Around the world in 3 pregnancies

How do hospital births in Britain compare with what happens in the United States and France? Margaret St John, the wife of Independent on Sunday foreign correspondent John Lichfield, has had babies in Washington, London and Paris. Here she recounts her contrasting experiences

Charles: born George Washington University Hospital, Washington DC, 13 February 1990

On our first meeting, my American obstetrician assured me that he had "very steady hands". He had, he explained, perfected his surgical techniques tending wounded soldiers on helicopters during the Vietnam War. Even though he had been recommended to me, he felt the need to interview himself for my benefit. It was important that we should learn to like each other.

Indeed, many women in the US develop a social relationship with their doctor. I preferred not to. On one occasion, I sat, embarrassed, beside a friend's "gynie" at a Washington dinner party as he boasted about how many of his patients asked him out on dates. My doctor thought I was rather strange. He called me "stoic" but I think he meant distant.

At any rate, his "steady hands" proved useful. My son was born by unscheduled Caesarean section. As I recovered from the shock, and the drugs, the doctor predicted that, with developments in anaesthesia, most women would opt for Caesareans over natural deliveries within 20 years. One advantage of Caesareans was that sex could resume after three weeks, rather than six.

The hospital, a short stroll from the White House, was technically efficient at delivering and taking care of babies. The switch from natural birth to emergency Caesarean was handled calmly: even my husband was dressed up in scrubs and allowed into the operating theatre.

This was the hospital where President Reagan was treated when he was shot but it looked nothing like the gleaming medical establishments of TV soap operas. It was dilapidated and dirty. The lifts seldom worked. The nursing staff seemed obsessed with their status; they wanted to be treated as professionals, but to provide the minimum amount of personal care. Unlike my doctor, they did not want to be pals, or even to talk to the burdensome patients.

There was a price to be paid for everything. The water placed beside my bed appeared as a charge on my bill. You paid separate fees for your bed, your nurse, the baby's nurse, hospitality (ie food) and medication. The average stay for your first baby was 48 hours. If your doctor felt you needed to stay longer, that had to be cleared by your insurance company. After the Caesarean, I was allowed five days.

Our policy covered 75 per cent of the costs and the full amount over $10,000 (pounds 5,900). But there were many pre-natal items, such as scans, which were not covered. Up to the time of birth, we had to pay out $3,000, on top of the premiums. If you don't have insurance, the public hospitals will deliver your baby but pre-natal care is non-existent.

The US system collapses when you leave hospital. There are no visits from the midwife or paediatrician, and no immunisation programmes. Health insurance companies won't pay for vaccinations, which count as preventive medicine, or for regular check-ups for well babies. No wonder Hillary Clinton tried to reform the US health system.

Clare: born Chelsea and Westminster Hospital, London, 4 March 1994

IN BRITAIN, throughout my pregnancy, I hardly saw an obstetrician. I saw my GP regularly but most of the pre-natal care was handled, perfectly competently, by midwives. They were always polite but it was clear that I was just a number among many: I was frequently kept waiting. I saw a doctor at the hospital twice, to discuss whether I should have an elective Caesarean.

In Britain, unless you go private, you have no choice who delivers your baby: it just depends on who happens to be at work. In my case, I had never seen the doctor before, and I haven't seen him since.

Most natural births are handled by the midwives, not doctors. An hour before the operation, I met the two surgeons on duty. Both assured me cheerily that they had had a good night's sleep and I was their first operation that day. They took a professional interest in the scar from my American Caesarean, which they described approvingly as "neat".

My husband arrived after dropping Charles, now 4, at nursery school. We all proceeded, in jolly form, into the theatre. Spending cuts may have made the NHS impersonal but the bedside manner remains fine.

Being on the public wardwas noisy but, on the whole, a relief. In the US, there were separate nursing staffs, both equally grumpy, for mothers and babies. When I had breastfeeding problems, I did not know who to call on the intercom. In London, the midwives cared for the adult and infant patients alike and were always passing by.

Friends say I was lucky and tell me gruesome stories of overworked staff in rundown buildings keeping the system going through sheer devotion. I heard stories of one anaesthetist trying to cope with a full ward of women in labour. Some friends thought they were rushed out of hospital too soon because of bed shortages. After my second Caesarean, my daughter and I stayed for five days, the same as in the US. The midwives said I could stay for another day or two, but I preferred to go home.

The home health visits were reassuring. Overall, for all its lack of frills and choice, I thought the UK system was excellent. Taxes apart, the direct medical cost of having Clare was zero.

Grace: born Hopital Franco-Brittanique, Levallois-Perret, 21 October 1997

IN THE US, my husband was referred to as my "coach". In the UK, he was my "partner". In France, he was "papa". At the ripe old age of 36, with two children under my belt, the French system treated me like a wayward child, to be chivvied and, sometimes, indulged. I had monthly visits to the obstetrician because of my previous complications.

She was a competent woman, friendly but distant: we called each other "madame". She was also overworked, and I was often kept waiting: on one occasion, to her astonishment, I stormed out. You don't treat doctors like that in France.

In America, pre-natal care is for those who can afford it; in Britain it is functional but effective; in France it is intensive and strictly enforced. You have three government-funded ultra-sound scans, compared to one in Britain and two in America. In France, you qualify for child benefit if you go for all the required pre-natal visits and send the results of your tests to the appropriate government department.

For me, the French system fell at the final and emotionally crucial hurdle: papa was not allowed into the operating theatre. Although he had already been at two Caesarean sections, there was a strict rule: fathers were not allowed in. I sulked and when that didn't work I cried but they would not change their policy. There is something odd about putting your knees around the groin of a complete, male stranger while you are given your epidural anaesthetic. No midwife accompanied me into the theatre and while madame la chef de service chopped away I was on my own, save for the occasional "ca va?" from the anaesthetist.

On the ward, the care was excellent, if a little bossy. The carers were divided into baby's nurses and maman's nurses. I was told off for changing a nappy on the bed and not in the nursery. Another nurse scolded me for bringing baby wipes into her hospital instead of cotton wool. I was also in trouble for putting liquid soap in the baby's bath. She must be massaged with soap and rinsed in bath water.

There was one authorised way of doing things. I chafed at the inflexibility, until it came to breastfeeding. In Washington and London, I was confused by the contrary advice. In Paris, there was one rigid policy, and it worked. On went the hot mudpacks and I was ordered to stop drinking. I was given tablets to cure the engorgement. The nurses sat with me while I tried to get the breasts going. The baby was taken away between feeds, and at night, so I left hospital feeling more refreshed than in London.

There was no home-calling midwife but the system of check-ups and vaccinations is similar to the UK. I am looking forward to my 10 government-funded sessions with the physiotherapist. But even if the system treats you like a child, you have to be a savvy adult to deal with the paperwork.

PUTTING THE SYSTEM TO THE TEST

The diet, the dummy, the internal examination

IN THE US I was issued with a soother, or dummy, the day my son was born. American theory dictates that new-borns want to suck more than they need to eat. In London the midwife could not conceal her distaste for the dummy my husband smuggled into the hospital. In Paris, they made me one with the nipple of a baby bottle stuffed with gauze.

THE US is obsessed with stopping drinking during pregnancy. In Britain, the phobia is for runny cheeses, which you can't even buy in the US. In France you are told to cut down on caffeine but you are positively encouraged to take a glass or two of wine a day. And in the home of the runny cheese the Great Camembert Threat to the unborn child is, predictably, ignored.

THROUGHOUT pregnancy the great dread is the internal examination. They are very common in the US and France, but not in Britain. In the US and UK, they are accompanied by lots of paper and blankets to preserve your modesty. In France you just strip off and put your feet in stirrups.

SO WHO IS THE BEST?

EACH experience was quite different - in ways that were both predictable and surprising. But each said something about the health care systems, and the cultures, of the three countries concerned. In the US, the obstetrician wanted to be my intimate friend (but probably lived in fear that I would turn into "the plaintiff"). On the NHS in Britain I was a number in the system. In France I was a child.

In Britain, pregnancy is treated as a commonplace and natural event. If there are no complications, you are expected to burden the system as little as possible. The system keeps a steady lookout for complications, up to and after birth. In France, pregnancy is officially approved by the state, and great provisions - maybe excessive provisions - are made to ensure that all goes well. All is fine if you shut up, obey the rules and fill in the forms. In the US, the medical and insurance establishment treats pregnancy as an illness. If you are rich or insured, you can afford to be ill. Once you give birth, you are cured, and on your own.

So which system is best? Taking account of pre-natal care and post-natal care, I have to say that Britain and France would come first equal. Britain lost points for impersonality; France for bossiness and bureaucracy. The US, which claims to have the best medical care in the world (it is certainly the most expensive) lagged far behind both.