Impact of maternity care policy in Catalonia: a retrospective cross-sectional study of service delivery in public and private hospitals

Abstract

BackgroundAs a result of the growing number of interventions that are now performed in the context of maternity care, health authorities have begun to examine the possible repercussions for service provision and for maternal and neonatal health. In Spain the Strategy Paper on Normal Childbirth was published in 2008, and since then the authorities in Catalonia have sought to implement its recommendations. This paper reviews the current provision of maternity care in Catalonia.MethodsThis was a descriptive study. Hospitals were grouped according to their source of funding (public or private) and were stratified (across four strata) on the basis of the annual number of births recorded within their respective maternity service. Data regarding the distribution of obstetric professionals were taken from an official government survey of hospitals published in 2010. The data on obstetric interventions (caesarean, use of forceps, vacuum or non-specified instruments) performed in 2007, 2010 and 2012 were obtained by consulting discharge records of 44 public and 20 private hospitals, which together provide care in 98% of all births in Catalonia. Proportions and confidence intervals were calculated for each intervention performed in all full-term (37–42 weeks) singleton births.ResultsAnalysis of staff profiles according to the stratification of hospitals showed that almost all the hospitals had more obstetricians than midwives among their maternity care staff. Public hospitals performed fewer caesareans [range between 19.20% (CI 18.84-19.55) and 28.14% (CI 27.73-28.54)] than did private hospitals [range between 32.21% (CI 31.78-32.63) and 39.43% (CI 38.98-39.87)]. The use of forceps has decreased in public hospitals. The use of a vacuum extractor has increased and is more common in private hospitals.ConclusionsCaesarean section is the most common obstetric intervention performed during full-term singleton births in Catalonia. The observed trend is stable in the group of public hospitals, but shows signs of a rise among private institutions. The number of caesareans performed in accredited public hospitals covers a limited range with a stable trend. Among public hospitals the highest rate of caesareans is found in non-accredited hospitals with a lower annual number of births.

The COVID-19 Pandemic in Spain: Experiences of Midwives on the Healthcare Frontline

“…Catalonia is situated in the northeast of the Iberian Peninsula, and it has 44 publicly owned hospitals and 27 private ones, which offer childbirth care. Pre-natal monitoring is carried out through the primary healthcare network which has care centers distributed throughout the territory; midwives are the professionals of reference for monitoring low-risk pregnancies [ 20 ]. Administratively, Catalonia is divided into four provinces with Barcelona as its capital, and the city where the hospitals of greatest complexity are located.…”

Transfers of Care between Healthcare Professionals in Obstetric Units of Different Sizes across Spain and in a Hospital in Ireland: The MidconBirth Study

“…However, there is a significant lack of midwifery staffing in the country [ 32 ]. In fact, in the region of Catalonia, all hospitals have more obstetricians than midwives, with just one exception: public hospitals classified as S3 [ 33 ], which nonetheless showed the highest proportion of transfers in our study. Furthermore, we found a strong link between larger hospitals and higher numbers of spontaneous vaginal deliveries attended by obstetricians when women were transferred in Spain.…”

“…This might also reflect the lack of midwifery staffing in Spain and a lack of autonomy in midwives’ practice in the country, especially in S3 hospitals. Transfers might be associated with the embedded social and cultural norms of an institution or their consequences on birth practices [ 13 , 33 ].…”

“…We would like to highlight that in S2 and S3 the percentages of induction of labour, oxytocin stimulation, severe perineal damage and episiotomy are considerably higher than in many European countries [ 8 ]. It is then plausible to assume that the elevated number of obstetric interventions and transfers of care is at least partly attributable to the medical obstetric practice that is predominant in Spain, which tends to be highly interventionist [ 33 ]. Unwarranted variation in medical care is also associated with non-evidence-based practice [ 24 , 34 ].…”

Rates of instrumental vaginal birth and cesarean and quality of maternal and newborn health care in private versus public facilities: Results of the IMAgiNE EURO study in 16 countries

“…In 2018, a large epidemiological review based on data from 169 countries found that cesarean was 1.6 times more frequent in private facilities than in public facilities,12 confirming findings from previous reviews both in low‐ and middle‐income13 and high‐income countries 14. Evidence from countries in the WHO European region—such as, but not limited to, France, Greece, Italy, Ireland, Kosovo, Portugal, Romania, Spain, and Switzerland—reported higher rates of cesarean in private compared with public facilities 15–23. However, little information is available on the rate of instrumental vaginal birth (IVB) and, most importantly, on overall maternal perception of QMNC around the time of childbirth, when comparing private versus public facilities.…”