In the context of Luxmama Club & ParentPrep asbl’s “#choicetohaveamidwife” campaign, a Luxmama blog contributor met with Martine Welter one of the most experienced midwives in Luxembourg, who has actively worked for the upgrade of the midwives role in Maternity and birth for many years.
In 2019, during the 100 Celebration of the Association Luxembourgeoise Sages-Femmes (“ALSF”) Prime Minister Xavier Bettel announced some great news for midwives in Luxembourg, so we asked Martine to explain a bit more about these changes and also to talk about her philosophy around birth and home birth, as she is the only midwife currently
accompanying home-births in Luxembourg.
Question: We heard some good news regarding the midwives profession in Luxembourg
lately? Would you like to tell us more about that? What will be the effect in the
future? Also, how long have Luxembourg midwives been trying actively to
achieve this change?
Martine: It’s our new midwifery “Reglementation” (regulation) concerning the competencies
and “techniques” we are or are not allowed to do. As the “old” one from 1981, even
though quite good and coherent for our profession and adapted to the European
Directives issued in 1980, needed a “lifting”, adapting to new techniques and
situation. Since at least 2006, we started with a working group at the ministry of health, that’s
just to say what time and energy it takes. We wanted to have the law for the new
curriculum for midwifery education that switched in 2012, but discussions were very
difficult and we needed to be very attentive and take care not to lose from our
responsibilities and autonomy, like being able to prescribe different medications.
Why do you think if birth is the same in humans do we have such very
different maternity care systems over the world?
Martine: You have different maternity care systems in different countries because in general
the health care system is different. In the United States for instance, you have
private care systems whereas in Luxembourg If you work you are supposed to have
your Social Security and then a lot of things are paid back by Social Security. There
is no difference between private and public system, this can create limitations in
Do you know the history of midwives here in Luxembourg? By which country
was the Luxembourgish system influence/resembles?
Martine: The first maternity was at the end of the 19th century and they had also the maternity
and midwifery school because before that the midwives were trained in France or in
Germany and the system here in Luxembourg is somehow based on these different
systems in the countries all along the road in Luxembourg. In 1967 the midwives were
no longer a medical profession, but they turned it to para-medical profession. This
situation resulted in midwives losing their autonomy and it is part of what we are
complaining about for a long time. This situation means we can mostly work if a
doctor gives a prescription.
What is your impression of the midwifery training in Luxembourg and how can
it be improved? Where did you do your training?
Martine: Only in 2012 it has become a direct entry profession. That means after a Bac
technique or classic you go into three years of midwifery before that it used to be
based on the nursing diploma. That means you had to do the nursing training and
then spend two more years to become a midwife. So, we were supposed to be a
specialized nurse, which is not the case. So we got the direct entry system for
midwifery but it has to become a four years Bachelors diploma, like in other
countries, because in three years getting to know what midwives really needs to
know is very concentrated and according to European standards, we are supposed
to conduct autonomously 40 deliveries which is again not very easy to have these
amounts of deliveries.
What do you think about the quality of maternity care in Luxembourg and how
it can be improved upon?
Martine: I would not say that the quality is bad but it often has very high rates of interventions.
The idea is to go into bigger and bigger maternity units and to close smaller units.
Before, there were seven Maternities here in the country and they closed the smaller
ones because they were not financially viable. As a midwife I think of course that
birth should not be looked only as a profit making business. With maternity care a
woman giving birth needs time and patience. So in Luxembourg there is not much place for these things. For me the opportunity would be now to put on a system, similar to other countries, called an ABC (Alternative Birth Center) system. In this system a Birth center (free-standing or an alongside midwifery unit) is the place where women with a normal non-complicated pregnancy are going and there, midwives have the responsibility for the pregnancies. Only if some problem arises and they need medical care the doctor will come into
this unit and see what is necessary.
Also, currently there is high use of synthetic oxytocin. Doctors are not taking into account that
sometimes a woman goes into labor and then labour stops and she might go back into labor
tomorrow. She simply needs to rest and not be given oxytocin to accelerate labour, however it’s understandable that in the hospital setting and organization there is a push not to occupy a bed too long… So, a good alternative would be to let the women that is having a normal pregnancy taken over by a midwifery-led-unit and doctors to only take over when a problem exists or arises. Also, for midwives and doctors to cooperate. A good example would be a Birth Center.
How would you describe equality between the midwifery and obstetric profession? Does it exist?
Martine: There is no equality between the midwives and doctors, they are two different
professions. We are supposed to take care of everything that’s physiological and the doctors are mostly trained to deal with pathology. And I always say it’s like a
train, you know a train runs on two rails and you need the two rails. So, in maternity
care we need them both. I know it’s a different job. So equality for me is respect for
every one’s profession. We need both to go on. So it’s not necessary to have equality but is is absolutely necessary to have respect!
What is your birth philosophy? Do you see birth as important in the context of
the larger society?
Martine: In Luxembourg there was a discussion about choosing how you die but there is none
around birth rights and how you would like to be born! These are both situations that
will only happen only once in everyone’s life. You will only be born once and you will only die once! So, I believe it’s important to carefully consider these two issues and why it is important how you are born.
Like some others said already before me, my philosophy around birth is also that being pregnant and giving birth is not an illness. Up to 90 percent of pregnancies are with no complications and that should also be with births. Birth should not be something that that there is some economical thinking about. In the past, the hospitals in general were run by a
congregation and the nuns were not paid much. Nowadays a hospital is an enterprise, a business with priority on “rentability” and not so much what would be the best for the mother and child: patience, time and to intervene as least as possible. But that brings no money….
The European Convention of Human Rights states that “Everyone has the right
to respect for his private and family life…” and observed that “…the
circumstances of giving birth incontestably form part of one’s private life”. Do
you believe birthing families here in Luxembourg have freedom of choice in birth? Will this now change?
Martine: While it’s true that, in some ways, in Luxembourg until now, a woman cannot
choose, because when she is pregnant, she has to give birth in the Maternity that the
doctor who follows her pregnancy works with.
Also, we only have 4 Maternities so there is not much choice in type of facility. In
other countries she follows a doctor during pregnancy and then she decides which
system she is going to give birth at, public or private or at home, in a small unit or in a
university hospital. As women rise up more, things might change, but … things change veeery slowly and don’t forget, they have already changed over all these years, in the 80’s for
example, a water-birth was not possible!
What is you role in pregnancy, birth or post-natally currently and in the past?
Martine: I was trained in Belgium, it was not a direct entry, I first became a nurse. Then I
came here and did a higher nurse degree and trained as head nurse. I was trained
also as a midwife and learned that midwives take care of pregnant women, women
giving birth and post-natally. When I came here I saw that I could only work in a
Maternity and I started quite early to do prenatal education courses with Initiative
Liewensufank because this was the only way to see pregnant couples and talk about
birth before meeting them in the Maternity during labor. The fact that in Luxembourg
midwifes were not very involved in pregnancy was not how I was trained and saw my
way of working as a midwife. I worked in Maternity at the delivery unit and then at the
Postnatal unit as a head midwife. I worked there during the rooming-in
implementation in the 80s it was hard to implement at the beginning.
I worked with the ALSF to get the right for women to get an early
discharge and for midwives to visit at home and get reimbursed by CNS which we
achieved in 1993!
Then I left the Maternity and worked as an independent midwife. At that time, I decided to learn more about home deliveries and I therefore stayed in The Netherlands with a Dutch midwife and learned about their system, how they take care of pregnant women and accompany them to give birth at home. In The Netherlands pregnant women go to the midwife first and if she sees a problem, she will send her to the doctor. Once a week they meet and discuss which
women should go to the hospital and which will remain under the midwives care. In the Netherlands, I attended my first home birth and realized what birth actually was all about! The midwife just stood and waited, and the woman did all the work. There were some midwives in the 90s doing that in Luxembourg, then I took over with some other colleagues and now actually I have about 3 to 12 home births per year. I do have exclusion criteria, like for instance first time mothers I just do a couple if someone asks me to. For me it is not “The” thing to do. You need to discuss with your partner with the midwife and prepare for it. If there are Birth centers or midwifery led units
available and function well the home birth is not that necessary.
Do you think the rate of medical interventions in pregnancy and birth in
Luxembourg is satisfactory? Seeing the c-section rate of over 30% how do you
think it can be reduced?
Martine: Yes the rate is quite high here in Luxembourg compared to other European
countries. You know the Germans have what it’s called “Geburtshilfe” and we do a
lot of what is called “Geburtsmedezin”. OK so if you would go back to “Geburtshilfe”
and leave more time and have more midwives working at the units (because
currently in the hospitals, midwives need to support too many birthing women at once) then you might be able to reduce all these interventions. Of course, this comes again to the bottom line and how uneconomical natural birth is. But all is a matter of choosing where to spend money, were to invest! And investing in the way babies are born and a woman’s right to choose how she will give birth is the right thing to do.
More about the contributor
Christina Anyfanti is a Certified Postpartum Professional & part of the Newborn Mothers Collective as well as a Birthlight™ Motherhood & Baby Yoga Teacher.
She also has a Diploma in Counseling Psychology among others. happynewmama.lu