October 10, 2003

Not just surprises, but shocks in Spain!

The final day of the workshop in Acuario certainly provided me with some shocks.

We were discussing ways of keeping women off the beds and the impact that the initial admission procedures have in setting the tone and laying down the “ground rules” about how the woman’s labour will be managed. It transpired that in many public hospitals, standard labour management starts with the woman being taken into a room where she is put up into stirrups so a doctor can do a vaginal examination to determine if she is in labour. She is then taken to a first stage labour room where she will be examined as often as every hour to record her progress. At the end of first stage she will be wheeled into a delivery room where she will be again find herself in stirrups, being given an episiotomy and being told to “push, push, push” in the traditional obstetric manner. After the baby is born she is taken to a recovery room and then finally to her post natal bed.

Many women have no assigned midwife: any passing midwife will check the notes on the end of her bed and if deemed necessary (for example, an hour has passed since the last VE) she will perform another examination and record the results in her chart. A woman may have 10 or more VE’s in the course of her labour, perhaps by as many as 10 different people.

No wonder that the epidural rate is around 75%! I cannot imagine how a woman could endure such atrocities without complete anaesthesia!

I asked the group how the women felt about all this and the reply came back from one senior midwife that “women don’t mind it - it is what they expect”. The look on my face must have made her stop and think and she then realised what she had said. Of course women have not been asked and these midwives had no mechanism for evaluating the results of this kind of “care”.

I raised the issue of sexual abuse victims and bluntly told the group that what they were describing sound to me like a form of ritualised rape. They were pretty shocked by this accusation, but I couldn’t see any other way to sensitise them to the plight of these labouring victims. How can midwives become so institutionalised that they can’t see the effect their care is having on the women in their community? It is lucky that Spanish women seem to be unwilling to take these issues further and I warned these midwives that this kind of physical abuse might easily lead to a court case in other western countries.

This group found the workshop very challenging. They had no idea of normal labour behaviours (they mainly see women with epidurals) and therefore relied totally on vaginal examinations to determine progress. They couldn’t tell me what endorphin driven behaviour was like and only a few knew about common reactions in transition. The “rest and be thankful” stage that sometimes follows transition was a complete mystery to many and the only way they knew to manage the birth was with a lot of shouted instructions, fundal pressure and large episiotmies so the babies could be pulled out with forceps or vacuum.

Sad times indeed for many Spanish women. Perhaps these kinds of humiliating experiences contribute to the low birthrate. Until midwives witness normal births they will not be able to offer any alternatives and it will be impossible for them to gain that experience in the state run hospitals where most work. Videos may have to provide the basis of an education in normality and workshops like this one will also have a role to play in encouraging midwives to think about their actions and challenge the system.

I will be making some enquiries about having my book “The Midwife Companion” translated into Spanish so that there is at least one practical manual they can use to develop better practice habits. We are already scheduling more workshops in Spain for next year - I can see a great need to expose midwives to other ways of working.

How could they have cut themselves off so completely from developments in maternity care in other parts of Europe? That is a question I find fascinating. Even from so far away as Australia, we know what is going on in other parts of the world, yet from a distance of only a few hundred kilometres there is complete ignorance of neighbouring countries policies and approaches to care. There is much work that needs doing in Europe, I fear, and we are only scratching the surface in Spain!

Posted by andrea at October 10, 2003 07:48 PM

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Dear Andrea, Reading this diary entry made me think of my own birthing experience in Germany (west) in 1985 & 1987. I had just completed my midwifery training in UK and therefore not strong enough to assert my belief and practice.

For my first daughter, she was post date by 2 weeks (according to ultrasound). The obstetrican, a Professor, convinced me to have second daily Amnioscope to make sure there is no meconium stained liquour. I managed to find reasons to escape except three amnioscopes. It was horrible. The head was not engaged, both os were closed. Needless to say the birth was emergency CS because the last amnioscope was showing a greenish liquor. The worst was yet to come! Postnatally I was kept strictly in bed for 72 hours, with drips and urinary catheter and two wound drains! When I asked to have them removed, I was told how dangerous it can be to get up too early etc etc etc! No food for 72 hours and not allowed to breast feed during this time. The baby was kept in nursery and given formula during this time. (I wonder now about her problems with allergies.) I was given twice daily subcutaneous heparin until the day of discharge. Most of them went down the sink because I requested to do the injection myself. Being a private patient and a RN/Midwife, this was the only bit I was allowed to contribute. I wish now I had been stronger in asserting what I wanted.

For my second pregnancy, I went back to the same Obstetrician and negotiated with him should CS happened, I was to be allowed out of bed after 24 hours and drips removed, given food, and allowed to breast feed. I did do all that but what a fight I had with the German midwives, especially to get some food. It was jelly, soups and fluidy stuff until I threatened to walk out! (I was not a good patient, but then I was not sick.)

The birth was elective CS, no talks about VBAC. And GA. I requested epidural but no anaesthetist would be willing to perform it.

For the first 24 hours, the baby was kept in the nursery and given formula feed. I was allowed only a quick cuddle. On the third day, the paediatrician did her SBR without my consent and found it to be a tat up. And formula feeds were suggested. By then, I was stronger and insisted to room-in with the baby much to everyone's horror. On the fourth day, another SBR was performed again without my consent. The next day, my clips were removed and I signed us both out of the hospital against the paed’s and obst’s. advice.

Now that I am an older midwife I know so much could be different for the woman and her baby. I am sad to read of so much bullying by obstetrician and midwives. I am not sure what is the current practice in Germany. Since returning to Australia, I am astounded how much we have progressed in terms of childbirth education and the support for the women and her family.

I will be in Hong Kong for 10 days over the Christmas Holidays. Do you have any contacts there? I would love to visit the maternity units there and talk to the midwives. I can speak Mandarin and Cantonese.

Ping Bullock from Mackay
(Met you in Nambour during the Active Birth Workshop)

Posted by: Ping Bullock on October 31, 2003 09:33 AM

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Intersting and insightful web site, I would suggest to every woman in Spain to read the contents as they are all so narrow minded as their own obstetricians.

My three children were born in London, UK, twins by an emergency caesarian under epidural(unnecessary, which left one of the boys sight-impaired and consequently disabled) and the girl was born at the same hospital in a natural drug free birth.
I was told off by the midwifes to be quiet as the other women on drugs were being distressed by my birth giving moans, but thanksfully all went happily, I gave birth to Paloma without drugs, without complications and without an episiotomy or a tear.

Now, expecting my fourth child, and living in Southern Spain, I am appalled by the medicalised approach to birth. It is virtually impossible to encounbter anyone willing to discuss a natural birth, obstetrician practically laughed at me and the pregnant women I met, look at me as if I was mad, wanting to go through the pain. They worry more about passing wind and stools during birth, than about the well being of their newborns. And the obstetricians 'offer' a vagina better than 'new', by performing an episiotomy!

Women stay quiet and regard the medical practicioners - mostly male - like gods!
I can't comprehend, since when did the men gain status of the knowledgable in birth-giving - which is a rather sacred ritual - that should be confined mostly to women. Everyone gives birth in a lithotomy position, with feet in the stirrups and not every hospital admits the father into the delivery room. Enemas, pubic shaving and episiotomies are performed on 100 % of women and the rate of the caesarian (by choice) is appx 30 %! If you don't give birth within the time limit, given to you by the obstetrician, you'll have the caesarian.... Everyone gets the IV ..... researching the human rights and health laws in Spain, I have encountered an official document, which promotes the use of the epidurals and suggests that the obstetricians encourage women to its use !

I have researched all of my options, and had I not found a midwife to attend to my home planned birth, I would have preffered to give birth unassisted.

I have, eventually found a British midwife, willing to attend me at home. It does cost an arm and a leg, but hopefully, my birth - any day now -will be safe from the scalpel and the institutionalised medical assault.

Good luck and perhaps you should do a round through the Spanish hospitals and enlighten the doctors as well as the pregnant women - who consider themselves to be 'patients'- in a beneficial approach to a natural birth!

www.arcadiaretreat.com
www.arcadiaruralestates.com
www.ruralspain.net
www.matyadio.com

Posted by: Martina on November 26, 2003 08:45 PM

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Posted by: blackjack on January 19, 2004 10:21 AM

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Dear Andrea
I am not a midwife nor have had children so i do not know much about this and i am quite ignorant. All i would like to say is that my grandmother was a midwife in Argentina South America and was there to deliver me and later my brother even though i was caserian and my brother 14 months later was a normal birth. But my grandmother back in 1956 and 1957 in Buenos Aires developed a technique to make childbirth easier and less painfull. it was via breathing and controlling breathing. My grandmother delievered a lot of children including most of her grandchildren. SO I am thinking have things gone backwards in Spain? I know Spain is not Argentina, but at the moment a country like Spain is very powerful and full of European influence. But I can also tell you the doctors here in Argentina are one of the best in the world, medicine is free. I have lived most of my time in Australia and I know medicine is changing there. I am not sure when i decide to have children where I will have them, I hope my grandmother will by my side giving me good advice.
Your blog is very very intresting. I am sending my grandmother the link so she can read it.

Posted by: Yamila on March 14, 2004 01:09 PM