The domestic participation in birth assistance in the mid-twentieth century

Abstract Objective: to describe how the progressive creation of the Social Security (providing widespread health care) affected the birth assistance in Spain from the 1940s to the 1970s in a rural area. Method: historical ethnography. Twenty-seven people who lived at that time were selected and interviewed guided by a semistructured script. Based on their testimonies, a chart was built with the functional elements involved in birth assistance in this region. Results: three agents performed such care: traditional midwives, women of the family/neighbors and health workers. Conclusion: although birth assistance had been transferred to the hands of the health workers from the forties in this region, women in labor continued to count on the domestic resources until the early seventies, when births were compulsorily transferred to hospitals. This research brings to light the names and recognizes the work performed by these female characters of the popular sphere, who helped women in labor of that community to give birth, for at least three decades.


Introduction
The decades from 1940s to 1970s were accompanied by many changes and advances in the public health system in Spain. The attention in the health care field was no longer a privilege of a few to become a right extended to almost all. Until then, the Spanish population was in a state of negligence and insecurity with regard to the health facilities and services, relying on the assistance provided by private institutions, to which a small percentage of citizens had access; or relying on the beneficence, which was intended primarily to people without sufficient resources (1) . The implementation, in 1942, During that period, in small towns and rural areas, the doctors, nurses and midwives began to take care of the members of the CHI and beneficence; public officials and the rest of the population not insured that was treated privately and represented a large portion of rural inhabitants. The birth assistance was among the tasks assigned to them, theme on which we will focus. Midwives also performed births, with the physician's monitoring; and practitioners would do likewise or whenever an authorized midwife in the same place did not. The lack of material and human resources to meet the demands of the population, subhuman conditions in which they worked, low pay and lack of recognition or the intrusiveness of untitled people who collaborated on tasks such as childbirths, were some of the complaints reported by this group of professionals. They also reported that, in part, the assistance provided to women in labor in the domestic scope lasted until the 1970s, with the advent of birth institutionalization.
The interest of this study, part of a doctoral thesis, is to deepen the knowledge on that evolution.
The study aim was to describe how the progressive creation of the Social Security in Spain affected the birth assistance in the rural context. For this, a chart was built with the people responsible to assist and provide primary care to women in labor (functional elements) (2) (3)(4)(5)(6)(7) , as well as their relationship with health professionals (8)(9)(10) . Others have chosen to assign to these female characters an absolute protagonist role, and built life stories based on their testimonies or on the testimonies of their relatives (11)(12)(13)(14)(15) .
Following these current research trends, and in order to understand the practice patterns of these popular agents of childbirth, their relationships and patterns of sociability, we will focus on finding in the study region, oral testimonies of people who were present during the development of such events.
As justification for the choice of subject, we mention that childbirth and the way it is performed, is currently a priority issue for most institutions responsible for promoting research in different countries of different cultures and trends. The dialogue between the institutionalization/hospitalization of childbirth and home/domestic childbirth is part of the current way these are interpreted. The reasoning of associating the local (regional) with the global (national-international) leads to increased specific knowledge in a variety of contexts and societies.
To end this introduction, we briefly describe the region of our study. The two municipalities of our study After a search tour through the towns, interviewing people we already knew, as well as elder people we were finding, we chose 24 women and 3 men for their age (between 60 and 90 years) and/ or condition (family of midwives and women who had given birth at home).
The data collection method was a semi-structured interview. For this, a script was developed with questions on the subject based on data discussed in the Ateneo Survey 1901, birth section, which had already been used by the lead author in earlier studies (4)(5)11) . A visit was arranged with each of these selected people, at their homes, explaining the purpose of the study. After all invitations to participate in the study have been accepted, people signed an Informed Consent form approved by the Ethics Committee of the University of Alicante that had the research details and authorized us to use the data provided. Each visit was attended by the principal investigator of the study, the interviewed person and a relative of the latter, in specific cases. Data were also recorded using a recorder.
The period spent to accumulate the testimonies was from April to September 2012, which was extended for three more months, from August to September 2013 and April 2014.
In most cases, we had a couple of meeting with each respondent to clarify and verify information.
The collection ended when the information became repetitive and the objective was clear.
The initial approach for data analysis was to explore the contents of the oral sources through transcription of recordings. After detailed examination, we proceeded to the categorization and classification

Results and discussion
There were three agents responsible for providing care to the women in labor and the first care to newborns in the locations of our study.
-First were the midwives, women with no education or specific training, whose knowledge was based on observation, application of common sense and oral exchange of popular practiceszero study (E3), here nothing was taught to anyone, by observing, as I worked, approaching more and more, they tied the cord and that´s it (E15), by looking they learned (E16), and also through listening, paying attention (E23) -and they shared the fact that they were mothers. These women combined housework to work in the field. They showed a sincere and cooperative nature, -she was determined and did it (E3), she was a little determined (...) formerly there were many people in need, and they were just a few of them (...) grateful people used to give them a dozen eggs, that was because then, it was times of need, so people were grateful to receive donations, I think it was pretty much like that, (E7), they were determined since they assisted everybody (E8), she was a very kind woman (E13), who decided at looking at you  In short, both midwives and close friends were the first people to be claimed by village women for assisting the birth of a new being, establishing an informal support network in those moments.
In the light of the statements gathered, it was noted that there was a symbiosis between childbirth care and female nature, showing that woman was better prepared for these duties due to their biology.
Since birth was considered a natural process, requiring follow-up, this could explain that among the potential agents selected, it was elected those from the popular sector. An activity related to home and its physiological characteristics (food, care, reproduction, creation), but also universal, as in many societies since the dawn of history. Other studies in nursing conducted in Spain concerning these decades also found the protagonist role played by women in maternal care (3)(4)(5)(6)(7)(11)(12)(13)(14)(15) . In recent studies developed recenty in Latin America, it was found that the main agents of these duties shared similarities -Other times, these duties were performed by people who were close to the mother in labor, usually female relatives: mothers, sisters, cousins, aunts, or mother-in-law. Also a neighbor, because they get along at home (E19), or because their direct relatives could not with those presented here, such as their modest origin, sex and maturity (16) . One of them, concerning a North American Indian community, has also revealed this explicit relationship between being a mother and being a midwife, as mentioned some paragraphs above (17) .
The gratuity of their actions were one of the characteristics that define the work of these women, which was supported by at least three basic pillars.
The first was the patriarchal society in which they were immersed, where women's work was secondary, worthless. The second was the ideology promulgated by the Catholic Church, with connotations such as helping others, kindness or charity. The third was the rural areas in which it was developed: the pressing need of that time, coupled with common interests related to the field, creating strong ties between neighbors; and the unity, coexistence and solidarity were some reasons for not putting price in almost anything. This altruism was observed among the popular midwives who were also found in other parts of the Spanish geography (4)(5)11,14) , or in more distant countries such as Mexico and Bolivia, where there are still some currently working in indigenous communities, who charged some kind of payment or even cash payment for their services (16)(17) .
Finally, we will mention that the way of acquiring their knowledge from experience, observation and ancient beliefs and practices, was similar to that developed by those living in more or less remote regions inside and outside of Spain (3)(4)(5)(6)11,14,(16)(17) .
The normal here and in other territories (11,(14)(15) and was part of the transition to the medicalization of childbirth.
The second relates to the group of professionals three characters, most were friendly (3)(4)(5)11,(14)(15) , although we found studies that mentioned disagreements (6,10) . In studies conducted in other parts of the Spanish geography, it has been found that this progress was also gradual and constant over time and similar regarding its occurence (6,(10)(11) . As demonstrated by some studies developed in more distant places such as Europe and Latin America (18) , the annulment of the work of midwives occurred along with the hegemonization of the biomedical model and hospitalization through the twentieth century. However, this did not happen in all societies. Several surveys recently conducted in Bolivian Andean communities (16) , indigenous Colombian (19) and Mexican (17,(20)(21) , to name a few examples, show how, despite the arrival of health professionals to their territories, in many cases, with free medical care, traditional widwives did not abandon the field of maternal care and continued to perform this great value function. In fact, in Peru and Bolivia nearly half of all births occurred in their territory in 2001 were still in the hands of specialized and non-specialized professionals (18) . In other words, health variables, but also variables of social, cultural and political nature truly influenced in our territory as well as in others, the change in the management of the childbirth assistance.

Conclusion
We have fulfilled all the objectives proposed in this work. That is, we described how the progressive Far beyond the scope of the medical or scientific studies, we must try to understand and recognize the role of all these women through the social and cultural context that accompanied them, considering that, despite their limitations and faults, they played a key role in those years. Undoubtedly, this has been, in our view, the main contribution of this research.