Towards the Humanisation of Birth A study of epidural
analgesia and hospital birth culture
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Elizabeth Newnham Lois McKellar
School of Nursing and Midwifery School of Nursing and Midwifery
Trinity College Dublin University of South Australia
The University of Dublin Adelaide, SA, Australia
Dublin, Ireland
Jan Pincombe
School of Nursing and Midwifery
University of South Australia
Adelaide, SA, Australia
ISBN 978-3-319-69961-5 ISBN 978-3-319-69962-2 (eBook)
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Foreword
This book is a timely and relevant addition to the movement towards
humanising birth, questioning the regular use of epidural analgesia in
normal labour by providing an incisive cultural analysis of hospital birth
culture. The evidence is indisputable that epidurals undermine childbirth
physiology and lead to increased intervention rates. As identified in this
book, the attitudes of maternity care practitioners towards pain in labour
will affect the way this information is presented in policy documents, in
practice guidelines, and in the information that is shared with women.
This results in a maternity service culture throughout the Western world
that privileges the use of epidurals over evidence-based forms of care that
are known to lower epidural rates and promote positive experiences for
women. As discussed here, the implications for women who enter large
obstetric units anticipating a normal labour and birth are profound.
In spite of ongoing resistance by women, midwives, and others who
wish to promote physiological birth, the epidural is framed as the mod-
ern way of giving women control over their bodies. We see research proj-
ects in low-income countries asking women if they would like the same
access to epidurals for pain-free labour as that enjoyed by their sisters in
high-income countries, and concluding that this is a human rights issue.
Thus, in practice settings across the world, the question is being asked:
‘Why would you not have an epidural in this day and age?’ Midwives
who critique this approach are accused of practising ‘medieval midwifery’
v
vi Foreword
and making women feel guilty if they choose to have an epidural. Worse
still, there are suggestions, enhanced by media frenzies, that midwives are
putting the lives of babies at risk in their attempts to promote normal
birth, creating a moral panic about childbirth, and placing the blame
with midwives rather than looking more deeply into the system of
Western birth culture.
Concerns to avoid making women feel guilty and a lack of faith in
women’s ability to manage pain in labour are perhaps understandable if
you practise in an environment where it is rare to see women giving birth
completely ‘under their own steam’, assisted only by encouragement from
others. We read of student midwives entering their third year of educa-
tion who have rarely witnessed women having drug-free labours. They are
being taught about the evidence that, overall, positive birth experiences
are not related to the level of pain experienced and that many women
view pain as part of a sense of triumph and transition to motherhood—
but they are rarely seeing this in practice.
The potential for women to emerge from their childbirth experiences
feeling empowered with an increased sense of self-efficacy has been widely
identified in qualitative research projects and media accounts by women
themselves. Sadly, the converse is also true, particularly where women feel
they were not supported or listened to and where they felt overwhelmed
and frightened by a cascade of events leading to post-traumatic stress,
depression, and disrupted parenting. With suicide now the leading indi-
rect cause of maternal death in many Western countries, addressing the
humanisation of birth is an imperative. This book shows how a core com-
ponent of this process is addressing the complexities of attitudes to pain
in labour. This is a starting point for changing the culture of birth in
institutions where epidurals are seen as the most appropriate way to man-
age pain even where labour is straightforward.
Interfering with birth in the absence of medical necessity has seri-
ous consequences in terms of the potential increased risk of complica-
tions for women and their babies. Furthermore, there is strong
evidence to support practices that promote physiological birth and a
positive experience for women. These include providing continuous
one-to-one support in labour, immersion in water for pain relief,
Foreword
vii
a home-like environment for labour, and avoiding routine interven-
tions and restrictions on the woman’s freedom to move around and
adopt positions of her choice.
Where there is patchy provision of one-to-one support in hospital
environments, it is perhaps no surprise that women end up opting for
epidurals. We should not assume, though, that this system failure is asso-
ciated with women’s preference. Women are embracing drug-free labour
at home, in birth centres, and in midwifery-led units with many more
unable to access these options. Stories arising from these settings and,
indeed, positive stories of drug-free births in large hospital institutions
should be much more widely circulated and discussed. This applies par-
ticularly where practitioners tend only to hear stories about complica-
tions and emergencies in case reviews.
This book identifies how the biomedical research on epidural use
encourages the concept of the ‘safety’ of the epidural, even when dis-
cussing its possible side-effects. This perpetuates an acceptance of epi-
durals as a modern, ‘common sense’ option. Research identifying the
physiological and emotional effect of the environment for birth and the
disturbance of hormonal processes in labour are rarely discussed with
women.
As suggested in this book, robust discussion is needed about the wider
effects of epidurals on women’s experiences of birth and an alternative
framing of supporting women through a ‘working with pain’ approach.
Such discussions need to be informed by descriptions from women about
empowering birth experiences and widespread dissemination of the
importance of hormonal responses during childbirth as described in
Sarah Buckley’s important text: Hormonal Physiology of Childbearing:
Evidence and Implications for Women, Babies and Maternity Care.1
The authors of this book propose that, rather than the fraught polaris-
ing of ‘normal birth’ and ‘medicalised birth’ (midwifery/obstetrics), we
should think about ‘the notion of a continuum, with intervention-free
birth at one end and medicalised birth at the other, with women, mid-
wives and obstetricians in the middle, maintaining a dialogue about what
is best for women as individuals’. They suggest that this would require a
shift by the medical profession to understand birth as a normal process
viii Foreword
until proved otherwise, rather than conceptualising birth as ‘only normal
in retrospect’. It would also require complex understandings of power
dynamics and how these influence the culture and practices within con-
temporary maternity services.
This text makes compelling reading. It articulates complex concepts
and ideas with clarity, drawing on rich data in a stimulating and coura-
geous challenge to the notion that epidural analgesia is safe and should be
universally available to women. A critical examination of how birthing
ideologies inform hospital practices is linked to the effect this has on the
choices women make about epidural use. A thoughtful analysis of the
effects of the global rise in interventions in childbirth is offered in order
to articulate the need to humanise birth, identify the potential dangers of
the technocratic birth paradigm, and promote physiological birth.
Complex issues associated with the role of epidural use within this conun-
drum are introduced, including the contested meanings of pain in labour.
The potential role of midwives in engaging with individual women in
relationships based on mutual trust while also engaging with uncertainty
is articulated with reference to discussions on how the social and cultural
construction of ‘normality’ can be problematic in the way midwifery is
viewed and enacted within contemporary maternity care systems.
Each chapter in this book starts with a participant’s poem, drawn from
the research data in order to provide ‘verisimilitude’. These poems are
very powerful; they bring to life the data and experiences of women in a
way that adds authenticity and credibility to the arguments that are posed
in each chapter.
An ethnographic study undertaken in the labour ward and interviews
with women are critically analysed drawing on an impressive blend of
theoretical perspectives and literature to identify the socio-cultural impli-
cations that need to be considered if practice is to be woman centred and
emancipatory. The spotlight is placed on a culture riddled with values
that perpetuate surveillance and contested notions of risk. The discourse
of pain in labour is thoroughly explored in relation to technocratic atti-
tudes and practices and powerful arguments are presented for how
women are placed at risk in institutionalised birth settings.
A critical review of literature related to labour analgesia includes an
analysis of how historical, social, political, economic, and cultural factors
Foreword
ix
influence the way in which women’s bodies are viewed by science and the
philosophical thinking that has underpinned medicine and midwifery.
This contributes to an analysis of the epidural within contextual belief
systems and the biomedical discourse of risk and safety that excludes the
social, physical, and emotional meaning of childbirth for women.
It might be easy for midwives working in institutions to feel paralysed
about the effect the dominant culture has on their efforts to promote
normal birth; however, the lead author’s analysis of interviews with
women offer an alternative framework for working with women around
managing pain in labour. As they grappled with the uncertainty of facing
the unknown, the majority of women interviewed wanted to trust their
bodies to know how to manage pain in labour; they also wanted mid-
wives they could trust to guide, advise, and support them in ‘going with
the flow’. Women were practical in their approaches to labour pain,
drawing strength in the idea that women have been giving birth since the
beginning of time. They also saw pain as potentially transformative and
associated with the joy of bringing their baby into the world. The trust
women placed in the midwife’s role of guiding them through labour was
at odds with many of the midwives’ ideas that women had already decided
what they wanted before coming into hospital and that the woman’s part-
ner should be the person providing them with support.
The conclusion is compelling; that midwives should focus on support-
ing women fully through labour in the understanding that most women
will have a sense of trust in their bodies and that this needs to be reflected
back by the midwife. Unless women specifically ask for an epidural in
their birth plan, midwives should assume that women want to be sup-
ported through the process of giving birth.
This is a stimulating and thought-provoking book that will no doubt
promote interdisciplinary discussion and be of significant interest in the
international arena. What is so impressive about the work is the broader
lens the authors bring to a quite specific topic, reminding us that multiple
domains impact on something that seems like a straightforward clinical
decision from the midwives’ or obstetricians’ perspective and a straight-
forward choice by a labouring woman. Institutional, neoliberal, gendered,
medicalised, technocratic, and professional project discourses have real
influences and help construct the space where decisions around pain
x Foreword
management in labour are made. In addition, drawing on her research,
the lead author brings a critical lens to how these discourses operate, chal-
lenging taken-for-granted assumptions, for example, an elective epidural
service, and making visible how these discourses diminish women’s agency
and body autonomy. All of this opens the space up for alternative choices
and, arguably, more authentic, embodied experiences for women. This
challenging text is essential reading for all who are committed to human-
ising birth and promoting positive experiences for women.
Nicky Leap: Adjunct Professor of Midwifery, University of Technology
Sydney, Australia.
Denis Walsh: Associate Professor in Midwifery, School of Health
Sciences, University of Nottingham, UK.
Ultimo, NSW, Australia Nicky Leap
Nottingham, UK Denis Walsh
Note
1. Available online: www.ChildbirthConnection.org/HormonalPhysiology.
Preface
Around the world, more and more women are using epidural analgesia in
labour. Epidural analgesia provides adequate pain relief, but is also associ-
ated with detrimental side-effects, including increased risk of instrumen-
tal birth and decreased oxytocin production. Epidural analgesia also
requires additional measures such as continuous electronic foetal moni-
toring and intravenous therapy, thus moving women out of a ‘low-risk’
labour category. Importantly, epidural use does not necessarily increase
women’s satisfaction with birth, which is not inevitably related to levels
of pain. Women’s attitudes to labour pain are complex and multifaceted
and, contrary to the broader medical view, pain is not necessarily the
primary concern of women anticipating labour.
In this book, we contribute to the growing movement of humanising
birth by providing an ethnographic critique of institutional birth, using
epidural analgesia as the point of entry into hospital birth culture. The
idea of looking at hospital birth culture through the medium of epidural
analgesia came to our attention through our experience as midwives:
watching epidural rates increase, noticing how it was portrayed to women,
and trying to ascertain women’s understanding of it. Early on in the
research process, we came across a paper by midwife academic Denis
Walsh, who articulated very clearly the complexities that epidural analge-
sia brings to birth as well as introducing the idea that epidural rates may
be increasing due to social and cultural factors, such as increasingly
xi
xii Preface
a lienating birthing practices, rather than because women are less able to
cope with pain. We therefore examine here concepts of birth pain and its
relief, with a particular focus on the institution as an arbiter between the
macro-culture of socio-political norms and the micro-culture of individ-
ual experience and interactions.
We begin the book by critically examining epidural use, looking at the
various influences on women, as well as the way birth ideologies inform
hospital birthing practice, and the resulting effect on the choices pregnant
and birthing women are able to make about their bodies. We use a Critical
Medical Anthropology (CMA) approach, which considers the interplay
of structural power relationships, and how these power relationships are
played out in the social world. CMA analysis begins with identification of
the problem; in this case the increasing uptake of epidural analgesia by
labouring women, with questions as to the amount of information
accessed by women, the role of midwives in this process, and the role of
pain in labour. Ultimately, what we provide is a study of hospital birth
culture which can inform and direct current and future birth practice.
In the case of critical ethnography, objectivity does not rely on absence
of bias. It identifies, rather, that biases are always present in the outlining
of the research problem: the choice of question being asked and the theo-
retical framework used. It is in the laying open of these biases that intel-
lectual rigour stands (and in this way is perhaps more honest than more
‘objective’ research that fails to question its implicit assumptions). We
locate ourselves, and our premise that the indiscriminate use of epidural
analgesia is a problem, not a solution, at the centre of this research. Thus,
this ethnography is not presenting ‘the’ version, it cannot. It is presenting
‘our’ version, and throughout we take the reader back to the data and
weave the theory around this, forming a piece of research that is, we feel,
both credible and necessary.
The preparation of this book has been, of course, a large piece of work.
We are grateful to the Australian government and the University of South
Australia for awarding the Australian postgraduate award which funded
this research. We especially thank the participants of the study, without
whom the book could not have been written. We have been pleasantly
surprised by the feedback: the women we interviewed were pleased to have
been able to speak about their experiences; those midwife clinicians from
Preface
xiii
the study who attended presentations of our research have also affirmed
aspects of the findings. Other midwifery colleagues and experts in the field
have responded to this research at both national and international confer-
ence presentations, including Australian College of Midwives’ National
conferences, the Normal Labour and Birth conference in the United
Kingdom, and at International Confederation of Midwives’ congresses, in
Prague and Toronto. There has been a high level of substantiation from
those midwives we have spoken to about similar issues occurring around
the world. We thank all of these midwives for their feedback.
Thanks also to others who have read early versions of chapters and pro-
vided constructive criticism as well as anonymous reviewers of journal
articles and the final manuscript of this book. We would particularly like to
acknowledge Robbie Davis-Floyd who gave valuable suggestions and gen-
erously provided us with a chapter of her forthcoming book. Thanks are
also due to Palgrave and the wonderful editors there. In addition, we are
indebted to Nicky Leap and Denis Walsh, who enthusiastically suggested
the publication of this research and who have kindly written the foreword
to the book.
Finally, we would like to thank our families, those people who know
us best and keep us going. This book is for you.
Dublin, Ireland Elizabeth Newnham
Adelaide, SA, Australia Lois McKellar
Adelaide, SA, Australia Jan Pincombe
Sections of this book were originally published in journal articles; we list these
below underneath the relevant chapters, which may contain additions and
amendments.
Chapter 1
Newnham, E., Pincombe, J., & McKellar, L. (2013). Access or egress?
Questioning the “ethics” of ethics review for an ethnographic doctoral
research study in a childbirth setting. International Journal of Doctoral Studies,
8, 121–136. Copyright permission obtained from the Informing Science
Institute Board of Governors and allowed under Creative Commons licence.
xiv Preface
Newnham, E., McKellar, L., & Pincombe, J. (2016). Critical medical anthro-
pology in midwifery research: A Framework for ethnographic analysis.
Global Qualitative Nursing Research, 3, 1–6. https://doi.org/10.1177/
2333393616675029. Copyright permission obtained from SAGE Publications
and allowed under Creative Commons licence.
Chapter 2
Newnham, E., McKellar, L., & Pincombe, J. (2016). A critical literature review
of epidural analgesia. Evidence Based Midwifery, 14(1), 22–28. Copyright
permission obtained from the Royal College of Midwives.
Chapter 4
Newnham, E., McKellar, L., & Pincombe, J. (2017). Paradox of the institution:
Findings from a hospital labour ward ethnography. BMC Pregnancy and
Childbirth, 17(1), 2–11. Copyright retained by authors under the BioMed
Central licence agreement.
Chapter 5
Newnham, E., McKellar, L., & Pincombe, J. (2017). It’s your body, but…’
Mixed messages in childbirth education: Findings from a hospital ethnogra-
phy. Midwifery, 55, 53–59. Copyright permission obtained from Elsevier
under pre-existing licence terms.
Newnham, E., McKellar, L., & Pincombe, J. (2015). Documenting risk: A
comparison of policy and information pamphlets for using epidural or water
in labour. Women & Birth, 28(3), 221–227. Copyright permission obtained
from Elsevier under pre-existing licence terms.
Contents
1 Introduction 1
2 The Epidural in Context 21
3 The Politics of Birth 67
4 Institutional Culture: Discipline and Resistance 103
5 A Dialectic of Risk 149
6 A Circle of Trust 193
7 Closing the Circle 245
Index 261
xv
List of Abbreviations
3:10/4:10 Stands for 3 contractions (or 4 contractions) in the space of
10 minutes.
ARM Artificial rupture of membranes
cCTG Continuous CTG monitoring throughout labour (rather
than an intermittent trace)
CMA Critical medical anthropology
CTG Cardiotocograph
Cx Cervix
EBM Evidence-based medicine
EFM Electronic foetal monitoring (used in the literature to refer
to CTG monitoring in labour)
EN Elizabeth Newnham (Field notes and interviews)
GBS Group B Streptococcus bacteria
GD Gestational diabetes
ID Identification
IOL Induction of labour
IV Intravenous
LSCS Lower segment caesarean section
MET Medical Emergency Team
MgSO4 Magnesium sulphate
MW Midwife (Field notes)
xvii
xviii List of Abbreviations
N2O&O2 Nitrous oxide and oxygen (‘gas and air’)
OP Occiput Posterior
PPH Post-partum haemorrhage
REG Registrar (Field notes)
SOL Spontaneous onset of labour
SRM Spontaneous rupture of membranes
T/L Team leader
List of Figures
Fig. 4.1 The journey board 111
Fig. 4.2 Paradox of the institution 127
Fig. 6.1 The circle of trust 196
xix
1
Introduction
ackground: Models of Care,
B
Philosophies of Birth
There is an ongoing debate regarding the provision of maternity care,
situated in the midwifery/medical dichotomy, which has permeated birth
discussion since the advent of medical involvement in birth in the seven-
teenth century (Donnison 1988; Ehrenreich and English 1973; Murphy-
Lawless 1998; Roome et al. 2015; Towler and Bramall 1986; Willis
1989). Since then, midwifery as a profession has become increasingly
concerned with ‘guarding normal birth’ (Crabtree 2008, p. 100; Fahy
and Hastie 2008, p. 22; Kent 2000, p. 28). Broadly speaking, the mid-
wifery model of birth is one that promotes the process of birth as a nor-
mal physiological process and a significant life event for a woman, which
impacts on her spiritual, sexual, and psychological development (Fahy
et al. 2008). The linguistic origin of the English word midwife, midwyf
(meaning ‘with-woman’), is foundational to midwifery philosophy, evi-
dent in contemporary terminology such as ‘woman-centred’ care. This
term describes the concept of the woman and midwife in partnership,
one based on mutual trust and respect, and to provide care during this
© The Author(s) 2018 1
E. Newnham et al., Towards the Humanisation of Birth,
https://doi.org/10.1007/978-3-319-69962-2_1
