I would imagine that the same people who determine whether a medical procedure is needed would determine the outcome on this one: the medical professionals (doctors and midwives).

I also don't really see this as a "woman's decision" issue, either, any more than it would be a "woman's decision" to dictate choice of anesthetic drugs used in any other medical procedure to someone who genuinely has a claim to knowing better what's going to work.

The current claim is that the state is paying for what basically amounts to a procedure that is *unhealthy for women*, and medical professionals would like that to stop, so that if women want to make an unhealthy decision, against the advice of their doctors, the state doesn't have to subsidize it.

The way it is being presented, the current situation could be compared to the state subsidizing alcohol or tobacco use among pregnant women. It may make them feel better, but it's causing medical problems. If you're wealthy enough to afford them, it's legal, but it's counterproductive to be encouraging it.

The only spot I see to attack this is in the assumption that epidurals are causing medical problems; if it can be shown that epidurals reduce pregnancy risks more than they increase them (by forcing caesarian sections, for instance), the entire premise goes away, and it does resolve to a women's choice issue, which de-facto decides itself in favor of the woman.

For that, you'll need to talk to other doctors and researchers.

I guess what I wonder is if medical professionals were to decide between who needs it and who doesn't, how would pain be measured. But then again, I'm no expert.

I find this offensive, and I've had labor without drugs. Pregnancy isn't, ideally, a medical condition so much as a bodily function, but that doesn't stop labor from, at least sometimes, hurting like hell. Admittedly I've never had a major broken bone, but I've had a cracked finger-bone (squashed in a door) and a migraine that got down to the "awful" level after two doses of intravenous morphine, and labor was worse. You don't make someone go through that without effective pain control if you can provide the pain control with reasonable safety and the woman in question wants it, as long as the possible hazards have been explained. Charging extra for epidurals effectively makes the poor and uninsured do without and, while I'm all for women choosing to do without pain control, I'm not at all in favor of them not having the choice.
I suppose local anaesthesia wasn't, strictly speaking, necessary for the dental work I had done two days ago, and neither was the Valium my dentist gives me so I can sit still for the dental work, but without both of 'em I probably wouldn't have been there to get the work done. Women in labor don't have that choice of not going through with it.

I don't know enough about the British medical system to really understand what this means, however I've never been a fan of government or insurance paying for elective or cosmetic proceedures. If you need a boob job because you got mauled by a bear, I think that should be included. If you want one because your nipples are not perky enough, then it should be on your dime.

Likewise, if a woman has no medical need for an epidural and just wants one, I don't see why the state should be compelled to pay for it. Unless it is a case where there is a medical reason why you need one (and those should always be covered) an epidural is done for conveniance. Most women are perfectly capeable of giving labor without one; either with no drugs or with lower levels of drugs. So I don't see much difference between an epidural and a tummy tuck. If you want it but don't need it, why should the taxpayers fund it? That money could probably go for something a heck of a lot more useful.

So I don't see much difference between an epidural and a tummy tuck.

Look, I usually prefer civil debate to name-calling, but you are a fucktard.

As advocates of natural childbirth, midwives are constantly worried about increases in medical interventions. Epidurals often lead to a cascade of interventions because they can slow down labour and because they tend to mean that women will give birth lying down. More epidurals means more episiotomies, more forceps and vaccuum births, more use of drugs to speed up labour and more C sections. I can't speak to the situation in England, but here in Canada there are hospitals where the epidural rates are close to 95%. This is of concern to midiwives everywhere, and should be of concern to pregnant women as well.

That being said, I don't think that the solution is to charge women for epidurals. As other people have already mentioned, this creates a 2-tiered system where only those who can afford it will have the "luxury" to labour with epidurals. Furthermore, from experience as a student midwife I know that some doctors are more epidural-happy than others. I suspect that some doctors will deem all epidurals necessary, which again creates an unequal distribution. We all experience pain differently, and no one but the woman in labour should make the decision about needing an epiidural.

I believe that the solution needs to be in the form of more support for labouring women. The most effective way to manage pain and increase positive birth outcomes is through continuous labour support- someone who is attuned to a woman's values and beliefs and can attend to her needs, massage her, comfort her and encourage her, and advocate on her behalf.

I think that a lot of women are afraid of labour. It's very painful. But there are things that can be done to manage pain, and for the most part studies show that epidurals don't lead to higher rates of satisfaction with the birth process. Women need to work with their caregivers to talk through their fears. And caregivers have the responsibility to inform their clients about the risks, benefits and alternatives to epidurals. And then women need to be able to freely decide what's best for them.

I think that concerns about a two tiered system are too little too late. We already have a two tiered system in this country, just scroll up a bit to Ann's post about birth control access.

Someone else mentioned dental work, currently my dental insurance (which I'm lucky to even have) doesn't any anastheic beyond Novocaine. I had my wisdome teeth extracted while awake as well as a broken tooth with an exposed nerve drilled. And I didn't get any Valium for the take home. And I lived to tell the tale.

We already have a two-tiered system here, not just in health care, but in all sorts of areas in society. In education, in politics, even in the clothes we wear or food we buy.

Maybe if the government saved all that money from unnecessary epidurals, they could put it towards paying for birth control or teaching/finding better ways to deal with labor besides just drugs. As aforementioned, epidurals are not problem free.

Awombofherown, you just took the words out of my mouth. I am a doula and I couldn't agree more with you. I'm an advocate of drug-free births, but would hate to see that choice taken away for any reason. Strong support and education are really the key to reducing epidurals. Thanks for your insight.

I'm in Australia and whilst there are differences between the English system and ours, there are fundamental similarities. One needs to remember that healthcare is free, regardless of our "in house" arguments; it is 90-100% free depending on one's choices. And you have to remember there is absolutely no similarity between their poor, our poor and the US experience (except the homeless, which is a huge mental health issue as they require proper care & supervision).

I hope this clarifies the issue a little.

The purpose of electing to have a birth by midwife is one desires delivery with minimum intervention; ergo one must be in the low end for complications. So if women have met these criteria, pain management should be the only issue and limited by this very choice ... these women ELECT to have a NATURAL delivery.

If during the course of delivery, a woman decides she requires epidural pain relief (a potentially dangerous procedure, for many reasons), this I imagine, as it would be the case here, requires the expertise of a medically qualified anaesthetists. Midwives are simply not qualified to offer this service, so of course there are all sorts of legal ramifications to be considered.

Therefore it is reasonable to imagine in many instances transportation to an appropriate facility is required. Of course, all this is time consuming in respect of the birthing process, even calling in an anaesthetist from another location within a hospital that offers delivery by midwife takes time. Ergo complications may occur that require further intervention. One also has to consider the conditions that led to this need in the first place, these same conditions may also require subsequent intervention.

My daughter (currently pregnant) had to sign-off on what pain relief they are allowed to use, should the need arise … this believe it or not, is in her best interests. If she elects no epidural, they will not under any circumstances administer this pain relief. Now this is not to say, if she presents with a medical emergency that they will not provide her with proper and due care. This situation has evolved as in earlier years various types pain relief were applied (mask, injection etc) whilst a woman was in the throws of contractions and sans the wherewithal to refuse. As happened in my own case, where I was in the middle of a contraction and suddenly found a mask on my face, of course they didn’t do it again and were really only trying to help. This was in the 70s when few women had absolutely no pain relief at all and they didn’t understand how I could be making noise (involuntary air movement) and not be in pain.

Well, technically, any anesthesia is "optional". You can just "bite the bullet", so to speak. As people said, this will create a two-tiered system, where only those who can have epidurals are those who can pay for them, and poor women will be screwed. Different people experience pain differently - I had a pain-free birth thanks to an epidural, and two of my friends's comments about their births were "worse than hell" to "it hurt, but i never felt like i was losing it", and both had doulas. Only the woman will know if she really needs an epidural or not. I wonder what kind of backlash this will create.....

Ooops! "I hope this clarifies the issue a little."

Was meant to be at the end of the post, not in the middle.

To clarify a point, SarahS, my dental insurance doesn't pay for anaesthesis or Valium (which isn't for take-home; it's for during the procedure so I can relax enough to have the procedure), for the quite simple reason that I don't have dental insurance. What if your insurance didn't pay for Novocaine, and your dentist wouldn't give it to you without payment upfront? Hey, it's possible to have dental work without local anaesthesia; my father's done it; you don't need the Novocaine, and I don't need the Valium - except that without the two, I almost certainly wouldn't be in that dentist's chair getting the work done (which, from the point of view of an insurance company paying for part of the work, would make those medications a darn good deal, by the way, as they allow early intervention and avoids later, more serious problems). The difference between childbirth and dental work is that a pregnant woman, barring mishap, is going to go through childbirth whether she's allowed painkillers or not, whether she's terrified at the prospect of no pain control or calm enough to use the techniques that make that pain bearable, and I do not find it morally acceptable to deny her pain control based on her ability to pay just because she can be forced to go through the process of childbirth without it.
Look, I chose to have my second child in a setting (at home) that would have made it difficult to impossible for me to get pain medications had I decided I wanted them, and even with skilled, experienced support that pain was the closest to unendurable I've ever had. To put it bluntly, I screamed a lot. It was my choice. It shouldn't be forced on a woman who doesn't choose it. That pain isn't without consequences; after each of my kids was born, the afterpains while nursing made me tense up to the point of not wanting to nurse - not because the pains themselves were so awful, but because they felt like the beginnings of those very, ah, uncomfortable labor pains.

The point is ... in the UK healthcare is FREE, no one is denying anyone pain relief ... one should just opt for a hospital birth, instead of using a midwife whose purpose is to facilitate natural birth.

If the UK is anything like my goverment, not only is it free, but they also contribute $3000 towards intial expenses for the baby ... which is going up to $4000 at the 1st July ... that is for absolutely every new baby, regardless of income.

It's a pity the US doesn't provide the same level of care for all. So many so called western countries provide at least the same level of care.

My daughter has 4 specialists who look after specific areas of her pregnancy, can be seen whenever she feels the need, and is looked after in a wonderful caring manner and it doesn't cost anything. So I imagine the English experience is not much different.

In other words, any woman who thinks she might want an epidural, and who can't afford to pay for it out-of-pocket, would be denied the option of choosing a midwife. I'm somewhat at a loss as to how this is a good thing.

No, that's not it at all ... the point is midwives only facilitate NATURAL childbirth ... no medical intervention ... epidurals require a qualified anaesthetist i.e. a medical practitioner.

So tell me … why, would one use the very group, who are obviously against epidurals (yet supposedly for women), in the first place. It’s not doctors or the Health Department who are trying to introduce this payment. It is midwives, making decisions that are, quite frankly, not theirs to make.

I have just read an article in the Sunday Times where the midwives apparently are trying to compare childbirth to running marathons.

Having had 2 children (both with epidurals - one that partially failed) and ran 2 marathons, words fail me. There IS NO COMPARISON. Even with a partial block the pain of childbrith is extraordinary. Yes, like a race, there is euphoria once it stops BUT you cannot compare such things. No-one would voluntarily put themselves through the type of pain I experienced in childbirth. Some women obviously find it easier than others - I am no wimp (hopefully you get that from the marathon running thing) But I found giving birth the hardest and most painful thing I have ever experienced - even with (almost) an epidural.

Not true--UK women do not choose midwives over obstetricians. It's the standard way of delivering. Only problematic deliveries are attended by consultant obstetricians. One's preference of birth style has nothing to do with it; the NHS decides who will deliver you based on clinical need.