Achtung Baby

by Sara Zaske

  The study pointed to inequality as a main issue: when looking at subsets of the data, the authors noted that “infants born to white, college-educated, married women in the United States have mortality rates that are essentially indistinguishable from a similar advantaged demographic in Austria and Finland.” I fit into that demographic, so perhaps my baby’s odds at survival were about even whether in the United States or in Germany. Yet for the millions of women who don’t fit perfectly into that privileged realm, they’d be better off in Germany, which does a better job at achieving equality than the United States.

  I’ve often heard the argument that European countries have better health outcomes because their populations are more uniform with fewer people of different races and backgrounds, but that’s not entirely true of Germany. More than 20 percent of the population consists of people with a migrant background (this term includes foreigners, as well as naturalized German citizens and citizens whose parents were migrants). One of the largest minorities are people with a Turkish background (about 2.7 million according to 2011 census figures).

  Pregnant Turkish women in Berlin used to have poorer perinatal results than their native German peers, but a study by Bielefeld University researchers found that the gap has narrowed considerably over time. From 2003 to 2007, babies born to mothers of Turkish origin had roughly equal outcomes to those born to mothers of German origin in terms of stillbirths, preterm births, and congenital malformations. The study’s authors cited two most likely reasons for the improved outcomes: that Turkish women had become more accustomed to German culture and its health system, and, on the other side, that health-care providers had adapted better to serving the diverse communities in Berlin. The government and other agencies also launched a number of initiatives during this period to improve health and access to care. Of course, there are still problems with inequity in Germany. The divide is just a lot greater in America.

  In Germany, all the services for prenatal, birth, and postnatal care were available to nearly every woman without regard to race, economic status, education level, or even citizenship. I, for one, took advantage of almost all of it. I went to every prenatal visit with Anjet. I listened to the baby’s heartbeat. I heeded advice to watch what I ate and drank. I stood on scales. I had an ultrasound. I peed in a lot of cups that were tested for signs of protein or too much sugar. It all felt similar to what I had done in America with my earliest pregnancy, except for one critical difference: I had control over my own health records.

  One of the first things Anjet did was to give me a mutterpass (“mother pass”), a little white notebook that she and other health-care professionals marked up with my test results and handed back to me. I was responsible for bringing that pass with me to any pregnancy-related appointment. I also had all my test results at my fingertips whenever I wanted them. In the United States, most health-care professionals do not let patient records leave the doctor’s office. You have to formally request them to be released to anyone, even to yourself. I did this when we left the States since I didn’t know who my doctor would be in Germany. To get my own information, I had to fill out a legal form, pay a copying fee, and wait several days before I could pick up my file.

  In America, I sometimes felt like my own medical information was being deliberately kept from me. For instance, for my first ultrasound in the United States, a technician did all the measurements of the soon-to-be Sophia but was not allowed to tell us anything other than the sex of the baby. Zac and I left that appointment with the eerie feeling that something might be wrong (there wasn’t). Different states and individual medical facilities have varying rules on what an ultrasound technician can and cannot say—ours apparently erred on the side of extreme caution refusing to say anything even though she hadn’t noticed any abnormalities. So we had to wait two weeks while a doctor whom we had never met looked over the technician’s measurements, then forwarded her report on to our midwife, who then delivered the information to us.

  In Germany, for the ultrasound, I made an appointment at a doctor’s office, brought my mutterpass—and the whole family. The doctor, not a technician, did the ultrasound right there in his office, in 3-D no less. As he measured each feature of our tiny fetus, the doctor told us immediately that the baby was in the normal range. Sophia sat next to us, alternately bored and fascinated—until the doctor announced the fact that the baby was a boy—then she almost cried. She’d wanted a sister. We parents, on the other hand, left the doctor’s office delighted that we were having a healthy baby boy. We had the evidence, the doctor’s full report, in our own hands.

  A Berlin Birth

  I grew bigger and slower. It took an extra-long time to get Sophia to her kita in Treptow that summer. She was still enjoying it, for the most part, even if she couldn’t understand most of what anyone said to her. The teachers assured us that she would pick up the language just through immersion, mainly by playing with other kids. And she did pick up some things. She learned a few key German words right off: nein and meine (no and mine), but that was not always enough to get along with children who spoke only German. At three and a half, she was just starting to play with other kids, instead of only side by side as many toddlers do, and she soon gravitated toward the two girls in her class who understood some English. It was funny to watch them play. Sophia would talk to them in English, and the girls, who could understand English but didn’t often speak it, would respond in German. Without even intending to, they were slowly teaching Sophia a new language.

  Then, early one fall morning in Berlin, a full week before my due date, I knew I couldn’t take Sophia to kita at all. I felt a deep pain low in my stomach. I looked at the clock: five a.m. Zac had a big meeting that afternoon. He’d told me the night before, half joking, that I could have the baby any day but that day. Still, there was plenty of time. After all, my first child had taken thirty-two hours to be born.

  “Oh!” Another pain. I nudged Zac. “What time did you say your meeting was?”

  He sat up. “What? Why? Is the baby coming?”

  “Maybe,” I said. “But you can probably still make your meeting.”

  Zac didn’t take any chances. He woke my mother, who was staying with us, and who, for some reason, started sweeping the floor. I called Anjet. She asked how often the contractions were coming. I had another contraction while I was talking to her. She said she’d be right over. Sophia got up and started running around the apartment.

  While my mother herded Sophia into the kitchen for breakfast, I got into the bathtub and tried to relax. I hoped this wouldn’t end again with a visit to the krankenhaus. At least I’d already filled out my paperwork. No matter what happened, everything would be covered by my German insurance. In the United States, I’d paid more than $3,000 out of my own pocket when Sophia was born. Despite being in a foreign country, I had a lot less to worry about. I added some more warm water to the bath.

  Anjet showed up and timed my contractions. “They are getting slower, yes? Maybe you are too relaxed. Let’s get you out of the bath.”

  Three hours later, Ozzie was born onto a flowered bed sheet spread on the floor of our Berlin apartment. It wasn’t painless, and I’ll never say it was easy—but compared to the thirty-two-hour drama of Sophia’s birth, it sure was fast. I would like to attribute the speed to that famous German efficiency, but it was probably because second births tend to be easier. I do credit the German culture around birth and its health system with giving me more control and support over the whole birth process than my home country did.

  That’s not to say Germany does everything around birth perfectly. I’ve heard plenty of negative stories from other mothers. One friend had a birth that ended with an unwanted suction extraction she felt pressured into. Another who went to a busy hospital in Berlin was told by a stressed-out attending midwife that she wasn’t the only woman in the hospital giving birth that day. That birth ended in a kaiserschnitt, “an emperor’s cut,” which is what a cesarean is called in Germa
ny. In fact, it seemed that nearly every pregnant woman I knew who went to the hospital for a birth ended up with a kaiserschnitt.

  Germany has a cesarean rate that is nearly as high as the United States, where one in three births end with the surgery. For more than twenty years, the international community has placed the “ideal rates” of cesareans at between 10 and 15 percent, according to the World Health Organization, which cautions that these major surgeries should only be done in emergencies because of the short- and long-term health risks for the mother and child. While most of the mothers I talked to felt they had no other choice than to opt for surgery, a kaiserschnitt rate that high indicates that German as well as American doctors might be in an unnecessary hurry to get out the surgical tools.

  Many of the Berlin hospitals are set up for natural birth, and theoretically, having midwives in charge should lessen the need for surgery, since they are trained in allowing the birth process to progress normally, as opposed to doctors who are trained in medical interventions. But unfortunately, many German midwives are leaving the profession following a recent dramatic hike in insurance costs.

  Lorna Ather, who works as a “pregnancy concierge” helping mothers-to-be arrange everything they need to prepare to have a baby in Berlin, told me it’s getting harder to find midwives. Many no longer handle the delivery part of the process, instead offering only before and after care. “Now women need to find a midwife as soon as they find out they are pregnant. They’re really booked out,” Lorna said.

  I was fortunate enough to have two midwives to help me. Anjet handled my prenatal care and the birth, and her colleague Kristine came over to my house for the postnatal care. This is not just for home births: all women receive follow-up home visits from a midwife. And if the mothers don’t already have someone at home to help with cooking, cleaning, or child care for siblings, Germany’s public insurance will cover the cost of hiring short-term help for that, too.

  Good after care is more than a matter of providing some help. Remember that NBER study that found such inequality around infant mortality in America? One of their key recommendations was to increase after-care home visits to new mothers, which are still relatively rare in the United States. The study found that having these visits can result in fewer infant deaths.

  My visits with Kristine were great. She not only checked the development of the baby and my recovery but answered my questions and gave me information on infant care in a way that was much more helpful than the condescending lectures I’d received when I had my first child. For instance, instead of telling me not to sleep with the baby in the same bed, as the American nurses did, Kristine gave me all the pros and the cons of co-sleeping—and then she left it for me to decide what to do. It was this way with almost every topic. Her primary purpose was to give me information, not to dictate my behavior.

  Our new baby grew strong and healthy for the most part—though he did catch a cold from his big sister a few weeks after being born. We named him Ozzie. Oz means “strength” in some languages, but what we didn’t realize at the time was that Ozzie also sounded close to the German slang word Ossi—a somewhat derogatory term for a person from East Germany. But he essentially was an “Eastie,” at least by birth.

  Ozzie lived up to his strong name and was holding his head up after ten days, a fact that impressed our pediatrician. By three months, he had managed to learn how to move by rolling around and scooting on his belly, which made my rückbildung exercise course a bit difficult. I was pleased to learn I could take this free course, which was specifically designed to help new mothers get back into shape. It was like a gentle Pilates or yoga class that spent extra time on the muscles that had been stretched by pregnancy.

  I thought the idea of such a course was fantastic. I could only find space in an all-German class so I learned many new words. For each class, all the mothers showed up with their babies. Some of the exercises even incorporated the child, but the instructor told us that we could also stop to tend to our baby’s needs.

  So at any given time, some of us were nursing, rocking, or changing our babies. Most often, I had to stop to reposition Ozzie because he would roll halfway across the room if I wasn’t careful. Other babies I noticed with some envy were calmer. Some slept through the entire class. I was rarely so lucky because, as I was discovering, one thing Ozzie did not like to do was sleep.

  3

  Attachment Problems

  When I took Ozzie in for his twelve-month checkup, the pediatrician took one look at me and said, “You need help.”

  I think I agreed with him. I don’t remember, because I was in a fog of fatigue that had lasted many months. He took out his pad and wrote me a prescription for a sleep consultant, and that’s how I met Cathrin. My prescribed sleep specialist started to visit our apartment on a regular basis. She asked a lot of questions about Ozzie’s routines and behavior and spent some time observing as I played with my son. She said she wanted to see what happened when I told Ozzie no.

  “Oh, I know what happens,” I told her. “He cries and throws himself on the floor.” For the most part, my son had a sweet disposition (still does), but as an infant, he had trouble dealing with any kind of disappointment or frustration. During Cathrin’s first visit with us, he demonstrated his capacity for drama when he grabbed for my glass of water, and I moved it out of his reach. He cried and flopped facedown on the carpet in an almost cartoon version of a tantrum.

  Cathrin raised her eyebrows. She made a note. “The first thing we will work on is getting him to accept no from you during the day, so that you can tell him no at night.”

  I nodded, but I was confused. I told him no all the time! “No, don’t stick your fingers in the electrical sockets! No, you can’t eat that piece of jewelry, that plastic toy, that moldy crumb of something you found from heaven knows where.” Ozzie didn’t pitch a fit every time I said no, but sometimes he did. I couldn’t always tell when it would happen, although he did have a knack for doing it at the most inconvenient times, like when we had guests over or in the middle of the grocery store.

  Cathrin gave me specific instructions on how to say no. I should say it in a calm voice, never angry, and if he had a tantrum, I should not immediately comfort him, but wait and observe. Only when he was calm again, without getting what he’d wanted, could I then comfort him. I followed her advice, and after a few weeks, his fits of anger grew less and less. It was working. I reported this success to Cathrin, and she said it was time to work on the bigger problem—sleeping through the night. Even with getting him to accept no during the day, my infant son still ruled the night, and I had a sinking feeling that I knew why.

  Like many American mothers, I believed in “attachment parenting,” as promoted by the books of Dr. William and Martha Sears, which meant I strove to create a bond with my infants through physical closeness and being responsive to their needs. So, I carried my babies as much as possible; I breast-fed, mostly on demand, and attended to their cries day and night.

  With my daughter, it had worked well enough, but I hadn’t followed everything the Seares advised. Since I had to return to work after three months, I still breast-fed, but the “on-demand” part was impractical, and I weaned Sophia at night at eight months. For a few bad nights, Sophia cried a lot even when Zac held her and rocked her. Soon, however, she accepted that milk wasn’t available at night and learned to self-soothe with a pacifier. After that, she woke up only two or three times at night.

  Ozzie was a different story. He was not having any of this night weaning stuff. He had no interest in a pacifier or his father’s lullabies—or mine for that matter. He would go back to sleep after having one thing, and one thing only: breast milk and not in a bottle—it had to come from the source. During the day, he didn’t care so much about nursing. Ozzie was eating solid food early and enthusiastically, but at night, nursing was the only thing guaranteed to make him sleep. Still, he was up on average eight or nine times a night, every night. I know, because Cathr
in had me keep a night journal with how many times and how long I got up to help him go back to sleep.

  I have many excuses for how this extreme situation came about: he got sick a lot that first year; I couldn’t let him cry too long in an apartment; he was keeping Sophia from sleeping well; and then after hours and hours of rocking and singing, for the love of everything good in the world, I just wanted him to go to sleep!

  Looking back, I can see that a large part of the problem was my over-devotion to attachment parenting. After reading some of the Seares’ books, I was convinced that I would damage my child if I didn’t follow their theories of constant closeness and attention to the baby’s needs, and I’m not the only one who thought this way. I know American mothers who have given themselves back problems from wearing their babies in slings; others who wouldn’t hear of having a babysitter for even a few hours, not even a relative, for fear the separation would somehow hurt their attachment with their babies. There are probably even more mothers who have been so focused on attending to their children’s nighttime cries that they go months, even years, without a decent night of sleep.

  To be fair, plenty of parents have gone to the other extreme with the so-called cry-it-out method, advocated by parenting “experts” like Richard Ferber. This method calls for instituting strict schedules for feeding and sleeping, and a willingness to let the child cry for long periods of time to train the baby to those schedules. Eventually the baby is supposed to get used to the schedule and fall asleep easily. It may work for some babies, but if you’ve ever had the experience of listening to a “Ferber” baby who is resistant to the method, it has got to be one of the most painful things in the world to hear.