 So, I'm going to introduce two of our speakers today who are going to present on midwifreled care during labor and birth, and I'm excited about these topics. So, we have two of our presenters, we have Les Selet, is a midwife who works as a scientific worker for Flemish midwives, where she's responsible for annual reports of midwifreled care in Belgium. She combines this with employment with workers study coordinator at the University Hospital in Brussels and general hospital at Cottridge. She's also part of the team concerning scientific research in Flemish midwives. Then we have Elki. Elki is a passionate first line midwife and lactation expert in Brussels. She's the founder of midwifreled practice. She's part of the team concerning autonomous midwifreled care in Flemish midwives. So, welcome both of you and the floor is yours. Thank you. Hello. Thank you, Eunice, for this introduction. Can you give us the rights to switch the slides? So, we will talk about midwifreled care during labor and birth in Belgium. We will talk about the actual status of working as a midwife in Belgium because it's not that easy and we will go into our numbers from year 2021. So, I'm Lieselot. This is Elke. We were already introduced. So, the situation in Belgium and also why this report because it's not easy working as a midwife in Belgium. I don't know if that is the same for you in your country. But the standard here in Belgium is if you are pregnant, mostly you will have a hospitalised birth in the hospital with your doctor. You can see in our statistics, more than 99% of the women will have a hospitalised birth and the midwifreled care is just a small part of it. So, we have a high medicalisation of care. We have lots of inductions, episiotomies, epidirals. But there are a lot of passionate midwives who are working in Belgium and their work is not that known in Belgium. So, that's something that we want to change. We also want to change the culture of some people that are saying and thinking that midwifreled care is dangerous So, that's another reason. And there's also no exact knowledge of how many midwives are no guiding women during labour and birth. So, that's quite a mystery for us. So, there are a lot of reasons why we are doing this. It's our second report. For the methodology, we used a registration form for each birth. We focused mostly on low-risk pregnancies, which we mean labourers that can start in the first line with a midwife and that are planned to give birth with a midwife. That can be at home in a birthing house in or outside the hospital or the midwife can go to the hospital and using labour work to guide her woman to her labour and birth. Mostly of our registrations are from the Flemish part of the country and Brussels. So, you can see on the map the green and orange parts. Belgium is really quite a difficult country. We speak a lot of languages. And from the French part, Wallonia, we have a little bit starting midwives who are started with registrations. But it's still also a mystery how many midwives we are missing. But from the Flemish part and Brussels, we can be sure we have more than 98% of the midwives that are working and guiding women during labour and birth are doing their registration with us. If we give you an overview for our numbers, we had in 2021 1,587 registrations with the French part included. So, that were all labourers that were planned to give birth with a midwife. And from them, we had 1,311 metrifilet births. Mostly outside the hospital, a lot of women prefer to give birth at home. Slightly 20% were in a birth centre and one on the go. There were also birth inside the hospital. We have one metrifilet unit in Belgium. I mean one in a hospital. In other countries, I think it's more metrifilet units in a hospital. We have just one in Brussels but they are really doing a lot of work. And then we have the birth where the midwife goes to the hospital and uses the labour ward of the hospital. There were also a few women that need to be transferred during labour and we will go into that in detail later. So, thank you. So we are going to talk about the differences between midwives guiding a woman during labour and birth inside versus outside the hospital. And we start with fetal monitor. So it will be a lot of data that I'm going to tell you. The fetal monitor outside the hospital, mostly we use intermittent excruentation like 97%. So the biggest part. And in the hospital we see that there is more use of CTG. For the outside hospital deliveries, we think that it's important in promoting the mobility for pregnant women and that's why we promote that too. You see also that outside the hospital 3% didn't have any fetal monitoring. So that's what we think or we call the speedies. They delivered very fast. And in the hospital you see also more continuous CTG, 6%. And if we go through the ruptures of the membranes we see in the hospital, we see a difference of 5%. So there is more spontaneous rupture of the membranes outside the hospital than inside the hospital. And what is also a difference is that you see that 1% of the babies are born in the amniotic sack. So in Belgium we call them born with a helmet and we say always that are lucky babies. So there are more intact amniotic sacks outside the hospital than inside the hospital. And then we go through the birth positions. So you see that it's a bit the same inside and outside the hospital that the majority of the women choose for an upright birthing position. Around 40% choose for the hands and knees position inside and outside the hospital. And also you see the same amount, 43% of the women had a water bird and that's water bird in the different positions. What is the difference inside the hospital? You see more supine positions or more lying down positions. And then about the perinium we are proud to announce that 97% of the birds were with an intact or mild perinium rupture. So that's very nice. And only 1% had an episiotomy outside the hospital and also inside the hospital. And also we didn't have had a lot of severe ruptures in between 1 and 2% for inside and outside hospitals. And then for the repair of the perinial lacerations 60% outside the hospital didn't need any stitches versus inside hospital 42%. And most of the women were searched by midwives inside and outside the hospital. And then the placenta so you see that's also a bit the same. So you have to understand had a spontaneous bird of the placenta means no use of medication outside the hospital and there were 14% less spontaneous birds of the placenta inside the hospital. And 6% active policy outside the hospital that means that there was use of oxytocin so use of medication. And there were 15% of active management of the placental phase inside the hospital. So there is a link with blood loss in the direct postpartum so the majority had an estimated blood loss of less than 500 milliliters and inside the hospital no sorry outside the hospital 3% we had to refer to the hospital for problems in the postpartum period instead of 6% from the hospital we have to transfer them to a special ward for placenta retention or mostly for bleeding and the bleeding then more than 500 milliliters. So and then we have the CPS so in Belgium it's common to check the GBS and we see that 11% of the women with a positive or an unknown GBS swab received antibiotics so that was not a lot and inside the hospital it was 55% so we know that it's due to the hospital protocol so if they are positive they are more forced to take antibiotics. Also 89% didn't not receive antibiotics but there were no neonatal infections that we have in our data and then we have the neonatal data so you see that outside the hospital so for home birds we had less girls 49% and 51% inside the hospital we don't know why but there is a little difference and also that in the hospital outside the hospital babies are 100g bigger than inside the hospital also a funny fact because last year it was the same and how babies react after their birth we saw that it was after 1 minute and 5 minutes very good abhaar scores so more than 7 also inside the hospital and there were 4% neonates or babies that had to go to neonatology for the animation and 3% inside the hospital so here you can see an overview of the data for the comparison between outside and inside for fetal monitoring we are happy to see that most is intermittent auscultation but you see inside the hospital when a CTG is available it's also more used for rupture of membranes we have quite similar results for the bird position we see in both settings that women could choose a lot of positions they preferred on hands and knees so outside and inside the hospital but inside the hospital we see slightly more zipine positions then for the perineum we have really good numbers here mild perineum rupture or an intact perineum for the placenta we see a more difference but it's like with alka seed it's like that some hospitals they make it available to use the labor word as a midwife but then you have to follow their protocols and in a lot of hospitals it is after the birth you have to give the woman directly medication like oxytocin and that's why we see here the difference is like the same with the GBS in a lot of hospitals it's like the protocol you have to give a woman antibiotics intrapartum if she has a positive or unknown GBS for the app cars we have in both groups app cars course like I said there were also transfers intrapartum like 17% why? mostly for stagnation 27% of the woman had to be transferred for no progression and dilatation we had also a lot of referrals due to other reasons like the need for pain relief and we are happy to see that the referral due to urgency are quite not that much just 7% so most referrals were due to no progression and dilatation or the need for pain relief if we then make a comparison between the multi and the premi para we see a really big difference if there was transfer needed it was 72% with premi para against just 28% multi para but the reasons why are the same but here also for stagnation of labor the difference between premi and multi para are quite a lot for urgency they are the same just low percent that we are happy to see that these are low and for the other reasons like need for pain relief we see also a big difference then how was the delivery after a transfer more than half of the woman had a spontaneous delivery a choir of the woman had an instrumental delivery which from two to four shifts and 14% had C-section almost half of the woman had more an epidural anesthesia after transfer and a choir of the woman that received an episiotomy so here it's difficult to say it's really easy to say in the hospital we see more medicalization but after transfer do we still speak about low risk pregnancy not in every case so it's normal to see more medicalization but if you would look at normal perting process in a hospital of a low risk woman you would also see more continuous use of CTG more use of spine position an active policy for the birth of the placenta so it's quite double here to say then the neonatal data we have slightly more girls the mean birth weight is quite the same as like the metrifilate birth around 3.5 kg and the upcar scores here are also really good after one and five minutes and just 7% of the neonates are required reanimation so who is now a typical woman that chose to have her delivery with her midwife we see mostly multi parawoman why is that we have mainly two reasons we have women that are afraid for the previous birth with midwife for the first child because in our society it's like the culture you go to the hospital to have your birth in the hospital with a doctor so it's quite alternative to do it with midwife but we also see a lot of women that are not happy or traumatized by their previous birth and want to have another experience for the next child or the next children for the mean age we see 33 years old and the preference goes to a home birth then the typical birth here for fetal monitoring it's intermittent auscultation with Doppler the birth position that is most preferred is on hands and knees placental phase we have blood loss less than 500 milliliters with spontaneous birth of the placenta we have good upcar scores for more of 7 after 1 and 5 minutes the mean birth weight will be around 3.5 kilograms and if they are transferred needed it will be mostly with primary para for stagnation or the need for pain relief this is one of the last slides so the project open hospital as we told in Belgium it's not so easy as a midwife to do birth or birth themselves midwives there are different reasons the culture for women to deliver with a midwife but also the culture for the midwives because they are often the assistant of the chinecologist and also there are not a lot of possibilities to do births there is a few birth centers and there is recently one ward closed last year and that's the reason that we start a working group of volunteers midwives to make a document open hospitals and we did that to empower midwives and to discuss with hospitals to open their ward to have the possibilities to do births yesterday I discussed that in the center of Brussels with one of the hospitals I hope they will give us a go but that's not sure yet and just to say that we do all this for women and also we like to wake up the government to tell them to see that it's very important to have women centered care because we believe that each woman should bear to give birth and with who as a caregiver so that's the end of our presentation here you can see also our poster about animal reports and you can find everything on this site where you can find the poster in different formats and languages too and languages too so thank you very much for listening Yes, thank you so much Lisolet and Elke for the nice presentation on midu free healthcare during labor and birth and I think that's quite inspiring so feel free for the viewers kindly feel free to ask questions you may unmute yourself and ask verbally or you may type your questions in the chat box I can see one question for you Lisolet so the question is what are the responsibilities of the midwives after transfer so it's really diverse for each hospital in some hospitals they close the door you cannot go with your woman and other hospitals you can go as Dula but not as midwife and other hospitals they let you go as midwife so it's quite different for each hospital midwives working in the hospital sometimes you have a really good connection with them or just not but if you transfer to the hospital then it's the doctor that is responsible on that moment so if you as midwife decide that it's too risky to do a home bird or to have a midwife bird in the hospital and you transfer then you're not responsible anymore so that was the question maybe so maybe a question for you all how is the situation in your country for the midwives is it easy to work or do you experience also like cultural difference or has it seemed like something alternative or something yeah that's a very good question maybe I'll take it fast for Kenya given that I'm a midwife in Kenya although mostly teaching in Kenya we actually don't have midwifery like care like outside the hospital setting generally so most of the birds take place within the hospital the home birds are very few and it hasn't been embraced within the country that you can have home birds so that's something I would like to maybe for you to share the lessons from your country how did you achieve this maybe from the history that you were able to have midwifery led care within the country because today we had international day of the midwifery celebrations and that's one of our asks that we want to be allowed to have midwifery led care outside the hospital but then of course they are talking about infrastructural challenges so maybe share with us also how did you go about it to have it more strengthened within your country thank you I also see a question for Selene midwives are part of the public health care system but payment is quite low so you have the convention where the midwives ask like amount that is set but for some midwives is really really low to survive at the end of the month so they have choose to de-convent and to ask more and for the reimbursement it's quite lower so the patient had to pay a little bit more but it's still not that much but it's part of the public care and I agree with Aisha that would be more cost effective we have tried to do some research for that in Belgium but they didn't accept it so we will keep trying maybe another question about the midwifery care model what are the types maybe in your country that you have embraced for example do you have midwifery care facilities which are alongside in the hospital but then there is typically one unit which is midwifery care and then another one obstetric led care or maybe you have another one which is midwifery led care outside the hospital but in their own setting or maybe so what kind of midwifery led care do you have in your country you are muted for us so mostly it is just one type of care and that's just the labour ward care there's only one hospital so you have the midwifery led unit in the hospital and you have the labour ward and those are not they are separated from each other but then the only settings you have are birth centres outside of a hospital and the home birds and in some cases a midwife can go to a hospital to use the labour ward but hospitals are open for that so as a midwife it's really difficult for working but also I'm pregnant now and I had the opportunity just to have with one midwife association to have my home bird because it's too far for other midwives and that's really sad if you want to have a home bird in Belgium and there is a question Sabrina so most women receive prenatal preparation they have all prenatal follow up but mostly with a gynaecologist and that's more medical checkups and they have not a lot of preparation so midwives take care of to prepare them for labour and and midwives are also giving courses in group but not for everyone for the moment okay that's a good actually question I'm just thinking about psychoprofilaxis like preparation in case of maybe an emergency alternative maybe what considerations do you usually have for women to choose that these women I can take care of them within a home setting and this one I need to refer maybe just a quick one for those people like for us who are still thinking of you know who are still advocating for this so before we start maybe what are some of the considerations you would maybe share with us so for I worked before as a midwife in Brussels and if we have home birds we can go to the hospital so we had a referral hospital so most of the time if it's urgent we go with ambulance or by car and we are welcome in one hospital so it's nice to work together with them and that's also the hospital that I ask to have a midwifery let's care yesterday okay thank you thank you so much