Has medicalisation of childbirth gone too far?

Editor—Several points in Johanson et al's review on the medicalisation of childbirth deserve comment.1 Firstly, maternal mortality related to anaesthesia has declined dramatically over the past few decades. Recent surveys from both the United Kingdom and the United States find that the few fatal complications of anaesthesia in obstetrics are usually related to complications of general anaesthesia—for example, loss of airway or hypoxia.2,3 The decline in the use of general anaesthesia for caesarean delivery must partly be attributed to the rise in use of regional analgesia during labour.4 In fact, the American College of Obstetricians and Gynecologists has issued a statement saying: “Failed intubation and pulmonary aspiration of gastric contents continue to be leading causes of maternal morbidity and mortality from anesthesia. The risk of these complications can be reduced by careful antepartum assessment to identify patients at risk, greater use of regional anesthesia when possible, and appropriate selection and preparation of patients who require general anesthesia for delivery.”5 Johanson et al's paper states that women are “encouraged” to receive epidural analgesia in labour. This paternalistic attitude ignores the fact that most women in labour choose epidural analgesia of their own volition, without influence. I believe firmly that the choice for women to elect to undergo natural childbirth should always be available (within the limits of safety with regard to certain high risk conditions), just as some of us choose to climb mountains or run marathons. This should also be accompanied by the attitude among all obstetric and anaesthetic care providers that there is nothing “wrong” with women who choose natural childbirth. But most people do not run marathons or climb mountains. And most women do not want to have pain during childbirth. The widespread use of regional analgesia in labour should be celebrated as one of the blessings of having a baby in this millennium. Pain free childbirth has become as much a part of modern culture as the mobile phone or the microwave oven. Johanson et al state that “Childbirth without fear should become a reality for women, midwives, and obstetricians.” As one of the cardinal fears of labour is pain, the widespread availability and use of regional analgesia should go a long way towards reducing this fear.