Prenatal healthcare in Norway (as compared to the United States)

Part 1 of 3 in a series about Norwegian Maternal & Child Healthcare

The United States and Norway have different approaches to reproductive, maternal, and postpartum healthcare. As a 35-week pregnant American citizen currently living in Norway on a family reunification permit, I thought I’d share my first-hand experiences as well as an objective overview about an area of healthcare that I am particularly passionate about.

While Norway has a positive international reputation for its of reproductive and maternal healthcare, known for both lower costs and a low prevalence of maternal morbidity and mortality,¹ a lot of people in the United States may not know why that is. Many of my “Blue No Matter Who” friends in the U.S., despite never having visited Norway, express to me their envy at having moved to some kind of progressive utopia — the rumor being that Norway is just more progressive than the U.S. is in every possible dimension of life. While I can identify ways in which Norway is more certainly more progressive than the U.S., in other ways I’d say it’s more conservative than American blue states, and I want to take the time to dispel the idea that American concepts about a left vs. right binary neatly map on to Northern European culture, politics, and society.

The way Americans tend to think of political labels is heavily influenced by our two-party system. We tend to think that Left = Democrat = Progressive and Right = Republican = Conservative, and think of these things existing on a linear continuum, with perhaps two extremes existing on either pole, but unidimensional nevertheless. Many Americans tend to conflate social democracy and big state welfare programs with a culture of progressive ideology, but the two are not necessarily one in the same. For example, while Norway is known for its robust welfare state it including its public healthcare system, my husband has pointed out to me when we were discussing my writing of this post that “Norway is far less captured by progressivism as an ideology than other European countries like the Netherlands.” It’s also worth noting that Norway’s welfare state is universal, not needs based, meaning those with higher incomes do not have reduced access compared to those with lower incomes, something that is not true of every European country with a large social welfare system.

In fact, I would consider Norway’s approach to maternal healthcare to be medically conservative in that it is less heavily reliant on technology and over-management of the patient through excessive testing and interventions to pursue its definition of quality healthcare, giving more room for nature to take its course and lowering costs for both the state and the patient.

When it comes to policy, whether Americans label something “left” or “right,” often obscures our motivation to scrutinize the details of said policy, and our ability objectively decide if those details are something we would actually be personally happy with. If anything, stepping away from a country with a two-party system has made me better separate policy from its surface-level marketing where a policy is either labeled “left” vs. “right” (which are synonymous with “good” vs. “evil” in the sphere of Public Health). While I’d personally rather be pregnant in Norway compared to the United States, instead of simply hailing Norway as a more enlightened and left-leaning society than the U.S., I’d like to spell out the details of exactly how reproductive and maternal healthcare is different between the two countries, and let you decide what specific aspects of the Norwegian healthcare model may or may not sound appealing to you without preaching my preferences as universal or indicative of my moral superiority.

My writings on this topic will be a three part series. In the first I will focus on abortion laws and prenatal care; in the second I will focus labor and delivery; and the third I will focus on parental leave, breastfeeding, and other aspects of postpartum care.

Abortion in Norway

Elective abortion is possible in the first 12 weeks of pregnancy (what is generally considered to be the first trimester) and can be requested directly through one of the twenty-six public hospitals that perform abortions without the patient going through her General Practitioner first. After 12 weeks, abortions are more complicated to obtain but they are still possible. In the beginning of the second trimester a pregnant woman can still request abortion, but she must apply for permission stating her reasons, which is then forwarded on to an abortion board at the local hospital who makes the final decision. If an abortion applicant is rejected by the local hospital’s abortion board, she has a right to appeal to the national board. ²

Most applications in the first weeks of the second trimester are approved, but abortion becomes illegal once the fetus is viable outside the womb (generally considered to be 21 weeks and 6 days into pregnancy, unless there is a specific medical reason that would make a fetus older than that non-viable). Healthcare personnel who are ethically opposed to abortion are also allowed to abstain from working in all processes involved with providing an abortion. ³

It is unusual for a woman to request an abortion after the first trimester. In 2023, only 4.7% of abortions performed in Norway were after 12 weeks, with just over 600 cases in a country of 5.5 million people, with most abortions in Norway occuring within the first 8 weeks of pregnancy. ⁴

It is hard to get data to compare that with the prevalence of second and third trimester abortions in the United States, as not all states report abortion data nationally (i.e. to the CDC).

Is Norway more progressive on abortion than the United States? Depends on which state! After the overturning of Roe vs. Wade in the U.S. Supreme Court, laws restricting abortion vary considerably from state to state (you can find a map of them here). Legally, Norway’s abortion restrictions are somewhere in the middle between a U.S. red state and a blue state (close to, but a little less restrive than Ohio, where abortions are restricted after 20 weeks).

Abortion is generally seen as something to be done in the first trimester, while still leaving room to make the case for specific exceptions in the first half of the second trimester. (Of course this is a generalization, individual Norwegians have different views based on their own personal ethics and religious beliefs). Growing up in the U.S., I thought there were only two ways to view abortion: you are either Pro Choice or Pro Life. However, after having many discussions with my Norwegian husband on differences between American and Norwegian politics, I realized that while many Norwegians support a woman’s right to choose in the first trimester of pregnancy and think first trimester abortion bans in U.S. red states are extremely conservative, they are just as shocked at how blasé American Pro Choice activists can be about de-stigmatizing second and third trimester abortions, especially in states like Minnesota, which allow abortions post-fetal viability. While individual Norwegians have their own individual opinions on the matter, I would classify Norway “socially moderate” on abortion overall.

Prenatal check-ups

After finding out I was pregnant, the first thing I did after doing an at-home pregnancy test was contact my General Practitioner (GP). All members of Norway’s national insurance scheme are assigned a GP through the state healthcare system, a family doctor who handles all of your basic care and acts as a “gatekeeper” to any further care you might receive through medical specialists. This is similar to the model of care that those with HMO insurance in the U.S. receive. This reduces healthcare costs as patients are less likely to make appointments with specialists when they aren’t warranted, but can be frustrating to patients stuck with a GP who doesn’t take their concerns for seeking a higher level of care seriously. Patients do have the option of requesting to switch GPs if this is the case, but the switch can take months to a year.

After letting my GP know I had a positive pregnancy test, he told me to make a prenatal appointment with him after I had reached at least 6 weeks of pregnancy. At about 7 weeks, I had my first appointment with my GP who took blood work, asked if I had any concerns, and told me to contact the midwife center to schedule the rest of my prenatal check-ups. Norway has a similar prenatal check-up schedule to HMOs in the United States: one main check-up in the first trimester to get established, then two check-ups in the second trimester, and four in the third trimester. The patient can choose whether or not to have these appointments through the local midwife center or through her GP, but most women prefer to go to a midwife. For Americans with PPO health insurance, the public Norwegian healthcare system will most likely offer fewer prenatal check-ups in the first and second trimester compared to what you’re used to in the United States.

The main difference between the Norwegian prenatal check-up schedule and a U.S. HMO, is the type kind of care I receive at those check-ups, and by whom. In Norway, I got initial blood work to screen for infectious diseases (HIV, syphilis, and Hepatitis), vitamin and mineral deficiencies (like iron and vitamin D), and blood typing. However, I did not receive a gynecological exam and never did throughout any of my routine prenatal check-ups, and my HCG levels were never checked (which is a blood pregnancy test), as at-home urine tests are considered accurate enough. These two things may come as a surprise to some Americans. I personally prefer this as I find gynecological exams and other extra tests to be stressful and invasive, but realize other patients may prefer them for peace of mind.

Additionally, follow-up screenings were done by a midwife, not an OB-GYN, who measures fundal height, baby’s heartbeat, and a urine and blood pressure screening for preeclampsia at each visit. At around 24 weeks I scheduled a glucose fasting test at my GP’s office to test for gestational diabetes but did not need an appointment with him in order to do so, he just reviewed the results and sent them to my midwife electronically. I was also offered a whooping cough (Tdap) vaccine booster from my midwife, which I was more than happy to receive, because my city had an outbreak at the time and members of my extended family got infected during my pregnancy, which was more than a little scary for me.

Ultrasounds

Most women are offered their first ultrasound (done at the hospital by a midwife, not at the midwife center) in the second trimester around the 20th week of pregnancy. However, if you are over 35 years of age or have another health condition you are offered an earlier ultrasound at 11-14 weeks along with an optional NIPT test (a blood test that tests for fetal chromosomal abnormalities). This is different than in the United States, as it is customary for all pregnant women to have a routine ultrasound in the first trimester and second trimester.

However, if you don’t qualify for a first trimester ultrasound and NIPT test through Norway’s public healthcare system, you can pay for one through a private OB-GYN (yes, there does exist private healthcare and supplemental private health insurance is offered as a benefit through some employers in Norway). Private OB-GYNs also offer transvaginal ultrasounds around 8 weeks if you want to confirm the baby’s heartbeat. Without private insurance, scheduling these visits cost somewhere between the equivalent of $100 - $200 each.

Additional Care for Higher Risk Pregnancies

If there is a specific health risk, a pregnant woman may be scheduled for more ultrasounds and other appointments at the hospital. Because I have a chronic medical condition, I got two extra ultrasounds conducted by OB-GYNs in the labor and delivery unit of the hospital, instead of midwives, who wanted to see the ultrasounds themselves and interview me to determine if my health condition was worsening with pregnancy. While prenatal care in Norway is generally low intervention, the health system does take higher risk pregnancies seriously, and the amount and type of intervention pregnant women receive are upped based on their appropriateness according to the current, available evidence. For example, I also met with an anesthesiologist in my second trimester to discuss her recommendation that I get an epidural during my upcoming birth. This is not normal, as epidurals are not given during the majority births in Norway (more on that in part two of my series), but because I have a medical condition for which epidurals in labor are recommended according to the existing medical literature, the need to make this available to me was taken very seriously by the hospital staff.

Respect for nature and natural processes

Since becoming pregnant I have heard many mothers and healthcare workers repeat the mantra “pregnancy is not an illness.” In addition to what the healthcare system covers and doesn’t cover, there is a cultural philosophy that pregnancy is natural and shouldn’t be excessively medicalized unless there is a specific health problem that requires more intense observation and intervention. Women are generally given space and respect to manage their own pregnancies, but can request more help or talk to their GP if they are struggling with mental or physical health problems outside of what is considered normal (albeit, mental healthcare through the public healthcare system is not one of Norway’s strengths). As someone with a chronic illness, which both increases my need to have my pregnancy more closely monitored, but which also can be exacerbated by aggressive medical intervention and being on too many pharmaceuticals at once, this philosophy personally works for me.

However, because maternal healthcare is delivered through the public healthcare system, it is designed to be standardized and cost-saving, it leaves less room for the patient to customize their care. Additional care must be medically approved, and is based on what doctors and midwives think the patients needs rather than what the patient wants. Americans with “good” insurance programs through their employers and/or Americans who prefer PPOs or even boutique subscription-based care over HMOs may not be fond of such limitations on their choice.

Cost for prenatal care

Both abortions and prenatal care in Norway incur no additional cost to patients (i.e. there is no co-pay) for members of Norway’s National Insurance Scheme. Members of this scheme include all Norwegian residents, who are required to pay part of their wages, salaries, business income, pensions, or disability benefits as taxes into it, and who then receive access to public healthcare and other benefits in return. As stated earlier, if a pregnant woman wants additional early ultrasounds, she can elect to pay out of pocket or use private health insurance in order to receive them from a private OB-GYN.

Major Takeaways

• Norwegian views on abortion would probably be considered “socially moderate” by Americans, and the overall political temperature on abortion is less polarized

• It is not common for Norwegians to seek abortions past the first trimester, although it is legally permissible in the second trimester as long as it is approved by a board and the fetus is not yet viable outside the womb

• Prenatal care in Norway is more similar to the care an American would receive through an HMO than an American with PPO insurance, offering patients a standardized form of care with fewer choices and lower costs

• Most prenatal care is provided by midwives, not doctors in Norway

• Check-ups are less involved and costly for prenatal care in Norway, unless further testing is specifically medically warranted

• Norway respects the natural process of pregnancy, but is not dogmatic about avoiding medical intervention for women with higher risk pregnancies and in my personal experience, doesn’t limit access as long as there exists evidence to support the intervention

Getting some fresh air in a northern Norwegian fjords at 7 months pregnant

Stay tuned for part two on labor and birth in Norway, which I will write after going through the experience first-hand.

1. According to the WHO: https://data.who.int/indicators/i/C071DCB/AC597B1

2. Helsenorge: https://www.helsenorge.no/en/sex-og-samliv/information-for-anyone-considering-having-an-abortion/

3. Norwegian law: https://lovdata.no/dokument/SF/forskrift/2001-06-15-635/KAPITTEL_4#KAPITTEL_4

4. FHI: https://www.fhi.no/en/ch/registry-of-pregnancy-termination/induced-abortion-in-norway/#2023