Ten years ago, Dr Christiane Schwarz - a lecturer and researcher - decided that she could no longer continue working as a midwife in Germany. “It was not so much about how we were treated but how the labouring women were treated, she says. “Having worked in the UK and New Zealand, I knew it is possible to care for women and babies with much more respect”.
Schwarz’s decision also had much to do with how midwives are treated in Germany: squeezed by flat wages, work pressure and a strict system of accountability that can send them to jail. The German Midwives Association estimates that of the 23,000 registered midwives in the country in 2015, only 13,430 attend to birth. “There was a time when all midwives attended to birth,” said Astrid Giesen, chairperson of the Bavarian Midwives Association. “After all, our profession is birth.”
Now, however, an exodus of midwives is under way. A tangle of factors is responsible, principal among them soaring insurance premiums,which have resulted in a substantial number of maternity unit closures. From 2010 to 2017, they have decreased from 807 to 675, according to the Federal Statistical Office of Germany. “On one night shift, I saw two midwives attending to six births at one of the largest Berlin hospitals,” said journalist Eva Schindele, who has been reporting on the crisis for the German press.
Then there’s the case of Anna Rockel-Loenhoff, a midwife and doctor well-known for advocating vaginal birth. In 2014, she was convicted of homicide, not negligent birth, for the death of a baby born by breech birth in a hotel room near her practice in 2008. She was sentenced to seven years in jail. Midwives are, of course, liable for medical negligence. This is why they pay for insurance. But the possibility that they might be jailed has snapped something in the community. “It is the straw that broke the camel’s back,” Giesen said. “Poor salaries, high premiums, now jail. It just doesn’t seem worth it.”
The repercussions from this affect women and newborns, too. In 2013, the last year for which comparative OECD data are available, Germany’s C-section rate was 30.9%, one of the highest in Europe. Only Switzerland, Poland, Portugal, Hungary and Italy had higher rates according to this data. The second European Perinatal Health Report, looking at comparative data from 2010, offers another significant statistic: at 15.9%, Germany has among the highest rates of emergency or non-elective Caesareans, second only to Malta and Romania. A higher rate of non-elective Cesareans as against elective Caesareans likely reflects decisions made under pressure during birthing. The World Health Organisation recommends a range of 10-15% for C-sections.
The damage is also qualitative in nature: the medicalisation of birth, and the lack of respectful care that troubled Schwarz so much that she quit. This kind of change is unfortunately not reflected in statistics. But it is starting to be acknowledged as a problem. In 2007, when Venezuela passed the Right of Women to a Life Free of Violence, it included excessive medical interventions and coercion at birth as a violation of human rights: the term used is “obstetric violence”.
Prof Lesley Page, the former president of the Royal College of Midwives in the UK, told me: “Midwives around the world, and Germany is no exception, often leave the profession because they are frustrated at not to be able to give it their best. This, as in Germany, is often because of the medicalisation of birth, the overuse of interventions including caesarean section, poor status and lack of respect in the health services, and difficulty in gaining insurance to practise autonomously.”
Today’s healthcare system necessarily involves co-reliance; it’s rare to find midwives and doctors working in isolation. Midwives, according to the Lancet series on Midwifery published in 2014, are better suited to low-risk births, the medical model to potentially risky ones. The series contended that midwifery holds knowledge of biological, cultural and social factors that aid labour, breast-feeding and the many changes the body goes through during and after pregnancy, and that women reported “greater satisfaction” with midwifery care. In 2011 and 2014, the United Nations Population Fund (UNFPA) brought out reports titled State of the World’s Midwifery emphasising that high-quality midwifery services are essential to improving maternal and newborn health across the world.
Some correctives are under way in Germany, albeit belatedly. In the past two years, the National Association of Health Insurance Funds has refunded two-thirds of the insurance fee to midwives, Schindele told me. But some of the damage might be irreparable. “I see now that midwives work just like doctors,” said Dr Brigitte Sanden, a gynaecologist and obstetrician in Munich. “They are on the clock, and are just as likely to induce labour or carry out an intervention. I myself learned about birth by watching the midwives. As a fresh graduate, you realise there are so many things the books don’t tell you. I worry about how much us doctors are losing out too.”
