Fear, lack of support, and hospital staffing can have greater influence on epidural use than a woman’s level of pain, according to a new book on the future of maternity care co-authored by Trinity academic and midwife Dr Elizabeth Newnham.
Increasing epidural rates globally are influenced by “industrialised” maternity systems which are failing to give women adequate support and information, according to Dr Newnham, Ussher Assistant Professor in Midwifery at Trinity College Dublin and author of a new book entitled Towards the Humanisation of Birth: A study of epidural analgesia and hospital birth culture.
Drawing on ethnographic research conducted by the authors in Australia, which involved observations of care delivered in a maternity hospital as well as interviews with 16 women over the course of their pregnancies, the book explores the personal, social, cultural and institutional influences on women in deciding whether or not to use pain relief in labour. In the book the authors place these practices within an international context, drawing on research to provide a history of the use of analgesia in maternity care in Western developed countries and an analysis of modern hospital birth cultures, which, according to the authors, operate in similar ways around the world.
Use of epidural analgesia for labour has increased over the last two decades. Currently, approximately 40% of women in Ireland use epidurals and this figure increases in some hospitals and for women having their first babies. While epidural analgesia is effective at covering the pain of labour, research has shown that it does not necessarily increase birth satisfaction, according to Dr Newnham. It has also been shown to interfere with the normal labour process, increase the risk of instrumental birth, and decrease the likelihood of successful breastfeeding. Epidural analgesia also requires other interventions such as bladder catheterisation, continuous electronic foetal monitoring and intravenous synthetic oxytocin, which can lead to further complications, according to the authors. Women are not always informed of these risks when choosing an epidural, Dr Newnham added.
Despite these risks, epidural analgesia has been promoted as a safe technology in maternity care, because labour ward practices are embedded in a scientific discourse that prioritises and promotes technology use, according to Dr Newnham in the new book.
Dr Newnham commented: “Our research into the personal, social, cultural and institutional influences on women in deciding whether or not to use pain relief in labour was carried out in Australia, but international research indicates that similar maternity care culture exists in many western developed countries, including Ireland. Our research identified a fundamental paradox at the heart of modern maternity care. Practices that fit within the medical paradigm, such as epidural use or induction of labour, are pronounced safe even though they might in fact carry some risk, while practices that support physiological birth, such as water immersion and mobilisation, which have minimal side-effects are treated as either inherently risky or somewhat ridiculous.”
“While pain relief should always remain an option, it should not necessarily be viewed the most important issue for women as they approach birth. Women in our study expected to feel some pain, and most were either ambivalent towards it, or even welcoming of pain as part of the rite of passage to motherhood. Although a few women gave fear of pain as a reason for planning an epidural, women also described fear of intervention, of loss of physical and emotional control, of the environment and of the unknown. Women’s approach to birth is more complex than just fear of pain.”
“As pain relief was being introduced into the birth room, it displaced older traditions that we now know decrease analgesic requirements in labour, such as use of upright positions, warm water, and the presence of supportive female companions, including midwives. The practices that replaced these with the introduction of medicalised birth — being alone, having to lie down, and the increased use of instruments for normal birth — probably increased initial demand for pain relief. When analysing the birth stories of two women who talked about their absolute need for pain relief, we found descriptions of isolation and lack of emotional and physical support that preceded this need.”
“The need for pain relief may in many cases stem from fear, loss of control, or lack of support. Midwifery practices that we know decrease the need for analgesia should now be incorporated back into all birthing spaces as a matter of course, prior to and alongside analgesic options.”
Some of the key research and ideas presented in the book include:
- The book provides insight into women’s views of labour pain. Current medical practice assumes that labour pain (and its relief) is the paramount issue for women, according to Dr Newnham. The authors found that although pain was feared by some women, it was not their primary consideration when approaching labour. These findings have implications for how labour pain is approached.
- The authors argue that current medical discourse presents epidural analgesia as safe, effective and accessible, despite continuing findings of associated risks. They found that women were not given all of the information about the risks and side-effects of epidural analgesia. Meanwhile, the option of water immersion was presented as risky and restricted even though it is actually relatively safe.
- The authors found that what is important to women was support by their midwife, access to options that support physiological birth and for midwives to direct them to these options.
- The authors found that fear, lack of support, hospital staffing and the beliefs of the midwife in the room influenced whether or not women had an epidural, and may be a greater influence than pain relief requirements.
- The authors describe how current maternity practice is characterised by surveillance and time restrictions to keep pace with institutional momentum rather than women’s birthing bodies.
- According to the book, midwives and doctors who attempt to provide normal birth practices are often obstructed in their attempts by having to conform to risk-orientated protocols. However, these protocols also reflect the institutional paradox, and may fail to acknowledge the introduction of harm caused by medical intervention