My friend is due to give birth in about a week's time.
Today she came in, sat down on the sofa and started crying. This is her first child, her parents are back in Romania, and she is absolutely terrified of giving birth, because she thinks it will be very painful. Which is fair enough, because the received wisdom is that it is rather painful, and can also take quite a long time.
"Never mind," my mother said, "if it gets too much for you you can ask for the epidural and that will make things much easier."
This only made my friend cry even more. It turns out that you have to sign up for the epidural, and she hasn't signed up for it.
She did ask if she could sign up for it. She asked her midwife. She told her midwife that she was afraid of giving birth and afraid of the pain.
Her midwife told her, "You're young and strong and you won't need it," and then moved on to talk about something else. I should think that my friend wasn't terribly forceful about it. Although she speaks very good English, she is a little shy, and still not one hundred per cent confident about speaking English to strangers. But she had clearly said that she wanted an epidural. And you would think that a midwife would understand that she was shy, and nervous, and particularly vulnerable because of her lack of confidence with spoken English - what with all of their woman-centred training and their position as advocate for a woman giving birth and stuff. But I'll come back to that in a minute.
Anyway, it got me thinking. I have never been told by a nurse or a doctor or a chemist that I am young and strong and don't need painkillers for, say, a headache. Or toothache. And I don't know anyone who's been to their doctor or to a nurse to complain about period pains - which are, I understand, very mild womb contractions - and been told that they don't need painkillers or the Pill because they are young and strong and don't need them. When I went to Moorfields Eye Hospital to have the small cyst on my eyelid removed I wasn't told that I was young and strong enough to have it done without anaesthetic. And although when I was very, very young indeed I remember a dentist telling me that I didn't need anaesthetic for a filling, I cannot remember ever being told by a dentist that I didn't need or couldn't have anaesthetic for one in the twenty or so years since then.
So you're not young and strong enough to be able to do without painkillers for a headache or a stomachache or toothache or a filling or an eye operation, but you are young and strong enough to be able to do without the option of an epidural for what is popularly believed to be one of the most painful and physically demanding ordeals that most women will have to go through.
"Young and strong enough." What exactly does that mean? Does it mean that a woman in her early thirties is so young and strong that labour isn't going to hurt? I've never given birth and I'm not a doctor or a nurse, but even I know that's absolute crap. Of course it's going to hurt. It's going to hurt some people less than others and take some people less time than others but I have yet to meet a woman who gave birth without an epidural who didn't describe the labour as excruciating. So it can't mean that.
What it means is that the midwife thinks it is better for you to put up with the pain than not to be in pain. Why?
I know that there are risks with an epidural. Inability to push means that forceps may have to be used. There is a risk of paralysis. There are probably other risks as well. But my friend wasn't told, "Here are the pros, and here are the cons, and here are the possible consequences for the baby, and here are the possible consequences for you, and now it is your decision." Because if she had been told the pros and cons, and then that it was her decision, she would have asked for the epidural. She knew she wanted one. She has always said to us that she wanted one.
Instead she was told, "You're young and strong and you don't need one." In fact, that's what all of my friends who have given birth were told, or if not that particular "reason" then one similar in tone. I have spoken to women who were told that they wouldn't need an epidural because they were young and strong, or because giving birth is "natural", or because in Africa people do it on their knees and go back to work four hours later, or any number of similar variations on the same theme.
Incidentally, every single woman I know who had a baby without an epidural the first time has said that they will ask for an epidural the next time. But that's by the by. This isn't about whether you have an epidural or not. It's about whether you get full, reasoned advice to help you make your decision.
And none of those reasons up there are good reasons not to have an epidural, are they? "You're young and strong and you don't need one." You don't need pills for headaches; lie down in a dark room, drink plenty of water and try to sleep and they'll be gone in a few hours. You don't need pills for period pains; they only last a couple of days at most. And it's not actually a reason not to have an epidural anyway, not in the way that "There is a slight risk of paralysis" might, for some patients, be a good reason not to. But it's a very effective form of emotional blackmail, isn't it? As well as being rather patronising. Who wants to admit to feeling old and weak and actually really needing an epidural quite badly? Who wants to say that they think they do deserve a relatively comfortable birth despite the countless women in less developed countries who can't have one? Who wants to point out that actually "natural" childbirth unadulterated by medical care was the main killer of women of childbearing age right up to the start of the twentieth century? Why should you have a pain free birth? Why are you any better than countless women who don't or can't? When you're only a few months into pregnancy and you aren't actually looking down the barrel of the gun it probably doesn't seem worth making a fuss. And if you're shy and unsure of yourself and it's your first child and you're dependent on your midwife to advise you properly, then you don't want to rock the boat.
Because you're a big girl. Because you're young and strong and you don't need an epidural anyway. Your midwife said so.
When I wrote my post about midwives and insurance (which sadly did not quite manage to scoop the Most Unintentionally Hilarious Post Ever prize - sorry, midwives) I remember quite a lot of people telling us all about Woman Centred Care and Patient Choice and how midwives act as an Advocate for Women in hospitals, particularly vulnerable women. Well, one of our prime motivations as human beings is to avoid unnecessary pain. By "unnecessary" I mean "pain that we do not need to feel because it can be controlled". And one of the most impressive advances in medical science over the twentieth and twenty-first centuries has been that human beings can now choose to avoid pain in a large variety of situations, one of which is labour.* Some of these painkillers come with side effects and some of them can cause other forms of harm. But in all cases it is up to the patient, isn't it? You read the booklet, you listen to the doctor, you weigh up all the circumstances and sometimes you take them and sometimes you do without.
Yet midwives continue to shame, rush, cajole and bully women into forgoing an epidural. Why? Why do they expect women to put up with that sort of pain and discomfort throughout a process that can take as long as two days, when they'd be the first to hand over two paracetamol if you had a headache or period cramps? And why should my friend now be dreading giving birth and feel that there is no one that she can talk to about it apart from us? Aren't midwives supposed to make sure that women don't feel like that?
If midwives really believe in Patient Choice and Woman Centred Care, why don't they just lay out the clinical pros and cons of having an epidural, and let the woman decide, and support her in her choice?
I don't know. But I am sure that if we hang around for a while some commenters will come along and tell us. Let's see if I'm right.
(My previous post on midwives and insurance here. Mr Kitchen on midwives and professional negligence here.)
(*This paragraph has been edited since original posting to remove what might have read as a suggestion that there are no circumstances in which pain cannot be controlled.)