The Pain That Is Unlike All Other Pain
Why does society treat labor pain with such reverence—and its relief with such scrutiny?
Not long after wheeling me into the room where I would eventually give birth to my eldest daughter, the nurse asked me what my plan was for pain management. I didn’t have much of an answer. I had just completed my second semester of graduate school, a feat managed largely by underpreparing for parenthood. My only birth plan was to listen to my doctors and nurses. “What do you think I should do?” I asked. The nurse walked me through my options and then suggested the common approach of at least attempting to give birth without medication. If I felt I needed pain relief, she told me, I could start with less invasive methods, such as nitrous oxide and morphine, before considering an epidural.
I followed her advice to the letter. The nitrous oxide did little to dull the pain but made me high, which I hated. The morphine, as far as I could tell, did nothing at all. The epidural, when I finally got one 19 hours in, almost immediately erased any trace of pain, and I fell asleep. It was awesome. My only regret is not getting one sooner.
Positive—nay, marvelous—though it was, I felt strangely self-conscious about how things turned out, in part because so many people asked about my experience. Many of those who congratulated me over the next few months wanted to know if I’d managed childbirth unmedicated. I found myself offering explanations and context for why I hadn’t: that the hormone they’d given me to kick-start labor had made the contractions worse, that it was the middle of the night and I was exhausted.
Eventually, I dropped this act, but these conversations made me wonder why society treats labor pains with such reverence. The questions of whether and how to relieve them are subject to deliberation and scrutiny that would seem absurd under any other circumstances. I certainly didn’t consider forgoing anesthesia when I had my wisdom teeth taken out. And no one asked me about it either.
The use of anesthesia in childbirth has been controversial for as long as doctors have offered it. When the Scottish obstetrician James Young Simpson began to give ether, and later chloroform, to laboring women in 1847, he was met with strong pushback, even as anesthesia was largely embraced for use in surgery. Historians disagree about how common religious objections to obstetric anesthesia were, but some opposition was no doubt laced with moral undertones. “You do not really bless a woman by removing the pains of labour,” one surgeon wrote in 1848. “Her true blessing flows from lifting up her heart to God, and asking for humility and strength to bear them.” Others could not see the use for obstetric anesthesia. The American physician Charles Meigs quipped that “pain of labor had never been great enough to prevent women from having more children.” But physicians were primarily—and rightfully—concerned about safety, worrying that the anesthetic would interfere with labor or harm the child, William Camann, the director emeritus of obstetric anesthesiology at Boston’s Brigham and Women’s Hospital and a co-author of Easy Labor: Every Woman’s Guide to Choosing Less Pain and More Joy During Childbirth, told me.
Despite all of this, Simpson predicted that obstetric anesthesia would eventually become the norm, as “certainly our patients themselves will force use of it upon the profession.” Although he was right that pain management would become more commonplace, he was wrong that patients would be of one mind about it. Prevailing feminist opinion on the practice has flip-flopped over the years, arguing at different times that pain relief liberates women from the cruelty of nature and alienates them from its beauty. And although the downsides of obstetric anesthesia have largely fallen away in the 175 years since its first use, the desire among some women to experience labor in all its brutality has yet to fully peter out, and perhaps never will.
At first, Simpson appeared to be correct: Objections notwithstanding, some women in American and British high society—Fanny Appleton Longfellow in 1847, Queen Victoria a few years later—received pain relief while in labor. High-profile births quelled concerns and galvanized support for expanding access to modern anesthesia beyond the wealthy few. By the early 1900s, feminists were pressuring physicians to administer “twilight sleep,” an injectable combination of morphine and scopolamine popular in Europe that kept women from remembering childbirth at all. The journalists Marguerite Tracy and Constance Leupp, who traveled to Germany to observe the method, wrote that making obstetric anesthesia accessible would “relieve one-half of humanity from its antique burden of suffering which the other half of humanity has never understood.”
Unfortunately, these early methods carried serious risks. Anesthetics occasionally caused smooth muscles to relax, which led some women to bleed out after giving birth. Morphine, when used in large doses or in combination with other drugs, caused some infants to suffocate. And even when mothers and babies survived, it’s not clear that anesthesia always improved women’s experiences at the time. In the late 19th century and well into the 20th, pain relief was often administered only after the mother’s cervix had fully dilated. “This makes no sense,” the medical historian Jacqueline Wolf, the author of Deliver Me From Pain: Anesthesia and Birth in America, told me. “Women had been through all the hard stuff.” At times, twilight sleep did more to dull women’s inhibitions than their pain, causing them to thrash so wildly in the resulting delirium that hospitals sometimes restrained and/or blindfolded them during labor. Twilight sleep fell out of favor after one of its leading advocates died in childbirth in 1915, but other drugs became routine, and by mid-century, many women were heavily medicated during hospital births and even unconscious for delivery. Again, Wolf suspects this had less to do with the mothers’ well-being than the fact that hospitals were inundated at the height of the Baby Boom. “What was an easy way to manage them? Drug them to the max,” Wolf said.
The heavy medicalization of the 1950s was met with fierce opposition. Nonmedical approaches to managing pain in labor championed by obstetricians like Grantly Dick-Read and Fernand Lamaze grew more popular. A new generation of feminists pushed for the right to give birth free from interventions, claiming that the largely male medical field had commandeered what was rightfully women’s domain. In doing so, they embraced the argument put forth by wary physicians a century earlier: Obstetric anesthesia unnecessarily stunted an otherwise transcendent experience.
The controversy has fizzled somewhat in the decades since, largely because anesthetic methods have improved. The fact that epidurals allowed women to remain awake during labor allayed some women’s concerns about them, and they grew significantly more commonplace in the 1980s. Further tweaks to the procedure have permitted women to receive an epidural without their legs being entirely paralyzed. The tension between those in the natural- and medical-pain-management camps has eased as a result. Earlier in his career, Camman told me, doulas often left after an epidural was administered, perhaps feeling they had failed at their job. Now, he says, they usually stay, recognizing that even those who undergo anesthesia need support.
Obstetric anesthesia is far more common and less controversial today than it was in the 1850s, but it remains a last resort for many and totally unwanted by a nontrivial minority. Wolf thinks that hesitation to accept pain relief is in part a reasonable response to its fraught history. “The truth is, it was very, very medically threatening for most of those years,” she said. And even today’s epidurals come with trade-offs. Anesthesia can cause low blood pressure, which can lead to fetal distress, so women getting an epidural typically also get IV fluids and have their blood pressure continuously monitored. Recent research has cast doubt on long-standing concerns that epidurals increase the likelihood of Cesarean delivery, but some studies suggest that they can slow second-stage labor and make it harder to push, both of which can increase the need for forceps or a vacuum to assist the delivery. Some women are understandably keen to avoid this possible “cascade of interventions,” Diane DiTomasso, an associate professor in the College of Nursing at the University of Rhode Island, told me.
But some experts I spoke with suspect that even as the trade-offs and risks of anesthesia continue to lessen, there will always be some women who want to experience labor without it. When I mentioned how befuddling I find that desire to Donald Caton, an anesthesiologist and the author of What a Blessing She Had Chloroform, he pointed out that humankind has long been ambivalent about pain, relentlessly seeking to rid ourselves of it while suspecting that it must “serve some purpose,” as he put it in one paper. Caton mentioned Ernest Hemingway, who once wrote to his fellow novelist F. Scott Fitzgerald that “you especially have to hurt like hell before you can write seriously.” When I wondered aloud whether Hemingway would have had his wisdom teeth removed without medication, Caton conceded that he presumes not. Humans derive meaning from all sorts of suffering, but we tend to avoid intense physical pain when we can.
Then again, labor is no ordinary kind of pain. Typically, pain is an indication that something has gone wrong, serving to alert us to a bodily threat. “You touch the hot stove. It hurts. You pull your hand away,” Laura Whitburn, a senior lecturer at La Trobe University who studies labor pain, told me. But labor is a natural physiological process that hurts even when nothing is going wrong. The accompanying pain seems to serve an entirely different evolutionary purpose; one theory is that it prompts the mother to stop whatever she’s doing, seek help, and ready herself for the child’s arrival. It is a productive pain, and according to Whitburn’s research, conceptualizing it that way can help women cope with it.
In fact, not all women experience labor in the excruciating way it is portrayed in movies or on television. Various studies have investigated perceptions of labor pain, and although women broadly describe it as “intense, demanding and difficult,” the language they use to describe the pain varies wildly. One woman called it the “pain of death”; another, “the sweetest pain in the world.” For some, it seems, labor pain can take on a satisfying element, less like the sting of an open wound and more like the burn of running a marathon.
Even having gotten an epidural, caring for my daughter during the first few weeks of her life felt like running a marathon directly after being hit by a train. There is enough suffering in early parenthood for me to feel at peace with letting the blessing of labor pain go. But having run a couple of marathons, I admit that I understand the appeal. That labor is difficult, even painful, is part of what makes the experience rewarding. This is perhaps what Simpson failed to understand so many years ago: Anesthesia is a triumph over nature, yes, but so is giving birth without it. Childbirth, then, sits at a strange place in the human experience, straddling a boundary between misery and meaning, between the kind of pain that damages a life and the kind that makes one.
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