Labour Epidural Injustice

Despite the enthusiasm for other modes of analgesia in labour, it is generally accepted that epidural analgesia provides the most consistently effective pain relief during childbirth. However, practical ethical issues abound around its provision. These extend beyond the commonly experienced disquiet of the anaesthetist regarding informed consent (as the mother urges them to just get the bloody epidural in, ignoring the operator’s desire to provide full disclosure of risk and benefits). We face questions within three of the four pillars of medical ethics – those of autonomy, non-maleficence, and beneficence. Midwives hold it within their discretion to decide when, if at all, to act on a mother’s request for epidural analgesia by calling an anaesthetist. Similarly, the anaesthetist has the power to prioritise other duties, or their own needs, over promptly attending the distressed woman. Additionally, resources may be limited such that, with the best of intentions, neither midwife nor anaesthetist can always promise timely epidural analgesia. These are real issues as revealed by a 2020 UK government inquiry, which, although reported by several media outlets, was never made public. While in Australia and New Zealand midwives and anaesthetists generally provide an excellent labour analgesia service, we can expect, and my experience in Australia confirms, that similar issues to those in the UK exist. Here we must consider the fourth pillar of medical ethics, often neglected in considerations of labour analgesia: justice.
In this article I shall examine how the labouring women requesting epidural analgesia can be the subject of injustice, and how we as anaesthetists may contribute to that injustice. I shall argue that society unwarrantedly regards the acute severe pain of childbirth differently from other situations of acute severe pain. The result is a subtle, sometimes subconscious, and unjust deprioritising of labour epidural analgesia.