Postnatal care: the heart of Swiss
midwifery

A Guest Post by DD Anija Jänes. We are honoured to host Anjia’s article and grateful that she has been able to find the time and energy to reflect upon, and write about, her postnatal care in Switzerland and how it contrasts with the care we routinely receive here in the UK. Read on to be amazed and enraged at the simple measures that have made such an enormous difference to Anija.

A midwife for everyone

Earlier this week my midwife assured me that she’d keep visiting me and my baby until we had nothing to do but drink a cup of tea together.

I moved to Switzerland 9 months ago, newly pregnant. I had no idea how the healthcare system here works, but I was quickly adopted by some new mama-friends who helped me set up the basics. The first question my new friends asked was, ‘Have you chosen your midwife?’ In Switzerland all pregnant women have a personal midwife. Most women choose their midwife – sometimes via searching midwives’ websites or the national midwife registry, but most often via the recommendations of friends and neighbours. If a woman doesn’t choose a midwife for some reason (usually because she’s a migrant like me, who is unaware that a personal midwife is available to her), she will be assigned one automatically. No woman is left behind!

At first I was confused! The women I met were planning all sorts of births, ranging from elective cesareans to homebirths. Some women were remarkably high risk and others were sailing through quiet pregnancies. Why would they all have a personal midwife?

I discovered that, when Swiss women refer to ‘my midwife’, they mean their postnatal midwife who visits them in their home. The wealthiest and humblest families all get the same standard of midwifery care: for an uncomplicated vaginal delivery, 10 home visits are standard; for an uncomplicated cesarean delivery, 16 home visits are routine. If mother or baby have any complications during birth or postnatally, unlimited additional visits can be prescribed by any head midwife or doctor. These prescriptions are not hard to get – sitting on my dining room table is a letter from my gynaecologist authorising my midwife to keep visiting me, with no maximum number of visits specified. So my midwife will keep stopping by, until all we have to do is chat over a cup of tea.

The Swiss believe that all women deserve to have midwifery care. No matter their birth choices or outcomes, a woman’s doctors cannot replace the kind of care offered by a midwife. Even women who do not see a midwife antenatally or perinatally receive the care of a midwife after they give birth.

Before moving to Switzerland (coming from Canada and the UK), I thought that midwives by definition accompanied women in labour and caught babies. How wrong I was to limit the midwife’s calling! The heart of midwifery in Switzerland is postnatal care – a kind of care that is more comprehensive than anything I could have dreamed of. Postnatal midwives are specialists. All have attended births in a variety of settings (hospital, birth centre, homebirth) but have chosen to specialise in supporting women after birth. Not surprisingly, many come to this work a bit later in their career, when the true soul-work of midwifery deepens in their practice.

They get to spend time weighing and caring for growing babies, guiding women in becoming mothers, helping families adjust to their new life with baby, and even patching up quite a few marriages.

I want to share my own experience with my postnatal midwife, because I know that a lot of my contacts in Canada and the UK will struggle to envision how the Swiss system really impacts a woman’s life after giving birth. Because we have limited family support, my husband and I have relied on the continuity of postnatal care more than perhaps the average family. But many families in Switzerland are far from their loved ones or have complex families who are less than supportive. So I know that we are among many families in Switzerland who have heavily relied on our midwife.

Finding my midwife

One of the first things I did when I moved to Switzerland was to download the Peanut app and connect with mothers in my new city. Some had newborns, others had toddlers, and the special badge of honour went to mums with ‘two under two’. I soon met a woman and her toddler who lived in the same city district. May was heavily pregnant with her second baby and planning a VBAC. She and I got along because we had similar views – we had both traveled and lived around the world, had an intellectual interest in motherhood, and were keen on balancing science and medical expertise with our own internal sense of competence as women. She had quit her job as a child development specialist to raise her son, while I was wobbling after handing in my own resignation letter earlier that month.

My new friend made sure I understood the most important thing about having a baby in
Switzerland: find yourself a postnatal midwife who will ‘get’ you and your mothering. She sent me a link to the national midwifery website listing all postnatal midwives. All I had to do was type in my postcode, and my neighbourhood midwives were listed for me to contact. Many of them provided their direct mobile number. It was hard for me to understand that they really didn’t mind me just ringing them up.

I lived in a smaller neighbourhood in the north of Zurich, and the list of midwives available to me was quite impressive. Some offered more ‘granola’ skills like homeopathy, but I’m not into that sort of thing. Others were IBCLCs and offered extensive breastfeeding support. I had the feeling that I was shopping for my midwife, finding one with the right vibe to suit my vision of my own mothering.

My first call went to May’s midwife Katrin. May had told me stories of how Katrin had helped enormously with her complex breastfeeding problems. Breastfeeding was very important to me! I wanted evidence-based care, so I was searching for a midwife who was pro-science, pro-medicine and pro-vaccination.

So I rang Katrin and she offered to stop by to see if we got on. She came over to my
barely-furnished flat (we’d just moved in!), and sat with me for 90 minutes. She was friendly and high energy, with a fantastic sense of style. We chatted about my birth plan and postnatal plan, and I got to geek out with her about midwifery! We both left our meetup with a feeling that working together would be nice, so she signed me up to her praxis. I wouldn’t see her for another 4.5 months, but knowing that she’d be there when the baby came was comforting. All I had to do was text her (or get my husband to text her!) after birth so she’d get ready to stop by our home. Katrin worked in a team of two, with her praxis partner Bettina, an IBCLC midwife. Their jobsharing meant that, even if Katrin were to be ill or unavailable for some other reason, Bettina could step in. No matter what, I would not be alone.

Held in healing hands

My birth went catastrophically wrong. I planned a homebirth but decided on my own to transfer into the hospital. In all, I had 2 weeks of heavy prodromal labour and was in intense active labour for 4 and a half days. It all ended in a frantic emergency cesarean section.

Within this haze of trauma, I found breastfeeding to be my primary point of focus. My baby’s little hands held my breast like a sacred fountain of life and I fixated on our feeding connection as a way of containing my trauma. If my birth had to go wrong, that was at least a relatively short experience. I needed breastfeeding to go right, to build a years-long relationship with my baby.

As I began to struggle with this new skill, I sought help from the hospital lactation consultants but still felt worried and overwhelmed. I was amongst the deluge of women giving birth to babies conceived over the Christmas holidays and the lactation team was extremely busy! I suddenly remembered that I had a postnatal midwife who was waiting to help me. I texted her from the postnatal recovery ward to inform her about my birth and cesarean, and told her about my breastfeeding woes. She offered to bring a special laser machine to treat my blistered nipples as soon as I was home from the hospital. She sent me breastfeeding instructional videos to supplement my visits from the hospital consultants.

I was discharged on Monday morning, and Katrin arrived at our home within a few hours of our arrival. She brought a special cream for healing nipple soreness. She came almost every day that week, bringing massage oils, probiotics, and recommendations for how to help my baby settle in at home. Bettina came, too, to help me with different breastfeeding positions. While Bettina offered a kind motherly presence, Katrin filled our flat with exuberant energy and swift practicality. Both women gifted me a sense of normalcy that grounded me. Everytime they left, I thought, ‘Of course I can do this, women always have!’

I vividly remember Katrin sitting cross-legged on my bedroom floor on our first day home with the baby, listening to me as I told my birth story for the first time. I will always be grateful for her response: she didn’t react in horror or treat me like I was broken. She simply acknowledged how hard it had been, and reaffirmed my own understanding of what went wrong. Her experienced view on things helped me start to build an intellectual context around my jumbled memories. Over the coming months, my difficult birth experience would come up in conversation but never in a triggering way. Katrin seemed to realise that I needed to focus on my baby, not reminisce about a past I couldn’t change. I believed Katrin when she said she’d help me when I was ready
to seek closure, even if that was many months in the future.

I learned a lot about gentle parenting from Katrin. She helped both me and my husband learn how to handle the baby — how to gently pick him up and set him down, how to soothe him. I learned not to lift his legs up to change his nappy, but to gently roll him side-to-side. We learned to hold his feet if he seemed disoriented in space, and to gently fold his arm to his chest if he seemed startled by a reflex movement.
One of the most important lessons I will always remember is Katrin’s sensitivity to the baby’s own experience of birth. Katrin supported my motherly intuition that Asko was re-experiencing his traumatic birth on a weekly basis, telling me that this was a phenomenon she had seen many times before. She helped me open up to the possibility that I could acknowledge his somatic memories when he seemed to be re-living his painful experiences. So, I would hold my baby in the predawn hours as he wailed and wailed, and cry with him, allowing my trauma to flow alongside his, out into the dark. We repeated our ritual of wailing together every Wednesday
night for six weeks, until the tears slowly faded and we simply forgot to meet in that place of pain.

It was from Katrin that I learned to allow my baby to express himself without projecting my own feelings onto him — to comfort him without trying to control his crying just so that I could feel less anxious! Katrin told me that babies need to release tension through crying, so it is best to make sure that they are comfortable (fed, changed, warm, pain-free, etc.), and then accompany them through their emotions with loving touch, acknowledging them and never letting them experience those scary feelings alone. She told me to set a timer for 8 minutes and hold him lovingly without trying to ‘fix’ or ‘stop’ anything. Instead of shushing my baby, I found myself
saying to him, ‘Yes, let it all out! Yes, I hear you!’ I strongly felt that this method ended up with a far more settled baby (and a far less anxious mama) than before. He was never still crying when the 8 minutes were up. We were usually both yawning and feeling ready for a nap.

On some days, Katrin primarily soothed my anxieties. Yes, that colour poop is fine! Yes, he’ll be warm enough if you go outside today in that outfit. Don’t worry, that tight feeling above your cesarean scar will be gone in a week or so! On other days, Katrin celebrated with me. Big smiles over my abundant milk supply. Cheers over the baby gaining 350g per week! A helping hand with those tender ‘first’ moments, like
baby’s first bath.

On days when I was struggling, Katrin would massage my belly or gently treat my cesarean scar with cream and gentle suction cups that relieve the scar tissue tension. When I was experiencing breast pain, she’d look at my nipples and check my breasts for blocked ducts. When we hit a tough patch with breastfeeding and my nipples developed shallow cracks, Katrin had her pharmacist mix up an antibacterial-antifungal ointment to help with healing.

Over time, I started to notice that Katrin had a method. She would always make a quick glance around the house and check in with me verbally on the basics. Was the fridge stocked? The house tidy and clean? Were my meals nutritious? Did I have company and friendship? I even noticed her spying my dishes on the counter and nodding when she saw the big bowls of apple
porridge and beef stew my husband had made for me that I’d half gotten through. Mothers need to be nourished!

On days that I seemed a bit overwhelmed, she offered to pick up supplements from the
pharmacy, a different brand of nappy to try for a better fit, or some food from the shops if I needed. Because of my support network, I never needed to take her up on these offers — my husband made delicious soups and stews every day, kept the house clean and organised, ran all the errands, and made sure I had a box full of midnight breastfeeding snacks next to my bed.
I also had wonderful doulas live with us for 5 weeks to help me get some sleep and guide me with those little daily baby tasks that can easily overwhelm. I know, however, that if my husband hadn’t been ‘that sort of man’ or if I hadn’t been able to find a doula to come stay with us, Katrin would have stepped in to make sure I was okay. Just knowing that made me feel held and warm.

Safeguarding the dyad

From the beginning of her visits, Katrin frequently reminded me to tell her immediately if anything felt ‘off’ or painful and abnormal. With this message repeated so often, I overcame my reticence and would text message Katrin anytime I felt something ‘not right’. Most of the time, these texts were just an opportunity for Katrin to reassure me that everything was okay. However, there were a few times when Katrin sprung into action and helped me to access immediate specialist care. Without my personal midwife visiting me regularly at home, any one of these complications could have led us down a more difficult path.

Both Bettina and Katrin noticed important subtle abnormalities about my baby that the
pediatricians missed – his asymmetric smile, his one-sided neck stiffness, his pain winces when lifted, and his sudden pain shrieks when held in certain positions. It turns out that I was not the only person stiff and sore from our marathon birth! Over six weeks we worked together to ease the baby’s pain and help him latch to the breast more deeply. Katrin helped us set up cranial-sacral and osteopathic therapies for him — within days, we had a therapist stop by for a home visit to help the baby relax his neck and shoulders.

A few weeks after the birth, I told Katrin that I felt my bleeding was slightly increasing and becoming brighter red. It didn’t look like lochia discharging, it felt like bleeding. Without a midwife visiting me at home, I might have waited it out to see if it would go away on its own. But Katrin told me that I should listen to my intuition. And so I called my doctor for an emergency consultation and went in later that day for a scan. Unfortunately the ultrasound did reveal retained or regrowth placenta with vascular supply. After an unsuccessful round of medication I ended up needing a curettage surgery. I tend to be avoidant when my alarm bells are ringing, so it was important to be reminded that, in Katrin’s words, ‘When a woman feels something is
wrong, it usually is wrong.’

The baby’s neck and jaw restrictions from his birth injury led to a chronic shallow latch that I couldn’t fix. The baby would bite down when in pain and I developed soreness. After my curettage surgery, I started to feel something wrong with my breast. It was the weekend and Katrin was not on call, so I contacted Bettina by text message late on Sunday night. She immediately responded and called Katrin so that they arranged for me to be seen the next morning. Katrin arrived in the morning, and after sitting with me for 30 minutes and listening to what I was experiencing in real time, she suspected that I might be showing early signs of a bacterial infection causing mastitis. I fretted that something other than neck pain might be causing my baby to have such a shallow latch. Katrin couldn’t see any signs of a tongue or lip tie, but she listened to my worry and called a lactation consultant friend, Judith. Judith is the top specialist in Zurich for tongue and lip tie. Despite being fully booked for consultations for the next two weeks, she was willing to stay late at work (and, as I overheard later while she was on
the phone, to shuffle her own child care around) to see me.

My husband, baby and I were on the train within thirty minutes of Katrin’s phone call. Within a couple of hours, I had seen both Judith and a doctor. I left the hospital with a breast ultrasound, blood test, confirmation of bacterial infection, a consultation ruling out tongue and lip tie, and a prescription for antibiotics and anti-inflammatories. Thanks to Katrin, we responded to signs of infection so early that it never developed into a painful or dangerous condition.

Reflections

I have spent the majority of my life living in the UK and Canada. Before moving to Switzerland, I was largely unaware of the beliefs I have inherited about medical care. From a very early age, I was accustomed to my GP not remembering who I was. I was also used to very quick appointments, with hardly the time to express my worries or concerns, especially related to sexual health and fertility. As a young woman, I dealt with a great deal of paternalism, my symptoms too often brushed aside like I was inventing them. In previous hospital admissions, I was made to feel guilty for pressing the call button when I needed help.

In Switzerland, I have become acutely aware that each of these encounters with Canadian and British health care caused a micro-trauma, a sense that I didn’t deserve and ought not expect adequate medical care. Here, my midwives, nurses and doctors have encouraged me to take more of their time, to speak more about my experiences, and to ask for more help. On the postnatal ward, a nurse actually got quite exasperated with me, saying, ‘We WANT to help you. Please press the call button more often!’ Since then, I’ve gotten used to talking with my doctor for 45 minutes and still feeling like I’m leaving the appointment a bit early. I now expect my midwife to be around for an hour or two, and I assume I’ll be able to access any specialist I feel I need without a referral.

When I needed to visit the emergency department at the hospital, I was seen within 10 minutes by a nurse and admitted to a private room straight away – no need to call ahead. The waiting room always contained no more than two patients every time I walked past. During follow up appointments, the staff remembered me by name and recalled why I had visited the hospital, kindly asking how I was doing.

Before you ask, I am on basic health coverage in Switzerland. I have only accessed state-run hospitals and clinics. I do not have access to the private health care for which Switzerland is famous.

My experiences in Zurich make me wonder, what would health care in Canada and the UK look like if women felt they deserved a better standard of care? What would women believe about their bodies and their capabilities as mothers if they all experienced a continuity-of-care model of postnatal midwifery? Don’t get me wrong, a Swiss postnatal midwife cannot provide all the support a mother needs to thrive after birth. Swiss doulas are busy! And families and communities still play a vital and irreplaceable role. But perhaps the question should be asked the other way around: Is the support offered by families, communities and doulas enough to make comprehensive postnatal midwifery unnecessary? In my case, at least, my midwives have been essential and played a unique role in supporting my transition to motherhood.

My midwives have offered me support and learning opportunities that my husband, doulas and friends could not. If it truly takes a village, then I believe that every village needs its midwife. So when we March With Midwives and shout at the Tories, what are we asking for? The bar has been set so low in the UK with NHS services driven into dangerous deficits. I worry that this sorry situation is redefining what we as women think of ourselves. If we have to fight for adequate staffing of the maternity wards, we have so little time to ask the most important questions: What do we deserve? What would help us thrive?

I hope that my account of postnatal support in Switzerland helps women imagine another system, another set of possibilities–to help women in other countries imagine what their ideal maternity care system might look like. Because women and mothers shouldn’t be so easily brushed aside, deprioritised, and left to cope at home alone. Vulnerable women can too easily fall through the cracks and end up in a place of postnatal despair, disease and damage. As a migrant woman with no family and a history of anxiety, I could have so easily slipped through the cracks. I believe that if I had given birth in the UK, I would be struggling as a mother far more than I am now. I envisioned the 4th trimester to be a time of frantic exhaustion, anxiety and worry, with overwhelming feelings of incompetence. I keep telling my husband how surprised I
am that I am well-rested and feeling really capable as a mum.

My birth went very wrong, but with the support of my midwives, husband, doulas and friends, I have thrived in the 4th trimester and been able to focus on soaking up all the delicious newborn baby snuggles!