The Battle Over Birth

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

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Her doctor may have had his own reason to offer the procedure — it decreases his chances of being sued. In Italy, litigation against obstetricians has soared; in 2002, there were about 8,000 lawsuits against obstetricians, accounting for about half of all medical lawsuits in that year, and a 1,600% rise over the number in 1987. Of greater concern: malpractice in Italy is not only a civil offense, but also a criminal one. Says Claudio Giorlandino, president of Italy's National Commission on Maternity and Birth: "The huge majority of legal suits regard litigation about caesareans that perhaps should have been done. They are never about an excess of medical treatment."

Nowhere is the baby battle more heated than over the question of C-sections. The numbers continue to rise: in Italy, the C-section rate stands at a sky-high 32.9%, up from 21% at the beginning of the 1990s. In Germany in 1991, 15.3% of babies were delivered by C-section; by 2001, the rate had risen to 22.6%. That's well above the 15% ceiling recommended by the WHO, although some physicians insist the who figure is hopelessly outdated. Critics of C-sections see them as unnecessary surgery. "There is such thoughtlessness about the way a C-section is being sold," says Elisabeth Geisel, German coordinator of the European Network of Childbirth Associations. "C-sections have a huge impact on a woman's body and are simply not the way nature has planned birth," she says.

Adding to the controversy is the trend among some higher-income women to choose C-sections out of convenience or to avoid the pain of a vaginal delivery. Around the late 1990s, medical literature started to feature essays on the ethics of C-sections-on-demand — known as "maternal choice" or "maternal request." Soon the popular press was filled with images of yuppie women slotting C-sections to fit in with their schedule-obsessed careers, or out of sheer vanity. Liz Hurley and Victoria "Posh" Beckham are among the celebrities who have had elective C-sections, although Beckham says hers was for medical reasons.

A close look at the data suggests that lifestyle C-sections remain rare. Three-fifths of U.K. caesareans are emergencies, occurring because labor is failing to progress or the baby is in distress. The remaining two-fifths are classified as elective C-sections, meaning those performed before the onset of labor, usually for a medical reason. Elective C-sections are clearly on the rise — in Britain in 2002, they accounted for about 9.3% of all births, up from 5.5% 10 years earlier. But many are scheduled by women who have had one emergency C-section and know they are likely to need another; in the U.K. in 2001, 67% of birthing women who'd had a C-section repeated the procedure. Maternal-choice C-sections — those without any clear medical reason — account for only about 1.5% of births in the U.K.'s public hospitals and 1.6% of all U.K. births. And doctors say most of those are not motivated by convenience or lifestyle factors; fear of labor plays a much stronger role. Says Robert Verwey, consultant obstetrician and gynecologist at Bronovo Hospital in the Hague: "Any sensible human being would do anything in their power to avoid hours of serious pain."

In the U.S., according to Health Grades, a company that evaluates the quality of health care, the number of maternal-choice C-sections jumped 20% between 1999 and 2001, when they accounted for just under 2% of the country's 4 million births. Samantha Collier, Health Grades' vice president of medical affairs, says that as long as the woman has been fully informed of all the risks "the ethic now is that mom is autonomous."

That's fine when mom is footing the bill, but even private insurers are balking at paying for C-sections. In 2002 AXA PPP Healthcare, a private U.K. provider, said it would no longer cover even emergency C-sections. Says David Costain, the company's medical director: "The number of C-sections we were being asked to pay for was rising so rapidly, and it showed no signs of leveling off. It just wasn't plausible that they were all medically necessary."

Who gets to decide? It's a question that experts everywhere are grappling with. In Europe, women dependent on state health care will necessarily have their choices limited. And if private insurance continues to clamp down, it may be only the wealthy who have total choice. In the U.K.'s Portland Hospital, among the best-known of the country's small number of private clinics, the maternal-choice C-section rate is about 15% — 10 times the number in the public system. At the Portland, smiling men in claret-colored waistcoats greet you at the entrance and take your bags. And when the time arrives, smiling medical personnel help you deliver your baby. As many as 2,100 women annually come to have their babies at the Portland — among them Beckham and actress Hurley.
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