relief going to doom the baby, but it’s a sign of unwomanly weakness.

dan, breastfeeding is in many ways much easier than bottlefeeding. Nothing to clean, you don’t have to heat the milk up or worry that you got it the wrong temperature, nothing gets thrown out, you don’t have to sterilize the breast first, etcetera. I’m not trying to say breastfeeding is morally superior, but at 3 a.m., believe me, it’s a lot easier to just roll over and latch the kid on than to haul out of bed and go through the bottle routine.

48

Joshua W. Burton 08.27.06 at 1:02 pm

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?

49

John Emerson 08.27.06 at 2:16 pm

I hate to go all Earth Mother on you guys, but putting an entirely negative definition (as pain and a medical problem) on one of the things that only women can do, one which is a wonderful contribution to the world, strikes me as a bit misogynist. The comparison with pain in athletic events strikes me as apropos, except the nothing of value comes from athletic events except the experience itself.

There are nuances, individual preferences, and special problems, but none of the Earth Mother types I’ve encountered personally are quite as unremittingly one-sided as several of the anti-Earth-Mother spokespersons here, who tend not to acknowledge the other side of the argument at all, except in caricature form. There’s been some misinformation, too.

The specific problems in Holland seem to come from bureaucracy and professional association as much as from the dogmatism of Earth Mothers.

50

ingrid 08.27.06 at 2:19 pm

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).

51

Matt McIrvin 08.27.06 at 2:19 pm

“In the event, my wife had an intense but brief labor and delivery (first contraction to full dilation about two hours, and another hour of pushing) and described the process as similar to pain/endurance management in her fairly hard-core sports experience. She declined the epidural, and is convinced that staying closely “in touch with the pain” enabled her to manage the birth.”

That’s another thing: the experience varies enormously from person to person even apart from differences in medical practice. My wife was in labor for about 26 hours total, the last 11 of which were in the hospital with intense, painful contractions, and she asked for the epidural after maybe 7 hours of intermittently intense pain. If it had been short, she might well have declined the epidural.

52

Matt McIrvin 08.27.06 at 2:30 pm

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.

53

H. E. Baber 08.27.06 at 2:39 pm

Sorry, Joshua, I “birthed” 3 babies, with Lamaze, no epidurals, the two later without any painkillers at all, and didn’t find it in anyway either “empowering” or disempowering or any bigger an emotional deal than heavy-duty dental work. You do not have to “prepare” for childbirth–it happens–and pregnancy is just a physiological process like digestion and hair growth. As for a supporting cast cheering me on I certainly never had any interest in that. I just wanted the whole thing managed by professionals with expertise who would do a good job, in a high tech environment in case anything went wrong. Childbirth is not an accomplishment.

It’s not logically incoherent to claim that both childbirth and gender neutral activities like professional activity, sports, arts or politics are “empowering.” But de facto on the ground that’s not the way it works. The Earth Mother cult that surrounds “birthing,” the sentimentalizing and obsessing about the details of childbirth and breast feeding, get quite a number of women hooked into an alternative reality, a subculture where you can spend all your time reading a zillion books and websites and having fascinating discussions about the respective merits of various breast-pumping systems.

This hobbiest subculture flatters women by suggesting that childbirth and breast feeding are achievements–comparable long distance running or doing a major project at work but it’s more of the same old story as paens to housewifing that were popular during the heyday of the feminine mystique (remember, “You’re not ‘just a housewife’–you’re a manager, an accountant, a corporate CEO, a psychologist, a chef…”). It’s the same old thing: bogus sense of accomplishment and busywork that sidetracks women.

54

harry b 08.27.06 at 2:50 pm

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.

55

Joshua W. Burton 08.27.06 at 3:13 pm

But de facto on the ground that’s not the way it works.

sentimentalizing and obsessing … women hooked into an alternative reality … bogus sense of accomplishment and busywork

If I have unintentionally said anything even half this patronizing or demeaning about the subjective experience of Ms. Baber or others, I apologize for setting the tone. My only notion of a good outcome is one in which views of childbirth as varied as hers and ours can all find congenial, appropriate, and affordable care.

In the United States, the noninterventionist end of the scale is demonstrably still the one operating under heavy institutional and regulatory restraint. I would oppose the opposite swing of the pendulum just as strongly, if it resulted in Ms. Baber being treated as we were treated in Illinois.

56

eudoxis 08.27.06 at 3:27 pm

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.

57

Joshua W. Burton 08.27.06 at 3:29 pm

Ingrid writes:

Knowing that it’s available, even if you don’t use it, can really help and make one more relaxed or feel under control.

I think this is a point that bears underlining. This discussion keeps circling around power not as political theater, but because flat on your back in a strange room with bright lights and a stranger telling you what to do is pretty close to the primal experience of human surrender, even without a gender subtext. Leaving childbirth aside, patient-controlled morphine drips have revolutionized pain management for cancer and burn victims, resulting in less pain with less cumulative medication, and faster recovery times. If we didn’t acknowledge the psychological impact of not being in charge, we’d probably let our honored guests at Guantánamo Bay administer their own waterboarding, too.

A childbirth experience that makes obtaining pain medication or refusing it burdensome does not meet the goal of putting the mother in control. It’s still her body.

58

harry b 08.27.06 at 4:04 pm

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

59

Dan Simon 08.27.06 at 5:16 pm

dan, breastfeeding is in many ways much easier than bottlefeeding.

For some women that’s true, and those women should obviously breastfeed.

there are good reasons to breastfeed for at least 6 monhts.

Perhaps. But then, there are good reasons to avoid an epidural during childbirth–and these were repeatedly driven home to us during our childbirth classes. (Some of them have been mentioned during this discussion, in fact.)

The link between the two issues is that in both cases, some small-but-measurable increase in risk to the baby’s health is weighed against a very severe hardship to the mother, and the latter is treated almost as a spiritual benefit, rather than as something potentially more worth avoiding than the former.

Of course, if small risks to a baby’s health were always considered paramount, then I would understand such a the rule extending to epidurals and breastfeeding as well. But society’s treatment of such risks is far from consistent.

For example, one of the studies cited above in favor of breastfeeding (thanks for pointing it out, Mark) suggests a link between breastfeeding and a reduction in the occurrence of ear infections–but the same study also suggests that pacifier use is linked to an even greater increase in the occurrence of ear infections. Are doctors advising against pacifiers with the same vigor that they devote to steering mothers away from formula? And if not, why not?

My hypothesis: taking away pacifiers would make many babies noticeably less cheerful. Taking away epidurals and baby formula only makes many mothers noticeably less cheerful.

60

J. Ellenberg 08.27.06 at 5:32 pm

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.

61

H. E. Baber 08.27.06 at 5:33 pm

Re #54, for sure home follow-ups are terrific. That seems to be one of the perks of socialized medicine–at least in the UK. I compared notes with my mother-in-law in the UK: she got this follow up with visiting nurses who checked up to see things were going ok after a leisurely 2 weeks in the maternity hospital, answered questions and got her on track (and when I was there a few years ago doctors were still making house calls).

When I had my first I was sent home 48 hours later with a cradle-sized cardboard box to stow the kid packed with samples of different brands of baby formula, a package of paper diapers, and lots of coupons for baby stuff. No one every told me anything about dealing with babies or followed up. The other 3 patients in my room all looked to be under 16 (this was a city charity hospital) and got the same treatment.

There was a nice article in the New Yorker sometime ago about a “nurse visitor” program in the Mississippi Delta where women who had babies were followed up in this way that had good results. But for the most part given the expense of maintaining an inefficient private health care system poor women especially don’t get this kind of support.

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.

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harry b 08.27.06 at 5:36 pm

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.

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John Emerson 08.27.06 at 6:58 pm

There seem to be particular problems with Holland’s establishment of medicine which are being projected on the very idea of natural childbirth and even breastfeeding. In my experience, these problems do not occur in places where natural childbirth is an option rather than an obligatory procedure. The convergence of certain unique personalities, including but not limited to Dan Simon’s, has magnified whatever actual problems there are.

“This hobbiest subculture flatters women by suggesting that childbirth and breast feeding are achievements—comparable long distance running or doing a major project at work”.

I’d like to apologize for my patriarchal suggestion that giving birth was in any sense an accomplishment or a good thing (like becoming the partner in a law firm for example), when in reality it is just a supersized, painful, life-threatening form of excretion.

The reason I said what I said, as per my post #1, is because I want as many women as possible to suffer as much as possible.

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Joshua W. Burton 08.27.06 at 7:04 pm

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.

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derrida derider 08.28.06 at 12:14 am

Phil Armstrong at #36 -
“Failed state” (ie no state) and near-famine conditions are the rule, not the exception, in human history. We’ve only got over the no-state bit in the last few thousand years, and the near-famine bit in the last few hundred. If you don’t believe me go googling around to find out what old skeletons tell us about nutritional status in the distant past. So I reckon my figures aren’t too far off the ones we evolved with – most Third World countries are much better off than that.

And the point about human birth being difficult compared with other animals certainly stands.

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Phil Armstrong 08.28.06 at 4:57 am

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.)

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John Emerson 08.28.06 at 8:22 am

D.D, no one here has argued for return to famine conditions and failed states. This thread is about “natural childbirth” and the use or not of spinal blocks, and a few anti-natural-childbirth militants have dragged in breast-feeding and several other somewhat related issues.

Your point about the difficulty of human childbirth is intrinsically valid and pertinent to some of the more extreme ideologues in the natural-childbirth field, but it isn’t terribly relevant to spinal blocks.

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blah 08.28.06 at 3:50 pm

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.

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John Emerson 08.28.06 at 4:09 pm

“Yet the breastfeeding industry rarely tells this to mothers.”

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

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blah 08.28.06 at 4:12 pm

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.

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John Emerson 08.28.06 at 5:49 pm

“Industry” was the wrong word. There are people making their livings in the business, but it’s pretty small-time, and it’s all voluntary.

The breastfeeding advocates I knew all acknowledged that it’s not for everyone, though they were definitely advocates. If ypou disagree with them, you can walk away, and as I understand, that’s what you did.

The animus here seems highly excessive.

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blah 08.28.06 at 6:47 pm

Ok, “industry” was the wrong word.

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blah 08.28.06 at 6:49 pm

But the animus results from the hurtful belittlement of mothers who do not or cannot breastfeed.

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H. E. Baber 08.28.06 at 10:30 pm

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.

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Dan Simon 08.28.06 at 11:00 pm

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?

Well, my wife found breastfeeding impossible, but she was able to pump more than enough breast milk for our daughter to be bottle-fed 100 percent breast milk for the first three months. Nevertheless, she was repeatedly told–based on what evidence I have no idea–that our baby would be better off if she switched back to breastfeeding. (I think one argument had something to do with facial muscle development.)

“Industry ” may not be the right word, but “cult” may be closer to the mark.

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jasper emmering 08.29.06 at 4:04 am

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.

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jasper emmering 08.29.06 at 4:41 am

Now, some debunking.

My wife and I have two young children, and I can attest from personal experience (as well as my experience as a medical student) that, yes, the vast-pain-is-natural-ergo-good-conspiracy (VPSNEGC) does exist, and it thrives here in the Netherlands. And it includes the gynaecologists as well.

The arguments used by the VPSNEGC are bollocks:

1. Yes, the pain is natural. So is the pain associated with acute appendicitis. I have never, in my life, encountered unnatural pain.
2. Yes, an epidural is associated with more adverse outcomes, at least here in the Netherlands. That’s because the “adverse outcomes” they measure are not, by and large, actual outcomes (such as dead or damaged babies), but their own medical interventions: assisted deliveries (i.e. with the help of vacuum or forceps), episiotomies, emergency caesarians, etc. So if the same gynaecologists who almost never allow women to have their epidural freak out when they’re in the unfamiliar situation that the mother is not in great pain, it’s the epidural’s fault. I am quite confident that if epidurals were causing subpar babies or even subpar deliveries then they would have been litigated out of existence long ago.
3. Yes, you can always wait and see if you really need an epidural. Except in the real world, that is. And what about those women who do not want to find out?

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jasper emmering 08.29.06 at 5:34 am

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.

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jasper emmering 08.29.06 at 5:52 am

Natural of painless: what does the literature say?

As it happens, I have had to research this question during my gynaecology co-schap (clerkship or what have you). And I know very well what is better: natural or painless. And there have been quite a few studies where mothers have been asked all the relevant questions, both shortly after giving birth and, say, a year later.

And the amount of pain is not a big factor in gauging customer satisfaction. The literature is quite clear on this. So what is it (apologies for the wingnutty allcaps):

WHEN WOMEN GET THE TYPE OF DELIVERY THEY WANT, THEY’RE MORE SATISFIED WITH THE EXPERIENCE.

That’s it.

Women who want all-natural, fully painful, eat the placenta type-births, getting rushed to a hospital is the biggest turndown. And for sensible women it’s having unnecessary pain because an epidural is unavailable or refused.

The obvious lesson here is that BOTH modes of delivery should be readily available, and neither should be frowned upon (at least not by a midwife or gynaecologist face to face with a patient).

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kid bitzer 08.29.06 at 10:18 am

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?

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jasper emmering 08.29.06 at 10:45 am

There are few things more vile to behold than a bloody, damp placenta. I suspect it tastes like black pudding only far more rubbery.

In short: there won’t be nearly enough lidocaine in the placenta to actually numb your tastebuds.

I’m also pretty certain that the lidocaine ampullae they use for an epidural do not contain the artificial flavor they use in lidocaine spray, otherwise it would taste like bananas.

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Seth Gordon 08.29.06 at 11:07 am

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

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jasper emmering 08.29.06 at 1:03 pm

From those knowitalls over at Wikipedia:

Human placenta tastes very similar to beef, with a springy texture similar to the heart.

Like I said, rubbery. But I don’t know where the beef-flavour comes from. It’s not a muscle.

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eudoxis 08.29.06 at 1:41 pm

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.

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