The model of maternity care in Brussels: its past and current developments Over the last decade, a shift in maternity care provision has been taken place in the Brussels Capital Region. Since the 1950s, Belgium has had an obstetrician-led care model for maternity care, with perinatal care predominantly provided by obstetricians. As an answer to this, a paradigm shift was initiated in 2014 in the Brussels Capital Region, by the establishment of the first alongside midwifery unit ‘Le Cocon’.
A midwifery unit is defined as a location offering maternity care to healthy women with straightforward pregnancies in which midwives take primary professional responsibility for care. Midwifery units may be located adjacent to or alongside an obstetric service, or standing alone, freestanding from a hospital unit6. Le Cocon and Le Nid, which opened in Namur in 2019, are the only midwifery units in Belgium that work together. These midwifery units combine the reassuring atmosphere of a home-like environment with the safety of an obstetrician-led unit nearby. Le Cocon is conceptualized as a low technicity midwifery unit7. With approximately 200 births annually (representing 11% of births in this hospital), it guarantees one-on-one care because it is managed solely by qualified midwives. According to a recent study by Welffens et al.8, women planning to give birth in Le Cocon had significantly fewer cesarean births, inductions, epidurals, and episiotomies, and there was no increase in negative outcomes for the newborn. A retrospective Master’s study aimed to determine the rates, reasons, and risk factors of intrapartum transfers from Le Cocon to the obstetric unit. It found that issues related to labor progression, as well as a desire for epidural analgesia, accounted for a significant portion of transfers9. These results are in line with international literature10,11. Additionally, a cost-effectiveness analysis study that was carried out at Erasme University Hospital in Brussels suggests that incorporating midwifery units might result in a reduction in costs for both women and the national payer. However, in order to reach definitive conclusions regarding the cost-effectiveness of incorporating midwifery units in Belgium, additional research with larger sample sizes and from various health economic perspectives is required12. The promising findings from these studies, along with comparable research, initially provided support for Brussels policymakers for the introduction of similar midwifery-led care pathways in other hospitals in the Brussels Capital Region8.
The law of May 2023, formalizes and stimulates the current shift in Brussels from obstetric-led to midwifery-led maternity care for straightforward pregnancies. From September 2024 on, Brussels hospitals with birthing facilities, subject to this particular legislation (n=8), will be required to integrate a midwifery birth unit, inspired by the Le Cocon model. The midwifery birth unit offers expectant mothers an alternative way to support their pregnancy in Belgium, where the practice of childbirth with the assistance of an obstetrician and medical staff is the norm. This new approach, which will tend to become more widespread in Brussels in the coming months, will allow women who are uncomfortable with the traditional hospital setting to feel more secure with provided care. The reform will allow expecting mothers to choose where their child will be born13. This move is aligned with promoting informed decision-making and continuity of care. Any change in current maternity care is expected to be coupled with concrete structural changes as well as cultural changes14. The reorganization of maternity care is expected to be accompanied with strategies to increase public awareness of the particular role of midwives in the continuum of care, for both women and their families. However, the project currently faces a significant obstacle as there is a lack of a comprehensive plan and necessary budget to enhance awareness. It is essential to get women’s groups, other professionals in maternity care, and policymakers involved in this structural change15. However, with the implementation of the Brussels’ maternity care model in just a few months, concerns arise regarding the adequate remuneration of self-employed, primary care midwives and the readiness of the healthcare system to accommodate this change. Particularly, in order to ensure the success of this initiative, midwives must be adequately prepared to staff these birth centers. Postgraduate training opportunities for midwives are being developed to help them become more adept at supporting straightforward pregnancies and births and managing emergencies. Hospitals that are unable to establish a midwifery unit are obligated to allow general practitioners, midwives, and primary care professionals to work in the facility in order to accommodate parents who wish to give birth naturally, make them feel at home, and be close to medical interventions if necessary. Because a structured collaboration between midwives and hospitals is typically limited to postpartum home care, the current situation in Belgium means that primary care professionals only have limited access to hospitals15. Between 6 and 10% of the hospitals in other Belgian regions and 45.5% of the hospitals in Brussels have maternity facilities that are open to primary care midwives17,18. Nevertheless, the recent Brussels’ law is strongly backed by recent research, indicating that enhancing the conditions for primary care midwives to gain access to hospitals in order to promote midwifery-led continuity of care models contributes to safe and qualitative care for all service-users15. In addition, the Flemish Professional Association of Midwives has recently proposed a model that supports midwifery-led birth guidance as a full option within Belgium’s conventional maternity care. This publication provides a solid foundation for productive collaboration between primary care midwives who want to independently assist with hospital births17. Through agreements that outline financial terms, responsibilities, capacity, timelines, and information exchange, the recent Brussels law encourages hospitals to provide birthing facilities for primary care professionals. The law also aims to ensure high-quality maternity care by encouraging professionals in the medical field to work together to ensure that vital information is transmitted between hospitals and primary care providers. Additionally, agreements must be made between hospitals and midwives for postnatal follow-up at home, with specific details regarding capacity, timelines, information exchange, and fees. The above-mentioned innovative measures are intended to guarantee complete childbirth care, improve coordination between hospitals and primary care midwives, and facilitate the access of primary care professionals to hospitals. toward a promising future The shift towards midwifery-led care represents a potential turning point in Belgian birthing culture, offering women, families and midwives more autonomy and options for their birthing experience. The successful initiative of Le Cocon, together with other local initiatives of primary care midwives, led to new insights regarding the organization of perinatal care in Brussels. As in other countries, the implementation of the Brussels’ maternity care model holds promise for ensuring safe and high-quality women-centered care. Recent studies19,20 demonstrate that this strategy ensures the accessibility of perinatal care and midwifery units without increasing the risk of maternal or neonatal complications. Furthermore, researchers are challenged to evaluate this subject to further enhance understanding and implementation. All regional governments in Belgium may be inspired to incorporate the Brussels maternity care model into their healthcare systems by the existing evidence highlighting the benefits of continuity of perinatal care and alongside midwifery units. In addition, countries confronting similar difficulties may look to the Brussels model as an example and investigate its implementation and potential advantages within their own healthcare systems. ACKNOWLEDGEMENTS
The authors wish to thank Isaline Gonze, Michèle Warnimont, Clotilde Lamy, Francis de Drée and Yvon Englert for their continuous support and insights toward a leading example of a midwifery-led care model in Belgium. We thank the Maron- Trachte Ministry Cabinet, and specifically Miguel Lardennois, for their innovative initiative and ongoing support for high-quality perinatal care in the Brussels Capital Region. We would also like to express our gratitude to Ines Rothman, a scientific collaborator of the Flemish Professional Association of Midwives (VBOV), for providing us with her thoughts on midwifery-led care. INTERESTS CONFLICTS The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors declare that they have no competing interests, financial or otherwise, related to the current work. J. Vermeulen claims to be The European Journal of Midwifery’s Associate Editor.
