NATAL MANUEVERS: Group care at France's largest maternity center
The Battle Over Birth
With elective C-sections, detailed birth plans and better medication, European women are demanding control over the birth process. But cash-strapped medical systems are fighting back. Who decides how we are born now?
Posted Sunday, March 28, 2004; 12.45BST
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."
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