Some Thoughts on Pregnancy and the Foreign Service

Now that I've announced my pregnancy to the world (or the twelve people who read my blog), I have a few things to say about what I've learned about prenatal care in the Foreign Service. If you can't tell, I'm not entirely pleased with what I've discovered. I wonder if others feel the same way. (This is a little lengthy, so don't feel compelled to read!)

For my first pregnancy, I was lucky that my husband was in the Marine Corps. Lucky in the sense that we had Tricare, anyway. The beauty of pre- and post-natal care with Tricare is that you can opt out of Tricare Premium and use Tricare Standard, which means you aren't limited to military bases for your care. That's right, I could choose from a wide range of civilian doctors and not pay a dime (seriously, not a DIME) for any of my prenatal or postnatal care. Then, after a year, I could switch back to Tricare Premium (or not - even on Standard, the copays are low and the catastrophic cap is only $1000).

I have yet to find out what prenatal costs will be like with the Foreign Service Benefit Plan, but I anticipate fairly low. So far I haven't paid anything out of pocket for the two exams and the ultrasound I had while in the U.S. last month. However, if I'd gone to London on a medevac, as I was supposed to, I'd have had to pay for everything up front and wait for reimbursement. Not exactly ideal, although tolerable. (Just so we're clear, a medevac is not nearly as dramatic as it sounds; it's a paid-for round-trip commercial flight to the nearest place with U.S.-quality medical care and usually three days of per diem. If there's a life-and-death emergency, they would charter a flight.)

But here's the thing. Prenatal care in the FS (at least for State Department employees and their family members) isn't really about insurance. It's about what Medical (in Washington and at your embassy) decides. And as it turns out, they have a whole lot of say in what you get to do for your care, even if you wholeheartedly disagree with it.

I admit I was incredibly naive. I assumed that, like all the women who get pregnant in Moscow, I'd get to use the medical unit there for my routine prenatal appointments. After all, we don't have a med unit at post (many consulates do, but not our teeny tiny one), and I just didn't think I'd be expected to get my care on the local market when there's an American doctor and American nurses in Moscow who (I thought) I could see for free. I was wrong. Moscow isn't considered a medevac point. I was told that's because the health care in Moscow is not considered better than the care in Yekaterinburg, to which I can only say, "WHAT?!" So I would have to get my prenatal care here, except for the once-per-trimester medevac everyone is allotted. Side note: if you have a "high risk" pregnancy, you get two medevacs in the first trimester - that means anyone over 35, or who has high blood pressure, or had a high risk pregnancy previously, or if you're having multiples. (Of course, how would you know you're having multiples until you get an ultrasound?)

Most women just wait until 12 weeks for their first prenatal appointment, which is a medevac to wherever their medevac point is, ours being London. Now, assuming everything is perfectly fine with your pregnancy, it's probably okay to wait until 12 weeks for your first appointment. It's not standard in the U.S. as far as I know, but let's ignore that. Here's the thing - how do you know if everything is fine? For my pregnancy with Jack, I had a dating ultrasound at 8 weeks to confirm I was actually as far along as I thought and to make sure there was a heart beat and that I wasn't having triplets and all that jazz. I wanted that again. I felt entitled to it. But I wasn't.

So I made the decision to use my single first trimester medevac to go to the U.S. (you can cost construct medevacs to America against your medevac point and pay the difference; lucky for me, it was actually cheaper to go to the U.S.) because John was already going and I knew I'd feel better if I did. It was very difficult to make this happen, which it shouldn't have been. Anyway, once I spoke to my doctor, we decided I'd skip the 12 week genetic testing and do the 15 week testing instead, since I already knew I'd be home then and it saved me having to pay for a trip to London.

I'll tell you one thing I've learned from my experience here. I will never, ever go to a tiny constituent post again if I can help it. Not only do you not get the same entitlements as people at the embassy - granted, we get 5% more hardship than people in Moscow - but you don't have the benefit of face-to-face time with the people responsible for your fate. Many of them haven't even been to your post, so they don't really know what the local conditions are like. There are NO English-speaking physicians in Yekat, at least as far as any of my expat friends are aware. At first Moscow wanted me to take along our local physician, a man who comes to the Consulate 4 hours a week and speaks about as much English as I speak Russian, the same man who has prescribed snake oil to two officers for pain management, told me Jack's staph infection was chicken pox, and told my nanny to dress Jack in warm clothing in the middle of the summer because his two pee accidents were clearly a UTI and he should never go out without socks. Yeah, right. When I explained that he didn't even know what a pap smear was and would do me no good whatsoever, they offered to send a non-Russian speaking nurse from Moscow and recommended I hire an interpreter to take with me to appointments.

Could I have stayed here for the rest of my pregnancy, or until 34 weeks, when pregnant women are generally medevaced to the states? (Just for a second, imagine being 34-weeks pregnant and having to fly to the U.S. from middle-of-nowhere Africa with your two small kids and no help, in coach. John thought it was ridiculous that I added the part about having to fly coach, but then, he's never been 34-weeks pregnant). Sure. I probably would have been fine. But "probably fine" isn't what I want for my pregnancy. I've heard enough overseas pregnancy horror stories (several in Russia) to make me wary, and I have no confidence whatsoever in the local healthcare system. Assuming I had a perfectly normal pregnancy, I guess it wouldn't matter if the local docs didn't speak English and I had no idea what was going on during my appointments (also assuming that peace of mind isn't worth anything to a pregnant woman). And of course I could take along a complete stranger to interpret for me while another stranger investigates my nether-regions. Why not?

But it was the "what-ifs" that scared me. What if I started bleeding and had to go to the nearest hospital? I know an American girl who (admittedly somewhat foolishly) had a home birth here and ended up having to go to the nearest hospital. She was tied down and woke up mid-way through surgery, and then had to get dressed in the hallway, covered in blood. What if, like my last pregnancy, I end up on bed rest again due to early contractions? What if I slipped on the snow and ice this winter and broke something? What if I got really depressed again like I did last winter? What if someone tries to tell me snake oil is perfectly acceptable for pain management and I go crazy-pregnant-lady on them?

I don't know. I just know I'd rather find out the answers to these things in America, with doctors I trust. Pregnancy, as far as I'm concerned, is a highly personal thing, something I want to be in control of. As long as I'm answering to someone in a city two and a half hours away by plane, or worse, someone twenty hours away in D.C., I won't be. That's why I'm going back to the U.S. next week. Maybe I'm being a wimp, but when it comes to the health of my baby, I'd rather be a safe wimp than a sorry one.