Do epidurals change labor?

Have epidurals changed labor?

Of course they have. They’ve made labor much less painful and much less feared than ever before. But Science and Sensibility guest blogger Dr. Michael Klein doesn’t care about that. He’s concerned that epidurals have changed the course of labor. Why is this important? Dr. Klein would like women to believe that epidurals increase the likelihood of C-section.

Dr. Klein has returned with part 2 of his post “Epidural Analgesia—a delicate dance between its positive role and unwanted side effects.” After the appearance of part 1, I wrote about Dr. Klein’s effort to delegitimize women’s need for pain relief in labor and how that fits with the tendency of natural childbirth advocates to treat women’s needs as invisible.

In a 1200 word post, Dr. Klein utterly fails to mention the excruciating pain of childbirth. There is not a single word about how women feel about pain and pain relief in labor.

True to form, Dr. Klein writes yet another screed on “the positive role and unwanted side effects” without bothering to mention the positive role or how women feel about relief of their labor pain.

In typical NCB fashion, Dr. Klein wants to talk only about the risks, whether real or imagined. Dr. Klein tells us what he personally found in his research on epidurals and why he believes that and not the Cochrane Review that showed epidurals have no impact on the C-section rate.

It is because of these studies that we had trouble accepting the results of the 2004 Cochrane meta-analysis that concluded that epidural analgesia did not raise the cesarean section rate. This conclusion was the same in the most recent Cochrane meta-analysis …

Here’s what Dr. Klein and his colleagues found:

We found that physicians with mean epidural rates under 40% for women having their first baby, had cesarean section rates of about 10%. In contrast, those family doctors with mean epidural rates of 71-100% had cesarean section rates of 23.4%, the others having rates between the two extremes. The women cared for by the three groups were similar. Thus it appeared that only physician practice difference could have accounted for such large differences in outcome…

In other words, Dr. Klein FAILED to show that epidurals increased the rate of C-section, but wait! The same doctors who had lots of patients who opted for epidurals had high C-section rates. And that means …. nothing!

To understand why Dr. Klein’s findings are meaningless, we can apply one of Hill’s criteria: consideration of alternative explanations. Is there an alternative explanation for Dr. Klein’s findings? Of course there is, possibly more than one.

Remember, Dr. Klein failed to show that women who had epidurals were more likely to have C-sections, which is, of course, is what he MUST show in order to impute causation. He only showed that certain doctors were more likely to a. have patients who requested epidurals and b. have a high C-section rate. The alternative explanations are rather obvious. Either the patients differed in important ways from doctor to doctor, or the doctors differed in important ways from each other.

We can use a related example to illustrate. Suppose I claimed that epidurals caused higher rates of admission to Harvard. First I looked to see if women who had epidurals were more likely to have children subsequently admitted to Harvard and found that they were not. Then I discovered that the patients in Dr. A’s practice had both a high epidural rate and a high rate of subsequent admission to Harvard, and the patients in Dr. B’s practice had a low epidural rate and a low rate of subsequent admission to Harvard. Would I have proven that epidurals cause Harvard admission? Of course not. Why not? Because an alternative explanation (for example, the fact that Dr. A practiced in a wealthy suburb whereas Dr. B practiced in the inner city) is far more likely to account for the difference.

In other words, Dr. Klein’s research most certainly does not show that epidurals increase the C-section rate, … but it does make a compelling case for Dr. Klein’s desperation to dramatically inflate the purported risks of epidurals and render the benefits invisible.