Women Are Being Denied Epidurals During Childbirth. Here's Why.
A forum post that asked mothers "anyone else tricked out of epidural?" attracted 1,000 replies in under two weeks.
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Vanessa Murphy still remembers the pain. “I was so traumatized,” the 39-year-old compliance officer says. “I remember repeatedly saying I wanted to die.”
When Murphy entered the maternity ward to give birth to her daughter in February 2016, she was told that she couldn’t have an epidural until she was in active labor. When she entered labor, she requested one repeatedly. She never received it.
“Every time I spoke about the birth, even over a year later, I cried,” she tells Broadly. “It affected my ability to feel able to have another child and also felt guilty that I felt traumatized even though the birth had resulted in delivering a healthy baby.”
Months later, she questioned her care at a meeting with the Head of Midwifery at her ward. She was told that the staff had made a clinical decision not to give her the pain relief she requested. They thought she was going to deliver before it took effect.
“When I wrote on my birth plan, I remember writing, ‘If I want [an epidural] I’ll ask for it,’” Murphy says. “What didn’t come across [in my antenatal class] was to bear in mind that—because of the way the system is—just because you want an epidural you’re not necessarily going to get it.”
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In the UK, National Institute for Health and Care Excellence (NICE) guidelines urge that nobody should be refused an epidural, even in the latent first stage of labor. But according to a 2014 UK national survey, only 28% of respondents received the pain relief they wanted “to some extent.” Nine percent said did not receive the pain relief they wanted at all.
The most commonly cited reasons from policy makers for people being denied epidurals are lack of staffing and, as in Murphy’s case, midwives determining the baby will arrive before the epidural takes effect. But according to Hanz Peter Dietz, an obstetrics and gynecology professor at the Sydney Medical School Nepean, University of Sydney, patients are being given inaccurate information about why they’re being denied epidurals.
“There is a lot of anti-epidural bias amongst midwives, and women are even lied to because some midwives think they know better. I call it ‘paternalism in a skirt,’” says Dietz. He points out that the contraindications for epidurals are “really rare.” They include coagulopathy, in which the blood does not clot on its own and causes prolonged or excessive bleeding; if the patient has abnormal anatomy of the spinal column, making an epidural more difficult to administer, and infection at the site of the epidural injection.
Obstetricians and midwives have long believed that epidurals elongate labor or increase the risk of Cesarean deliveries. An epidural may increase labor time, but the exact numbers are up for debate. Researchers have suggested that it could prolong labor between 25 minutes to up to three hours—or by none at all. According to the British Journal of Anesthesia (BJA), the cause and effect relationship between analgesia for labor (i.e. pain relief like an epidural) and higher cesarean and instrumental delivery rates is unclear.
Danielle Trickett, 25, from Hampshire, UK, planned to have an epidural. She even included it in her birth plan. Instead, she was refused all pain relief—including gas and air (a.k.a. nitrous oxide, which is widely used in the UK for pain relief during labor).
“Firstly because they told me I wasn't in labor and to go home half an hour away,” Tricket tells Broadly. “Then I was continually told over the phone I still wasn't in labor [even though] I was in horrendous pain.” When she was finally examined, midwives told her it was too late for an epidural—or even gas and air.
It would be comforting to believe Murphy’s and Trickett’s experiences are rare. But according to Kim Thomas of the Birth Trauma Association (BTA), a charity that supports women who experience PTSD after birth, denial of pain relief is all too common in childbirth.
"We hear a lot of stories from women who have been denied epidurals, and part of the trauma comes from being left to labor in severe pain for hours," she says. "Not enough people are aware that it happens."
The BTA estimates that 20,000 women a year experience birth trauma in the UK, but there is little research into just how many women have been denied epidurals during childbirth. The experience, however, is robustly borne out on online motherhood forums filled with horror stories. A 2011 Mumsnet post "anyone else tricked out of epidural?" attracted 1,000 replies in under two weeks.
""I begged them right from the moment I arrived in hospital but nobody was bothered."
"I can't understand the extreme negativity towards epidurals in this country," writes a Canadian woman in a Mumsnet thread titled "Negativity toward epidural in UK?" "I said a definite no to home birth and no to the midwife led unit, as I wanted to have the option of an epidural. [The midwife’s] response was to write down that I was told to go with the midwife-led unit, with no mention that I wanted a hospital birth."
"The midwife's attitude was that I don't need an epidural, it’s only for wimps…" writes London7 on the Mumsnet thread titled "The right to have epidural?" "I begged them right from the moment I arrived in hospital but nobody was bothered."
Since 2005, the Royal College of Midwives’ (RCM) Campaign for Normal Births (succeeded by Better Births back in 2014) has sought to demedicalize childbirth and reduce the number of invasive and potentially unnecessary procedures many women were subjected to during labor.
But there are fears the pendulum may have swung too far. In a 2017 article in The Times entitled "Midwives back down on natural childbirth," RCM chief executive Cathy Warwick admitted that the campaign had created the wrong impression. "What we don’t want to do is contribute to any sense that a woman has failed because she hasn’t had a normal birth. Unfortunately that seems to be how some women feel," she told the Times.
Murphy certainly does.
"There is this pressure from social media for women to feel that they’ve achieved something if they’ve done it without pain relief," she says. "I think some of the hospital staff have that attitude—the nurses were saying 'you’re being a drama queen,' basically."
Mandy Forrester, Head of Quality and Standards at the RCM, says that the "normal birth" agenda is no longer valid. "Now midwifery is all about personalized care," she says. "But the majority of NHS trusts aren’t providing in depth antenatal education… and it would probably help laboring women’s expectations."
Of course, midwife support is crucial. Some evidence suggests women who are well supported by midwives and partners throughout their labor are the ones who manage their pain the most effectively and require the fewest drugs. But there needs to be more honesty from the healthcare community about the amount of pain labor can cause so that women can advocate for themselves, argues Birth Association spokesperson Kim Thomas.
Her perspective is supported by a study published in peer-reviewed journal BMC Pregnancy Childbirth that found the current approach of antenatal preparation in the NHS—of asking women to make decisions antenatally for pain relief in labor—needs reviewing. The study found that women had too much uncertainty about the level of pain they would experience in labor and the effect of different methods of pain relief. Another study found significant discrepancies between women's expectations of labor and their actual experience, concluding that many women go into labor vastly underestimating pain and overestimating their ability to manage without drugs.
"If women want an epidural and they understand there’s a risk to it," Thomas concludes, "that’s their choice."