Maternal Care in the US, Turkey, and Germany: General Overview of Healthcare Systems and Parental Leave, Plus Statistics on C-Sections, Maternal and Infant Mortality, and Postpartum Depression/Anxiety

As I’ve previously mentioned, two big things have happened in my life recently: my husband and I moved to southwestern Germany at the end of 2017, and we are expecting our first child in May.  These are both pretty significant life developments and I feel like I’ve really hit the ground running this past month, between trying to settle into a new country/culture and suddenly panicking that the third trimester is right around the corner and I actually need to start, like, preparing to have and take care of this baby.

A big part of that has been figuring out the German healthcare system and learning what is available to me here, and how things are typically done.  This is an ongoing process that has involved some research on my part, talking to doctors and midwives, and asking tons of questions to women in the area (sometimes in person through meet-ups, and also through a local mom’s group I joined online).  It’s also made me more curious about maternal and infant care in general, so I’ve been asking my American and other foreign (ie, non-American and not-living-in-Germany) friends about their experiences too.

The answers I’m getting are incredibly interesting, and I’ve noticed one huge pattern specifically:

The vast majority of the women I talk to in Germany about their pregnancy, childbirth, and postpartum experience are incredibly positive about it.  Most talk about what a calm and wonderful experience it was, and how great their care was– before, during, and after birth.

The Americans I talk to, on the other hand, are all incredibly stressed out.  Most seem fairly neutral about the actual care they received in the hospital during delivery (there are exceptions to this– I have a few friends who had great experiences with their doctors, and a few friends who had absolutely horrible experiences) but money issues, insurance issues, lack of postpartum care, and issues with maternity leave make this period a really stressful time for almost everyone, it seems.

General Overview

Here is what I know about the various healthcare systems of the countries I’ve lived in, as they relate to maternal and infant care (disclaimer: I am not an expert by any means, and if any of this is incorrect, please feel free to let me know):

America: The US is infamously the only developed country that doesn’t require employers to provide paid maternity leave.  (As a personal example, the public high school where I taught in North Carolina before moving abroad offered zero paid maternity leave.)  New parents are entitled to twelve weeks unpaid leave via the FMLA (Family and Medical Leave Act) if they’ve been working at the company for more than one year, and if the company has at least 50 employees; otherwise, they are entitled to six weeks unpaid leave via FMLA.  You have a hospital bill you need to pay after insurance; people I’ve talked to have mentioned bills that were fairly low, to several thousand dollars.  Midwives don’t seem to be especially common (I think I know one person who has used one?, and I know several people who said they wanted one but their insurance didn’t cover it), postpartum care seems virtually nonexistent after the 2-3 days in the hospital, and follow-up postpartum appointments can be hard to get.

Turkey: You get four months of paid maternity leave, two weeks of which are required to take before your due date; however, you get paid this money at the end of the four months, not in monthly installments like you would your normal salary.  After that, you can take another eight months of “breastfeeding leave” where you work 3/4ths of your hours for full pay (so basically, part-time).  It seems like most employers let you take up to two years maternity leave unpaid, with job protection; I don’t know if this is a law or just common practice.

One thing that was not great about the Turkish system is that private health insurance won’t cover anything maternity-related until you’ve been on one specific plan for a minimum of one year.  I didn’t know this.  I had switched jobs and was only on my private insurance plan for either ten or eleven months when I got pregnant, therefore they wouldn’t cover any of my pregnancy care.  I could have used the public insurance to see a state doctor, but since I really wanted/needed someone who spoke English well and also wanted someone who was a proponent of vaginal births (the c-section rate in Turkey is astronomical), I chose a private doctor and we paid for my prenatal check-ups out of pocket.  It wasn’t cheap, but it was manageable (and significantly cheaper than non-insured, out-of-pocket care would be in the US).  That said, I really liked my doctor and was happy with the care I got there for the first half of my pregnancy.

I know the cost of birth there can differ dramatically depending on what hospital you give birth in, your doctor, and what kind of birth and care you have.  I don’t really know many details about this, but the top of the range seemed to be around $5,000 USD, with cheaper options available.  I’m not sure about midwife or postpartum care, but midwives seem more common than in the US.

Germany: You can have either public or private health insurance; either way, you pay one fee per month for your insurance and all care is covered 100%, meaning you don’t pay anything for prenatal check-ups or for giving birth.  You can choose either a public or private hospital regardless of which insurance you have.  (I have public insurance but will be giving birth in a private hospital.)  Midwives are common– it seems like everyone has them, and they check up on you for several weeks after birth with home visits.  Hospitals offer birthing and prenatal exercise classes when you’re pregnant, and postpartum classes for you and baby (including things like pelvic-floor-strengthening-class and baby yoga).  All of this is covered by insurance.

There is maternity leave (only available for the mother) at 100% pay that covers six weeks before birth and eight after.  On top of that, there is parental leave that can be taken either by the mother or father, or a combination, of up to fourteen months after birth at around 70% pay.  (So, the mom can take all fourteen months, the father can, or they can split it between themselves with one person taking, say, eight months, and the other taking six months.)  It also seems like you can take those fourteen months in three separate chunks during the first eight years of your child’s life– so if you know you’ll need to take some time off later, you can save some of those months.  However, I might be wrong about this, since it’s something that I’ve come across in my research but haven’t confirmed with anyone who’s done it.

Statistics

C-section rates (source)
America: 32.8% as of 2012
Turkey: 47.5% as of 2011
Germany: 30.3% as of 2009

Maternal mortality rates as of 2015 (source)
America: 26.4 deaths/100,000 live births
Turkey: 15.8 deaths/100,000 live births
Germany: 9 deaths/100,000 live births

(I would be remiss here if I didn’t mention that maternal mortality rates in the US are sharply divided along racial lines, with Black women 2 to 6 times more likely to die during or shortly after childbirth, even when controlled for other factors like education, lifestyle, and income.)

Infant mortality rates (source)
America: 6.1 deaths/1,000 live births
Turkey: Not found
Germany: 3.4 deaths/1,000 live births.

Postpartum Depression and Anxiety

While thinking about all this, my mind turned to postpartum depression and anxiety.  I’m lucky in that I’ve had several women in my life who have been very open with their experiences with PPD/PPA, so I was aware of it long before getting pregnant, and a lot of these women have become advocates for better PPD/PPA care in the US since experiencing it themselves.  However, PPD/PPA is notoriously difficult to get properly diagnosed and treated in the US; if you need proof, read this story about Jessica Porten, who told a nurse at her first postpartum check-up (four months after giving birth, the first appointment she could get!) that she wanted to talk about treatment options for her PPD.  The nurse called the cops on Porten and she was taken to be involuntarily admitted to ER, held for ten hours, and then released without ever seeing a doctor or getting her PPD addressed.  (The link above is to an MSN article but you can read Porten’s original post there as well, and I recommend you do.)

It seems to me that the mere existence of better postpartum care, and of midwives doing frequent postpartum home visits, would really go a long way towards helping new mothers dealing with PPD/PPA.  Most of the women I know who experienced PPD/PPA did not have it properly diagnosed and treated until their babies were around five or six months old, and a lot of it came from feelings of being completely overwhelmed by taking care of a newborn or from some sort of specific issue they were having trouble with and didn’t know how to fix, like breastfeeding.

And if you have someone who is qualified stopping by to check in you regularly– a professional who can answer your questions, give advice and guidance, assure you that you’re doing a good job, and who is trained to look for signs of PPD/PPA– it has an enormous potential to alleviate a lot of the aforementioned feelings of being overwhelmed or anxious before they spiral into full-blown PPD/PPA.  Of course, preventative measures aren’t perfect, and having a good system in place for diagnosis and treatment is an important aspect, too.  (As is, OBVIOUSLY, not criminalizing or stigmatizing it; see above, re: what happened to Jessica Porten.)  I was very pleased recently when I picked up a packet of brochures in English at a birthing information session at a hospital and it mentioned PPD on the very second page of the first brochure.

Page 2 of the brochure packet from the hospital

So I got curious and looked up the PPD/PPA rates by country.  I couldn’t find a resource that listed PPD/PPA statistics by country, unfortunately (although this is is an interesting academic article from the NIH that talks about cultural factors that can engender PPD/PPA, with rates being significantly higher in Asian countries); however, digging around a bit, I did find individual statistics for countries.

According to the CDC, PPD rates in the United States are anywhere between 1 in 9 to 1 in 5 (so, between 11-20%).  This was corroborated by a few other sources I found, some of which averaged the range and landed on a rate around 15%.

According to the NIH, PPD rates in Turkey are around 21% in developed cities and 25% in developing areas, averaging out to about 23.8%.

In Germany, according to a 2008 study done at Heidelberg University, PPD rates were around 6.1% in and PPA rates were around 10.1% in the sample community.  However, the study self-reports the limitation that it was conducted in a predominantly middle class community.  This report by the NIH lists PPD rates as being around 3.6%, and their conclusion of the study was that there is a high acceptance of for the management of PPD from healthcare professionals.

Honestly I was surprised at how difficult it was to fine reliable statistics on postpartum depression.  Regardless of the country, this is obviously something that needs more attention.

As mentioned earlier in the post, I’m not a healthcare expert or a statistician; I’m just someone who finds this kind of stuff both interesting and important to understand.  I can’t claim with any sort of confidence that there is definitely a direct causation, rather than just correlation, between any of this.  But as a pregnant lady who has experienced all these systems, it’s information that I’m glad to know.