New research just published in the BMJ has found that women should not be denied opioid painkillers after childbirth as the drugs are unlikely to harm breastfed babies. This is a welcome step for new parents who are all too often left to deal with painful recovery from childbirth without adequate relief.
But it also highlights a much larger problem. As an historian of women’s health, and someone who is currently pregnant and dealing with severe back pain, it is clear that pain during pregnancy, childbirth and afterwards has been, and remains, routinely dismissed and diminished.
At 12 weeks pregnant, just when I was supposed to be transitioning from the sickness of the first trimester into the relative calm of the second, I woke up one morning with excruciating back pain. I was unable to walk without yelping in agony, unable to leave my house, see my friends, or even commute to work. At my next appointment, I spoke to my midwife who cocked her head to one side and said sympathetically: “Yes, lower back pain is very common in pregnancy.” She referred me to a physiotherapist, and in my appointment with him 10 weeks later, I was told the exact same thing. He suggested I keep moving (despite the agony), said that paracetamol would do nothing and ibruprofen was too risky, and he didn’t think it necessary to see me again.
From discussions with other women, it is clear that my experiences are neither unique nor extreme. I’ve heard countless stories of pregnant people housebound for weeks with debilitating pain, offered little more than group or 30-minute online physiotherapy sessions. Much of this is likely down to an overstretched health service, but there is also a pervasive attitude that pain in pregnancy and childbirth is “natural” or “normal”. The implication of the repeated refrain – “yes, that’s very common in pregnancy” – seems to be that because it is frequent, it ought to be acceptable. Discomfort is expected – your body is undergoing extreme change – and pregnant people are not, of course, the only ones who have their pain undermined or ignored. But no one should have to tolerate unalleviated agony that prevents you from leaving your house for months on end.
The routine diminishing of pain in pregnancy and childbirth has a long history. For centuries, reproduction was seen as woman’s divine and natural purpose. As the theologian Martin Luther said in the 16th century: “If women become tired, even die, it does not matter. Let them die in childbirth. That’s what they are there for.” In the 1910s and 20s, the painless childbirth movement hinged on the radical notion that women should be given the right to give birth without pain. But this was relatively short-lived, and throughout much of the 20th century, pregnancy and childbirth remain dogged by these historical associations between womanhood and the “natural”. From 1930s obstetricians to second-wave feminists, the idea that reproduction ought to progress unimpeded by medical intervention has recurred and recirculated. It crops up again and again in feminist and wellness circles, but has also permeated medicine and midwifery. Women today are still dissuaded from or denied epidurals, last year’s Ockenden report about avoidable deaths at Shrewsbury and Telford hospitals detailed the trust’s unwillingness to perform caesareans, and there’s an ongoing scandal over the shortage of gas and air for labouring patients.
While everyone should be empowered to pursue the birth they want – with or without pain relief – this notion that pregnancy, childbirth and post-partum is better “natural” has seeped into all aspects of those experiences. We are expected to love being pregnant, bask in its “glow” and tolerate its suffering. This expectation is born out in the way our pain is talked about, managed, and in many cases, completely denied.
Part of the problem is the one addressed by this new study. There is limited reliable data or research available on pharmaceutical solutions to pain in pregnancy and childbirth, and during breastfeeding. Healthcare professionals are therefore risk-averse, reluctant to prescribe potentially untested drugs. But sometimes this reasonable caution tips over into scaremongering and people are often left to navigate potential risks either alone or with the support of their peers.
Should we take antidepressants, opioids, decongestants, certain antibiotics or antihistamines during pregnancy? The data is paltry and while other pregnant people can provide crucial community, they can’t prescribe drugs or administer treatment. Without careful counselling from an informed expert – which is almost always absent – these decisions are fraught, and only exacerbated by the huge emotional burdens placed on women to self-sacrifice to protect their unborn children.
It is difficult if not impossible to conduct experimental trials during pregnancy. But solutions need to be found. While observational studies, like this one on postpartum opioid use, are one answer, they not only need to be funded and resourced to a much greater extent, there also needs to be a fundamental change in the attitudes of healthcare professionals and society as a whole. We may have come a long way since the days of Martin Luther, but in the realm of women’s health, we still have so far to go.
Agnes Arnold-Forster is a writer and historian of medicine and healthcare
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