AIMS Journal, 2008, Vol 20 No 2
Andrea Anguera & Angela Müller look at the medical attitude to birth in Spain and efforts to support midwifery and normal birth
pain has a population of 45 million people. In 2006 482,957 babies were born. A high percentage of all pregnancies in Spain are considered high risk due to previous caesarean, various operations, diabetes, obesity, maternal age of more than 35, myopia, IVF, and many other reasons. In general, pregnant women 'need to be controlled'. It is very common for the gynaecologist to contact the mother and her partner if she declines any optional antenatal test. Some gynaecologists state clearly from the beginning, 'undertake these tests or find another attendant.'
Birth attention has turned into a highly defensive medical care, caesareans have become such a normal thing that even some gynaecologists admit they often perform them 'just to be sure'.
The routine of birth and its outcome is often a cascade of intervention with the final result either a caesarean or more intervention (forceps, etc.)
Although to us it looks obvious, we need to explain how the machine works to people that are not involved in this topic.
Although it is illegal to fire pregnant women, it is still common. Unbelievably, it is only recently that a project has been star ted to prohibit firing domestic workers when they are pregnant.
Maternity leave for working women is 16 weeks plus vacation days plus 'breastfeeding-hours' which makes a maximum of 5 months. It is possible for a woman to take a year off, but this is often detrimental to her career.
Paternal leave is about 16 days (more for civil servants).
The medical system in Spain is divided into public and private systems. The public system is said to be much better (although many doctors have contracts with both systems), but private hospitals offer shorter waiting lists and more comfort.
Those who can afford to pay extra private medical insurance do so. In big companies it is part of the employment package and it often includes the whole family. 6.7 million people (15%) in Spain have private medical insurance.
As soon as a woman knows she is pregnant the question often is, 'public or private?' Many women prefer private clinics because they get the comfort of a single room and a sleeping chair or bed for their partner. Even though the partner sleeps in the same room, the baby is often taken away during the night and even during the day so the mother can rest. Some people especially like private clinics for their 'nursery' service, which takes care of the child at night or even 24hrs a day during the whole stay. Rooming In is known as a term, but often not practiced.
In the private system the same gynaecologist, or the same team, will see the mother during the whole pregnancy and birth, whereas in the public system the woman is usually attended by a different professional at each appointment.
The problem is that in order to guarantee this special attention in the private system, it is completely normal to do inductions and perform all kinds of interventions in order to programme or accelerate the process of labour. This leads to an almost double rate of caesareans in the private sector.
Although public hospitals have half of the caesareans of the private clinics, they are usually understaffed and one midwife can be caring for ten or more women at once.
Hospital birth
Public system: 3 ultrasounds (weeks 7-8, 12-16 and a detailed scan at week 20) and monitoring each week during the last month. Usually there are two appointments with a midwife.
Private system: Ultrasound each time you visit your gynaecologist, plus special ones at weeks 12 and 20 monitoring at least once a week during the last month. A midwife is not part of antenatal attention.
In Spain almost all antenatal analysis is done by routine, not by indication; and gynaecologists tend to recommend the 'whole package'.
Preparation for birth
Despite all the fantastic names that have been invented for birth preparation courses, the majority of these do not really inform the woman, in fact they only make her fit into the system. They prepare her for all that is going to happen in hospital once she arrives so she will not be surprised by any intervention nor by all sorts of routine manipulation. In the public system these courses are run by midwives whereas in the private system they are mostly run by gynaecologists.
More and more women also inform themselves with books, the internet, and a wide range of magazines dedicated to pregnancy, birth and post partum. There are at least five monthly magazines exclusively dedicated to the topic.
Home Birth
There is no public system in place for bir thing at home. A very, very small percentage of all babies in Spain are born at home. Home birth is not covered by the social security (public system) in any way.
Some of the mothers and fathers of the current generation have been born at home assisted by doctors in rural environments or midwives in cities. Hospitals became the most common place to birth around 1950-1960.
Home birth is also not supported by the mentality of society in general. Women who want to birth at home are still called irresponsible and the usual comment they receive after the birth is, 'Thank God everything went well, lucky you.' It is very problematic when a homebirth ends in hospital and there is no contact doctor informed in advance. These women usually end up with the whole package of interventions and abuses, including verbal abuse.
There is an official home birth register, but there are no national statistics about home births.
In Spain most people only make a distinction between caesarean and 'natural birth', and it is hard to explain to somebody that 'natural birth' is not the same as 'noncaesarean born baby'. We are trying to get this message to the media.
Caesarean birth rate: 22% public hospitals, 33% private hospitals.
It is really surprising how hospital statistics vary from one place to another. Some hospitals in Spain do more than 50% caesareans while some in the same area show a rate of 15%.
We do not know the percentage of instrumental births. It is normal not to publish these rates, and most hospitals do not even register them.
An episiotomy rate of around 90% is a tragedy in Spain. Women usually arrive at hospital taking this intervention for granted as during the preparation course they were directly shown how to heal the stitches. It is a big taboo and a lot of women do not receive any care for the consequences of episiotomy.
There are no statistics about the number of women considered 'high risk'.
Although we do not have numbers for VBAC (PVDC in Spanish), we know that there is an increasing tendency; we even have a few VBA2C stories on our site.
Epidural is an important indicator of quality and epidural anaesthesia is used in approximately 85% of normal births. This percentage has gradually increased since 1998 when the Spanish Health Ministry announced the intention to make it available to 100% of women in labour. In Spain the traditional epidural, not the 'walking epidural', is the one used most of the time.
Hospitals with less than an 80% of epidurals are considered of low quality service.
The epidural has not only been sold as 'the best invention ever', but also as 'the one and only'. There is no complete information on side effects, contra-indications or alternative pain relief. Only in a few places do they offer walking epidural or water.
In order to be able to understand this situation it is necessary to know that in Spain there was an important movement by women to make epidurals available. The epidural was an election topic once and there were public demonstrations claiming for the right of every woman to get anaesthesia.
Most women do not even think about not accepting the epidural. Having your child without anaesthesia is still said to be 'totally crazy'. They fear labour and birth and the thought of making the pain go away is perfect.
There is a growing interest in water and other alternative pain relief.
The perinatal mortality rate is 6/1000 and in Spain is recorded for all babies stillborn and newborn deaths within the first week.
In 1995 the abortion rate was 5.1 per thousand women between 15 and 44 years, in 2006 the rate was 10.62 per thousand. Abortion before the 22 weeks of pregnancy was made legal in 1985.
10% of babies born in 2007 were premature.
Premature babies increased from 17 000 in 1997 up to 33 000 in 2006. Twenty years ago, premature babies were about 5% of all births, now this rate has doubled. Out of this 10%, between 1% and 2% are estimated to be extremely premature, born before week 29.
Put in place under Franco's regime, the current old law about the midwife's role, used authoritarian language (e.g. 'instructions', 'superiors', 'orders') and referred to the midwife as a mere 'helper'.
The gynaecologist is still considered the most important person in pregnancy and birth. However, the main problem with gynaecologists is that most of them have never seen a normal birth in their whole career. They have been exclusively trained in the things that can go wrong, and although they occur in a small percentage they don't keep this in mind, and therefore cannot see the big picture.
Midwifery in Spain was regulated by law in 1973. It left very little competency for them; gynaecologists were in charge of labour and midwives were simple assistants. A 1980 European law returned midwives to their traditional role, but still Spanish society judges and even some midwives believe they are not in charge of normal birth. It is usually understood that physicians are in charge of labour.
During the years 1987 to 1994 no midwife graduated in Spain, schools were closed because of a political decision. This meant the elimination of almost two generations of midwives, and as a result it took away the relevance of this profession. Even nowadays, it is the gynaecologists who give them lectures, not other midwives, and it is still a fact that a trainee gynaecologist is more important than a midwife.
In 1994 there were 5 861 midwives officially registered in 2006 there were 6 868.
Only one in 200 midwives are actually members of FAME (The Spanish Federal Association of Midwives). One of their main worries is to increase the number of midwives in Spain. It is also their aim to promote a change in midwifer y study plans, in order to comply with the Bolonia process, which expects midwives to be able to work in any country in the EU.
In general in order to become a midwife in Spain, the person has to do three years of nursing courses and then they can specialise. We understand there is a big difference in this regard compared with other countries where the professions of midwife and nurse are differentiated and each one specialises in their own area.
Nowadays the role of midwifery is growing in importance, but it is still not common to run private appointments and take the whole responsibility, as a midwife, to attend all the process of pregnancy, birth and postpartum.
If a pregnancy is attended in the private medical system, the woman probably does not get to see a midwife until the day she gives birth. Many women cannot say if there was a midwife present during their labour, they just remember the anaesthetist and the gynaecologist.
This profession is very new in Spain. The problem of a doula accompanying the birthing mother is that most hospitals only admit one additional person, so you have to choose between the doula and your partner or another person.
This topic is a big issue at the moment and our current campaign is dedicated to it: www.quenoosseparen.information
It is still completely normal to separate the baby from his mother once born, in some cases for only m inutes, but often hours or even days, especially if the baby is taken to another hospital without the mother or the father. 'The baby belongs to the hospital' they would still say in order to explain any type of separation.
In Spain 10% of newborns are premature and the figure is rising. Care of premature babies is a very important issue:
Parents have free access to neonatal departments in only 11% of all hospitals .
Only 23% of all neonatal departments practice Kangaroo Mother care, most do not apply any special care for premature babies.
Usually breastfeeding is 'not possible' when the baby is in neonatal care.
But it is not only premature-born babies who are being separated from their parents. In some places they do this as a routine, all babies go under the heating lamp for four hours, or all babies go into the nursery for their first bottle of milk so they 'do not starve till their mother has milk', or all babies delivered by caesarean must stay in nursery for observation for at least 24 hours.
This routine separation happens for various reasons. In most Spanish hospitals during years or even decades protocols have not been adapted, neither are they based on scientific evidence. There is a big lack of continuous education in general. Sometimes it seems impossible to us that other neighbouring countries have actualised their protocols years ago, yet here these changes are completely ignored.
Post-partum attention hardly exists. Social security does not include midwife visits to the home, although there is one pilot project in one of the biggest public hospitals in Spain (La Paz in Madrid), but it is only focused on premature babies. Usually the only contact with the system after birth is the monthly paediatric appointments mother and child attend.
There is a postnatal appointment at around four to five weeks after delivery as a general check-up for the mother.
In Spain a woman has got 16 weeks of maternity leave. If she takes time before the baby is born it will be deducted from those 16 weeks. Normally if the woman works she will try to work until labour starts.
It is not rare for some women to start labour at their work place, although there is an increasing number of pregnant women who take off the last month on medical prescription (this is something quite new), so they still have 16 weeks after the baby is born.
These 16 weeks significantly determine the time the mother dedicates to breastfeeding her baby. The other important factor is the lack of breastfeeding consultants; as soon as the first problem appears the woman will change to bottle feeding. It is very common for women to stop breastfeeding because their paediatrician told them that their milk is not good anymore.
Lately there has been a lot of public discussion when a mother was invited to leave the famous Madrid Prado Museum because she started to breastfeed her three month old son in one of the exhibition rooms.
It is more common to see women bottle feeding than breastfeeding in public, but things are changing! Breastfeeding is also still connected with another issue. Spain is the European country with most cosmetic surgery. It is not rare to see an announcement in the newspaper, 'Want to lift your breasts after breastfeeding?' Or others like, 'Get your caesarean scars done beautifully.'
This WHO initiative exists in Spain, at the moment there are 13 Baby Friendly hospitals and there are some more in process. We like this idea, although we would prefer them all to be also mother friendly hospitals.
At the end of last year a new protocol was released by the Ministry of Health, which was given to all autonomous regions as a result of a long process that brought together several groups of professionals (midwives, gynaecologists and other professionals) and associations. We were also invited to form part of this working group.
This protocol is a huge step forward, although it is still to be put in practice nationwide. Now the Ministry of Health has created a commission of doctors and midwives in order to control the process of improvement. An important detail is the fact that this new protocol is about 'normal birth', not about 'natural birth' which also is a big advance.
There is a lack of transparency in data regarding all details around birth and labour, episiotomy, breastfeeding rates, separation rates.
At the moment Spain does not have national statistics concerning attending birth, the majority of hospitals and clinics do not publish their numbers, and not only do they not publish them, in many cases they do not keep a proper record of their statistics. In the few cases where they do, the indicators are different so comparison is impossible. For example, there are hospitals that do not register episiotomies, or hospitals that always do caesarean when the baby is breech, but do not include this rate as being elective caesarean into the total caesarean rate of this centre, so they go under recorded.
El Parto es Nuestro started a campaign last year to get all hospitals to publish their statistics, same base, same conditions, in order to be able to compare. We publish all results on our webpage, also indicating when there are no statistics available from a hospital. Not much has been obtained yet from this campaign.
Everything started with a few women about six years ago and their need to change the system and the way birth is being attended systematically, losing all quality on its way.
Our first goal was to get the issue public, to start a discussion in society and to offer proposals of how to make it better. Since the publication of an important article in one of the leading newspapers in August 2006 and all its reaction to it, things have started to change more quickly. Just two weeks ago this same newspaper, El País, published a four page special about birth attendants with the name of our association as its title.
We always try to insist that we do not want 'natural birth units'; we want normal birth attendants for everybody, in every corner of the country. We also would like homebirth to be an issue and to be included in the social security system as an option.
www.elpartoesnuestro.es
www.quenoosseparen.information
www.episiotomía.information
References
Data from Spanish Ministry of Health & National Statistics Institute
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