Selling the epidural at Shaare Zedek

A glossy promotional brochure came to my house a couple of weeks ago with one of the Hebrew-language Friday newspapers – a paper that targets the “religious Zionist” public. The brochure calls itself a “special supplement marking the dedication of a maternity ward and Israel’s largest neonatal intensive care unit, in the ‘Next Generation’ building at the heart of Shaare Zedek Medical Center.”

A state-of-the-art NICU, women’s health and fertility units, upgraded hospitalization conditions for new mothers, more beds – altogether an impressive array of services and facilities in which cutting-edge technology is employed by highly skilled, dedicated and caring professionals in order to save women’s and babies’ lives or improve their quality of life. It seems almost petty to find fault here; yet I couldn’t help but be struck by some very problematic values, manifested in the way that the brochure markets its epidural “service” to prospective “customers” – i.e., to the women it wants to come and give birth at Shaare Zedek.

There is certainly nothing wrong with a hospital publicizing its fertility and women’s health services. It is reasonable to inform the public about the labor, delivery and maternity experience at a hospital that has recently refurbished its facilities in this sphere. What is not justifiable is the promotion of a specific type of obstetric pain relief – one that constitutes a major medical intervention, with its attendant risks – while pretending that there are no other worthwhile – and nonmedical — options. Essentially, SZMC is promoting a particular kind of birth experience and, by doing so, is delegitimizing other types of childbirth and undermining women’s freedom of choice.

I expect a hospital to present all available options in a value-neutral way when it publicizes its childbirth and obstetric pain management services. I do not expect it to express a preference for one mode over another.

The SZMC brochure portrays medical pain relief as the only option that a sensible woman will choose, and the epidural as the default pain relief mode once that choice has been made. The implication is that if you don’t go with the epidural, there must be something wrong with you.

An entire section of the brochure is devoted solely to the topic of epidural analgesia in childbirth; although it strives for an informational tone, one can’t ignore the way it hard-sells the epidural. The article takes a three-pronged approach: it dismisses women’s “fears” about the epidural; it tries to instill fear in multiparas about the pain they will suffer if they don’t take the epidural in repeat births; and it uses peer pressure.

Dismissing legitimate concerns

“Many women fear epidural analgesia. The main fear is that an injection into the back might disrupt the course of labor or, later, impair the woman’s health or functional status […] ’It used to be claimed that the epidural could delay delivery or even lead to C-sections or instrumental delivery […] but that is not true of the methods that we use.’”

“There is no need to fear. The drugs and anesthesia methods used are very safe and do not endanger the patient.”

The language is unequivocal. Is the situation as clear-cut as the SZMC epidural article would have it?

The SZMC article doesn’t actually clarify what drugs and methods are used. One would have to assume that they’re referring here to the combined spinal-epidural procedure – the so-called “walking epidural” that has been around for a while – but then again they could be referring to the low-dose epidural (apparently these are two different animals). Whatever the case may be, the anesthesiologists interviewed for the article make light of the idea that the epidural might have adverse effects. Professor Yaacov Gozal, head of SZMC’s Anesthesiology Department, admits, for form’s sake, that there is a certain level of risk involved in any medical procedure; but the message is clear (and conveyed aggressively not just in the text but also in the bold letters of the article subtitle): the epidural carries no risks that a reasonable person would take into account.

Now, just about a month ago the mainstream media – including the New York Times and the Huffington Post – devoted considerable attention to a new study in which (per NYT) “epidurals are associated with an even longer duration in the second stage [of labor] than is generally recognized.” Although, as a physician interviewed for the NYT article points out, association should not be confused with causality, one can hardly dismiss such an association as a mere “claim.” If the American Congress of Obstetricians and Gynecologists has established guidelines that recognize differences in labor stage length with and without the epidural, surely it is disingenuous to talk of “claims.”

What’s more, the assertion that the particular epidural methods used at SZMC, compared with the “traditional” epidural, “prevent urinary retention and drops in [fetal heart rate] and [maternal] blood pressure” itself strikes me as a somewhat exaggerated “claim.” Prevent is a rather strong word, after all. A 2012 Cochrane Database Systematic Review that compared the combined spinal-epidural with the traditional and low-dose epidural found, for instance, no difference between the different epidural types in maternal hypotension rates; it also found no difference in the rate of caesarean birth or in the incidence of post-dural puncture headache – a distressing complication that the SZMC article neglects to mention but that is regarded by the medical community as “common.” One young woman of my acquaintance had a nightmarish experience, lasting a week or more, with just this complication a few months ago – at SZMC.

For what it’s worth, I will venture a not very scientific supposition: that women are not, as a rule, terribly concerned by the incidence of complications when they are deciding for or against the epidural. They are either motivated by a strong desire to experience natural childbirth, or massively turned off by the idea of having to curl themselves into an awkward position during contractions while a total stranger “[threads] a needle between the bones, through the ligaments and into the epidural potential space taking great care to avoid puncturing the layer immediately below containing CSF under pressure.” I would also venture a guess that there is considerable overlap between these two groups. What’s more, I would surmise that there is a fair amount of fluidity between the no-epidural population and the yes-epidural population. SZMC’s epidural promo tells the story of a woman who finally tried the epidural during her 17th labor – she wanted to give her pregnant daughter a “first-hand” account. What they don’t mention is the movement that exists in the other direction – women who, after medicated births, go natural. The point isn’t that one option is better than the other. It is that childbirth is a personal affair and every woman can and should decide for herself what she wants to experience or not experience, what she can or cannot handle – and how.

Scare tactics

SZMC is bothered by the fact that, “compared with hospitals in the center of the country, where 80% or even 90% of women in labor receive epidurals, in Jerusalem as a whole and at Shaare Zedek in particular the figure is low.” Women with large families seem to be the culprits responsible for this low market penetration: “80% of first-time mothers […] ask for and receive epidural analgesia, but the percentage is lower in repeat births.” The impression one gets is that grand multiparas are messing up SZMC’s stats – pushing their babies out too fast and bypassing the epidural. But wait – there’s good news: “The good news: you don’t have to decide in advance. You can also ask for the epidural close to the time of delivery or even as it is starting.” That way, SZMC won’t lose out on a crucial market segment.

In order to secure that market segment, SZMC does not balk at scare tactics. The article shares research findings, from a study “conducted at the hospital” – i.e., at SZMC – to the effect that the pain suffered in repeat births, “contrary to popular belief,” is no milder than that suffered in birth number one. Rather than letting mature, experienced multiparas go with their own sense of competence and faith in their ability to work through and with the pain of labor on their own, SZMC wants to frighten them into asking for the epidural.

Peer pressure

The physicians interviewed for the article (actually they are listed as the article authors, though this seems highly unlikely) are confident that their marketing tactics will, as it were, bear fruit: “[I]n the coming years, there will be a rise in the number of women who choose to give birth via epidural. ‘Women read about it, hear from other women who gave birth.” As in that old shampoo commercial: I told two friends, and they told two friends and so on, and so on, and so on …

I don’t think you need to be anti-epidural to object to SZMC’s portrayal of the procedure as the default option, or find its attitude toward women profoundly demeaning.

Contradictory messages

The brochure is as remarkable for what it excludes as for what it includes. In an article entitled “A Child Comes into the World,” Head Nurse-Midwife Chana Chacham is quoted as follows:

“We recommend that every woman inform us of her preferences on arrival at Labor and Delivery, so that we can coordinate expectations. There are women who want to delay cutting of the umbilical cord, others ask that the baby not be bathed right away, there are those who want an epidural and others who prefer that we decide for her.”  [emphasis mine, JR]

Apart from this very questionable idea of the medical staff deciding for the patient about whether or not she should have the epidural, the article, like the brochure as a whole, is striking for the minimal attention that it devotes to natural childbirth — exactly two sentences: “Many women choose natural childbirth, and in order to aid them in fulfilling their desire some of our nurse-midwives have acquired expertise in this approach […] They undergo in-service training in yoga, relaxation and calming techniques – methods that help reduce pain and relieve tension.”

This brief acknowledgment of the natural childbirth approach then segues into a discussion of how the nurse-midwife really “addresses pain” – as though Head Nurse-Midwife Chacham had not just mentioned some low-tech methods for managing pain that many women find perfectly adequate. “There is an anesthesiologist present in Labor and Delivery at all times, and all of the nurse-midwives are permitted to continue [administering] analgesia from the moment the anesthesiologist starts the epidural. We’ve created a situation where the laboring mother doesn’t have to wait for the anesthesiologist while in pain.”

It’s interesting to compare this latter article in the promotional brochure with the Hebrew Labor and Delivery page on SZMC’s website. Here the options are presented in an evenhanded way, as they should be. There’s a sense that the Labor and Delivery staff is fully on-board with natural childbirth for those who want it – very different from the impression one gets from the brochure. There’s even a link to a warm and fuzzy video – narrated in English, oddly enough – about the SZMC birth experience, with an emphasis on friendliness to the natural approach – and, most importantly, on choice.

In this highly idealized video, an obviously secular couple arrives at Shaare Zedek’s delivery ward and is presented with all manner of options, including a big red physio ball. You see the laboring mom getting massaged by a sympathetic nurse-midwife while rocking on the physio ball. The video is so PC, it even shows the laboring mom both choosing and not choosing to get an epidural. The viewer is assured that one may give birth in whatever position happens to tickle one’s fancy – crouching, on all fours, birthing chair …

So why can’t SZMC get its story straight?

I humbly submit that there is more than one story – that SZMC is trying to market itself to two different publics in two different ways. The secular woman who may, perhaps, give birth only 1.8 times in her life, is invited to partake of the empowering natural-birth experience with all possible support from the L & D staff. The religious woman, who will give birth numerous times and who may also be perceived as relatively ignorant and uninterested in empowerment, is pressured into taking the epidural – again, and again, and again.

Part of a trend

Am I being too hard on Shaare Zedek Medical Center? Actually, these marketing tactics could be regarded as fairly benign compared with the way in which Hadassah Ein Kerem chases after the big birth bucks.

Check out how H-EK sells its “luxurious” Natural Birthing Center. Cost of service: only NIS 3800. (I can only imagine what it must be like to attempt a “natural” birth in H-EK’s regular labor ward.)

Then there’s Hadassah Baby – the much-touted “maternity hotel.” I seem to remember that years ago there was something called a “beit havra’a” or “beit hachlama” where women who had had five or six or twelve babies could go for a couple of days to get a little peace and quiet with their newborn before heading home to a very full house. Then came Hadassah Baby. Suddenly the postpartum hotel stay became a not-to-be-missed experience, even for first-time mothers. Once the possibility exists of enjoying a 3-day hotel idyll rather than simply going home with your baby, how can you do without it? Gospel of consumption, anyone?

The Israeli medical community needs to stop commodifying childbirth, and treating parturients and new mothers as cash cows.

About the Author
I am a Jerusalem-based translator and former academic librarian.
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