Esra Erkal-Paler is used to being in control. As a London-based corporate affairs director for a global cosmetics company, she runs a team of five people. When she married in 1994, she and her husband, Robert, put off having a family because she didn’t want to risk derailing her career. But she always told herself that she would have a child no later than 35 — and now that her first baby is due in May, it’s only logical that Erkal-Paler, 34, wants to be in charge of every aspect of the birth.
Britain’s National Health Service (NHS) has other ideas. Erkal-Paler is one of many European women whose desire for control is running into opposition from state medical systems that weren’t designed with consumer choice in mind. Worried about the pain and unpredictability of a vaginal delivery, Erkal-Paler asked for a maternal-choice caesarean section — an operation performed because of preference rather than medical necessity, enabling a woman to control the time and manner of her baby’s birth. The procedure was all but unheard of before the late 1990s, but Erkal-Paler is one of roughly 18,000 pregnant women in the U.K.’s public hospital system (3% of the total) who will request it this year. Maternal-choice caesareans have been lampooned in the British tabloids — the Daily Mail’s famous headline was are you too posh to push? — and that infuriates Erkal-Paler. “Why attach such a critical stigma?” she says. “It’s nothing to do with that. It’s only natural to fear the unknown.” But like half the British women who ask the NHS for maternal-choice C-sections, she was turned down by her midwife, who said she had no medical need for one. When Erkal-Paler protested, the midwife referred her to counseling — but still no C-section. “They say they offer patient choice,” says Erkal-Paler. “But they’re denying me the most fundamental choice of all.”
Erkal-Paler could have gone to a private hospital to schedule a maternal-choice C-section (about 450 other women did so last year in the U.K.), but her private insurance wouldn’t cover it and she didn’t want to pay thousands of pounds. So instead, she resigned herself to a vaginal delivery and drew up a birth plan — a wish list, put together by about 20% of the U.K.’s expectant mothers — detailing how she wants her labor to proceed. Her plan mandates use of a “birthing pool” (a deep tub of warm water, which relieves some of the pressures of labor) and whiffs of nitrous oxide to take the edge off her pains. If the contractions prove unbearable, she wants an epidural: an anesthetic that numbs most of the torso. Her birth plan notes her objection to forceps and requests that if she needs stitches, she’d rather be sewn up by a doctor than a midwife. Putting it all on paper helped allay some of her anxieties — but not all. “My biggest fear,” she says, “is lack of control.”
Welcome to the power struggle in the maternity ward. European mothers-to-be — older, better informed and more assertive than their forebears — are increasingly dictating how and where they want to deliver their babies. And since women in Western Europe today have fewer children — an average 1.5 each, compared with a global fertility rate of 2.7 — and more high-powered careers than their mothers and grandmothers, they want to make sure that their childbirth is not only safe but precisely tailored to their expectations, needs and lifestyles. “Women now are more vocal, better educated and have higher expectations,” says Edwin van Teijlingen, senior lecturer in public health at Scotland’s University of Aberdeen. “But if at any given time lots of women want different things, the systems can’t cope.”
Taxpayer-funded national health systems across Europe are hamstrung by budget shortfalls, staff shortages and fears that providing alternative birth services will lead to mistakes and litigation. They’re desperate to keep a lid on the rising costs that consumer choice requires. The U.K.’s National Institute for Clinical Excellence (nice), part of the NHS, is set to issue guidelines for England and Wales next month aimed at bringing down the 22.3% C-section rate, because those procedures cost the NHS as much as $206 million extra per year. Between 1996 and 2000 in France, over 100 small maternity units were closed due to low frequency of births and understaffing; since 2002, Health Minister Jean-François Mattei has continued this practice as part of a four-year plan to make way for large, centralized birthing centers, where natal services can be scheduled to fit in with staffing levels. “Unfortunately, due to reasons of volume,” says Paul Cesbron, an obstetrician at the Maternité Hôpital Laennec in Creil, “you are obliged professionally to organize childbirth in an industrial fashion.”
But women confronting childbirth don’t want to be treated like widgets. Before Parisian lawyer Laurence Verna-Loupiac, 35, gave birth to her daughter in January, she considered making a birth plan, but abandoned the idea, feeling it would be misconstrued. “They would have looked at me like I was an extraterrestrial,” she says. She asked her midwife to warn her if the doctors were going to perform an episiotomy, in which a woman’s perineum is cut to prevent tearing during delivery. “The midwife didn’t seem to understand how it was possible that a patient had an opinion on the act of surgery,” she says. “For her, if it was to be done, it was to be done; that’s the medical staff’s responsibility, not the patient’s.”
Despite these obstacles, increasing numbers of European women are finding ways to have the kind of birth experiences they want. In Germany, deliveries in “active birth” centers, which emphasize birth without medical intervention, have increased by 50% since 1999, to 7,500 in 2002. In the Netherlands, requests for pain relief during labor — long shunned by many midwives as “unnatural” — shot up by 28% between 1995 and 2002. “Women are much more a part of the process now,” says Elmar Joura, associate professor of gynecology and obstetrics at the University of Vienna, who helped develop a 20-minute C-section. To take decisions out of their hands, he warns, “is just not good medicine.”
And there’s ample evidence that maternity planning is good for mother and child. Monika Birner, associate professor for gynecology and obstetrics at St. Pölten General hospital in Austria, surveyed over 1,000 women and found that those happiest with their birth experiences were those that had dictated their terms. “It sounds simple,” says Birner, but “women like things most when they get what they want.” A positive birth experience, no matter what form it takes, helps a woman feel positive toward her baby. “Over the last two to three years,” says Birner, “gynecologists have become more aware of the psychological effects of birth.”
The struggle for choice in childbirth began in the 1970s, when feminists advocated a return to “natural” childbirth, beseeching women and doctors to trust Mother Nature. Over the next generation, that impulse morphed into a kind of maternity consumerism, based on individual preference rather than feminist ideology. “For years and years, the natural childbirth movement was talking about the need for choices,” French obstetrician Michel Odent, a central figure of the movement, told Time. “Women and doctors now just view medical interventions like elective C-sections as being among those choices.”
The trend has been accelerated by advances in obstetrics, as medical procedures that women used to fear have given way to more appealing alternatives. Vacuum extraction is replacing forceps as the preferred choice for assisted vaginal deliveries because it is widely deemed to be less harmful for the mother and child. “Walking epidurals,” a diluted version of the traditional anesthetic, have gained widespread use because, unlike immobilizing epidurals, they let women move around even as they block the severe pain of labor. And crucially, the C-section has changed from a high-risk, high-drama emergency operation into a relatively short and safe procedure, carried out under local anesthetic so the mother remains conscious as her baby is delivered. In 1998, 2001 and 2002, Joura and his team published groundbreaking research on the C-section’s latest evolution, in which the uterus and abdomen are sewn up in three stages rather than the previous seven — which halves a woman’s blood loss and recovery time (about four days). That seems likely to increase the popularity of an already popular procedure. Global statistics on the frequency of the C-section are difficult to come by; neither the World Health Organization (WHO) nor the United Nations keeps such data. But while the numbers vary widely — in France in 2001, the C-section rate stood at about 18%; in the U.S., it was 24.4%; in private clinics in Brazil, the figure was about 80% — there’s no doubt the procedure is more widespread than it was a decade ago. As maternal age increases (almost half of the European women who give birth each year are over 30) the chance of a successful vaginal delivery decreases, and that’s an obvious factor in the rise of C-sections.
But if the female body is straining to accommodate new birth trends, so are Europe’s public-health bureaucracies. France is closing down smaller wards in favor of what are popularly known as “baby factories.” France’s largest maternity facility, the Polyclinique de l’Atlantique in St. Herblain, just outside Nantes, delivers 5,000 babies a year, and is a model for France’s evolving style of centralized maternity care. Built in 2002, the gleaming maternity ward, bathed in natural light, has three levels. There’s a birthing pool, an anesthesiologist available 24 hours a day, 12 delivery rooms, and two operating theaters for C-sections. Says Olivier Teffaud, one of the clinic’s obstetricians: “In the big majority of cases, the new moms here are quite happy. I think it’s possible to remain humane in a large service.” Certainly Nadège Molin, a new mother sitting up in bed in the clinic, is delighted with the outcome of her visit: her Justine, who had arrived by natural delivery last Thursday. Although Molin admits she was dubious about the size of the new ward, the gleaming medical equipment reassured her that she was in the right place if something went wrong. However, she notes, “at smaller maternity wards, doctors, nurses and midwives may have more time to spend with expectant mothers and new moms.” Indeed, such centers are finding it hard to shake the “baby factory” label. Following the recent deaths of two newborns in rural areas, who perished when their mothers were unable to get to proper care in time, Jean-Louis Chabernaud, head of pediatric emergency services and neonatal transport at the Antoine-Béclère hospital in suburban Paris, condemned the new strategy. “I’m concerned that expectant mothers in some regions don’t have guaranteed access to maternity care,” he says. Even where patient choice flourishes there are financial and logistical struggles. Outside of the U.S., Britain leads the way in the popularity of birth plans. This summer, the U.K.’s Department of Health will release national maternity guidelines that for the first time include birth plans as part of nationwide antenatal care. Yet there’s still resistance from some doctors and midwives. Detailed maternal instructions, says Lesley Regan, professor of gynecology and obstetrics at St. Mary’s Hospital in London, “put everybody’s back up. Immediately the midwife thinks, ‘Oh God … there’s going to be a fight.'” In principle, the British government is trying to give women more options. In February 2003, the U.K.’s then Health Secretary, Alan Milburn, said that he planned to extend the choices available to the U.K.’s mothers-to-be. “We have got to move on from the one-size-fits-all-take-it-or-leave-it health service,” he declared. Yet in some ways Britain is still restricting choices. The nice guidelines that look set to limit the number of C-sections performed in England and Wales are one example. The problem, of course, is money: the surgical procedure costs the NHS $1,729 more than a vaginal delivery, and requires physicians to spend an extra 20 minutes with each patient. Time and money are two things the NHS lacks. “The government [doesn’t] seem to realize that they can’t promise choice if they haven’t provided the infrastructure,” says Regan. “Choice is an expensive thing to provide.” The NHS says that there must be rules to govern how and why the procedure is performed. Not all the issues are financial. Historically, pain relief has not been widely available to Dutch women; many Dutch midwives believe pain is a necessary part of the process. Last November, Els Kruit, 29, a Dutch midwife in Zutphen, had her second daughter at home — one of the 30% of Dutch women who still do so. The labor itself lasted just 90 minutes and after a further 10 minutes of pushing, Sara was born, weighing in at a robust 4 kg. Kruit didn’t have pain relief — because she didn’t want it.
Of the 90,000 Dutch women who gave birth with a doctor present in 2002, 27% received pain relief — up from 21% in 1995. But the pain, says Kruit, “is meant to be there. It tells you and your baby to go further or to stop.” Not everybody is so sanguine. “It’s like a religion,” says author Heleen van Royen, whose best-selling novel The Happy Housewife tells the story of a woman driven insane by the agony of childbirth. “The midwives say the pain is good for bonding with your child. It’s medieval.”
In Italy, too, maternity services still tend to see suffering as part of childbirth. In 2001, only a quarter of Italian women were allowed to choose their birthing position. And although 50% of Italian women ask for pain relief, only 10% get any in the public hospital system. To compound the problem, the system suffers from a shortage of some 1,500 anesthesiologists. No wonder one in three Italians is now born under private insurance cover. Monica Mercuri, 39, gave birth to her first child in 2002. In her second month of pregnancy, she went to see a private gynecologist in a public hospital. She was told two things — that her pelvic area might be too small for her to deliver her baby, and that her doctor could not schedule a C-section unless the labor was prolonged or at risk. This was too much to bear. “The hypothesis of suffering like a dog for 10 hours only to finish by having a caesarean was too much,” she says. She found a surgeon who assured her of a C-section by appointment. The fee: €6,000.
Her doctor may have had his own reason to offer the procedure — it decreases his chances of being sued. In Italy, litigation against obstetricians has soared; in 2002, there were about 8,000 lawsuits against obstetricians, accounting for about half of all medical lawsuits in that year, and a 1,600% rise over the number in 1987. Of greater concern: malpractice in Italy is not only a civil offense, but also a criminal one. Says Claudio Giorlandino, president of Italy’s National Commission on Maternity and Birth: “The huge majority of legal suits regard litigation about caesareans that perhaps should have been done. They are never about an excess of medical treatment.”
Nowhere is the baby battle more heated than over the question of C-sections. The numbers continue to rise: in Italy, the C-section rate stands at a sky-high 32.9%, up from 21% at the beginning of the 1990s. In Germany in 1991, 15.3% of babies were delivered by C-section; by 2001, the rate had risen to 22.6%. That’s well above the 15% ceiling recommended by the WHO, although some physicians insist the who figure is hopelessly outdated. Critics of C-sections see them as unnecessary surgery. “There is such thoughtlessness about the way a C-section is being sold,” says Elisabeth Geisel, German coordinator of the European Network of Childbirth Associations. “C-sections have a huge impact on a woman’s body and are simply not the way nature has planned birth,” she says.
Adding to the controversy is the trend among some higher-income women to choose C-sections out of convenience or to avoid the pain of a vaginal delivery. Around the late 1990s, medical literature started to feature essays on the ethics of C-sections-on-demand — known as “maternal choice” or “maternal request.” Soon the popular press was filled with images of yuppie women slotting C-sections to fit in with their schedule-obsessed careers, or out of sheer vanity. Liz Hurley and Victoria “Posh” Beckham are among the celebrities who have had elective C-sections, although Beckham says hers was for medical reasons.
A close look at the data suggests that lifestyle C-sections remain rare. Three-fifths of U.K. caesareans are emergencies, occurring because labor is failing to progress or the baby is in distress. The remaining two-fifths are classified as elective C-sections, meaning those performed before the onset of labor, usually for a medical reason. Elective C-sections are clearly on the rise — in Britain in 2002, they accounted for about 9.3% of all births, up from 5.5% 10 years earlier. But many are scheduled by women who have had one emergency C-section and know they are likely to need another; in the U.K. in 2001, 67% of birthing women who’d had a C-section repeated the procedure. Maternal-choice C-sections — those without any clear medical reason — account for only about 1.5% of births in the U.K.’s public hospitals and 1.6% of all U.K. births. And doctors say most of those are not motivated by convenience or lifestyle factors; fear of labor plays a much stronger role. Says Robert Verwey, consultant obstetrician and gynecologist at Bronovo Hospital in the Hague: “Any sensible human being would do anything in their power to avoid hours of serious pain.”
In the U.S., according to Health Grades, a company that evaluates the quality of health care, the number of maternal-choice C-sections jumped 20% between 1999 and 2001, when they accounted for just under 2% of the country’s 4 million births. Samantha Collier, Health Grades’ vice president of medical affairs, says that as long as the woman has been fully informed of all the risks “the ethic now is that mom is autonomous.”
That’s fine when mom is footing the bill, but even private insurers are balking at paying for C-sections. In 2002 AXA PPP Healthcare, a private U.K. provider, said it would no longer cover even emergency C-sections. Says David Costain, the company’s medical director: “The number of C-sections we were being asked to pay for was rising so rapidly, and it showed no signs of leveling off. It just wasn’t plausible that they were all medically necessary.”
Who gets to decide? It’s a question that experts everywhere are grappling with. In Europe, women dependent on state health care will necessarily have their choices limited. And if private insurance continues to clamp down, it may be only the wealthy who have total choice. In the U.K.’s Portland Hospital, among the best-known of the country’s small number of private clinics, the maternal-choice C-section rate is about 15% — 10 times the number in the public system. At the Portland, smiling men in claret-colored waistcoats greet you at the entrance and take your bags. And when the time arrives, smiling medical personnel help you deliver your baby. As many as 2,100 women annually come to have their babies at the Portland — among them Beckham and actress Hurley.
American actress Gwyneth Paltrow, 30, was rumored to be considering the Portland for the birth of her first child with British rocker Chris Martin. British newspapers have been obsessively tracking Paltrow’s choices — a prenatal yoga regime, birthing pools reportedly installed in her homes in London and the U.S. In the end, she is said to have opted for London’s other celebrity hospital, St. John and St. Elizabeth, where model Kate Moss had her baby.
These private clinics are a far cry from the busy wards of Britain’s public hospitals, but they come at a price. For a regular vaginal delivery at the Portland, patients can expect a bill for $4,340 for the birth and the first night, $1,712 per night thereafter. The Portland offers package deals for non-medical C-sections: $7,973 for the first night and the operation, $2,114 for subsequent nights, including medication. Most C-section patients stay five days, at a total cost of $14,315.
At 8 a.m. this Friday, 34-year-old freelance consultant Betsy Ludwig is scheduled to have her baby at the Portland by maternal-choice C-section. As she’s an American expatriate, the cost will be covered by her insurance, but that’s not the the reason why she chose the Portland. Instead, she wanted maternal choice there because she considers it the lowest-risk way to give birth. “Pretty much every woman I know who is my age or above has had to have an emergency C-section,” says Ludwig. “Why go through all of that if you don’t have to?”
In Germany, private insurance offers other options, too. Ruth Wishart, a 40-year-old Scottish woman who has lived in Berlin since 1999, started thinking about having a child two years ago. She decided she wanted to have a natural birth, so she opted for the Birth Center Klausenerplatz, which doesn’t provide medical intervention. Since 1997, the number of such organic birth facilities in Germany has doubled, although only 2% of women actually give birth outside the hospital system. In the lead-up to the birth of Wishart’s son, Ben — now three months old — she met with the center’s midwives, who monitored Ben’s position and his size. When her due date came and went, the midwives suggested that she drink first herbal tea, and later, a mixture of castor oil, vodka and orange juice. After just two slugs of that, she went into labor. In the center, she stayed in the birth tub for a couple of hours. Then she moved to the rope, and later the large birthing ball — both of which help the muscles relax. The pushing stage lasted an unusually and agonizingly long four hours, but soon after Ben emerged, she was sitting, sipping champagne. The midwives “absolutely knew what they were doing,” she says. “They managed to get strength out of me that I did not know I had. In hospital they would probably have used forceps.” The centers are proving so popular that soon they may be covered by the state-sponsored insurance scheme. That kind of progress suggests that European women are destined to win the battle for control of their births. But it certainly is a slow, painful delivery.
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