The end of German midwifery as we know it?


The disintegrating state of midwifery care in Germany is an issue of great concern, yet somehow it has failed to elicit a passionate response from much of German society. With midwives disappearing from the birth community left and right, I find myself wondering how many women will have to face potentially harmful health issues or unexpected challenges with breastfeeding, postnatal concerns and the like, before German society and its politicians finally begin to listen and value the lives of its citizens.

This morning, I came across a report written by Claudia Wildenrath that appeared in the online version of news publication, Merkur. As very little information about the midwifery situation in Germany makes it way into the English press, I have recapitulated many of the brilliant points Ms. Wildenrath so clearly articulates in her well-written piece as well as incorporated my personal perspective on the situation.

DISCLAIMER: **This is not a translation of Ms. Wildenrath's article.

Midwifery care in Germany, especially in Munich, is in a dire state of affairs. Of the 21,000 midwives registered nationwide, only 3,500 actually attend births. Due to soaring medical malpractice premiums, the vast majority of midwives have transitioned from providing their expert knowledge and skills during childbirth to solely providing perinatal education and care.

In 2001, midwives recall paying a yearly medical malpractice insurance premium of roughly 400€. This past July (2015), that sum has now climbed to surpass 6,000€ annually. One home birth midwife had her tax consultant crunch some numbers. The results: in order to cover the annual cost of her medical malpractice insurance alone, she would need to attend 11 births.

In an effort to find a sustainable solution to this critical and impending public health crisis, the German Midwifery Association (Deutscher HebammenVerband) has been engaging in talks with representatives of the National Association of Statutory Health Insurance Funds (GKV-Spitzenverband) this past year.

At the end of negotiations in September, the GKV-Spitzenverband proposed a plan, declaring a willingness to reimburse up to 2/3 of the medical malpractice premium. The reimbursement, however, would be contingent upon a new set of guidelines requiring midwives to attend, and submit claims for, at least one birth in each financial quarter of the year. Yet there's much more to it. Along with these administrative guidelines, new protocols have been developed in order to "ensure the safety" of mothers and babies. Midwives claim that some of these are not evidence based.

One such example would be a mother whose pregnancy continues beyond three days past her estimated due date. In order to maintain eligibility for a home birth, the expectant mother would have to schedule an appointment to be examined by an obstetrician and obtain a certificate of good health stating that birth at home still remains a safe option. For midwives, this raises many concerns. Across Germany, obstetricians' offices are routinely closed on weekends and holidays meaning that pregnant women would be unable to obtain the necessary paperwork in the specified timeframe to remain eligible irrespective of their state of health. Beyond such logistical obstacles, midwives are concerned that any remote health concern, such as low amniotic fluid (which evidence indicates cannot always be accurately ascertained), discovered at one of these examinations may bind obstetricians, from a legal perspective, to withhold approval or potentially risk litigation themselves.

Consequently, it appears that a midwife attending a home birth may not receive any reimbursement for the entire year if the only mother she supports in that quarter develops, at short notice, a health concern risking her out of a home birth and requiring her medical care to be transferred an obstetrician.

In the past, midwives had been able to receive a medical malpractice "allowance" for each individual birth. Should the new requirements proposed by the insurance providers take effect, this allowance would no longer be allocated. The implications of this would be a clear financial disadvantage for midwives providing care to multiple families as they would receive less compensation for their services than they do at present. This can only be categorized as the marginalization of an entire profession built upon providing medically safe, woman-centered care.

And, as a part of the profession, home birth midwives gladly make personal sacrifices to be able to serve the women and families in their communities. They spend much of their personal and professional lives on-call, abstaining from day trips and occasionally, or even frequently, missing out on holidays and special family occasions.

Under such conditions, home birth, and quite possibly all out-of-clinic births, are set to disappear completely from the otherwise relatively broad spectrum of birth options available in Germany currently, and with it, women's right to choice in childbirth. In 2013, there were 2,200 out-of-clinic births in the Free State of Bavaria based on statistics collected by the Landeshebammenverband, the Bavarian Midwifery Association. This total constituted 2% of all births. Of these, nearly a third of the children were born at home.

It's not just the midwives who attend home birth who are affected. Midwives working in clinics may face losing their jobs as clinics and hospitals, especially in more rural areas, seek to reduce costs by discontinuing midwifery and obstetric care. Within the past several years, 25 maternity units of the 140 there once were in Bavaria have been made obsolete with even more on the verge of closure.

For many expectant mothers outside metropolitan areas, this means longer travel times to a chosen birth location possibly while in labor. As it stands now, Bavarian midwives have noted a clear strain on the remaining clinics and hospitals to accommodate the increasing flux of mothers requiring perinatal and intrapartum care.

Many of these clinics in the Munich area work with midwives who share the same self-employed status as their home birth counterparts and are thus obliged to pay the same skyrocketing medical malpractice insurance premiums. If costs continue to rise, the midwifery model of care may soon vanish from several clinics in and around Munich which reportedly to work with teams of self-employed midwives. These are said to include clinics such as Starnberg, Dritter Orden and Taxisstraße.

The struggle to provide adequate obstetric care is particularly evident in Munich. In past months hopsitals and clinics have had to turn away women in labor because their wards are full - even in cases in which mothers had registered early on in pregnancy. Some clinics recommend registering as early as 8 weeks in order to best guarantee availability around the estimated due date.

Due to over-filled maternity floors, some midwives are opting to leave the profession on their own accord. Understaffed, many find themselves responsible for all delivery suites and accompanying examination rooms together with only one other midwife. **As a doula, I have seen the grave toll an understaffed facility can have on the physical, mental and emotional well-being of birthing mothers hoping to experience the most memorable and profound moment of their lives.

Germany has also been both well respected and well renowned for the invaluable - not to mention stellar - quality of postnatal care midwives provide to new families. Yet telephone calls to over 20 postnatal midwives has yielded no results for some families living in Munich. German midwives play a central role in ensuring the health and safety of babies and their mothers after birth in the comfort of their own homes. If the ever-rising costs of insurance premiums drive midwives out of the birth community before, during and after birth, what will remain?

What can you do? Join the Midwifery Support Facebook group to follow developments, updates and find out about the specific ways you can contribute:

Midwifery Support

To read the original article in German, please click on this link:

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If you have any comments or suggested corrections for any information I may have misunderstood from the original, I am happy to make any necessary revisions. Thanks so much!

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