As my two children grow older their similarities and differences have gradually become more apparent. Whether it be physical features or their personalities, there is no question that they exhibit qualities from both sides of the family. These traits are on full display as they both take advantage of having their parents close during the COVID-19 crisis. The time together is precious and not something we are taking for granted. It has also given us time to ponder differences between their birth stories.

Although both of our children were born under normal circumstances, we could not have had different experiences. The main factor to these differences: Elise was born two years ago in Brussels, Belgium while Jones was born 5 months ago in Boulder, Colorado. This highlighted significant differences within the respective healthcare systems, evidenced by emphasis of care, parental leave, and opposing cost structures.

Birth Comparison

• Elise        vs.         Jones
• December 2017               vs.         December 2019
• 3.1kg                                 vs.         3.05kg
• Brussels, Belgium           vs.         Boulder, Colorado
• Socialism                          vs.         Capitalism
• 6,000EUR                         vs.        50,972.88USD

Yes, that cost line is correct. And no, these figures are not an exaggeration. They are the direct comparison between the birth of Elise in Brussels (left side) and the birth of Jones in Colorado (right side). Both births were normal and fortunately no complications: vaginal birth with an epidural. Both births were at top quality hospitals – Delta Hospital in Brussels was brand new at the time with great amenities and comfortable surroundings; Boulder Community Hospital is a modern hospital with a high-quality atmosphere. Both births were supported by a relative high level of care for both my wife, Sarah, and our two children. The doctors, nurses, and support staff were all tremendously supportive ensuring the health and overall well being of mother and child.

Emphasis of Care

Interestingly though, the focus of care was completely different. From the onset, Belgium has their focus on the mother. From our perspective it seemed their thinking was that if the mother is well, then the mother can better care for the baby. This logic played out time and time again – whether during prenatal check-ups or postpartum appointments. For example, once we were in the recovery room after the birth, the first thing that the Belgian nurses checked during their daily rounds – my wife; the first thing a Boulder nurse checked – my son. In fact, in Boulder there was almost the feeling that unless Sarah mentioned something was wrong, they assumed everything to be okay without confirming firsthand. Maybe that was unique to our nurses and our situation, but it seemed routine and not necessarily exceptional to our family.

Another emphasis of care difference is how the healthcare system supports the new family. In Belgium the minimum hospital stay is three nights (recently down from a mandatory five-night stay) while in Boulder it is 24 hours. This is significant as those first days as a new parent are extremely important to rest, recover, and adjust to a new life. The relative lack of stress to have nurses and doctors on call for two more days is important to both the mother and baby. We were cognizant of this difference and took full advantage – asking plenty of questions, having lactation consultants show proper latching techniques every feed, and enjoying meals that we didn’t have to prepare.

Additionally, Belgium offers 5-10 home visits after you leave the hospital. Nurses scoot around Brussels in Smart cars providing additional care as the new parents adapt and inevitably have questions or concerns in the first few days and weeks. And beyond the hospital, there are also free support systems (French: ONE; Flemish: Kind en Gezin) that provide free well patient check-ups, free immunizations, and free parental support. 

Alternatively, Boulder offers the standard level of care for a privatized healthcare system. This includes one follow-up visit that is focused solely on the mother, and pediatric appointments where you pay for everything (depending on how your insurance plan is structured) but also free basic resources or groups for new parents. Basically, the involvement of the doctor post birth ends once you leave the hospital and there is no proactive approach that supports those first few weeks for mother and baby.

We had a consistent feeling of being a ‘number’ rather than a person within the US system and while we had a high quality of care from the staff at the doctor’s offices or the hospital in both locations, in Belgium the entire experience felt more personable and intimate.  My assumption is that costs surrounding health care and the business of insurance in the US is the main driver of this disparity.

Parental Leave

Another key differentiation between the US and Europe as a new parent are the parental leave benefits. In the US, parents are entitled to 12 weeks of unpaid, job-protected time off for both parents through the Family and Medical Leave Act (FMLA)[1]. Depending on the company and its internal policies, additional paid leave may be available to parents, although often the father is entitled to less time than the mother. The EU has different benefits across its member states, but the minimum is 16 weeks of paid leave, with job protection provisions to ensure a smooth reentry into the workforce[2]. Some countries within the EU go even longer – for example Bulgaria provides 6 weeks prenatal and 52 weeks postnatal, at 90% salary coverage[3]. For a father in Belgium, there is 2 weeks of paid leave at 82% of the salary[4]. For a father in the US there is no legally mandated paid leave time although my employer provides one week of paid leave for new fathers.

The benefits of parental leave are significant. Spending time as a new family and settling into a new routine is important for the parents as much as the child. Without having to worry about work or related income allows the new parents to focus their attention on the well being of the child. For the mother, it allows them to recuperate and care for the child in the home setting. For the father, longer leave leads to higher engagement, promoting bonding between the parent and child, as well as “leading to improved health and development outcomes for children”[5].

Cost Structure

I am not the first to point out that the cost of healthcare in the United States is out of control. Even with insurance, a normal birth can be costly in the US depending on what kind of deductible your health plan states. For us, we reached our ‘Out-of-Pocket Max’ with birth of Jones and therefore had significantly higher direct costs than when in Belgium. It is worth noting two things: first, my employer has a high deductible health plan and second, we had private insurance in Belgium, so we had no deductible.

A high wealth country like the United States would be expected to spend more per person on healthcare than lower income countries. But in comparison to other wealthy countries, the United States spends a disproportionate amount per capita on healthcare. In 2017, healthcare accounted for 17% of the US GDP[6]. By contrast, in 2016 Belgium only spent 10% of its GDP on healthcare[7] which is subsidized by the federal government. 

Granted Belgium has a socialized healthcare system which allows for lower costs at the point of care. Their main philosophy is ‘equal access and freedom of choice’[8], which includes a mandatory national health insurance plan and benefits that are consistent across service providers. When comparing the effective tax rates between Belgium (50%+) and the US (20%+), you begin to realize that perhaps the costs of healthcare, education, retirement, etc. evens out over time. It is also challenging to compare Belgium, a country of 11M residents and a healthcare system that contains 115 acute care hospitals[9], to the United States, a population of 328M[10] and an acute care hospital network of 5,276 facilities[11].

All is Well that Ends Well

In the end we have two beautiful and healthy children. They happen to have been born on opposite sides of the world, in countries with opposing views on economic and social policies. The societal differences are pervasive across daily life and this is especially true in the healthcare sector. We were fortunate to have two different birth experiences so we can see firsthand how capitalism and socialism can support the birth of a child from a completely different perspective. There are pros and cons to both approaches and neither system is flawless. 

The experience of having a child while an expat is quite the experience – different cultures, different languages, and completely different healthcare systems. It provided me and Sarah with a whole new perspective on parenthood. Not just the birth, but the pre-and post-partum support provided a glimpse into how different life can be in another country. The overall parenting philosophies of Belgian culture have forever shaped how we view parenthood and we firmly believe we are better parents because of it. 

Being an expat has its ups and downs but birthing and raising a child abroad is a privilege.

[1] https://www.dol.gov/agencies/whd/fmla

[2] https://eur-lex.europa.eu/legal-content/EN/TXT/?qid=1414661428912&uri=CELEX:32010L0018

[3] https://www.europarl.europa.eu/RegData/etudes/ATAG/2019/635586/EPRS_ATA(2019)635586_EN.pdf

[4] https://www.europarl.europa.eu/RegData/etudes/ATAG/2019/635586/EPRS_ATA(2019)635586_EN.pdf

[5] https://www.dol.gov/sites/dolgov/files/OASP/legacy/files/PaternityBrief.pdf

[6] https://www.healthsystemtracker.org/chart-collection/health-spending-u-s-compare-countries/#item-since-1980-the-gap-has-widened-between-u-s-health-spending-and-that-of-other-countries___2018

[7] https://ec.europa.eu/eurostat/web/products-eurostat-news/-/DDN-20181129-2

[8] https://healthmanagement.org/c/icu/issuearticle/belgian-healthcare-overview-of-the-health-system-and-financing

[9] https://ec.europa.eu/health/sites/health/files/state/docs/chp_be_english.pdf

[10] https://www.census.gov/quickfacts/fact/table/US/PST045219

[11] https://blog.definitivehc.com/how-many-hospitals-are-in-the-us