Midwives have been used in Sweden for hundreds of years. Midwives are the primary point of contact throughout pregnancy, birth, and postpartum care of women. Midwifery is a protected profession and requires four-and-a-half years of combined university education and practical training. Midwives are funded by the public health care system.
Doulas are only sparsely provided for by the health care system. Doulas are currently only publicly funded when the expectant mother either does not have a support person such as a spouse, or when a “cultural doula” is needed because of the expectant mother’s weak Swedish-language skills. The use of private doulas is increasing but is still uncommon.
Alternative birthing methods, such as home births, may be funded by the municipality in certain regions. Home births were common until the mid-twentieth century.
I. Health Care System Funding in Sweden
Health care services in Sweden are provided and funded at the local level. Under Swedish law local regions, which are distinct legal entities that operate at the municipal level, must provide health care to their residents. Thus, all legal registered residents are guaranteed health care. In addition, asylum seekers and undocumented immigrants have a right to a limited number of services including urgent health care, maternity care, care in connection with abortions, and contraceptives. The municipality may also be financially responsible for certain care received abroad. The municipality funds the health care it provides through municipal taxes. Maternal care, delivery care, and postpartum care are provided through the public health care service. The regions have their own programs for how pregnancy related care should be organized.
As many as 650,000 Swedes have private insurance in addition to the public health care available to them. Out of the ten million residents of Sweden, that means that approximately 6.5% of Swedes have private insurance. Doulas may be used by mothers outside of the public and private insurance framework. No insurance provides doulas as part of their private health insurance.
During 2014 to 2016 a private hospital was operating in Stockholm (BB Sophia at Sophiahemmet) but it was closed in 2016, following a maternal death subsequent to the birth of the child. Its main concept was that the expectant mother should be able to have one midwife with her for the entire pregnancy, and including the whole delivery, thus not sharing midwives between patients on the same ward.
II. Legal Framework Regulating Midwives
A. The Role of the Midwives
Annually, approximately 115 to 120 thousand children are born in Sweden. Primary pregnancy care (including prenatal care, birth services, and postpartum services) is provided by midwives. Nevertheless, approximately half of all expectant mothers in Sweden see a doctor during their pregnancy. Postpartum visits are typically scheduled with a doctor only if there was a traumatic event during the birth. Giving birth by cesarean section is becoming more common in Sweden. In 2017 the total percentage of births by cesarean section was 17%, up from 5% during the 1970s.
In addition to pregnancy care, midwives may also assist in abortions, but under current legislation may not administer the abortion-inducing drug.
B. History of Midwifery in Sweden
Sweden has a long history of employing midwives in the birth of children. The first Church Ordinance that mentions midwives (or “earth mothers” as they were called) was the 1571 kyrkoordning. In 1663 Collegium Medicium was formed to control the earth mothers. This function is now performed by the National Board on Health and Welfare.
The first legislation on midwives was passed in 1711. The legislation required that midwives receive practical training prior to working as a midwife. The Midwife Regulation of 1777 included a midwife oath. By 1771 all use of equipment by midwives was prohibited. The prohibition was reversed during the 1800s. Further legislation was passed during the 1900s; legislation from 1955, including amendments, was in force until the 1990s.
Historically, most births in Sweden took place in the home. Between 1920 and 1960 more and more children were born in hospitals instead of the home, and by 1962 mothers that wished to give birth at home were sent to hospitals. Midwives that had previously worked in the homes were now instead included in the births at birth centers and later hospitals.
C. Education and Licensing of Midwives
Midwives must have a barnmorskeexamen (midwife degree), which only nurses may apply to complete. Thus, midwives are first educated and trained as nurses and then as midwives as a subspecialty, for a total of four-and-a-half years of combined university education and practical training.
Following completion of the midwife specialization course midwives must also be licensed (legitimerade). Licenses are obtained through an application filed with the National Board on Health and Welfare. Licensing also requires previous medical practical training. Statistics from 2017 published by the National Board on Health and Welfare show that 100% of licensed midwives are women. Midwives educated and trained outside the European Union may also be licensed, subject to special requirements, including a review of the underlying midwife education, a theoretical and practical test as a nurse, and a theoretical and practical test as a midwife. In addition, a foreign midwife must also demonstrate her Swedish language skills and take a knowledge course in Swedish laws and regulations pertaining to midwifery.
The Barnmorskeförbundet (Association of Midwifes) has issued a kompetensbeskrivning (description of competency) of the midwife profession. Previously the kompetensbeskrivning was issued by the National Board on Health and Welfare. It addresses how a midwife should conduct herself in the profession.
A proposal was made in the Swedish Parliament in 2018 to change the current educational requirements for midwives. The proposal suggested the establishment of a stand-alone midwifery program, so that women could get directly educated as midwives without first having to complete a nursing program. The Members of Parliament suggesting the change argued that this would lead to a greater number of women choosing the midwife profession. The proposal has received general support in Parliament, and has been referred to the government for further investigation.
D. Funding of Midwives
As mentioned above, midwives are employed and funded by the health care system—i.e., through the payment of local taxes. In areas where it is difficult to employ full-time midwives, the responsible regions have used contract midwives who have been offered as much as SEK 90,000 (about US$9,300) per month in salaries (approximately three to four times the salary of a normal midwife). Resident expectant mothers do not pay anything for midwives during prenatal, birth, and postpartum care.
E. Challenges Facing Midwives
A number of challenges have surfaced in relation to the midwifery in Sweden. The greatest problem facing Swedish midwives is understaffing and overcrowded hospitals. This has led to initiatives such as Midwife the Whole Way (Barnmorska hela vägen) and the use of expensive contract midwives. Most providers of health care in Sweden have a plan that allows the expectant mother to see the same midwife for all of her appointments, from prenatal through birth and postpartum care. However, this typically does not work out in practice. The Midwife the Whole Way initiative was meant to create a situation where expectant mothers could contact a midwife that she knew any time of the day throughout her pregnancy. The region therefore tried to hire additional staff, but in the end three midwives were employed on part-time basis (75%) instead of the intended four full-time midwives, and therefore services could only be provided between 7:00 a.m. and 11:00 p.m. In the end, 49% of the expectant mothers had a known midwife at the time of delivery.
III. Regulation and Funding of Doulas
A. Doula Profession Largely Unregulated
Historically, doulas have not been commonly used in Sweden and no legislation exists governing their practices. The use of the professional title “doula” is not protected through legislation and can be used by anyone, unlike the title “midwife,” which can only be used by persons who have completed required midwifery education and obtained a license.
B. Use of Privately Funded Doulas
Statistics on the use of privately funded doulas is very limited. The Organization for Doulas and Birth Pedagogues in Sweden (ODIS) performed a survey in a doula group on Facebook with thirty-six doulas responding showed that those doulas had together performed 172 doula assignments. There are no official statistics on either the number of doulas in Sweden or the number of birthing mothers that use doulas. Media reports suggest that there are as many as 250 registered doulas in Sweden.
C. Education of Privately Funded Doulas
Doulas are generally educated over two weekends for a total of four days of training. The main education provider is ODIS. The education costs approximately SEK 6,500 (about US$670), excluding taxes. No prior education is needed.
D. Certification of Privately Funded Doulas
Swedish doulas (not cultural doulas, see below) are certified using a private certification service, through ODIS. ODIS is a nonprofit association that was founded in 1999. Currently there are 251 registered (active and inactive) doulas with ODIS. Of these, thirty-five are ODIS-certified doulas, and about 140 of them are doulas that have undergone the ODIS education. ODIS is also part of the European Doula Network.
E. Municipal-Funded Doulas
Typically, two forms of public doula services are provided by municipal health care services in Sweden—doulas in lieu of other support (for example instead of a significant other) and cultural doulas (doulas that function as cultural bridges between immigrant women and hospital staff). In addition, mothers may opt to privately fund a doula.
1. Doulas in Lieu of Other Support
In Stockholm, women may chose not to bring a family member to the delivery room and instead have Stockholm Region (formerly Stockholm Landsting) pay for a doula. This service was initially introduced to support mothers who did not have a social network or a support person (such as a spouse) who could accompany them to the delivery.
If an expectant mother wants to bring a doula in addition to a family member she must pay for the service herself. Such services may be expensive; reports indicate that an experienced doula may charge as much as SEK 15,000 (about US$1,600). One reported reason for the increase in demand for doulas is that Swedish midwives currently cannot provide the continuous care that mother seeks—i.e., one person of contact throughout the prenatal, birth, and postpartum stages of a pregnancy.
2. Cultural Doulas
Local Regions also fund cultural doulas for immigrant mothers. These cultural doulas have area-specific knowledge from the country of origin of the mother as well as knowledge of Swedish culture—specifically, language skills that will enable Swedish hospital staff to communicate with the mother. Not all Regions provide this service, thus not all mothers are guaranteed the same service throughout the country. The website Doulakulturtolk.se provides examples of places where cultural doulas are used.
In total more than 1,200 assignments have been performed by cultural doulas, representing twenty-three languages. Doulas that work in the province of Sörmland undergo limited (eight-day) education that focuses on a number of issues, including female anatomy, etc. Cultural doula education is provided by midwives. When introduced the hope was that cultural doulas would also create more equal access to health care. Currently, there is no national legislation mandating the use of cultural doulas.
IV. Home Birth Services
Home births are on the rise in Sweden, particularly in the capital region of Stockholm. In 2018 a total of eighty home births were recorded, up from thirty in recent years. However, doctors have voiced criticism of home births, questioning how safe they are. Some statistics from Sweden show that home births may result in fewer birth injuries to the mother, but statistics also show that women who choose home births are healthier to begin with and could therefore be expected to suffer fewer injuries in the hospital as well.
Currently, only Stockholm and Västerbotten fund home births. In some areas of Sweden, home births may become part of the vårdvalet—i.e., the services that the Region may provide to the patient if so elected. Stockholm has provided that service since 2002 and currently twenty-two home-birth midwives are registered with the municipality. Home-birth midwives working in Stockholm are compensated at the rate of SEK 22,000 (US$2,300). Other regions consider it a separate form of health care, which it does not provide. Swedish insurance companies insure home births in the same manner as other births.
Foreign Law Specialist
 8 kap. 1, 2 §§ Hälso- och sjukvårdslag [Health Care Act] (SFS 2017:30), https://www.riksdagen.se/sv/ dokument-lagar/dokument/svensk-forfattningssamling/halso--och-sjukvardslag_sfs-2017-30, archived athttps://perma.cc/YLB4-ACP8.
 4 § Lag om Läkemedelesförmåner [Act on Medicine Benefits Etc.] (SFS 2002:160), https://www. riksdagen.se/sv/dokument-lagar/dokument/svensk-forfattningssamling/lag-2002160-om-lakemedels formaner-mm_sfs-2002-160, archived at https://perma.cc/ZN7W-LWJY. For an explanation of Regions in English see Municipalities and Regions, Sveriges Kommuner och Landsting,https://skl.se/tjanster/english pages/municipalitiesandregions.1088.html (last visited May 9, 2019), archived at https://perma.cc/QK5E-G6RM.
 7 § Lag om hälso- och sjukvård till vissa utlänningar som vistas i Sverige utan nödvändiga tillstånd [Act on Health Care for Certain Aliens Who are Present in Sweden Without Necessary Documents] (SFS 2013:407), https://www.riksdagen.se/sv/dokument-lagar/dokument/svensk-forfattningssamling/lag-2013407-om-halso--och-sjukvard-till-vissa_sfs-2013-407, archived at https://perma.cc/L2ZS-TCTQ.
 Lag om landstingens och kommunernas kostnadsansvar för viss vård i utlandet [Act on the County Councils [Now Regions] and the municipalities’ Financial Responsibility for Certain Care Abroad] (SFS 2013:514), https://www.riksdagen.se/sv/dokument-lagar/dokument/svensk-forfattningssamling/lag-2013514-om-landstingens-och-kommunernas_sfs-2013-514, archived at https://perma.cc/4NU9-LFDF.
 See, e.g., Kommunalskatten, StockholmsStad (Apr. 24, 2019), https://stad.stockholm/sa-anvands-dina-skattepengar/kommunalskatten/, archived at https://perma.cc/QHZ5-3SGZ.
 See, e.g., Mödravård, preventivmedel och massor av erfarenhet, Stockholms läns sjukhusområde, https:// barnmorskemottagningar.sll.se/ (last visited May 9,. 2019), archived athttps://perma.cc/PU3P-DJX8.
 See, e.g., Östergotlands Region, Basprogram för mödrahälsovården, Dok-nr 26350 (Jan. 4, 2019), http://ledsys.lio.se/Document/Document.aspx?DocumentNumber=26350, archived athttps://perma.cc/5PPA-Y26F.
 Så här fungerar en privat sjukvårdsförsäkring, Svensk försäkring, https://www.svenskforsakring.se/om-forsakring/vad-ar-och-hur-funkar-det/sa-har-fungerar-en-privat-sjukvardsforsakring/ (last visited May 8, 2019), archived athttps://perma.cc/RJ8D-ZUS2.
 Sanna Björkman, Sorg och ockupation när BB Sophia stänger idag, Vårdfokus (May 16, 2016), https://www. vardfokus.se/webbnyheter/2016/maj/sorg-och-ockupation-nar-bb-sophia-stanger-idag/, archived athttps://perma.cc/RW4L-MH8Y.
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 Björkman, supra note 10.
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 See, e.g., Östergotlands Region, supra note 8.
 Andelen kejsarsnitt och allvarliga bristningar varierar stort i landet, Socialstyrelsen (Mar. 21, 2017) https://www.socialstyrelsen.se/nyheter/2017/andelenkejsarsnittochbristningarvarierarstortilandet, archived athttps://perma.cc/4KLD-PMF8.
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 Förordning med instruktion för Socialstyrelsen [Regulation with Instruction for the National Board on Health and Welfare] (SFS 2015:284), https://www.riksdagen.se/sv/dokument-lagar/dokument/svensk-forfattningssamling/forordning-2015284-med-instruktion-for_sfs-2015-284, archived at https://perma.cc/8AJ6-R4L8.
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 Barnmorskor 1920-1960, Bengt Dahlin, http://www.bengtdahlin.se/HoSstoryn1/filer_del_1C/ barnmorskor_1920-1960.html (last visited May 8, 2019), archived at https://perma.cc/K8BG-9ZUT.
 4 kap. 1 § Patientsäkerhetslagen [Patient Safety Act] (SFS 2010:659), http://www.riksdagen.se/ sv/dokument-lagar/dokument/svensk-forfattningssamling/patientsaker-hetslag-2010659_sfs-2010-659, archived at https://perma.cc/UN2Z-4A7H.
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 4 kap. 4 § Patientsäkerhetslagen; Legitimation, Socialstyrelsen, https://www.socialstyrelsen.se/ ansokaomlegitimationochintyg/legitimation (last visited May 8, 2019), archived athttps://perma.cc/CF7X-HQSV.
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 4 kap. 5 § Patientsäkerhetslagen.
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 Utbildningsutskottets betänkande [Education Committee on Education Report] 2018/19:UbU13, at 125, https://data.riksdagen.se/fil/61E0733C-1932-4048-99F0-141D41434A0F, archived at https://perma.cc/XS2D-DFZF.
 Sanna Björkman, Hyrbarnmorskor får 95000 kronor i Västernorrland, Vårdfokus (Apr. 12, 2019), https://www. vardfokus.se/webbnyheter/2019/april/hyrbarnmorskor-erbjuds-90-000-kronor-i-vasternorrland/, archived at https://perma.cc/32DS-CL7E.
 4 § Lag om Läkemedelesförmåner.
 Susanna Pagels, ”Barnmorska hela vägen” kom bara halvvägs, Vårdfokus (Jan. 23, 2019), https://www.vard fokus.se/webbnyheter/2019/januari/barnmorska-hela-vagen-nadde-bara-halvvags/, archived at https://perma.cc/4YSC-CUE4.
 Björkman, supra note46.
 See, e.g., Gudrun Abascal & Nina Campioni, Sveket mot de födande är ett brott mot lagen, Expressen (Nov. 3, 2017), https://www.expressen.se/debatt/sveket-mot-de-fodande-ar-ett-brott-mot-lagen/, archived at https://perma.cc/8HWL-YRC2.
 4 kap. 1, 4 §§ Patientsäkerhetslagen.
 Jan Färingö, Mammor betalar dyra pengar för stöd vid förlossningen, SVT (Nov. 21, 2017), https://www.svt.se/ nyheter/lokalt/vasterbotten/radslan-har-blivit-business, archived at https://perma.cc/4649-9WW3.
 For an example of ODIS education provided in Gothenburg see Doulautbildning i Göteborg, En bra start…, http://enbrastart.se/kurser/doulautbildning-i-goteborg/ (last visited May 9, 2019), archived at https://perma.cc/KSR5-EHVT.
 Statistik, ODIS, supra note 55.
 Member’s List, European Doula Network, http://european-doula-network.org/member-list/?wpv-country=sweden&wpv_aux_current_post_id=317&wpv_view_count=326-TCPID317 (last visited May 9, 2019), archived at https://perma.cc/7RX7-L8L4.
 See Part I, above.
 Frida Claesson, Födande i Stockholm får doulastöd, SVT (Nov. 2, 2017), https://www.svt.se/nyheter/lokalt/ stockholm/fodande-i-stockholm-far-doulastod, archived at https://perma.cc/2HH6-N5HD.
 The service is not included in the covered health services provided by the Region. Stockholms Läns Landsting, Basprogram för vård under Graviditet (Feb. 4, 2018), https://www.vardgivarguiden.se/ globalassets/behandlingsstod/barnmorskemottagning/basprogram.pdf?IsPdf=true, archived at https://perma.cc/GKM7-RRB9; see also Östergotlands Region, supra note 8.
 Jan Färingö, Mammor betalar dyra pengar för stöd vid förlossningen, SVT (Nov. 21, 2017), https://www.svt.se/ nyheter/lokalt/vasterbotten/radslan-har-blivit-business, archived at https://perma.cc/4649-9WW3.
 Anna Bergh & Estrid Wagersten, Allt fler anlitar doula vid förlossning, Sveriges Radio (Feb. 19, 2018), https://sverigesradio.se/sida/artikel.aspx?programid=128&artikel=6889386, archived at https://perma.cc/PL6G-2NG8.
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 Sörmlands förlossningsvård görs mer säker med doulor, Vårdfokus (Nov. 1, 2018), https://www.vardfokus.se/ webbnyheter/2018/november/sormlands-forlossningsvard-gors-mer-saker-med-doulor/, archived at https://perma.cc/66JT-HVVG.
 Satens Offentliga Utrednignar [SOU] 2013:44 Ansvarsfull hälso- och sjukvård [Government Official Report 2013:44 Responsibble Health and Hospital Care], at 161-62, https://data.riksdagen.se/fil/2D3A369C-6A97-4A0F-ADBF-D6907B20D3FA, archived at https://perma.cc/TW36-8WPJ.
 Sanna Björkman, Hemförlossningar kan bli en del av vårdvalet, Vårdfokus (May 25, 2018), https://www.vard fokus.se/webbnyheter/2018/maj/hemforlossningar-kan-bli-en-del-av-vardvalet/, archived at https://perma.cc/VRS9-LXA5.
 ”Karin Petterson, För riskfyllt” – läkare kritiska till hemförlossning, SVD (Aug. 29, 2018), https://www.svd.se/ for-riskfyllt--manga-lakare-kritiska-till-hemforlossning, archived at https://perma.cc/UL9P-9TX2.
 Färre kvinnor spricker eller klipps vid hemförlossning, Göteborgs universitet (May 4, 2017), https://sahl grenska.gu.se/forskning/aktuellt/nyhet/farre-kvinnor-spricker-eller-klipps-vid-hemforlossning.cid1461437, archived athttps://perma.cc/2AE7-ZAR8.
 Björkman, supra note 80.
 Hemförlossning kan bli egen vårdform, MittiStockholm (May 24, 2018), https://mitti.se/nyheter/sjukvard/ hemforlossning-egen-vardform/, archived at https://perma.cc/6J34-4EZ4.
 See, e.g., Östergotlands Region, supra note 8.
 Hemförlossning - ett allt mer populärt alternativ, Länsförsäkringar, https://www.lansforsakringar. se/stockholm/privat/forsakring/personforsakring/gravidforsakring/hemforlossning/ (last visited May 6, 2019), archived athttps://perma.cc/MDC9-XELG.
Last Updated: 12/30/2020