Monday, November 19, 2012

Introducing. . . maternity care in Norway

Jeg er gravid. . .  Jeg har baby i magen. . .  Vi venter et barn!
All Norwegian expressions meaning:
I am pregnant. . . I have a baby in my belly. . . We’re expecting a child!
All true, my friends. All true.

Although I am now much further along than when I originally wrote the following post, at 10 weeks gestation back in late July. You’ll have to forgive me for keeping the news off the blogosphere for a few months.

I promise this will not morph into a mommy-blog, or a pregnancy-blog, but will try to keep it true to its roots of an American-Woman-Making-Her-Way-Through-Life-in Norway-blog. But as an American midwife, with many friends and colleagues back in the States in the baby business, my experiences and impressions of pregnancy care in Norway are a big part of my ex-pat experiences in general. So here goes a back-dated-July blog:

I had my first svangerskapkontrol (pregnancy appointment) in mid-July at 10 weeks. I should point out that while insurance is "free" in Norway (supported by their hefty taxes), general medical care to adults is not free. Care for children and for pregnant women is, however, 100% covered. Midwives attend approximately 70% of all births in Norway, leaving the complicated pregnancies and births to the physicians. Midwives are, by law, required to be available to a pregnant mother in every community in Norway for her prenatal care as well. Most midwives seem to practice either in the clinic setting providing prenatal care, or in the hospital setting providing care surrounding birth, but not both, as most midwives do in the US. Either you are employed by the kommune (community/city) for prenatal care or by the public hospital for labor/delivery/postpartum care.

Despite this overwhelming presence of midwives, it is normal for a woman to have her first prenatal appointment with her fastlege.  A fastlege is her family doctor, whom she may or may not have had many options in choosing. I had a decent fastlege, but thought he was a bit too male for my liking, and switched to a female fastlege who had helped my own dad with some dental pain. But just four days before my first appointment with her to diagnose and treat a sinus infection, she began her maternity leave. I was then automatically switched to a third fastlege. Another male.

So at 10 weeks gestation, with Erik in tow, we go to meet my fastlege for my first prenatal appointment. This pregnancy was much like my first—virtually undetectable, virtually asymptomatic—of which I dare not complain. That said, there is something very reassuring about symptoms, however unpleasant they are—you realize that something is in fact developing deep within your body.

Last time around, I was well-connected to (ok, employed by) the obstetric department at a major regional medical center and teaching hospital, and started off the pregnancy being reassured by rising serial hCG levels (pregnancy hormones) and two early ultrasounds to help in dating our somewhat surprise pregnancy. All of which were medically justifiable, in my mind. So, despite any symptoms of nausea or fatigue last time around, I knew things were OK. This time around, without any medical reasons for hormone levels or ultrasounds, I just had to trust nature and my body and my training that everything was proceeding as normal. And I was OK with that, too. Honestly, I was! (Ok, I was a little uneasy about it. . . but that's normal, too).

At 10 weeks into a pregnancy, a health care provider could be able to hear a fetal heartbeat (as my midwife was able to do when I was pregnant with Greta), although admittedly this is not always possible. This is really the only reason why I dragged Erik along to this otherwise rather boring and routine appointment. My fastlege, however, had no intention of attempting to hear the heartbeat. “It won’t give us any useful information,” he informed me.
“Uhhh. . . yes it can,” I countered, getting a little testy, and trying to express myself calmly in Norwegian. “For one, it can reassure me that everything is OK! And, it would give you some idea whether my dates are accurate or not.” I wasn’t asking for a ultrasound, for Pete’s sake, just a heartrate check.
“Well. . . we don’t actually have the capability of doing that here at this office anyway,” he responded. Which, it occurred to me later, is probably bullshit. Even though most women see the midwife for their prenatal care, some do choose to see their fastlege and most women go back for at least one or two visits with their fastlege during the course of the pregnancy. And if a pregnant woman is showing up at her fastlege for a routine prenatal visit, would the physician not check the fetal heartbeat? I think not. Somewhere in that damn office was a handheld Doppler ultrasound. I just knew it.

My blood pressure was rising, can you tell? Five minutes into this visit and I was not impressed with maternity care in Norway.

Speaking of blood pressure, he then proceeded to take my blood pressure (surprisingly low, considering) and do the all-so-informative-yet-obligtory listening to a perfectly-healthy-woman-in-her-mid-30’s heart and lungs. ‘Cause that would give him so much useful information. . .

Next on his list was the gathering of Important Information to be entered into a computer database: my job, Erik’s job, my religion, was my first birth a vaginal or c-section delivery, how much she weighed, and what her Apgar* score was (although when I reported them as 8 and 9 (1 and 5 minutes), he said, “. . . and?. . . “ waiting for the 10 minute Apgar score. In the US, once you hit a score of 9 at 5 minutes, we don’t do a 10 minute score. Aside from a brief health history, that was the extent to which he was curious about my previous pregnancy. No questions about use of anesthesia, length of labor, breastfeeding, postpartum depression. . . 

He moved on, namely to the issue of prenatal genetic testing and/or screening, specifically for Trisomies 18 and 21. As I will be (full disclosure here) right around the ripe young age of 38 when this baby is born, I automatically have the right to genetic testing, provided and paid for by the Norwegian health care system. Apparently, if you are under the age of 38, you are not offered these tests (although I’m sure there are some extenuating circumstances). In the US, it’s really available to any woman of any age. . . given that your insurance pays for it, of course! 

In my previous job, the midwives used an increasing amount of time of our 60 minute first prenatal visits counseling our patients on the different options of prenatal testing, so I was quite informed on what the options were, what information they gave us, how accurate they were, etc. So, I was a bit surprised when my fastlege told me we’d have to hurry to get me into the ultrasound to measure the nuchal translucency (neck thickness), because time was getting late. “Odd. . . “ I thought. “That’s usually at 12 weeks. I’m only 10 weeks. Do they do it earlier here? Is this test somehow different? Am I not remember this correctly?”

So, I asked him, and inquired about which hormones they measure along with the ultrasound—is this a first trimester test only, or a combined test with more labs drawn in the second trimester? The tests are becoming more extensive and therefore more accurate in the US—the more hormones you measure, the more information you get, and the more accurate the screening becomes. His response, “You’ll have to talk to the doctor about that when you get your ultrasound at the hospital.”

Huh? This is the doctor that I am sent to when I encounter a “complication” in my pregnancy, unless it’s too complicated, and then I’m sent to the obstetrician? But he can’t adequately counsel me on a screening test done immediately following my first prenatal visit? Assuming I knew nothing about these tests, I would have to base my decision on whether or not to do this screening based on this crappy counseling? And what if I get to the ultrasound/screening visit and decide I don’t want the test after all? What a waste of everybody’s time!

As you might guess, 15 minutes into this visit and I was even less impressed with maternity care in Norway. I was quite furious when I left the office, although I really tried to keep it in perspective. I had high expectations, or probaby more accurately, I had high standards. To add to my frustration with the whole system, I knew that the care, reassurance, and counseling that I provided women during their first prenatal visit was highly superior to what I had just received. If I dare say so myself.

Coming soon: my screening tests (more confusion) and first visit with the midwife (she’s wonderful!). So a mix of annoying and good.

*Apgar score:  a score of 0-10 given to a newborn at 1 , 5 and possibly 10 minutes of life, evaluating their transition to extrauterine life. Their color, tone, respiratory effort, pulse and reflexes are given points of 0, 1 or 2. A low score indicates that the baby needs assistance and possibly resuscitation to transition to life outside the uterus. 


  1. Wow. I feel extra lucky to have the wonderful midwives at DHMC. At least Norway is ahead of the game for maternity leave - or so I've heard anyway!

    1. They are a special crew, and I feel very blessed to have been a part of that practice!

  2. congratulations! i was very happy with my care during my pregnancy in norway - my gp found the heartbeat at the 10 week appointment, and the midwives at the hospital during the birth were amazing. (i also had the 12 week scan due to special circumstances.) that said, the gp of one of my friends couldn't find the heartbeat at 12 weeks, told her it was nothing to worry about; couldn't find it at 16 weeks, said it was nothing to worry about (though of course she was); and then at her 18 week scan they discovered it was a partial molar pregnancy that hadn't progressed beyond nine weeks. i think it's very negligent that that wasn't picked up earlier.

    1. Thanks norlight! I'm glad to hear you had a good experience with your GP (and midwife, too). I agree with you: that was negligent. As a midwife, I would have been concerned if I couldn't hear it at 12 weeks, and would begin to wonder "do we have the right due date? Is she really 10 wks? Or is this not progressing normally?" and either done an ultrasound then, or have her come back in a week at 13 weeks and THEN done the ultrasound. There's a lot of cost-cutting measures in care here, I think.

  3. Thanks Lisa! It has been so nice to have something pleasant to focus on and has put a different perspective on lots of the other "stuff" I've blogged about lately--the news reports (in which I was barely squeezing into my jeans), the trip back to the States, my time alone here in Oslo, my desperation to find a job, etc.

  4. Hi Emily,

    Congratulations to you and Erik on the wonderful news - very exciting indeed! We have not been so lucky and we really are fine with that, but it's always a bit vicariously thrilling when you hear of others expecting. Glad to hear you liked your midwife, that must be a relief to you.

    (As an aside, are the tax rates for your income and healthcare that much more expensive in Norway? We pay about $1200 US/month for our coverage and have a $50 copay...)

    Hopefully the other big issue of being able to work as a mid-wife will get resolved. It really seems like they bungled the evaluation from the beginning and now don't want to back down.

    Keep us posted on all your news and take good care!
    best, Suzy

  5. Thanks Suzy!

    As for our taxes, it's really tough to compare. We pay about 25% income tax (I think), but then we also pay 25% tax on EVERYTHING that we buy: clothes, shoes, FOOD. Yes, food is taxed at 25%. And gas: about $10/gallon. So, how to you figure what is going to "health insurance"? You don't. . . you just know that somewhere in there, your health insurance is paid for, and what medical care you do pay for is affordable. (although quality? choice? don't get me started. . . ) And your childcare is heavily subsidized, and the schools are free, and the environment is being looked after, and other things are ignored. . . A give and take.