What Women Want During Labor: Cultural Competency in Uganda

Janel Feliz Martir
uvmmedicine blogger Janel Feliz Martir ’17

“What’s an epidural?” Phiona asked casually as she swayed toward the cabinet of binders in the International office at Makerere University holding her pregnant belly, her brow furrowed in obvious curiosity. Sruthi, one of the two medical students on the maternity wards with me, and I looked at each other, speechless. We fumbled, unsure of where to begin. Epidural is a word with deep cultural and visceral resonance among women in the United States. Even nulliparous women (medical jargon for women who have never experienced labor) joke behind closed doors—”I’m so getting an epidural”—before bursting into fits of laughter when the topic of possible or future childbirth slips into the conversation. The reliance on immediate relief to ease labor pains is a truism reflected in many American movies: screaming women frantically rushed down hospital hallways—huffing and puffing and sweating as they demand anesthesia. Phiona’s honest question stunned us because it confronted us with a poignant global reality: the pain of childbirth that is a choice in the United States is an expectation in Uganda, as well as many other parts of the world.

Sruthi and I started to explain how an epidural numbs and essentially paralyzes the nerves from the waist down. But the luxury of pain relief has its disadvantages. Once a woman gets an epidural, she is committed: women cannot walk after they receive the shot, remaining in bed in the lithotomy position (on their back with their legs up and knees bent), hooked up to IV fluids with a monitor placed on their bellies so the medical team can monitor uterine contractions. Epidurals essentially disconnect women from the pain that signals to push, thus requiring equipment monitors to signal when a woman should “bear down” in conjunction with uterine contractions.

Phiona chuckled and retorted – “If a woman screams too much here”, her lips widening into a smile, “a nurse in Mulago’s Ward 5B can go up to her and tell her to stop being so dramatic!” She shook her head in disbelief at what we told her, astonished that American women will actually forgo walking to not feel labor pains. This is Phiona’s second pregnancy. She labored naturally without medication and delivered a healthy baby boy through a spontaneous vaginal delivery in a private hospital in Kampala years prior, so her perspective on this subject was legitimate.

During this interaction, I fought the urgent desire to debate Phiona on this, and considered the topic of expected anesthesia for childbirth from a new perspective. Since starting my global health work in Mulago Hospital, I have learned to question my immediate reactions to what I encounter with the understanding that I bring my own set of cultural biases and beliefs. I reflected on epidurals and their popularity in the United States: In 1909, Walter Stoeckel, a German obstetrician, was the first to use caudal anesthesia for childbirth. By the 1940s, epidurals, as opposed to spinal anesthesia, were used sporadically in the Western world and then more frequently by the 1970s. Its more widespread use coincided with the rise in childbirth technology, specifically the use of oxytocin, known as “pit” on the labor wards. Oxytocin causes uterine contractions so although women may not actually feel the signal to push, they can be assured that their uteruses are working. The more I mused, I realized that, in a sense, epidurals had effectively transformed childbirth as a normal process into a medical event. Epidural use creates a different set of complications, as women can feel immobilized and have adverse reactions to the treatment, requiring an organized hospital setting equipped to manage the anesthetic side effects.

Many of my patients who labor in the low-risk wards at Mulago generally neither request nor expect pain relief. Most are able to deliver their babies without the need for surgery. I once asked some of my postpartum patients about pain relief and many of them laughed at me while suckling their newborns in the postnatal ward. It surprised me that given the choice, a number of my patients would still forgo pain relief. This non-reliance on pain relief during labor, I am told, is rooted in a deep Ugandan cultural belief that labor pain is a test of a woman’s strength. Ugandan culture posits the belief that real women are mothers and caregivers, and real men are fathers and providers. Although I do not necessarily adhere to this particular belief system, who am I to dispute another woman’s personal conviction? Especially as a mzungu (white person or foreigner) doing global health work in Uganda, my job is not to impose my values onto my patients, given that the choices my patients make keep them safe and healthy. And in reality, many women are able to be safe and healthy while delivering their babies without epidurals. The medical team’s job, and my job, is to monitor patients for any indication of an unsafe situation that may necessitate immediate action, like a caesarean section.

Conversations regarding women’s global health rightly focus on reducing maternal mortality, family planning, and the provision of effective prenatal care. However, I find that these conversations are sometimes problematized by the notion that more developed countries think they know what is best for developing countries. This sort of medical elitism is dangerous and underlies the notion that global health is about the exportation of westernized values – namely and problematically – democracy and capitalism. This is unfortunate given that the discipline of global health was conceived within the ambitious idealism and self-determination spurred in the era of decolonization in the 1970s.

The practice of global health is not about the imposition of one’s cultural values on another’s as some sort of ideological imperialism. It is about keeping patients and communities healthy and safe, and recognizing that health is a right, not a luxury. Global health experiences are opportunities for learning, and it is important to remember that the exchange of knowledge and information ought to be bidirectional. Developed countries can learn just as much from what works in the developing world. Among what works in Uganda is the fact that healthy low-risk women are able to experience childbirth without the use of an epidural or of obstetric services, both of which have become almost expected in more westernized countries like the USA. The use of epidurals during childbirth is a luxury many American women have come to expect. It has become socially legitimized and culturally solidified into American culture, yet Ugandan culture is not American culture. I am an advocate for choice and envision an ideal world in which women all over the globe will have the choice of pain relief during childbirth, but I will not dispute a woman’s choice to forgo pain relief. I am learning every day that to be an effective global health worker means to practice cultural competency and to be open to new perspectives.

Read this blog post and others from students participating in the University of Vermont College of Medicine/Western Connecticut Health Network Global Health Program on the Global Health Diaries blog.

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