Tuesday, August 12, 2014

Obstetric Drugs

In the final section of the article the authors decry the use of drugs during labor to treat pain.

They refer us to the early debate regarding whether or not it is appropriate to use pain relieving medications to treat women in labor.  It is well known, that many early religious (mostly Christian, but some Jewish as well) authorities felt that pain was a natural part of labor, and that women were supposed to have pain due to the curse associated with Eve's sin when she took a bite of the forbidden fruit.  They felt that it was therefore inappropriate to provide women with pain relief.

This philosophy would strike most modern readers as incredibly cruel, and indeed the overwhelming response of the Rabbinic authorities has been to support, and even encourage, the use of anesthetic and analgesic medications to relieve the pain of childbirth.  The authors quoted R' Moshe Feinstein in YD:2 p140 where he recommended that women be put to sleep for delivery so as not to feel pain.  This responsa was written in 1972, when it was common practice to give women heavy doses of sedatives during the final stages of labor to treat pain.  This usually required the physician to intervene and deliver the baby with forceps as the woman was not awake enough to push the baby out herself.

This practice fell out of favor well over 35 years ago when doctors realized the risks of forceps deliveries when done routinely, and the risks of the medications involved in heavy sedation.  I am not aware of any doctors or institutions that have practiced this way in almost two full generations.

So the authors agree that Judaism does support pain relief during labor and does not subscribe to the "curse of Eve" philosophy which would prohibit pain relief.  However, they then introduce us to another concern, which they feel should be a halachic basis for avoiding the use of drugs during childbirth:
"... Nevertheless, not all objections to obstetric analgesia and anesthesia can be dismissed as mistaken religious obscurantism based on the Genesis narrative.
As Rabbi Immanuel Jakobovits outlines, Christian objection to the use of drugs during childbirth was two-pronged. While some cited the curse of Eve as their source, others objected for medical reasons. Rabbi Jakobovits writes that, “towards the end of the last century, a Catholic medical moralist still forbade the use of chloroform at normal births because it might endanger the mother and the child…” Jakobovits then praises Judaism for being above any such considerations."
The authors are suggesting, that halachically speaking, we need to reconsider our use of drugs in labor because they may be dangerous.  They make this suggestion as if it can be assumed that drugs in labor are inherently dangerous, but they do not have evidence to back up this claim.  In fact, every treatment used in labor is subjected to controlled clinical trials and years of experience that have attested to their safety and efficacy.  It is far far beyond the scope of this blog to review every pain treatment and its' specific risk/benefit profile. However, we have established that in Judaism, treating pain in labor is an honorable and appropriate goal. Every woman is not religiously obligated to suffer to atone for Eve's sin.

A fascinating exchange about this topic took place in Montreal Canada in 1849, shortly after the discovery of anesthesia.  An article about this debate was published in the Journal of the American College of Obstetrics and Gynecology, also known as ACOG.  The Journal is called "Obstetrics and Gynecology", and in volume 88 No. 5, November 1996, pages 895-898, Dr Jack Cohen writes of the debate that took place in Montreal between Dr James Simpson and Rabbi Avraham De Sola.  Rabbi De Sola was the first rabbi in Canada, and he was the new young Rabbi of Montreal's oldest congregation, the Spanish Portugese synagogue - Shearith Israel.

Dr Simpson had argued against the use of anesthesia for women in labor based on Genesis 3:16, the verse declaring that "B'etsev Tayldi Banim".  By using his knowledge of Hebrew, and the Jewish commentators (primarily the Radak), Rabbi De Sola boldly took on the Christian interpretation of the verse and shows how the word "B'Etsev" refers to the uterine contractions of labor and not the pain experienced by the woman in labor.  Interestingly, Rabbi De Sola went on to become a Professor of Hebrew Language at McGill University in Montreal.

The poskim in the almost 175 years that have passed since Rabbi De Sola's debate have almost universally understood and acknowledged the importance of treating the pain of labor.  It is accepted that we must treat a woman's labor pain the same way we would treat all pain and suffering for every person.

This is true even though every treatment has some level of risk. When risk is balanced against benefit, halachah has determined that since these treatments are overwhelmingly safe and effective when administered by trained professionals, they are halachically desirable, not just permitted. Furthermore, every patient has the opportunity to choose whether or not to avail themselves of these treatments, and each person can evaluate the risks of benefits of each medication before deciding whether or not she desires to use it.

In their conclusion, the authors clarify their case, and they cite some "evidence" to back their claims:
"To begin with the third example, the dangers of drugs during pregnancy, including obstetric analgesia and anesthesia, are well documented today. In fact, they have been well documented since at least the 1980s. Both the mother and child can suffer side effects ranging from sluggishness to brain damage and death. The fact that no Jewish authority has restricted or discouraged the use of drugs during labor may not be an occasion for self-congratulation; it may call for some serious halakhic soul-searching."
As sources for their assertion that obstetric analgesia and anesthesia drugs are dangerous, they quote two articles from 1981 (see their footnote #24).  If one carefully examines the sources used to support this article's assertions, and the general tone of the article itself, one is struck by impression that the authors are reflecting a worldview that views modern medicine, and especially obstetric medicine, with an extreme amount of suspicion. I suspect that arguments like these will go on forever, as they are not amenable to resolution by providing evidence to support one point of view over the other. For example, one of the sources cited was titled "Malepractice: How Doctors Manipulate Women".  If someone believes that doctors are guilty of intentionally manipulating their patients, then it will be very difficult, in fact almost impossible, to convince him/her by quoting evidence from the medical literature.

I hope that I at least provided some information for those people who are open minded enough to look upon their physicians, midwives, nurses and other appropriate caregivers as their allies instead of their enemies.  I totally agree with the authors of the article that we should never engage in self congratulation.  However, the fact that "no Jewish authority has restricted or discouraged the use of drugs during labor..." does not reflect a lack of "serious halakhic soul-searching", as the authors declare.  Rather, it reflects centuries of serious halachic concern for the comfort and well-being of women in labor.

I do owe you one more brief post on this topic regarding the safety of home births, and then we can move on to our next topic.

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