Maternity care in Luxembourg

AIMS Journal, 2008, Vol 20, No 2

Maryse Arendt gives an overview of the situation for mothers in her country

Luxembourg is a tiny country situated between Belgium, Germany and France. 5724 babies have been born in 2007 in one of the six maternity hospitals. The size of the maternity hospitals is quite different ranging from 143 births per year to 1953 births per year. Only a few mothers choose to give birth at home and two midwives are ready to assist home births. There have been five home births in 2007.

Luxembourg's health care system is based on three fundamental principles: compulsory health insurance, free choice of provider for patients and compulsory provider compliance with the fixed set of fees for services. This free choice of health care provider does not include midwifery care as midwives have very limited possibilities to work as free standing midwives. Midwives can only provide, charge and get reimbursement for one prenatal visit and one postnatal visit. In the case of ambulant birth they can provide assistance and follow-up at home. If a woman needs more assistance for example because of breastfeeding problems then they need a medical prescription to get the midwifery care reimbursed by social security.

Only a few women are aware that the choice of a gynaecologist actually involves the place where the birth will occur, as pregnant women usually give birth in the clinic where the gynaecologist is working. Luxembourg's health care system is mainly publicly financed through social health insurance. The standard contribution level is set by the Union of Sickness Funds; it provides statutory health insurance for 99% of the population. Curative treatment is a shared responsibility of the Ministry of Health and the Ministr y of Social Security. The former supervises the organisation of the health services and subsidises the hospital sector, while the latter is responsible for the sickness insurance system.

The supply of primary health care is given on demand, as the patients have free choice of care provider and there is no legal means to limit the volume of medical activity. The health costs reached 6.9% of the Gross Domestic Product in 2003, the expenditure per person was 3705 US Dollars. In 1999 there were 0.14 gynaecologists per 1000 inhabitants, one of the highest rates in the original 15 EU countries. (Greece: 0.2, Germany: 0.18, The Netherlands: 0.05, Denmark: 0.09) ¹

Pregnancy

A certain amount of money (580 Euros) is given to women who have attended compulsory medical visits during pregnancy: five with the gynaecologist and one with a dentist. Only recently midwives have been allowed to provide one visit for pregnant women which will be reimbursed by social security. In reality women have many more visits with the gynaecologist, at least one monthly if not more. This means that pregnancy is totally medicalised creating a dependency of women on the expert doctor reassuring them that their baby is fine. Childbirth education courses are not reimbursed by social security. Initiativ Liewensufank has been offering holistic childbir th courses for 20 years now. In recent times more and more hospitals are star ting to organise their own courses including a visit of their premises. Some doctors have hired midwives or childbirth educators to offer courses to their patients.

Childbirth

All maternity hospitals are offering at least one birthing room with a gymnastic ball and a birthing chair or other alternatives to the lithotomy position. The presence of alternatives does not mean that they are widely used, nor that midwives are familiar with their use. Although all maternity wards have a birthing pool, water births are still rare and a lot of doctors refuse water births. Epidural anaesthesia is getting more and more widespread (37%-98% depending on maternity hospital.) The same applies to caesarean section where hospital data shows the percentage is between 9.5% - 32.5%. The rate of spontaneous bir th varies from 57.7% - 90.5%. The perineum stays intact for 10% of women or 50% of women, again depending on the hospital. Induced labour is widespread and ranges from 8% to 32%.

Breastfeeding

Three maternity hospitals have Baby Friendly Hospital status and are evaluated regularly. The number of live births in baby-friendly hospitals in 2007 was 2865 babies. This represents about 50% of all babies born in Luxembourg in 2007.

In the Baby Friendly hospitals the breastfeeding initiation rate was 90.75%. This is slightly higher than the national data based on a survey in 2002 which was 88%. The breastfeeding status when leaving the Baby Friendly maternity hospital after a medium stay of 3 - 5 days is: 87.8% exclusive breastfeeding at discharge, 86.6% exclusive from birth to discharge, 89.6% any breastfeeding at discharge. A baby referred to as exclusive breastfeeding at discharge (day 5) can have had infant formula, tea, water or maltodextrin since birth, yet had no bottle on day 5 when the recording is done, and may even have a bottle later during that day. He will be recorded as exclusive breastfeeding on day 5 for the statistics, which makes them look much better than the reality.

There is a big difference to non Baby Friendly hospitals, where the exclusive breastfeeding rate in 2002 was 73.1% at discharge. The breastfeeding rates have gone up in the past decades from 13% at four months in 1987 to 30% in 1994 to 58% in 2002. A similar rise applies to breastfeeding at six months where it changed from 10% to 42% in 15 years. In 2002 14% of all babies were still being breastfed at 12 months. Since 2007 a national action plan on breastfeeding exists. It was presented by the Minister of Health in February last year and it is based on the document Protection, promotion and support of breastfeeding in Europe: a blueprint for action.

Perinatal leave

Working mothers have paid maternity leave from eight weeks before until eight weeks after birth. In case of premature birth or when the woman is breastfeeding an additional 4 weeks of paid postnatal leave are added on demand. Additionally each parent has the right to six months paid parental leave under certain circumstances. The monthly allowance during the parental leave is 1780. 22.4% of the parental leave is requested by fathers. Never theless, a lot of employers are putting pressure on parents not to take this leave or are ill treating them when they return from the leave, pushing them into resigning.

Initiativ Liewensufank

We are a non-government organisation working for more than 20 years to improve pregnancy, childbirth and breastfeeding conditions in Luxembourg. We do so by offering counselling and courses to parents and liaising with decision makers. Initiativ Liewensufank offers women and men a place and an opportunity to meet, both before and after the birth, and attend courses or groups to discuss the changes, hopes, fears and joys around this turning point in their lives. A multidisciplinar y team, some of whom work on an unpaid basis, provides comprehensive information, advice and courses for expectant and new parents, carry out public awareness raising and administrative work and advocate on behalf of the organisation. We are partly funded by government funds (mainly from the Ministry for Equality), partly by our own efforts (members' subscriptions, fundraising events, course fees) and donations.

www.liewensufank.lu

marendt@liwensufank.lu

References

1. Source: Eurostat