BACKGROUND:
Spain’s highly medicalised maternity care system offers limited access to physiologic, midwifery-led care, despite international recommendations. In 2017, the first midwifery-led unit (MLU) integrated into the Spanish National Health System (NHS) was launched, an unprecedented opportunity to study how system design, care models, and politics shape birth outcomes and maternal experience.

OBJECTIVES:
To evaluate the clinical outcomes, maternal experiences, and system-level impact of Spain’s first NHS-based MLU, and to analyse health system and policy factors that shaped its implementation and temporary closure.

METHODS:
Mixed-methods project: (1) retrospective cohort analysis of maternal and neonatal outcomes in an MLU versus standard care (n=1,286 women); (2) a qualitative phenomenological study of women’s experiences across birth settings; and (3) cross-sectional trend analysis of all Catalonian hospital births 2018-2023 (n = 223,821) with interrupted-time-series analysis at the host hospital. Quantitative analysis included descriptive statistics and multivariate logistic regression.

RESULTS:
MLU care produced higher spontaneous vaginal birth rates, fewer interventions, and very high maternal satisfaction. Seventy-five percent of users came from outside the catchment, revealing unmet demand. Hospital-wide caesarean sections fell from 23.5% pre-implementation to 13.5% while the MLU operated, then rebounded to 22.9% after closure; spontaneous vaginal births rose from 64.2% to 78.7% and later dropped to 69%. Safety indicators remained unchanged. Qualitative data highlighted autonomy, respectful care and trust in midwives, but exposed systemic barriers that led to temporary closure in 2022 despite positive results.

CONCLUSIONS:
Embedding an MLU inside a conventional obstetric hospital can rapidly and safely shift practice toward physiologic birth, reduce costly interventions and align care with value-based principles. Enduring change, however, demands financing mechanisms, governance structures and political commitment that actively reward midwifery-led, woman-centred care.

KEY MESSAGE:
Midwifery-led units can safely shift maternity care toward high-value, woman-centred practice in medicalised systems, if supported by health system reform and sustained political investment. MLBC - implementation