Feminist Philosophers

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A Brief Defence of My Current Hero, Denis Walsh July 13, 2009

Filed under: feminist men,medicine — brynhild @ 7:33 pm

J-Bro sent us a link to an article in yesterday’s Daily Mail entitled “top midwife says labour agony is a ‘rite of passage’ and pain relieving epidurals weaken the mother’s bond with babies”. In it, we learn that

Dr Denis Walsh, an influential midwife, said the agony of labour should be considered a ‘rite of passage’ and a ‘purposeful, useful thing’.
He criticised the ‘epidural epidemic’ sweeping the NHS, saying maternity units should abandon routine pain relief and instead embrace a ‘working with pain’ approach.

And later

Dr Walsh said labour pain was a timeless component of motherhood. ‘Over recent decades there has been a loss of rites-of-passage meaning to childbirth, so that pain and stress are viewed negatively,’ he said.
But Sally Russell, of the Netmums website, said he was talking ‘absolute rubbish’.
‘What he is promoting suggests to me that women who can’t go through normal birth for whatever reason find they are stigmatised and made to feel they have let themselves down, and that’s very damaging.’

SO, big dumb MALE midwife versus women just trying to do the best they can to cope with horrible pain, right? No. Not at all. Denis Walsh has made it his mission to write about and try to put into practice good, well-designed midwifery and obstetric research, with a particular emphasis on respect for the woman as a dignified person in a highly vulnerable and difficult circumstance. I know this because–in preparation for a second delivery, of which I was formerly shitless on account of a *terrible* first–I happen to have recently read Walsh’s midwifery text Evidence-Based Care for Normal Labour and Birth. Here is a brief run-down of what I took from his text wrt epidurals:

* epidurals interfere with, slow, and generally throw off the body’s efforts at expelling the fetus, thus greatly increasing the instance of assisted delivery. (For those not in the know, “assisted delivery” means they slice into your genitals with a sharp knife and then shove heavy metal tongs up your vangina to yank the baby out. It is not fun, and even if it’s “simple” (as you’ll hear in the interview linked below), it is certainly not nice–nor are the lasting pain and disfigurement caused by it. And charmingly, in many instances of use (take my experience, for example) it doesn’t even seem to be medically indicated.)
* Midwives (a) have in some delivery ward contexts become so accustomed to routine intervention and pain releif that they’ve simply lost the ability to accurately judge ‘how it’s going': they see a woman screaming in labour pain and think something’s gone wrong, when in fact she’s simply in labour. Because of this, midwives are quite often quick to try to “fix” the situation by offering epidural; (b) are sometimes simply not willing to take part in helping women to manage pain; in a nutshell, they simply don’t like putting up with screaming patients; and so they like for their patients to receive epidural as quickly as possible.
* Childbirth is a frightening experience, especially for women who aren’t well-educated about it, and as such, midwives tend to influence very heavily what decisions women make for themselves in childbirth.

Walsh’s recomendations are aimed at midwives. And what they amount to is “hey midwives, instead of setting these women up for almost certain genital mutilation because you can’t be bothered (or you don’t know how) to support them through their pain, let’s all reeducate ourselves on being an effective support for labouring women; let’s try to save a few women from the knife–truly give them all the options by making labouring without epidural back into a real choice”. Walsh is deeply concerned that women’s bodies–and indeed women–should be respected in the process of delivery; that the midwifery and obstetric communities not behave as if anything and everything to yank the fetus out quickly is fair game; and that delivery be conducted in positive, effective ways identified by good research. Another example of this concern is Walsh’s writing about “coached” second-stage labour (where midwife shouts at you to PUSH! PUSH! -which btw, seems to be totally ineffective and even dangerous in some cirsumstances):

One wonders how women delivered babies over the centuries without the stern, exhorting voice of the midwife, coaching them every step of the way. In twenty years of practice I have yet to hear a woman say ‘Thank you so much for shouting at me at the end there. In fact, I am so grateful to all of your for aggressively telling me how to do that pushing bit. your volume 10 instruction made all the difference…’ … There is little doubt in my mind that this style of care could be construed as bullying…It is quite simply no way to talk to another human being regardless of setting or context. (From EBCfNLB, pp.94-94)

Denis Walsh is not the slimy pig-man who’s out to demonize women who choose pain relief, as the Daily Mail (or the BBC, for that matter) would have us believe. He’s a midwife who wants midwives to act as advocates for women: to put the needs of the labouring woman on the map, rather than letting the midwive’s own needs as professionals or the the baby’s (purported) needs push all mention of the woman’s well-being out the window. I, for one, am very thankful I’ve read his work in preparation for the birth of my second child.

(The bit about ‘preparing for the responsibility of motherhood’ by experiencing pain, btw is also Mail spin. There’s evidence that the hormone rush one experiences from the intense pain of labour is actually the cause of the “love at first sight” that some women experience at the birth of their babies. Walsh thinks a further reason to value normal delivery is that this hormone-induced intense love probably helps the women who experience it to cope with those grueling first few weeks with newborn. He does not claim that being in pain makes one more responsible, nor does he claim that pain relief in childbirth makes you a less-good mother!)

You can listen to a six minute interview with Walsh and a (female; just to stir the pot) obstetrician set up as his adversary on bbc online. Or if you’re interested, I highly recommend Evidence-based Care for Normal Labour and Birth.

 

86 Responses to “A Brief Defence of My Current Hero, Denis Walsh”

  1. extendedlp Says:

    sorry, i forgot to say (my, how i do go on!): thanks for the link J-Bro!

  2. Nicole Wyatt Says:

    Ina May Gaskin says very similar things about the importance of paying attention to the natural signals of women’s bodies and the problems with epidurals in her “Ida May’s Guide to Childbirth”. I think she would disagree that un-medicated childbirth must be intensely painful, but then it’s not clear from what you say here that Walsh thinks that is the case either.

    In any case, no one seems to be accusing Gaskin of fetishizing women’s pain.

  3. Nicole Wyatt Says:

    I strongly recommend Gaskin’s book to expectant mothers btw — it’s US-centric in it’s critique of current practice, but the positive picture of how maternity care could be and is in Gaskin’s own practice is fascinating and enlightening.

    I’ll have to get back to you in ~4 weeks about whether it actually helps during labour.

  4. The belief that pain in labor is beneficial has a long and sordid history. A large body of scientific literature shows that women’s pain (of any kind) is much less likely to be taken seriously than men’s pain.

    The Girl Who Cried Pain: A Bias Against Women in the Treatment of Pain, Journal of Law, Medicine & Ethics, 29 (2001): 13–27, provides a disturbing description of the ways in which the pain of women is systematically devalued, disbelieved and undertreated.

    “…Women who seek help are less likely than men to be taken seriously when they report pain and are less likely to have their pain adequately treated…

    The study by McCaffery and Ferrell of 362 nurses and their views about patients’ experiences of pain found that while most of the nurses (63 percent) agreed that men and women have the same perception of pain, 27 percent thought that men felt greater pain than women… The same study also found that almost half of the respondents (47 percent) thought that women were able to tolerate more pain than men …”

    These erroneous attitudes are particularly prevalent in regard to childbirth:

    “Bendelow found that “the perceived superiority of capacities of endurance is double-edged for women — the assumption that they may be able to ‘cope’ better may lead to the expectation that they can put up with more pain, that their pain does not need to be taken so seriously.” Crook and Tunks point to the influence of the psychoprophylaxis movement in the United States with its implicit assumption that it is good to experience childbirth without the aid of analgesia… [A]ccording to the authors, “these attitudes imply that we have a value system … that suggest women should be encouraged to keep a stiff upper lip.”

    The authors believe that people discount women’s expressions of pain.

    “A deeper examination of why women are treated this way is explored by several feminist authors. They attribute it to a long history within our culture of regarding women’s reasoning capacity as limited and of viewing women’s opinions as “unreflective, emotional, or immature.” In particular, in relation to medical decision-making, women’s moral identity is “often not recognized…”

    …These findings are consistent with studies reporting that female pain patients are less likely than their male counterparts to be taken seriously or are more likely to receive sedatives than opioids for the treatment of their pain.”

    It is not a coincidence that the philosophy of “natural” childbirth was promulgated by men steeped in the ethos that women’s pain was not worthy of serious consideration. Their claims that childbirth pain is socially constructed, that women can and should manage pain through psychological means, and that women are “empowered” by pain are simply elaborate justifications for not acknowledging and not treating the pain of women. It is also not a coincidence that the ONLY form of pain thought to be “empowering” is a type of pain that ONLY women can experience.

    Those claims can and should be rejected as expressions of sexism. Women’s experience of severe pain in labor is real, authentic, and biologically based. Respect for women demands that we acknowledge that pain, not minimize it, and not suggest that it should be psychologically managed. There is no reason take the word of a bunch of middle aged white men, steeped in a medical culture that minimized and ignored pain in women, that women “benefit” from pain.

  5. Jender Says:

    Amy, many thanks for that excellent data. The subject of women and pain has come up here before, and the data you give seem to confirm what many of us suspected. I am totally with you on the rejection of the idea that pain is good for women in childbirth. In fact, I had a planned c-section, and I think that women should be allowed to choose these (which they’re not in the UK). However, my impression from elp’s post and correspondence with her is that Walsh does not think women’s pain is unworthy of consideration. Rather, he thinks that the long-term effects of interventions that tend to follow on from epidurals in our current system are so damaging that women need to be genuinely given the option of not having an epidural– and he feels they aren’t really being given this option. When elp was trying to convince me not to be disgusted by Walsh, by the way. she mentioned that he actually agrees with me on elective c-sections, because he thinks that as things are currently structured it’s one of very few ways that women can actually take control of childbirth. So he’s not one of those people insisting that if we e.g. think of the pain as “pillow fluffs” it won’t bother us. He takes it seriously, but he also takes the effects of various interventions seriously and he wants women to have genuine choices.

    *However* there is that stuff about the endorphin and the bonding. Apparently this is based on studies. But, more importantly, my impression is that it’s not his main argument– the effects of interventions is his main argument, and this is a possible side benefit to rejecting the interventions.

    I do agree, very wholeheartedly, that many of the advocates of analgesic-free childbirth do not take women’s pain seriously enough. But it doesn’t sound like that’s what he’s doing.

  6. Monkey Says:

    Another personal anecdote: my mom had to fight hard NOT to be given pain relief for the birth of her second child. She didn’t want any after a terrible allergic reaction to pain relief with her first (me). But the doctors, midwives, and so forth were absolutely adamant that she needed to have some.

  7. Monkey Says:

    Forgot to say – extremely interesting article, extendedlp!

  8. extendedlp Says:

    nichole, thanks for the book suggestion!

    amy: yes, i think this long history you speak of is exactly why we have such trouble listening to what walsh is saying without punching him in the face (so to speak) after the first sentence. surely there is such a history in medicine, and as we’ve discussed before, it seems to be alive and well in gynecology (there’s a post somewhere around here about pap smears and pain–if anyone has the link, do post!) and probably obstetrics as well.

    but like jender says, walsh is *not* saying that childbirth isn’t so bad. and actually, he’s not even saying that women shouldn’t have pain relief: he devotes an entire chapter in the book i mentioned to pain relief, with a focus on looking at the combined data of reported effectiveness *and* compatibility with physiological labour. and he does shocking, breakthrough things like *insist that data about women’s reported experience of relief be taken seriously as evidence* (ooo! actually listen to the women themselves!!). what he’s concerned to do is to limit pain relief to those forms that work but don’t bungle the body’s natural processes.

    what he is arguing on the topic of epidural is that epidural interrupts the course of labour, such that women end up having to have interventions that have long-term and potentially disasterous consequences for women’s health: painful scarring, infection, and so on. and his argument is based entirely on empirical evidence: not ‘childbirth philosophy’. most of the evidence he presents comes directly from the cochrane report.

    (he also notes that one of the ways that it interrupts is by making it impossible for women to take any other position than supine. this makes delivery difficult, tearing more likely, and further, in walsh’s words, “there is a sense in which posture impacts on attitude…[Belaskas's] ‘stranded beetle’ metaphor graphically captures the psychosocial dimensions of birth posture to illustrate the powerlessness and helplessness of being on your back. In this position, the woman is passive, as she assumes the pose of a compliant ‘patient’, and her status vis-a-vis her professional carer is subordinate.” -and if you can’t tell from the quote, walsh thinks this is bad. both in itself, and because it makes birth feel less safe, and the hormonal reactions a body has to feeling unsafe, again, can slow down labour.)

    i filed this post under ‘feminist men’ because i really do think that walsh is about as non-white-male as you can get without actually having your man license revoked. which is why i think it’s a terrible shame that the press are painting him as this misogynist ogre. from reading his work, i take it that he views obstetrics as an entitled-white-men’s club, where best-practice decisions are made on the basis of what shiny new toys they’d like to play with, and what will sound impressive in case of a malpractice suit. and how could he not, given so much *fact* on his side? again, his emphasis is on encouraging and empowering midwives to act as advocates for the rights and dignity of the woman in labour.

    if you’re a medical professional, amy, and you have an interest in this issue: first off, i give you a cyber-hug for caring about it! and second, i really highly recommend you read walsh’s book. i think it’ll change your mind about walsh and about normal childbirth.

    (btw also, lamaz and the like: totally creepy manhate. i completely agree with you. absolutely.)

    (and btw monkey: glad you enjoyed it!)

  9. extendedlp Says:

    i’m rambling. sorry, but i wanted to say also: amy, i actually really appreciate your contribution to this discussion. i am a veyr big un-fan of the nct; i think they are bullies, i think they belittle women, i think they create new and ridiculous reasons for women to feel guilt and disappointment. in reading about childbirth recently, i’ve come to realise–to my great disappointment– that actually, the supposed facts that the nct spew are mostly, well, actual facts. ugh. BUT, they’re not simply offering facts. they’re offering facts and telling us what to do with those facts; how to feel about them. so, eg, we get from the nct both the fact that c-section can make establishing breastfeeding difficult (true), and the judgment that therefore c-section is bad (totally depends on what the other factors are that you’re weighing!!). but if we don’t question childbirth wisdom in precisely the way you’re doing, amy, then we wind up taking the opinion with the facts. so, thanks much for adding to the discussion!

    (40 years ago, certain factions of the natural childbirth movement in america were insisting that women ought to labour alone in a dark room and be as silent as possible! -that’s just one example of amy’s men in the movement!)

  10. Clare Says:

    I was really disappointed as to how this has been represented in the media. Even the Guardian seemed content to lazily set up a controversy – implying that Walsh was stating that pain made you a better mother.

    I don’t know if this is already widely recommended but “Misconceptions” by Naomi Wolf is a really great read for indicating how over-medicalisation can hinder rather than help women in childbirth. It really gave me the self-confidence when I was pregnant (far more than the NCT classes) to plan how I wanted to give birth rather than ending up getting pushed around in the labour suite.

  11. PTS Says:

    I do think there is something objectionable about saying it is a “rite of passage” (was he misquoted?). It seems to imply that people who did use the “wrong” kind of medication didn’t go through that rite of passage and are, therefore, somehow unready or inadequate as parents. That does strike me as problematic.

    If there are, in fact, good medical arguments against epideurals (and I have no reason to doubt either Walsh or extended that there are), then I see no reason why we have to use that kind of rhetoric.

    And while I readily admit that I know very little about pain management in obstetrics, I have read a lot of literature that argues that medical professionals have, quite often, consistently overstated the negative effects of pain management through drugs while understating the negative long-term consequences of being in a lot of pain. This is a general feature of medical practice, though Amy is certainly right that particular (and particularly pernicious) instantiations of it are definitely gendered.

  12. certifieddad Says:

    We had a similar idea. His comments were reported in popular media in a similar fashion here is Australia. I searched for the video you referred to on BBC and got a very different view to the one presented in a local newspaper!
    Certified Dad

  13. Thanks for your thoughtful comments. My concern is that Walsh’s claims are just the 21st Century version of the willingness to dismiss the pain of women.

    Walsh has dressed up his claims in scientific jargon to make them more palatable to a more sophisticated audience, but there is no scientific basis for his claims. He either making them up or repeating claims make by other advocates of “natural” childbirth who made them up.

    There’s NO scientific evidence that unmedicated childbirth is better, safer, healthier or superior in any way than childbirth with pain relief. And the stuff about endorphins and bonding, that’s entirely fabricated; it was made up by Michel Odent.

    Walsh is merely the latest update in an endless string of men (and sometimes women) who discount, dismiss and disbelieve women’s suffering. The original reaction was to claim that pain was all in a woman’s head; the updated version is to claim that if she cared about her baby and herself she would gladly embrace the pain and be a better mother and woman for the experience.

    Curiously, no one has been able to find a form of male pain that supposedly benefits men. I suspect that it is more than mere coincidence that the only pain that is supposedly beneficial is pain that only women can experience.

  14. extendedlp Says:

    PTS: i agree the statement isn’t ideal. i don’t know what the context was for his saying this (or indeed whether he was misquoted), but yes. if it helps, remember again that his recommendations are geared towards midwives: so, you’d have to read it as a a suggestion for how midwives ought to think about the matter. and his concern is that midwives view labour pain as always negative, and this leads them to always act first to get rid of it. so, perhaps he simply wants for midwives to have ways in their consciousness that they could think of pain in a non-negative way.

    clare: thanks for another good book suggestion!

    i’ll add a book to the list: sheila kitzinger’s _the politics of birth_ is an excellent read for a background in how gender inequality has shaped obstetrics and midwifery. particularly fascinating (if you’re listening, stoat) is the chapter on how birth is approached in women’s correctional facilities in britain.

  15. extendedlp Says:

    amy, again, he’s not claiming that being in pain benefits anyone, nor is he denying that childbirth is painful. he’s claiming that pain is a side-effect of the body pushing the baby out, and stopping the pain by epidural also stops the bodily processes that caused the pain (ie, stops the body pushing the baby out).

    i think things like running a marathon are often viewed as pain that’s enriching, and sport is male-dominated. so, i certainly can think of examples where people tell men they’ll be better for the pain. and examples of intensely painful experiences that men can have that are viewed as positive even though (and perhaps partly because) there was intense pain.

    i’m just not sure about your claim that there’s no medical evidence. after reading walsh’s book, i went to the medical seciton of the uni bookstore and bought the cochrane pocketbook on pregnancy and childbirth. and the data they tabulate in it matches the evidential claims walsh makes. so, does that not count?

    finally, i think you need to back away from this insistence that walsh can’t have legitimate things to say on the matter because he’s male. that’s simply sexist.

  16. jj Says:

    I think the underlying bio-chemical explanation goes something like this: it’s oxytocin that causes the contractions and so it is important in the progress of giving birth. Of course, this means that oxytocin causes (or is a big causal factor in) the production of the pain. But oxytocin is also wonderful, since it underlies lots of the bonding that occurs with birth and breastfeeding.

    The anti-epidural claim may in part be that epidurals and other pain medications inhibit oxytocin, thereby making birth longer, more likely to need medical interventions and inhibiting a bonding mechanism.

    Having spent a little time on various web search engines, I don’t have a quick confirmation of the last part other than the fact that epidurals do seem to extend labor. The wonders of oxytocin are pretty well documented, I think.

    Oxytocin is also implicated in the timing of the start of the birth and so it gets studied by people interested in circadian rhythmns – the biological mechanisms for timing. Here’s a blog post that gives one a bit of what is going on;it links to a study of mice that don’t produce oxytocin that has put a bit of the stuff in question.

    (Mice are biologically similar enough to us to be good sources for reasonable hypotheses, even if not proof of anything much.)

    “Rite of passage” must be a pun, don’t you think? It seems to me his language is problematic – it’s given rise to all this negative publicity – and one has to wonder at how the editors, readers, etc, let that happen.

  17. jj Says:

    elp – I’m so glad you bring these topics in – and with such intelligence, experience and courage!

  18. “i’m just not sure about your claim that there’s no medical evidence.”

    Think of it this way: It’s as if an anti-choice activist justified opposition to abortion by claiming that a few women get an infection after abortion.

    Is it true that some women will get an infection after an abortion? Yes, it’s true. Is that a reason to claim that women who want an abortion shouldn’t have one? No, it’s not. Is that a reason for a professor of midwifery to teach other midwives to encourage women to endure an unwanted pregnancy? Certainly not.

  19. extendedlp Says:

    jj, yes i haven’t had time to look back over the in-depth claim, but it was oxytocin he was talking about, and the way you describe it sounds right based on what i remember.

    amy, once again, walsh isn’t claiming that women shouldn’t be allowed assisted births. his concern is to counter what he sees as a trend in midwifery of midwives discouraging women from attempting to cope with the pain without epidural.

    and i don’t understand your analogy: when one is pregnant and doesn’t want to be, abortion is the only way to satisfy that need. there is no similar poverty of options in the case of epidural with vaginal delivery. also, infection rates are monstrously higher for unplanned c-section than they are for vaginal delivery, as i’m sure you’re aware…so the infection analogy seems a particularly ill-conceived one.

    but even if it weren’t so, it doesn’t give any support to your claim that his views are not backed by evidence, given that he’s backing his views with mainstream obstetric and midwifery research from both the cochrane database and such silly, untrustworthy journals as the JAMA, british journal of obstetrics and gynecology, lancet, british medical journal, etc etc etc. are you sure your knowledge isn’t simply out of date?

  20. Nicole Wyatt Says:

    I’m not sure what kind of evidence Amy is looking for, but here is some data from Gaskin’s book.

    The midwifery practice Gaskin founded does not screen patients for ‘low risk births’ — they deliver multiples, breech babies, attempts at vaginal birth after caesarian etc. They refer to obstetricians when medically indicated. Pain relief is pursued first (though not exclusively) though varied labouring positions, massage, water immersion, meditation, and other non-drug options. These stats include all women receiving prenatal care in the practice, even those who are referred to an obstetrician early on due to complications.

    For the period 1970-2000, a total of 2028 births:

    1.4% caesarian
    0.5% forcep assisted
    0.05% vacuum extractor deliveries
    1% postpartum depression
    68.8% intact perineum
    0 maternal mortality (i.e. no maternal deaths)
    5 fetal deaths due to lethal anomalies (0.2%)
    8 fetal deaths for other reasons (0.39%)

    The book includes lots of other data from various sources, I just picked these out as ones that seem obviously relevant to women considering the outcomes for both them and their babies of various approaches to prenatal and childbirth care.

  21. Nicole Wyatt Says:

    Whoops, I wrote “8 fetal deaths for other reasons (0.39%)” but that should have been “8 neonatal deaths for other reasons (0.39%)”, as that statistic includes 4 babies who died within a week of birth.

  22. The Farm actually has a HIGH rate of neonatal mortality, and the only way that Gaskin and colleagues have been able to conceal it is to compare The Farm to a tiny fraction of high risk deliveries.

    There has been only one published scientific paper from Gaskin’s midwifery practice at The Farm and that shows a very high rate of perinatal mortality. The Farm study (Durand, 1992) compares homebirth to the 1980 US National Natality-National Fetal Mortality Survey and claims to show that homebirth is safe.

    But what is the 1980 US National Natality-National Fetal Mortality Survey. According to the survey itself:

    The NN-NFMS deliberately oversampled high risk births. This fact is acknowledged within the Durand paper, but it is not explained. The neonatal mortality rate in the NN-NFMS sample is substantially HIGHER than the overall neonatal mortality rate for the entire country in 1980.

    The NN-NFMS is known to be a tiny (0.3% of births) NON-REPRESENTATIVE fraction of the deliveries in 1980. That is deliberate on the part of the authors, but it means that under no circumstances can the NN-NFMS mortality data be substituted for the 1980 birth certificate data.

    Durand calculated a perinatal mortality rate for homebirth at the Farm was 10/1000 and compared it to the perinatal mortality rate for the NN-NFMS of 13/1000. However, the neonatal mortality rate at the Farm was 8.2/1000 and the neonatal mortality rate for the entire US in 1980 was 8.5/1000. It was only 7.6/1000 for white women and was substantially lower for low risk white women at term, probably in the range of 3.8/1000 or less. So, rather than showing that homebirth is as safe as hospital birth, the Farm study showed the the neonatal mortality rate at homebirth is more than double that in the hospital.

    This is a classic in the homebirth literature. It is a deliberate attempt to obscure unacceptably high neonatal mortality by comparing it to a high risk group instead of to a group of comparable risk women.

  23. jj Says:

    People who are interested in Walsh’s credentials might like to look at this page.

  24. Duckrabbit Says:

    I emailed this article to my trusty OB/GYN for a second opinion. He says:

    Multiple studies show that when they are used correctly, epidurals have no effect on labor duration.

    (Incidentally, he took issue with the description of assisted delivery: “they slice into your genitals with a sharp knife and then shove heavy metal tongs up your vangina (sic) to yank the baby out” — in his words, “too much to even be funny.” It’s true, the verbs “slice, shove, yank” sound kind of reckless… and what, would it be better if they used a dull knife? Or lightweight tongs? But when you get rid of all that high-powered verbage, it doesn’t sound so bad.

  25. extendedlp Says:

    duckrabbit: if you take away the high-powered verbs, you lose the accuracy of the description. tell your obgyn i’ll thank him not to tell me how to describe my own experience. what i would rather is that i was given full information about the likely effects of epidural so that i could actually give informed consent (or refusal) to a procedure that would lead to my experiencing unnecessary genital mutilation. and yes: mutilation. i absolutely class it as that. i’m not supposed to: i’m supposed to be happy to undergo anything ‘for the baby’, so i’m supposed to thank the people who sliced open my genitals. but i do not: i was mutilated unnecessarily; to make someone else’s schedule easier. in any other setting, it would count as assault.

    jj: thanks for the link!

  26. extendedlp Says:

    also duckrabbit (now that i have cooled down): there’s a huge amount of research that goes on every day in medicine. a doctor with a busy practice is not necessarily going have the time or energy to keep current on it. i much sooner trust someone whose career is based around research medicine to tell me what best evidence shows. a few studies might not tell the whole story (eg at one point in history, there were several studies that showed that consuming horse hair was what gave one intestinal worms. those studies were obviously methodologically flawed, but that wasn’t obvious to the researchers at the time.)

    gosh, i just can’t get over your obgyn’s wording. too much even to be funny! like i was aiming at funny! like there’s anything at all funny about disrespecting a woman’s bodily integrity! (alright, i guess i’m not entirely cooled down.)

  27. jj Says:

    Epidurals not really a big deal? How about fecal incontinent?

    Obstet Gynecol. 2007 Jan;109(1):29-34.

    Risk factors for anal sphincter tear during vaginal delivery.

    Fitzgerald MP, Weber AM, Howden N, Cundiff GW, Brown MB; Pelvic Floor Disorders Network.

    Loyola University Medical Center, Division of Female Pelvic Medicine and Reconstructive Surgery, Maywood, IL 60153, USA. mfitzg8@lumc.edu

    OBJECTIVE: To identify risk factors associated with anal sphincter tear during vaginal delivery and to identify opportunities for preventing this cause of fecal incontinence in young women. METHODS: We used baseline data from two groups of women who participated in the Childbirth and Pelvic Symptoms (CAPS) study: those women who delivered vaginally, either those with or those without a recognized anal sphincter tear. Univariable analyses of demographic and obstetric information identified factors associated with anal sphincter tear. We calculated odds ratios (ORs) for these factors alone and in combination, adjusted for maternal age, race, and gestational age. RESULTS: We included data from 797 primaparous women: 407 with a recognized anal sphincter tear and 390 without. Based on univariable analysis, a woman with a sphincter tear was more likely to be older, to be white, to have longer gestation or prolonged second stage of labor, to have a larger infant (birth weight/head circumference), or an infant who was in occiput posterior position, or to have an episiotomy or operative delivery. Logistic regression found forceps delivery (OR 13.6, 95% confidence interval [CI] 7.9-23.2) and episiotomy (OR 5.3, 95% CI 3.8-7.6) were strongly associated with a sphincter tear. The combination of forceps and episiotomy was markedly associated with sphincter tear (OR 25.3, 95% CI 10.2-62.6). The addition of epidural anesthesia to forceps and episiotomy increased the OR to 41.0 (95% CI 13.5-124.4). CONCLUSION: Our results highlight the existence of modifiable obstetric interventions that increase the risk of anal sphincter tear during vaginal delivery. Our results may be used by clinicians and women to help inform their decisions regarding obstetric interventions.

  28. jj Says:

    I can’t find a definition of “shaking rigors” but they sound like convulsions. Anyway, they seem to be another possible result of epidurals:

    J Reprod Med. 2008 Sep;53(9):685-90.
    Shaking rigors in parturients.

    Benson MD, Haney E, Dinsmoor M, Beaumont JL.

    Department of Obstetrics and Gynecology, Evanston Northwestern Healthcare, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA. benson.michael@comcast.net

    OBJECTIVE: To describe the frequency, duration and timing of shaking rigors during parturition and their associations with several clinical variables. STUDY DESIGN: A total of 467 term, singleton paturients at a single hospital over a 13-month recruitment period were observed by their labor nurses for shaking rigors. Thirteen clinical variables, including length of labor, were also recorded. Multiple regression procedures were used to evaluate associations with presence or absence, number and total duration of rigors. The relationship in time between shaking rigors and sentinel events in labor was also examined. With this sample size, we had > 80% power to detect differences as small as 0.26 effect size units for continuous measures, or ORs of 1.75 or greater for categorical measures, when comparing patients with and without rigors. RESULTS: In total, 57% of parturients experienced at least 1 rigor. Epidural usage was related to risk, duration and number of rigors. Increased maximum temperature was associated with an increased chance of rigors. Epidural, birth and maternal fever were antecedent events. CONCLUSION: Over half of parturients experienced shaking rigors. Epidural administration and fever were associated with an increased probability of rigors and an increased number of episodes.

  29. This is why it is important to understand statistics.

    According to the paper: The addition of epidural anesthesia to forceps and episiotomy increased the OR to 41.0 (95% CI 13.5-124.4).

    You seem to think this is “proof” that epidurals lead to 4th degree tears, but that’s not what it says. The parenthesis contain confidence intervals (95%CI). Confidence intervals are a measure of the accuracy of finding, in this case, the odds ratio (OR). These confidence intervals are extremely wide meaning that the accuracy of the finding is extremely low.

    Moreover, the confidence interval overlaps with that of the odds ratio for forceps alone, meaning that there is potentially no difference between the risk of a 4th degree tear with forceps and with forceps plus epidural.

    This paper does not show that epidural is a risk factor for 4th degree tear, only that forceps is a risk factor.

    Most importantly, the paper tells us nothing about the association between epidurals and 4th degree tears in the absence of forceps.

  30. I can’t find a definition of “shaking rigors” but they sound like convulsions

    They’re not. They’re just “the shakes” that many women get during transition or after delivery.

    If that’s the best you can come up with, you’ve basically demonstrated that epidurals are very safe.

  31. jj Says:

    AT: let me just note that the interpretation of the statistics in a peer reviewed journal is quite different from yours.

  32. extendedlp Says:

    further, there seems to be quite solid evidence that epidural increases the use of assisted delivery techniques. so, the study doesn’t need to show that forceps _with epidural_ increases the risk, it simply needs to show that forceps increase the risk (which AT concedes it does): if epidural increases the use of forceps, and forceps-use increases the risk of tear, then epidural increases the risk of tear. the only thing that would show otherwise is evidence that adding epidural to the forceps equation actually _lowers_ the risk of tear. and if nothing else the results surely indicate that that isn’t the case.

  33. Do you let your child play outside? Isn’t it true that he or she could be struck by lightning, stung by a bee and have an anaphylactic reaction, or run over by a car that jumps the curb? All those things can and do happen on a regular basis. We know that some children playing outside will be struck by lightning, fatally stung or injured by a car. Does that make playing outside unsafe?

    Do you feed your fresh child vegetables and fruit? We know that fresh vegetables and fruit are more likely to cause serious food borne illnesses like E.coli than canned vegetables and fruit. E. coli food poisoning from fresh vegetables and fruit happens on a regular basis and each year children actually die because of it. Does that mean that fresh vegetables and fruit are dangerous?

    Similarly, the fact that an epidural can be administered improperly or that there are rare side effects tells us nothing about safety. The way we determine safety is to look at large groups. There is no measurable difference in health outcomes for babies born to women who had epidurals. At no point, from birth to old age, can anyone find any difference at all.

    Unless and until you are willing to count yourself as a negligent mother because you let your child play outside or because you feed her fresh vegetables and fruit, you are not in a position to claim that women are exposing themselves or their children to harm by having pain relief in labor.

  34. Jender Says:

    Just a quick note: I’ve had the epidural shakes. Strange, but not at all serious. (Scary for Mr Jender to see, mostly.)

  35. extendedlp Says:

    the side-effects of epidural–further intervention in particular–are not *rare*. far from it. second, there are clear and guaranteed benefits to my child in letting him play outside; not so for epidural. and finally, talking exclusively about outcome for the baby is completely disingenuous (even if your claim was consistent with published research; and it’s not). and it’s anti-woman: talking that way implies that the woman’s well-being is unimportant and shouldn’t be taken into account when choosing treatment in labour and delivery. and i simply don’t accept that point of view. i am not a chunk of meat wrapped around a patient.

  36. jj Says:

    AT: thanks for the correction.
    Jender, from what I can see, the shakes can go from mild to, e.g., 90 teeth chattering. It doesn’t sound so awful, but interestingly it shows up as pathological in all sorts of conditions. Perhaps childbirth is again an exception.

    Since this is a philosophy blog, I think we should be clear that the following argument is an instance of the fallacy argumentum ad ignoratium (argument from ignorance).

    If that’s the best you can come up with, you’ve basically demonstrated that epidurals are very safe.

    The fact that a philosophy professor searching for 20 min through pubmed for all the supposed studies showing epidurals are safe (before she’s finished her first cup of coffee) hasn’t found something is about ZERO evidence about epidurals.

    My interest in this discussion, let me be clear, is principally due to the fact that when elp raises such issues the discussion often becomes polarized and too often insulting. I certainly chose to have an epidural for my one birthing experience, though unfortunately I couldn’t convince the staff at the Radcliffe Maternity Hospital that I was in labor until it was too late – it’s very hard to get the epidural going when your contractions involve most of your body. (Not that I remember that with bitterness or anything…)

  37. extendedlp Says:

    i’ll say again, just so that no one misses it (one easily could, given the direction the discussion has gone): i am not claiming that women shouldn’t be allowed to choose epidural. WALSH is not claiming that women shouldn’t be allowed to choose epidural.

    my main concern (and i take it, walsh’s also) is that (a) women are fully-informed by their healthcare providers about the benefits *and risks* of medical procedures carried out in the course of delivery (and at present, it doesn’t seem that they routinely are); and (b) that appropriate mechanisms are in place to support women who choose not to have epidural; and if what walsh reports about the state of midwifery in 2009 is accurate, it’s less and less common for that to be the case.

    it strikes me that supporting a woman who doesn’t have an epidural is probably a heck of a lot harder for a midwife than doing so for one who does. all i’m claiming–and i take it, all walsh, in the end, is claiming–is that women need to be offered even the care that’s more difficult to give.

  38. I find the philosophical aspects of the issue most compelling. The idea that childbirth pain is beneficial to women is a socially constructed idea that has a long and unsavory history. It is an offshoot of a general trend that dismisses the pain of women.

    “Natural” childbirth was the product of white men acting on racist, sexist stereotypes. The father of “natural” childbirth, Grantly Dick-Read, had strong eugenicist leanings and was deeply concerned about “primitive” people taking over from white people. His solution was to encourage white women to have more children by pretending that the pain of childbirth was all in their heads.

    In keeping with prevailing theories of “racial difference,” he asserted that “primitive” women had painless childbirth. He believed that because he had been taught that civilization weakens women and leaves them prey to maladies like “hysteria” located in the uterus of course.

    In a fascinating article, The Race of Hysteria: “Overcivilization” and the “Savage” Woman in Late Nineteenth-Century Obstetrics and Gynecology, Laura Briggs argues that the comparisons between “overcivilized” white women and “primitive” women who gave birth easily was not merely the product of racism, but reflected the anxiety that men felt about women’s increasing emancipation.

    This anxiety over women’s increasing education, independence and political involvement was expressed in medicine generally, and in obstetrics and gynecology particularly, by the fabrication of claims about the “disease” of hysteria and the degeneration of women’s natural capabilities in fertility and childbirth compared to her “savage” peers.

    Simply put, the result of women insisting on increased education, enlarged roles outside the home and greater political participation was that their ovaries shriveled, they suddenly began to experience painful childbirth and they developed the brand new disease of “hysteria”, located in the uterus itself.

    We are all aware that religion viewed childbirth pain as women’s punishment, but I suspect that most people are not aware that the idea that women “ought” to suffer pain in childbirth has been transmuted to the idea that women “benefit” from pain in childbirth.

    It is critical to explore the philosophical roots of the natural childbirth movement, and its founding racist and sexist principles in order to understand why contemporary claims that women “benefit” from the pain of childbirth are both factually incorrect and philosophical distasteful.

  39. [...] the cause of huge discussions everywhere, ranging from a well-constructed defence of his opinion by Feminist Philosophers to a series of expletives, tempered with some thoughtful comments, on the Mumsnet [...]

  40. extendedlp Says:

    AT, in philosophy we call this “the genetic fallacy”: confusing the history of an idea with the philosophical import of it. it’s interesting and disturbing what you say, and it gives us cause to be wary. but it doesn’t prove anything about the thinking behind current movements or research into natural childbirth.

    a similar example: modern research into fetal alcohol syndrome had its birth in the eugenics movement. i’m sure you wouldn’t want to say that researching the effects of alcohol on the fetus is philosophically unacceptable on this account, right?

    walsh isn’t (and i’m not) advocating what he’s advocating because dick-read told him so. (and in fact, i think you’ll find that most prominent advocates of natural childbirth these days expressly reject most of what dick-read claimed.) he’s advocating it because well-designed medical research seems to speak in favour of it.

  41. But I’m not offering the philosophical backround to determine the truth of Walsh’s claim. The claim is not true because the scientific evidence doesn’t support it. I realize that “natural” childbirth advocates claim that all of the scientific evidence is on their side, but they’re simply making that up. Indeed most have never even read a scientific paper in its entirety, let alone analyzed it.

    “Natural” childbirth advocates start with a philosophical idee fixe and then scavenge the literature for papers that might support it. They routinely ignore the bulk of the scientific literature that discredited their theories long ago. The are like the creationists in that they ignore the science because they have a pre-determined, philosophically driven conclusion.

    I offer the philosophical background to discredit their philosophy. Science has discredited their empirical claims long ago.

  42. [...] the cause of huge discussions everywhere, ranging from a well-constructed defence of his opinion by Feminist Philosophers to a series of expletives, tempered with some thoughtful comments, on the Mumsnet [...]

  43. extendedlp Says:

    so, sorry, you’re telling me that denis walsh, phd, reader in midwifery has never even read the journal articles he’s citing? that he’s ‘making it up’? interesting.

    “I offer the philosophical background to discredit their philosophy. Science has discredited their empirical claims long ago.”

    again, you haven’t offered philosophical background. you’ve offered historical background. it’s not the same thing. where an idea came from is not the same as what it’s moral status now is. and as for science discrediting natural childbirth long ago: long ago science “discredited” the possibility that women could possess basic reasoning skills. so, are feminists simply evidence-shirking cranks?

  44. Most feminists are not “natural” childbirth advocates and many “natural” childbirth advocates are not feminists.

  45. extendedlp Says:

    most feminists think that women have the capacity to reason as well as men. and this idea was “discredited” by “research” in times passed. my point is that evidence changes over time: science marches forward and new evidence is constantly available.

    here’s another example that might be less emotive: science spent quite a long time “discrediting” heliocentrism. we wouldn’t want to say that, because science discredited that idea “long ago” there’s no evidence now for the earth revolving around the sun.

    as for what most feminists think, i couldn’t possibly say. and, i suspect, nor could you.

  46. extendedlp Says:

    sorry, rather, i couldn’t say what most feminist think about natural childbirth.

  47. “my point is that evidence changes over time: science marches forward and new evidence is constantly available”

    I agree with that, but that’s not what has happened here. The philosophy of “natural” childbirth exists and there is no scientific evidence to support its claims.

    Why do you think that “natural” childbirth is a belief system limited only to Western, white, relatively well off women? Doctors know it’s not true and most women in the US and around the world want nothing to do with it. It’s like creationism. Only the people who already agree with it are the ones who claim that science supports it. Everyone else is well aware that it doesn’t.

    If someone wants to have her baby without pain medication, that’s up to her. Not everyone needs or wants pain medication. Anyone who wants to buy into the claims of “natural” childbirth advocates like Walsh are free to do so, but it is critical to understand that what the scientific evidence really shows is very different from what “natural” childbirth advocates claim.

    You will never see a professional “natural” childbirth advocate appear in any forum where they can be questioned by doctors or scientists. They make pronouncements to each other and to lay people. They know better than to go head to head with anyone who really understands science; they are well aware that they would look foolish.

  48. extendedlp Says:

    AT, i’ve said several times now that walsh’s work cites research in well-respected, peer-reviewed journals, as well as the cochrane database. i’ve asked how this can be, given that, as you claim, there is no evidence for the claims he makes. you, first, several times didn’t reply to this question, and then, later, seem to imply that walsh is a fraud: that he hasn’t read the articles he cites and that he is ‘making it up’. Walsh, who is a senior lecturer in research, has a PhD in midwifery, is, so you are claiming, simply making things up. i would ask what evidence you have for this rather drastic claim, but i’m simply not interested in listening to you bang your fists against the table any more.

    you’re obviously not interested in having a reasoned discussion about this. further, what you say about walsh and others interested in this issue is slanderous. for the sake of anyone else reading this thread, here’s a link to a list of walsh’s publications:

    http://www.uclan.ac.uk/health/research/denis_walsh.php

    and here’s a link to the cochrane review’s entry on epidural use in labour:

    http://www.cochrane.org/reviews/en/ab000331.html

    AT, i won’t be responding to your comments any more. find another blog to dump your opinions on.

  49. Squillo Says:

    I’m not ready to vilify Walsh based on the DM or other articles, however the points you raise in his defense don’t seem reassuring.

    I would be interested to know how accurately Walsh was quoted in the Daily Mail; the article they refer to has not yet been published– contrary to the DM’s statement–according to the journal in question it is still undergoing peer review. (One wonders how the DM article came about.)

    IF many of the quotations in the article are accurate, and not simply taken out of context for the sake of sensationalism, Walsh deserves the criticism he is getting (which should have nothing to do with his gender, in my opinion.)

    I also take issue with the second point you took from Walsh’s Evidence-Based Care text. While I agree that care-givers should be willing and able to assist patients with any (clinically appropriate) pain-relief/management strategy the patient wants to try, it is not the care-giver’s job to determine “how it’s going” in terms of at what point the patient “needs” pain relief; it is his/her job to ask, and to determine what is likely to be safe and effective in relieving that pain, if the patient so desires, and to offer those options–including epidural. There is a world of difference between “offering” epidural and “encouraging” epidural.

    Would Walsh have written the same if he were talking about any other painful experience?

    When I have dental work, I expect my dentist to ask me about my pain levels and whether or not I feel I need medication; I don’t expect him to encourage me to try alternative methods of pain relief first, unless, of course, medication is not a safe and effective option for me. I expect no different from my labor attendant, whatever his/her personal feelings about medication.

    Walsh may have simply been encouraging his fellow midwives to offer pain management techniques in addition to offering epidural; I have no quarrel with that. However, some of his other writings appear to support the assumption that he feels lower epidural rates are a desirable end in themselves (search http://www.intermid.co.uk for citations).

    I can’t think of any clinical context other than childbirth in which safe, effective pain relief methods are looked upon as intrinsically undesirable.

    Finally, whether or not the DM “spun” Walsh’s “preparation for motherhood” comment, any evidence that labor pain prompts the “love at first sight” reaction must be weighed against the demonstrable benefit of pain relief. Are outcomes any different for “love at first sight” dyads than for those that don’t experience it? What outcomes and measurements should be used to determine it?

  50. extendedlp Says:

    squillo, totally reasonable points.

    re midwife’s role: think it’s much more subtle a matter than midwifes telling women what pain relief to take. for example in my own experience, the midwife acted distressed when i squealed with pain; she insisted i should calm down; she insisted i needed to sit down; she made comments like ‘this is really not going well for you’ and ‘you’re really not coping'; and so on. this said to me, the novice at childbirth ‘i must be coping really badly, i should get an epidural immediately’. had someone said to me ‘that’s good: squeal, pace, hop, whatever impulse you have, follow it; everyone’s body has a different way of reacting to pain; you just let me know what i should do to help you’ etc, i would’ve had a completely different impression of the state of things. the prompts she was giving encouraged the idea that things weren’t going well, needed to be fixed. it wasn’t that she was *telling* me to have an epidural (altho, i do know women who have had that happen, even when they insisted they didn’t want one; one woman i know was even asked ‘please, just do it for me?’ by the midwife), or even exactly that she was telling me how it was going. but she had decided how she thought it was going, and was reacting based on that assessment.

    this is what walsh is talking about. the way that a midwife reacts to the labouring woman can have a huge effect on what decisions the woman makes in the course of labour, and even on how she perceives her own coping. and this effects not only whether a woman chooses epidural, but even whether she *needs* one. women who feel supported have an easier time coping with pain than those who’re made to feel their labouring is a burden.

    we’ve already discussed this in this thread, but to recap: he’s explicitly _not_ taking pain relief as *intrinsically* undesirable; he’s taking epidural in particular as undesirable because of its consequences for birth outcome.

    re love at first sight, again: i find it highly unlikely that walsh or anyone else (who isn’t a nutter) would take that effect as a reason, on its own, to endure labour pain. i take it that he simply mentions it as an additional good thing that can come from avoiding epidural. that’s the impression i got reading his book, anyhow.

  51. philfemgal Says:

    I don’t have any of the scientific expertise to know what to think about the possible dangers of epidurals.

    But this claim “there are clear and guaranteed benefits to my child in letting him play outside; not so for epidural” strikes me as absurd. How can the relief of excruciating pain of the woman in labor not be a “benefit”?

    Is the point supposed to be that there is no guarantee that an epidural will actually work correctly and numb the lower half of the body in the expected amount of time? Sure it’s true that there are rare cases where they don’t work, but then aren’t there also rare cases in which a child could experience no benefit at all from playing outside?

    This is not to say that I think Amy’s analogy (between epidurals and letting children outside) is perfect. But isn’t the real issue here whether, in general, the benefits of epidurals outweigh the costs (and how should an individual balance the benefits/costs to her/her baby when they do not align)? And perhaps an even larger issue, I would think, is what the proper attitude is for various health professions, health advocates, etc. to take toward these choices. I agree that health professionals do push interventions and pain relief on their patients even when they don’t want them. I also think that some advocates of natural childbirth (breastfeeding, etc.) take up attitudes which also seem to devalue women’s pain and autonomy and present only one “right” way to give birth or feed a baby. I’m a person who, if I were planning childbirth, would feel constrained and judged by both sides.

  52. extendedlp Says:

    philfemgal, i suppose i don’t take the benefits–even given the niceness of not being in pain–to be clear and guaranteed. epidurals are not always effective; but epidurals do very very often do things like prolong labour and trigger further intervention that can have lasting bad consequences, even when they work ‘as they should’. but again (again again again) all i want is for everyone to be able to make an informed choice. if you think the benefits of the pain relief outweigh all the risks (and you’re put in a position, by healthcare professionals to know what all the risks are), then you should absolutely be able to make that decision for yourself, in my opinion!

    “But isn’t the real issue here whether, in general, the benefits of epidurals outweigh the costs (and how should an individual balance the benefits/costs to her/her baby when they do not align)? And perhaps an even larger issue, I would think, is what the proper attitude is for various health professions, health advocates, etc. to take toward these choices.”

    totally. that’s exactly the real issue.

    i should say: i’ve been forced into a position i’m not entirely comfortable in the course of this thread. i’ve been cornered into defending the natural childbirth movement. i don’t actually have a settled opinion on that movement as a whole (in so far as it is a cohesive whole). as i told a pro-ncb friend recently, for myself i have no loyalty to ‘natural'; my concern is with good outcome. and so far as good outcome goes, the evidence seems to be on walsh’s side.

  53. extendedlp Says:

    sorry, you should be able to make the decision for yourself whatever position you’re put in by health professionals! but also, health professionals should make it their business to give you all the information.

  54. Jender Says:

    elp, one thing that strikes me in your description of your experience is how terrifying it must have been to have the midwife tell you that there must be something wrong if you’re in pain, and how demoralising to have her say you’re obviously not coping. Quite apart from the issue of epidurals, it’s clearly really a bad thing for midwives to take this attitude to labour pain. I worry a little bit that many issues get jumbled up in this discussion. (Perhaps one reason that elp somehow finds herself being seen as arguing strenuously for natural childbirth when all she wants to argue for is full information and support for women’s choices.)

  55. extendedlp Says:

    well, i think it’s probably in the nature of the beast. i think there simply are a lot of jumbled issues surrounding childbirth. another thing: it’s pretty damned frightening looking ahead to childbirth. and i think for a lot of women (and i put myself in this camp prior to the birth of my first) it’s really important to be able to think ‘no worries, i can always have an epidural, so it won’t be *so* bad’. someone saying anything that sounds anti-epidural, then, is bound to make a person feel nervous. and it’s only natural one would want to resist that.

    to my mind there are two main problems with modern childbirth, neither of which is centred round epidural use, but both of which walsh addresses in his work. and these are why i’m very interested to defend walsh. the first is the issue of access to information: are women getting all the facts they need in order to make the decisions that will get them the birth outcome they want? and i think the answer to this, at present, is a big NO. and second, are the *woman’s* interests being taken into account in standard decision-making by midwives and doctors? and again, i think the answer is NO: i get the very strong impression that, at the beginning of the 21st century, in britain, *the baby is THE patient*; and women who want their own well-being weighed in equally are seen as selfish or short-sighted. women are asked to take huge risks to their health and well-being for very very small *chances* of benefit to a baby who may not even need to be so benefited. and i don’t think this is right. i don’t think it’s necessary, and i think it’s immoral.

  56. Lewanne Says:

    Oh, great… “Dr.Amy” found you.

    Please keep up the great work on this blog. Your personal experience with the truth of what is happening in maternity care lends way more credence to this argument than anything else.

  57. extendedlp Says:

    lol! well, i think it’s official that “dr amy” doesn’t play here anymore. mean-spirited, dogged determination to stick to a point of view and ignore evidence or argument to the contrary has no place on this blog.

    thanks for the kind words!

  58. Nicole Wyatt Says:

    I suspect one’s history with medical professionals will have an undeniable impact on how one reads Walsh et al. elp has a history with poor pain support and unwanted medical procedures in childbirth. I have a history of having to fight against unwanted medical interference for a very mild case of epilepsy.

    There are absolutely women who have experienced the reverse problem — medical professionals who do not take their pain or other problems seriously, tell them to stop complaining, and refuse to provide wanted treatment.

    Unfortunately discussions of childbirth seem to pit these women against each other, when really they should be allies. The route of both these problems is an refusal to see women as autonomous adults with the right to full information and both the right and the ability to make their own choices. Unjustified paternalism is no better when it forces treatment than when it denies treatment.

  59. extendedlp Says:

    well-put, nicole! that really helps to clarify what’s going on.

  60. Amber Says:

    I think the statistics on post natal depression at The Farm are screaming for attention. Coincidence?

    Personally, my experience with the weeks of pain recovering from caesarean section was much more severe that the few hours of intensity in childbirth. I also tore as I birthed my son, but it was MY tear. (does that make sense?) The one-to-one support I received throughout pregnancy and birth from my amazing midwife made a massive difference to how I laboured and birthed, I then got the amazing benefits of sustained hormone release, avoided the post natal depression I had had twice before and breast fed for 4 times longer. Coincidence?

    Good midwives are very important.

  61. Amber Says:

    If anyone missed my point, it was that the care I got from my midwife through pregnancy, birth and beyond was an integral part of creating a positive experience for me and my family. I was well informed, in control (as much as one can be) and was able to make decisions. This contributed greatly to my ability to labour and birth. Unfortunately women are missing out on this kind of support when they need it the most, because with the implementation of all kinds of medical interventions comes the implementation of all kinds of paperwork, when does a midwife get the time to offer real support?

    Interventions in their various forms may take the physical “pain” away from a labouring woman for a short time, but what other kinds of pain are being created in the process?

  62. extendedlp Says:

    amber: i suspect it’s more global a problem for the individual midwife. i think (and of course, i’m not the originator of this idea) she misses out on crucial training in care while she’s doing the paperwork. she doesn’t actually learn how to care in the way you describe. -and also of course you’re right, she doesn’t have time to anyway. esp when “she” is several midwives throughout the course of labour, as is often the case in larger hospital delivery wings.

  63. Why would the concept of psychoprophylaxis in childbirth be troubling to some? Cesareans and other surgeries have been performed using psychoprophylaxis. Is it really so hard to imagine that the same concepts could also be effective during vaginal birth? Sometimes a cigar is just a cigar and psychoprophylaxis is just psychoprophylaxis, not a social movement.

    Great post.

  64. [...] Walsh has found some support among feminist bloggers for challenging the medicalization of birth, he’s also been roundly criticized: Anna N. at Jezebel says he’s setting new mothers up [...]

  65. BT Says:

    I find it strange that people would call it anti-feminist to promote natural methods of pain relief over pharmacological pain relief. The argument by Walsh and pro-natural birth advocates is not that the choice to have medical pain relief should be taken away from all birthing women, rather that more support should be given for natural methods of pain relief due to the evidence-based information showing risks of epidurals etc. There are circumstances in labour where it may indeed be the best thing for a woman to have some pharmacological pain relief, and the fact remains that no matter what level of pain every woman should have the choice to take pain medication – so long as they do it knowing the risks.

    I feel it is strange too that people can’t view pain as beneficial, or a rite of passage. In many cultures painful traditions are used to mark various kinds of rites of passage. I would also argue that top athletes, male or female, who are encouraged by their coaches to deal with the pain that comes along with their training and competition performance are in a similar situation to women who are birthing unmedicated. Each person needs mental techniques, physical techniques, and support from others to overcome the temporary pain to reach their goals. For our society, getting through the pain is seen as positive (and heroic!) in the case of athletes, but somehow birthing women are told “Just take an epidural.” and “Don’t be a martyr.”. Are there motives…

    Pain medications make life easier for hospital staff who won’t have to deal with women making noise, moving around halls/lounges/rooms, and wanting to birth in different positions – which is all what would happen for women birthing unmedicated and unhindered by protocols. It also takes more time and effort to support a woman birthing unmedicated. Medicated birth means that women are easier to manage – in bed hooked up to monitoring equipment. Some women want a managed birth and some don’t, but the NORM should not be medicalized and managed birth for every woman under the guise of it being a “better” or “safer” birth.

    As a feminist, that is my view :)

  66. Karyn Says:

    Hmmm…. labor pain or epidural +/- pitocin, episiotomy, vaccum, forceps, cesarean. I choose labor pain.

  67. extendedlp Says:

    me too karyn! but more than that: i choose for each woman who’s faced with the choice to get all the facts, so that she can make a fully-informed decision that’s right for her!

  68. Jender Says:

    Me, I choose planned caesarean. But I also think elp and Karyn should be given full choices and full support for their choices.

  69. Karyn Says:

    Jender, I support your choice because I know you’ve done the research.

    You know you have an increased risk of death, massive blood loss, blood clots, increased recovery period, readmission to hospital, reduced fertility, bowel and bladder problems, infection, painful adhesions, future cesarean surgery through VBAC bans, difficulty breastfeeding, and the possibility that you are a rapid metabolizer of opioids and may deliver your baby a lethal dose via breastmilk. You also are aware that you may find the surgery and recovery extremely traumatic which may lead to PPD and PTSD.

    You’re also aware that your child is more at risk for death, prematurity and the associated developmental problems (especially before 39 weeks), NICU admission, respiratory problems due to wet lungs, jaundice, intestinal problems, surgical bruising (forceps and vaccums are sometimes used to remove the baby) and lacerations, asthma, diabetes, and the loss of early bonding because of maternal complications.

    For those who have not looked into these facts, a good place to start the decision making process is ICAN. Childbirth Connection is another online source. Medical journals can be also be accessed online and via your local medical school library.

  70. extendedlp Says:

    karyn, of course simply knowing that the chances of these things increases doesn’t, by itself, tell us all we need to know in order to make a decision. for example, if the chance of each increased by 0.00001%, then it probably wouldn’t or shouldn’t factor into our decision-making so heavily; if, on the other hand, say, the risk of death increased by 25%, that might hold real sway. (altho even then, we’d need to know what the risk of death was in the first place. an increase of 25% on 0.00001%, after all, would only mean than now your risk is 0.0000125%; and that’s not very impressive.)

    additionally, once we know what sort of risk we’re dealing with in real terms, that has to be weighed against benefit. and i think it would just be disingenuous to try to say that there is no benefit to planned c-section. the big one to my mind–and, i know, for jender–is the increased level of control one has over what happens to one’s own body. it’s no longer a case of a bunch of men with scalpels deciding on the fly what should happen while you’re in no condition to make a decision for yourself; you get to decide ahead of time, and chances are your decisions are stuck with. if the risks you mention above are quite small, then i don’t think it would be so unreasonable for someone to say ‘i value choosing for my own body enough that being able to do so outweighs these small risks’.

    again, i’m with you on choosing natural childbirth for myself (this time; after having not done so to bad effect the last); but i wouldn’t want to say or imply that it’s necessarily the right choice for everyone. and in the end, i’m not sure that _any_ statistical fact can say whether or not it is. every woman is different, eh?

  71. Jender Says:

    Thanks, elp. And thanks for your concern, Karyn. As it happens, the present tense in my comment was misleading– sorry about that. I already did it and it went great. It was exactly as I planned it– which is something hardly anybody else I know can say, but extremely common for planned c-sections. I was, by the way, breastfeeding 11 minutes after birth and continued for a year. My recovery was much smoother than that of any of the women I attended NCT classes with– all of whom began by planning natural childbirth and ended up with unplanned and very damaging and traumatic interventions. (They, however, tried to do natural childbirths in hospital rather than at home and it’s quite possible that the interventions were the result of pressure from midwives and doctors rather than real medical need. This is one reason that elp’s desire for a home birth makes a lot of sense to me.)

  72. Karyn Says:

    I absolutely understand women who make the choice to have an MRC after a series of traumatic interventions in a previous birth, or because of the idea that they would loose their autonomy to an interventive, scalpel-happy M/F OB/GYN. I also understand the women who choose to homebirth with or without an attendant, but would not feel comfortable myself without a midwife or physician.

    My concern is that women see c/s as a way to be in control of their births, when what actually is happening, in my perception, is that they are giving that control directly to their provider by choosing the end result that the provider prefers in the first place, which is not really a choice at all, it’s just giving in. Planned c/s moms usually have much better experiences than emergency/emergent c/s moms, and are given perks like direct skin-to-skin contact right after birth for being good patients, which other c/s (and vag.) moms are not getting even with stable and healthy infants.

    If I had to choose between the types of c/s, I’d choose planned, but I personally would not choose MRC before an unmedicated birth. I am really glad that it worked out for you Jender. Every woman deserves to make an informed choice about her care during birth, and be respected by the community and her physician. Unfortunately it seems like the only choice respected by many doctors is that of a MRC or Elective LSCS.

    The fact that so many women are coming out of the hospital with preventable injuries, who are then unable to access the type of service they prefer because of risk factors created by poor care is a whole ‘nother story. If drug-free, mother and baby friendly births are attainable at home, then we need to change the practices which are making them unattainable in the hospital.

    Thanks for the chance to comment. Karyn.

  73. Jender Says:

    You write:

    “what actually is happening, in my perception, is that they are giving that control directly to their provider by choosing the end result that the provider prefers in the first place, which is not really a choice at all, it’s just giving in.”

    This is, I think, another one of those things that varies by country. I actually had to fight long and hard for my planned c-section here in the UK.

    I absolutely agree with you, Karyn, that women shouldn’t be pressured into this choice (or any other).

  74. Jender Says:

    I should add: Skin-to-skin contact right after birth w/mother is *not* viewed as a perk here. It is viewed as wholly mandatory– unless there’s something about the *baby’s* condition that prevents it. The mother’s condition or views are not considered. I know mothers in agony after tearing in birth, or totally out of it who have had babies thrust onto their breasts when they really felt they couldn’t cope physically or mentally. And when they really would rather have had the father hold the baby while they recovered a bit.

    V. interesting how the pressures differ from country to country.

  75. extendedlp Says:

    i certainly had the skin-to-skin thrust on me. i was flat out on my back; midwife didn’t even raise the back of the bed. she expected me to–what? do crunches to hold myself up??–and have a nice cuddle & breastfeed with the baby. i’d just been thru a very gruesome forceps delivery and was completely whacked out on pethidine, and when i said ‘no that’s okay, [mr lp] would like to hold him’ the midwife insisted ‘it’s very important to bond and establish breastfeeding right away. you want to breastfeed, don’t you? it really is best’ etc etc. i ended up holding him and making a half-hearted gesture towards feeding (baby, of course, was whacked out as well from pethidine & epidural, so had no interest in the breast) simply so that the midwife wouldn’t think me a bad mum.
    ridiculous.

  76. hippocampa Says:

    And then this.
    A woman in New Jersey refused to consent to a C-section during labor in the event that her baby was in distress. She ended up giving birth vaginally without incident. The baby was in good medical condition.
    However, her baby was taken away from her and her parental rights were terminated because she “abused and neglected her child” by refusing the C-section and behaving “erratically” while in labor.

  77. [...] just seen that  an earlier reference to this story appear as a comment on this post.  Thanks, Hippocampa.   Leave a [...]

  78. shylove Says:

    Good Article! I like this post. thank for your sharing … very helpfull for me :)

  79. daoine Says:

    I gave birth at home five months ago and it was a peaceful, wonderful experience. I’m excited about doing it again. Biodynamic childbirth is not nearly as painful as the spasms of food poisoning. It’s really hard work, that’s all. And the endorphin rush at the end really is amazing.

    Ina May’s Guide to Childbirth is a good book to read for preparation as is GP Sarah Buckley’s Gentle Birth, Gentle Mothering. I found them both so helpful in getting the right headspace; I never for one moment felt anxious or unable to cope with natural labour and birth. It’s liberating.

  80. great website. keep up the good work.

  81. [...] break down the article to all who haven’t read it but the feminist philosophers have done it so much better. AKPC_IDS += [...]

  82. midirs published midwife Says:

    This most certainly has been a very interesting read. I have just spent the weekend a one of Denis’ “enhancing skills for normal labour and birth” workshops. The man is an absolute genious and pioneer. I read a book of his called “Birth stories for the soul” and truly beleive there is a story in their which every mother could connect with. I’m so pleased the crazy Amy Tuteur got the message and stopped posting, her views on Denis are so warped. He is a wonderful Midwife whose SOLE concern is advocating women in labour and birth – period!! He is a wonderful teacher and those who have had the fortune to learn from him will be the future of Midwifery.

  83. Ali Woozley Says:

    Any midwife who has been in the biz for long enough knows the negative consequences of epidural anaesthesia: ranging from higher instrumental delivery rate to dural tap to long-term nerve damage to ramdom bits of a woman’s body.

    From the midwive’s point of view it’s really weird looking after a woman who forgoes that altered state of consciousness during labour: you’re engaging with her on a banal level while her body is anaesthetised trying to do it’s thing.
    It seems like just another peculiar activity that we’ve accepted as ‘normal’ in this culture. Like formula feeding or imagining that a newborn baby will happily sleep in a cot.

    I welcome Denis’s article, quite cheered me up.

  84. You all do realize that the Daily Mail is a horrid source for any sort of accurate news, don’t you? As several others have posted the paper is only reliable for paper mache and picking up dog droppings. Mr. Walsh may be a wonderful person, but DK is known for taking the smallest grain of truth and spinning a completely false “news” story out of it.

  85. So pleased to have found this blog article having just read the news pages that it defends.

    I am a midwife myself, and have spent several days on a training course with Dennis Walsh. His is completely inspiring, factual at all times, and as worthy an advocate a woman could ever want for. Bravo for telling Amy straight, I think you were incredibly patient.

    Birth IS a rite of passage, how you birth has an effect on you for your whole life. He doesn’t ever put across the belief that women who do not have pain relief are better mothers, just that a birth where they are entitled to be in control and make informed choices does make better mothers.

    Think about it, more control = a birth YOU are happy with = long lasting effects of confidence that affect your life and your parenting

    Sometimes we need to acknowledge common sense as well as good research evidence.

  86. KM Says:

    The risks of an instrumental delivery aren’t in fact that much greater with an epidural. The research in the UK shows a 15% increase, while Canada shows a less than 5% increase. And an epidural where no instrumental delivery is required (the overwhelming majority) actually greatly decreases the chances of a 3rd or 4th degree tear, which it is theorised may be because the muscles are relaxed, and no overwhelming urge to push experienced.

    I agree whole-heartedly that the US model (flat on back, stirrups, medicalised to the extreme) of birth is not woman friendly. But nor is misrepresenting the risks of epidural, as you do here (how is a 15% greater risk translated into “almost certain genital mutilation”? Especially as the proven protective effect against involuntary serious tearing an epidural provides is ignored?) even though you also ignore the risk of sub-dural membranous leaking, leading to appalling headaches after the birth which can last some days, and rarely even weeks. That’s a very good reason to pause before choosing one, in my view.

    Infantilising women, and seeking to deny them pain relief in an extremely arduous process on principle is appalling. In the UK, women are already almost systematically denied an epidural unless they are very assertive and very fortunate. It is not the USA and there is a problem in terms of provision, as midwives are invested as a rule in natural delivery. Natural delivery can be extremely damaging, and as a woman who had a lovely natural labour, which ended up causing me rectocele, cystocele and severe tearing at the last, I for one would have been infinitely better off with an epidural – however well I managed the pain, however lovely the birthing pool, and however proud my midwifery team were of me.

    Feminism should not be about dominance over other women’s bodies. It should be about respecting their bodily autonomy. That includes respecting women’s right to choose pain relief in labour.


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