German and Australian postpartum care
Interview with Ruth Gray
I chat with Newborn Mothers graduate and German qualified midwife, Ruth Gray. Together we discuss the publicly funded postpartum care system in Germany that brings together medical and personal care. At the core of this conversation, we explore how Germany views this comprehensive continuity of care as essential for women's wellbeing and what we can learn from this system in countries without it.
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About Ruth
Ruth Gray qualified as midwife in Germany in 2007, as yoga teacher in 2011 and most recently as a Pilates instructor. Ruth provides support, care and guidance to new mothers in their homes before and after birth to ensure that they feel loved, supported, nurtured and assisted in the beginning stages of motherhood.
Ruth is trained and qualified in breastfeeding support, nutrition, pre- and postnatal massages incl. labour preparing massages after Dr. Gowri and babymassage, Yoga and Pilates incl. pre- and postnatal. All of Ruth's services are offering support and care, without administering any medical treatment. She is a mum to 3 beautiful children Martha, Henry and Frieda and lives on the Mornington Peninsula.
We explore the following questions:
Is postpartum care in Germany fully funded? And can people choose their own midwife?
Do you know the history of how this program came to be funded by private health insurance?
Could you choose a midwife with a particular interest, cultural background or whatever angle you’re looking for that’s going to be right for you?
Have you worked as a midwife in Australia?
Can you tell me anything more about the German system that we might find surprising? What is the cultural attitude to postpartum care?
Are there any still any traditional German postpartum care like rituals or ceremonies that are still practiced commonly or has that all kind of been lost?
Do you find that people like family and friends have a much better understanding of postpartum needs just because of that culture of care?
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Transcript
Julia Jones:
Hello and welcome to the podcast. Today we have Ruth, who I've been trying to catch up with for ages because she has a really fascinating perspective as a German woman who's birthed in both Germany and in Australia. You'll know recently we had a podcast interview with Layla who was Irish and had had babies in both Germany and Ireland. I was really fascinated to learn more about the German system because it does sound like one of the better places in the world to have a baby, particularly for postpartum care. Ruth, you particularly have an interesting perspective as a midwife and a mother. Do you want to introduce yourself?
Ruth Gray:
Hello. Yes, so my name's Ruth. I did a midwifery education in Germany and have worked there as a midwife providing prenatal and postnatal care and also home birth. But since the system is different in Germany as a midwife you see women not just to help them deliver their babies, you see them in their pregnancy and mostly or mainly after they come back home. So the first eight weeks after women give birth, they have a midwife come to their house and look after them and the baby, and just check on everything that might come up. Just the breastfeeding, the weight of the baby, the healing of the mum, and of course the whole family unit, including the fathers and anything that pops up in that time. Then if it's necessary, you can see the midwives for longer. I usually saw the women I took care of, for probably, so when they started to be pregnant until the babies were about a year old when they had a final meeting to let them off into the world.
Is postpartum care in Germany fully funded? Can people choose their own midwife?
Julia Jones:
That's beautiful. One thing that really struck me, it's fully publicly funded and women can choose their midwife. Is that correct?
Ruth Gray:
That's right. It's all taken care of by your health insurance that you have, and yeah, you just look for a local midwife. Since I left Germany in 2011, there's a shortage of midwives now. So what I've heard recently is that it's actually quite hard or it can be hard, especially in the rural areas, to find a midwife to come and see you. So at the moment, I think it's nearly as soon as you figure out that you are pregnant you ring around and book your spot with the midwife that you can book in with. Quite interesting.
Julia Jones:
And it has to be a midwife, it can't be a doula or any other kind of allied health professional.
Ruth Gray:
No, no. It is a midwife. The doula system isn't very common in Germany. It has become more common now because the midwives in the hospitals are generally quite busy and understaffed. So there are more doulas popping up to just accompany women for their birth, but I haven't heard of any postpartum doula so far just because-
Julia Jones:
Yeah, you wouldn't need one necessarily, because the midwife system is so good.
Ruth Gray:
Yeah. But I don't know, maybe there might be somebody who introduces that system to the German system just because there is a shortage of midwives to look after you.
Do you know the history of how this program came to be funded by private health insurance?
Julia Jones:
And just to backtrack a little bit, sorry, you said it's funded by private health insurance. Do you know the history of that at all?
Ruth Gray:
Sorry, the history of what?
Julia Jones:
Of how it came to be funded by private health insurance? Do you know when or how that happened?
Ruth Gray:
No, I'm not sure. I think after the World War II the whole system was just kind of overlooked and then really sorted through, and that was considered one of the basic needs for families or for women. That's just how it came to be funded by either if you're privately or normally insured, that's just taken care of.
Julia Jones:
And everyone has insurance in Germany.
Ruth Gray:
Yes. Yeah.
Julia Jones:
And is that sort of instead of a public health system or as well as?
Ruth Gray:
No, it is the public health system. The difference to Australia is that Medicare is funded with taxes from my understanding and in Germany it is that there is a percentage of your wage taken out which then pays for the insurance that you've chosen. There's different providers so you can just pick one that you like or that's local, and then that's just taken out of your wage, and that's how it's paid for. So the women don't pay the midwife. As a midwife, I bill the insurance and then I get the money paid out to me.
Julia Jones:
Oh, that's great. So mums don't even have to find the cash upfront or anything.
Ruth Gray:
No, no, nothing, no, all they do is give me their insurance card and I take the numbers down and then they have to sign the visits that I do so you can't cheat on how many visits you've done, but that's all, then they don't have anything else to do with that.
Could you choose a midwife with a particular interest, cultural background or whatever angle you’re looking for that’s going to be right for you?
Julia Jones:
Yeah, that's amazing. Then the other question I had was, we were talking in the last podcast about how a lot of the time the midwives do have other skills, a lot of them might have done certain herbal courses or acupuncture, and that's not seen as in conflict, because in Australia there's very much a division between medical and any other allied health. But it sounds like in Germany that's much more [accepted]. You could choose someone with a particular interest or cultural background or whatever angle that you're looking for that's going to be right for you.
Ruth Gray:
Yeah, that's right. Yeah, because there is a law that you have to have continuous... What do you call it? Continuous learning in your job as a midwife so I have to fulfill, I don't know, 12 hours of professional learning per year. A lot of midwives use that to do acupuncture or do Ayurvedic things, or even, I don't know, mental health issues, how to help with that. So as a woman, if you have enough midwives to choose from you can pick the one that's most to your liking.
Julia Jones:
I love it. And so you've got three children, did you have two there?
Ruth Gray:
I do. No, I had them all in Australia.
Julia Jones:
You've had them all in Australia and that must have been quite a shock for you.
Ruth Gray:
I was shocked especially in the after birth care. I did have a private midwife because I had planned to have a home birth because since I'm a home birth midwife or I was, I wanted to have a home birth, but it didn't work out. But she did do the postnatal care with me too which was great because even with all my knowledge, I felt overwhelmed and I struggled, and I just had to have somebody to say, "Yes, this is normal. You are doing a good job. It's normal that children cry and babies cry." Things like that.
But what I found too, that with the system, with the maternal child and health nurse, while it gives at least a little bit of help along the way, but my first one was a cesarean and I couldn't drive for six weeks. Luckily I had in-laws who could drive me to the maternal child and health nurse's office, but otherwise I couldn't have reached them. So I thought, yeah, there's a bit of a need here, in my opinion, to have people come to women's houses and just look after them in their own home.
Julia Jones:
Yes, absolutely. I have to say that's one of the biggest benefits of a home birth. Even if you don't birth at home, which I didn't end up having any of my children at home, but I did have home birth midwives just because then they could do all my prenatal and postnatal checks at my house. Particularly with more than one child I found that was just the hugest benefit. There's nothing worse than trying to get your toddler and your newborn and your four-year-old or whatever, all into the car to go to see the child health nurse or to go and get vaccinations or to check up with the hospital. It's so much nicer if they just come to you.
Ruth Gray:
Oh, yeah. And they have time. I think I had two visits with a GP because I was with the hospital to book in. They wanted to see me twice, and they just saw me for five minutes and the waiting time was 45 minutes and then they saw me for five minutes. When I had my midwife come to my house to do the antenatal checkups she was here for an hour.
Julia Jones:
Yes. And even if she's running late, you're just sitting at home anyway so you don't have to work with the baby or get dressed.
Ruth Gray:
That's right. Yeah.
Have you worked as a midwife in Australia?
Julia Jones:
Yeah, I know. It's such a huge difference. You haven't worked as a midwife in Australia?
Ruth Gray:
No, I haven't because education is an apprenticeship in Germany, so you do three years. It's very practical. So you work mainly as a midwifery student in the hospital alongside midwives, qualified midwives, but because in Australia you go to uni and do a bachelor or a master. So my license is actually not recognized in Australia.
Julia Jones:
Which again it's that real division between medical care and just more personal care, isn't it? But it sounds like Germany is a lot more balanced that midwives obviously know the red flags. So you'd know when to refer onto a pediatrician or when to get a lactation consultant in, and that sort of thing. You can do the basics like blood pressure and fetal heart rate and things, but as long as things stay within the realm of healthy and normal then you could take care of all of that. Whereas in Australia, I think a lot of midwives feel like they're being pushed into a much more medical role that actually means they can't be with women in the way that they really wanted to be.
Ruth Gray:
Yeah. That's what I've observed in the hospital that I gave birth. I went to a public hospital, and it seemed to me like there was a lot of paperwork done and a lot of administration guidelines to be followed which took a lot of the time up for the midwife who was wanting to be with me to give birth.
Can you tell me anything more about the German system that we might find surprising? What is the cultural attitude to postpartum care?
Julia Jones:
Can you tell me anything more about the German system that we might find surprising? I'm curious, for example, what the cultural kind of attitude is to postpartum care given it's so much more normal over there.
Ruth Gray:
The official which is actually in the law, if you wanted to go back to work after you give birth, the first eight weeks are absolutely nearly sacred. You weren't allowed to do it even if you wanted to. So in that period it's probably more like six weeks in the back of the minds of people, but these six weeks are very much considered as a period of rest and a period for the mum to get back onto her feet. So the families are prepared to step in. This is obviously also the period where the midwives come the most often. So I would come to the women's house probably daily at the start in the first week, and then every other day, and then slowly reduce it to at the end of that timeframe, probably once a week.
You do leave the house to see the pediatrician I think around the day 14 for a baby to just have a little checkup, but apart from that there's nothing considered really seriously important to be able to leave the house or to make you leave the house. This is also where a lot of people come in to help. So this is where people would bring you food or your family or your friends or your community, depending who's around you, they would step up and help out and also kind of leave you space if you wanted to. So probably the first two weeks the only visitors you'd get is probably the family or the close friends, and everybody else kind of waits to see baby and mum until they're at least settled in a little bit.
Are there any still any traditional German postpartum care like rituals or ceremonies that are still practiced commonly or has that all kind of been lost?
Julia Jones:
And are there any still any sort of traditional German postpartum care like rituals or ceremonies or anything that are still practiced commonly or is that all kind of been lost?
Ruth Gray:
I've been thinking about it after listening to what is traditional in your country question and I can't pinpoint anything that I would say this is specifically German. Yeah, no, I can't. It's a kind of mix of things now, which come from different cultures, but I think that the really only traditional thing is the timeframe that's been left up to this day with the eight weeks.
Julia Jones:
Yes. Which I think described, as Layla said, I think she said two weeks in bed, two weeks around the bed, and two weeks around the home or something. Is that something... Or the neighborhood even.
Ruth Gray:
Yes, that's right. That sounds right.
Do you find that people like family and friends have a much better understanding of postpartum needs just because of that culture of care?
Julia Jones:
I can't remember exactly what she said, but she said as an Irish person, she learned that in Germany and found that quite like, oh, that's a really good thing conceptually to give yourself that space. So you find that people like family and friends have a much better understanding of postpartum needs just because of that culture of care?
Ruth Gray:
Yeah. Yeah. I mean, they grow with it too. So the first baby is probably, people are more keen to come and see you, whereas then if you have the consecutive children they know more and they know better on what actually is needed for the new mum and the dad.
The dads, by the way, that's awesome too. Compared to here, they get 64, oh, sorry, 46, no, 64 hours, get the numbers backwards, 64% of their wage is being paid out, and they have paternal leave where they can choose everything in between six weeks and three months, and then they go back to work after that.
So a lot of dads choose to be home after the baby is born for at least four weeks or maybe even the full six weeks at the start. If there's a premi baby or if something's going on and the dad needs to stay at home longer, that's possible too, which I found I missed here because my partner had only two weeks off after each baby and he was flat out for two weeks, so he didn't get any rest himself and then he had to go back to work.
Julia Jones:
Yeah. So they can choose the amount of time and they get that time off at 64% of their regular wage.
Ruth Gray:
That's right. Yeah.
Julia Jones:
Oh, that's amazing. I have a friend here who's just had a baby and the father is trying to... They had a cesarean and she's struggling a little bit, as most women do, and he tried to extend his two weeks of parental leave by adding his carer's leave. So he asked his employer if he could use his carer's leave to care for his wife because she can't drive or lift heavy things or any of that stuff and they said no. So they're feeling really quite upset about that and they're not sure whether they push it too much, but they don't want him to lose his job. It becomes very difficult, doesn't it?
Ruth Gray:
Yeah, it does. Yeah.
Julia Jones:
Yes. And two weeks I think it's not enough. I mean, you're only just starting to get to know each other by then.
Ruth Gray:
Yeah. Yeah. You're just kind of coming down from giving birth. I did after two weeks.
Julia Jones:
Yes. That's right. Just starting to find your rhythm and things, but it's very early, isn't it? Oh, wonderful. Is there anything else you can think to share with us?
Ruth Gray:
No. Not at the moment.
Julia Jones:
It sounds like you managed to replicate a little bit of the German system just by having a private midwife here, yeah?
Ruth Gray:
That's right. Yeah. Yeah, that was right. So yeah, as you I didn't have a home birth or I didn't plan a home birth for the second and the third, but I still did my prenatal and postnatal care with her because I knew that I just need it. Even with my second and my third, because every baby's different, they needed different things, and then I needed different things so it was great.
Julia Jones:
And the more children have the more help you need, really.
Ruth Gray:
That's right. Yeah. Even if the handling gets easier I think you just need more rest for yourself or more help for yourself.
Julia Jones:
Yeah, that's right. Because a lot of people think, "Oh, I've got the hang of it now." And yes, it is easier to parent because you have a better idea of what's normal, you might be a bit more confident and more in touch with your intuition, but at the same time, there's more mouths to feed and more shopping to do and more nappies to change and more laundry, and it's just more tantrums to deal with all of that kind of stuff. The more help the better.
Ruth Gray:
That's right. Yeah.
Julia Jones:
Wonderful. Thank you so much for sharing, Ruth. I think it's really insightful.
Ruth Gray:
Thank you. My pleasure.
Julia Jones:
Yes, and hopefully we can do something to improve our system here in Australia and also in other parts of the world because yeah, there's really not many places in the world that have that comprehensive postpartum care that's completely free and the woman's choice who she has to support her. So it's really amazing to hear about.
Ruth Gray:
Yeah, it would be great to just... Because there are systems out there that are working so I would hope for Australia to just say, “Oh, let's copy exactly the system that's already running and up and obviously working quite well."
Julia Jones:
Yes. On that note, I wonder if you know if there's any data about Germany's breastfeeding rates, postpartum depression rates, returning to work. Do you know if there is any kind of studies done on how... I know this sounds a bit brutal, but economically successful that system is because that's often the way we get to the change to go through.
Ruth Gray:
Yeah. I'll research that. I'm not sure, but I'll stretch out my feelers a bit and then I can get back to you on that.
Julia Jones:
Yeah, I'll look into it as well. Because that's the other thing, if we can find models and not just say it's nice for the mum, but actually have some solid proof.
Ruth Gray:
Yeah, it actually works.
Julia Jones:
Yeah. Awesome. Thank you so much. It's been really inspiring.
Ruth Gray:
Thank you.
