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Under the Milanese Bureaucracy

By
October 9, 2009

Public health care threw every conceivable obstacle at one pregnant American in Italy—bureaucracy, long waits, condescending doctors—yet she still favors the public option. Here’s her story.

italy300.jpgThe first clue that an Italian pregnancy would be complicated was that after positive results from two home pregnancy tests, I had no idea where to go. My primary care physician was rumored to have a number, but I wasn’t privy to it. I had a gynecologist, but she was a specialist, and for specialist visits I was pretty sure I ’d need a referral from my primary physician. I took my chances and called the gynecologist’s office. The receptionist said I’d need to have a blood test in the hospital to confirm I was pregnant before the doctor would see me. For the test, I’d need a referral from my primary care physician. I had been in Italy for seven years and had little experience with the public health system. I learned I was pregnant on a Tuesday. It was a week before I could get confirmation from the hospital of what the home tests and debilitating all-day “morning” sickness had already made quite clear.

This was only the beginning of what Italians call dolce attesa or “sweet wait.” It would be a nine-month odyssey of shuttling from office to agency to another long line with all of my test results and other required bureaucratic documents stuffed into a turbo-charged pink Trapper Keeper, the envy of all the expecting Italian mothers who carried bulging accordion files held together with string or rubber bands.

Italy’s universal health care system is regional, not national. From what I’ve heard, the system is better in historically socialist Tuscany and Emilia-Romagna and much worse farther down the boot. I live in Milan, in Italy’s wealthy north, and soon learned that in the regional system, Band-Aids and urine cups are considered frills. Patients learn to bring these vitals to the hospital, where most tests are performed. By the time I got pregnant, I knew gowns—paper or otherwise—were not offered during a gynecological visit.

As my nausea waned and my belly grew, I became increasingly frustrated with the pregnancy shuffle. At each visit, my gynecologist would write out a list of tests I’d need to have done in the hospital before our next visit. I’d then take the list to my primary care physician, who would write out referrals for the tests and sign and stamp them. With phone and email out of the question, scoring the referrals required me to wait near the visiting room door during an often changing four-hour window and try to squeeze past the ill and angry hordes when a patient exited. Referrals in hand, getting an appointment for hospital tests could be just as challenging. Many hospitals don’t have phone numbers for making reservations, so you have to wait in line for an appointment. Sometimes the lines were long. Sometimes not. Sometimes you got there and they were “closed” or “at lunch” or had a “be right back” sign and never came back. It was a huge pain in the ass for a hormonal, uncomfortable pregnant woman traveling on public transportation with a cup full of urine. It wasn’t unusual for me to have four different exams to do in four different hospitals spread throughout the city. And I’d have to return to these various hospitals to pick up test results in person. Being pregnant became a second job, an exhausting one in later months.

Signora,” she said. “It’s not like The Cosby Show, where the doctor runs out the door with a black bag in the middle of the night to be by his patient’s side.”

Once, for a test, I arrived at the hospital with my urine sample and bulging Trapper Keeper, only to be turned away because the attendant said the doctor hadn’t checked the box on the referral saying I was pregnant. She remained unmoved by my visible belly and large pink binder full of documents; I returned home defeated. After this episode, I confided to my gynecologist that I was feeling a bit overwhelmed by the system, unsure what form needed to be filled out and where I needed to go for the endless number of tests.

This is the beauty of our system as opposed to yours,” she bellowed from across her desk, scolding me but giving me the formal Lei form at the same time. A bespectacled woman in her fifties, Dottoressa Rossi wore oversized, yet tasteful jewelry and was fond of railing against the Bush administration during my pelvic exams. I had gone to her for years for annual pap tests and found her to be competent and thorough. But her opinionated, tough-love approach didn’t work for me during pregnancy, and I later changed gynecologists. She called me an “extremist” for being vegetarian and prescribed a Fiorentina steak weekly, as well as twice-daily espressos for my low blood pressure. “We offer choice. You can go wherever you want. When you go into labor, you can go to a hospital, any hospital. Well, as long as they can find a bed for you, of course…”

When I asked her if I should call her when I went into labor, she laughed.

Signora,” she said. “It’s not like The Cosby Show where the doctor runs out the door with a black bag in the middle of the night to be by his patient’s side. My dear girl, I see you’ve romanticized this experience and I fear you are setting yourself up for disappointment. Our hospitals don’t have the comforts and the bedside manner you may find in America, but medically speaking, they are just fine.”

It was not reassuring. I didn’t see the beauty in deciding which hospital to give birth in when the first contraction hit and then laboring among strangers. And while many Italians would employ the “beggars can’t be choosers” argument, I often reminded them that most of us were tax-paying “beggars” and shouldn’t have such low expectations.

If I’d romanticized pregnancy and labor at all, an experience in my fifth month left me wary of Italian public hospitals and was the stuff of my nightmares. One late summer night, I woke up doubled over with shooting pelvic pains. My husband, Cristiano, rushed me to the emergency room, where I was checked out by a gynecologist who could not determine the cause. I’d be kept overnight for observation, and was put on a gurney and wheeled into a dark room with three other patients. My poor, chairless husband stood next to me. As my eyes adjusted to the dark, I could see that the other patients each had a friend or family member hovering near their gurneys, too.

“Mamma, mamma, will I die from the encephalitis?” yelled the thirty-something man on the gurney next to mine.

“Shhhh,” said his mother.

My husband looked at me in alarm and mouthed, “Is that contagious?”

I was in too much pain to care. There was no nurse call buzzer, so my husband combed the halls looking for a nurse to see if I could take anything for the pain. He couldn’t find one. The pain got so bad I became delirious and started to cry out loudly.

A young nurse appeared and barked, “Who is making all this racket? You aren’t the only one in here, you know!”

I begged for pain relief and she told me there was nothing I could take in pregnancy. I continued to beg, even for a Tylenol, which she didn’t want to give me. Then I vomited all over myself. Her stance softened and she gave me a muscle relaxer.

In the morning, the man with encephalitis was brought breakfast, but nothing was offered to the rest of us. A doctor with a clipboard came and informed the man that he’d be moved to the infectious diseases ward as soon as a bed opened up. As he left the room, he gave the rest of us a curt “Buongiorno.” By noon, the room had become unbearably hot; we were all hungry, thirsty, and wondering when doctors or nurses would update us on our respective conditions.

“We’ve been left here to rot!” said an elderly woman who’d been admitted complaining of chest pains the night before. “For all I know, I had a heart attack last night.”

Like Michael Moore, I think universal health care is a worthy goal. But at that moment, all I could do was throw the remote control at his fat smug face.

Suddenly a commotion broke out in the hallway. A paramedic burst into the room and pointed to the pregnant woman and the elderly woman. “You two—up! We need the gurneys. The ambulances don’t have gurneys and we can’t make our runs without gurneys,” he yelled.

Another paramedic entered the room and looked at me and the man with encephalitis.

“Those two have IVs attached to their gurneys, so we can’t take theirs,” said the first paramedic.

They wheeled the two gurneys out, and we heard them continuing down the corridor looking for others. The pregnant woman and the elderly woman were left standing awkwardly until plastic chairs could be found. Finally, that afternoon, a gynecologist came to sign my release forms. The only thing they had found wrong with me was a swollen bladder, so I was given an antibiotic and sent home.

I had been told to bring my own gowns, Band-Aids, bandages, sanitary napkins, nipple cream, bottled drinking water, paper cups, cutlery, salt, pepper, and parmesan.

When we got home, Michael Moore was on TV. He had been in Rome a few days earlier to promote his movie Sicko, and they were replaying the news conference on Italian satellite television that night. Moore repeatedly praised Italian health minister Livia Turco for Italy’s health-care system, which offered access to all. Like Moore, I think universal access to health care is a worthy goal. But at that moment, all I could do was throw the remote control at his fat, smug face. Moore would have probably been surprised to know that I’d paid quite a bit out of pocket for care during pregnancy.

My pregnant friends in the States knew that when the time came, there’d be a waiting hospital with a team of doctors and nurses (including their personal doctor) at the ready. Not here. During prenatal classes, my classmates gossiped about the hospital’s dreaded “broom closet,” where laboring women were put during overcrowding. The hospital had three delivery rooms and delivered something like seven babies a day. With the average labor lasting twelve hours, being turned away from the hospital was a very real possibility. “My sister gave birth to my nephew in that broom closet,” said one of my classmates to nervous laughter. I was disturbed for the rest of the class.

When I was ten, off the coast of Florida, I suffered from a panic attack. I was out on a boat with my parents and grandparents. As soon as we couldn’t see land anymore, I just freaked out. Classic agoraphobia. Panic attacks were not as commonly talked about then, and my family took this kind of tough love “get ahold of yourself” approach that made me even more hysterical. I developed a fear of being in a place where I’d need help but nobody would help me.

An American friend who gave birth a few months earlier told me, “Watch _Oprah_ or _Rachael Ray_ or one of those mindless shows. It takes your mind off the contractions.” I had to tell her that not only would I have no television in the delivery room, but I had been told to bring my own gowns, Band-Aids, bandages, sanitary napkins, nipple cream, bottled drinking water, paper cups, cutlery, salt, pepper, and parmesan. I also mentioned that the epidural wasn’t a given. Most hospitals in Italy didn’t even offer it. To be eligible, I had to jump through a series of bizarre hoops, including two information sessions with an anesthesiologist to make sure I “knew what I was getting into,” a spinal exam, a dental check, a blood coagulation test, and an EKG.

I chose my hospital for its epidural-friendly policies and because it was one of the few in Italy that would allow me to save my child’s cord blood and have it sent to Switzerland for storage. Cord-blood storage in Italy for personal use is illegal. Whenever I’d asked why, I’d been told, “Italy has the Vatican, you know.” It was the same answer I’d been given when I asked why it was so hard to get an epidural—Genesis 3:16: “In pain thou shalt bring forth children.”

I put my head in my hands and tried to imagine I was somewhere else, breathing through the contractions as I’d been taught.

Five days past my due date, while on the phone with my cousin in Ohio, I began to have menstrual cramping and lower back pain. I was unsure whether it was finally “the real thing,” and the mother of two told me, “If it hurts so much you can’t talk, let’s get off the phone. You are in labor.” My husband came home; we dutifully labored at home for several hours until my contractions were four minutes apart, just as they told us in prenatal classes.

Cristiano and I arrived at the hospital with two large suitcases full of the things we’d been told to bring, along with a big, metallic silver box for cord-blood storage. We’d obtained it in Switzerland, and on driving back into Italy, it was as if we were carrying contraband. I imagined the Popemobile appearing in the rearview mirror, sirens blaring.

Fortunately, when we got to the hospital, I was admitted quickly, put in a wheelchair, and taken to the maternity ward on the seventh floor. As we got off the elevator, my relief deflated. The waiting area, which is really more of a hallway outside the double doors leading to the maternity ward, was more crowded than I had ever seen it. The attendant parked me in the waiting area with relatives of laboring women who’d already entered the ward. I felt conspicuous—very obviously in labor and sitting uncomfortably in a wheelchair.

I put my head in my hands and tried to imagine I was somewhere else, breathing through the contractions as I’d been taught. About an hour after I arrived, one of the doors off the hallway opened and a nurse carrying an admissions form ducked her head out. “Is there a woman out here in labor?” she asked, and we gathered our belongings. As soon as we entered the maternity ward, a blond midwife stopped us and asked to see my file.

“Don’t you see what a mess we have here tonight?” she snapped.

This was the moment I’d feared: when my chosen hospital—where my gynecologist worked, where I’d done all of my testing, where I’d completed the prenatal course, where I’d done the maternity ward tour and signed up for the epidural, and where I had an agreement for the preservation of the baby’s cord blood in a space-age metallic box from Switzerland—turned me away in labor. As if sensing my distress, my water broke at that exact moment and the hospital had to admit me by law.

Unfortunately, I was in for a long, painful labor. For sixteen hours the baby would not come out (his head was in a posterior position—thrust back instead of being tucked to his chin). The doctors decided that if they waited any longer, he could go into fetal distress; they began prepping me for a C-section. Then, things happened _fast_. After having been abandoned for much of the night, I became the focus of the whole ward. Several doctors and nurses materialized out of nowhere and moved with precision. As they led me into surgery, they told me I was going to be fine and the baby would be fine. One nurse in particular held my hand and began telling me stories about her trips to the U.S. and kept asking me questions about myself to distract me. They wouldn’t let Cristiano in during the C-section so this nurse said she’d stay with me and wouldn’t leave my side. I was really delirious at that point after having labored all night, so it really didn’t take much to distract me, but I finally felt like I could just relax and be taken care of. I ended up relaxing so much that I slept through the whole surgery and didn’t even hear my son cry. “Thank God this is all over,” I thought. “I can rest now.”

My primary care physician may not have a receptionist or be reachable by email, but she’s eagle-eyed and has a knack for diagnosing and treating rare ailments. Looking back, I think that my circumstances might have been atypical in that I am a foreigner who had rarely used the system. Were I to get pregnant in Italy again, I’d know from the beginning what services are available and that, because this is Italy, shortcuts can be taken. After my son, Dylan, was born, I found a state-funded family planning center in my neighborhood staffed by caring midwives that would have been a godsend in pregnancy and would have in many situations spared me the chaos of the hospital. There I received excellent post-natal care and help with breastfeeding.

G

**Michelle Schoenung** is a freelance writer and translator based in Milan. This is an excerpt from her manuscript tentatively titled In Dolce Attesa (The Sweet Wait), for which she is currently seeking representation.

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One comment for Under the Milanese Bureaucracy

  1. Comment by Ria Mchaffie on January 25, 2010 at 12:39 pm

    Between my wife and I we’ve attempted more ways over the years than I can remember, such as high fertility positions, hormone improvements, various times of the month, etc. But, the last couple of years I’ve pinned it down to one kind of treatment. Why? Because I was happy to discover how effective the results were.

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