Germany’s remorse for its Nazi past is well known. To this day, many Germans have an uncomfortable relationship with nationalism, and the government continues to pay billions of dollars in reparations 70 years after the end of the Second World War. As of 2012, they had paid out $89 billion to Holocaust survivors.
And yet, Germany retains at least one Nazi policy: In 1939, Adolf Hitler’s government passed the Hebammengesetz law, mandating that all German babies had to be delivered by German midwives. Not a doctor, but a midwife. “[Nazis] were notorious penny-pinchers,” Patty Stokes, assistant professor of Women’s and Gender Studies, Ohio University, told Ozy magazine.
Prior to the law, midwifery had almost died out in the early 20th century, Robert Proctor wrote in his book Racial Hygiene: Medicine under the Nazis. This was due to the professionalization of medicine and the growing influence of gynecology. Hebammengesetz ended up unintentionally reviving midwifery in Europe.
The law helped keep tabs on the number of Jewish, handicapped, and ‘undesirable’ babies born. The Nazis also encouraged a return to nature, including traditional medicine — perhaps because Hitler himself did not smoke or drink. But the moving force behind this policy was the mother of the Reich’s health minister, a woman named Nanna Conti who was a midwife. Proctor noted that Conti had presented evidence that maternal mortality was highest in those industrialized countries where hospital births were the sole method of giving birth.
Current evidence for the midwife-based model of care remains strong. The Lancet edition on midwifery (2014) notes that outcomes improved by midwifery care include reduced maternal and newborn mortality, reduced stillbirth, and fewer newborns with low birth weight, among a host of other health benefits for mother and child. And the Lancet analyses found that women reported “greater satisfaction” with midwife-based care.
Over the past decade, however, midwives in Germany are increasingly dropping out of the work of attending to birth.
The German Midwives Association estimated that of the 23,000 registered midwives in the country in 2015, less than 60% attend to birth. Instead, many trained midwives are opting for less stressful work, like conducting pre- and post-natal classes on topics like breathing, nutrition, and breastfeeding.
“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.”
AA tangle of factors is responsible for the recent decline of midwifery, primary among them the soaring cost of liability insurance. Over the last decade, the annual liability premium paid by midwives — to pay for damages in medical negligence cases — has climbed from about 1,200 to 6,200 Euros ($1,400-$7,200) for an independent midwife. This has hit independent midwives hardest, who unlike hospital-employed midwives have to pay out of their own pockets.
High insurance costs have led to a number of maternity unit closures — over 130 in the last seven years. Non-urban areas are especially badly affected, leading to hospitals in large cities being over-crowded. “On one night shift, I saw 2 midwives attending to 6 births at one of the largest Berlin hospitals,” said journalist and writer Eva Schindele, who has been reporting on the crisis for the German press. The UK’s health watchdog, the National Institute of Health and Care Awareness, recommends a one-on-one ratio of midwife to women during labor.
Then there was the case of Eva Rockel-Loenoff, a well-known midwife and doctor. In 2014, Rockel-Loenoff was convicted of homicide and sentenced to seven years in jail for the death of a baby born in breech position under her supervision in 2008. She birthed the baby at the hotel the parents were staying in, and was accused of not moving to a hospital when there was indication, and later evidence, of the baby choking on meconium (fetal feces) during labor.
Schindele, who reported the case for the Munich-based daily newspaper Sueddeutsche Zeitung, wrote that the verdict of homicide for Rockel-Loenoff was a first in German legal history. It’s quite clear that Rockel-Loenoff made a mistake here; a verdict of homicide indicated it was intentional.
“The possibility that midwives might be jailed has snapped something in the community. “It is the straw that broke the camel’s back,” Giesen said. “High premiums, now even the possibility of jail. It just doesn’t seem worth it.”
“T “The crisis is really harder on the mothers,” said Katharina Hartmann, a member of the German activist organization Motherhood. “A lot of the midwives that I know quit attending birth but they continue to earn their livelihood by teaching baby yoga, pregnancy sport, prenatal preparation. What about mothers in labor? Women have to travel longer distances if a local birth unit closes. The remaining birth units tend to be more and more over-crowded. Several hospitals that offered twin births and breech births do not offer them any more because they lack the staff to do these.”
Motherhood has been organizing protests and marches across the country for several years. The German media too has been reporting the issue for several years now. There are other, more intangible, reasons why midwives are leaving their profession. The work pressure on midwives means less attentive, and less respectful care. The possibility of a genuine conversation about choices and consent is less likely too, according to midwifery researcher Christiane Schwarz.
There is also a devaluing of the skills of midwives, said Brigitte Sanden, a gynecologist and obstetrician practicing in Munich for over three decades. “That [midwife] law is still in place but only in the letter. Midwives still need to sign for birth but hospitals want doctors present even when the midwives don’t need their help. I am often asked at my hospital why I wasn’t present at a birth. I find this problematic, why is it necessary to pull rank between doctors and midwives in this way?”
“I learnt about birth by watching the midwives at work,” said Sanden. “As a fresh graduate, you realize there are so many things the books don’t tell you. Today, midwives are on the clock, and are just as likely to induce labor or carry out an intervention. We doctors are losing out on what we can learn too.”
