How Does the U.S. Compare?
Childbirth is an event that, despite its extraordinary nature, occurs daily throughout the world. But the circumstances under which this miracle occurs vary dramatically, even in places that don't seem that dramatically different. I can personally attest to this: Three years ago my Dutch husband and I moved from Texas to the Netherlands, where I gave birth to our son, Bram. I was surprised by many differences there, and I have friends from other countries with stories just as interesting. So I put together a roundup of birthing practices around the world, based on my own experience and accounts from friends.
Most expectant moms in Holland don't see an obstetrician, but are instead referred by their family doctor to a local midwife practice. Doctors only intervene in high-risk cases or if complications arise during delivery. Dutch women decide whether they want a home or hospital delivery. I was surprised to learn that more than half of the women at my midwife's practice deliver at home. In fact, all expectant mothers in Holland are required to pick up a kraampakket that includes all of the medical supplies necessary for a home birth. If you choose not to deliver at home, your midwife will make a house call to check on the progress of your labor and determine the ideal time for you to go to the hospital.
Even if you opt for a hospital birth, it's unlikely that you'll get an epidural. Epidurals are usually only given if it's convenient for the anesthesiologist's schedule (people often joke about the Dutch 9-to-5 epidural) or if an obstetrician determines it is necessary. Giving birth naturally remains the ideal for the vast majority of Dutch women. As my due date approached, I became more open to the idea, and in the end, no one was more surprised than I was to realize I had given birth to our son without any painkillers.
If a mother gives birth early in the day without complications, she and the baby may go home in as little as two hours. Then the unique Dutch system of kraamhulp (maternity home care) is set into motion. For seven days we had a nurse come to our home, a benefit covered by insurance. Not only did she provide medical care, but she also cleaned our apartment, cooked, and instructed us in basic parenting skills.
Local custom: Another important duty of the nurse is to manage the flow of visitors and make the traditional snack to celebrate a birth: beschuit met muisjes, which literally translates as "biscuits with mice." The "mice" are actually miniature licorice bits with blue-and-white coating for boys, pink-and-white for girls.
Malin Haugwitz, a Berlin resident who is originally from Bethesda, Maryland, says that German women focus on the event of giving birth almost more than the outcome. Following her second c-section, she heard many words of pity from friends and even from her midwife, who asked, "Do you see it as a failure?"
German women who hold full-time jobs can feel secure knowing their position will be waiting for them when and if they decide to return to work. As soon as a woman tells an employer she's pregnant, she cannot be fired. Thus, during economic downturns, being pregnant can essentially save your job. Women may stop working six weeks before their due date and are forbidden from working for eight weeks after giving birth, all with full pay. Mothers may even take up to three years of unpaid leave, the third being a floating year that can be taken at any time and by either parent.
Local custom: Another practice that Haugwitz recounts is that government offices keep a list of "accepted names" that parents must adhere to when registering the name of their child. In the case of an unusual name, they must give a compelling reason why an exception should be made. The government policy is intended to act in the best interest of the child, in an effort to thwart potential ridicule of a child with a name that's too different.
Like Dutch and German women, the majority of Japanese women strive to give birth without the use of painkillers. According to Ai Azuma, a Tokyo native, this preference relates to the Buddhist perception of suffering: There is a belief among Japanese that labor pains act as a kind of test that a woman must endure in preparation for the challenging role of motherhood. This centuries-old belief endures despite the fact that a growing number of doctors in Japan are recommending epidurals for their patients, suggesting that they create a more peaceful birth experience. Although more women are beginning to exercise this option, centuries of tradition still keep many others from considering the procedure.
Japanese women deliver in hospitals, but it's not a given that the baby's father will act as the labor coach or even be in the room. Fathers are permitted to be present at the birth only if they have taken prenatal classes with the mother-to-be; if a c-section is performed, they must go to the waiting room. In general, hospital stays in Japan tend to be longer than in the U.S.; mothers can expect a minimum of a five-day stay for a vaginal birth and 10 days or more for a cesarean delivery.
Local custom: After leaving the hospital, mother and baby often stay at the mother's parents' home for a month or sometimes longer -- it is a cultural tradition that women stay in bed with their baby for 21 days. During this time friends may drop by to greet the new baby and join the family in eating the celebratory food osekihan (red rice with red beans).
In this South American country, elective c-sections have become almost commonplace, according to Masumi Mello e Silva, who recently immigrated to the U.S. from Sao Paolo. The overall c-section rate in Brazil is 40 percent, according to the International Cesarean Awareness Network. And if you look at only private hospitals, the rate is even higher.
There are some with cesarean birth rates of 100 percent, according to Marsden Wagner, MD, a perinatal epidemiologist who works for the World Health Organization. Private hospitals are the choice for roughly one-quarter of expectant Brazilian women, and these women hail mostly from the middle and upper classes. Trying to explain the reasons for the overwhelming number of cesareans, Mello e Silva speculates that many doctors perform the procedure in order to receive higher payments from insurance companies. Private hospitals likewise reap the benefits of higher payments for the longer hospital stays that cesarean procedures require. Also, the convenience of performing a 60-minute cesarean procedure versus attending to a long labor and delivery may lead many doctors to see the time saved as vital to their practice. In Brazil, the doctor-patient relationship is very strong -- women receive nearly all of their information about childbirth from their doctor, rather than from prenatal classes. If a woman's doctor is advocating a c-section, she may well be swayed by his opinion.
The tide is beginning to turn, at least in public hospitals, where the Brazilian government has instituted procedures to reduce the number of c-sections. In 1998 the government set a goal to reduce the public hospital cesarean rate to 25 percent or lower by 2007. To achieve this goal, the government stipulated that public hospitals with c-section rates over 30 percent would no longer be compensated for procedures they performed above that number. In 1999 the average cesarean rate in Brazil's public hospitals dropped to 24 percent, from 32.4 percent in 1995.
Local custom: According to Mello e Silva, pregnant women are treated like princesses -- for example, they are ushered to the front of any line so they don't have to wait. Once mother and baby leave the hospital, visitors flock to their home. They give a gift to the baby and receive one in return. Traditionally, it's something small, such as a bottle of perfume or candy, with a message from the baby attached thanking friends and family for the visit.
This European country has recently changed its approach to childbirth, according to Tulin Sevil, who comes from the capital city of Ankara. As recently as 20 or 30 years ago, midwives supervised most of the births in Turkey, especially in rural areas. Doctors were in short supply and most tended to practice in metropolitan areas, such as Ankara and Istanbul. But as more university medical schools were founded and the number of doctors increased, care shifted away from midwives in favor of ob-gyns.
The shift toward doctors has also brought about a growing preference for elective c-sections among Turkish women. In a recent survey, overall c-section rates for private hospitals in Turkey were nearing a staggering 75 percent, according to Kybele, a U.S. nonprofit group that promotes safe childbirth practices in developing countries. One reason for this trend, according to Kybele, is that only a few Turkish anesthesiologists have specialized training in obstetric anesthesia. Many women know they will not have the option of an epidural, so they instead opt for a c-section with general anesthetic. Kybele reports that this use of general anesthesia may be a contributing factor in Turkey's having one of the highest maternal mortality rates in Europe. Kybele coordinates programs to train doctors in administering epidurals (the group maintains a database of U.S. doctors willing to go to Turkey to share their knowledge); the doctors then teach their fellow physicians. Turkey has been very receptive to the program, so the hope is that epidurals will be more widely administered in the future.
Local customs: Unlike in the U.S., baby showers are not given in Turkey -- all celebration is postponed until after the baby is born. According to Ahu Terzi, who emigrated from Turkey to New York City, mother and baby stay home for the first 20 days after the birth. Friends drop by and drink a special beverage called lohusa serbeti. After this period, the mother and child make return visits to gift-givers' homes, where they receive a handkerchief filled with a single egg (for a healthy baby) and candy (for a good-natured baby). They also rub flour on the baby's eyebrows and hairline, which is supposed to grant him a long life.
Women in the U.S. know they are fortunate to have access to arguably the best medical care in the world. After my very positive birthing experience in the Netherlands and hearing stories of other people's births, I realize we Americans have much to learn, as well as much to be thankful for. Now that we've moved from Holland back to Texas, I'm wondering how I'm ever going to survive the next time without my kraamhulp nurse!
Lara Schalken lives with her husband and son, Bram, in Frisco, Texas. All content here, including advice from doctors and other health professionals, should be considered as opinion only. Always seek the direct advice of your own doctor in connection with any questions or issues you may have regarding your own health or the health of others.