Anna says neither the doctor nor the midwife gave her the option to choose how she wanted to deliver her baby at the pre-natal course. When she struggled delivering her baby, weighing 4.5kg, she was refused a caesarian. “They put my life and that of the baby in danger,” Anna says.
Stories like her's are not out of the ordinary in southern Italy, where women have less access to epidural pain relief during labour than those in wealthier parts of the country.
Epidurals are a form of anaesthetic administered to the back that block sensation in the lower spinal segments.
A map of Italian hospitals offering epidurals for free shows a country cut in half: In the northern region of Lombardy, the rate of women who had access to an epidural during childbirth was around 20-25% in 2016, with some hospitals peaking at 38%, while in the south, less than one in 10 women could choose to have the pain relief.
According to Onda, an observatory for women’s health, southern regions lack public monitoring on the issue.
What's the situation in other countries?
The World Health Organization (WHO) says it recommends epidurals for healthy pregnant women requesting pain relief during labour in a 2018 report. Yet, epidural rates in Italy are lower than many other countries in Europe.
In France, 82% of women choose to have an epidural, said a 2016 government report, compared to 4% in 1981.
At the Croix Rousse Hospital in Lyon, 98.6% of first-time mothers choose the epidural analgesia for vaginal births, a hospital staff member told Euronews.
The Italian Society of Anesthetists estimates that 67% of American women opted for an epidural in 2017 compared to 40% in Canada (2017), 66.1% in Sweden (2015), 89% in Finland (2010), and 31% in Denmark (2010).
According to the NHS Maternity Activity report, the proportion of women in England who received the pain relief fell from 68.6% in 2006/2007 to 60% 10 years later. In Spain, an epidural is always recommended and is chosen by seven out of 10 women, according to the Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor, SEDAR.
Why does Italy have such low rates?
The birth analgesic "will remain a 'phantom right' in many hospitals" due to the lack of staff, said Alessandro Vergallo, president of the Association of Italian Anesthetists (AAROI EMAC). He estimates that the health system falls short of at least 3,000 doctors and anesthetists: “If we want to guarantee epidurals 24/7 in all hospitals, we need to double this figure.”
But Vergallo is confident the country will make great strides over the next years. He pointed out that “there have been great leaps forward, overcoming the distrust of a few years ago” at the cultural level.
The doctor's target rate is 30% for epidural births across the country.
Resources are another issue. Often labour rooms are at a considerable distance from the emergency operating room where caesareans take place. If there is a shortage of anaesthetists, they will not be able to administer the epidurals.
"An emergency caesarean has priority over a childbirth analgesia. If the labour room is far away and the anesthesiologist is busy with a caesarean four rooms away, this need cannot be satisfied," said Vergallo.
AAROI EMAC estimates that new recruits could cost the national health system €200 million euros, adding that this cost could be reduced by cutting staff overtime and closing small maternity wards.
“A hospital with a small maternity ward, which delivers 100 births a year, needs at least six gynaecologists and 12 midwives to ensure 24-hour cover. There are many small birth centres, which are close to each other in the north and are kept open for political reasons,’” said Vergallo.
“The goal is to have a 24-hour epidural centre in each province. [Small towns like] Sondrio must also have the same rates as Milan, Viterbo should have what is available in Rome,” said Dr. Ida Salvo, a member of the advisory board at Onda observatory and head of the anaesthetist unit at Bambini Vittore Buzzi hospital in Milan.
Fighting obstetrical violence
"When women do not receive information about epidurals, they feel violated in their right to choose, in their self-determination," said Elena Skoko, founder of the Observatory on Obstetric Violence.
Skoko also denounced the lack of information in some hospitals about "alternative methods of pain relief” like water relaxation, breathing techniques, 1:1 support by the midwife, different positions, massages, and acupuncture.
All of them allow women to deal with pain but also to move more freely, without being forced stay in bed, in a lying position, she said.
According to the group, four out of 10 mothers said they suffered physical actions that violate their personal dignity while giving birth in Italy; a trauma so severe that 6% of total mothers decided to not have any more children. Every year, around 20,000 children die for reasons related to obstetrical violence.
Skoko is not convinced that small and mid-sized hospitals should be closed: "Let's not forget that the bigger the hospital is, the bigger the chances of obstetrical violence.”
To ease the problem, Skoko called for more midwife units and supervised home births for low-risk cases.
The association Onda said that more than half of the caesareans requested by women (especially in small wards) were caused by fear of the pain during labour. “Guaranteeing access to the epidural, therefore, would also reduce the number of caesareans,” said Salvo.
“In Italy, the number of caesareans is high, especially throughout the south, where we are at around 40% when it should be below 20%," added Salvo.