Impact of midwifery-led units in Spain: lessons from the first 5 years

Background: There has been a growing concern over rising medical interventions during childbirth, particularly caesarean sections, without corresponding improvements in maternal or neonatal outcomes. Midwifery-led units (MLUs) offer a model that promotes physiological birth while reducing unnecessary interventions. In Spain, where maternity care is predominantly hospital-based and obstetrician-led, the first public MLU opened in Catalonia in 2017. Its temporary closure after five years offers a unique opportunity to assess its impact on interventions and outcomes. Objective: To evaluate the MLU's implementation and its effect on childbirth interventions within the unit and across the host hospital. Methods: A retrospective cross-sectional trend study of childbirth data (2018–2023) from all public Catalan hospitals, and a retrospective cohort study of women contacting the MLU (2017–2022). Results: MLU demand tripled between 2018 and 2022. Among 1286 attendees, 64.8 % were nulliparous and predominantly had low risk pregnancies. Half who planned an MLU birth began labour there, achieving 92.3 % spontaneous vaginal births and 4.1 % caesareans. Hospital-wide, caesarean rates fell from 23.5 % to 13.5 % (2019–2021), while spontaneous births rose to 78.7 %, suggesting a spill-over effect beyond the MLU. These trends reversed after closure in 2022. Conclusion: Spain's first public MLU was successfully implemented, safely reducing interventions and influencing wider hospital practices. Its closure and subsequent regression in birth outcomes highlight the need for sustained support and investment. MLUs can be an effective strategy for lowering intervention rates in highly medicalised systems, benefiting both unit users and the broader maternity care environment.