Health insurance in Germany is compulsory. Among the covered basic services are pregnancy-related and maternity care services, which include, among other things, midwife assistance. Obstetric care in Germany can only be performed by doctors and midwives. Doctors are required by law to consult a midwife for the delivery of a child.
The profession of midwife is regulated by law. Only people who fulfill the educational requirements and receive an authorization may practice as midwives. The education and practice of doulas on the other hand is not regulated by law. Voluntary doula classes are offered by various doula organizations in Germany. Doulas are a fairly recent phenomenon in Germany. They provide nonmedical services, which are therefore not covered by health insurance.
I. Overview of the German Health Insurance System
Health insurance in Germany is compulsory. Everyone whose annual income is below a statutorily defined threshold must purchase statutory health insurance (gesetzliche Krankenversicherung, GKV), whereas everyone who earns more than that may instead elect to purchase private insurance (private Krankenversicherung, PKV). The statutory income threshold is recalculated every year. For the year 2019, it is set at €60,750 (about US$68,304). Unemployed persons are also subject to the insurance requirement. Self-employed persons may choose to purchase private insurance instead of statutory health insurance, as they are not subject to the insurance requirement.
Even though insurance is compulsory, people who are subject to the insurance requirement may freely choose their insurance company. The selected insurance company must accept the person as a member.
All health insurance companies are required by law to offer certain basic services, but they may cover additional services. Covered basic services include pregnancy and maternity care, which include, among other things, midwife assistance, the prevention of illnesses and the aggravation of illnesses, birth control, sterilizations, abortions, the assessment of health risks and early detection of diseases, treatment for diseases, and medical rehabilitation. The law contains an exhaustive list of permissible additional reimbursable services—for example, additional midwife services for pregnancy and maternity care beyond the already covered basic services.
II. Pregnancy and Maternity Care
The covered pregnancy-related and maternity care services include medical care and midwife assistance; the supply of medicines, bandages, therapeutic products, and assistive devices; delivery of the baby; in-home care; home help; and maternity pay. The law further clarifies that the right to midwife assistance applies to pregnancy and the time during and after delivery, including the diagnosis of pregnancies and prenatal appointments. In addition, there is a right to midwife assistance postpartum for up to twelve weeks after the birth; any postpartum care services beyond the twelve weeks must be prescribed by a doctor. If the mother as the insured cannot take care of the child after the birth, for example because she died, the right to midwife assistance is transferred to the child.
What falls under midwife assistance is further specified in a contract concluded between the Central Federal Association of Health Insurance Funds (GKV-Spitzenverband) and the professional associations that represent midwives (Midwife Assistance Agreement). It includes prenatal services and care, obstetrics, services during postpartum care, and help to deal with breastfeeding difficulties or feeding problems in babies.
For delivery of the child, women have a choice between outpatient or inpatient delivery. A child can be delivered either in a hospital, in an institution run by midwives, in a midwife practice, or at home. In 2017, 98.72% of babies in Germany were born in a hospital; only 1.28% were born at home or in birth centers. Doctors are obligated to consult a midwife for delivery of the baby. With the exception of emergencies, only midwives and doctors may provide obstetric care. Obstetric care is defined as monitoring of the birth process from the start of the first contractions on, assistance with the birth itself, and monitoring of the postpartum period.
III. Regulation of the Profession of Midwife
The German Midwife Act regulates who can use the professional title “midwife.” It provides that anyone who wants to use that title requires an authorization. Such an authorization will be granted to persons who have fulfilled the educational requirements and passed a state exam, who have not exhibited any behavior that would make them untrustworthy to perform the job, who are not unsuitable health-wise to perform the job, and who have the required German language skills to perform the job. Currently, the German Midwife Act provides that midwives must complete a three-year apprenticeship consisting of theoretical and practical study and practical training. Courses and training are provided at accredited midwife schools in hospitals. The apprenticeship concludes with a state exam. In order to be admitted to a midwife apprenticeship, the person must have completed either ten years of general school education; nine years of general school education followed by two years at a nursing school or followed by an apprenticeship of at least two years; or have an authorization to work as a nurse.
However, the current version of the European Union (EU) directive that regulates midwifery education and practice in the EU, among other professions, requires that midwives complete at least twelve years of general school education. In March 2019, the German Federal Ministry of Health (Bundesministerium für Gesundheit, BMG) published a draft act that would amend the Midwife Act to improve the education of midwives and to implement the requirements of the 2013 EU Directive.
Midwives work either as employees at a hospital or as freelancers. In 2017, around 11,230 midwives were employed at hospitals. Around 20,070 of the freelance midwives were organized in the German Midwives Association, the Federation of Freelance Midwives in Germany, and in the Professional Association for Home Birth Assistance. However, as membership in a professional organization is not mandatory for freelance midwives, actual numbers might be higher. In addition, membership might overlap.
Until a few years ago, doulas were not very common in Germany. According to statistics published by the association Doulas in Germany (Doulas in Deutschland e.V.), in 2008, seventeen women had a doula present during the birth. The education and practice of doulas is not regulated by law in Germany. However, three organizations offer doula classes that women can take voluntarily to get certified as a doula.
Doulas provide services considered nonmedical in nature and therefore do not qualify as pregnancy and maternity care services covered by health insurance; only midwife assistance qualifies as outlined above. Anyone who wants to use doula services therefore must pay for it out-of-pocket. A position paper published by the German Midwives Association in 2010 stated that “doulas do not perform medical services for a birth; those are reserved for midwives alone.” In addition, “midwives are generally not liable for the work of a doula. The doula has the status of an accompanying person.”
The paper points out that “the common goal of midwives and doulas is to achieve appropriate and comprehensive one-on-one care that allows for a low level of intervention during the birth assistance.” However, it criticizes the fact that the tasks and costs of doulas are transferred to the woman, even though a lot of the services that midwives and doulas perform overlap and are covered by health insurance. It therefore suggests improving information about nonmedical services performed by midwives and ensuring the nationwide provision of midwives.
Foreign Law Specialist
 Sozialgesetzbuch (SGB) Fünftes Buch (V) – Gesetzliche Krankenversicherung [SGB V] [Social Code Fifth Book – Statutory Health Insurance], Dec. 20, 1988, Bundesgesetzblatt [BGBl.] [Federal Law Gazette] I at 2477, as amended, § 5, http://www.gesetze-im-internet.de/sgb_5/SGB_5.pdf, archived at https://perma.cc/7WQT-RVCL.
 Id. § 5, para. 1, no. 1, § 6, para. 1, no. 1.
 Verordnung über maßgebende Rechengrößen der Sozialversicherung für 2019 [Sozialversicherungs-Rechengrößenverordnung 2019] [SVBezGrV 2019] [Social Security Operand Regulation 2019], Nov. 27, 2018, BGBl. I at 2024, § 4, para. 1, http://www.gesetze-im-internet.de/svbezgrv_2019/SVBezGrV_2019.pdf, archived at https://perma.cc/B4YE-3SNU.
 SGB V, § 5, para. 1, nos. 2, 2a.
 Id. § 5, para. 5.
 Id. § 173, para. 1.
 Id. § 175, para. 1.
 Id. § 2, para. 1, §§ 11-68.
 Id. § 11, paras. 1, 2.
 Id. § 11, para. 6 in conjunction with § 24d.
 Id. § 24c.
 Id. § 24d.
 Id. § 24d, sentence 2.
 Id. § 134a; Vertrag über die Versorgung mit Hebammenhilfe nach § 134a SGB V [Hebammenhilfevertrag] [Agreement on the Provision of Midwife Assistance According to § 134a SGB V] [Midwife Assistance Agreement], Sept. 25, 2015, as amended, https://www.gkv-spitzenverband.de/media/dokumente/krank enversicherung_1/ambulante_leistungen/hebammen/aktuelle_dokumente/1_Vertragstext._Hebammenhilfevertrag_09-2017.pdf, archived at https://perma.cc/5PSA-V7YZ; Anlage 1.2 Leistungsbeschreibung zum Vertrag über Hebammenhilfe nach § 134a SGB V [Annex 1.2 Description of Services for the Agreement on Midwife Assistance According to § 134a SGB V], Dec. 11, 2017, https://www.gkv-spitzenverband.de/media/doku mente/krankenversicherung_1/ambulante_leistungen/hebammen/aktuelle_dokumente/Hebammen_Lesefassung_Leistungsbeschreibung_ab_2018-01-01.pdf, archived at https://perma.cc/LC4W-H3RG.
 Midwife Assistance Agreement, supra note 15, preamble.
 SGB V, § 24f.
 Geburtenzahlen in Deutschland [Birth Numbers in Germany], Gesellschaft für Qualität in der außerklinischen Geburtshilfe e.V. [QUAG] [Society for Quality in Out-Of-Hospital Obstetric Care, http://www.quag.de/quag/geburtenzahlen.htm (last visited May 6, 2019), archived at https://perma.cc/ 66GH-8HC5.
 Gesetz über den Beruf der Hebamme und des Entbindungspflegers [Hebammengesetz – HebG] [Act on the Profession of Midwife] [Midwife Act], June 4, 1985, BGBl. I at 902, § 4, para. 1, sentence 2, http://www.gesetze -im-internet.de/hebg_1985/HebG.pdf, archived at https://perma.cc/H8V2-37RT.
 Id. § 4, para. 1, sentence 1.
 Id. § 4, para. 2.
 Id. § 1, para. 1.
 Id. § 2, para. 1.
 Id. § 6, para. 1.
 Id. § 7.
 Directive 2005/36/EC of the European Parliament and of the Council of 7 September 2005 on the Recognition of Professional Qualifications, 2005 O.J. (L 255) 22, https://eur-lex.europa.eu/legal-content/EN/TXT/PDF/? uri=CELEX:32005L0036&from=en, archived at https://perma.cc/S5EX-5DSD; Directive 2013/55/EU of the European Parliament and of the Council of 20 November 2013 Amending Directive 2005/36/EC on the Recognition of Professional Qualifications and Regulation (EU) No. 1024/2012 on Administrative Cooperation Through the Internal Market Information System (“the IMI Regulation”), 2013 O.J. (L 354) 132, https://eur-lex.europa.eu/legal-content/EN/TXT/PDF/?uri=CELEX:32013L0055&from=EN, archived at https://perma.cc/SR7B-X8SM.
 Referentenentwurf des Bundesministeriums für Gesundheit. Entwurf eines Gesetzes zur Reform der Hebammenausbildung (Hebammenreformgesetz – HebRefG) [Draft of the Federal Ministry of Health. Draft Act to Reform the Education of Midwives] [Midwives Reform Act], Mar. 20, 2019, https://www.bundes gesundheitsministerium.de/fileadmin/Dateien/3_Downloads/Gesetze_und_Verordnungen/GuV/H/Referentenentwurf_Hebammenreformgesetz_HebRefG.pdf, archived at https://perma.cc/L65Z-JXZP.
 Destatis, Gesundheit. Grunddaten der Krankenhäuser [Health. Basic Data of Hospitals] 49 & 51 (2017), https://www.destatis.de/DE/Themen/Gesellschaft-Umwelt/Gesundheit/Krankenhaeuser/ Publikationen/Downloads-Krankenhaeuser/grunddaten-krankenhaeuser-2120611177004.pdf?__blob= publicationFile&v=4, archived at https://perma.cc/F3J4-B6WY.
 QUAG, Qualitätsbericht 2017. Außerklinische Geburtshilfe in Deutschland [Quality Report 2017. Out-Of-Hospital Birth Assistance in Germany] 10 (2017), http://www.quag.de/downloads/QUAG_bericht 2017.pdf, archived at https://perma.cc/7JP7-3689.
 Doulas in Deutschland e.V. [Association of Doulas in Germany], Statistische Auswertung der im Jahr 2008 begleiteten Geburten [Statistics on Accompanied Births in 2008] (May 2009), http://s246153258. online.de/dl/statistik_did-begleitungen_2008.pdf, archived at https://perma.cc/2KGG-8QGL.
 These organizations are the Doula Netzwerk (the umbrella organization of Doulas in Germany), Doulas in Deutschland e.V., and the Gesellschaft für Geburtsvorbereitung, Familienbildung und Frauengesundheit e.V. See Deutscher Hebammenverband e.V. [German Midwives Association], Positionspapier zum Thema Doulas in Deutschland [Position Paper on Doulas in Germany] 6 (2010), https://hebammenverband. de/pressespiegel/datum/2013/07/30/artikel/doulas-was-tun-die-dienerinnen-der-geburt/index. php?eID=tx_nawsecuredl&u=0&g=0&t=1565017108&hash=4eb41df69f0fa1444ffb6e823f52aece7b88ea84&file=/fileadmin/user_upload/pdf/Stellungnahmen/PositionspapierDoulas.pdf, archived at https://perma.cc/NP65-2VWE.
 Id. at 1. Translation by author.
 Id. at 7. Translation by author.
 Id. at 8. Translation by author.
 Id. at 9.
Last Updated: 11/13/2019