Brief history of midwifery

The first state school for midwives, along with a maternity ward, was established under the auspices of the Medical Council in Pfaffenthal, a suburb of the City of Luxembourg, in 1877. This was followed by the establishment of the Association Luxembourgeoise des Sages-Femmes (ALSF) to defend the interests of the profession in 1919. The association brings together midwives from Luxembourg with diverse cultural backgrounds. In 2023, it represented 137 midwives of which 112 were professionally active. Membership is not mandatory and is not linked to the midwives’ license to practice. The association participates in various consultative bodies¹⁴ for maternity care, such as the Committee for Perinatal Health Monitoring in Luxembourg¹⁵. Additionally, the ALSF represents Luxemburgish midwives in the International Confederation of Midwives (ICM) and the European Midwives Association. Alongside midwifery educators, the association advises on the curriculum, provides guidance on training needs, and assists with adapting training to the Luxembourgish context. The ALSF adopted the ICM International Code of Ethics for midwives¹⁶, which addresses the midwife’s ethical mandate to promote the health and well-being of women and newborns within their families and communities¹⁷. This moral guide for midwives includes details on professional relationships, midwifery practice, upholding professional responsibilities and duties, and how to assure professional integrity of the profession of midwifery¹⁸.

In the GDL, the state, the medical community, and society recognize the art of midwifery. In certain places, public spaces are named after midwives to perpetuate the memory of individuals and their knowledge in service to successive generations. Since 2019, D’Hiewanskonscht (midwifery) has been registered in the national inventory of the intangible cultural heritage of the GDL. Additionally, in 2023, Luxembourg successfully secured the inscription of midwifery on the World Heritage List of the Intangible Cultural Heritage of Humanity of UNESCO¹⁹.

System of education for midwives

Midwifery education in the GDL is currently organized at a higher education institution, the Lycée Technique pour Professions de Santé (LTPS). The midwifery education is a 3-year direct-entry program of 180 European Credit Transfer and Accumulation System (ECTS) points leading to a Brevet de Technicien Supérieur diploma, an advanced technical certificate. The number of admissions into the program is predetermined each year (18 places/year) and the selection process is based on application documents followed by an interview. Previous accreditation commissions in 2017 and 2022 suggested the implementation of a fourth year of study, as the curriculum is very intense for a 3-year programme²⁰. This is especially important since new competencies which are more complex and aligned with the competencies described by the ICM were assigned to Luxembourg midwives in 2019^20,21. The most significant changes include the increased involvement of midwives in prenatal care, as well as an expanded list of medications and tests that they are authorized to prescribe²². As a result of these new responsibilities, autonomy has increased allowing midwives to adhere more closely to international standards for maternity care²⁰.

In the last decade, midwifery education in most European countries has moved into higher education institutions²³. The Bologna Declaration and EU Directive 2005/36/EC²⁴ were instrumental in bringing about this change. The GDL will comply with this process in the near future²⁵. Indications suggest that the degree of implementation of the Directives concerning midwifery education varies across individual EU countries²⁶ and within the World Health Organization (WHO) European Region – straddling 53 Member States across Europe and Central Asia – due to differences in healthcare systems, cultural contexts, and resource available²³. A study on the education level at which midwives complete their education in EU countries reported that in most countries, midwifery training concluded with a Bachelor’s or Master’s degree. In four countries, including Luxembourg, midwives graduated with a diploma¹⁸. The other three countries, Croatia, Estonia, and Germany, have since moved their midwifery education to the Bachelor’s level. Today, the GDL is the only country in the WHO European Region that does not educate midwives exclusively at the Bachelor’s or Master’s level²⁷. Although the current program delivered by the LTPS is in line with Directive 2013/55/EU²⁸, the Lair-Hillion⁶ report, which provides a comprehensive overview of the medical and health professions in Luxembourg, recommended upgrading midwifery education to an academic level in order to address both the quantitative and qualitative needs of the healthcare workforce⁶. In all countries, except the GDL, midwives have the opportunity to pursue postgraduate education, such as a Master’s or Doctorate in midwifery or related disciplines. A growth in midwifery research has been observed across Europe²⁹, with many midwives in various countries engaging in research and advancing their studies through postgraduate degrees¹⁸.

As of September 2025, due to major reforms of many other health professions in the GDL, midwifery training will move up to university level. To obtain a Bachelor’s degree, candidates must take part in a 4-year training program of 240 ECTS credits. This decision is aligned with the recommendation of the WHO³⁰ and was welcomed by the ALSF because a university-recognized degree will improve the attractivity of midwifery education and allow for greater professional autonomy. While the program at the LTPS is already operating at a higher education level that includes research methodology courses and a final thesis, there is a desire to deepen and expand courses, which is not possible in the format of the current 3-year program. Consequently, it is for this reason and also in line with the 2022 National Accreditation Commission’s recommendation that a fourth year has been requested²⁰. Ensuring that training concludes with at least a university Bachelor’s degree is essential in enabling midwives to pursue Master’s or Doctoral studies, either domestically or internationally³¹. This aligns with Luxembourgers’ familiarity with seeking higher education opportunities abroad. Midwifery education in the GDL will be fully academicized by 2029 and will be offered exclusively at the University of Luxembourg.

As in line with international requirements²³, the University of Luxembourg’s midwifery curriculum will be meticulously designed based on the latest evidence and learning will be facilitated through simulation exercises. This is paired with practical training alongside seasoned midwives across various practice settings, ranging from home to hospital births. Under close mentorship and guidance, students will develop the skills needed to become qualified midwives. In most countries, research and evidence-based practice is part of midwifery education²³. With a strong focus on evidence-based practice, these programs are designed to equip midwives to meet the demands of modern maternity care. Consequently, the midwifery course of the University of Luxembourg will be no different, focusing on family-centered care and evidence based midwifery. A particular emphasis will be given to interprofessional collaboration and the provision of safe and high-quality perinatal care. The well-being and quality of life of students will also be taken into consideration.

Legal status of midwifery

Midwifery practice in the GDL is determined by the European Directives, outlining midwifery’s particular competencies, which are specified in national legislation. Specifically, in the Grand-Ducal Regulation of 22 November 2019 and the Law of 29 June 2023 determining the status, duties, and rules governing the practice of the midwifery profession, it is stated that midwives in the GDL are autonomous and competent to practice independently in an uncomplicated pregnancy, labor and childbirth^22,32. The midwifery profession in the GDL is a regulated profession that includes diagnostic and prescriptive authority. Midwives primarily practice in hospitals but also offer services privately or in family planning centers. They specialize in normal pregnancies and are involved in all stages of childbirth, from preparation to postnatal home care^20,22. In the GDL, midwives are specialists in eutocia and provide care in both hospital and primary care settings. They offer counseling and supervision to healthy women and newborns throughout the preconception, prenatal, intrapartum, and postnatal periods. However, the development of pre- and postnatal care within primary healthcare settings remains a challenge, as hospitals remain the primary employers of midwives⁶.

A recent study, carried out in 2019 across Europe, highlighted significant under-utilization of midwives, whose professional duties include monitoring normal pregnancies and performing normal births, including episiotomies¹⁸. In the GDL, midwives are not consistently fulfilling these responsibilities across all maternity units, as Luxembourgish pregnant women predominantly receive care from an obstetrician⁶. The choice of having an obstetrician as the primary care provider affects the place of birth, as pregnant women usually give birth in the clinic with which the obstetrician is affiliated³³. To qualify for a prenatal allowance from the government, women are required to attend five prenatal visits with an obstetrician. During pregnancy, 99.6% of women are monitored by a healthcare professional, and the majority (92.6%) of them consult a healthcare professional during the first trimester of pregnancy¹⁵. Moreover, a medical prescription for midwifery care is only required for monitoring pathological situations. For uncomplicated situations, midwifery care is reimbursed directly by the Luxembourg social security^33,34.

Midwifery in numbers

In 2019, there were 234 midwives actively practicing in the GDL, all female, and 37.1% of them worked fulltime. Amongst professionally active midwives, 38% were Luxembourgish, while France and Belgium together contributed more than 56% of the midwives in the GDL⁶. The ratio of midwives in the GDL has remained unchanged between 2010 and 2020 at 0.8 midwives per 100000 inhabitants³⁵. By contrast, the number of midwifery graduates per 100000 inhabitants in 2018 was amongst the lowest in the EU (less than 1.0 in Germany, the Netherlands, Austria, Luxembourg, Italy, Spain, and Cyprus)³⁵.

Nevertheless, the recruitment pool, which covers the entire territory of the GDL, has a high demand for midwives today and will have in the coming years. Between 2019 and 2034, it is projected that there will be 81 anticipated departures out of a total of 234 midwives, i.e. 34.6% of the current workforce²⁰. To replace these departures, the GDL will need to produce an average of 5 certified midwives per year, exceeding the number of graduates in recent years. Furthermore, the number of students is slightly decreasing, while demand rises. Reconsidering the training program is therefore fully justified because current recruitment is barely meeting demand²⁰. A university-affiliated midwifery degree course may encourage more students to apply.

In 2019, 7108 births were recorded at the four maternity hospitals in the GDL³³. The size of the maternity hospitals varies significantly, ranging from 770 births per year to 3019 births in 2019¹⁵. One of the typical characteristics of maternity care in the GDL is its large proportion of foreign women who give birth in the country. In 2019, 23.5% of pregnant women were of non-European Union nationality. Among the women from the European Union giving birth in the GDL, the majority had either Portuguese, French or Belgian nationality. Another characteristic of Luxembourg is the proportion of non-resident women who receive medical care as numerous cross-border workers commute daily for work. Consequently, they are insured by the National Health Fund and have the option to receive medical treatment either in their country of residence or in Luxembourg. Between 2017 and 2019, cross-border women giving birth in the GDL accounted for 14.0% of all births¹⁵.

The number of planned home births was 6 in 2019. Meanwhile, between 2017 and 2019, 21 unplanned home births occurred¹⁵. In the latest perinatal epidemiology report, covering data from 2014–2016, the average cesarean section rate was 32%, and the rate of instrumental vaginal births was 11.4% in the GDL¹⁵. There has been a significant decrease in episiotomy rates over the last decade. In 2019, 13.7% of vaginal births involved an episiotomy, and this rate dropped to 10.8% when stand-alone episiotomies, excluding associated tears are considered¹⁵.

Challenges and prospects

This article aimed to assess the current state of midwifery in the GDL and use these insights to develop a new educational program that meets the future needs of the profession. Ensuring that learning outcomes are relevant and sustainable will enable Luxembourg to address existing challenges and adequately prepare its midwifery workforce.

The Luxembourg government initiated reforms in 2021 to enhance the attractiveness of healthcare professions, particularly focusing on nurses and midwives. These reforms aimed to address current and anticipated workforce shortages and improve healthcare delivery³⁶. In 2023, WHO/Europe ministers from the smallest member states, including Luxembourg, committed to improving health outcomes through greater investment in healthcare worker education and retention³⁷. Strengthening recruitment and retention in midwifery is key to expanding access to safe, respectful maternity care¹¹. To attract candidates to the midwifery profession, it is essential to effectively promote its competencies, roles, and opportunities³⁸. However, Luxembourg faces significant recruitment challenges, notably the difficulty of attracting non-Luxembourgish students due to the bilingual language requirements (French and German). Additionally, the existing midwifery program is recognized only as a two-year degree, making salaries less competitive²⁰. Consequently, 50% of midwives working in Luxembourg are from neighboring countries²⁰. With WHO targeting a 50% reduction in foreign recruitment by 2030, proactive policies are needed to encourage local students to pursue midwifery and enhance the program’s value to improve the profession’s image⁶.

A key solution lies in elevating midwifery education to a university degree³⁹. In recent years, many countries have transitioned midwifery education to universities to ensure autonomy, professionalization, and readiness for future challenges²⁵. A university degree could not only enhance the profession’s attractiveness to graduates but also better prepare midwives for delivering safe, evidence-based care⁴⁰. In Luxembourg, the shift to a university model can reinforce professional identity and offer continuous updates on best practices, thus driving transformative change in the sector. The recent academization of midwifery posed significant challenges for Germany; universities needed to innovate in curricular and practical teaching, fill professorships, and secure adequate resources⁴¹. The anticipated changes will have far-reaching effects on midwifery care quality in Luxembourg. By elevating midwifery education to a university level, midwives will be better equipped to meet the complex demands of modern maternal healthcare, ensuring that they are able to deliver high-quality, evidence-based care⁴². This approach may help to address current recruitment challenges by attracting more students and improving retention rates. Additionally, the combination of extended clinical placements and an emphasis on interprofessional education will ensure that midwives are not only clinically competent but also confident in collaborating across healthcare settings, enhancing the overall quality of care provided to women and families⁴².

The University of Luxembourg is currently developing a four-year Bachelor’s degree in midwifery, which aims to provide students with the necessary knowledge, skills, and behaviors for safe and competent practice. High-quality clinical experience is one of the most critical factors in midwifery education, as it is essential for developing the ability to provide competent care⁴³. The program will incorporate extended clinical placements to ensure students gain hands-on experience in all aspects of midwifery care, from pregnancy to postpartum. Collaboration between the University of Luxembourg and local healthcare institutions – such as hospitals, clinics, and community birth settings – through structured placements, mentorship, and interprofessional learning, will ensure that students gain practical experience in real-life environments. This will build their competence, confidence, professional identity, and teamwork skills, enabling them to deliver competent, evidence-based care⁴³.

The emphasis on interprofessional education and simulation platforms will further enhance learning and clinical competence, aligning with international standards. The objectives of the midwifery 4-year Bachelor’s degree at the University of Luxembourg is to provide students with the knowledge, skills, and attitudes of future midwives so that they are able to practice all aspects of the midwifery profession safely and competently as defined by law in Luxembourg. The ultimate aim is to empower students so that they will be able to deliver healthcare to a high standard to all women of childbearing age and their families. The program will be designed to encourage critical thinking in an academic setting and form solid foundations for students to develop a sound professional practice that best prepares them to face everyday real-world challenges of the midwifery profession and for future study. For long-term success, continuous review and adaptation of the midwifery curriculum are essential. Collaboration between educators, healthcare providers, and stakeholders will ensure the curriculum meets evolving health challenges and remains aligned with European and national qualification frameworks. Stakeholder engagement will also help bridge the gap between theory and practice, ensuring that midwifery education remains responsive to societal needs^44,45. While the positive impact of quality midwifery education on maternal and newborn health has been acknowledged by the WHO, it highlights the need to engage with stakeholders in education⁴⁶. The clear symbiosis of quality midwifery education with quality care for women and their families cannot be ignored⁴⁷. A continuing dialogue with organizational management in the clinical area is important for establishing joint positions across academic and healthcare institutions.

Our aim is to foster collaboration between practicing midwives and educators to integrate clinical leadership with research, advancing midwife-led continuity services and delivering sustainable, evidence-based care⁴⁴. In line with the theory of participatory curriculum development framework, stakeholder engagement will be promoted. The provision and maintenance of quality education and practice require shared responsibility between education providers and healthcare services⁴⁸. Professional programs benefit from this involvement by maintaining a strong connection between theory and practice. Inclusive representation creates a curriculum that is responsive to changes within knowledge and societal expectations⁴⁹.

Beyond the Bachelor’s degree, Luxembourg could also consider the possibility of introducing postgraduate programs in midwifery. A Master’s degree can prepare midwives for advanced roles in management, research, education, and clinical specialization³⁹. There is a pressing need to design Master’s programs tailored to the field. Additionally, it is crucial to consider specific advanced roles for midwife practitioners and develop corresponding educational programs. A clear pathway towards clinical specialization in midwifery at an advanced level needs to be established, in alignment with health policy regulations. For example, over the past decade, Ireland has established high-quality midwifery education programs that ensure graduate midwives can deliver safe and competent care⁴⁵. This has led to increased opportunities for registered midwives to pursue higher level qualifications, with several universities offering Master’s and Doctoral programs in midwifery. In Ireland, midwives can specialize in various areas such as normal and complicated pregnancy, birth, postpartum care, and reproductive health⁴⁴. Moreover, advanced midwife practitioners are playing a pivotal role in advancing midwifery practice in some settings⁴⁵. Furthermore, there is a need to establish doctoral programs for midwives in fields such as social health sciences, psychology, and education. This would contribute to the growth of midwifery research across Europe. While midwives in many countries have the opportunity to engage in research and pursue postgraduate studies, including Master’s and Doctoral degrees, Luxembourg notably lacks such opportunities.

The experiences of other European countries demonstrate that a strong theoretical foundation at the university level, positively influences the professional identity of midwives⁵⁰. Future research in Luxembourg should explore how midwives perceive their professional identity within this new educational framework. Insights from this study could guide midwifery educators globally in shaping their programs and addressing the challenges midwives face in practice. While the global trend toward university-level midwifery education is clear, it is important to recognize that educational models must be adapted to the specific context of each country. Differences in healthcare systems, regulations, and scope of practice require tailored approaches to ensure that education aligns with local needs⁵¹.

Currently, midwives in Luxembourg are under-utilized, as many of their competencies, such as monitoring normal pregnancies and issuing medical certificates, are not fully recognized by the authorities or employers⁶. Independent midwives have no access to hospitals to support the women they care for during labor and childbirth. Currently, there are few options for women to access midwives directly and community midwifery care is not widely available. Ongoing legal reforms are addressing these issues, and the introduction of a university-accredited degree is expected to further elevate the recognition of midwives’ competencies by healthcare professionals and administrators.

As the midwifery profession evolves, Luxembourg’s experience may offer valuable lessons for other countries facing similar challenges. The shift toward university-level midwifery education, combined with legal reforms and stakeholder collaboration, has the potential to strengthen the profession both nationally and globally. The identification of midwifery as a distinct profession and the implementation of transformative practices have led to substantial changes in midwifery education in Australia⁴⁸. Knowledge sharing through exchange programs, such as ERASMUS, can also foster international co-operation and raise standards of midwifery education worldwide.

Conclusion

This article highlighted the urgent need to reform midwifery education in Luxembourg, focusing on recruitment, retention, and elevating midwifery training to a university level. As Luxembourg is the last country in the EU to implement Bachelor’s or Master’s level midwifery education, it has a unique opportunity to learn from the experiences of other countries and consider the obstacles they encounter. Addressing current challenges, such as language barriers, and under-utilization of midwife competencies, will require targeted policies that emphasize professional development and the creation of advanced educational programs. By aligning with international standards and fostering collaboration between educators, healthcare institutions, and stakeholders, Luxembourg can futureproof its midwifery workforce and contribute to the global advancement of midwifery care. The emphasis on collaboration, stakeholder engagement, and the creation of advanced educational pathways offers a blueprint for strengthening midwifery education globally.