10.07.2008

The Profit of Pain Relief

Well, let's get straight to the point: hospitals make a lot of money from epidurals. This article gives particular insight into this hostile fight over finances... now don't miss it:
“According to him, much of the information that women receive is incomplete or inaccurate, and that the lucrative “natural childbirth industry.... Natural childbirth has become a multimillion-dollar industry. The fear of epidurals is promoted by those who discourage their use - and who have a vested interest in doing so."
Ok - so, we have a vested financial interest in a woman not getting pain medication? Yes, you are right, my vested interest is to support a safer, more effective labor and birth for mom and baby while preserving her physical body and autonomy as much as possible, but we are not making a living off of this, NCB is not a lucrative industry by a long shot... What Mr. Grant fails to tell you is that we don't have thousands of dollars to loose per birth, as he does, if a woman refuses pain medication. No wonder he wrote his completely inaccurate book, Enjoy your labor: A new approach to pain relief for childbirth

How many of you can remember a nurse coming in every hour to ask you, “Are you ready for your epidural now?”. Sometimes, it is even more of a demand, "Well, we know what you want, but sometimes it is about what we need to do and how it is going to happen." (yes, I have heard that one personally). Ever wonder why the push so much? In America, an epidural costs anywhere from $800 to $2500, depending on the hospital and community. The United States spends more money on birth ($50,000,000,000/year) than any other nation in the world... and that is without getting better results.

The average medicated hospital birth costs $7,500 - $12,500 and that can mean double for cesareans. It is not conspiratory to see that this provides nice profits for obstetricians, anesthesiologists, and the drug companies that market to these hospitals. Did you know that many pharmaceutical companies offer incentives and bonuses for the 'top sellers' in any given hospital or practice? In fact, my OB told me that one such rep offered a new plasma TV to the OB with the most medicated births in the first month of the new year from the hospital I was planning on birthing at. As I have said time and time again, the majority of hospital policies are based on financial goals and protection from litigation.

Ok, back to that wonderful article:
"It is barbaric that pain should still be viewed as an integral, even desirable, element of childbirth."
(Let me reiterate, his book is full of misinformation, and this article is no different. I am only hitting on a few of the lies therein) . Contrary to his claim, medical studies have shown that pain in labor and birth is beneficial to the process and allows for a safer and healthier outcome. I know I have cited it before, but check out Dr. Buckley's wonderful article on this phenomena.

If you want pro-epidural substantiation of this fact, see this video. The poor CNM talks out of both sides of her mouth saying that epidurals are safe for labor and birth and alludes to them not slowing down/stopping labor, or raising the incidence of cesareans and yet, the flash-board says, first, "Myth: Epidurals are unsafe and I should wait as long as possible to get one.".. and then is followed up with "Fact: pain causes body to release stress hormones that cause muscles to contract not relax"...

Well DUH! that is the whole point, thank you for proving it for me. Epidurals cause your uterus to RELAX because your body does not feel the discomfort associated with it and does not, as a result, contract the uterus as efficiently - causing an increase in the use of pitocin, instrumental delivery, and cesarean.. all of which are profitable to some degree or another. I know what she was trying to say, that tension can inhibit progression of labor, but she fails to acknowledge the uterus is just one. big. muscle. A relaxed uterus does not contract, which does not dilate, which does not birth.

One woman hit the nail on the head when she said "Epidurals are for tolerating hospitals, labor is the easy part". With hospitals 'requiring' that a woman dilates 1cm every 2 hours or she will be given pitocin, which, in turn, makes contractions less tolerable, requiring women sit or lie on the bed for continuous fetal monitoring, making contractions less tolerable and dilation slower, requiring women to have multiple vaginal exams, which mentally discourages women and causes tension (both of which discourages dilation)... it is no wonder that they are making the nice profit that they are.

Now things begin to line up... why women are being refused VBACs because of hospital policy or individual practice, why a nurse refuses to adhere to one request out of many on her birth plan: that medication not be routinely offered, why the AMA refuses to acknowledge that home birth is as safe as hospital birth for low-risk women and why they are attempting to outlaw home birth all together, and why hospitals across the board are pushing for the 'safety' of medication in birth... profit.

But, you shouldn't take my word for it. After all, we NCB advocates are in such a lucrative industry, and have selfish vested interest for you birthing our way....

31 comments:

TopHat said...

They're right. The NCB "industry" totally got rich off my birth. right...

I spent $50 on towels and chux pads at a local store and whatever amount on electricity for boiling water. We did spend $40 on a childbirth educator during my pregnancy. Yep. Lining the pockets of the NCB advocates...

Amy Tuteur, MD said...

Epidurals are not profitable. That's why patients on Medicaid often cannot get an epidural if they want one. One of the biggest problems with "natural" childbirth advocacy is that "natural" childbirth advocates have no idea what they are talking about. They just make it up as they go along, just like you just did. Then they can't understand why no one takes them seriously.

Christina said...

You had me nodding and "uh-huh"ing here at my computer. Great entry!

Nicole D said...

Amy- you are known in the medical community (yes, my doctor knows of you) and the NCB community as a nonsensical dolt who never makes a valid argument.

You haven't refuted anything in numerous arguments placed against you and your 'facts'. This is just one more of your attempts and it won't be had. Good day.

Rebekah Costello said...

I'm a natural childbirth advocate and a fledgling freelance doula. I have never charged a dime for my service and there isn't a stauncher supporter for natural birth anywhere than me. I DON'T GET PAID. And most of the women I know that are staunch supporters of NCB also do not get paid. Hell, you think that all of us birthing women have an invested financial interest in this? Well, I suppose we do, if health, fertility, healthy babies and longevity can be called an "invested interest".

I have a lot of very unkind things to say about him already; I'm afraid to read his article...

Sheridan said...

I would just like to add that just because you go unmedicated doesn't mean that you have to experience pain. Using things like Hypnobabies and other great things like water, position changes can help moms be more comfortable without epidurals!

Great post, which does lead to some conclusions on why hospitals don't want to encourage NCB.

Paula K said...

Dr. Amy is wrong. Epidurals are profitable for the hospitals because insurance companies are going to pay them for it. The reason Medicaid patients may not get one is because it's the government footing the bill and they're trying to spend as little as possible. Socialized health care supporters beware! If the US adopts a similar system to England you will see a decline in epidurals and c-sections and an increase in vbacs because doctors and hospitals will be capped as to how much they can charge for a birth. Oh wait, maybe I should be in favor of socialized health care after all. ; )

Sarah said...

Ugh, this raises my blood pressure just reading it!! I've realized over the past year that the profession I'm entering is one that will often cause me frustration and anger b/c of lies like this, but more than that, heartache for all the women who are vicitmized by this type of perpetuated non-sense. At the same time, though, this is where my passion lies, and if I can help even one woman, then I'll keep pursuing this work.

How do you keep a level head, Nicole? I mean, how do you balance your passion for serving women with the anger/frustration of the current state of obstetrics in our country? Thanks for continuing to be a source of wonderful info and encouragement!

Jill said...

Aww, how cute, "Dr." Amy stopped in for a visit. Always a pleasure seeing her name pop up, I know it will be followed with a good joke. ;)

Oh yes, we NCBAs/HBAs sure do have an agenda here...conning all these women into spending a mere $2,000-$4,000 on their births instead of $20,000. Shame on us! And we are putting that money into the pockets of MIDWIVES instead of a pharmaceutical company. Horrors! We should be tarred and feathered for our ignorance!

And then there are the women like Rebekah up there who don't make ANY money! My doula has been attending births for 12 years now and has never recieved one penny for it. Yup, they're all definitely in this for the money, aren't they?

Oh, and one more thing: I had no problem whatsoever getting an epidural while on Medicaid. The staff was all too happy to give me one. ;)

webirth said...

Really Dr. Amy? We know of a hospital that tried to bill a mother for an anesthesiologist's time. She didn't have any pain medications, but the hospital had entered into an employment contract w/ the anesthesiologist where he/she was to be paid whether or not an epidural was given. Just being there was the "service."

Take the time to delve a little deeper. Or perhaps that is another area you actually don't know anything about: your own industry.

Dale
www.independentchildbirth.com

...love Maegan said...

we are still in the trying stages but all of this drug pushing really REALLY infuriates me. To. No. End. It is just all bullshit. Great blog. I'll be back for more :)

I'm planning on finding a midwife but my husband is pro-doctors ...not sure what to do about it.

amanda said...

I didn't post anon or attack you, yet you still wouldn't post and respond to my comment. What about it offended you so?

Nicole D said...

Amanda - I didn't see your comment on moderation - perhaps I accidentally rejected it? Feel free to repost... I don't often refuse a comment.

amanda said...

I posted that I wasn't so sure that simply because something costs money or makes money for someone that there is a conspiracy at work. All the midwives and doulas in my area charge fees (some of them sky high) for their services. I don't understand why so many are quick to see a conspiracy at work when OBs or anesthesiologists charge for their time and then don't apply those same standards to midwives and doulas. The other side could argue that doulas have a stake (separate from concerns about safety and birth outcome) in having more women refuse pain relief because if more women got epidurals, less women would hire doulas and doulas wouldn't make money.

Also I do know a few L&D nurses and I can tell you that they are human, and it is hard for them to see someone suffer. They don't offer epidurals for bonuses, they offer them because they are trying to help. The ones I know don't offer it more than once though. You also need to keep in mind that they are required by JHACO to ask every patient what their pain is on a scale of 1 to 10 every hour and record it. They aren't doing it to disrupt anyone's "laborland", they do it because it is a requirement of their job.

I just think posts like this foster an "us against them" mentality and I don't see that as being helpful. The fact is that over 90% of women want an epidural in labor and that is unlikely to change. They are women capable of making their own decisions every bit as much as the women who decides to go all natural, or the women who choose UC. Taking an attitude that essentially says "if you were informed like me you'd make the choices I approve of" is exactly what people hate Dr. Amy for doing.

Rebekah Costello said...

I think Amanda has a good point. There are people out there that choose epi's knowing exactly what they are doing and there are nurses out there who are respectful and compassionate.

That being said, I think Nichole's post is right on. I doula'd for a client a few years ago who truly was pressured into an epidural. Let's face it, a laboring woman on an epidural is an easier patient to deal with. Literally every. single. nurse that walked through that door, EVERY TIME they walked through that door asked her if she wanted it, when she was getting it, told her she needed it, told her to her face she could never make it without, etc. One nurse, after hearing my client's refusal for a fourth time said, "Well, ok, but I'm going to go ahead and order it for you anyway because I know you are going to cave eventually. You can't do this by yourself, honey, it's ok, no need to be a hero."

My client was 16yrs old and was well informed. The nurses cajoled, berated and flat out lied to her and eventually, after 16hours of putting up with their bs and making little progress (which they never stopped reminding her of) she did cave. And there was nothing I could do about it. I've seen this many, upon many times and while I do think Amanda's caution is a good one (let's keep a realistic perspective on both sides of the issue here!) I do think that Nicole's post speaks the truth for the vast majority of women. Not ALL of them. Not all ob's have an agenda. Not all nurses are selfish. But what Nicole is describing here is an ugly reality that women really need to be aware of.

Nicole D said...

Amanda -

No one said there was a conspiracy. The problem is, when the sales to make that profit infringe on my desires and safety. Think of it this way: a woman is at a vulnerable time, working hard at birthing her child, and they have sales pitches being thrown at her and people attempting to coerce her into accepting something she simply does not want and has made it clear.

I, like many doulas, don't take more than 3-4 clients a month. This is tops... if I hit my 3-4 mark, I refer out. That is not making a living off of doulaing. And, I can tell you, there are far more women ALREADY who want NCB with a doula than doula's to go around in many areas of the U.S.

I completely understand the difficulty of a nurse seeing someone suffer. The problem is right there though - they view it as unproductive and 'suffering'. I liken it to a marathon runner - if you knew it was really important to someone to run a marathon and they had their heart set on it, would you consider them 'suffering' and try to discourage them to either forgo it all together, sit down and give up, or hop on the back of a truck to ride to the finish line? Or would you encourage them by saying 'I know it's hard - just a little longer'...? This is no less a human approach than feeling bad for someone who is in discomfort.

I don't know 'a few' L&D nurses - I know a LOT... MY doula (for three of my babes births) was an L&D nurse who was a friend as well. Many of my clients are nurses in some field or another, and all of them have confirmed that they/other nurses push it when the doc pushes it and they push it more after rep visits...

I have been to many a birth where the nurse will offer every few hours for an epidural, interns will come in in between nurses visits giving misinformation, and doctors will 'push it' after vaginal exams. JHACO requires that a patient be assessed for pain, not pushed for relief of that pain. And, JHACO supports the patient bill of rights, including the right to refuse. So, if they refuse, it should be honored... But I do understand they aren't TRYING to disrupt their birthing space, it is simply a byproduct - one of many things we have in the public health system in regards to maternal health issues that does not support healthy, normal, physiological labor and birth.

Posts like this did not make any such assertion of 'us against them'... I used a hospital for each and every one of my births and had a GREAT birth team... I had OBs for each but my last as well and was very happy with them.. but they were in the minority. It IS helpful because it helps women to make more educated choices based on ALL the facts, not limited facts. It also takes ALL subjects into consideration. That is informed consent or denial.

I also will have to disagree with you about the % of women wanting epidurals not changing... home birth is on the rise, doula use is on the rise, midwife use is on the rise - and women taking alternative birthing classes is on the rise - this would lend to the very real possibility that women choosing NCB or alternative pain management will also continue to rise.

And, I am sorry that you felt I copped the attitude of 'if you were informed like me'... that is NOT my attitude, and it glares assumption. I support EDUCATED and INFORMED decisions, no matter what they are... ask any number of my clients whom I work with and those whom I teach...

BUT, I also want to see medical practices CHANGED to support women who make their own educated and informed decisions - not attempt to coerce them. And I am not content to sit by and watch the American health system continue in this technocratic, bureaucratic, corporate nonsense that is not healthy or helpful for women of childbearing years.

I support a person's choice to drive a car, in fact, I drive a car - but, if I see an unsafe car, or see the majority of cars being driven in unsafe conditions - you better bet I will make a stink of it until I see people care more about the cars they are driving and the car manufacturers make safer changes to the design.

P.S. I don't hate Amy for choosing that attitude - I hate what Amy represents: limited and completely inaccurate information, outright lying about people, and lofty assumptions about people because she thinks her credentials makes her a superior assessor of my health care.

Nicole D said...

P.S - thanks for reposting... I have no idea what happened to your initial post.

amanda said...

Well I do come at this issue as a result of my own experience with doulas. Toward the end of my pregnancy it became clear to me that my husband would not be able to present during my labor. I called a few local doulas and informed them of my situation and I was told that I would need to pay their fee up front in order for them to work with me. the fees ranged anywhere from $350-$500 and I just didn't have the money to cut anyone a check like that. So I was alone during my labor. The pain was by far the worst thing I've ever experienced (and I've had several broken bones and dry sockets after wisdom tooth extraction). Hypnobabies went right out the window and I chose to have an epidural rather than endure that kind of pain all alone. I spent the rest of my labor reading Cosmo and watching TV.

I think it just caught my attention because someone upthread said that doulas aren't in it for the money, they are in it to help women. I certainly didn't find that to be true in my case.

Rebekah Costello said...

Amanda, that's awful. I would have attended you for free. *hugs*

Nicole D said...

Amanda -

I am so sorry for your experience. Let me put it this way:

The majority of OBs, in my experience, and like Amy, are as I described in my post.
The minority of OBs are like the ones I chose and many women search for.
The majority of M/Ws and doulas are in it to help women, not the $$ signs...
The minority of M/Ws and doulas are in it for $$...

I have talked to many women who want, but can't afford, a doula. I either try to work with them on price, payment plan, or help them find someone who can take them. Many new or provisional doulas don't charge a dime, many work with Operation Special Delivery (who offer their services for free to women whose dhs are deployed at the time of birth), and many more are listed at www.bellywomen.net - where they try to pair women with free to low-cost doulas for just such situations as yours.

I am sorry you weren't treated well and given the support you needed. I can understand why you would choose Cosmo and TV if you were alone...

Anonymous said...

epidurals don't work by "relaxing" the uterus, they have nothing to do with the uterus... it's analgesia directly bathing the spinal nerves, like a nerve block for a dental extraction

Nicole D said...

Anon - I didn't say that they 'worked by relaxing the uterus' - I said that epidurals CAUSE the uterus to relax... and that they do.

both fentanyl and bupivacaine directly affect muscle strength AND indirectly affect the sympathetic nervous system, which lowers bp which, in turn weakens muscle contraction.

It is common knowledge that an epidural works by blocking pain receptors... it is not so common knowledge (as demonstrated) that the medications in epidurals cause muscle relaxation.

In addition, epidurals effect the peripheral nervous system, which directly affects the ability to contract muscles both voluntarily and involuntarily.

amanda said...

Childbirth Connection states in Listening to Mother II that only 7% felt pressured into getting an epidural. 7% is too much, it's true, because no one should be pressured into anything, but there is a big disconnect between CC's findings and what I see women talking about in NCB blogs.

Nicole D said...

I agree that 7% is too much... but something to take into consideration is that the CC report is reporting on women who were planning medication to begin with as well as women intent on an NCB.. so, naturally, the assumption can be made that the women who refused (10%) something would include epidural medications and result in around a 3% difference in women who weren't further pressured to do something they did not want.

womantowomancbe said...

Amanda,

I, too, went through labor alone, but it was primarily my fault -- can't blame anyone but myself -- I had hired a midwife and then didn't call her because the contractions weren't "close enough" -- you'd think I'd know what real labor was, having done it once before. Anyway, I just want to say that while I am an ardent natural-birther, I know what it is like to labor alone, and it is horrible. It was all my fault too -- I told my husband to go to work and wouldn't call the midwife until my water broke or ctx got more regular. My labor was 24 hours long, and there were times I just walked around the house from one room to another crying. If I had been in a hospital, I would absolutely have had an epidural. The only reason I didn't was that I would have had to have totally change everything, including getting somebody to take me to the hospital, and I kept saying to myself, "but the contractions aren't even regular, and I'm not calling the midwife, so why would I go to the hospital?"

But I know what you've been through, as far as laboring alone. It sucks, and I can't recommend it to anyone. But I do recommend that everyone have somebody to support them throughout labor, whether that is a supportive friend or family member, a doula, or a midwife.

Seeing the difference that having a midwife/doula made between my first birth (constant attendance) and my second (completely alone), has made me determined that if I'm ever pregnant again, I *will* have a midwife and/or doula in labor... and I'll use her too! :-)

-Kathy

Unnecesarean.com said...

Dear Nicole,

We are sorry that you have not received your yearly check in the mail.

Please expect a large sum in the mail within two to four weeks.

Regards,

Natural Childbirth, Inc.
A Fortune 500 Company that Makes You and Me RICH!

I am a Monkey's Mama said...

Funny how "Dr." Amy never came back.

Wonder why???

I got my bill the other day for my cbac after laboring at home for four days. The total bill was $8,000. Add in the cost of my midwife that I paid for with cash, my total cost was $12,000.

My best friend had a c/s last year after laboring for about 24 hours or so in the hospital. Her total bill was $27,000. TWENTY SEVEN THOUSAND DOLLARS--HOLY CRAP! And that doesn't even include her OB's global fee for all of her prenatals or treatment for the infection she got after her surgery.

I can *totally* see how those who support NCB are getting rich. Right....

~g~ said...

Wow, great post. I know for me personally, the decision to ditch my OB and find a midwife was made when my OB told me "hiring a Doula is great, but don't kid yourself, birth is EXCRUCIATINGLY painful and if you DO decide to do an epidural, there really isn't a need for the Doula".

Wendyrful said...

I'm so sorry that someone had to go through labor and birth completely alone! I almost did that, while my husband was deployed to Saudi Arabia with my first baby. Luckily I had a wonderful dear friend who came and stayed with me, and helped during my birth. I actually ended up helping another mom time contractions, etc.(American servicemembers wives, in a foreign country), while I was still in the hosp postpartum.
Being a NCB professional is not a "Get Rich Quick scheme". I have been a doula for 8 yrs now, and this is the first year that I have ever 'made' money.
I began teaching Natural Childbirth classes, where I recieve a modest amount from several couples all at the same time, for weeks of classes.
I also began charging a bit more. I finally decided - shouldn't my time and physical efforts, and my family's time with mom running off to births or prenatals visits or postpartum visits, count for something?
Up to this point all my money has gone back into my 'business', buying supplies, attending conferences to learn how to be a better doula and childbirth educator, and paying for recertification, etc.
I volunteer for Operation Special delivery, and have helped mom's for free. I offer discounts and I take payments. I have attended births where the mom has a quick birth, 4 hours or less (the fastest was probably 1 1/2 hrs or so) and we don't spend so many hours laboring together, *but I usually spend about 2-3 hrs with the mom postpartum, and then I have an additional postpartum visit sometime in the following weeks. I have also attended births where I was with the mom for over 40 hours of labor. I get paid the same for both births. I also will go for as many prental visits as the mom feels she needs, durring the months of her pregnancy, and I spend hours sometimes researching specific things for that mom and her pregnancy and birth concerns or issues.
I personally have a hard time turning anyone away, but I also have a hard time accepting that someone can't 'afford' to pay for my time and efforts, and yet they only dress their children in name brand clothes from specialty stores, and all their furniture comes from pottery barn, while I am shopping at Wal-mart and discount stores.
If they *REALLY* wanted me/my services, they would look at their priorities, and decide what was the most immportant thing. Appearantly having trained labor assistance isn't it, but don't ask me to do it for free. I have found that when I do give away my services expecting nothing in return, the mom's often don't care as much since 'they don't have anything invested' and so they either don't call when I have had my family and my time 'on call' for the 2 weeks before their due date, and up to 2 weeks afterward. Yes this has happened on a couple of occasions to me, so I am wary. I promise you doula's and Midwives, even if they charge a bit more than another (in other lcations, or based on their level of experience, etc.) are NOT getting rich.
Sorry this one just hit a sore spot for me. Great blog post - although I think the birth scenario for the unsupported birth, was a bit over the top for most places, and I am in an area that is very backward and it is hard to achieve a natural birth in the hospital. IMHO

mcdoula said...

Amanda,
I am very sorry that you had to labor alone but I find it insulting that you would be offended that someone would charge a whole THREE HUNDRED DOLLARS to attend you birth. It makes me think that you really have no idea what doulas do. Here is a rough breakdown of our expenses (which doesnt even BEGIN to cover them). At 300.00 if this doula was able to book 4 clients every month which is pretty rare, her net would have been, drum roll please... 14K and after expenses (gas, time, supplies, membership dues, food, etc) I'm guessing she would have possibly made about 50 bucks doing one of the most physically and emotionally demanding jobs there is (and I was a labor and delivery nurse for YEARS before becoming a doula and believe me, the reason nurses PUSH the epidurals is because they are trained to INTERVENE, not support, they dont know how):

From www.bestdoulas.com
Many people ask about the breakdown of professional labor support fees.
HOURS
Most first labors last longer than 18 hours; some can last as long as 40 or more. The average time I spend with a woman for her labor and birth is about 12 hours, I spend at least another 6-9 hours in prenatal/post-partum meetings
Phone calls, individual research and responding to e-mails often adds another hour or two per client.
CLIENTS
When I make a commitment to be available to attend you in labor, I limit the number of clients I put on my calendar to avoid birth conflicts and to ensure that I am reasonably rested when you go into labor. I try to schedule four clients per month. When I put your due date on my calendar, I commit to being available two weeks beforehand and two weeks after that date. This means that when I schedule a two-week vacation, I have to add another four weeks during which I cannot accept clients.
SELF-EMPLOYMENT FACTOR
The rule of thumb is that a self-employed professional's income is only half of what they earn, after deductions for vacation and sick time, self-employment taxes, health insurance, and business expenses. Communication expenses are high for a doula -- you can reach me in any situation, a pager, a cell phone, a web site, and a computer with a high-speed Internet connection. I also have routine professional and office expenses and unusual transportation and supplies expenses (I personally spend an average of 85.00 per client). In addition, there are supplies I bring with me to your birth and give you at appointments and interviews.
TRAINING AND EXPERIENCE
It’s important to me to keep up with all of the most current information. In order to attend conferences and training opportunities, I often have to limit the number of clients I can accept around the time I will be unavailable, thereby reducing the number of clients I can work with each year. (Yearly membership and certification dues are apx. 250.00-500.00 per year depending on organization).
INTANGIBLES
Being on-call all the time requires a very high level of personal sacrifice, including a willingness to be awakened after half an hour of sleep to go attend a labor for the next 40 hours. Personal family events are frequently missed or interrupted for births. When I go to a movie with a friend, we have to take two cars, in case I have to leave suddenly for a birth. I can attend a party, but I’ll have to forgo that glass of wine and I have to bring a change of clothes with me(and shoes) wherever I go.

Jennifer Valencia said...

While we're talking about books wtih misinformation surrounding epidurals, check out Epidural Without Guilt and the response I wrote to it.

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