Before epidurals were readily available, skilled maternity nurses employed a wide range of techniques to help women with the pain of labour, while managing their charting and the equipment, including IVs and the newly available electronic fetal monitors. With the advent of routine epidural analgesia, things began to dramatically change. More and more women were demanding epidurals, and across North America, dedicated epidural services were developing, especially in high-volume birth settings. In many such settings, anaesthesiologists were on salary to provide twenty-four-hour service.
As routine epidurals became available, the skill set of the maternity nurses changed. Experienced labour nurses retired, and their younger counterparts were more engaged with managing the equipment that was then required for safety reasons when epidurals were in use, distracting nurses from their traditional role of hands-on support for the labouring woman. In one key study, it was shown that only 15 per cent of a maternity nurse’s time was spent “hands on” with the women under their care. The rest was spent on the equipment, charting and the many demands placed on nurses by the institutions for which they worked. Many nurses appreciated the tension between what they knew they should be doing and what they had to do for the job, and they were not happy about it.
When doulas appeared in the 1990s, they began to take on some of the intimate caring that had previously been the role of the maternity nurses. Some nurses were at first resentful of the doulas, but with time, nurses came to appreciate the complementary nature of the nurse-doula role. An important study showed that maternity nurses could not function as doulas, even when trained to do so. This was because the nurses, no matter how motivated to provide the intimate maternal care needed, had primary responsibility to the hospital, whereas doulas had primary allegiance to the woman.
Meanwhile, across the world, epidural research was developing, run mainly by anaesthesiologists, who investigated the role of epidurals in Caesareans and other procedures. The typical RCT compared epidurals against narcotics. There have been no studies that compare epidurals against physiological techniques, or physician births versus midwife births. Nevertheless, the “scientific” community managed to convince themselves, most of the medical community and many women that routine epidurals did not have negative consequences.
Of course epidurals have many positive attributes, especially when used selectively to problem solve, but many of us could see the negative effects when they were used routinely, without thought for consequences. This was vigorously denied by the anaesthesia community, which over time had developed a deep attachment to the procedure, especially as dedicated anaesthesia services had developed specifically around the provision of epidural analgesia for labouring women. Anaesthesiologists, using the new scientific approach to birth, learned how to design the studies that would give them the answers they sought.
Some of us knew that other methodologies beyond the RCT would have to be used to understand the full effect of epidurals on the birth environment. My first epidural study compared births as managed by high-volume versus low-volume epidural users in my own department at BC Women’s. It demonstrated that the high epidural users had much higher Caesarean section rates than the low epidural users. Moreover, the high users had more newborn complications as well.23 Next we compared epidural use at BC Women’s with a nearby community hospital. When we controlled for all the relevant variables, it was clear that epidurals increased the Caesarean section rate threefold.24 Then I looked more deeply at the evidence that indicated epidurals had no effect on various procedure rates. To do this, I separated the studies that used epidurals after labour was well established (when epidurals should ideally be used) from those that employed epidurals early in labour. When I eliminated the studies that appropriately used epidurals late in the birth process, I was able to demonstrate that early epidurals more than doubled Caesarean section rates.25
The anaesthesia community greeted these studies with outright derision. Only their own RCTs mattered. In fact, what mattered was how the epidural was used and under what conditions. The problem with almost all the studies that claim epidurals had no effect is that they took place in tightly controlled settings that did not approximate clinical reality. Moreover, epidural use cannot be separated from the whole range of interventions that characterize birth today. There is only one study that has shown that in a low Caesarean environment, epidural analgesia done early in labour will not increase the Caesarean section rate. This is because in that study environment, nurses and staff were using a variety of methods to help women with their labour pain. Epidurals were only one of the tools that they used. In such an environment, the staff do not use epidurals routinely as the solution to most problems. When birth attendants use epidurals selectively, the epidural either does not have the usual negative effect, or even has a positive effect (with no increase in Caesareans, or, rarely, a decrease). Many conventional practitioners and the anaesthesia community either don’t know about or dismiss this information.
What is needed is right-brained thinking, or seeing the whole picture, for any procedure, both for the first time it is used and the implications for its potential repeated use. This is best exemplified by the way a Caesarean sets the scene for a cascade of negative outcomes for mother and baby in subsequent pregnancies, leading to placental attachment problems, infertility, ectopic pregnancy and stillbirth. The problem is that trying to avoid stillbirth, through frequent use of induction of labour in late pregnancy, paradoxically results in an excess of stillbirths in subsequent pregnancies.
Sadly, with the overuse of Caesarean sections and the current obesity epidemic with resultant diabetes, for the first time, the maternal mortality rate in BC, since 2014 through 2018, has risen rather than dropped, increasing from 3 per 100,000 to 5 per 100,000. In some jurisdictions of the US, maternal mortality in 2017 reached 18 per 100,000—some because of the overuse of Caesarean section. As of July 2017, President Trump and the Republican-dominated US House of Representatives and Senate are trying to remove health care from between 21 million and 32 million Americans. This strategy includes defunding Planned Parenthood and making drastic cuts to Medicaid, which funds almost half of all births in the US. They also plan to deny coverage for vaginal birth after Caesarean (VBAC) because it is a “pre-existing condition.” These draconian cuts, designed to free up funds for a tax cut for the uber rich will result in a further dramatic increase in maternal mortality.
To understand the role of attitudes in maternity practice in a scientific manner, I launched a funded national study of attitudes and beliefs of the full spectrum of providers of maternity care: obstetricians, family physicians, midwives, obstetrical nurses, doulas and the women they serve.
In some respects, the results were no surprise. In other ways, they were illuminating. It was clear that most obstetricians were deeply attached to Caesarean section, 20 per cent failing to appreciate that it was not as safe for the mother or fetus than a planned vaginal birth. Many in the new generation also did not appreciate that epidural analgesia had transformed birth in Canada, sometimes for the better and sometimes not. The older obstetricians knew the negative effects of epidurals as well as the positive, as they had been in practice when epidurals transformed birth. The younger obstetricians could not see the change because they had grown up in an epidural environment.26
The younger obstetricians, 82 per cent of whom were women, were the most likely to employ epidurals, Caesarean section and some other procedures. They were also less likely to feel that the woman had a significant role in her own birth than their older, usually male colleagues. Many were planning never to experience vaginal birth, because of their fears of urinary incontinence and pelvic floor and sexual dysfunction. Importantly, it was not a gender issue, as the 18 per cent of male obstetricians in the study felt the same; it was a training issue.
Although obstetricians were generally supportive of midwives—less so doulas—they were deeply distrustful of home birth and other out-of-hospital birth settings. In many respects, these attitudes were not surprising, as they had been exposed in their training only to high-risk situations—never spending any time with midwives or training on the normal situations. Their only exposure to home birth occurred when a labouring woman was transferred to hospital with a problem. Most of the time, it was only for further pain management, but obstetricians-in-training focused on the rare negative outcomes, failing to appreciate the positive.
The idea that obstetricians supported midwives but distrusted home birth, almost half of what midwives did in practice, demonstrated how critically important it is to look for opportunities for obstetricians to work with midwives, particularly during training.
Our study highlighted that opportunity for collaboration between several birth-related disciplines certainly exists, as we found that 20 per cent of obstetricians had attitudes and beliefs that were similar to those of midwives. Our study also demonstrated that most obstetricians and some family physicians believed that the majority of women should be encouraged to receive routine epidural anaesthesia. Many failed to appreciate the connection between routine epidural analgesia use and an increase in forceps, Caesarean section and other interventions. Insufficient numbers of practitioners appreciated that even the first Caesarean can lead to known problems in placental attachment in subsequent pregnancies.
Although I focused earlier on the central role of obstetricians in the evolving birth crisis, my discipline has its own problems. We found that the new generation of family doctors who were delivering babies were progressive and appropriately positive in their attitudes toward childbirth, but those family physicians who were not delivering babies were, for the most part, still providing antenatal care. In fact, more than 50 per cent of the antenatal care in Canada is delivered by family physicians who did not attend the actual birth. Their attitudes toward birth were often negative or frankly wrong, and these attitudes began when they were in training.
What was disturbing was that family physicians who didn’t attend births were in a position to expose their patients to their negative attitudes before transferring them, usually to an obstetrician, for the actual delivery.27 Since so many family doctors practise only antenatal care and have problematic attitudes, we family doctors need to arrange courses to help those doctors acquire and maintain attitudes, knowledge and beliefs that are correct and supportive of normal vaginal childbirth, even if they themselves do not attend births. I am pleased to say that such courses are now beginning to be offered.
The good news from my perspective is that a significant number of obstetricians in our study would have preferred to work only as consultants to family physicians and midwives rather than practise first contact OB/GYN. These obstetricians are the natural allies of both midwives and family doctors and represent hope for a more rational future. Although the professionals have a great deal to account for, to blame them completely is unfair. Women and families are often willing participants in today’s dystopic birth environment. It is unreasonable to expect health professionals, on their own, to change the attitudinal environment of birth.
Solutions to the accelerating birth crisis will require pressure from women, as was the case in the 1960s, ’70s and early ’80s, when hospitals were forced to open up births to partners, improve the physical setting (birth rooms and single-room maternity care) and reduce or eliminate harmful practices like routine shaving, enemas and episiotomy. This led to what we now call family-centred maternity care, which now includes early skin-to-skin contact between mother and newborn, universal rooming-in and the demise of central nurseries, on-demand breastfeeding and doulas to mother the mother. Dr. Marshall Klaus was responsible for many of these positive changes, changes that flowed directly from his research on bonding and attachment and the role of a supportive companion (doula). Today, for the needed change to happen, in what might be called a new birth revolution, women need to be educated about truly evidence-based maternity care.
We know from our national parallel study of women approaching their first birth that most, even late in pregnancy, are unclear about issues that are fundamental to the birth process.28 Most do not take prenatal classes, and many get their information from the deeply flawed internet. Childbirth education should not teach compliance with a flawed system but rather be evidence-based and woman-centred, not institution-centred. Our study showed that, depending on the issue (Caesarean, episiotomy, induction), 30 per cent to 50 per cent of women, even late in pregnancy, are unsure of these critical issues and therefore unprepared to express their concerns and enter into a dialogue with their chosen provider. And if 20 per cent of obstetricians have misinformation about these same issues, we can see how problematic a discussion might be between an uninformed woman and a misinformed birth provider.
As the issues are so pervasive, I am afraid that minor alterations will not fix the system. The educational and delivery system for women requires a complete refit. I hope to be around to at least see the process begin.