by Dr. Leila Onbargi

I arrived in Barcelona ten years ago, after finishing my medical training in the U.S.A., to start up my Obstetrics and Gynaecology practice. Although I found that the quality of medicine was good here, with similar protocols in terms of screening and treatment in gynaecology and prenatal care, I found great cultural differences in the approach to child bearing.

Here, childbearing is approached almost as a surgical procedure. The patient in labour is admitted, shaved, receives an enema, an epidural (anaesthesia injected into the lower spine), her labour is usually stimulated with oxytocin, and several hours later, a child is born and the smiling new mother is handed her happy bundle clothed and wrapped in blankets. The great majority of Spanish patients are, in fact, perfectly happy with this arrangement.

Those patients wanting a natural or personalized approach are hard pressed to find willing doctors, midwives, and hospitals to achieve this. Patients are not allowed to choose different birth positions, intermittent foetal monitoring, or request to try a vaginal labour without an "episiotomy" (a broad incision or cut made in the perineum) to help make room for the baby. Husbands are not allowed to be with their wives in the case of a caesarean. Birthing plans are unknown to both patients and doctors, and completely natural births, ie. without any anaesthesia whatsoever, are generally looked down upon. Most staff are unable to comprehend why a patient would be willing to undergo such horrific voluntary pain when obstetrical anaesthesia is readily available. I would venture to say that the fixation on anaesthesia and complete pain relief is actually taken too far, with overuse and abuse of epidurals leading to a greatly increased incidence of caesareans and instrument-assisted deliveries. As patients lose complete sensation in the pelvis, they are unable to participate in labour by pushing, and frequently, the baby has to be "helped" out by forceps or spatulas, aided by fundal pressure on the abdomen and generous episiotomies to allow use of such instruments.

These conditions are very different from my experience in the U.S. I was trained to perform episiotomies only if strictly necessary. In addition to not providing any long-term benefits, avoiding an episiotomy allows patients to recover much more comfortably after the birth. Shaving of the perineum is considered unnecessary and outdated. Enemas are optional. I learned to support different birthing positions and encourage the husband's complete participation whether by vaginal birth or caesarean. My patients are encouraged to write birthing plans that are discussed prior to labour and they are counselled to come into the hospital well into labour rather than showing up at the first contraction requesting anaesthesia, as most Spanish patients do.

I am not at all against obstetrical anaesthesia, and in fact think that an epidural, if used well, i.e., placed well into the active phase of labour, and a light anaesthetic, that is to say that the patient loses most of the pain, but not the sensation to push and participate actively in the birthing process, is a wonderful tool and a great advance in modern obstetrics. Used this way, the epidural does not slow down labour or increase the chances of caesareans, and makes labour much more comfortable.

I also attend patients, mostly foreigners.... German, Dutch and some Americans, who request natural labours without any anaesthesia whatsoever. I respect and support their decision. Although the traditional hospital setting is not completely adapted to the "home" environment that these patients desire, giving birth in the same space with their smiling, anaesthetized Spanish counterparts, as they themselves grunt, moan, and shout obscenities at their infinitely patient husbands, they are generally happy with the outcome and satisfied to be in hospital for any unexpected emergencies. Initially, these patients, as well as myself by attending them, would receive unbelieving and uncomprehending looks from staff, but as the years have gone by, there is an acceptance of this approach from colleagues.

As more foreigners move to Spain, there is an increasing demand for birthing options that include the personal touch, with or without anaesthesia, and a less surgical approach. More options have become available in private medicine. Interestingly, over the last few years, I have seen an increase in demand for this kind of approach among Spanish patients as they begin to recognize the benefits and advantages.