Pregnancy Care in the Axarquia

This isn't a pregnancy diary. It isn't an hilarious account of cravings, nor of driving down the mountain in labour. But I've now been through two pregnancies via the Málaga healthcare system and so can review the system. If you are pregnant in Andalusia, what should you do? Should you look up the Spanish for 'birthing pool', check the private clinics in Marbella, or head for the airport?

First the good news. Málaga's medical care seems to me to be highly competent. Spain is a European country and, however apparently disorganised (and I've never heard that about the NHS, ho, ho!), it does provide fully modern medical services. Moreover, treatment is sometimes not only competent, but prompt, caring and kind. During my first pregnancy at three months I started to bleed. We rushed to the hospital and I interrupted the Doctor's offer of a translator with, “Never mind that now, I'm having a miscarriage.” Doctor and assistant took me seriously: they quickly got me scanned without fuss or panic; they gave me the good news (no imminent disaster) as soon as they could, but didn't neglect a very thorough check. They explained the problem (a placental tear) and the necessary treatment (two supremely boring weeks of horizontal rest), with the patience needed to be certain we understood. I have never forgotten the relief and confidence their approach gave me.

Second time around, and more stress: late in the pregnancy when my partner had, unavoidable and unexpectedly, had to go to the UK, I was told I would need a caesarean. As nervous as I was, I found the obvious professionalism, competence and care of both the surgical team and the follow up staff immeasurably heartening. The anaesthetist, especially, was superb.

Less good news. A friend said that Spanish health services may be competent but they aren't interested in making your labour a 'beautiful experience'. My best experiences were at the sharp end of immediate action. Care basics (check-ups, education, patient choice etc.,) are sloppy. For example, UK advice books say your first visit to a midwife will involve:
1. a urine test (to confirm pregnancy)
2. a blood pressure check
3. a weight check
4. a discussion of your medical history
5. a check on your family medical history
6. a detailed explanation of future care (what, when and why, etc)
7. Your preferences for the birth
8. Advice on exercise, diet, supplements, work etc.
At the Cómpeta consultario, my first visit to a midwife involved:
1. congratulations,
2. a brief check of my medical history and
3. a weight check
The tone of treatment is casual: medics presume you know what comes next and their reaction to concerns tends to vary from irritation to the classic Spanish shrug. Just making appointments can be nightmare. In my second pregnancy I told the midwife I'd be in the UK the week the first scan would be due. The midwife couldn't make that appointment himself, but added a note to the request for it. He assured me the hospital would ring to confirm the date, but when I got back from the UK they hadn't. I contacted the local health centre; they told me the appointment had been made: for the week I was away; its confirmation had been sent to them. The health centre had not, of course, rung to let me know this. And I still needed to have that scan: could I make another appointment? Of course not; I would have to make an appointment to see the midwife, ask him to request another appointment, and then wait until the hospital rang me (ha, ha) to confirm what the new date was. What a waste of everyone's time!

Language problems make all this much worse. My second stay in hospital was much because my Spanish is better: the first time I was really at a loss. Of course foreigners like me should speak the language or use an interpreter: it isn't reasonable to expect every medic to study languages as well as medicine. All the same, it isn't unreasonable to expect some patience, courtesy, and help with information.

Some pre and post birth education is available. I enjoyed my first maternity classes, but didn't learn much. The midwife recommended exercises; taught us to clean a baby's eyes, and asked me for an English lullaby. There was no tuition on pain-management, advice about birth options or further info on baby care, but we were given a tour of the hospital, which helped, even if the answers to the questions were a bit disappointing:
Are birthing stools available?
Answer: yes, in Granada…
Why are labour beds (which make labour longer as the woman must work against gravity) still used?
Answer: they make life easier for the medics.
Would I be allowed to give birth standing, instead?
Answer: Phhffff! You can ask…
However, this year's classes (with male midwife Jose-Manuel), were more useful: he gave detailed information, and invited questions: when I found out I might need a caesarean he gave the class the full what, why and how on the procedure.

Spanish post-natal care can seem very casual to a Brit. Two weeks after I'd had my first child I made an appointment, guessing that the baby (and I) could use some after-care. I wonder how long it would have taken before anyone asked what had happened to the baby, if I hadn't. UK-based friends asked me what the health visitor, who does home visits to check your (and the baby's) progress. An easy question: there was no health visitor and no home visit. In the UK the hospital is responsible for the wellbeing of the infant until you are out of the hospital grounds: a nurse carries your infant to your car and straps it in the car-seat; you aren't allowed to. In contrast, after my C-section I was left alone but immobilised in bed with my newborn at my side, wondering what I would do (and how many stitches I would burst) if I needed help. The one unsympathetic nurse on the ward (there is always one) aggressively told me off for not having family to look after the baby and sneered when I told her my husband was away as his father had died. Luckily, my Spanish room-mate was offended by this ill-natured display, and promptly volunteered to give me all the help I needed. But Nurse-Nasty had highlighted a fundamental cultural difference. In the UK we expect full care and responsibility to be taken by the state. That means the 'system' tends to take over, with all the bureaucracy and limitations to freedom implied. In Spain, the state is very flexible (rules can be bent), but expects the Family to do all the basic care, and struggles to accommodate those strange individuals (like foreigners) who don't have plenty of relatives with the time and inclination to help out.

This is a limitation. A 'beautiful experience' some UK services aim for (lowered lights, soft music, incense and all) isn't necessary, but a total absence of bedside manner (being told 'this is really going to hurt' by the nurse coming at you, syringe in hand) isn't helpful either! Some of the fluffy stuff, like education and post-partum visits, prevents problems and even saves lives. It's no coincidence that the best mother and infant survival rates are found in Sweden, which boasts fantastic education, patient choice and post-natal follow up.
bedside manner (being told 'this is really going to hurt' by the nurse coming at you, syringe in hand) isn't helpful either! Some of the fluffy stuff, like education and post-partum visits, prevents problems and even saves lives. It's no coincidence that the best mother and infant survival rates are found in Sweden, which boasts fantastic education, patient choice and post-natal follow up.

Spain is missing an opportunity. They could turn the continued existence of strong extended family links into an advantage, and perhaps a route for education. But presuming every patient has family to chase appointments, teach baby-care and provide basic nursing care is dangerous: it ignores the fact that Spanish society has changed and is still changes. Really the input of abuelos should be a bonus, not the bedrock of healthcare.

So? In the end…
…I got two healthy kids. Maternity care in Málaga is a mixed bag, and can be very frustrating and scary. But in the end the services I got (in Cómpeta, Málaga and Velez-Málaga) were good. So if you are'expecting
Decide early if you are going to run for home (the UK or wherever) or not, and stick with it. If you stay get your dictionary out and look up relevant words.
Don't read the blogs! The most popular blogs are horror stories: partners refused, women strapped down, refused pain relief, yelled at in Spanish, or thumped in the abdomen. This may have happened, but it isn't standard Spanish practice. In my labour the only swearing and shouting came from me.
Get some good books for information: it saves frustration. I recommend What To Expect When You are Expecting, and especially Miriam Stoppard's Conception, Pregnancy and Birth. Just remember their healthcare comments are based on UK services.
Be demanding: double check appointments, ask for maternity classes, ask for a hospital tour, ask for labour choices (as the midwife said, you never know…).
Unless you are a fluent Spanish-speaker consider getting help from interpreters, especially for hospital visits. We managed, but I regret not booking help on the first run!
Consider hiring an English-speaking midwife: that might even make a home birth possible, or at least widen your options.
Book up family, warn your friends: you'll want hospital visitors and help. I was very unlucky that my partner couldn't be there: I was very lucky that some very supportive friends (and my wonderful Mum) helped out. Think about who you will talk to, if you, like me, need unexpected help.