Maternity care and infrastructures in Spain during Franco's regime

Depósito de investigación de la Universidad de Sevilla https://idus.us.es/ “This is an Accepted Manuscript of an article published by Taylor & Francis in Women’s History Review on 2024, available at: https://doi.org/10.1080/09612025.2024.2317056.” Note: Snapshot PDF is the proof copy of corrections marked in EditGenie, the layout would be different from typeset PDF and EditGenie editing view. Author Queries & Comments: Q1 : ORCID details have been taken from information supplied with your manuscript submission. Please correct if this is inaccurate. Response: Resolved Q2 : Please provide missing department and city for affiliations “a–c” if necessary. Response: a: Department of Economics, University of A Coruña, A Coruña, Spain; b: Department of Surgery, Medical, and Social Science, University of Alcalá, Alcalá de Henares, Spain; c: Department of Economics and Economic History, University of Seville, Seville, Spain Q3 : Please check whether the affiliations has been set correctly. Response: Resolved Q4 : Please provide missing address details for corresponding author. Response: Margarita Vilar-Rodríguez, Faculty of Economics and Business, Campus de Elviña, w/n, 15071 A Coruña, email: [email protected] Q5 : Funding details have been taken from information supplied with your manuscript submission. Please correct if this is inaccurate. Response: Resolved Q6 : The page range is not clear “571–558”. Please check and correct if needed. Response: 571-83 CM1 : it should be written: is an associate professor of History of Science and Medical Humanities at the University of Alcalá (Alcalá de Henares, Spain). Her research..... 0000-0001-9082-2734Margarita Vilar-Rodrígueza[Q1], 0000-0001-8884-6139Dolores Ruiz-Berdúnb, 0000-0003-0491-7038Jerònia Pons-Ponsc aUniversity of A Coruña, Spain[Q2] bUniversity of Alcalá, Spain cUniversity of Seville, Spain[Q3] CONTACT Margarita Vilar-Rodríguez [email protected][Q4] History : Copyright Line: © 2024 Informa UK Limited, trading as Taylor & Francis Group Over the last century, Western countries have undergone a process of medicalisation and hospitalisation of childbirth. This process led to the subordination of midwives to doctors’ authority and made the hospital the main focus of childbirth care, which entailed a break with the traditional formula. This article analyses the case of Spain, a country of special interest due Maternity care and infrastructures in Spain during Franco's regime Recto running head : WOMEN'S HISTORY REVIEW Verso running head : M. VILAR-RODRÍGUEZ ET AL. ABSTRACT to the convergence of three elements: a belated passage of public health insurance, a shortage of beds for maternity care and the context of a dictatorship where a woman’s role was almost exclusively that of wife and mother. Under these circumstances, home childbirth continued well into the 1970s, despite the interests of health policymakers who defended hospital childbirth although infrastructures were insufficient. Hence, when hospital delivery care finally became predominant in Spain, the debate about natural childbirth and a rejection of invasive techniques used in hospitals had already begun in other countries. KEYWORDS Maternity childbirth hospitals Spain twentieth–twenty first centuries This work was supported by the European Union, the European Regional Development Fund (ERDF), and Spain’s Ministry of Science and Innovation -State Research Agencyfor the project entitled ‘The historical development of private sector hospital companies in competition and collaboration with the public sector: Spain from an international perspective (1920– 2020)’, ref. PID2021-122699OB-I00.[Q5] The medicalisation of life in general and the reproductive health of women in particular was not an exclusively local process, but rather it took place throughout the West from the late eighteenth century onwards. Within this process, during the twentieth century, a change occurred in the traditional setting of childbirth in most industrialised countries, moving from the home to the hospital. However, the evolution of the change of care model was not the same in every country, although they shared the same aim of reducing maternal and perinatal mortality. According to Loudon, maternal mortality rates started to fall among a group of developed Western countries (USA, Australia, England and Wales, Sweden and the Netherlands) from approximately 1937. The differences had disappeared between them in this respect in barely twenty years. In fact, from the mid-twentieth century, there was a drastic reduction in maternal mortality rates in most developed Western countries. At the beginning of the 1960s, the transfer of childbirth from the home to the hospital had almost concluded in many Western European countries, such as Belgium where 83% of mothers were admitted to a hospital with resident medical staff, with 82.5% in France and 99.6% in Sweden. However, home childbirths continued to be predominant in other countries in Southern Europe. This was the case of Portugal, where 19.7% of deliveries were attended in a hospital, or Greece, with 39% of deliveries in hospital. Moreover, in these two countries, unlike the other countries mentioned above, most of the deliveries were attended by midwives rather than doctors. There is currently an ongoing debate about the way in which childbirth care is being approached in the West. For some authors, the fall in maternal and perinatal mortality actually became widespread long before the appearance of antibiotics or any medicine effective in dealing with infections, and was due to the impact of other sociocultural variables such as improvements in domestic hygiene, diet and housing conditions[Q6]. On the contrary, other authors point to three key elements in this process of reducing maternal mortality: the role of medical professionals, that is, the professionalisation of delivery assistance; the development of medical science and technology; and the role of the state in the areas of education and infrastructures. Within the educational process, it is important to note the pedagogical role of midwives and nurses in many countries. Medically, advances over the centuries included the development of surgery and anaesthesia, improvements in suture techniques and the incorporation of new instruments such as forceps. Hygiene became a new ethos and the spread of the principles of asepsis in hospitals towards the end of the nineteenth century helped reduce mortality levels. On the other hand, state control over reproduction as an indirect instrument of social control also influenced the migration of childbirth from the home to hospitals. Furthermore, the implementation of public health insurance and the construction of new health care infrastructures prompted the process of the hospitalisation of childbirth. In the late nineteenth century in Spain, some obstetricians complained bitterly that the country did not even have a modern maternity hospital in its capital. At this time, pregnancy, childbirth and child rearing were still activities that belonged to the intimacy of women and families, and the state hardly intervened in this sphere before the twentieth century. The few governmental measures adopted in Spain during the nineteenth century included the obligation to establish a maternity and foundling home, a clinic for the poor known as a Casa de Socorro y Misericordia and a public hospital in each province. FUNDING Introduction 1 2 3 4 5 6 7 8 9 10 11 12 Maternity homes known as Casas de Maternidad were public establishments intended to provide refuge and sustenance to women who had conceived illegitimately and were trying to hide the pregnancy and birth. These institutions maintained a clear ideological justification in circumstances where the Catholic Church had great influence and women had limited rights and freedoms, both at home and in society in general. Within this context, midwives played a key role in assisting with child delivery and transmitting scientific knowledge of childbirth in nineteenth-century Spain. Nevertheless, these professionals were not incorporated into municipal charity institutions on a mandatory basis until 1925. However, given the high number of births and the shortage and meagre recompense of these professionals, in many cases births were assisted by keen and willing but unqualified women. This situation did not change until the beginning of the twentieth century. One of the factors that contributed to this change was the fact that the maternity of working women started to be considered as a matter of collective interest for which the state should take some responsibility. In this respect, laws regarding rest periods for working women before and after childbirth were passed in 1900 and 1907. These measures were scarcely effective, because these working women did not receive any economic aid. They were therefore obliged to go back to work as soon as possible after the birth in order to procure basic resources to sustain the family, even if this was in illegal conditions. This gave rise to a dual problem: one was a health issue of a lack of hygiene and high mortality, and the other was related to the poverty of working-class families during this period. Two of the very few projects launched to help with maternity at this time were Casa de Salud de Santa Cristina in Madrid and Casa de Salud de Valdecilla in Santander. Both experienced severe financial difficulties. At this time, and within the international framework, above all in the United States, an intense debate arose as to what could be considered as ‘ideal obstetrics’. This debate arrived in Spain in the 1930s. It was argued that all childbirths should take place in hospitals. Thus, ‘ideal obstetrics’ would be deliveries that took place exclusively in hierarchical health centres, where midwives would take on an auxiliary role and all decision-making power would be in the hands of obstetricians. The interest in having all childbirths in hospitals was backed by claims that not only would this lead to a reduction in maternal and perinatal mortality but also that it would also improve the reproduction of the workforce in a context of economic growth. In Spain, the state intervened to promote this process by implementing the first maternity allowance in 1923, as a preliminary step to introducing compulsory maternity insurance (Seguro Obligatorio de Maternidad ) in 1929. This did not actually come into force until 1931, but was especially significant at a time when the country had no public health insurance. The need to implement some kind of health care provision in this area in Spain was evident in the worrying data on maternal mortality during this period. From 1906 to 1925, 66,112 women died during childbirth or as a result. Overall, maternity insurance in Spain only covered a small number of women, given that it only protected workers registered with the insurance. The percentage of the female population between 16 and 65 years of age covered by the insurance did not exceed 7% in any region of Spain in 1933. The maternity insurance also prompted the signing of agreements with private professionals due to the lack of public infrastructure in a country where public health insurance had still not been passed. Consequently, until 1935, maternity insurance in Spain only contributed to a small reduction of 0.30% in perinatal and postpartum mortality among the insured, while the general female mortality rate in the country (including insured and non-insured working women) was 0.33%. The coup d'état of July 1936 and the subsequent civil war (1936–1939) subjected the country to a long dictatorship of almost forty years. The analysis of the case of Spain is hence especially interesting, as there are three elements that converge to differentiate it from the cases of Northern European countries. First, the belated passage of a compulsory state sickness insurance (Seguro Obligatorio de Enfermedad, hereinafter SOE), which was introduced in 1942, with severely restricted affiliation and coverage, without its own infrastructure network and with very little state funding. Second, the context of a dictatorship where the role of women was essentially that of wife and mother. This was at a time when the Catholic Church exerted a huge influence in the moral sphere. As part of this ideology, maternity care was promoted as the linchpin of the new sickness insurance and hospital births were used as a basic fundamental propaganda tool of the dictatorship’s social policies and population control. Third, the central role of hospitals within the health system (hospital centrism) was also driven by the interests of health workers—especially doctors—who generally considered hospital to be the main place for their education and the development of their professional careers. As part of this strategy, the dictatorship promoted the subordination of midwives to the authority of doctors and made the hospital the main focus of childbirth care, which entailed, a priori, a break with the traditional formula of home births. Nevertheless, home births were prolonged in Spain until well into the 1970s, despite the interests of health policymakers and the opinion of medical professionals, who defended hospital childbirth. The main aim of this study is to understand the reasons for this tardiness, and as a starting premise it indicates the lack of public hospital infrastructure. Thus, in the 1970s, when in other European countries the excessive medicalisation of childbirth was already being 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 questioned, the hospital was consolidated in Spain as the main point of reference for health care in general and for delivery assistance in particular. This article is therefore an important contribution to the international debate on childbirth care from a historical perspective, through a case study of a country that has barely been taken into account in comparative studies on this issue. After a devastating civil war that lasted almost three years (July 1936–April 1939), the Francoist dictatorship was established by those who had rebelled against the legitimate Republican government. In fact, the war helped bring about a change in mentality of part of the population in the cities with regard to attending institutions in order to give birth. Indeed, requests to be admitted to maternity clinics exceeded all the expectations of those who had drawn up the maternity insurance regulation. Several factors influenced this change. On the one hand, the streets had become dangerous, especially at night, and it was difficult to find professionals prepared to visit the homes of women in labour. On the other hand, admission to hospital also entailed receiving sustenance, and this opportunity to eat for free, at a time of scarcity, was something that could not be squandered. The first decisive factor affecting maternity care during the post-Civil War period was related to the role of wife and mother assigned to women and the dictatorship’s new ideological model. This model was not exclusive to Spain, as the same notions were also prevalent in Mussolini’s Italy and Portugal under the Salazar dictatorship. Under a philosophy of ‘eulogising and protecting’ the traditional family, work outside the home of the ‘wife and mother’ put the welfare of the family at risk, and therefore also threatened the social order. This typical role of women according to the traditional Catholic model, which was in decline in Spain under the Second Republic (1931–1936), returned with a vengeance during the Franco dictatorship and was even more stereotyped and radicalised than previously. As part of this strategy, women were encouraged to leave the official labour market—work outside the home was considered a form of treason to the family and to the motherland—and working mothers were even accused of being responsible for the fall in the birth rate and the increase in miscarriages, abortions and infant mortality. To provide an incentive for women to abandon the labour market, husbands whose wives did not work outside the home were rewarded with pay supplements, and women who left their job on getting married were offered a ‘dowry’. Meanwhile, married women lost the right to administer matrimonial property, appear in court or acquire or transfer property without the explicit permission of their husband. Diverse state institutions were created to consolidate the legal inequality of women. On the one hand, in 1937, the ‘Social Service’ was established, which was obligatory for all single women and widows under 35 years of age and without children. Its main function was to prepare women for their future role as mother, which in the view of the regime was the most important objective of their lives. On the other hand, in 1942, the Ministry of Justice created an institution called Patronato de Protección a la Mujer, which was intended to inculcate the moral rectitude and dignity of women through Catholic instruction. There is no doubt that the Catholic Church, as one of the pillars of the Francoist regime, mercilessly hounded women with constant reference to ‘crimes against morality’ (delitos contra la moral), ‘punishment for sin’ (castigos por pecado) and ‘public scandal’ (escándalos públicos). This helped condition women’s education and their social role for various generations. The second decisive factor in this respect was the struggle between the different political ‘families’ that participated in the dictatorship, which had serious consequences in the field of maternity care. Thus, the Directorate General for Health (Dirección General de Sanidad, hereafter DGS), dependent on the Ministry of the Interior ( Ministerio de Gobernación), was in the hands of Catholic groups, while the National Welfare Institute (Instituto Nacional de Previsión; hereinafter INP)— managing body for social insurance—was linked to the Ministry of Labour, controlled by the Falangists. This duality, as we will see later, created serious problems for the management and funding of maternity insurance. As well as centres linked to both of the aforementioned institutions, some maternity homes were also created by Auxilio Social—the flagship aid organisation of the Spanish Falange—and the maternity welfare services of Obra 18 de Julio, a health care institution also belonging to the Falange. In particular, the DGS passed various legislative measures related to maternity in the immediate post-war period. The law of 12 July 1941 on children’s and maternal health had three main aims: to promote a higher birth rate and to reduce infant and maternal mortality, as a key element of the strength of the race and the nation; centralisation of the health care system; and ideological control via the Sección Femenina of the Falange, the single party and ‘union’ of the dictatorship. This was to guarantee adherence to their ‘model of woman’ based on three pillars: Motherland, Family and Church. Within this context, women in Spain were blamed by the doctors who held posts in the dictatorship’s institutions for poor obstetrical outcomes, 27 28 The reorganisation of maternity care in the post-Spanish Civil War period: a new philosophy and new projects (1939–1948) 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 lack of control over their pregnancies, high infant mortality, the poor hygienic conditions of their homes and their ignorance in caring for newborns. The control of the processes of pregnancy and childbirth by doctors was justified by these arguments. Under such circumstances, women under the Franco dictatorship were subjected to great pressure and their opinion was not taken into account, unlike in other European countries. In France, for example, women could choose the place and the type of assistance for giving birth. Moreover, it should be borne in mind that Article 19 of the aforementioned law of 1941 included the need to extend the establishment of small maternity hospitals and emergency maternity and paediatric facilities. These were to be in or near rural hygiene centres in order to reduce maternal mortality and stillbirths. The intention was also educational and ideological in the fight against ignorance in matters of maternal health. The high rural population in Spain justified the setting up of these centres in key districts; generally speaking municipalities with over 5,000 inhabitants. An order of 20 December 1941 implemented the project. These emergency maternity centres were to have between five and ten beds and also the same number of cots, distributed in three rooms: one general, another individual for cases requiring isolation and a third, also individual, for ‘distinguished or paying’ patients. Alternatively, these rooms could be allocated permanently to workers covered by the compulsory maternity insurance, if this was agreed with the INP, which had responsibility for maternity insurance. The centres also had to have a delivery room, a bathroom and a room for the doctor or midwife. As was already becoming common with these types of projects in the post-Civil War period, the legislation did not arrange any funding and municipalities were called on to collaborate. To this end, a period of one month was given for municipal councils that aspired to establish an emergency maternity and paediatric centre to send their application to the DGS. This had to include a proposal for adapting premises. The renting or purchase of these premises was to be paid for by the municipal council. Furthermore, a drawing of the premises was required, along with a report on conditions at the rural hygiene centre. The decision on whether the proposal was to be authorised lay with the Ministry, depending on the reports received from the provincial health authorities (Jefaturas Provinciales de Sanidad ). The order was accompanied by an implementing regulation establishing the organisation, requirements for the premises, the right to be admitted, staff, management and funding. In this case, the state’s exiguous contribution was restricted to the finances obtained through agreements with the INP for care related to the maternity insurance, paying patients, donations and money allotted to this cause in the budgets of provincial bureaucratic agencies known as mancomunidades sanitarias provinciales. The regressive tax system of the Franco dictatorship, in this case as with other activities arising from the regime’s social policy, determined the meagre state contribution, devolving responsibility to local and provincial bodies. It is necessary here to note that, with the restructuring of the INP after the war, by 21 July 1939 it had already been agreed to set up a commission to take responsibility for reorganising the Falangist Obra Maternal e Infantil. The new regulation of this maternity organisation was passed on 28 November 1940. The members of this commission had the task of drawing up a first plan to provide facilities for maternity insurance (Plan de instalaciones para el Seguro de Maternidad y la Obra Maternal e Infantil). This plan intended the construction of maternity hospitals of diverse capacity: the largest were to have 125 beds, 100 allocated to obstetrics and 25 to related gynaecological services. The project also included maternity hospitals of 60, 50, 40, 20 and 10 beds, which would be built depending on the size of the municipality. However, in response to real needs in different locations, in some cases even smaller maternity homes of only five beds were required. Nonetheless, on the completion date of this first plan (May 1942), given that the work of the commission charged with drawing the preliminary draft of the SOE was already very advanced, the members of the INP management decided to suspend the approval of this plan. Indeed, just a few months later, in December 1942, the INP implemented the SOE, a project that had remained unfinished in the Second Republic. Article 28 of the Ley del Seguro Obligatorio de Enfermedad established that the medical service of the insured would depend on the INP. Subsequently, in article 36 of the law, it was specified that care of insured persons was to take place in clinics and hospitals ‘at the exclusive service of the insurance’ as soon as possible. But the INP’s own infrastructures were completely insufficient to meet needs at that time. This made it necessary to reach agreements with public and private institutions to provide the insured with medical attention. In particular, the right to hospitalisation of women in labour covered by the insurance was included in article 51 of the implementing regulation of maternity insurance (1943). This stated that ‘All beneficiaries who meet the health care precepts determined by the medical staff may occupy a bed prescribed by the same in the maternity insurance establishments, for a maximum period of eight days from birth in normal cases, and for as long as necessary in pathological cases’. This article opened the way to hospitalisation for normal births —it had previously only been considered necessary for complicated births—and thereby endorsed the medical professionals who wanted to put an end to home births, under the aegis of the new sickness insurance. 44 45 46 47 48 49 50 51 52 53 54 55 The liaison committee that was in charge of planning all the necessary facilities for the implementation of the SOE was formed on 2 March 1943. Drawing up a plan of health care facilities was assigned to the first board. This, in turn, was divided into three groups that were to take responsibility for a general plan for hospitals and clinics (Plan de Dispensarios y Hospitales), a plan to deal with infectious diseases such as tuberculosis and venereal disease (Plan Nacional de Luchas) and a plan for maternal and child health (Plan Nacional Maternal e Infantil ). Joaquín Espinosa Ferrándiz was responsible for this last plan. The needs that had to be covered by obstetric care were much easier to calculate than the needs of paediatric care. The experience gained with the implementation of compulsory maternity insurance facilitated the calculation of expected birth rates. It was calculated that the general birth rate in Spain was 20%, which meant that every 100,000 beneficiaries of the insurance could be expected to produce 2,000 births a year. On the basis of these figures, it was estimated that three different categories of maternity clinic would be necessary, according to the number of beds they housed and the population to be covered. In tandem with the work of the first board of the liaison committee, a second board was given the task of creating the ‘health care cadastre of Spain’, that is, a census of health care facilities, both inpatient and outpatient and of any functional dependency. The resulting statistics showed that Spain had 529 outpatient institutions and 1,055 inpatient institutions, but the lack of homogeneity of data meant that a new more specific questionnaire had to be created, and visits were made to centres where the questionnaires raised doubts about what were considered to be key factors. However, the economic reality made itself felt. The cost of providing each bed would vary between 30,000 and 50,000 pesetas, depending on whether the building that housed it had been remodelled or was a new construction. Moreover, its maintenance would cost between 8,000 and 10,000 pesetas. On the other hand, the costs accrued by each stay of twelve days would vary between 265 and 300 pesetas, including staff expenses, food and the use of general services. These costs were much higher than the amounts that were to be paid to medical personnel who attended to home births: 48 pesetas for doctors and 32 pesetas for midwives. It is therefore not surprising that the construction of maternity hospitals was very limited, and that home births persisted for a large part of the dictatorship, accompanied by a variety of resources for dealing with complicated births, such as old maternity homes or emergency maternity clinics. By 1951, there was a total of 70 emergency centres, distributed throughout the country. By the end of the 1940s, the old charitable institutions known as Casas de Socorro, which existed in Spanish provincial capitals, were dealing with almost 7,500 births a year. At the end of the 1950s, this figure was still in excess of 5,000 births a year. These figures demonstrate the low affiliation to the SOE, the lack of adequate infrastructures and the fragmentation of childbirth care among a constellation of different institutions. The Obra Maternal e Infantil was officially terminated in July 1948, being incorporated completely into the SOE, including all of its personnel. At this time, it only had three maternity hospitals set up in its own buildings: one in Barcelona (25 beds), another in San Sebastián (30 beds) and the third in Valencia (15 beds). Another five maternity hospitals were located in buildings rented in the cities of Madrid, Seville, Segovia, Vigo and Almería, each with a capacity of between 15 and 25 beds. Other maternity beds were located either in general hospitals of the National Sickness Insurance Fund ( Caja Nacional del Seguro de Enfermedad) or in other authorised institutions, whether public or private. Specifically, 42 agreements had been reached with the DGS and another 51 agreements with other official or private entities. With regard to outpatient clinics, the INP did not have any of its own facilities at this time, but it did have 252 outpatient clinics in premises rented exclusively for the Obra Maternal e Infantil, another 12 shared with users of the national sickness insurance fund and two thanks to agreements with other institutions. Meanwhile, another 98 clinics were in the preparation and organisation stage, without it being specified whether these were in the INP’s own buildings or not. The INP, the managing body of social insurances linked to the Ministry of Labour, passed a law of 18 June 1942, which extended the benefits of maternity insurance. Until then, the maternity insurance passed in 1931 only covered those directly insured. The new legislative framework followed a clear strategy of focusing on the coverage of workers’ wives—termed as beneficiaries. This arrangement was necessary under the new ideology that encouraged women to leave factories and urged them to form a family and act as mothers. Almost immediately after, the Ley del Seguro Obligatorio de Enfermedad was passed in 1942, and incorporated the recently reformed maternity insurance. This incorporation was conceived as one step further in the ‘national policy of family protection’, a key element of which was the Régimen Obligatorio de Subsidios Familiares governing family allowances. It should be borne in mind that the SOE was also managed by the INP, a body dependent on the Ministry of Labour, under the political control of the Falangist wing of the dictatorship. Hence, fecundity within marriage was defined as ‘an exemplary civic act’. Consequently, extending maternity coverage to the wives of workers registered with the Régimen Obligatorio de Subsidios Familiares was a further incentive to reinforce the domestic and 56 57 58 59 60 61 62 63 64 65 66 67 The infrastructure plan for maternity care under the SOE (1949–1975) 68 69 maternal role of women. Within this process, the SOE also received the funds corresponding to the breastfeeding allowance and maternity bonuses. Finally, the regulations also authorised investing 25% of the reserve funds of the National Family Allowance Fund (Caja Nacional de Subsidios Familiares ) in the construction and provisioning of ‘cot hospitals’ (hospitalescunas), and maternity and child welfare clinics. Thus, all the women who were beneficiaries of the maternity insurance had the right to appropriate medical care, provided by the SOE, during the gestation period, the birth and the puerperium. However, the new law had been drawn up by men and obviously with a ‘masculine’ mentality. Although a close examination of the law and its regulations makes it possible to confirm that working women were not excluded from medical care—their right to obligatory and voluntary rest was recognised—only the wives of insured ‘producers’ were named as beneficiaries. This strategy aligned with the discrimination against women in both private and public spheres. During the dictatorship, the Obra Maternal e Infantil proposed to fight against women working in factories. In 1943, the head of this organisation, Juan Bosch Marín, affirmed that women working outside the home led to a drop in both the marriage rate and the birth rate. He also stated that it led to an increase in the number of miscarriages and maternal, perinatal and infant mortality. Consequently, women working could not be more pernicious and should be proscribed, as indicated by the Work Charter (Fuero del Trabajo). It is not surprising, therefore, that the concession of premiums for maternity insurance and the payment of family allowances were paid to the head of the family, if his wife did not work in the regulated official market. This was in a context where motherhood outside ecclesiastical marriage was considered ‘indecent’ and women working outside the home was deemed to be ‘undesirable’. Nevertheless, the medical provisions of maternity insurance included free medical attention (regular check-ups, assistance with births and incidents) and midwife care (auxiliary services, advice and monitoring). They also included the right to use all care facilities for mothers and infants linked to the SOE free of charge. This access was very important due to the extremely limited nature of the SOE’s own maternity infrastructure. The lack of the insurance’s own health care infrastructures prompted the signing of agreements between the SOE and private clinics, particularly in the area of delivery care. Meanwhile the National Health Care Facilities Plan ( Plan Nacional de Instalaciones Sanitarias) was introduced by an order of 19 January 1945. This initial plan envisaged 86 large hospitals (known as residencies sanitarias), with a total of 24,000 beds, 149 large outpatient clinics and 110 smaller ones and 73 maternity institutions. The development phase of this programme was to last for ten years and had a budget of 1,000 million pesetas. However, just one year later, the plan was reformed due to the need to bring projections more in line with the economic reality of the country. On the one hand, the numbers of large hospitals and large outpatient clinics were reduced to 68 and 62, respectively, while the number of smaller outpatient clinics was increased to 144. On the other hand, the maternity institutions envisaged in the initial plan disappeared and they were integrated into the hospitals, except for one in Madrid. On 22 July 1949, a new circular was issued related to the economic regime of the emergency maternity and paediatric centres. The circular required municipalities to intensify their collaboration, and authorised the creation of up to 50% of these facilities for paying patients, which increased the inequality of maternity care. It should be noted that the budget item allocated to the DGS, as a percentage of the total state budget, remained unchanged in the 1940s and 1950s (1943: 1.05% and 1958: 1.02%). This percentage fell in the 1960s (1967: 0.81%), but then recovered and finally reached a maximum of 1.81% at the end of the dictatorship in 1975. Given this limited budget of the DGS and the restricted financial resources of small municipal councils, it is remarkable that in 1943, Juan Bosch, head of the Obra Maternal, emphasised the great investment made in maternity infrastructure in the country in recent years attributable to the DGS. In fact, in 1943, the health services of the compulsory maternity insurance of the INP, with its Obra Maternal e Infantil, had 50 maternity and child welfare clinics and six maternity hospitals. There were also another 76 emergency maternity and paediatric centres registered in 1952, but concentrated in only 26 of the 50 Spanish provinces. It was not until the construction of large complexes known as ‘ciudades sanitarias’ in the 1970s, which included maternity and children's hospitals, that a significant change was evident in the map of maternity infrastructures. Thus, the slow growth of public provision allowed private maternity hospitals to maintain an important market niche (Table 2). It should be noted here that the law establishing the Social Security (Ley de Bases de la Seguridad Social )—passed in 1963, but in force from 1966—extended the right of hospitalisation to paediatric, obstetric and medical cases. This new stage coincided with three important processes: a baby-boom phenomenon, mass migration from the country to the cities and a new concept of hospital. There was a concentration of privately owned hospitals during this period. That is, their number fell but they increased in size in response to a situation of growing competition from the SOE and great technological advances (Table 1). 70 71 72 73 74 75 76 77 78 Source: BOE (Official State Gazette) 140, 13 June 1966, 7389–7427 and BOE (Official State Gazette) 70, 22 March 1973, 5631–5662. In short, if one analyses the 1963 catalogue of hospitals, published in 1966, attending to the criteria of proprietorship and functional distribution, it can be seen that in that year there were 212 clinics and hospitals classified as having a maternity function in Spain. Half of these were public and the other half private, and they accounted for 13.43% of the total number of hospitals (Table 1). Of the 50% that were public, the greatest weight corresponded to hospitals linked to the DGS, with their 73 maternity and paediatric units (34.43% of all hospitals); followed by 18 centres linked to provincial councils, inherited from the provincial public charity of the stage prior to the civil war. Of the 50% that were privately owned, there were 103 clinics belonging to private for-profit companies (46.58% of all hospitals) and only three maternity centres continued with proprietorship connected to private charity (Clínica Larrasquitu in Biscay, Cottolengo del Padre Alegre in Nuñomoral, Cáceres, and Sanatorio de San José in Madrid), all of them linked to the Catholic Church. The precarious financing of hospital infrastructure, along with a policy that promoted and achieved high fecundity and a high birth rate, gave rise to a slow growth of delivery care in hospitals and the persistence of high maternal and infant mortality rates. A study undertaken from 1947 to 1949, of 270,000 deliveries that took place under the SOE, reflected the dual reality of home and hospital births (Table 2). However, in view of the lack of infrastructure, the former option was preferred when ‘the birth is presumed normal and the expectant mother’s home has minimal hygienic conditions’. On the contrary, admission to a maternity clinic was prescribed when the pregnant woman’s home did not meet basic sanitary requirements; there were presumed difficulties for home delivery care (social dystocia); there was a chronic illness that could influence the birth; or when an abnormality became evident when birth had begun (real dystocia). Under this philosophy, during the three years analysed, home care was overwhelmingly predominant (94.2% home births and 5.8% in maternity clinics), while difficult births were concentrated in clinics (31% of those attended to, compared to 8.4% of home births). Furthermore, the greater percentage of difficult births would explain the higher maternal mortality in clinics (1947– 1949: 3.2 per thousand births) compared with home births (1947–1949: 0.4 per thousand). The results are also similar for the case of perinatal mortality in the same period: 6.8% in maternity clinics and 2.4% at home. The predominance of home births continued in 1950, a fact that some health managers and professionals related to the lack of sufficient maternity beds in the country. Source: Elaborated from Bosch, de la Cámara, and Sáez, 270.000 partos, 17. Number of hospitals classified as maternity clinics from 1963 to 1970.Table 1. Spain 1963 1970 Public Private Total Public Private Total Maternity hospitals 106 106 212 93 98 191 Total hospitals 541 1037 1578 523 885 1408 Maternity hospitals as percentage of total hospitals 19.59 10.22 13.43 17.78 11.07 13.57 The prolongation of home delivery care and the shortage of maternity beds during the Franco dictatorship 79 80 81 Deliveries by type of care under the sickness insurance, 1947–1949.Table 2. By doctors By midwives Others Total birthsBirths % Births % Births % 1947 24,933 39.9 51,344 63.5 4,513 5.6 80,790 1948 26,090 36.5 43,029 60.1 2,413 3.4 71,532 1949 36,106 38.3 55,231 58.6 2,962 3.1 94,299 Triennium 87,129 35.3 149,604 60.7 888 4.0 246,621 Rodríguez, eds., La mujer moderna sociedad urbana y transformación social en España, 1900–1936 (Madrid: Catarata, 2022). For further information on the active participation of women in labour and political spheres during the Second Republic (1931–1936), see Ana Aguado, ‘Citizenship and Gender Equality in the Second Spanish Republic: Representations and Practices in Socialist Culture (1931–1936)’, Contemporary European History 23, no. 1 (2014): 95–113; Rosario Ruiz-Franco, ‘La república de las mujeres’, Espacio, Tiempo y Forma, Serie V, Historia Contemporánea 18 (2006), 171–85; Gloria Nielfa, Mujeres en los gobiernos locales alcaldesas y concejalas en la España contemporánea (Madrid: Biblioteca Nueva, 2015). 35 Josep Bernabeu Mestre, ‘Madres y enfermeras. Demografía y salud en la política poblacionista del primer franquismo, 1939–1950’, Revista de Demografía Histórica 20, no. 1 (2002): 123–44. 36 Margarita Vilar-Rodríguez, Los salarios del miedo. Mercado de trabajo y crecimiento económico en España durante el franquismo (Santiago de Compostela: Fundación 10 marzo & Diputación da Coruña, 2009); Vilar, ‘Diferenciales salariales’ and Carmen Sarasúa and Lina Gálvez, eds., ¿Privilegios o eficiencia? Mujeres y hombres en los mercados de trabajo (San Vicente de Raspeig: Publicaciones de la Universidad de Alicante, 2003), 39. 37 An excellent example of this mentality can be found in Carmen Isern, La mujer en la vida del trabajo. Su Misión Social. Su Aspecto Jurídico (Madrid: Dirección General de Sanidad, 1948). 38 Behind this service was the Falange’s Sección Femenina, a body designed to impose certain lifestyle guidelines and values on women, see Jordi Gracia and Miguel A. Ruiz, La España de Franco (1939–1975). Cultura y vida cotidiana (Madrid: Síntesis, 2001), 96. 39 Mary Nash, ‘Pronatalismo y maternidad en la España franquista’, in Maternidad y políticas de género: la mujer en los estados de bienestar europeos, 1880–1950, ed. Gisela Bock and Patricia Thane (Madrid: Instituto de la mujer, 1996), 279– 308. 40 See Gracia and Ruiz, España de Franco, 92. 41 Arturo Álvarez Rosete, ‘¡Bienvenido, Mister Beveridge! El viaje de William Beveridge a España y la Previsión Social Franquista’, International Journal of Iberian Studies 17, no. 2 (2004): 105–16; Arturo Álvarez Rosete, ‘Elaborados con calma, ejecutados con prisa. El avance de los seguros sociales y la evolución del Instituto Nacional de Previsión en España entre1836 y 1950’, in La previsión social en la historia, ed. Santiago Castillo and Rafael Ruzafa (Madrid: siglo XXI, 2009), 255–63. 42 For further details on Auxilio Social, see Ángela Cenarro, La sonrisa de la Falange. Auxilio Social en la guerra civil y en la posguerra (Barcelona: Crítica, 2006); for more on ‘Obra Sindical del 18 de julio’, see Daniel Lanero Taboas, ‘¿La salud es lo que importa? la O.S. 18 de Julio y la asistencia médica en Galicia (1940–1965)’, Historia social 68 (2010): 47–67. 43 ‘Ley de Sanidad Infantil y Maternal’, BOE (Official State Gazette) 209, 28 July 1941, 5650–5. 44 Baldomero Bueno, ‘Crítica de las intervenciones obstétricas en relación con las orientaciones sanitarias actuales’, in Estudios oficiales primera reunión anual médicos puericultores del Estado, Juan Bosch and others (Madrid: Al Servicio de España y del Niño Español, 1943), 109–124. 45 Rosa Ballester, ‘La salud de las mujeres: modelos históricos, saberes y prácticas’, Dossiers feministes 5 (2001): 51–8. 46 ‘Orden sobre creación de Centros Maternales de Urgencia’, BOE (Official State Gazette) 355, 21 December 1941, 9993–4. 47 Instituo Nacional de Previsión, El primer semestre de la vida en el niño español (Madrid: INP, 1941). 48 Enrique Bravo, Centros Maternales y pediátricos de urgencia, Ministerio de Gobernación (Madrid: Dirección General de Sanidad, 1952). 49 For further information on the deficiencies of the tax system in Spain at this time, see Francisco Comín, Historia de la Hacienda Pública II. España (1808–1995) (Barcelona: Crítica. 1996) and Sara Torregrosa, The Spanish Fiscal Transition: Tax Reform and Inequality in the Late Twentieth Century (Switzerland: Palgrave MacMillan, 2021). 50 Margarita Vilar-Rodríguez and Jerònia Pons-Pons, ‘Competition and Collaboration Between Public and Private Sectors: The Historical Construction of the Spanish Hospital System (1942–1986)’, Economic History Review 72, no. 4 (2019): 1127–636. 51 Resumen de las actas de la Obra Maternal e Infantil, Legajo 49-E, INGESA Historical Archive [Records of The Historical Archive, Ministry of Health], Madrid. 52 Plan de instalaciones del Seguro de Maternidad y Obra Maternal e Infantil, Legajo 49 A-1, INGESA Historical Archive [Records of The Historical Archive, Ministry of Health], Madrid. 53 Gobierno de España, ‘Ley de 12 de diciembre de 1942 por la que se crea el Seguro Obligatorio de Enfermedad’, BOE (Official State Gazette) 361, 27 December 1942, 10.592–7. 54 María Gloria Redondo Rincón, ‘El seguro obligatorio de enfermedad en España: responsables técnicos y políticos de su implantación durante el franquismo’ (PhD diss., Complutense University of Madrid, 2013). 55 Gobierno de España, ‘Decreto de 11 de noviembre de 1943 por el que se aprueba el Reglamento para la aplicación de la Ley del Seguro de Enfermedad’, BOE (Official State Gazette) 332, 28 November 1943, 11.430. 56 Actas de la Comisión de enlace del Seguro de Enfermedad, Legajo 49 A-1, Acta n° 1, INGESA Historical Archive [Records of The Historical Archive, Ministry of Health], Madrid. 57 Dolores Ruiz-Berdún, ‘Objetivo: repoblar España. El Plan Nacional Ideal de la Obra Maternal e Infantil’, in Ciencia útil. Investigación básica y aplicada en Farmacia y Ciencias de la Vida durante el franquismo, ed. Antonio González Bueno and Alfredo Baratas Díaz (Madrid: Ediciones Complutenses, 2019), 291–316. 58 Actas de la primera ponencia de la comisión de enlace del Seguro de Enfermedad, Sub-ponencia del Plan Nacional Ideal de la Obra Maternal e Infantil, Legajo 49 A-1, INGESA Historical Archive [Records of The Historical Archive, Ministry of Health], Madrid. 59 Plan de Instalaciones del Seguro de Maternidad y Obra Maternal e Infantil. II Construcción. Legajo 49-A1, INGESA Historical Archive [Records of The Historical Archive, Ministry of Health], Madrid. 60 The idea was to include those directly dependent on the state, the provinces, the municipalities, but also those belonging to the Falange, foundations, mutuals, companies, partnerships and individuals, see Sebastián Criado del Rey, Problemas Sanitarios del Seguro de Enfermedad (Madrid: INP, 1947), 28. 61 Ibid., 28–32. 62 Primitivo de la Quintana and Joaquín Espinosa, Seguro de enfermedad: estudio para un plan general de instalaciones de asistencia médica (Madrid: INP, 1944), 74. 63 Juan Bosch Marín, El Hospital Infantil y Maternal en España (Madrid: Ministerio de la Gobernación, 1951), 8. 64 ‘Servicios prestados en las Casas de Socorro existentes en las capitales de provincia en 1946 y 1947’, Anuario Estadístico de España [Statistical Yearbook of Spain] (Madrid: INE, 1948), table X. 65 ‘Servicios prestados por las Casas de Socorro’. Anuario Estadístico de España [Statistical Yearbook of Spain] (Madrid: INE, 1958), table V. 66 ‘Decreto, de 9 de julio de 1948, por el que se íntegra en el Seguro Obligatorio de Enfermedad la Obra Maternal e Infantil’, BOE (Official State Gazette) 209, 27 July 1948, 3.509. 67 Ponencia del Seguro de Enfermedad. INGESA Historical Archive [Records of The Historical Archive, Ministry of Health], Madrid, Book 299, no. 82–90, from 16 January 1948 to 15 October 1948. 68 BOE (Official State Gazette) 184, 3 de julio de 1942, 4783–4. 69 BOE (Official State Gazette) 361, Ley de 14 de diciembre de 1942 por la que se crea el seguro obligatorio de enfermedad, 10592–7. 70 The fact that breastfeeding was abandoned relatively early after birth was considered to be one of the main causes of the high infant mortality that existed in Spain, that is, deaths during the first year of life. The maternity insurance passed in 1931 already included a special allowance for mothers that breastfed their babies, which consisted in receiving 5 pesetas a week for a maximum of 10 weeks. The breastfeeding allowance was also included in the new legislation of the dictatorship for the same reason and the amount was increased to 7 pesetas a week for the same period of time, 10 weeks, except in the event of multiple births, in which case the allowance was extended to 15 weeks. This amount was far less than was paid in other countries such as Portugal. Information obtained from Boletín Informativo del Instituto Nacional de Previsión 6 no. 3 (1946): 731–2. 71 Bosch, El Hospital Infantil y Maternal, 3. 72 The Obra Maternal e Infantil was incorporated into the Seguro Obligatorio de Enfermedad via a Decree of 9 July 1948: BOE (Official State Gazette) 209, 27 July 1948, 3059. 73 Pons and Vilar, Seguro de Salud Privado. 74 Gobierno de España, ‘Reglamento de los Centros Maternales y Pediátricos de Urgencia dependientes de la Dirección General de Sanidad’, BOE (Official State Gazette) 284, 11 October 1953, 6109–11. 75 Pedro Marset Campos; José Miguel Sáez Gómez and Fernando Martínez Navarro, ‘La Salud Pública durante el franquismo’, Dynamis 15 (1995): 211–50. 76 Juan Bosch Marín, Trabajo, Maternidad y lactancia (Madrid: INP, 1943), 11. 77 Margarita Vilar-Rodríguez and Jerònia Pons-Pons, ‘El papel de hospitales municipales y provinciales en España desde una perspectiva histórica’, Dynamis 41 (2021): 53–78. 78 José García González, La implantación del hospital moderno en España, el Hospital General de Asturias, una referencia imprescindible (Oviedo: Ediciones Nobel, 2011). 79 Juan Bosch-Marín, Juan P. de la Cámara, and Venancio Sáenz, 270.000 partos, sus enseñanzas sanitarias, observaciones sobre la asistencia tocológica prestada en el seguro obligatorio de enfermedad durante los años 1947 y 1949 (Madrid: Instituto Nacional de Previsión, 1950). 80 However, the authors point out that it is possible that some of the births that appear as having been assisted at home actually took place in clinics not linked to the organisation of the insurance and that they do not have data to clarify this. In any case, it can be concluded that the percentage of births that took place in clinics in Spain was very low. See Bosch, de la Cámara and Sáenz, 270.000 partos, 12. 81 Bosch, de la Cámara and Sáenz, 270.000 partos, 22. 82 Bosch, Hospital Infantil, 12–51. 83 Comín, Historia de la Hacienda Pública and Torregrosa, Spanish Fiscal Transition. 84 Margarita Vilar-Rodríguez and Jerònia Pons-Pons ‘Competition and Collaboration Between Public and Private Sectors: The Historical Construction of the Spanish Hospital System (1942–1986)’, Economic History Review 72, no. 4 (2019): 1127– 1636. 85 Consejo Superior de Cámaras de Comercio, Industria y Navegación, Comercio, Industria y Navegación de España (Madrid: Publicación del Consejo Superior de Cámaras de Comercio, Industria y Navegación de España, 1947), no. 20, 59. 86 Information obtained from: www.diaridegirona.cat/opinio/2012/03/18/historia-clinica-lalianca/552732html (accessed December 2023). 87 Data refer to 31 December of each year. Anuario Estadístico de España [Statistical Yearbook of Spain] (Madrid: INE, 1970), 307. 88 Dolores Ruiz-Berdún, ‘Pilar Primo de Rivera y la reorganización de las carreras auxiliares sanitarias tras la Guerra Civil’, in La Tutela Imperfecta. Biología y Farmacia en la España del Primer Franquismo, Antonio González Bueno and Alfredo Baratas Díaz (Madrid: CSIC, 2013). 89 For a detailed study of this law, see Margarita Vilar-Rodríguez and Jerònia Pons-Pons, ’La Ley de Bases de la Seguridad de 1963: ¿una oportunidad perdida?’, in El Estado de Bienestar entre el franquismo y la transición, ed. Damián A. González and Manuel Ortiz (Madrid: Sílex, 2020), 125–156. 90 ‘Orden de 25 de septiembre de 1964’, BOE (Official State Gazette) 234, 29 September 1964, 12769–70. 91 Memoria Estadística de los Seguros Sociales Administrados por el I.N.P. Año 1965–1977. 92 Esteban Rodríguez-Ocaña, ‘La Construcción de la Salud Infantil. Ciencia, Medicina y Educación en la Transición Sanitaria en España’, Historia Contemporánea 8 (1998): 19–52. 93 Margarita Vilar-Rodríguez and Jerònia Pons-Pons, Un Siglo de hospitales entre lo público y lo privado (1886–1986) (Madrid: Marcial Pons, 2018). 94 For further information on the difficulties faced by midwives in rural Spain in the twentieth century, see Dolores Ruiz- Berdún, ‘Las dificultades de las matronas en la España rural del siglo XX’, Genealogías de la reforma sanitaria en España, ed. José M. Martínez-Pérez and Enrique Perdiguero-Gil (Madrid: Catarata, 2020), 21–62. 95 Federico Mayor Domingo, La asistencia sanitaria en las zonas rurales (Madrid: Centro de Estudios de Asistencia Sanitaria, 1979), 49. 96 García, Implantación del Hospital Moderno, 72. Disclosure statement No potential conflict of interest was reported by the author(s). Notes on contributors Margarita Vilar-Rodríguez is an associate professor of Economic History at the University of A Coruña (Spain). Her main research interests cover the history of social insurance, especially health and industrial accidents, as well as wages and wellbeing. She has published extensively in these fields in a historical perspective. Dolores Ruiz-Berdún is an associate professor of Surgery, Medical and Social Sciences at the University of Alcalá (Madrid, Spain). Her research focuses on the history of midwifery, history of obstetrics and gender history. She has published extensively in these fields. Jerònia Pons-Pons is professor of Economic History at the University of Seville (Spain). Her research focuses on the economic history of insurance, both private and social. She has published extensively in the field. ORCID Margarita Vilar-Rodríguez http://orcid.org/0000-0001-9082-2734 Dolores Ruiz-Berdún http://orcid.org/0000-0001-8884-6139 Jerònia Pons-Pons http://orcid.org/0000-0003-0491-7038  1