Opinion: Labour Analgesia in the Developing World; Why Not

Abstract

• The provision of western-style safe, highly effective labour analgesia requires levels of training, staffing and technology that make its applicability in the developing world in current circumstances questionable. This review examines the reasons.

You will note that there is no question mark at the end of the title above. It is no exaggeration to say that for the most part, and for the vast majority of women in labour in the developing world (i.e. the majority of the world), pain relief in labour does not exist even as a concept. This is an attempt to explain why not.

Priorities

Almost all of the 500,000 maternal deaths each year occur in the developing world (1), with bleeding and infection as the leading causes. To bring this appalling total down (Millennium Development Goal 5) it is necessary to strengthen the hospitals where these life threatening complications can be treated effectively. Improving the availability of safe anaesthesia, surgery and blood transfusion are of the highest priority.

For those women without complications, the vast majority of births occur outside a hospital environment, and in the absence of a fully trained and equipped health professional. For example in Kenya, there is no skilled birth attendant present at 60% of births. Since some births outside hospital are attended by skilled birth attendants, 60% is the lowest possible figure for the proportion of women giving birth outside hospital; in India the figure is 50% (2). For these ‘normal’ deliveries, the paradigm of sophisticated analgesic care in a hospital setting is simply irrelevant. For those mothers who do come to hospital with complications, the priority for most is to have personnel able to assess, resuscitate and provide safe anaesthesia for instrumental or caesarean delivery. There is a severe shortage of trained anaesthetists (physician and non-physician). In Uganda, for example, with 30 million people and one of the highest population growth rates in the world, there are 350 anaesthetists of all cadres (3), with perhaps 20% of them having the skills to do an epidural (but not necessarily the equipment). In this setting, labour analgesia will spend a very long time at the end of the queue!

It is sad but true that most women in the developing world have little idea that pain relief in labour is even a theoretical possibility. They would certainly, if asked, rate it below safety. Of course, they have not actually been asked…

Safety issues

Consider the setting of a busy labour ward in a referral hospital. There are perhaps 15 women each day waiting for or returning from Caesarean sections, and an equal number delivering vaginally in the ward. There is no electronic foetal monitoring (and almost by definition no foetal distress!). There is no automated blood pressure monitoring device – all measurements have to be made manually, and no pulse oximeter is available. There may be only two trained members of staff. Which of our means of routine labour analgesia would be considered safe in this setting?

Or perhaps consider a peripheral unit with only 1000 deliveries a year (but still dealing mostly with complicated births). The clinical officer anaesthetist is single handedly providing care for all the surgical and obstetric patients, the latter including five or six a year with a ruptured uterus, and perhaps an eclamptic patient once a week. How much safe care will that anaesthetist be able to provide in response to a request for pain relief?

Training

Most anaesthetic and midwifery staff will have had little or no training in advanced pharmacological techniques such as epidurals and the use of intravenous or neuraxial opiate drugs. They will lack confidence in initiating such techniques, and be unaware of potential complications. There is often widespread fear that the use of opiates for acute pain will rapidly lead to addiction.

Supplies and equipment

This is listed fourth because priorities, safety and the lack of training are more important and harder to remedy than a simple lack of supplies. It is nonetheless the case that many obstetric centres lack essential supplies (3), including electricity, oxygen, intravenous fluids, giving sets, analgesic drugs of all categories, sterile spinal and epidural needles, epidural catheters, and infusion pumps.

What then can be done?

In many instances little support for the mother in labour is available; it has been shown that the presence of a supportive lay adult known to the mother is effective in reducing anxiety, pain and complications (4). To this may be added some of the non-pharmacological means of pain relief: massage, position, relaxation - although other non-pharmacological methods used in the West such as acupuncture, water births, aromatherapy etc, also depend on the availability of trained people or special equipment. We should also consider trying to identify and discourage any practices that make pain worse or are dangerous: for example, the widespread use of potent ‘herbal’ oxytocic drugs, and the use of benzodiazepines instead of analgesics.

Other possible means of analgesia – not used at present – include inhalational analgesia. Nitrous oxide mixtures are too expensive, and trichloroethylene, which had a proven track record of safe use in a fixed concentration of 0.35%, is no longer available. A recent study claimed sevoflurane in a concentration of 0.8% to be equivalent or superior to entonox (5) and the use of isoflurane in labour has also been described (6). At present no fixed concentration vaporisers are available for these agents (unlike the Tecota and Emotril vaporisers of previous generations), so there exists a risk of overdose and consequent unconsciousness unless used under specialist supervision. Others have advocated single-shot spinals with low-dose opiates, but although this has some technical advantages in theory, no clinical trial has been done. Low-dose ketamine is another theoretical possibility, but with associated monitoring and staffing implications. With these and other technologies, we must resist the commonly adopted ‘why don't they just…?’ strategy that results in the shipping of ‘our’ technology to locations where it cannot be safely used. Even worse is for us to advocate techniques that we would not use ourselves.

In medicine the practical necessity is to focus on saving lives and preventing disability. There is certainly a role for those with the training in pain relief to apply that training wherever possible, but sadly it is beyond the current capacity of our colleagues in the developing world to undertake the sort of commitment to pain relief in labour that we are accustomed to as western specialists. The situation is unlikely to change until other development goals are achieved, and levels of staffing, training and equipment improve. Our responsibility is to develop and evaluate techniques that could change the situation - however it is for our colleagues in the developing world, and their patients, to decide what priority the application of such techniques should receive.