The Battle Over Birth

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

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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.
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