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On-line version ISSN 1695-6141
Enferm. glob. vol.11 n.26 Apr. 2012
ENFERMERÍA Y PERSPECTIVA DE GÉNERO
Gender-based social relationships of midwives in a rural district in Spain
Relaciones sociales de género de matronas en un distrito rural en España
Linares Abad, M.*; Moral Gutiérrez, I.**; Alvarez Nieto, C.*; Grande Gascón, M.L.*; Pancorbo Hidalgo, P.L.*
*Profesor Titular. Dpto. Enfermería. Universidad de Jaén. Email:
**Enfermera. Complejo Hospitalario de Jaén.
Objective: Increasingly research is giving more importance to Women's Studies taking into account the context of gender-based social relationships. From this theoretical framework we have focused on the work carried out by midwives in a rural district in southern Spain (Sierra Mágina, Jaén), in order to learn about the social relationships established around their profession.
Design: Ethnographic qualitative research using personal interviews and discussion groups.
Setting: Rural district of Sierra Mágina (Jaén, Spain).
Participants: 9 midwives and 11 close relatives of midwives from this rural district who worked there during the second half of the twentieth century. Also, there were 16 discussion groups with women from towns in the district who had been assisted by midwives.
Findings: We have described and analysed discussions with both informants and midwives themselves, the relationships the midwives established in the community and with other health professionals in the districts where they worked.
Conclusions: The study of the daily interaction between neighbours and healthcare professionals, and the study of the impact caused by the work performed by midwives brings us closer to their reality, their status, and empowerment.
Key words: Midwife. History. Gender-based relationships. Women's studies.
Objetivos: Son muchas las investigaciones que cada vez dan más importancia al Estudio de las Mujeres teniendo en cuenta el contexto de las relaciones sociales de género. Desde este marco teórico nos hemos acercado a las matronas que realizaron su trabajo en una comarca rural situada en el sur de España (Sierra Mágina, Jaén) para conocer las relaciones sociales que configuraron en torno a su profesión.
Diseño: Investigación cualitativa etnográfica mediante entrevistas individuales y grupos de discusión.
Lugar: Comarca rural de Sierra Mágina (Jaén, España).
Participantes: 9 matronas y 11 familiares directos de matronas de esta comarca que ejercieron la profesión en la segunda mitad del siglo XX. 16 grupos de discusión con mujeres de los pueblos de la comarca con experiencias de haber sido atendidas por matronas.
Hallazgos: Hemos descrito y analizado a través de informantes y matronas, las relaciones que éstas últimas establecieron con la comunidad y otros profesionales de la salud en los municipios donde trabajaron. Con la comunidad unas matronas establecieron relaciones jerárquicas y otras relaciones igualitarias. Con practicantes y ayudantes técnicos sanitarios (ATS) configuraron relaciones basadas en intereses laborales; con médicos las relaciones fueron complejas y estrechas dada la interdependencia a la que estaban sometidos, y con parteras, en general, las relaciones fueron distantes aunque a veces hubo relaciones de conveniencia.
Conclusiones: El estudio de las relaciones diarias entre vecinos y profesionales de la salud, y el estudio del impacto de la labor realizada por las matronas nos acerca a su realidad, a su estatus, y a las relaciones de poder.
Palabras clave: Matrona. Cuidado. Relaciones sociales de género. Estudios de mujeres.
Women and gender-based studies have established new research lines in which the study of the working class or people's history (1) is as important as the study of eminent women. As well, there is an increasing interest in the study of women in healthcare professions. Research in general examines the role of women within the framework of gender-based social relationships and in the context of the economic, cultural, political and religious structures that bind contemporary society (2). An interesting and new research line targeted by experts on the subject is concerned with the role of women and healthcare professions. The historical evolution of midwives and their relationships with nurses throughout the twentieth century has been studied by several authors in Spain (3,4,5) and other countries (6). This work sheds a valuable light on the construction of identity of midwives as a collective group.
In this way, our purpose is firstly to contribute to the writing of a more universal history, concerned not only with the experience of men, but also with that of women. And secondly, to acknowledge and confer authority, by researching past experiences of women in healthcare. This is a way of acknowledging and conferring authority to all working women, and particularly those in the health sector (7)
Under this theoretical framework our aim is to describe and to analyse the gender- based social relationships which midwives established in the districts where they worked with their inhabitants, the traditional birth assistants (lay midwives) and other healthcare professionals, such as physicians, healthcare technicians ("practicantes" in Spain) and ATS' (healthcare technical assistant). Both "practicantes" and ATS were two types of nursing technical professionals, almost always men, with basic in-house training. Their practice was limited to: drugs administration by injection, minor surgery procedures and, eventually, birth assistance. They worked in Spain during the twentieth century until seventies).
It is a retrospective, descriptive and content analysis approach to local ethnography. The data was collected during different periods between February 2004 and November 2006.
Our study focuses on a rural district of Sierra Mágina in southern Spain (in Jaén province). It encompasses 16 small towns with populations between 531 and 12,155 inhabitants. Until 1950 the population in the district was growing, but after that year it started to decrease primarily because of migration towards the north of Spain. This transformation was caused by the deep economic crisis and the hard living conditions after the Spanish Civil War, as well as the geographical and social isolation of this rural district from areas experiencing industrial development in Spain, this combination forced the young population to emigrate during the fifties and sixties. As a result, the population of Sierra Mágina got olded and there was a demographic decrease of 50%. This study deals with the relationships established during the second half of the twentieth century which includes the period of substantial out-migration.
We have selected two groups of participants in this research: a) Women who were pregnant or experienced the childbirth during the studied period, and (b) midwives in this district and their close relatives.
Women with experience
In order to collect data through discussion groups we contacted the representatives of women's associations in towns from the Sierra Mágina. We explained to them on the phone the aim of our study and we told them that we were looking for six or eight women with the following conditions:
- To have a sense of historic memory.
- To be born and live in the studied area.
- To be older than 60 years old.
- To be mother or women with direct experience with maternity assistance.
We have collected information for this research from 16 groups from the towns in the district (Albanchez de Mágina, Bélmez de la Moraleda, Cambil-Arbuniel, Mancha Real, La Guardia de Jaén, Jimena, Noalejo-Hoya del Salobral, Pegalajar, Huelma-Solera, Larva, Torres, Los Cárcheles, Cabra del Santo Cristo, Jódar, Campillo de Arenas and last Bedmar-Garcíez).
Midwives and relatives
In order to identify the midwives who worked in the Sierra Mágina district during the twentieth century, we started with the only surviving registry book of midwife diplomas in the archives from the College of Nursing of Jaén. 29 out of the 201 midwives registered in this book, worked in the rural district of Mágina. Women with related experiences in the district also gave us data about close relatives of midwives from the district, postal addresses and phone numbers belonging to the studied midwives. We were able to interview 9 midwives (Table I) and 11 close relatives (3 daughters, 2 sons, 1 sister and 1 niece).
We used the same tools used in ethnographic research for collecting information: discussion groups and semi-structured interviews.
The discussion group technique provides knowledge about the participants' attitudes, perceptions and opinion using open questions to our informants. The groups were formed according to the standard recommendations from the specialised literature (8). The data related to opinions and perceptions is enhanced by people's interaction, since individual participation can be improved by a group scenario (9). The discussion group's sessions were in the afternoons (with two exceptions), in order to take advantage of the interviewees availability. The sessions were carried out sitting at a table in the premises of the different towns Women's Associations, except two, one at the meeting room of the Town Hall and the other one at the house of the Association's president.
Before starting the group dynamic itself, the president of each of the women's associations introduced the researcher who also chaired the meeting. In order to break the ice we explained in detail the purpose of our meeting and that all the collected data was going to be strictly confidential. As a rule, before each session, we established that each participant would be allowed to speak without interruption, in order to avoid mistakes and overlaps in the transcription. At the beginning, each time a participant had a turn to talk, she would introduce herself until everyone could remember her name. We didn't notice any unusual or shy behaviour in the participants; however in some occasions we had to encourage the more introverted, by sitting strategically next to the most out-going people, or gently persuade the more extroverted and willing to participate to speak less. Each session lasted between 2 and 4 hours. The age range of the women participants was between 65 years of age, the youngest one, and 94 years of age, the oldest one. All the discussion groups took place as scheduled.
In-depth interviews aim at understanding the different points of view the informants have of their own experiences. One of the fundamental benefits of the strategy is that it provides information construed with discourse and behaviour; in fact the information collected during the interviews is drafted by the informant herself from her background experience in the researched subject and rapport with the person carrying out the interview and the situation itself (10).
All the informants were also later interviewed in their own homes, except for two (one in a nursing home and the other in a relative's home). Firstly, we got in contact with them by telephone, introducing the researcher and the aim of the study, as well as asking for their participation. In this first contact we arranged a date and place for the interview. The day of the interview we started reconfirming our objectives, then we explained them the necessity of using a tape recorder to be able to transcribe, as accurately as possible, the contents of the interview. Out of respect for the participants and ethical issues in qualitative research(11) we offered strict confidentiality to the informants; though for the midwives and their relatives it wasn't necessary, they felt proud to be the subjects of a research project that acknowledged and remembered them, their mothers, sisters, or aunts. In the case of informants with no relatives we followed the same confidentiality procedure. In every case we tried to create a relaxed atmosphere in which the interviewees would feel at ease. The shortest interview lasted thirty minutes, the longest one three and a half hours.
For our analysis, the chosen process for interpreting the data has been content analysis and discourse analysis. The data processing was done using the Huberman and Miles model (12): data reduction, data presentation and, at the end, extraction and verification of conclusions-a last stage devoted to finding a meaning through data interpretation. As a tool for analysis we used the Nudist Vivo programme.
With all the participants we took into account the ethical aspects of any research, offering data confidentiality, we also asked for permission to use a tape recorder to be able to render a faithful transcription of the collected information, we were also allowed to take photographs.
Relationships in the community
The relationships that midwives established with people depended on the period they worked as professionals, if the place where they were born and worked was the same, and particularly in the specific character of each midwife. Each of them had different approaches in the conception of their personal relationships: there were those who established a hierarchical relationship with the neighbours, similar to those they knew from their academic training. Others, formed part of the community with more egalitarian relationships. Women from the towns contributed to reinforcing the midwives status, since they were the reference in any normal birth assistance, though some towns took a while to adapt to the new situation, since there was still some reticence towards this new type of professional. Midwives were respected and always interacted between maternal and professional relationships. They were always addressed to as 'doña' (Mrs.), even in the case of those who arrived right after finishing their studies and at a young age. Notwithstanding, we have observed a pattern between the use of their names in diminutive or pet name, after the 'doña', and the youth of the midwife; i.e. doña Paquita, doña Encarnita, doña Manolita, doña Isabelita. This is interpreted as a way of acknowledging their status and showing respect to the midwife whilst willing to establish a closer relationship and familiarity.
When asking them if they had been invited to official or other social events, we found out that the midwives status was reinforced during Easter by giving a formal role in the religious processions. In other occasions, they were presented with free tickets to bullfights or dancing parties during local festivities:
On Palm Sunday we were given palm fronds. It was unusual to invite women. During local and religious festivities some doctors, "practicantes" (rural healthcare technicians) or someone from the "Guardia Civil" (Civil Guard) were treated to some wine (E. R. H., midwife in La Guardia).
Apart from these specific occasions, the Sierra Mágina midwives haven't taken part in any institutional event as we have been told by our informants:
Midwives didn't have time to spare, they were on standby the whole day and then they had their own chores. And anyway, there weren't so many celebrations as there are now. (Informant from Bedmar)
The midwives were occasionally also invited to the new-born's christening as a gesture of recognition for having assisted the mother during childbirth. These weren't crowded celebrations, some consisted just of the christening of the child, and the guests would simply have some hot chocolate together and perhaps throw a few sweets and pennies to the kids that were demanding it in the street. During the studied period, however this invitation didn't have the same significance as it did in earlier days when the midwife took the new-born to the baptismal font as was tradition and custom (13). In the past, midwives even attended the christening of royal new-borns, and it was a sign of social prestige. By the middle of the twentieth century, however, christening was a celebration that was disappearing, although some wealthier families celebrated it more often. We understand that it was partly because of their financial situation and partly for the nostalgia of past times:
Normally you were invited by those families that were better off. (I. M. L., midwife from Jódar).
Yes, you would frequently take part in a christening, it was another way of thanking you for the work you've done with them. (I. L. R., midwife from Cabra del Santo Cristo).
I told Mr. Paulino "This doesn't mean I want the rest to do the same, I'm only going to be polite with you but I really don't like taking the children to church". (F. G. C., midwife from Huelma).
Nothing was celebrated as we do now, we went with the kid and christened him and that was it. It wasn't a custom, the midwife was told to go to the big houses, to the domicile of the rich, she was told to go to the church and to the christening, I have been with her, the midwife went. (Informant from Bedmar).
Relationships with other nursing professionals
The relationships established with "practicantes" (Spanish healthcare technicians) and ATS' were both based on professional interest and reciprocity for helping at working level. The interviewed midwives or their relatives have always told us about the cordial relationships between midwives and the ATS' in the studied district; however in some towns there were problems concerning monetary issues.
If midwives needed to arrange a leave of absence, they would advise the doctor and the Town Council and negotiate substitutes for those services that would need cover and these substitutes could include healthcare technicians or ATS'.
Despite the fact that from the beginning of the twentieth century community nurses were taught the skills for childbirth assistance during their learning period, and some were able to fill in the midwife's post in the towns were there was a vacancy, we were not informed of any conflicts concerning interfering in the midwives work. The trainees and "practicantes" knew when to back off from a childbirth situation unless they were asked by the midwife for assistance. We believe this situation occurred, on the one hand, due to the recognition male healthcare technicians had for the midwife's professional skills and their area of influence. On the other hand, because of women's prudishness and reticence to being treated by men in issues concerning pregnancy and birth. The old idea that birth was an issue about women and for women only was and it is still strongly held by women in the studied towns.
These quotations from women and midwives reinforce these ideas:
When the "practicante" (healthcare technician) was ill, we did his work so that he could continue to get paid. (E. R. H., midwife from La Guardia).
They used to help each other out all the time. They would give injections to my family when necessary, or I would help their wives with their childbirths. We were close to each other. Often, the women used to say to me "Hey! Doña Paquita why don't you come and give me my shots, I don't want that "practicante" to look at my ass, I feel embarrassed". "Look that "practicante", the tall one, he is not going to see my bum", and I had to tell her, "A bum doesn't mean anything to them, for us a bum is just a part of a body, given by God, one for delivering the foetus, the other to be given shots, neither the doctor, nor him, nor I, when we look at your bum, you must call him". Healthcare technicians were chuffed with me, Don Antonio, do you know Don Antonio? poor him, Don Francisco went to Granada. (F. G. C., midwife from Huelma).
Relationships with physicians
The relationships with physicians were more complex and closer. In general, they established good relations with the General Practitioners (GP) of Sierra Mágina because of their dependence with each other. Midwives and GP were interested in working with competent professionals, the more competent the midwife was, the less phone calls the GP had; especially at odd hours. Like in any other profession, when a team forms a strong unit and they get along fairly well they are less vulnerable to conflicts caused by negligence and they help each other out in work. We haven't perceived a hierarchic relationship among these professionals in the scope of this study, and as we have said before, midwives created their working space based on a day to day practice, often in adverse conditions. They knew that they were professionals with good and specialised training in childbirth. Nonetheless, the social system and healthcare structure established that the midwife was under the command of the doctor.
Physicians from Sierra Mágina handed over the control childbirths to midwives, accepting and considering their decisions as the best for each case: He [the GP] used to tell me "just do whatever you think is right" (E. R. H., from La Guardia).
Relationships with physicians also had a tinge of complicity and canniness. For example, during the studied period children's diarrhoea, or any other upsets related to food were treated by injections of serum. In some occasions, the town's doctor and the midwife would arrange in advance that she would call him to look at a boy, when his presence was actually un-necessary. We think this was part of the complicity game between two healthcare professionals.
In general, the relationships with the medical profession have been perceived by informants, relatives, and midwives as good ones, proof of that are some of the collected testimonies:
I got on extraordinarily well with them, you see, Don Ebelio was the first one from Granada... with every single one of them... Don Paulino, there were three; one of them was a bit funny. Many times I would say "you see, for this person the doctor has to come and give his opinion", I also had an opinion... Other times I'd say "why should I call him if this is... " I kept the doctor informed, anyway. (F. G. C., midwife from Huelma).
We worked together. If there was a distoxic childbirth the doctor had to come, I told the family to call the doctor. The doctor went. The first doctor was one of two brothers called Siles, later on came Don Pedro. (M. S. S., midwife in La Guardia).
Relationships with traditional birth attendants.
Relationships between midwives and traditional birth attendants or lay midwives were varied, less homogeneous than those established with healthcare professionals. We were surprised to see how many traditional birth attendants, there were still in the area helping out women during birth, while there were qualified midwives taking over their place. Traditional birth attendants didn't charge for their work, with the only exception of a birth attendant from Bedmar, authorised by the doctor to attend childbirths. They got paid for their services with presents, with things that would cover their basic needs, from an apron or pair slippers to a handful of chickpeas, a soap bar or some oil, in any case never demanded by them. This was a survival economy in a family were the man's income wasn't enough.
We know, according to the collected testimonies, that there was a time when the work of traditional birth attendants and professional midwives was taking place simultaneously. These lay midwives were present; they weren't noticeable but they were always ready when needed. For many women in this district it took some time to adjust to the change, as they were reluctant to delegate to unknown midwives such an intimate moment in their lives, and who mostly came from other areas. Childbirth was still a women's issue but it was the start of detachment process of birth, from the private to the public domain, from a natural and spontaneous conception of birth to a technified process considered as an illness (14).
The midwives from this study had to juggle between respect, hierarchy, approach and integration. They had to become part of the community but also be on a higher level. They had to be both neighbours and professionals in order to have their work recognised little by little. However, we haven't perceived this transition period too traumatic according to the collected testimonies. We shouldn't forget that hygiene was officially fostered in the middle of the century in order to eradicate practices based on customs and habits without any scientific basis (15). Also, the Consejos Nacionales de Matronas (National Midwives Council) were campaigning hard to fight against the lay midwives. The traditional birth assistants were able to back down from childbirth situations without problems; pregnant women hardly noticed that this was the end of such an important, and at the same time controversial, figure in history. When midwives were already working, traditional birth attendants were still needed by those women who didn't have health coverage or didn't have money to pay their fees to a professional, despite the humanitarian nature of midwifery. Some women refused to give birth to a child with a stranger, especially when a previous childbirth had been good with their town's traditional birth attendant. Midwives called this the 'townswomen's adaptation process to midwives' but they handled the situation sensitively. Moreover, they also had to adapt themselves to the place were they worked.
These were also relationships of convenience with traditional birth attendants, though they haven't been openly acknowledged in their discourse. Sometimes midwives required taking leave, and traditional birth assistants would do their job instead of the doctor or community nurses who officially had to replace them. This was despite the existence of rules that established that in case of a leave on absence the midwife had to designate her substitute. The reality was that she would be absent for a day or two without any official substitute, sometimes to go to a capital city where her own children were at school, others to do some paper work or attend an event. Some midwives didn't designate a replacement during their leaves on absence, especially when they were in charge of women who were not particularly well off or were close relatives:
When I used to go Jaén, she [the traditional birth attendant] would make a little money. There were some who didn't want my services because I had increased my fees and it wasn't just pocket money. So the poor ones had to call her, the ones who had a bit more wouldn't call her, only the more destitute women. (F. G. C., midwife from Huelma).
When Doña Paz went travelling she would tell the other, Juana "la candileja" [the traditional birth attendant] . When Doña Paz was here and she had to go somewhere as well, there were the doctor and the community nurse. When Doña Paz was away and I wasn't feeling well and said to myself "I just wish she was here for my childbirth", we felt embarrassed with the community nurse. (Informant from Torres).
There were also situations with simultaneous childbirths when the midwife would tell the neighbours to call these lay midwives to assist, generally, the less complicated childbirth:
The women came two or three times during the day, but that night there was another woman that started labour, the one married to the soap maker. Do you remember her? Her child was dead within the womb.... and she came up because she was in labour and Doña María told my mother and mother-in-law "You have to help your sister because I can't leave this young woman by herself, her baby is dead within the womb and I must stay with her". Then when she had finished with the other one, she came to my house but by then my baby was born, I was clean and set. (Informant from Mancha Real)
In those towns where there were older midwives, traditional birth assistants would be more active:
Doña Carmen would say "go and pick up such and such... [A traditional birth attendant] I can't go there, I can't any more". There were many steep streets and she was old and would send Isabel or Agustina or anybody else. (Informant from Cambil).
However, physicians were the first in being interested in eradicating the work of traditional birth assistants. They were so interested in the midwives' work, that they felt they were safer and calmer. According to some midwives from La Guardia, they were very active in trying to eradicate the traditional birth attendants. Only in very remote or small districts traditional birth attendants continued working. In some of them there was no midwife.
In other countries there has been research reviewing issues concerning the training and the professionalization of nurses trained as midwives (nurses-midwives) (6, 16). The power loss of midwives in the U.S.A. has a close resemblance to the European situation. In both continents they struggled against the doctor's professional organisations which were trying to limit their range of action. Ironically, both physicians and midwives had previously worked together to eradicate traditional birth assistance or lay midwifery (17).
Our study shows the characteristics of the relationship between professionally trained midwives and traditional birth attendants. There was a relationship based, first on cooperation; to change to gradual substitution. Lay midwives had an important role in the assistance of births in Spanish rural districts, a very similar situation found by some authors in countries culturally related as México (18, 19) or those with different cultural background as the U.S.A. (20) or South Africa (21).
The limitations to the professional development of trained midwives showed a lack of autonomy and subordination to physicians in general (22). Other research of great interest by English authors has contributed to the study of midwifery analysing their technical work during the nineteenth and twentieth centuries, and the professional autonomy in relation to new technologies, as well as including gender analysis during the transition periods, relationships with patients, between peers and forms of professionalization (23).
The study of rural midwifery in this southern Spanish district has to consider in its framework the socio-political discourse of the regimen of General Franco, who had won the Spanish Civil War and still ruled the country at the time we are studying. This discourse was construed on a twofold authority: the traditional and scientific patriarchy used to disguise a perpetual and interested custody over women (24). This gender-based social control found a parallel situation in healthcare institutions where physicians, with the state's support, defined the complementary but hierarchical job descriptions of midwives. They outlined the midwife's practice limitations and when she had to step out and leave to a doctor the most important tasks. This study has allowed us to verify how midwives were marking their territory and becoming more prominent in the rural area of Mágina. Physicians let midwives to take over the management of childbirths, and in this way the theoretical hierarchy of the healthcare system was turned up side down in rural areas. Midwives' authority was also strengthened by the women from the towns because they considered them as the most appropriate professional to assist a healthy childbirth. Healthcare technicians ("practicantes") and traditional birth attendants knew how to step back from childbirth situations when midwives took over their places; both of them did it progressively without any disturbance.
Rural midwives believed in taking their own decisions, developing a feeling of professional pride. The division of the action range between physicians and midwives shows that their role, through experience, gave them a sense of professional independence. Training contents learnt in the classrooms were transformed in the space and context where they worked, which in practical terms granted authority to them. Alongside with the study by Rhodes (25) in Great Britain, we can affirm that the study of the social and labour relationships of midwives from Sierra Mágina, allows us to come closer to the building of the professional identity they created as a collective.
The oral testimonies of the social stakeholders offer us valuable information about the past, since self-assessment of one's own experience allows us the study of gender-based social relationships. The study of the daily interaction between neighbours and healthcare professionals, and the study of the impact of the work performed by midwives brings us closer to their reality, their status, and empowerment. The working conditions and assignments of rural midwives, common to other small towns in Spain, as the responsible person for any childbirth marked, in this collective group, a social and healthcare status which contrasted with the reduced empowerment of women with the general inclusion of obstetric assistance in hospital and maternity hospitals in the seventies of the twentieth century.
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