Labor Epidural Education and Hispanic Ethnicity: Reply

We appreciate Dr. Wecksell’s comments on our article, “Education Program Regarding Labor Epidurals Increases Utilization by Hispanic Medicaid Beneficiaries.”^1,2  Dr. Wecksell asserted that the marked improvement in epidural rates for the educational intervention group in the Hispanic arm, coupled with no significant difference for the intervention group in the non-Hispanic arm, was a demonstration that “marketing works.” One might reasonably argue an educational intervention and a marketing campaign can be similar in how they deliver information to individuals, but the likeness should end there, lest one embarks on an equivocation fallacy.

A fundamental objective of an educational intervention is to improve knowledge. Properly executed, new knowledge provides a person with skills to make better, more informed decisions, decisions that should be beneficial to the individual first. And while a primary objective of a marketing campaign is to inform individuals of a company’s or an industry’s products or services, the benefits are directed toward the marketed entity first (e.g., sales revenue and profits, market share). There may or may not be benefit to the individual; a successful campaign could cause them harm. R. J. Reynolds’ Joe Camel advertising campaign³  is one case in point. Importantly, the goal of our intervention was to create educational equity and promote informed decision-making in a cohort of women (Hispanics) that historically lacked access to accurate information. The educational program was created with the intent to benefit Hispanic women.

In response to the author’s statement that “utilization does not always equal a health benefit, as the many papers on ‘natural childbirth’ in the nonanesthesia literature might argue,” we believe that facilitating informed decision-making for the management of severe pain is an end with intrinsic value. Our educational program was evidence-based and avoided value judgments. Furthermore, in an era where nearly one third of births occur by cesarean delivery, epidurals offer a health benefit in certain circumstances.⁴ 

Last, we did appreciate the account provided to explain why American women began shaving their legs. We warn our audience, however, of the hazards of making causal declarations from observed correlations. We believe a reading of the Bradford Hill criteria for establishing causality from observational data could help avoid future misconceptions.⁵ 

The authors declare no competing interests.