Once again, the number of women’s sexual and reproductive health services is falling due to a lack of midwives, a problem that has plagued the health system for years and which is worse in July and August. The shortage of professionals is putting pressure on delivery rooms and stifling health centres. In this country there are only six specialists for every 10,000 women between the ages of 14 and 65, while the European average is nine. 5,093 more workers are needed to make up for the difference, according to the Report on the development of the midwifery profession in Spain: challenges and recommendationspublished in February 2023. There is concern about the replacement because it is expected that 30% of these healthcare workers will retire in the coming years. For this reason, they are demanding more public places to practice the profession. The Federation of Associations of Midwives of Spain (FAME), responsible for the study, also advocates creating a specific degree instead of accessing the profession through a specialization after completing a degree in Nursing.
There are 9,834 midwives, 93% of whom are women. Of the total, 7,777 are active members of the professional association, according to the latest data available from the National Institute of Statistics. The Ministry of Health acknowledges in a report that Spain only has 12.4 midwives for every 1,000 births, while the average for countries in the Organisation for Economic Co-operation and Development (OECD) has 25 to cover the same quota. In Finland, Belgium and Ireland there are more than 30 midwives for every 10,000 citizens. These figures place Spain at the bottom of the list in Europe, only ahead of Hungary, Romania and Slovenia.
The secretary of the FAME board of directors, Cristina Franco, admits that “it is a difficult summer, especially in Primary Care, where waiting lists are increasing, non-specialist professionals are attending and some services are no longer offered during the summer period”. These healthcare workers are offered not to take vacations and to work “extra days” to alleviate the problem. Madrid outpatient clinics have 266 midwives to attend to more than 3.5 million women.
Franco explains that the nursing services are covered in delivery rooms, as they are essential, but even so the number of colleagues per shift is decreasing and they are overwhelmed. Last summer was more critical because the residents of Obstetric-Gynecological Nursing, whose preparation to become a midwife takes two years, began their internship in September and not in June due to the Covid-19 pandemic, which delayed the moment in which their training began. Therefore, they could not return to work in the summer period, as they were still learning.
“These months we are very busy, we are doing more shifts in the hospitals than we should be due to incidents because the new contracts made to cover vacations are very tight,” says the representative of midwives in the General Nursing Council, Montserrat Angulo. Last week in her hospital they attended nine births in one day, four were assisted by three specialists and five by two others.
“At some point, expectant mothers are left alone, although they are always monitored and the assistants and residents try to accompany them,” says Angulo, after acknowledging that they aim to offer the best quality of care possible, although she knows that this can be improved if they are given more resources. “Attending to two dilations at the same time is a danger, especially if there are complications,” warns Paloma Repila, a midwife and spokesperson for the Nursing Union.
The percentage of these health workers who are going to retire soon is higher than the number of nurses who specialize annually. “We need to create extraordinary positions in view of the imminent retirements. I’m not saying that they should double.” sine diebut in the coming years a push is needed. Right now, the supply is scarce,” insists Repila. According to professional associations, 30% are close to retirement.
In 2016, 48% of midwives were between 36 and 50 years old and 34% were between 51 and 65. The Catalan Association of Midwives reported that 90 midwives would retire in their autonomous community in 2022 and that 711 more would do so between 2022 and 2026, but they calculated that they would only train 359 specialists in that period. If this is the case, the number of these professionals in Catalonia will fall by 27.6%, moving even further away from the European average.
People who passed the Resident Nursing Intern exam, necessary to work in public health, only had 451 places in the last call to access the Obstetric-Gynecological specialty, one of the favorite options among those who apply, According to the dean of the Faculty of Health Sciences at the University of Granada, Inmaculada García, Franco believes that the figure is low and does not understand why 18 fewer vacancies have been offered than last year, when the shortage of professionals and the lack of generational change are becoming increasingly worrying. In 2022, 11,166 nurses graduated in Spain.
This problem has been dragging on for decades, since in 1987 the Midwifery Schools were closed because Spain joined the European Economic Community and had to adapt its training as some of them were considered obsolete. But there was a pause until 1992, when it was stipulated that it was compulsory to complete the specialisation after studying Nursing in order to practice the profession. In 1994 they returned to the labour market. “For a long time there was not a single midwife on the street in Spain. There were seven years without new graduates,” says Angulo.
For this reason, Franco believes that increasing the number of public places is not enough and advocates designing a specific degree to become a midwife, instead of resorting to the longer specialization system. Following the model of Germany, France or Italy, with a direct access modality, he believes that entry into the profession is facilitated with a lower public training cost. England has both educational modalities in force.
Many people study abroad. But within the sector there are differences of opinion on the subject. “The current model provides a lot of rigor, it is two years focused specifically on the public health system, not on the University,” says Repila.
What everyone agrees on is the growing concern in the sector about professional intrusion, favoured by the shortage of midwives. Doulas, women who accompany pregnant women without specific formal training, are increasingly present in the labour market. “They help make decisions with little scientific evidence without being sufficiently trained because there are many types of pregnant women with different complications,” warns Repila.
They also agree on the need to improve working conditions. Angulo explains that many temporary contracts are offered to cover long weekends or holidays and that the salary is around 2,300 euros net because they are not given a financial supplement in line with their training: “Some prefer to work as nurses, being specialists.” But according to scientific evidence, births assisted by midwives reduce the possibility of being instrumentalized by 50% and severe perineal damage by 40%. Therefore, the model with the best obstetric results is the One To One, in which each woman is cared for during pregnancy, childbirth and the postpartum period by the same specialist, something that is not feasible in Spain.
However, what worries them most is the situation in health centres. “We will never be absent from delivery rooms, but we are disappearing from Primary Care, where we have fewer and fewer responsibilities,” laments Franco, noting that they are relegated to the reproductive sphere without addressing the sexual and gynaecological sphere.
“The postpartum period is the great forgotten one and it is the ultimate test for women because they are very alone. In addition, the infertile period, which is very long, is neglected,” explains Repila. 84% of the midwives surveyed by the General Nursing Council say that they cannot handle all the tasks for which they are trained, something that Angulo confirms: “We do not want to be confined to the delivery room.”
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