Posted Sunday, March 7, 2004; 14.48GMT
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
The midwives absolutely knew what they were doing. They managed to get strength out of me which I did not know I had
— RUTH WISHART, 40, Germany
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.
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