The Battle Over Birth

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NATAL MANUEVERS: Group care at France's largest maternity center

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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.
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