By Emily Berns
"Please make underneath free," the nurse said, pointing to a semiprivate nook in the spotless, modern gynecology office. I looked around, locating a mirror and a hook for my clothes, but no hospital gowns. After a few moments of confusion, I realized this was no oversight on the nurse's part: There were no hospital gowns. Gritting my teeth, I emerged bottomless from the dressing area for my examination, feeling exposed and slightly ridiculous. Dimly I recognized that, to paraphrase Dorothy in The Wizard of Oz, I was not in Kansas anymore.
It was the end of my very first week as a resident of Munich, home of my German husband, Uwe. The conclusion of that examination--a confirmed pregnancy--left me stunned. I had just started to meet Uwe's friends; I was learning where the food stores were and familiarizing myself with the comparatively limited product choice and with German coins and bills; I'd even lined up a freelance job. But my pregnancy was to derail any additional plans to adapt gradually to my new surroundings. Instead of taking lessons in the German language, I would be thrust into German society through a crash course in German medicine. Uwe pointed out that there is rarely a convenient time for a baby to arrive, and his philosophical attitude helped me adjust to my condition. If he, who a few months before had been a carefree, sociable bachelor, could accept this sudden new responsibility without a murmur, I could but follow his lead.
Meanwhile, without half trying, I picked up a specialized vocabulary--one heavily weighted with prenatal terms. Schwangerschaft. Gebärmutter. Fruchtwasserprobe. (Pregnancy. Uterus. Amniocentesis.) The fact of my pregnancy soon acquainted me with Germany's vaunted system of medical insurance (which provides, for a price, generous coverage for all) and its successful variation on socialized medicine. I learned that I must choose a hospital in which to undergo certain required pregnancy tests and eventually give birth. With some trepidation I discovered that the doctor who delivered my baby would be whoever was on duty at the time.
I chose a huge, turn-of-the-century hospital in our neighborhood that had been recommended by several young mothers Uwe knew. Though its wide corridors, 20-foot ceilings, crucifixes, and occasional shrouded religious sculptures were old-fashioned and somewhat intimidating, I came to have confidence in the skill and efficiency of the doctors, and their anonymity ceased to bother me. As my gynecologist and the hospital doctors carefully noted the progress of my pregnancy in my Mutterpass, or "mother's passport," I realized that I was part of a well-run, well-thought-out system. Yet I was puzzled when, after several mysterious but apparently benign bleeding episodes, the doctors saw no need to explain what could have caused them. "Wouldn't you want an explanation if you were me?" I asked Uwe. "No," he replied, "as long as I knew nothing serious was wrong." (Years later, an ear-nose-throat specialist who operated on both my sons responded to a query of mine in this fashion: "If I were to tell you how I operate, you might as well become a surgeon yourself.")
German patients' more resigned attitude, less insistent on what Americans would see as their right to know, is a further indication of something I had sensed during that first visit with the gynecologist: the direct connection between a country's culture and its approach to medicine. In what other country but this home of superb chocolate would a pediatrician describe it as Nature's healthy relaxant? And where else but in Germany would beer be considered not an alcoholic beverage but food?
As any trip to a public swimming pool in Germany demonstrates, Germans have an accepting, no-nonsense attitude toward the human body and a lack of understanding of what Americans would call modesty. Topless women of all ages and shapes, often with unshaven legs and armpits, men in the briefest of swimming trunks, and open-air changing are the norm.
Eventually I would learn that I was not the only foreign woman who gritted her teeth in German gynecologists' offices. A few months after I arrived in Munich, I met a British-educated but partially German-raised Indian woman at a birth-preparation class. Sonu became my class translator and my friend, and her fluency in not only the German language but the ways of German society was a frequent help to me. She sympathized with my discomfort in the examination room, telling me of her gynecologist's disdain when she asked to be draped for her examination because her two-year-old was present. "You Asians should get over your prudishness," he said. Such self-righteous contempt for other cultures' mores is, of course, unattractive. But the Germans' lack of prudery, their natural approach to all things natural, also has a positive effect on the way their doctors practice medicine.
Like many Americans, I suspect, I had always assumed that the way medicine is practiced in the US is the way it ought to be practiced. It had never occurred to me that the way we Americans are--demanding of immediate results and certain that any ailment can be cured--might have an effect on our doctors' approach to their profession. But I was able to be more objective about German medicine, whose differences from the American version are subtle but telling. German doctors, for example, are far slower to prescribe antibiotics, painkillers, and other strong drugs than their American counterparts, and even those who don't consider themselves strict homeopaths make frequent use of medications derived solely from plants and other organic products. (They use antibiotics sparingly, especially with children, because of the body's tendency to develop immunity to such drugs over time.) Though they admire American medicine for its technological advances, sending their more ambitious colleagues to the States for on-the-job training, they still choose to take a less invasive approach.
After my first child, Charlie, was born, I learned that the most frequently prescribed German solution to lingering bronchial problems was "plenty of fresh air," regardless of the weather, with a plant-based syrup thrown in as a mild corrective. And before prescribing a drug, many German doctors will suggest an alternative. For women with incipient breast infections, they recommend massaging the breasts while nursing; to bring down a baby's fever, they tell parents to wrap the child's legs in a towel enclosing a cold, wet cloth. (In my experience, both these prescriptions work.)
This more natural approach occasionally demands stoicism on the part of the patient. Local anaesthetics and painkillers are used only when absolutely necessary. German methods also require patience on the part of the sick person or the parents, patience I have not always been able to muster. "Damn it!" my American upbringing sometimes has cried out. "Can't we get rid of it already?" But time and again I have been forced to admit that while milder remedies usually take longer to cure an illness, the end result has been the same as that achieved by a more aggressive treatment--and without tampering with the body's natural defense system. The fact that German doctors have less fear of being sued for malpractice may have something to do with this more relaxed approach. (The law allows patients to sue, but few do--reflecting, perhaps, the greater deference Germans pay to authority.) In addition, of course, their less invasive remedies help keep costs down.
After living in Germany for some time, I arrived at what I believe is a more significant explanation. This is a nation with a centuries-old passion for the Great Outdoors, a nation of bike riders (and bike paths), of nature walkers and mountain climbers of all ages, for whom exercise is a pleasure, not a grim duty (one reason why obesity is a rarity, despite the heavy German diet). Unlike Americans, Germans have never quite forgotten medicine's sources in the natural world. This tendency shows itself in other areas of German life as well. Real candles still grace some family Christmas trees, and well-crafted wooden toys stock children's rooms. Cotton next to the skin is a near-religion (fireproof polyester baby pajamas are regarded with incomprehension and horror), and air-conditioning is looked upon as both wasteful and unhealthy. This is a land of recyclables and returnables, where throwaway plastic bottles never quite took over and people bring their own, environmentally sound, baskets or cloth bags with them when they shop (plastic bags are available, but one must pay for them). Napkins, either paper or cloth, rarely are used by younger Germans, who regard the former as an unnecessary waste of good trees and the latter, because they have to be washed, as an inessential consumer of energy. (I persist in setting the table with paper napkins, but I usually am the only person to use one.)
German appliances are, in fact, distinguished by their energy-saving technology. Yet many Germans choose not to own a clothes dryer, because even the most advanced dryers are energy guzzlers, and as such are not only expensive to run but ecologically unkosher. Encouraged in such "green" tendencies by the high cost of energy, Germans of all ages and political stripes are consistent in their conservationism. In the US, power mowers roar where hand mowers buzz in Germany, fans and air-conditioners hum where Germans would close curtains and head for the shade. In the US, lights are left on in unused rooms and showers can last more than 15 minutes--both serious faux-pas in Germany.
This is a country where even the most ordinary drugstore or pharmacy is stocked with herbal teas to treat a wide variety of complaints, from colds to digestive or circulatory problems to kidney ailments. As I discovered in the hospital after Charlie's birth, newborns in Germany are fed a particularly mild herbal tea to settle their stomachs and quench their thirst. And, as I learned several years later, kindergartens often serve their three- to five-year-old pupils a sugarless tea rather than juice. (Amazingly, most of the children seem to like it.)
In Germany, the ancient practice of midwifery is still a respected and respectable profession, not the fringe alternative or vogue it has become in the States. The hospital where I delivered my children has a midwife school. During labor, the only person constantly attending me (besides Uwe) was a sweet, helpful midwife student of about 20. The midwife herself checked in from time to time, and the doctor only appeared for the delivery itself, in which she was assisted by the other women. Despite its old-fashioned appearance, the hospital featured all the latest medical equipment and could accommodate many current birthing fads--a gymnastic ball to sit on during labor, a birthing stool to use during delivery. I avoided the latter, but when it came time to push the baby out, there were no rings for me to grasp or stirrups to place my feet in: I was simply instructed to hook my elbows around my knees and push as hard as I could. Crude, but effective--and fully in keeping with a society that has not yet forgotten the body's power both to heal and to do for itself.
The German focus on what is good for the patient does not necessarily include what it most comfortable. My hospital stays after the births of both my sons showed me in specific detail how this attitude plays itself out. Hours after giving birth the first time around, I was roused from a much-needed sleep at 6:30 a.m. by a woman I came to call the "wake-up nurse." "Guten Morgen," she announced in loud, insistent tones to my four drowsy roommates (several of whom had been awakened twice in the night to nurse their babies) and me, while turning on the harsh overhead light and flinging open the windows to let in the fresh February air.
The wake-up nurse was the first in a series of official visitors who would keep us new mothers from relaxing during the generous hospital recovery periods allowed by German medical insurance (on average, five days after normal births and a week to ten days after cesareans). She was followed by the mineral-water lady, who placed a daily bottle on each mother's bedside stand, and by several hospital workers bearing medication for women with special problems. The wake-up nurse then reappeared carrying our breakfast trays, loaded with healthful foods, which she deposited, with meaningful firmness, on the table opposite our beds. That first morning my next-bed neighbor, a young Albanian woman, took pity on me and brought my breakfast tray over to my bedside table. When the wake-up nurse saw me eating in bed, she warned me in thunderous tones of what would happen to me if I did not get out of it. My uterus would not contract fast enough; my recovery would be delayed: I must exert myself! Something American in me rose up in protest at this unfeeling logic, and I ignored her. Like most of the other new mothers, I had had an episiotomy, and I did not want to sit on a hard chair. The doctors who came every day to examine us proved the wake-up nurse wrong, at least in my case--my uterus was contracting rapidly.
The routine at the hospital had more obviously positive aspects. I was impressed by the astonishingly efficient baby nurses, who cleaned and swaddled their dozens of charges in cloth-diaper packages and tiny suits several times a day, while keeping track of each child's feeding schedule and particular needs and instructing new mothers in nursing techniques. Their experience and efficiency sometimes led them to be patronizing to insecure mothers, but they handled the babies with warmth, even a sense of humor. I was particularly grateful for the conscientious attention they gave Charlie, who, as a slightly premature baby, was under their care for a full two weeks.
I was also impressed with the care we mothers received. Every morning those who had had an episiotomy were scheduled to take a ten-minute sitz bath of healing chamomile. Every afternoon all new mothers received personal, bedside instruction on how to begin to get back into shape. In general, we were not pampered or indulged but told and shown what was good for us.
But there are certainly aspects of being a patient in Germany that I will never enjoy. I doubt, for example, that I will ever learn to feel comfortable in a bottomless state, though with two children born and no others planned, I may experience it less than I did my first few years here. But as I lay in my hospital bed following the birth of Michael, my second son, suffering sharp afterpains without the benefit of a frowned-upon painkiller, I realized that I had learned something from the way Germans practice medicine. I had learned to accept my body's natural processes, and that was an adjustment of which I could be proud.
Emily Berns lives with her family in Munich, where she has done freelance editing and translating while raising her sons, to whom Laura Ingalls Wilder is as familiar as the Brothers Grimm. Berns has also devoted many hours to personal writing projects, including a group of essays inspired by her observations of Germany, numerous short stories, and a novel based in Munich.