Interview with midwife Mireia Marcos
Do you know what percentage of mothers in Spain opt for home births?
It's less than 1% in the whole country, we could say it's a 0.5% but there's no reliable data. In Catalunya we reckon it's a 1% as there's more homebirth than the rest of Spain. I have to say that in Catalunya there are hundreds of women who would choose homebirth but they have the baby in a hospital because there are not enough midwives. This is just a hypothetical count, but it could be a 5% or more if they had a choice.
What are the main reasons women choose to have a homebirth?
Some women just believe it's the best way to welcome their babies and follow the natural way of their body, but the majority (especially Spanish women) are just afraid of hospitals because of a really bad experience that made them reconsider hospitals as a safe place.
What are people´s main concerns about homebirth?
Women's concerns are mainly to know the midwife and be assured that when she goes into labour she will come, or to be supported by partner and relatives. Some are concerned about getting blocked in labour, coping with pain, being good enough as a mother, or breastfeeding... it depends on their previous experience in life.
Men's concerns are more about safety, midwife's skills, equipment such as instruments and oxygen, and being near a hospital or have a good transport.
Are some women better suited to homebirths than others?
Yes, a woman should be healthy and have a low risk pregnancy in order to be suitable for homebirth. Also, I think she's better suited if she opts for homebirth out of hapiness and peace of mind, rather than deciding because of a big fear or anger towards doctors and hospitals.
In what circumstances would you advise against a woman having a homebirth?
If the partner is against homebirth, or doesn't support her at all in her decision, or if she has a health problem that makes her high risk. For example if a woman has a baby with growth restriction (too little), or her blood pressure is becoming very high and has other symptoms (pre-eclampsia).
Why do you think that many pregnant women today dream of a homebirth but end up delivering their baby in a hospital?
If we are talking about women who are transferred from a homebirth to hospital, there aren't that many, it's around a 10 - 15% in general, at least in Catalunya. Women normally are transferred because of a lack of progress in labour or their own wish to go. Sometimes we have a fight inside ourselves. As a modern woman you read and get information about natural birth and believe that homebirth would be the best. But inside you, there is a little girl who feels safe in the hands of doctors or doing what mama and papa find right, and it's unconscious so you just find that a part of you wants to go back to the “normal” way and don't know why at that time. Just an example, of course it isn't always like this.
That's how sometimes women who couldn't dilate at home after so many hours arrive at hospital dilated and pushing and have a quick and normal birth there.
Some health professionals advise against homebirths because of the risks involved in an emergency situation, how would your respond to their concerns and what potential problems are you prepared to deal with at home and which ones require hospital transfer?
First of all, because women who have homebirth are usually healthy, it's very rare to have an emergency situation. But if we encounter it, as midwives we are trained to deal with most of them, like shoulder dystocia, postpartum haemorrhage, baby not breathing. It can be solved in the house. If we encounter something like meconium or signs of fetal distress there's time to transfer to hospital and deal with it there. It takes more or less the same time than transferring the woman form a hospital room to the theatres.It's very unusual though, and it is true that sometimes there's not enough resources or time to transfer, but that is something that the parents accept when they choose a homebirth. According to our knowledge, the very few times when death has occurred, it wouldn't have been avoided by being in the hospital, where, I have to say, tragedy is much more frequent as they have all the high risk cases as well.
There has been concern amongst our readers regarding the number of Caesareans performed in Spain - do you think the concern is justified?
I think that the number of caesareans is too high and in many cases they are not necessary. It's a 25% in Spain. Should be less than 15% according to WHO. In private hospitals the numbers go up to 50%, I wonder if it has something to do with doctors getting more pay if it's caesarian or just a way of working. In public hospitals, recently they have the goal of reducing caesarian numbers, I wonder if it has do do with the expenses for public health... but they are not very successful so far, bad habits maybe... ;)
Why do you think Spain offers little opportunities to women for homebirths and do you think the situation is changing?
I'm optimistic and I believe the situation is changing. Mothers are changing it by asking for it. Doctors in general are very afraid of homebirth and believe that taking birth to hospital in the 60's saved many lives, which isn't actually true. Most doctors have never seen a normal birth in their lives. Of course they are against homebirth, in an old fashioned and paternalistic way. But they didn't have to make much effort beacuse women and midwives were as afraid as them and believed how dangerous it is too.
Historically in Spain women have never had a voice in society, never had choices, there is a generalised “low self-esteem” in this culture that is starting to change very slowly. Women never got together to ask for their rights up until 7 years ago when the association “El parto es nuestro” started via internet. Midwives are afraid of attending homebirth, they feel prosecuted, or ostracised, not supported at all by their colleagues. There is a lack of training and information amongst midwives, to the point that some of them think it's illegal, or that in the Netherlands they have ambulances in every house door so that's how they get homebirths. There's another reason why I think women will have more choice for homebirth. This summer we are starting the official training for midwives to attend homebirth, with practice included. This is a pioneer course in Spain, and has been facilitated by the Associació Catalana de Llevadores (Association of Catalan Midwives). I'm with my sister the coordinator of the training and it's really exciting, we start in June 2010. I hope many midwives will feel more confident to attend homebirths after the training.
Is there is any kind of regulation for midwives who conduct homebirths?
Not any different from hospital midwives. We could say there is a “legal gap” as no law or official document mention our existence. We are registered in the Nursing council as nurses, because we don't even have a midwifery council in Spain!
How can women prepare for a homebirth?
Well, in some way “unpreparing”, undoing all the cultural lies and myths, doing something to connect with their bodies like bellydancing, yoga or swimming, talking with their homebirth midwife, some alternative antenatal classes are good just doing that. There isn't a standard way to prepare for it, really. It has to come from the inside.
How can women find their homebirth midwives? How do women decide which midwife to work with? If someone decides to interview a few midwives do you have any advice on what sort of questions they could ask?
You can find a homebirth midwife by “mouth to mouth”, or by the internet, for instance checking in the website www.nacerencasa.org, where there's a list of homebirth midwives in Spain. In Catalunya there are four organisations at the moment: Titania, Migjorn, Marenostrum and Mudra, where they have a team of professionals attending homebirth. Very soon we will hear about new teams. There's also an independent midwives list and their contact details are available in the website www.donallum.org.
What are your top tips for coping with the labor pains when birthing at home?
Movement, is the top for me. Women usually are afraid of moving when in pain, but all find it very helpful when encouraged. Breathing the way you feel, thinking positive. Massage in the lower back. The favourite is water, getting in the birth pool with warm water is a great pain relief. Some women use the TENS machine and find it helpful too.
Do you ever induce or augment labor with herbs or otherwise?
I don't. I'd rather wait. Sometimes the body needs that time for a rest, and augmenting wouldn't be wise. The only remedy I've used to help to induce when the situation requires it is the castor oil, and very few times, only when the alternative is to be induced in hospital.
How do you handle slowly progressing labors?
By getting my pyjamas on and waiting!! I would encourage sleep and rest for the mother, food, and in some situations leaving them alone for a while and coming back later has worked out. Sexual stimulation works wonders but that's husband's job!
Do you monitor the baby's heart rate during labor? If so, what is your policy on this?
Yes, I listen to the heartbeat for a whole minute with a portable doppler (sonicaid), depending on the stage of labour every 30 minutes or every 15 minutes, and by the pushing stage more frequent, like 5 minutes, unless I'm disturbing the mother's position. It's the way I trained in England.
What is your policy on breaking the bag of waters?
I'd never do that in a homebirth. In my opinion, if I'm ever considering breaking the waters in a homebirth, that means we should be in a hospital.
How many babies have you delivered here in Spain? Could you tell us the story of one of your homebirths?
I have attended around 120 homebirths since 2007 when I returned to Spain. Last week I attended the second birth of a mother who had first baby also with me 2.5 years ago. Her first birth was a very long, slow labour. My sister Inma, who is also an independent midwife was there too, but as she was pregnant she waited for the pushing stage to come. So I lived in the woman's house for a day and a half and she was so brave, she kept faith that she would do it, althoug there was little progress after so many hours. Sometimes baby's head gets “stuck” in the canal in the wrong turn. I encouraged her to dance, and to try some positions, and after a while it seemed that the baby had turned. She got in the water and started feeling pressure, the baby was free to move again and found the way! It took a long time for pushing, she got out of the pool and birthed squatting a good sized baby with a shaped head from the position. In total it took 48 hours! For her postnatal she got the prize of an easy breastfeeding, and such a loving creature. This time she was even more confident, and as the first baby opens the way, it was quick. I arrived at the house early and she was chatty and happy sitting on the ball, then she felt more pressure and got on her knees leaning on the husband and concentrated in her body. In less than two hours of labour a baby girl was born between her knees in the same dining room, I passed to her and she hugged her smiling with a loving gaze. This time I only watched, she did all, she didn't need encouragement, she knew what to do all the time. I was there “just in case”. So lovely to see the brother with little sister!
How do you help mothers after the birth? Do you feel there is adequate support for mothers in Spain in terms of caring for the baby and breastfeeding?
Some homebirth midwives focus mainly on the birth and they do few visits postnatally only. The midwives I've worked with so far and myself prefer to give a complete care in the puerperium, meaning a full support of their breastfeeding, home visits depending on the needs up to 6 weeks. Some mothers may need only 5 postnatal visits in total, but some others, specially when it's first time breastfeeding, may need 10 or even mor visits. It's not just breastfeeding, it's also mother care, baby care, emotional support. For me, the puerperium is the heaviest work. In Spain there isn't much support to women for breastfeeding from the Health system, the professionals such as pediatricians and midwives or nurses don't know much about breastfeeding anyway, they get no official training at all. But there is a great support net with the breastfeeding support groups, Alba, la leche league and others have groups in most areas. There are some IBCLC too. It's up to every woman to find out.
What is your opinion of the pre- and post-birth services for women in Spain compared with other countries?
I can only compare to England, where they do postnatal home visit from day 1 up to a month. In Spain they are starting in some rural areas to do home visiting again, but it's not that frequent and not extended. I think women are left on their own in Spain.
You have recently been involved in the Guideline for Homebirth that has been published by the Nursing Council - can you provide us with a little more information?
When I returned from London the guide was already written, they have been working very hard since 2004, I was involved in few meetings and wrote a few paragrafs to add. It has taken all this 6 years to be accepted by an organisation that really doesn't like the idea pretty much. It's the Nursing Council of Barcelona, and they had the duty to provide support, but inside many people were really against homebirth and the guide. Making it public means that they accept and acknowledge the existence of homebirth within their own professionals, and that for me is the biggest step. We couldn't even mention it few years ago, all the midwives have been in the shadow, not daring to say they attend homebirth for fear of being critisized, losing their other job in hospital or health center. They were brave enough to ask the council to provide a place for their meetings, and to edit the guide. They have been meeting many times during years and had to start from scratch to put together some basics for homebirth, because every midwife does things differently and had to learn about homebirth on her own. The guide itself is not really our bible. I don't follow all the recomendations of the guide for instance. It's just that it has been made public. That's what matters right now.
For our readers who are interested in homebirths, how would they contact you?
At the moment they can contact me through the website www.mireiamarcos.com, via e-mail or telephone.