Quality Care Means Access to Adequate Pain Relief

I've previously blogged about the epidural rate in British Columbia - in short it is very low and varies fairly substantially between areas of the province. Depending on the reasons for it's lack of use in this province, it might be very concerning as failure to provide access to pain relief when requested, in my opinion, is "a bit of a failure to provide quality care."

The rate has improved somewhat between last year and this year - but it remains low. Among first time mothers in British Columbia with labour, nearly 50 percent of them had an epidural (49.7% - source BC Perinatal Services) in 2010/11. This ranged from a high of 66.2% of moms giving birth at BC Children and Women's hospital to a low of 32.5% of moms giving in the Northern Health Authority. In Vancouver Island Health Authority, 46.4% of first time moms with labour had an epidural, up from 43.8% the year before. In some jurisdictions in North America the epidural rate for first time mothers exceeds 80 percent.

According to the Canadian Institutes for Health Information - the use of epidurals for all vaginal deliveries in British Columbia in 2009/10 was 30.3%, compared to a Canadian average of 56%. This suggests that the use of epidural anaesthesia is even lower among women who have previously given birth.

Anecdotally, I know of women who gave birth in Vancouver Island Health Authority who wanted epidural anesthesia and could not get access to it - I was one of them when I gave birth in 2010.

However, much like how the specific process of giving birth (c-section versus vaginal) should not be used to judge the quality of care - neither should the specific mode of pain relief. A very low rate of epidural use tells me very little about the reasons for the low rate. Given the extreme variation regionally - I suspect that it is a matter of accessibility. However, at the end of the day, I don't care about how a woman achieves relief from her labour pain - rather I care about her right to achieve that relief from her pain if she desires to be relieved of it and her ability to access pain relief that indeed does relieve her of the pain. Unfortunately, there's a "bit of a gap" in the statistics in this regard - and at the very least the discrepency between what is observed (low epidural rates relative to some parts of BC and the rest of Canada) and what would be expected should be investigated further.

Quality care means access to adequate pain relief.

Is avoidance of labour pain a reason to opt for an elective cesarean?

In most of the literature on choosing an elective cesarean, the avoidance of labour pain is considered to be an inadequate reason to choose to have an elective cesarean section. It certainly wasn't THE reason I was lobbying for an elective cesarean during my last pregnancy - after all I had no idea what the pain of labour and delivery would be like. I had people assume that it was the reason for my choice, with my own step-mother-in-law greeting the news of our birth plan with "oh honey, just get the epidural". I'd typically responded with "my choice isn't just about the pain of childbirth.". In truth, the first time around, I anticipated that choosing cesarean wouldn't mean less pain overall, just different pain. I was anticipating trading the pain of labour and birth for the longer recovery and a longer duration of pain. I anticipated a qualitatively different kind of pain that on the whole would be roughly equivalent.

The thing is, I never imagined a circumstance in a major urban area in Canada where access to effective pain management (ie. an epidural) would be a problem. I had no reason to believe at that point in time that I would not have access to an epidural should I have decided to proceed with a vaginal birth.

Now, knowing what I know - I feel very differently about this. I think that the avoidance of being in a situation where the pain is not in control and is extreme, is a valid and reasonable reason to elect for a cesarean. It shouldn't be the only reason - but it certainly ranks a heck of lot higher this time around than it did the last time around. If the health system cannot guarantee access to effective pain management when it is known to be available, why should it expect women to just chance it with a natural delivery? If spontaneous labour comes with a risk of unmanaged and insufficiently mitigated pain that is off-the-scales, why should we expect women to willingly submit to that?

Why is pain in childbirth considered to be 'okay' - when pain in any other medical arena is seen to be something that should be managed and mitigated?

I believe part of the reason I found giving birth to my first child was traumatic (apart from a complete violation of my right to determine what happens to my body) - was the insufficiently mitigated pain I experienced during the process.

If access to effective pain relief (epidurals) during labour and delivery was guaranteed to occur on demand, then it likely isn't a valid reason to elect for a c-section. In the absence of that situation - I personally, think its very logical for a woman to choose a cesarean - particularly now that I know what I know about access to epidurals during labour in most of British Columbia.