The Battle Over Birth

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."