May 17, 2018 Read Original Story

Inquirer delivers well-rounded report on using laughing gas for labor pain–except for two things

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Rating

Laughing gas makes a comeback for women in labor - like Kate Middleton

Our Review Summary

Is nitrous oxide (“laughing gas”) — which is frequently used to treat labor pain in other countries — gaining more acceptance in the U.S., where more aggressive pain management has traditionally been the norm?

In answering this question this story draws on many sources to mostly tout the benefits of nitrous, but falls short in providing readers — many who would be interested mothers — in two areas:

What has research shown–in quantified, measurable terms–about how effective nitrous oxide is?
How high-quality is that evidence?

Research findings addressing these concerns should have been included. Or, if such research hasn’t been conducted, the story should have made this clear.

The story is otherwise well-rounded and did a job particularly on costs, sourcing, and availability.

Why This Matters

The U.S. approach to labor and delivery is arguably one of the most expensive, high-tech, and medicalized in the world. According to a New York Times analysis, the charges for delivering babies in this country have tripled since 1996, and maternity and newborn expenses are now “the single biggest category of hospital payouts for most commercial insurers and state Medicaid programs.”

Issues surrounding pain management during delivery are contentious, highly personal, and potentially both expensive and fraught with concerns about complications. This means that any interventions that offer affordable and safe options have the potential to improve patient satisfaction and patient outcomes.

Stories about such interventions (like using nitrous for pain management) mean a great deal to mothers — and our health care system — and should include details about the strength of the evidence behind the claims.

Criteria

Does the story adequately discuss the costs of the intervention?

Satisfactory

The cost of nitrous oxide for use during labor in one facility ($250) is included. It’s also mentioned that most insurance plans won’t cover it.

A bonus that may have been appreciated by readers would have been comparing its price to the two most common approaches for managing labor pain (in the US): epidurals and IV narcotics.

Does the story adequately quantify the benefits of the treatment/test/product/procedure?

Not Satisfactory

The story lists these benefits:

“It makes many women — not all — feel less anxious, more relaxed, and better able to deal with suffering.”
“It’s simple to self-administer, takes effect in less than a minute, and wears off just as quickly.”
“It’s also safe for the baby, doesn’t slow down labor, and can be used at any point.” (ie. even for pain issues after the delivery.)

But these benefits are presented anecdotally. This is unsatisfactory because — as the story rightly points out — there is extensive experience with the obstetric use of nitrous oxide in Great Britain, Finland, Canada, and Australia. Providing supportive evidence from this international experience is highly relevant.

Does the story adequately explain/quantify the harms of the intervention?

Satisfactory

It’s mentioned:

“Nitrous comes with some caveats. It can cause nausea and dizziness. It also interacts with vitamin B12, so women with a deficiency of the nutrient shouldn’t use the gas … but studies — and generations of use worldwide — have not found complications or long-term problems.”

This is enough for a satisfactory rating. However, we’re left asking: where’s the evidence? Some research findings to support a midwife’s statement in a review that nitrous is “safe for the mother, fetus, and neonate” would be salient for many expecting mothers.

It’s also important to point out that if you Google “nitrous oxide & harms” you will come across a much larger list of harms, some of them quite ominous. But most of these occur in the setting of the prolonged and extensive abuse of recreational nitrous oxide (aka “whippets”). But, presumably, the obstetric use of nitrous — which is a brief exposure to limited doses — would pose much less risk. Mentioning this would help clarify things.

Does the story seem to grasp the quality of the evidence?

Not Satisfactory

This story never cites a specific study (though it quickly mentions a literature review), nor does it provide links to several existing studies documenting benefits and harms.

On the one hand, this article relies heavily on the anecdotal support of benefits (more so than harms); but on the other hand, we’re told that neither the American Society of Anesthesiologists nor the American College of Obstetricians and Gynecologists have official positions on the use of nitrous. Why is that? Does it have something to do with the balance of benefits vs. harms? Not including evidence makes that question difficult for readers to answer.

Does the story commit disease-mongering?

Satisfactory

None.

Does the story use independent sources and identify conflicts of interest?

Satisfactory

The story employs several independent sources. A minor point, but it would have been helpful to hear from a source from one of the countries where using nitrous oxide during labor is far more commonplace, and for an ACOG spokesperson to comment on the lack of guidance on using it during labor.

Although not strictly conflict of interest issues, the article rightly points out two advocacy considerations. First, that many midwives are advocating for nitrous as a low-tech option at a time when labor and delivery are becoming increasingly medicalized. Second, that some hospitals are approaching nitrous as a marketing tool; presumably to position themselves as low-tech-friendly.

Does the story compare the new approach with existing alternatives?

Satisfactory

The story does well to provide relevant historical and cultural context; namely, that the traditional approach to labor pain in the US is biased toward epidural anesthesia, despite the fact that nitrous oxide is a common alternative in other countries.

Given the current opioid epidemic in this country, it may have been timely to mention the extensive use of narcotics in managing labor pain in the US.

Does the story establish the availability of the treatment/test/product/procedure?

Satisfactory

It’s mentioned that currently “an estimated 500 U.S. hospitals and birthing centers offer nitrous — up from a handful less than a decade ago.”

Does the story establish the true novelty of the approach?

Satisfactory

It’s well established that obstetric nitrous oxide is widely used in several countries.

Does the story appear to rely solely or largely on a news release?

Satisfactory

The story doesn’t appear to rely upon a news release.

Total Score: 8 of 10 Satisfactory

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