STSM: Maria Jesús Pueyo’s report on Policies and practices to improve in the field of obstetric interventions

You can download the pdf of this report here. The full report is published below.

Report of the Short Term Scientific Mission

Policies and practices to improve in the field of obstetric interventions

COST Action: IS1405.

Reference : ECOST-STSM-IS1405-031016-079964

Date of STSM: 3rd October- 9th October

HOST: Dra Ana Pilar Betran. Department of Reproductive Health Research. World Health Organization.

Researcher: Dra Maria Jesús Pueyo


Purpose of the STSM

The main objective of this STSM was to work with Dr. Ana Pilar Betran, member of the Department of Reproductive Health Research in the World Health Organization. Dr Betran is a known expert about implementing policies to reduce C-sections and the use of Robson classification. My purpose was to work in two main areas of interest: a/ to learn about which policies and practices implemented abroad have improved the rate of C-section, and to explore if these experiences could be applied in our country; b/ to design a qualitative study to know which organizational, professional, and personal factors are influencing in the election of C-section against normal labor delivery.

Apart from the above mentioned, the second objective was to meet experts about mistreatment and violence against women. The first idea was to talk about genital mutilation, a problem that is increasing in Spain and in Catalonia in the last years. However, the topic was widened to mistreatment, a problem that emerged in a workshop with midiwifery students and has been reported for some professionals in the last years.


Description of the work carried out during the STSM

Catalonia has a rate of C-section that has remained without modifications for the last 10 years. Although the objective of lowering the rate has been present every year in the agreements between the public insurer and each hospital, few or any positive results have been achieved. Many factors have been proposed as influencing over the outcomes as: organizational factors, volume of births, characteristics of the hospital, type of professional, preferences of women or cultural factors, among others.

The Department of Reproductive Health Research is doing, among other initiatives for decreasing the rate of C-sections over the world,  a systematic revision of the literature about women’s and professionals’ preferences and opinions about deliveries. This revision is going to be ended in May 2017.  The 5 days work plan included a daily meeting with AP Betran, the  revision of almost a hundred of manuscripts related to studies about women’s and professionals’ preferences, and the design of the content and methodology of a qualitative study about factors influencing  C-section rates taking into account the results of the systematic revision and the experience of Dr Betran.

Also, in addition of the above mentioned, I could meet with Meghan Bohren from the Maternal and Perinatal Health and Preventing Unsafe Abortion. She and her team are working in order to highlight the abuse that women suffer when they give birth, a question that is growing in importance in our country.

Main results on the topic of C-sections

Purpose of the work with Dr Betran

Catalonia has a moderately high rate of C-sections  that has not changed through the last 10 years. During this period, different policies have been implemented in our country to decrease the rate of C-sections but unfortunately they have failed. As a consequence, a new approach has to be made taking into account all the factors that are influencing the rate. The first step is to know which factors are influencing and which are the barriers and facilitators to any intervention aimed to reduce the rate. Some research about these issues has been done in the Department of Health in Catalonia during the last two years. From our research we know that organizational factors, such the adoption of a Non-Medicalized Delivery strategy, which facilitates the use of specific birth rooms or the use of bathtubes, are influencing on the rate (Pueyo et al. In press). Also, the influence of some estructural factors, as the volume of births or the level of complexity attended, was described in a previous work, which evidenced that small hospitals have more than expected number of C-sections (Escuriet et al. BMC Pregnancy and Childbirth 2014, 14:143). The type of professional in charge is another relevant factor as there is some evidence of decreasing rates of C-sections when deliveries are assisted mainly by midwives. In order to know which are the outcomes of the different professionals attending deliveries, a multicentric study has been launched (Midconbirth). The last dimension to be taken into account are the women’s preferences, shaped by cultural factors and information, and the professionals’ opinions about the way of giving birth. Those factors are going to be described through a qualitative study designed during my stay in WHO.


Results of the work with Dr Betran

From the interviews with Dr Betran and from the revision of the literature about women’s preferences, some facts influencing on the rate of C-sections can be highlighted:

a non-negligible percentage of women prefer a cesarean delivery;

among the reasons cited are the reduction of pain, fear of losing control, and the convenience of planning the schedule of birth;

the preferences are shaped by the cultural background;

there is little knowledge of the risks that may arise in a caesarean, and

an undetermined percentage of caesarean sections could  be induced by professionals.

Among professionals the reasons cited for performing a C-section were comfort, familiarity with the procedure and the practice of a defensive medicine.


As a result of the collaborative work with Dr Betran, a qualitative study, formed by three parts, has been designed  in order to know: the preferences of women when giving birth; the opinions and attitudes of obstetricians; and the opinions, attitudes and rol of midwives.


Preferences of women when giving birth

A questionnaire on preferences of women when giving birth and what percentage demand a Cesarean has been designed during my stay in WHO. The questionnaire asks for  information about sociodemographic characteristics of women; preferences of delivery and the reasons for these preferences; information about the risk of vaginal or C-section delivery; and previous experiences of giving birth.

We have managed to include the questionnaire in the next wave of the Catalan Health Survey, an official survey about the health problems and the use of health services in Catalonia, which is going to be launched through 2017. The target population will be women in reproductive age (15-50) and the sample is going to be about 700 women that will be surveyed at home.  We agree with Dr Betran in collecting the questionnaire in women of all ages, with and without experience about pregnancies, in order to obtain the cultural climate about these topics. Very young people are of high interest as they are the future users of health services.


Opinions and attitudes of obstetricians

The beliefs about C-sections between obstetricians is a key factor on the rate of C-sections performed. In the end, the medical decision is taken by the professional in charge and it implies an agreement between patient and professional. The more obstetricians convinced about the need for avoiding the medicalization of the delivery, the more natural  deliveries we will get.

A questionnaire to obstetricians about their opinions and attitudes on C-sections, their knowedge about the percentage of ceasereans performed without medical indication and the factors influencing on it, and their availability to perform a caesarean section on maternal request, is going to be designed in the first quarter of 2017. We are looking for a collaboration with the Catalan Society of Gynecologia and Obstetricia to send the survey to its members before the end of 2017.


Opinions and attitudes of midwives

The role of midwives in the attention of deliveries is not well known in our country as all the units attending deliveries are obstetric units, ready for the attention of complex cases. As a consequence a medicalization of all the process is usually observed. There is evidence about the decrease of C-sections when deliveries are attending mainly by midwives.

A questionnaire to midwives about their role in the attention to deliveries and their opinions and attitudes towards cesareans is going to be designed in the first quarter of 2017. The survey will be sent through the Catalan Society of Midwives and the Catalan Nursing College before the end of 2017.


Expected impact

Taking the results as a starting point, a new health policy will be designed in order to decrease the rate of C-sections, more focused on the cultural climate about the type of delivery, on information to empower women, and on reorganization of maternal services taking into account some structural and organizational characteristics.


As a result of the collaborative work with Dr Betran, an agreement of future collaboration has been achieved for further work on the design of the health policies aimed at decreasing the rate of C-sections in Catalonia.


Main results on the topic of mistreatment

Following a workshop held with midwifery students at the Nursing School in Barcelona, it was revealed the existence of situations of mistreatment  and abuse of women during the delivery. Besides, last year the public health insurance made a survey on satisfaction about pregnancy, childbirth and postpartum. In this survey, questions related to information in every phase of the whole process obtained the worst scores. In the same survey 80% of women rated as excellent or very good the treatment received, while more than 5% rated it as poor or very poor.

As a consequence the issue about the treatment that women receive through the process of delivery is growing in importance. During my stay in Geneve, I could meet with Meghan Bohren  from the Maternal and Perinatal Health and Preventing Unsafe Abortion. She and her team are working in order to highlight the abuse that women suffer when they give birth. The results of their work will be public through the next 2017 but she could share with me some of her research.  She also connected me with other european’s researchers and activists about this topic.

As a result of our meeting, it was decided to conduct a survey to women  for knowing  the existence of a possible disrespectful treatment during the pregnancy and delivery. The survey will be designed through 2017 and the questions will be included in the periodical surveys on satisfaction about pregnancy, childbirth and postpartum, done by the public health insurance. Also an appropriate strategy of information and education of women and professionals about respectful treatment will be designed and launched in the next year, with special emphasis on the training of young midwives.


As a conclusion the stay in WHO has allowed me to do a rigorous work of designing tools to better understand the reality and be able to tackle it with more effective and better focused public policies. It has also allowed me to establish networks with professionals and experts from different countries about obstetric interventions and mistreatment during the pregnancy and delivery. I hope that this collaborative work with experts will result in better care for women in my country.


Maria J Pueyo

Department of Health

Government of Catalonia




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