MIDIRS Essence > May 2009 > Student/Tutor feature

An elective placement in Germany - by Andrea Hansel-Hides, 3rd year Student Midwife, University of Nottingham

Originally posted on May 2009

As I have always enjoyed community midwifery best, I chose to spend my elective placement in Germany where midwives incorporate alternative therapies into their practice. I decided to work with a community based, self-employed midwife specialising in phytotherapy (herbalism) and aromatherapy.

This article will outline the German health insurance system and maternity care provision. It will then discuss the work of the self-employed midwife, which includes the promotion of antenatal and postnatal well-being and exercise, addressing breastfeeding problems and breast milk finger feeding, the use of low level laser therapy (LLLT) for wound healing, as well as aromatherapy and phytotherapy for minor ailments experienced by mums and newborns.

German maternity care provision and health care insurance

German maternity care is provided in two ways:

by gynaecologists/obstetricians

by midwives

.

To understand how maternity care is provided in Germany it is paramount to understand the provision of health care insurance.

There is no sole health insurance provider like the NHS in Germany, but there are several ‘Krankenkassen’, so called ‘health insurance schemes’, to choose from, each specialising in a certain area but all costing the same. Maternity care, which is provided through midwives and doctors, is free in any scheme.

German midwives work in three different ways:

1) in hospitals and/or providing postnatal care in the community
2) in the community sector as self-employed midwives
3) as a ‘Beleghebamme’ who contracts in to a hospital to birth her women there.

1) Hospital midwives

Hospital midwives are employed by a hospital. These midwives provide all care in that hospital. Some are also contracted to do some independent work and give antenatal and postnatal care out of hospital. German hospitals are independent businesses, unlike England’s NHS monopoly of health care provision. Health insurance schemes contract in to hospital services and thus provide health care to their members.

2) Self-employed midwives

Self-employed midwives provide antenatal, intrapartum and postnatal care, as well as workshops and courses on infant care and antenatal and postnatal exercise classes. The self-employed or ‘independent German midwife’ is paid through the German health insurance scheme and not by the women directly.

3) Beleghebammen

‘Beleghebammen’, which means a self-employed, ‘independent’ midwife, has a contract with an associated hospital where she has a number of ‘booked beds’ for her women choosing to have a hospital birth. She can accompany and care for her women in that hospital.

Midwifery

My mentor had 27 years of midwifery experience and 16 years experience of working independently and a home birth rate of 16%. Her specialist areas are breastfeeding and breastfeeding problems like engorgement and mastitis, perineal care aided by aromatherapy and phytotherapy and the preparation of herbal teas and tinctures. She runs antenatal fitness classes including belly-dancing and post-partum pelvic floor exercise classes. As a UK focus is the creation of a healthier nation (DH 1999), these antenatal and postnatal exercise classes were of particular interest.

Antenatal and postnatal well-being

The postnatal exercises aim to rebuild the pelvic floor and give women general fitness. I was told to bring my sports gear and I thought it would be a piece of cake for me to exercise next to new mums, who were a minimum of six weeks postnatal. Well, I got pretty much out of breath during one hour of floor exercises, which used big and small birthing balls together with an exercise tool called the ‘Flexi-Bar’ (Flexi-Bar 2009). The Flexi-Bar is the most cost-effective method of adding the benefits of vibration training to the exercises through its swinging action, creating vibrations that target the deep, core muscles of the body. The abdominal and pelvic floor exercises were done using ‘Tanzberger’, a rehabilitation concept for the pelvic floor and continence training following birth (Tanzberger 2009). Women are invited to attend 10 sessions when they are six weeks postnatal. The sessions are paid for through the German health insurance scheme. I believe that becoming aware of the pelvic floor and understanding its importance in female sexual and reproductive health helps women to look after themselves and promotes healthy living in the long run. For myself I have to say after two weeks’ placement and attending four sets of two-hour sessions, my pelvic floor was as good as new. Because every woman can see the effect, it is very well attended. New mums were very tenacious and motivated and it was amazing to see how well women performed after only attending three times. After 10 sessions the pelvic floor and abdominal muscles, aka ‘rectus abdomini’ and possible previous ‘rectus diastatis’ are tested. If beneficial, the midwife can refer the women to their doctor who will prescribe a further course of 10 sessions on the health insurance scheme.

Antenatal care: birth preparation

Another specialism in Germany is the provision of intense birth preparation classes for women and couples. The focus is on breathing and relaxation techniques to help women in the early and late stages of labour. The aim is to relax women and for them to learn to guide their breath so that they breathe into the painful area. This will help them to stay in tune with and control their bodies, and works by the elimination of distress in transition. By attending only one session I was already able to reduce my respiration rate from seven to four. It is interesting to know that most of the women who birthed at home did so with the help of breathing techniques and without any pain relief. This finding was supportive of what I experienced when visiting the Albany Practice in London (Albany Midwives 2009) where most of the women birthed without even Entonox. I suppose it comes down to the two camps of philosophy on pain in labour. One suggests there should be no need to suffer unnecessarily during labour and when effective analgesia is available ‘pain relief’ should be offered. The other believes that pain is part of the experience of labour and advocates that women should be supported and encouraged to ‘work with the pain’ of labour (Odent 1994, Dick-Read 2004, NICE 2007, Walsh 2007).

Interestingly, Entonox is not used anymore in Germany as it is the German opinion that research does not support its use. Unfortunately for this article, I could not find the research to provide the evidence. A further difference is that continuous fetal monitoring (CTG) is used even for low-risk women and is a legal requirement in Germany. Even independent midwives will still do what we know as an ‘admission CTG’ when caring for a woman in labour but, at her own discretion, will use or replace it with intermittent monitoring. However, as my German midwife friend explains, CTG-monitoring in Germany has entered the 21st century. The availability of ‘telemetry’, a remote CTG technique which enables women to mobilise in labour, makes it more acceptable to women and hence feasible for midwives to avoid litigation. On the other hand it can be argued that it is a defensive technique based on a medical model of care rather than a holistic, woman-centred one (Walsh 1998, 2007).


Breastfeeding problems - finger feeding * Wound healing – Low Level Laser Therapy (LLLT) * Complementary therapies of aroma - and phytotherapy

Breastfeeding and phytotherapy

During my placement it became apparent that more women in Germany breastfeed than in the UK. The German KiGGs results (2007) showed that 76.7% of the children were ever breastfed and 22.4% of all KiGGS children were exclusively breastfed for a period of six months. This compares with only 35% of UK babies being exclusively breastfed at one week, 21% at six weeks and only 7% at four months and 3% at five months (The Baby Friendly Initiative 2008). The average duration of exclusive breastfeeding in KiGGS was 4.6 months. However, as in the UK, it was concluded that there is a need for further breastfeeding promotion, especially to support the socially disadvantaged, and most of all to encourage a positive attitude towards breastfeeding in society.

During my placement I only met breastfeeders, including a mum of premature twins. I was privileged to observe very practical and interactive breastfeeding. A mother with inverted nipples suffered extreme tissue damage due to the anatomy of the breast and an initial incorrect latch that subsequently caused engorgement. It amazed me how determined the woman was to continue breastfeeding despite the immense pain, discomfort and extra commitment the couple had to endure. She was regularly pumping to maintain the milk supply and the engorged breast was treated with compresses of Quark (a special yoghurt) to cool the breast. The effect is similar to using Savoy cabbage. Also a compress soaked in brewed, sifted and cooled tea of ‘Calluna vulgaris’ (heather) achieved relief of the engorgement and took the swelling down. The sore inflamed nipples were bathed in ‘Quercu robur’ (English oak), which had an astringent effect on the wound. Further treatments consisted of vitamin E, calendula, and arnica which works particularly well as a sit-batch to treat perineal trauma (Grimme & Augustin 1999). The treatment effect was astonishing as the engorgement was marginally reduced within two days without any atypical antibiotic treatment which is normally prescribed through doctors with the effect that breastfeeding ceases. In order to maintain lactation, breast pumping and breast milk finger feeding by the dad or with the aid of the natural supplemental nursing system (Medela 2009) was used. A lot of daily support was given to these women and incorporated the fathers who assisted with the feeds while mum was pumping.

Wound healing

Wounds and sores of the breasts and perineum were treated with the latest technology of ‘Low Level Laser Therapy (LLLT)’. A cold laser is used to assist healing and pain relief. There is substantial clinical evidence published in peer reviewed medical journals that ‘cold’ LLLT can stimulate repair of tissue, reduce inflammation and relieve pain in musculoskeletal disorders. Meeting other self-employed ‘community midwives’, I learnt that LLLT is the method of first choice before more intensive alternative therapies are tried, because it achieves quick results. Low Level Laser Therapy is a painless, sterile, non-invasive, drug-free treatment which is used to treat a variety of pain syndromes, injuries, wounds, fractures, neurological conditions and pathologies (Carroll 2009).

Complementary therapies: phyto - and aromatherapy

The main reason I had come to Germany was because of the regular use in maternity care of alternative complementary therapies for mothers and babies. During my placement I witnessed the use of various phytotherapy treatments, where teas were made to either ingest or to use as compresses, cleansers or in sit baths. A typical goody-pack for postnatal mothers consists of a herbal tea mixture to aid lactation, an arnica tincture to aid healing and pain relief of the perineum to use in a sit-bath and vitamin E spray for nipples.

Colicky babies were prescribed fennel tea in between feeds and smudgy newborn eyes got a treatment of ‘Euphrasia officinalis’ (eyebright). Its effects are anti-catarrhal, astringent and anti-inflammatory.

Sore bottoms were treated with ‘calendula officinalis’ (pot marigold) or a healthy nappy packing of the non clinically-tested but traditionally tried and tested house remedy ‘cleaned fatty lambs wool’. Applied on to the cleansed naked bottom, the high fat content protects the skin and the fine fibre activates the capillary system which facilitates mild warming, effecting relaxation of the deep muscle layers, thus enables healing, an especially helpful effect in the treatment of bronchitis. Because wool stops germ multiplication and is extremely air permeable, it facilitates healing and it is especially useful in the topical treatment of sore bottoms and wounds.

Aromatherapy oils and mixtures were used postnatally to aid involution of the uterus, to treat wind and colic and to stimulate sleepy neonates at feeding time.

Conclusion

The elective placement fostered my commitment to natural woman-centred antenatal and postnatal care. It has evoked a great interest in studying alternative and complementary therapies, so as to be able to provide holistic care to achieve physical and mental well-being of the mother and child and create a healthier nation.

References

Albany Midwives (2009). The Albany Midwifery Practice: articles and reports.

Association for Improvements in the Maternity Services (AIMS 2007). AIMS: for a better birth.

Carroll J (2009). Low-level laser therapy: increasing uptake. [Accessed 1 May 2009].

Department of Health (1999). Saving lives: our healthier nation. London: Department of Health.

Dick-Read G (2004). Childbirth without fear. London: Pinter & Martin Ltd.

Flexi-Bar (2009). FLEXI-BAR: effective portable vibration training.

Grimme H, Augustin M (1999). Phytotherapy in chronic dermatoses and wounds: what is the evidence? Forsch Komplementaermedizin 6 (Suppl 2:5-8). [Accessed 8 May 2009].

Lange C, Schenk L, Bergmann R (2007). Verbreitung, dauer und zeitlicher trend des stillens in Deutschland: ergebnisse des kinder- und jugendgesundheitssurveys (KiGGS). [Accessed 20 May 2009].

Medela (2009). Supplemental nursing system.
http://www.medela.co.uk/UK/breastfeeding/products/nursing.php [Accessed 9 May 2009].

National Institute for Health and Clinical Excellence (2007). Intrapartum care: care of healthy women and their babies during childbirth. London: NICE.

Odent M (1994). Birth reborn: what childbirth should be. 2nd ed. London: Souvenir Press.

Tanzberger R (2009). Das Tanzberger Konzept.

The Baby Friendly Initiative (2008). UK breastfeeding rates. [Accessed 20 May 2009].

Walsh D (2007). Evidence-based care for normal labour and birth: a guide for midwives. Abingdon:Routledge.

Walsh M (1997). Models and critical pathways in clinical nursing: conceptual frameworks for care planning. 2nd ed. London: Baillière Tindall.

Andrea Hansel-Hides | 3rd year Student Midwife| University of Nottingham

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