Sunday, September 21, 2008

Maternity care in France

I've been corresponding with an American woman who teaches at a midwifery college in France. I asked her about what maternity care is like in France. I think many of us Americans will be surprised at what really goes on there. We sometimes have this rosy vision of midwives in European countries, but the reality can be quite different than the picture we've had painted for us. She traveled to England for a HBAC after no midwives in France would accept her, as she discusses later on in her post. She has several American degrees, then went back and got an MA and PhD in France. She is currently a professor of psychology and does outside teaching in Paris, Nancy, and in Toulouse at the midwifery school, as well as occasional private practice and teaching jobs at international schools. Below are excerpts from our email conversations, reposted with her permission.

Although France has a great national health system, there is a lot that isn't said about it, in my opinion, that isn't great. Ironicaly, NPR did a piece on it this summer. I responded to them as follows:
As an expat living in France for the last 16 years, I always cringe when I hear NPR wax lyrical on the French health system. I will grant NPR (and the rest of the inhabitants of the US) that it is a decent system, its most perfect quality being that the extremely poor and disadvantaged can have access to care. But this doesn't tell the whole story, as your report failed to do as well. While providing comprehensive healthcare is an excellent goal, it isnt the only goal. Although the WHO does recognize that the French system is one of the best, its approach to maternity care is not well-regarded by the WHO. For example, France is a leader in performing excessive numbers of questionable interventions in birth (episiotomies, epidurals, cesareans, etc). I do research in the domain of maternity and breastfeeding, and not only does France have one of the lowest rates of breastfeeding in Europe (how can a good health system allow this?), it doesn't provide any constant or long-term support for mothers after the birth, like the German system does. Your report mentioned the baby nurses--their visits are limited to one visit post-partum! A woman must then motivate herself to go to well-baby clinics, but again, the focus is entirely on the baby, not the mother. So while France does provide excellent care for babies and pregnant mothers, I would submit that aside from the fact that your report glossed over a large number of unpleasant realities about the French system (too many to ennumerate in this comment), it isn't truly focused providing care for new mothers.
France is a VERY medicalized system. Teaching at the midwifery school I see it, and these women are on the fence about it. Some like the medicalizaton; some are horrified. But you have to take a step back and realize that people who are training to be midwives in France STARTED as medical students. After year 1, they do a big test and the best get to go onto medical school, the next best get to be dentists, the next best get to be physical therapists, and the next best can be midwives. In my opinion, a weird way to get people into midwifery to start with.

Toulouse is particularly medically oriented, and so the midwives trained here are little medical robots for the most part. I did direct the thesis of one woman last year who had done her internships in Lyon with an independent midwife (IM) and "discovered" what birth could be. She realized what a rarity she was.

The problem with IMs in France is that they no loner have insurance coverage for home births, not since 2001. There are a few who treat the quasi-legal area and go ahead and do home births ("Too late to transfer"...) but they are rare. And even those who do really, really pick and choose their clients. For example, with one previous c/s I was not an acceptable candidate for any IM here. Which is why I went to England for my hbac attempt. I found VERY supportive IMs there who, ironically, do not have insurance either but instead of letting the system wear them down, they have clients sign off when they engage an IM. Very different reaction from the French IMs.
Really, there are a few supportive midwives here, but they seem to have their hands tied. They won't do home births. They might do really good birth prep classes (which is part of the prenatal care; the classes can range from awesome to absurd depending who gives them). But that is it. And in the hospital or clinic, it isn't obvious who is a midwife and who is a nurse or baby nurse (puericultrice) or whatever.

And don't get me started on breastfeeding. Extraordinarily low rates. Really poor support. Rampant erroneous beliefs about
breastfeeding (the biggest one is "breastfeeding will make my baby too dependent on me"... sigh... What is a baby if it isn't dependent??? And why would we want them to be anything but dependent at the beginning???) And extended breastfeeding, snort, we just won't go there, lol!!! (My younger daughter is nearly 3 and still has "nursies." My older daughter had them until about 3 as well. This current one may go longer, but reaction can be quite shocked. I ignore it for the most part.)

Maternity care here is like anywhere else. On one hand, it is a "normal" event but this has transformed it into a factory-style approach (go to hospital, get heplock, get induced/augmented/whatever, get epidural, if you don't progress, get a c/s). If a woman has a traumatic experience it is written off and she can't talk about it ("The most important thing is a healthy baby...") I also do PTSD research in birth here. And to think Odent came from France! But of course, it is obvious why he lives in England now, which is having its own woes with regards to birth and independent midwifery. But I think they will muddle through still providing women with what they want and need for birth. (Did you know that the UK is the *only* country to my knowledge that guarantees a woman the right to birth where she feels most comfortable, despite what medical opinion might recommend: be it home, hospital, a tree, wherever???)

There is such a dopey perception about France and midwifery, and then the fact that Odent came from here makes it an obligatorily "great" place to birth. But then he left, and the "real"countries to birth in are the Netherlands and England, in my opinion.


  1. Shucks, and to think I was all starry-eyed for France when I saw how glowingly Michael Moore portrayed it in Sicko. Bleh. They don't sound much different from us. :(

  2. I think it would be interesting to have an insider story like this one from the Netherlands. Coming from a "medicalised" birth culture in Russia I was pleasantly surprised to discover how the Dutch system works...

  3. Don't get me wrong--I have nothing but glowing reports about medical are in France, in general.It's just that the maternity care system isn't this rosy, happy, crunchy thing that sometimes we imagine it to be. They use midwives for most healthy women, but they are more like obstetrical technicians, and in France they don't enter the profession with the same ideals or motivations in the US or UK would, for example.

    We've had many occasions to use it during our summers working there (not usually for us, but for our students) and have been blown away by the quality of care, accessibility to almost anything you need with little to no waiting, and the price. Even when we, or our students, were paying in full out of pocket, the cost was about 1/10 of what it would be in the U.S. For example, one student broke her finger. Her entire ER visit--including the x-ray, physician's exam, medications, and cast--was just a little over $100 total. And if you are French, you get most or all of that reimbursed.

  4. Well, socialized medicine obviously does not automatically mean a flawless, rational, and always humane system. I wish I could say that conversely, 'for profit' medicine can be perfect, rational, and humane, but no example comes to mind! LOL. Health care is just one immensely complex set of issues, eh?

    This confirms my vague impression that all things maternity are not all right in France. Did you notice we never hear praises about its maternity care system as a whole, unlike the Netherlands or Scandinavia or the UK? No one ever claimed that Odent's ideas became widely practiced in his home country... there's a few red flags. And I heard about their high cesarean rate from somewhere too.

    I am surprised by the low bf rates because they do have much more and better maternal leave than we. I guess moms still need a lot of education prenatally, and lactation support post. Or maybe overmedicalized births make for rough breastfeeding everywhere. The cultural stuff is just rationalizations, after the fact. I wouldn't be so worried about what people say about breastfeeding, if the majority of women and babies have positive births that respect the physiology of the mother-baby dyad. Start by making sure that all moms and babies are healthy and alert enough to enter into that first breastfeeding experience. They might still wean earlier than advertised by AP, but even a few months make a world of a difference!

  5. The 'right' of UK women to birth wherever they choose often doesn't happen in practice. In my county, for example, the midwife-led birthing centres have been shut down for lack of funding. They also discourage home births, quite strongly, and in some areas, inform women that home births will not be available to them (a knowledgeable woman can fight this, but most don't). This is because a home birth requires the presence of two experienced midwives - one for the mother, one for the baby - whereas at the hospital, health trusts can get away with lamentable understaffing. During my own labour last year, I was frequently left unattended - at one point, my poor husband had to mop vomit off me while I was in transition and then go out to try and find a midwife who was free to help me. During the course of my labour, we could hear midwives audibly panicking in the corridor at one point. I gather that my experience of an understaffed maternity unit was far from unusual.

    So, to conclude, you're presented - as I was - with the 'right' to choose between THIS hospital and THAT hospital. Terrific.

  6. I lived in France for 18 months and with all the breasts I saw on billboards and just around, I am surprised that BF isn't more accepted and supported. Because breasts aren't taboo, so I assumed breastfeeding wasn't either. What a shame that it isn't more supported.

  7. Breasts aren't taboo if they're being used in a sexual way, of course. Only if they're being used to nurture a baby. Pfft. And to think Odent is French! Life is full of ironies... I'm sorry that maternity care in France is so bad, but not at all surprised.

  8. Hi Rixa,
    I'm a Canadian, an aspiring midwife, and have been following your blog. I also have lived on and off in France for the past 10 years, and I must say that your recent post validates what I have been *trying* to tell people about the state of care offered to the child-bearing and -rearing women of France. I can confirm - it isn't the peachy portrait most paint it ! Not only is birth heavily medicalized, but as is every single aspect of health care. There is a 'Pharmacie' on every street corner, doctors are treated as gods there, raised high up on pedestals, and anitbiotoics are still seen as the absolute cure for even the puniest of colds... but I digress. While I didn't give birth in France (thank goodness, no ! I birthed my girls at home, both times, in Canada with two Registered Midwives in attendance), I simply cannot stop in without lamenting the state of breastfeeding duration/success in that blasted country (said of course with tongue in cheek, eh - France is a fantastic country for many other reasons, and produces some of the most beautiful men on the planet - I know first-hand because I married one, and he makes gorgeous babies ; ). So YES, breasts are everywhere in France, and nude beaches reign, but it is *because* they are so highly sexualised there that the baby does not stay for long at his mother's breast - as those breasts are for the MAN's pleasure, you see. :-/ That, coupled with what was mentioned about the intense desire of the French to "make their babies autonomous" --and this, from BIRTH ONWARDS-- and there you have it : dismal, truly catastrophic rates of breastfeeing in that country. And lest not we forget France's beloved cheri, either : NESTLé... and formula literally takes the cake. My own father-in-law encourgaed me to be feeding my 6-wk old infant hard-boiled eggs ! And my husband's step-mother told insidious lies about us behind our back, that we were "depriving our 8-mth-old daughter of food, yet stacking our own plates full...". Unheard of there, that an 8-mth-old still be exclusively breastfeeding, and showing no interest in solids. So anyway, no, the French still have a long way to go in terms of the health of their mums and babes - indeed, I concur.

  9. wow im so surprised and saddend by this news. i have spent quite a bit of time in france and have romanticized it since ive been back. i always thought that there would be like minded women over there, and an abundance of jobs in the midwifery model of care.i have heard that 80% of births outside of the us occur at home and it was wrong for me to assume that france fell into that category! thanks for the information!

  10. Wow. I had my baby in Germany, and it was a positive experience. I am glad we decided to go to Germany instead of staying in France after reading this.

  11. I stumbled across this blog while doing a research project for school and I must say that this is an interesting read. Everything I've found has said that birthing in France is a breeze, wallet-wise, and that it is sooo much easier than in the United States. Your blog is definitely very eye-opening, thank you for the read.

    To Judit, please read The Healing of America by T.R. Reid, I think you would find it interesting.

  12. I am from the UK. Having just given birth in france - 7 weeks ago - both my antenatal and postnatal care have been excellent. My baby was 5 weeks early, (we spent over two weeks in hospital) and both of us received an amazing level of care. My baby has not taken that easily to breastfeeding, but at every stage the midwives have given me strong encouragement- in fact practically forced me - to carry on. At no point have they suggested that giving up breastfeeding is an option. I have had twice-weekly breast feeding follow up sessions at the hospital, in addition to weekly visits from the health visitor. They have done everything they can to encourage me to keep breastfeeding and it is paying off.

  13. Birth in Europe really isn't as great as it's cracked up to be in the US. I've been living in Bosnia for the past two years and when I was pregnant, I was looking for a place to birth. The system here in Bosnia is pretty bad. Even though there is universal health care and midwives handle most births, hospitals are understaffed, Drs are in charge and some pretty antiquated practices are enforced. It seems that much of the Balkans are the same. I have several friends in Paris, so I thought I could perhaps birth there, but the fact that I couldn't even find a birth centre is a pretty clear message that natural birth isn't on the cards. I also contacted a few independent midwives and none responded to me. I', also beginning to agree that it's really just the UK and the Netherlands that have good maternity systems in Europe. Perhaps some Scandinavian countries too?

  14. I am a single mum of 2 and lived in.france 11 years so both were born here and. the care i recieved was amazing and fantastic and i would like to become a midwife myself now but not sure if i can in france

  15. Would love to be a midwife after havinng my 2 children in france and lived here 11 years fantastic care annd after care

  16. Wow, this is a pretty extreme article. And so are the comments.
    There is many things that are pretty exaggerated, I don't want to enter a debate, but there is one thing I would like to precise because it is inaccurate (which is troubling because it is a very basic thing which is not a good sign for the rest of the article).
    --> In France, at the end of the first common year in medicine, the students have a big test that has a numerus clausus. Only the best students can go further. There is a number that say how many will be admitted and how many students can go in which sector. For instance, in a university, 140 seats will be open for doctors, 70 for pharmacy, 40 for dentistry and 18 for midwifery. The best students are the first to choose (which doesn't seem that stupid to me), they can go anywhere, and so on until the numerus clausus of some disciplines are reached. Some students at the beginning of the list choose to be midwives, because it is their passion, or to go in pharmacy. It is true that proportionally, the pool of people wishing to become doctors is bigger that the other sections and that a student at the end of the list who wants to be a doctor will not have that choice anymore. But he has an alternative: - he can go in whatever is left if he also likes it, midwifery for example, or - he can go back and do the first year again, knowing that he was good enough to be included in the list this year and that he will spend another year working on that same material (and will have a better spot in the list). Quite a bit of students actually do that.
    Anyway, just to say, let's not speak to fast, because sometimes we think we understand things but we make erroneous deductions. Same thing: generalities are not good. It is not because it is one way in such town or hospital that it will be the same thing in another one.
    For instance, if you say Toulouse is super medical, well Strasbourg is really natural for what I've seen and their midwives are quite experts in breastfeeding.

  17. Does anyone know a midwife still active or retired in France who would accept to help me give birth naturally to my twins?

    Thank you!!!


  18. Hello,

    Could you please tell me who this American woman is, so I could contact her?
    I have a little less than 2 months now before the birth of my twins, and I have not found anymore who could help me to give birth naturally.
    All doctor want to plan a C/S, or induce them early etc. I really want to avoid all of that, and I know it is possible. These are my first children, so I still feel the need for someone near me, in addition to my husband who is really dedicated and helpful. We have been studying with the Bradley method and we are both convinced these babies do not need all this French medical system.
    Thank you in advance for your help.


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