De Living of AZ Monica: ‘A piece of home in the hospital’.

Two years ago, ‘De Living’ opened in AZ Monica in Deurne. It is a homely room with a box-spring bed, bathtub and mood lighting where you can give birth with your own midwife. A kind of home birth within the walls of the hospital.

The walls are painted yellow and white. There is a comfortable grey armchair and a box-spring bed, and a plant hangs from the ceiling. At first glance, ‘De Living’ looks like a cosy Airbnb studio, but one where they welcome new guests very often.

“You do not notice that you are in a hospital and that was exactly our intention,” says head midwife Karima Soussi of AZ Monica in Deurne via video call. There is no medical equipment visible, nor can you hear any bleeps or peeps from surrounding rooms because the walls are well insulated. “The Living is a bit like being at home in the hospital. Sometimes I see people entering nervously, but once in De Living you see the stress levels drop.”

And that is hugely important for giving birth, says Soussi, who has been a midwife for 28 years and has been head of service at AZ Monica since 2006. Time, space and reassurance are the most important things women need during labour. And there is plenty of that in De Living.

How did De Living come about?

“De Living came about after requests from parents who wanted to give birth with their own midwife, but found a home birth a bit too exciting. In recent years, we have noticed that pregnant women are increasingly asking for such one-to-one care. This fits in with the spirit of the times: women are becoming increasingly aware of their pregnancy. Some people think such women are demanding, but I call them self-aware. They are well informed and know that pregnancy is not an illness. They like to give birth with a familiar face that can offer one-to-one care. At the same time, they need the certainty that they can intervene quickly in the event of complications. This is exactly what De Living offers: a delivery without bells and whistles in a homely environment, within the walls of the hospital. We drew inspiration for this concept from De Cocon in Brussels.“

“Some people think such women are demanding, but I call them self-aware.“

What did the midwives in your team think of this idea?

“They were quickly convinced. Forty per cent of the midwives in my team are self-employed as part-time workers. They do pre- and post-natal follow-ups at home and sometimes supervise the deliveries of their own clients. So we know the added value of an independent midwife. In the hospital we also like to provide as much personal care as possible, but the reality is that our midwife at the delivery centre sometimes has one woman in labour and sometimes five. Then you have to divide your attention.”

Can any independent midwife attend deliveries at De Living?

“No, they have to have a partnership agreement with us. We work with 20 or so external midwives who I can trust blindly, because I don’t want anything crazy to happen under my roof. These midwives know what they are doing and they know their limits. They must work closely with the midwives in the delivery ward and with the gynaecologists in the event of complications. They therefore all know each other and have met each other. It also happens that an independent midwife calls a gynaecologist for a brief consultation, or that the gynaecologist comes to De Living. This is assessed on an individual basis and actually goes very smoothly.

Can any pregnant woman give birth at De Living?

“The same conditions apply to a delivery at De Living as to a home delivery: it is only possible in case of a normal, healthy pregnancy with a baby in head presentation. About ten to fifteen percent of our babies are born in De Living. About five percent are delivered by an independent midwife, and the rest by the AZ Monica team. Because you can also give birth there if you are monitored by our team and that will not cost you anything extra. We think that everyone should be able to give birth in such a serene environment. It’s all-inclusive here.” (laughs)

How did you convince the doctors and hospital management?

“Of course I had to convince the gynaecologists, paediatricians and hospital management to make it happen, both financially and in terms of mindset. It wasn’t just a question of heavily rebuilding an old delivery room and getting rid of everything that reminds you of a hospital. Above all, I had to get them on board with my philosophy. Since 2014, AZ Monica has been recognised as a ‘baby friendly’ hospital. So I said: I also want to become ‘mother friendly’. For me, De Living was the logical next step, because one-on-one care, peace and time lead to less stress and better outcomes for mother and baby.”

“The gynaecologists were on board pretty quickly, I noticed. You have to involve them in the process and once you have one or two, the rest will often follow. I also noticed that they were really curious. Our gynaecologists are not arrogant academics, they are also concerned with how they can improve their care and what new insights there are.

The paediatricians were a little less convinced, but they have adapted completely. This was also thanks to the trust in the midwives that they got to know better. Paediatricians noticed that you can easily wait half a day to check the baby and you can also take a blood sample while the baby is with the mother. Are they completely convinced now? They have no choice but to get used to it.” (laughs).

“We as healthcare providers must learn that we are there for the pregnant woman, rather than her being there for us. As a healthcare provider, you cannot say: this does not fit in my schedule. If you let go of that, it also leads to much less stress for women in labour, as a result of which they give birth much more easily. I always say: to force something or someone leads to creating problems.

Did you have to make major adjustments to the hospital?

“The renovation was quite difficult and the budget had to be doubled. But in terms of policy, the step to De Living was not so big. Our maternity ward has never been one where you had to come in for quick and planned inductions where you have to give birth between nine and five. We prefer quality to quantity. Most mothers nowadays only give birth two or three times in their lives. That should be a special and beautiful moment where they feel in control and their baby can be born peacefully and comfortably. Why should it have to be quick? If it goes well, it doesn’t matter if a delivery takes four or fourteen hours.”

“Personally, I also like the stress that sometimes comes with working in a busy delivery room, but mums should pick up as little of that as possible. Because how beautiful is a natural birth, in which the primal force of the woman can and may come out. In the end, giving a woman space and confidence to do it all by herself is much more difficult than giving her medication and putting on a monitor. All my midwives agree on that, otherwise you can’t work in my team.

So why still De Living?

“The conditions there are optimal. You don’t get stressed by alarms or IVs because they’re not there and you have the option of one-to-one care from your own midwife.”

Does that indeed produce better results?

“Yes, women who give birth in De Living are less likely to get an episiotomy and are also less likely to have a tear. There are fewer interventions. In a traditional delivery room, as a midwife you reach for a monitor or an aid more quickly because it is available and in view. In De Living, we first have to bring in a monitor or IV. You have to follow the body’s rhythm there. Women in labour also ask for an epidural less often. Because of the support they experience, they often manage without it and you can see that it really boosts their self-confidence.”

“That self-confidence is so important for young mums. Even after giving birth. We have to empower them and confirm them in what they are doing, you have to “boost and compliment” them, is what we say in Antwerp. Then they will feel better. I impress that on my midwives.

How do parents experience De Living?

“They are happy with it. We get a lot of cards from parents who write that they are so happy with the human, respectful care. In fact, it has been such a success that we are bringing more and more ‘living’ into the ordinary delivery room. In the traditional delivery rooms there are now coloured towels and a dressing gown. They may seem like trinkets, but they make a difference. There are also little plants hanging everywhere now. It is much more pleasant to fixate on a beautiful flower pot during a contraction than on a blood pressure meter.”

“We also follow the De Living mindset during caesarean sections. Women are allowed to bring their own music and their own midwife and, in the case of a gentle sectional, to pick up their own baby, for example. It all has to be done in a medically responsible and safe way, but even in that setting you can create a peaceful environment.”

Will the plants and independent midwives soon be competing with gynaecologists? Will fewer babies be born in the regular delivery rooms and with a gynaecologist?

“No, not at all. The Living is not in competition with the gynaecologists, nor do they see it as such. The Living mainly attracts mothers who are considering a home birth. The public there is slightly more alternative and progressive. The independent midwives with whom AZ Monica works often send these mothers here for the ultrasounds. If a gynaecologist is needed during childbirth, chances are that is also a familiar face.”

Do you hope that this model will also be picked up elsewhere?

“For our own sake, no, but for the mothers I absolutely hope so. And I mean especially the vision. The mindset of time, respect and affirmation. You can renovate all your delivery rooms but if you use an aggressive approach to care in them, it makes no difference.”

MASTER THESIS OPEN VERLOSKWARTIER

For her thesis for the Master’s degree in Management and Policy of Health Care, Katelijne De Koster researched the ‘access of the self-employed midwife to Flemish hospitals – in the context of independent delivery’ in 2011. To this end, she conducted 23 in-depth interviews with midwives and gynaecologists in three open and three closed hospitals. “Tradition in cooperation, financial aspects and the related competition, the independent midwife’s vision of normal midwifery, her competence and willingness to integrate into a hospital setting all play a role. A central role in determining access is played by the (head) midwives of the hospital as advocates towards the doctors who will make a decision based on this,” De Koster concluded.

The study also provided insights for the entire professional group of midwives. Whereas in open hospitals (independent) midwives could work completely autonomously with good agreements, in closed hospitals gynaecologists only delegated partial aspects to hospital midwives. “In this model of cooperation, the independent performance of a normal delivery by the midwife is not included and the doctor retains final control over the care provided and thus also a certain position of power over the profession.”