In collaboration with Duitslandnieuws.nl
Recently, the debate surrounding pregnancy and childbirth has once again erupted in the Netherlands. Are we in the Netherlands a model for other countries, or is the situation better in Germany, for example? Journalist Ulrike Nagel has now experienced pregnancy in both countries. According to her, we can learn from each other. She is of German descent but lived and worked in the Netherlands for many years, where she had two children. She has now been living in Berlin for four years and has since become a mother of three. She is now well-positioned to compare the healthcare and cultural aspects of pregnancy in both countries. Which do you prefer?
You’ve already given birth twice in the Netherlands, even though you grew up in Germany. Did you experience things back then that you found strange as a German?
When I realized I was pregnant in 2007, I went to see my family doctor in Utrecht and expected something to happen. She sat there with one of those little discs you use to calculate the due date and congratulated me. And for the time being, she said, nothing was going to happen. “Just find a midwife and you can check in with her again in a few weeks. No, we don’t check to see if you’re really pregnant—the pregnancy test already confirms that 99% of the time.” So. That did surprise me, for example, but I just took her word for it that that’s how it worked. Living in Germany at the time, I didn’t really know how things worked there, because I was one of the first in my circle of friends (both German and Dutch) to have a child, and I’d already been living in the Netherlands for almost ten years.
So I looked for a midwifery practice and started going there regularly. The whole process—the first-trimester ultrasound around 9–10 weeks to determine the exact due date, the 20-week ultrasound, a quick weigh-in, checking blood pressure, and mostly listening to the heartbeat, plus the 3D ultrasound around 30 weeks—seemed like a logical sequence to me. The visits to the midwife were always fairly short, which I found a bit of a shame—in the Netherlands, you’re out the door again after just 5 to 10 minutes. But the approach was always very positive and kind; she assumed I was healthy and that everything would proceed naturally, and that’s exactly what happened. So I was never referred to a gynecologist for either of my children—there was no reason to. I learned that only if there were risks would a slightly more “medical” course of treatment at the hospital be necessary.
Since everything went very well for me both times, I found the whole experience very positive at the time.
Especially the approach to childbirth: it was made very clear to me that I had the choice—to give birth as an outpatient (meaning I could go home quickly after giving birth at the hospital) or at home.
As a true Berlin native from the big city, the idea that you could give birth at home in the Netherlands struck me as very strange at first. It seemed like something you’d find in small villages at the beginning of the last century, so my natural choice was the hospital. As a German, you’re simply less likely to consider something so “unknown”; the hospital seems like the safest option—if anything happens, they can intervene quickly.
And then the birth went very differently than I’d imagined: way too fast. “We’re not going anywhere,” the midwife said when my first child was born, and I immediately agreed—I hadn’t even managed to make it down the stairs. Those hours that followed are etched in my memory—contrary to my expectations, I found the whole atmosphere at home to be fantastic. A postpartum care provider joined us; all the supplies were tidied away without me even noticing; my bed was made up just like in a hotel room; everything was completely harmonious and perfect.
That’s why, 3.5 years later, I made a conscious decision to have my second child at home as well. I was simply a little anxious about having to get into a car right before giving birth and then possibly having to endure pain on the way, thinking, “If only we make it, if only we make it.” It just seemed more relaxing to me at home, and that was also the case the second time around. That approach—“it’s a natural process; your body can handle it”—has always resonated with me; it brings a lot of peace of mind. I’ve never been afraid of giving birth in the Netherlands.
Now the third one is on the way, and you’ve been living in Germany again for a few years. What differences have you noticed so far compared to the Netherlands?
For one thing, here you don’t go to your family doctor first—you go straight to your own gynecologist. I was already used to that from back in the day, because if you want to take the birth control pill in Germany as a teenager, you’re required to see a gynecologist—or “Frauenarzt,” as it’s usually called here. You have to get a Pap smear, have everything checked, and only then can you get your birth control prescription from the nurse. And if you get pregnant, you naturally go to the same practice. So I got used to that again right away.
However, the exam was immediately very different. And so was the doctors’ approach. Instead of congratulating me right away, she asked cautiously, “Is this a planned pregnancy?” I noticed how incredibly neutral this question was, and also that the doctor wasn’t necessarily cheerful or exuberant about me and my news—it was as if she was deliberately keeping her options open. Because of that, I immediately sensed the hierarchical distance between “doctor” and “patient.” At first, it seemed less warm, less compassionate to me, but when I thought about it more, I realized it made perfect sense. The practice is located in a city with nearly 4 million people; by no means will every woman who walks in here be happy about her pregnancy. And so, a cheerful “Congratulations” could actually come across as completely inappropriate to someone else. And that’s the experience they’re basing their approach on.
In terms of testing, they do a lot more here than in the Netherlands. Right during the first appointment (when you’re usually 5 or 6 weeks pregnant), they use an internal ultrasound to confirm the pregnancy, check whether there’s one or more fetuses, and make sure everything looks okay. You have to provide a urine sample in a cup (and you have to do this every single time at every appointment), because your urine is tested for pH level, protein, and bacteria. In addition, they weigh you thoroughly, and they take blood samples not just once, but more frequently. The gynecologist handed me a sort of checklist: Toxoplasmosis test, 15 euros; an additional ultrasound, 60 euros; and there are many more tests listed that you can have done. That seemed like very good precautionary care, but it also made me realize that a practice like this simply makes money from each individual test. Either you pay for it out of pocket, or your health insurance reimburses you and then pays the practice. That is definitely one of the reasons why gynecologists in Germany perform so many tests, in addition to the fact that the German healthcare system is extremely risk-averse. If something could happen, then we’ll also check to see if it might happen. Even if it’s unlikely that anything will happen. But you never know. After all.
Starting at the 25th week, you’re therefore hooked up to a machine for a full 15 minutes to measure whether you’re having contractions, for example. Unthinkable in the Netherlands if you’re just seeing your midwife. And starting around 30 weeks, they use a CTG to monitor your baby’s heartbeat for half an hour. It all seemed very excessive to me, especially since they don’t really give you a clear explanation of why it’s all necessary. Until one day at the clinic, I saw a somber-looking couple sitting in front of me. They were clearly worried, and a short while later, the woman was indeed picked up by an ambulance on a stretcher. I subtly tried to find out what was going on: She was only a little over 20 weeks pregnant. At the clinic, they’d been able to see on the ultrasound that the baby was much too small, and on top of that, they’d already detected contractions. Bad news—so off to the hospital right away. Ever since then, I’ve wondered if something like that would have been spotted just as quickly in the Netherlands. The woman was bleeding, and in the Netherlands, you’re usually sent home for a while in such cases. Not here, though—a good German friend of mine once spent an entire week in the hospital for that, even though nothing was wrong.
Two things happen then: On the one hand, all that fuss—all those tests, all the things that could go wrong—makes you feel insecure. Giving birth feels less natural and takes on a medical connotation. You become less confident in your own body. But on the other hand, doctors can act much more quickly if something is actually wrong.
In the Netherlands, this is a very topical discussion right now; and I, too, have friends and acquaintances in the Netherlands who lost their babies before birth. And often they don’t know why, and it can’t really be properly investigated. And while I’ve always been a big fan of the Dutch “natural” method, I’ve started to wonder a bit more whether the German “monitoring” approach is really so bad.
In any case, it’s very expensive—it can sometimes get completely out of hand here. But as a parent who might be at slightly higher risk, you’d probably benefit from it the most.
Since I’ve had two children at home, I’m not really keen on a hospital birth here either. Although that is definitely the norm (though about 3% of German women give birth at home, and nationwide there are only about 380 midwives who assist with home births), but first of all, you have the choice of which hospital you want to give birth in (which seems to be quite a science, judging by what other pregnant women say— they spend entire afternoons and days figuring out which hospital is the best), and you can also choose other options, such as a birthing center—a hybrid between home (cozy, warm, and inviting) and the hospital. There are several options, and everyone chooses what feels best for them.
I started looking for a midwife who performs home births, and there are very few of them. The midwifery practices I called often told me: “We only handle the preparation for the birth and the care afterward, but we don’t handle the delivery itself.” This is due to the exorbitantly expensive insurance that midwives are required to carry here. They pay 4,000 euros or more per year to insure themselves against the risks of childbirth—which is simply unaffordable for a great many midwives. That’s why so many are quitting, and it’s becoming a dying profession in Germany. Or you have to work as a midwife in a hospital—but that’s not what everyone wants, according to my own midwife, who therefore favors the “natural” approach and never fails to tell me regularly how excessive she finds the medical process in Germany.
For my body, that natural approach is just fine. And yet, and yet. When I show her an ultrasound photo, she barely reacts to it, because she also thinks far too many ultrasounds are being done. She feels how the baby is positioned, she measures my belly and uterus (with a measuring tape, actually), she listens to the heartbeat, and she always takes a full hour and a half for each consultation. That often feels a little too long to me, because we frequently get bogged down in discussions about how things are done in the Netherlands (which she seems to prefer) and how there are far too many elective C-sections in Germany, or how people react hysterically if you’re even one day past your due date. The only thing she just doesn’t get is that they don’t check urine in the Netherlands—she can’t understand that at all, since it’s such a simple way to detect preeclampsia, for example. By now, I don’t understand why that isn’t done in the Netherlands either. And listening to the baby’s heartbeat for half an hour—she does that in her small practice, too.
(Part 2 to follow: The Birth and Afterward)
