NATURAL CHILDBIRTH IS OUT, DRUGS IN

How painful is childbirth?

In surveys, women have rated it worse than a toothache, a migraine, a
broken arm or even most cancer pain. No wonder "natural" childbirth
without painkillers has lost favor in this country, while the
controlled use of anesthetics during labor has grown.

Despite this trend, controversy dogs the most effective method of pain
relief, the epidural block, which numbs the woman below the waist.
Epidurals have been accused of slowing labor, stopping it altogether
and increasing the need for cesarean surgical delivery.

A study in the latest issue of the Journal of the American Medical
Association comparing epidurals to narcotic injections offers
reassurance. Researchers at MCP Hahnemann University of the Health
Sciences and the University of Toronto found that while epidurals
slightly lengthen labor, they do not increase cesarean rates. And
epidurals give women more complete pain relief, with fewer bad effects
on their newborns, than narcotics such as Demerol or Fentanyl.

"This information should be available to women so that they can make
informed choices about labor pain relief," the authors conclude.

The study is not likely to end the epidural debate, because it is a
meta- analysis, combining the results of 10 clinical trials with a
total of 2,369 patients. Meta-analyses have the advantage of large
numbers but the disadvantage of mixing disparate study designs.

"Will it settle the debate? Probably not," said Owen Montgomery, an
obstetrician-gynecologist at Pennsylvania Hospital in Philadelphia.
"But in our own practice, well-done epidural anesthesia does not
appear to increase the cesarean-section rate. It's nice to see a
meta-analysis confirm our clinical judgment."

Natural childbirth, a movement that coincided with feminist calls for
women to take control of their lives and bodies, was once touted as a
superior method of delivery. But studies have shown that inadequate
pain relief can do lasting harm by increasing the incidence of post
traumatic stress disorder and postpartum depression.

"A lot of sociopolitical stuff surrounds the issue of pain relief for
childbirth," said Barbara Leighton, the director of obstetric
anesthesia research at MCP Hahnemann and an author of the new study.
"The problem is, labor really hurts a lot."

The use of drugs to relieve labor pain has been growing, obstetricians
say. One study found that from 1981 to 1992, epidural use increased
from 16 percent to 29 percent of deliveries, while narcotic use
increased from 49 percent to 55 percent. The number of women forgoing
painkillers dropped from 32 percent to 22 percent.

Leighton said the trend partly reflects the fact that babies are
getting bigger and thus harder to push out. A nine-pound baby, a
rarity in the 1950s, is now common.

Another factor: Competition for obstetrical patients has led more
hospitals to offer epidurals. An anesthesiologist gives a local
anesthetic by way of a tiny tube, or catheter, inserted into the
woman's lower spine. The drug relieves labor pain by numbing nerves
leading to the lower half of the body.

Leighton and her colleagues found several disadvantages to epidurals,
compared with narcotics. Epidural labor lasted about an hour longer,
instruments such as forceps that help with delivery by grasping the
baby's head were more often used, and the mother more often had to be
treated for a mild fever or slightly low blood pressure.

But the difference in cesarean rate was not statistically significant
- - 8.2 percent for epidurals compared with 5.6 percent for narcotic
injections.

And women reported superior pain relief with epidurals. Their babies
were born more alert, with less acid in their bloodstreams and with
less need for noxalone, a drug that reverses the effects of narcotics.

The findings are welcome, especially in the wake of recent reports of
California hospitals denying epidurals to low-income women who
couldn't pay for them, Montgomery said.

"I am a firm believer in giving women the choice," he said. "I don't
believe there is only one right way. The option of natural childbirth
... is important, but so is safe, effective anesthesia."