To the Editor:—

Labor is extremely painful for many women. Effective pain relief (i.e. , regional labor analgesia) should be available on request to all women in labor. As Chestnut 1points out, the absolute cost of providing epidural labor analgesia, as detailed by Macario et al.  2and Bell et al. , 3is not great. I am certain that providing cardiac anesthesia for a mitral valve replacement or neuroanesthesia for a cerebral aneurysm clipping costs more than does providing an epidural labor anesthetic. The problem is the reimbursement rate. I think that the reimbursement will not increase until our services are valued more highly, and our services will not be valued more highly until we are viewed as labor facilitators.

If one were an insurance company executive, would one volunteer to pay handsomely for an optional service that increases other costs by increasing the duration of labor, causing greater need for oxytocin augmentation, increasing the incidence of neonatal fever, and possibly increasing cesarean delivery rates? Of course not. Now, imagine that epidurals shortened labor and decreased cesarean delivery rates in addition to keeping patients happier. That would be a valuable service. If anesthesiologists threatened to stop providing that service, one would negotiate and increase the offered reimbursement rate.

Many of my colleagues view the labor-slowing and fever-inducing properties of epidural labor analgesia as trivial problems. I disagree strongly. If we do not fix these problems, a day may come when we are not invited to participate in labor analgesia. We owe it to our patients (and to ourselves) to make sure that that does not happen.

Chestnut DH: How do we measure (the cost of) pain relief? Anesthesiology 2000; 92: 643–5
Macario A, Scibetta WC, Navarro J, Riley E: Analgesia for labor pain: A cost model. Anesthesiology 2000; 92: 841–50
Bell ED, Penning DH, Cousineau EF, White WD, Hartle AJ, Gilbert WC, Lubarsky DA: How much labor is in a labor epidural? Manpower cost and reimbursement for an obstetric analgesia service in a teaching institution. Anesthesiology 2000; 92: 851–8