After the COVID-19 pandemic brought a new government to power in Romania, and a state of emergency that began on 23 March, the eastern European country is about to begin a gradual ‘de-confinement’ on 15 May.

Two weeks after that, Cristina Niculae, a 28-year-old woman in Bucharest, Romania’s capital, is planning to give birth to a baby girl, during a scheduled Cesarean section at a private hospital which has a baby-friendly reputation.

Niculae says she chose this hospital and birth plan after a traumatic experience delivering her first child at a public hospital five years ago. She can afford it thanks to family support programmes from the city government.

She considers herself fortunate, but it has still been a very difficult pregnancy – and despite her careful planning, the world that her daughter will be born into looks very different from the one Niculae had been preparing for.

“I'm 33 weeks pregnant and I've already missed seven check-ups since the pandemic started,” says Niculae. She has been self-isolating very strictly since March, and has only left the house once in two months, to visit a doctor, because she has been too afraid of contracting the virus.

Even if she had been willing to leave her house, most pregnancy check-ups were postponed or cancelled between late March and late April, under controversial Ministry of Health guidelines, since partially revised, that had suspended all “non-emergency” medical appointments.

Romania’s lockdown may be easing now, but 24 hours before her scheduled C-section, Niculae will be tested for the virus. Based on these results, she will either be sent to a designated COVID-19 maternity hospital, or she will spend the next four days having a C-section and then recovering with her baby.

Regardless of her test results, however, she will go to the hospital alone. “Now you're not allowed to come with a spouse, or anyone else. You just have to be alone in this,” Niculae explains. This part of the government’s guidelines has not been revised: partners are banned from hospitals.

“A very dangerous situation”

Cristina Niculae is one of thousands of women in Romania whose pregnancies have been affected by COVID-19 and the Ministry of Health’s guidelines, a number of which contravene the World Health Organisation’s advice on childbirth during the pandemic, which was also issued in March.

Women with confirmed or suspected COVID-19 cases were also separated from their newborn babies until they had two consecutive negative coronavirus tests, a process that takes weeks. In addition, they were not allowed to breastfeed as their breast milk was classified as “waste”.

After maternal health and women’s rights groups protested, the government sent revised guidelines to regional public health offices on 27 April. Under these revisions, prenatal check-ups and abortions were classified as “essential” appointments that should not be postponed or cancelled.

But the guidelines still separate women from newborns, and ban companions from accompanying women to hospitals, or visiting them after births.

And for many women, damage had already been done.

“We had a lot of women telling us that doctors were advising them not to come for their prenatal visits,” says Ana Maita from the NGO Mothers for Mothers in Bucharest. “This was a very dangerous situation.”

For years, Maita’s NGO has monitored the treatment of pregnant women in Romania. When the ministry’s guidelines came out, she appealed to the government to change them and also contacted WHO’s local office for help.

The WHO’s recommendations say that all pregnant women should be treated with respect and dignity and, regardless of COVID-19 status, they should not be separated from newborns and should be supported to breastfeed. They should also be allowed companions of choice during delivery.

Maita says the WHO contacted the ministry and that “some steps have been made in the right direction”, including allowing doctors to decide on a case-by-case basis whether to advise women to breastfeed.

Only ten ‘baby-friendly’ hospitals

Although the health ministry’s commission that issued these guidelines is composed of obstetricians and neonatologists, Maita says: “Most hospitals in Romania are not baby-friendly. So it's rather easier for them to separate mothers from newborns, than to keep them together.”

Across Europe, COVID-19 has had a negative impact on national health systems, and Romania’s was already under-resourced. The country’s health spending is the lowest in the European Union (EU), for instance, at about €1,000 per capita in comparison to the EU average of almost €2,900.

In 2002, a joint project of the WHO and UNICEF counted a total of only 10 ‘baby-friendly’ hospitals in the country, which has about 20 million inhabitants. The situation has not noticeably improved since then, and the COVID-19 pandemic has made it worse, according to maternal health experts.

Midwife and certified lactation specialist Adina Paun describes the health system as overwhelmed, while a lack of leadership and coordination has led to a “to each, his own” attitude amongst hospitals and health personnel.

“The average tenure of a health minister in Romania since 1990 is eight months,” Paun notes. Since the start of the COVID-19 pandemic, a new government has come into power, including a new health minister.

On the ground, “people do whatever they think is correct”, she said. And when it comes to following guidelines “some doctors do it, some don’t”.

Paun also stressed that there are stark “differences between the health systems in Bucharest and in the rest of Romania”. For example, Calarasi is “the city with the horrible fame of having the highest neonatal mortality in Romania, fifteen per 1,000 [births]. In Bucharest, you have five per 1,000.”

The WHO recommends that mothers and babies are kept together after births, but you have to have enough personnel to care for them, as well as personal protective equipment (PPE), says Paun.

“These are simple, stupid things, but you have to have eight PPEs [personal protective equipment] per 24 hours, per mother and baby. In hospitals where you don’t even have masks for the people working there, it's impossible.”

Last year, the Filia Centre, a women's rights NGO, published a study showing that only 112 public out of 425 hospitals across Romania normally provided legal abortion services. However, during the pandemic they recently found that only 12 of these hospitals were still performing abortions.

The centre’s Andrada Cilibiu and the author of this research, said of the first study: “I thought to myself 'it can't get any worse than this'. Then, the pandemic came and proved me wrong.”

Though, she adds: “There's always this idea that there's something more important to take care of than women's health and women's rights, and this hasn't changed with the pandemic.”

Maita from Mothers for Mothers echoed this. But she said she hopes this crisis will encourage more and longer-term communication between NGOs and authorities, which she believes could produce better policies for women.

“Now is the time to nudge the authorities in the right direction and come up with solutions. In a few months, the time will come to sit down, to analyze and to make some changes, so that we're better prepared,” she says.

As Niculae’s C-section date gets closer, she describes pregnancy during the pandemic as “scary” – even if you have access to a hospital with a good reputation, and are able to self-isolate.

Missing check-ups added to her anxiety, she says, while she is still preparing to go to the birth alone. “This is hard for me”, she says, as well as for her husband, who “won’t be there to have a moment with the baby, like he was with our first child. Due to COVID, it will be really different this time.”