It’s morally repugnant to recommend saving money by forcing women to labor in agony at homebirth


I wrote last week about Dr. Neel Shah’s piece in The New England Journal of Medicine musing on the desirability of homebirth.

Dr. Shah piously presents his musing as a way to save women from overtreatment from C-sections, which he derides as like an airbag exploding in a woman’s face. Apparently, Dr. Shah views the promotion of homebirth as a way to save money. On Thursday I noted that Dr. Shah never mentioned (and seemed to be unaware) of the multiple studies and datasets that show that US homebirth has a death rate up to 800% higher than comparable risk hospital birth. He never mentioned (and seemed to be unaware) that in contrast to the UK, the US has a two tier midwifery system with the bulk of American homebirths attended by grossly uneducated, grossly undertrained second tier midwives.

On Friday I asked what message we send to women when we derided C-sections as unmitigated disasters and argued that we convey the message that women who undergo C-sections have failed, have been failed by their obstetricians, or both. That’s hardly a message of support.

Today I’d like to ask another question:

What message do we send to women when we advocate saving money on healthcare by undertreating their agonizing pain? Homebirth doesn’t just save money on over treatment; it saves money by undertreatment, preventing women from getting the most effective form of labor pain relief, an epidural.

We send the ugly, morally repugnant message that, whereas we would never contemplate saving healthcare dollars by undertreating men’s pain, we should not merely permit, but we should encourage saving money by refusing to treat women’s agony.

After all, they’re just women; presumably they’ll get over it. You know what they say: women forget the pain of labor once they see the baby. After all, women’s agony in childbirth is natural, so why should we waste our health dollars ameliorating it? After all, think of how much we could improve healthcare financing simply by forcing women to give birth at home and letting them scream their throats raw.

That’s the odious subtext of saving money by promoting homebirth; women’s excruciating pain is not “worth” treating.

How have we reached the point where women’s pain is not worth the cost of relieving it?

We’ve had lots of help along the way.

To being with, most of us have been raised within religions that view women’s pain in labor as appropriate “punishment” for having sex (even within marriage).

That view received a secular gloss with the advent of the philosophy of natural childbirth. Grantly Dick-Read was explicit in his view that primitive (read: black) women didn’t have pain in childbirth because they understood that their primary role in life was to bear and raise children. Those uppity white women of the wealthier classes, had been “over-civilized” by their educations and their desire for legal and economic emancipation. Their pain in labor reflected their refusal to accept their lot in life. The fear-tension-pain cycle that Dick-Read conjured from whole cloth reflects his view that pain in labor was punishment for women who didn’t wholeheartedly welcome the relegation of women to baby making factories.

Lamaze, the competing philosophy of unmedicated birth, had its genesis in the Soviet Union in the years after WWII. It was a response to the fact that the USSR could not afford pain relieving medications and, in an effort to compete with the West, created a free alternative: Pavlovian conditioning to convince women they weren’t in pain. This was presented as the socialist effort to make pain relief accessibly to the proletariat, when in reality, it was inaccessible for all.

Midwives, contemporary avatars of the natural childbirth philosophy, have demonized epidurals for a different reason; they can’t provide them and therefore cannot profit from them. They don’t oppose all forms of pharmaceutical pain relief; they’re happy to drug women with nitrous oxide since they can do that themselves, but epidurals are verboten. What’s the difference between inevitably agonizing labor described in the Bible and the “empowering” pain of midwifery approved natural childbirth? Salesmanship.

Is it any wonder then that Dr. Shah (just like the money counters at the British National Health Service) finds it perfectly reasonable to save money by depriving women of the chance for effective pain relief in labor? He’s come of age in a society where women’s pain in childbirth is merely acceptable punishment, and within a medical sysatem where it is being aggressively peddled by midwives as positivly desirable: spiritually fullfilling and personally empowering.

While it may be reasonable to Dr. Shah and other who promote homebirth as a cost saving measure, it is morally reprehensible.

Women’s pain matters.

Treating women’s pain is an ethical mandate.

Saving healthcare dollars by deliberately putting effective pain relief out of reach of women forced to labor at home is immoral.

That Dr. Shah (and others who promote homebirth for financial savings) never even considered this dimension of encouraging homebirth is testament to how far women still have to go in being taken seriously as human beings who have the same right to pain relief as men.