How many labours and births in Belgium are midwife led and so guided and supported from start till the end by the independent midwife? Due to the current way in which birth registrations are happening, we simply don’t know. In the working group ‘midwife led care’, independent midwives are collaborating to highlight the results of their work.
In Belgium, only a small group of midwives work in primary care. Often, they work outside of the hospital. These midwives are the ones who support home births, and in some cases, they also offer midwife led continuity of care within the four walls of a hospital.
As independent midwives, we are convinced we are providing good care. At the same time, we are very vulnerable if it comes to our work. Regularly, we are confronted with preconceived ideas because we offer the option of giving birth at home; an option of place of birth which is not very well known by Belgian people and which is usually brought to the attention when a very rare but serious incident happens. When an incident happens ‘old wives tales’ are spread, we always have to defend and justify our way of working; even in the hospitals independent midwives collaborate with, they don’t just assume that we too try to give the best possible care and it is difficult to talk openly about our position. At the moment, for midwives in Belgium, there is still no script on how to deal with incidents and the communication around them.
This is why, in 2018, we have founded the working group ‘midwife-led care’. Because, even though we all work in independent practices, professionally we do the same job. During a study day, we decided to work together. Thus, the working group is now working on a script on ‘how to deal with incidents in midwife-led care, for midwives’. The script exists of 3 themes: first aid for the midwife after going through an incident during birth, a juridical and practical overview for the midwife after an incident and a long-term network providing help and support for the midwife after a traumatic experience.
Furthermore, we made a plan to make our work more visible using numbers. We have started with a first round of audit to see which colleagues were registering their work already and looked at how they were doing so. For the first time ever independent practices have shown their numbers to colleagues, we really went out ‘butt naked’.
Very soon, it became clear that not all midwives register their work and that everyone was doing it in their own ways. Hence why, shortly after we began, a tool was created for independent midwives to use for registering births on top of the existing registration system of SPE, the study centre for perinatal epidemiology, which counts all births in Flanders. In fact, the SPE-system counts only the home births supported by midwives, but not the births in hospital where an independent midwife is the main responsible healthcare provider. Nor are the births led by a midwife employed by the hospital counted. A knowledge gap, we believe. It does not only make the counts incomplete, this way of counting makes most of the work midwives do invisible. Because of this, no one knows how many births are midwife led and the perception even exists that midwives are merely the assistant of the obstetrician.
The aim of this working group ‘Midwife led care’ exists to make sure that all births led by a midwife will be registered as such; at home, in a birth centre and in the hospital. Only in this way a balanced and honest image of midwife led care in Belgium will arise.
Besides birth numbers and outcomes, midwives are also interested in more than the strictly medical information which is currently registered by the SPE. For instance, the position for birth which women choose, whether she uses hydrotherapy in labour and/or has a water birth and whether this position and the use of water have an influence on tearing or not are found to be interesting by midwives.
With this article, we give a little insight in our first round of audit in 2019.
We started on paper and in the first instance; we registered numbers of 10 independent midwife practices in Flanders, very soon after we expanded to 21 practices. The information was analysed manually in January 2020 by a group of enthusiastic midwives. We knew already that midwives like to write about their experiences and this became also apparent in the registration forms. Much more detail was provided on these forms, which sadly made the counting more difficult.
This is the reason why in 2020, we decided to use an online tool and based on our experience in 2019 we made improvements. In the new system all items have to be run through – so all registrations are complete – and there is only limited space to write, so no unnecessary information is shared.
As mentioned before, this article contains a first overview of our first audit in 2019. These numbers give interesting insights, which we will share later, but due to the method we have used, these numbers cannot be officially processed yet.
Primi- or multipara?
In total, 804 births were registered by the 21 practices included in 2019. Of these women, 682 (86%) birthed with a midwife as the main healthcare provider. 122 women were referred to obstetric led care due to the need for pain relieve or failure to progress. Of these 804 women, 29% were primiparas (pregnant of their first child), 71% were multiparas (had a baby before). The mean age in both groups was 32 years old.
Place of birth
The place of birth was mainly at home; 455 women (67%) birthed in their own house. 107 births (16%) were led by a midwife in the hospital and 58 (8.5%) in a birth centre. One baby was born before arrival.
In total 12 babies (1.8%) had to be transferred to the special care unit.
The SPE registered in 2018 (the numbers for 2018 are not available yet) only 380 home births in Flanders and no births led by midwives in the hospital. On the basis of our own registration in 2019 we suspect that the registration of home births is incomplete, even though we don’t know this for sure. We get the impression that not all midwives are motivated to get the numbers counted by the SPE-system, because it only registers a small amount of the work they do. There is another registration system called CEPIP, which registers numbers for Brussels and Wallonia.
As independent midwives, we don’t just register the place of birth, but also different variables which in our opinion are important to get an insight in the quality of care. Next, we review the results of these variables.
The SPE does not register birthing positions; neither do they register pool births. Midwives find this an important variable because they want to give women this freedom and encourage them to stay mobile and active during birth. This is why we love to speak about the ‘freedom of movement at birth’ rather than a static ‘birthing position’, but we did register it as such.
We registered 229 pool births (34%). Furthermore, 166 women birthed on all fours (24%), 95 on the birth stool (14%) and 57 lateral (8%). 15 women birthed standing (2%). Only 89 women (13%) birthed being in the semi-recumbent position (on their back).
The placenta was born naturally 620 times (91%). This means that a physiological third stage was facilitated in which the cord was aloud to stop pulsating and the placenta was given the time to be born, while the baby was having undisturbed skin-to-skin contact with mum. No medication was used. In the registration for 2020 more details will be registered about the birth of the placenta.
327 women (48%) supported by an independent midwife had an intact perineum after birth. 185 women (27%) had a first degree tear, 137 (20%) had a second degree tear.
In total, the independent midwives performed 13 episiotomies (1.9%).
Only the numbers of this last variable could be compared with the numbers of the SPE. The overall percentage of episiotomies recorded in the SPE is 39.7%. When only primiparas are included this percentage increases even up to 61%. Perineal tears are not registered by the SPE.
Screening for Group B Streptococcus (GBS-screening)
The screening result for GBS was negative for the 538 women who were tested (79%). For 80 women the screening was positive (12%). 64 women (9%) had an unknown result as they declined the GBS-screening.
Of the women who tested positive for GBS, 35 consented to have antibiotics administered in labour (24%), 109 declined antibiotics’ (76%).
Of the 109 births, 5 babies were admitted to the neonatal unit. Whether the admission was related to the GBS-screening result is unknown due to a gap in the registrations. Neither were the outcomes after admission to the neonatal unit registered. In 2020 more details will be registered around this variable.
A comparison with the numbers of SPE are sadly impossible due to these numbers being registered but for unclear reasons not being made publicly available.
Birth weight and Apgar score
The weight of babies at birth varied between 2485gr and 4940gr.
The Apgar score is given 1 and 5 minutes after birth. 655 baby’s (96%) had an Apgar score after one minute of more than 7 out of 10. 668 or 98% of the baby’s had an Apgar score of more than 7/10 after 5 minutes of birth. This means that 98% of all babies had a smooth transition from womb to life outside the uterus.
12 baby’s (2%) were transferred to the neonatal unit. For 9 registered births (1.3%) this information is missing. One baby was stillborn in the hospital.
Referral to hospital
The independent midwives registered 122 intrapartum transfers to hospital (in a total of 804 planned home births). Failure to progress was the most common reason for transfer (108 women, 89%). In 14 cases (11%) an urgent transfer to hospital was needed.
In 73% of cases (89) these were primiparas, compared to 33 multiparas (27%).
After referral 68 women (55.7%) had a spontaneous vaginal birth. 18 women (0.8%) had an instrumental birth and the same amount of women ended up with a caesarean section (0.8%). In 18 births, registration was for this variable was missing.
If we look at the total registered births (804), 2% of spontaneous vaginal births led by midwives were after a previous instrumental birth and 2% were after a previous caesarean section. These are low numbers compared to the SPE. One of the possible explanations for this phenomenon is that independent midwives look after women who have undergone a risk selection; so we work with a population of women who are healthy and well and are having straightforward pregnancies. Whether this is the completely conclusive answer, is the question as the differences are quite significant. For 2018 the SPE registered 21% caesarean sections. This is the highest amount of caesarean sections since the start of registration of SPE in 2007. Furthermore, the percentage of caesareans differs a lot between maternity units: between 15% and 29%.
The amount of instrumental births registered at SPE is 9.4%.
Looking forward to 2021
We are very happy that from now onwards, we will be assisted with our audit by Lieselotte Vandeputte, a midwife with a masters in management, policy in healthcare and economy. She has been employed one day a week by the Flemish Organisation of Midwives (VBOV). Lieselotte will look after the analysis of the information of 2020 and will make sure the audit of 2021 will start smoothly, with our registration system improved. She will also be responsible for the translation of the audit tool in French for our French-speaking colleagues, so we can register information from 2021 in two languages. We strive to get an overview on numbers of midwife led care on a Belgian National level.
Our dream is to register 1000 births led by midwives this year. We suspect that the coronavirus might give a helping hand in this matter…but most importantly: more numbers are going to give a clearer overview of the work we do and quality of care we provide. Both for our colleagues as for (future) parents.
Furthermore, we will try to start a conversation with SPE so eventually data can be transferred into one big database, provided that the necessary adaptations are done to the SPE-system.
For anyone who has new ideas or who is not yet registering their births but would like to, please email firstname.lastname@example.org. Together we can make our work insightful!
Elke Van Den Bergh
In 1993 I graduated as a midwife and after a lot of wandering around in various hospitals, I founded the midwife practice ‘Zwanger in Brussel’ (Pregnant in Brussels) together with a colleague in 2008. After 12 years of ups and downs as a self-employed midwife, I am still happy every day that our practice is there and that, together with an enthusiastic team of midwives, we can welcome new residents of Brussels! For years I have also been passionate about breast milk and in 2015 I graduated as a lactation specialist IBCLC.
I graduated in 1997 as a midwife in Leuven. After that I started working in a hospital in London (1997-1998). There I got a taste of midwiferyled care. Since 1999 I work as an independent midwife at Bolle Buik, Leuven. I am fascinated by the universal and timeless part of being a midwife in the constantly changing birth scenery of today.