Healthy living Prenatal care: check-ups and advice

Prenatal care refers to the advice and regular check-ups provided to pregnant women during their pregnancy. Check-ups are important for monitoring the development of the pregnancy. During these check-ups, a doctor or midwife regularly checks the health of the expectant mother and the unborn baby. This enables early detection of risks and abnormalities. Prenatal care also includes advice for the expectant mother, for example, in relation to nutrition, oral health and vaccines. Check-ups are initially scheduled on a monthly basis during pregnancy. From week 32 of pregnancy onwards, they take place every 14 days. The costs are covered by statutory health insurance funds and usually also by private health insurance providers.

Pregnancy is a special stage of life. It is a time of constant change, as the unborn baby develops and grows and the expectant mother’s body also changes.

During prenatal check-ups, changes and developments are closely observed to enable a swift response to any health problems or risks that may arise in relation to the mother and baby. The results of the check-ups are then recorded in the mother’s maternity record (“Mutterpass”). 

Parents-to-be are informed about the results of check-ups and how the pregnancy is progressing. They are also given advice on important aspects of the pregnancy, such as nutrition and oral health. In addition, they are provided with information about additional testing and, where relevant, treatment options. If necessary, they receive advice about regional supports for parents and children.

Prenatal care for those covered by statutory health insurance includes the following:

• Advice for the mother
• Tests for the mother, including blood pressure checks
• Blood tests and urine tests, including tests for gestational diabetes
• Monitoring of high-risk pregnancies
• Ultrasound scans
• Palpation of the uterus through the abdominal wall, checking the baby’s position, and monitoring the baby’s heart sounds
• Screening for infections: HIV, hepatitis B, syphilis and chlamydia
• Determining the Rhesus factor: In mothers who are Rhesus-negative, a blood group characteristic of the unborn baby known as the Rhesus D factor is determined from a sample of the mother’s blood.

Statutory health insurance also covers the costs of check-ups and advice for mothers in the weeks following the birth.

Additional tests

Special tests, such as the toxoplasmosis test and certain prenatal diagnostics, are not included in statutory prenatal care services.

Prenatal diagnostics is the medical term for tests performed on an unborn baby before birth.  The term is usually used to describe additional tests performed in addition to regular antenatal check-ups for the purpose of detecting congenital abnormalities or genetic changes, such as trisomy 21 (Down syndrome), in the unborn baby. All prenatal testing is voluntary. Some of these additional tests involve a procedure to take a sample of amniotic fluid (amniocentesis) or tissue from the placenta (chorionic villus sampling).

However, health insurance funds will cover the costs of certain additional tests if there is a medical reason to suspect a disease, if the pregnancy is high-risk or if abnormalities need to be investigated. Otherwise, these tests are classified as individual health services or IGeL (short for “individuelle Gesundheitsleistungen”) in Germany. As such, they can only be performed if the expectant mother gives her consent and has been informed of the potential benefits and risks. Individual health services also have to be paid for by patients themselves.

More information about prenatal diagnostics is available on the familienplanung.de portal operated by the Federal Institute for Public Health (Bundesinstitut für Öffentliche Gesundheit, BIÖG).

Check-ups are generally every four weeks from the start of the pregnancy and every 14 days from week 32 of pregnancy. The maternity record is usually issued at the first check-up. All important information about the health of the mother and baby, as well as about the progression of the pregnancy and the birth, is recorded in the maternity record. The results of all tests performed as part of prenatal care are also entered in the maternity record.

At each check-up, the pregnant woman’s blood pressure and weight are noted, and her urine is tested. During ultrasound scans, the doctor checks the position of the baby and measures the baby’s heart rate. The uterus is also palpated. A blood sample is taken from the mother to detect deficiencies or diseases at regular intervals. Finally, the doctor or midwife checks whether any vaccinations are required, for example, against whooping cough (pertussis), rubella or flu.

More information about vaccinations during pregnancy is available on the familienplanung.de portal operated by the Federal Institute for Public Health (BIÖG). It also provides information about COVID vaccination during pregnancy.

In the third, sixth and eighth months of pregnancy, three routine ultrasound scans are scheduled:

First scan (week 9 to week 12)

This first ultrasound is mainly performed to confirm the pregnancy and to check if the embryo/fetus has attached to the uterus. It is easier to determine the week of pregnancy and the due date at this point than at a later time. The shape of the body and the beating heart give an initial indication of whether the pregnancy is intact and how far along it is. A multiple pregnancy can also usually be detected at this scan.

Second scan (week 19 to week 22)

At this check-up, pregnant women can choose between having a regular routine scan or an extended (“big”) scan. The costs of both are covered by statutory health insurance. The routine scan is an ultrasound scan to check for stage-appropriate development of the baby – the size of the head, abdomen and upper leg bones, as well as the amount of amniotic fluid and the position of the placenta. If abnormalities are detected, further tests may be necessary.
 
In an extended scan, the doctor also checks that the abdominal wall and spine are closed and that the stomach and urinary bladder are visible. The head, cerebral ventricles and cerebellum, as well as the proportions of the chest and heart, are measured more precisely. Not all gynecologists are qualified to perform an extended scan. A referral to a qualified specialist may be necessary.

Third scan (week 29 to week 32)

This is another examination to check the development of the baby. The position of the baby and the placenta, as well as the amount of amniotic fluid are also checked. These check-ups are important for planning of the birth, for example. If there are any abnormalities, the doctor may order further tests.

In certain cases, a pregnancy will be deemed to be high-risk, for example, if the mother is over 35, has certain pre-existing health conditions or is expecting multiples. High-risk pregnancies need to be monitored closely. This usually involves more frequent or specific tests to detect complications at an early stage.

Why is it important to determine the Rhesus factor?

From week 11 of pregnancy onward, the unborn baby’s Rhesus D factor can be determined from a blood sample taken from the mother. Rhesus factor D is a specific blood group characteristic. It is important to determine the Rhesus factor because, sometimes, women who doesn’t have this blood group characteristic and are therefore Rhesus-negative are carrying a baby who is Rhesus-positive. The mother’s immune system may form anti-D antibodies in this case. This can lead to complications later in the pregnancy. This situation can be prevented by giving the mother anti-D injections. Between week 27 and week 29 of pregnancy and after the birth, the mother receives injections of anti-D immunoglobulin. There are several different ways to determine whether anti-D injections are needed:

• The baby’s DNA can be tested before the birth by taking a blood sample from the mother from week 11 of pregnancy.
• A test can be performed to detect anti-D antibodies in the mother’s blood from week 23 of pregnancy.
• The baby’s blood can be tested after the birth by taking a sample of blood from the umbilical cord.

The Federal Joint Committee (Gemeinsamer Bundesausschuss, G-BA) provides more information online about determining the Rhesus factor in pregnancy.

Two further check-ups are normally scheduled after the birth. Within the first week after the birth, a red blood pigment (hemoglobin) test is performed for early detection of potential anemia in the mother. Six to eight weeks after the birth, the mother then has a general check-up and a gynecological exam. Her blood pressure is measured and urine is checked for protein, sugar and infections. The mother is also given advice, for example, in relation to contraception.

Midwife assistance for postpartum care begins immediately after the birth or after discharge from the hospital. The costs are covered by health insurance funds. The midwife usually visits the mother at home and examines and weighs the baby regularly. She examines the mother, asks her questions and advises her regarding any physical complaints she may be experiencing. She offers support with breastfeeding, changing diapers, sleep routines, and much more. New mothers are entitled to consult a midwife at least once a day for up to 10 days after the birth. In the first 12 weeks after the birth, the midwife will visit the new parents at home up to 16 times. If there are any problems, for example, with breastfeeding, the costs of any additional midwife visits are covered by health insurance.

Information about supports for young families is provided in our article “Postnatal support for families”.

Pregnancy is a special time. During pregnancy, it is especially important for patients to have a doctor with whom they feel comfortable and well supported. Midwives can also perform most of check-ups during pregnancy. This does not include medical ultrasound scans, however.

There are also certain tests, such as special prenatal diagnostic tests, that can only be performed by a doctor. In some situations, it may therefore make sense to choose to have some check-ups with a doctor – even if your regular prenatal care is mainly provided by a midwife. This applies in particular if any health-related abnormalities or increased risks are detected.

Midwives can sometimes have a little more time than doctors to answer questions or address concerns. They can help with choosing where to give birth and provide valuable support overall. In addition, it is good to get to know the midwife early on, as she may later be able to take over postpartum care.

An easy way to find a midwife is to use the midwife search tool provided by the National Association of Statutory Health Insurance Funds (GKV-Spitzenverband). All midwives whose services are covered by statutory health insurance are listed here.

All benefits provided by statutory health insurance during pregnancy and shortly after the birth are listed in the maternity regulations defined by the Joint Federal Committee (Gemeinsamer Bundesausschuss – G-BA). You can read and download the maternity regulations on the website of the G-BA.