What I’ve been reading…the Women’s Health and Education Center

I stumbled across this site run by the Women’s Health and Education Center which is associated with the UN.  And I really really dig it.

Some choice quotes:

“The use of techniques and medications to provide pain relief in obstetrics requires an expert understanding of their effects to ensure the safety of both mother and fetus. Positive attitudes and the need for good medical care should be stressed.”

Positive attitudes?  That’s code for YE SHALL DELIVER RELIEF ON DEMAND TO A LABOURING WOMAN AND THOU SHALL NOT JUDGE HER OR CONDEMN HER TO PAIN BECAUSE OF YOUR OWN PERSONAL IDEOLOGY.  It’s really sad that in this day and age we have to spell this out…it is really sad that women suffer worldwide in terms of their health because of their gender.

“Maternal mortality relating to anesthesia has reduced 10-fold since the 1950s, largely due to an enhanced appreciation of special maternal risk with anesthesia.”

Anesthesia as a whole has gotten a lot better (safer) since the 1950s.  There have been advances in monitoring, technique and in the availability of drugs with better safety profiles.  We now provide pain relief in labour and anesthetics for surgical and instrumental delivery with an enviable safety record.  Far from the Ina May’s of the world who believe, and like to proselytize, the idea that modern interventions are increasing the maternal mortality rate, physicians have been working diligently to increase the safety and efficacy of their interventions.

I am proud of my colleagues and my specialty.  Deaths due to anesthesia are down.  By 10x…even though the proportion of women receiving epidurals has increased..even though the global C/S rate today is greater than it was in the 1950s and all those women need an anesthetic.  Check out this paper from 2011 in Obstetrics and Gynecology if you are interested.  The maternal death rate due to anesthesia from 1991-2002 was 1 per million live births…an improvement of 60% compared to the ten years previous.

I recently read a great anesthesia memoir, Laughing and Crying about Anesthesia, by Dr. Zeitlin.  During his career, anesthesia went through tremendous changes and he was able to witness its transformation from inauspicious beginnings into the safe and highly respected specialty it is today.  He makes the point that since anesthesia in and of itself isn’t life-saving or – prolonging the way surgery is, patient harm (death and other damage) is unacceptable.  I completely agree…and so do my colleagues who will continue to strive to reduce these maternal mortality numbers even further.

I am digressing…more quotes:

“Regional analgesia provides a superior level of pain relief during labor when compared with systemic drugs and, therefore, should be available to all women.”

In Canada, we are failing on this point.  We have manpower issues.  We have geographic issues.  We have resource rationing issues.  We have ideological issues (Google Michael Klein)  Epidurals aren’t available to all women that want them, particularly those outside of large urban centers, but even those at tertiary and teaching hospitals.  Unacceptable?  I think so.

The best part of this website, though, are a series of articles about pain management during labour and delivery.  They are intended for health care workers that provide obstetrical care (OBs, Family Docs, RNs, Midwives) but they aren’t written in thick medicalese so I think they are a good resource for pregnant women and their partners, doulas and childbirth educators as well.  They are fully referenced and evidence based.

Epidural analgesia failures: the technique review, has a great discussion about why epidurals sometimes are less than adequate and what can be done about it.  It offers up the reassuring statistic that with enough tinkering 98% of epidurals provide satisfactory pain relief.  I think that in the real world, the one I work in, with health care rationing where we don’t have enough anesthesiologists on the ground to provide this tinkering and certainly no DOBA (dedicated obstetrical anesthesia), we fall short of 98%.

On the other hand, I learned that some of my colleagues are so interested in making sure epidurals work for women that they were willing to do studies where they injected stuff into the epidural space of cadavers to analyze how medications spread.  Now that is dedication to women’s health and well-being!

From Epidural and Spinal Anesthesia: understanding the facts (which is a great general overview article if you’ve ever been confused about the difference between a spinal an epidural and a combined spinal-epidural plus you want to look at some pretty pictures):

“The American Society of Anesthesiologists (ASA) and the American College of Obstetricians and Gynecologists (ACOG) recommend that third-party payers should not deny reimbursement for regional analgesia and anesthesia because of an absence of other medical indications.”

I would like to see a third-party payer deny pain relief as medically unnecessary in any other context!  Seriously.  Why are we so cruel to labouring women?  And good on the ASA and ACOG for standing up to the insurance companies who really only want to decrease their payouts and increase their profits.

The only beef I have with this article is that it is from 2009 and still includes some (now false) statements about how epidurals before 4-5 cm may increase the risk of C/S…which has been shown to be untrue in two prospective randomized controlled trials.  See my post on the subject, here.  I guess my recommendation of this website should come with a caveat…check the date the article was published (clearly stated at the bottom of the article) and, as always, discuss your options with your care provider.

What do you think of this website?  I was wondering if we could get them to lobby the BC government since BC has an appallingly low epidural rate that is at least partially explained by barriers to access.


  1. The BC government needs to be lobbied on this issue – it is a tremendous failing in the maternity care services that are provided, and I would welcome any additional support on this issue! Updated statistics from CIHI about the use of epidurals should be available in mid-May, I anticipate that the release of those statistics (I anticipate that they continue to be abysmal) would be a good time for renewed calls for improved access to anesthesia during labour and delivery for all woman in BC. Thank-you for bringing attention to this issue via your blog.

    1. I agree wholeheartedly that every woman who wants access to pain relief — epidural or otherwise — during labour and delivery should be provided with such. I agree that all hospitals with a maternity ward should have a dedicated obstetric anesthesiologist available around the clock (I was utterly shocked to find out this is not the case at most major hospitals!).

      What I don’t agree with, however, is labelling epidural rates with value judgements such as “appalingly low” or “abysmal,” since the overall rates tell us absolutely nothing about the proportion of women who wanted or did not want this treatment and did or did not receive it according to their wishes.

      Case in point, I was one of the women who did *not* want an epidural, and somehow found myself in a position where I was basically given the choice of having an epidural or foregoing pain relief altogether. The irony of the situation is that I was actually “lucky” the anesthesiologist was busy at the time. This delay allowed the nurse to justify giving me narcotics to tide me over, which is what I had requested in the first place, and which was sufficient to get me through the rest of my labour.

      I would be curious to know, though, what the epidural rate is among women who have requested that as their pain relief of choice, and whether that rate is improving or declining.

      1. I’ll take your points about the value judgements. I don’t, by any means, think that everyone should have an epidural. I do think everyone should have timely access to pain relief in labour whether that is some narcotic or an epidural, i.e. true choice. I find the numbers abysmal because I interpret them to mean that significant barriers to access exist when it comes to pain relief for women in labour.

        You are right in that the really interesting statistic, would be the proportion of women who requested an epidural and actually got one…and in what time frame. I haven’t found a study on that question, but I do know that when access barriers to epidurals are removed (ie dedicated OB anesthesia or DOBA, modern non-judgemental attitudes towards pain medication in labour) the epidural rate shoots up to around 80%. Of course, in Canada only teaching centers have DOBA and those centers also have a higher proportion of higher risk labours where epidurals may be encouraged (eg breech, multiples, maternal disease) but they also take care of enough low risk women that the numbers are not likely to be very affected.

        I really appreciate your comment…thanks for keeping me honest!

        As for your labour, I really hope that more centers get the resources to offer remifentanil patient-controlled analgesia (PCA) to women in labour. Remifentanil is a narcotic that is ultra-rapidly cleared by blood plasma in both mom and babe allowing it to be used even during the second stage (pushing) without significant risk of respiratory depression in the newborn. It’s a great emerging option for women who want *something* during labour and delivery, but don’t want an epidural. But it also requires anesthesiologist involvement for set up and supervision…and thus also needs DOBA.

        1. If people can be “outraged” at high csection rates without any further data on why they are occurring – why not be equally appalled at low epidural rates? Both sets of data suffer from the same kind of flaw, and I would say both merit further investigation and the willingness to collect better data on these issues.

        2. Is remifentanil similar to fentanyl? That’s what I ended up having, and I suspect the midwives were hesitant to give it to me because I was on the cusp of second stage labour by the time I arrived at the hospital. I like the idea of PCA – it would be nice for women to be able to have their pain relief on demand, rather than have to beg for every dose!

          1. Remifentanil, like fentanyl, is a synthetic opioid. The brilliance of Remi, however, is that it is metabolized so quickly in the blood that if I gave you a dose, the effect would be gone in about 5 minutes. That means it won’t accumulate in body tissues and could be used up to, and even during, the pushing stage of labour.

            It’s use isn’t widespread in labour and delivery units yet although there are a few centers that offer it. I think it’s a great option for women that want something, but don’t want an epidural. And I agree with you, being able to control when you get a dose of pain relief is very very nice…and it’s been shown to result in lower pain scores at lower doses of the drug (which means less side effects) compared to nurse-delivered pain medication.

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