Labor pain in the 21st century

Abstract

Every year in the United States, four million women give birth, and four million women experience pain during the process. Ninety-nine percent of women give birth in hospital settings (1), where the majority are offered opioids or epidural analgesia for pain relief during labor (2). Despite the fact that there are more hospital admissions for childbirth than any other single diagnosis (3), neither practicing clinicians nor pregnant women have access to reliable data on the topic of pain in labor. The set of papers published in a special supplement to the May 2002 issue of The American Journal of Obstetrics and Gynecology corrects this deficit. This issue of the gray journal is essential reading for everyone caring for women in labor. The peer-reviewed papers you will read were presented at a symposium last May titled, “The Nature and Management of Labor Pain: An Evidence-based Symposium.” The Maternity Center Association, as part of a national program to promote evidence-based maternity care, and the New York Academy of Medicine jointly sponsored the symposium after a year of preparation by a steering committee with representatives from all relevant disciplines, under the leadership of Judith Rooks, CNM, MPH, FACNM. The presenters followed the strict methodology for conducting systemic reviews when possible and as a result, seven of the papers are based on an evidence-based paradigm that systematically minimizes bias. The issue includes an executive summary and eleven commissioned papers designed to provide an overview of the topic: four papers on the nature of labor pain, social history of labor pain, pain and women's satisfaction with childbirth, and access to choice among methods. Seven papers are on the safety and effectiveness of specific methods of labor pain relief. As a participant at the symposium, I was humbled with the realization that what we know about labor pain is not incorporated appropriately into either the information given to women prior to labor or the clinical management of pain during labor. More importantly, what is not known about labor pain may be the most important information we need in order to help women giving birth. There are important questions to address. First, is there a discrepancy between what women want and what we as health care professionals think they want? What factors influence satisfaction with the childbirth experience? The paper by Ellen Hodnett, RN, PhD (4) is based on a review of the best available literature on factors associated with women's satisfaction in childbirth. She found four factors that affect satisfaction to a greater extent than all others. Interestingly, the provision of pain relief is not one of these factors. This finding alone hints that there is a possible discrepancy between what women want and what we think they want. As a member of a profession whose motto is “with woman,” I found this a concerning thought. Other lessons from this symposium should be pursued. Weighing the risks associated with unrelieved pain versus the risks associated with pharmacologic pain relief methods is a complex process that women undertake after receiving information from a variety of sources. This would be a good time for leaders among all the relevant health care disciplines to take the next step, and work to formulate a list of the agreed upon facts women should be informed about, before labor starts. Pain is a critical concern for all women. Supporting a woman in pain is a critical. element in a midwives “art.” We need to pursue research, we need to reevaluate our current practices and, we need to continue the multi-disciplinary process so aptly demonstrated during the Nature and Management of Labor Pain Symposium. The supplement to the May issue of the American Journal of Obstetrics and Gynecology will set the stage and summarize what we know today. The Journal of Midwifery & Women's Health will look forward to providing a forum for future discussions.