Hospital childbirth: a conveyor for the production of children or the most reliable way to protect a woman and a child? Source: Sergey Venyavsky/RIA Novosti. All rights reserved.
“The midwife beat me on the legs, because I was wincing at the pain of ‘cleaning me up’.”
“When I was in labour, the doctor put so much pressure on my stomach that some of my ribs got broken.”
“They injected me with oxytocin, to speed up my labour: ‘we always do that’.” The medical staff were in a hurry to get the baby out, sew me up and send me back to the ward.”
There are so many stories like this, and they all boil down to the same thing: women are reduced to incubators, and successful deliveries depend on the mood and loyalties of the medical staff. Ukraine follows the conveyor belt approach to childbirth that was standard in the Soviet Union.
Lack of professional skills among staff is an issue as well, as is the state’s monopoly on obstetric care. The concept of a “home birth” just doesn’t exist in Ukraine. So women have basically no choice – they have to abide by the rules of the system.
According to the World Health Organization, midwife aggression is a universal issue that is more or less common all over the world. But both scientific research (such as that conducted at the European University at St Petersburg and the work of Viktor Radzinsky), as well as surveys by human rights organisations dealing with maternity issues, show that the situation is particularly bad in the post-Soviet space.
In 27 years of independence, nothing much has changed in Ukraine in terms of training specialists in the psychology of pregnant women, medical ethics and the culture of interaction with women in labour. According to the specialists at the Natural Rights Ukraine organisation, which works in this area, any training programmes that do exist are generally concerned with the pathology of childbirth and ignore recent international research, as well as paying little attention to the borderlines of natural childbirth, where medical intervention is unnecessary. All this results in a low professional level where the culture of obstetrics and medical intervention in childbirth is concerned.
Source: Рівне Вечірнє/Flickr. All rights reserved.
When Maria’s contractions began, she and her husband phoned for an ambulance to get her to the hospital. As her labour progressed very rapidly, the paramedics announced that they didn’t know how to deliver a baby or what to do with a woman about to give birth. But this lack of medical expertise is not the only problem: ethical issues are also often bypassed. Midwives are happy to invite groups of medical students to observe the mother-to-be or even the birth itself, without asking for her permission.
“When I was transferred to a delivery room, the doctor checked my dilation and, without asking my permission, stuck his fingers up my cervix to open it – this happened four times during my labour,” Larisa recalls. “After this I was given a general anaesthetic, so that I would be unconscious and no bother, as it was during the night. In the morning, students turned up at the hospital and were directed to my delivery room, despite the fact that I had refused them entry.”
“Women about to give birth are subjected to both physical and emotional violence,” says Anastasia Salnikova, a doula who works at the Ukrainian Catholic University’s Public Health Development Centre offering women physical, information and psychological support through their labour. “Women are often made to feel like a mere incubator, an object, or else an infantile, incompetent ‘disobedient’ person who can be punished or ignored for their ‘bad behaviour’.”
According to Natural Rights Ukraine, the most common forms of obstetric aggression are medical intervention without warning or asking the woman’s permission (breaking her waters, episiotomy, limiting her movement during labour etc.), the use of synthetic oxytocin (sometimes under the pretext of vitamins and glucose) and not allowing the woman’s partner to be present at the birth. Ukrainian law gives a woman the right to choose her birth position, but in practice no one asks her what she wants and she has to give birth lying on her back, which is convenient for the doctor, but risky for her and her baby. The medics’ unwillingness to place the baby next to its mother’s body immediately after its birth; feeding it with a mixture of formula and water without its parents’ permission, and the lack of help for the mother with breastfeeding are all examples of this aggression.
Ksenia, who had a baby last spring, tells me that her birth went well in general, except that her waters were broken without anyone telling her: “The man who did it was presumably a doctor. He was very rough and physical, just as he was when he looked at me on a gynaecological examination chair.” According to gynaecologist Lyudmila Kyrychenko, the waters are artificially broken if labour is proceeding too slowly – in other words, when there are clear indications for it and it may indeed be essential. But in Ukrainian maternity hospitals it’s often carried out without good reason, just to speed up labour (even if it is going normally), and then they use oxytocin. “They broke my waters, to make my labour shorter,” says Alina, who gave birth to a son a month ago, “The doctor thought he would be born in another hour or hour and a half, and when that didn’t happen they put me on an oxytocin drip, and speeded it up as much as they could.”
Yevhen Kubakh, a specialist with Natural Rights Ukraine, believes that one simple step could improve the situation considerably – medics’ compliance with existing Ministry of Health regulations, which are very progressive but rarely observed. These 2003 regulations state, among other things, that maternity facilities should regard a pregnant woman or a woman in labour “not as an object for certain medical manipulations aimed at hastening her delivery, but as a person and the central figure of an important moment in her life – childbirth”. The reality, however, as psychologist and doula Olha Gorbenko points out, involves “a failure to observe the rights of women during pregnancy and childbirth in Ukrainian maternity hospitals, and a lack of respect for their requirements and dignity.”
No money, no birth facilities
Ukraine doesn’t have a universal insurance-based medical system of the type usual in most of western Europe. Under Ukrainian law, medical care, including during childbirth, is provided free by medical facilities and their staff, and the health system is financed by the taxpayer. This situation, however, only exists on paper. As well as paying their taxes, Ukrainians also have to pay the medics “under the counter”. Childbirth is no exception to the rule and is a pretty expensive business.
Natalya tells me that the doctor did a good job of her delivery: it all happened quickly and without complications: “but then he demanded $1,000 for his services. We also had to buy several bags of medications, as listed by the hospital, in advance and couldn’t return those that weren’t actually needed during the birth.”
Maryna prepared very carefully for her baby’s birth: she discussed everything with the doctor in advance, knowing that she would need a C- section: “I gave the hospital a charitable donation of 2,000 hryvnya [roughly €60] and paid the doctor as well. The doctor didn’t give me a figure until the last moment, and said after the birth that the sum was up to us. We paid him $1,000. He told other people what they had to pay straight away. It would have been easier if all the payments had just been agreed at the start.”
The working conditions of medical staff determine the quality of care for women in labor. Photo CC BY 2.0: 40weeks_ua/Flickr. Some rights reserved.
“Charitable donations”, in other words voluntary payments, are only voluntary in theory. As medical treatment is supposedly free in Ukraine, and the maternity hospital can’t give you an official invoice, medical facilities resort to subterfuge and disguise their fees as donations. But in practice, they are anything but voluntary – if you don’t pay up, you’ll be left having your baby in a corridor.
And despite the fact that expectant parents have to pay for medical services, the conditions and atmosphere in hospital wards are far from pleasant. “I decided to pay for a private ward,” says Yulia. “There were two of us in it: it was a terrible, Soviet kind of place. But the free wards had up to ten women in them and every night there’d be someone in labour, groaning and screaming. The antenatal wards were just as Soviet – redecoration (or rather, lack of it), ghastly furniture and too many people. They were so crowded as well: there was only 40cm between beds. I also paid for a post-natal ward, just because they allowed your husband or mother to stay there with you. The only women in the free wards either needed long bed rest or had no money at all.”
The medical staff are not known for politeness or tact – especially the junior staff, who often see a mother-to-be as less a women preparing to give birth and more a bottomless purse: “Reception staff are the rudest, and they are of two types,” says Natalya. “The first are nasty and rude, and don’t answer your questions until you put your hand in your pocket. The second are nice and friendly and tell you and show you everything, but they need a ‘present’ as well.”
In general, young couples can expect their child’s birth to set them back about €1,000, and to have to pay unofficially and out of their own pockets. Given the monthly minimum salary in Ukraine is around €120, this is a large sum for many families.
A system that needs changing
Medics refuse to comment openly on the issue of obstetric aggression. But in private, they admit to stimulating labour artificially without there being any real need for it, just to have the baby born on their shift, so that they, and not their colleagues, will get an unofficial bonus from the happy parents. “Why does a doctor agree to deliver a specific couple’s child? Because it’s the only way to earn some money,” says an obstetrician who has asked to remain anonymous.
The other side of the problem is the low pay earned by gynecologists, obstetricians and neonatal specialists. The medical profession is one of the lowest paid in Ukraine, despite its eight-year training, and the level of responsibility carried by an obstetrician is the highest of all medical fields. The basic monthly salary of a junior doctor two years out of medical school is just €100-150. As a result, doctors accept extra, unofficial remuneration, and you end up with a vicious circle.
Another significant factor is fatigue and overwork. “A tired doctor is more interested in getting a baby out than waiting for the process to happen naturally,” an anonymous obstetrician-gynaecologist tells me. “A woman might arrange to have her child delivered by a hospital’s medical director, but the night before the agreed date he or she is called out for a difficult birth. They then arrive at work at 7.30 in the morning and spend the whole day dealing with difficult administrative matters and operating on a patient. They return home and have just sat down to eat when the woman phones to say that her contractions have started. Are they going to be up all night for her son to be born at 7am the next morning after a previous sleepless night and stressful day? And that’s what they face day in, day out.”
“Many obstetricians transfer fears and negative experiences from one unfavourable outcome to others. Instead of a clinical review that might help other colleagues avoid a similar medical error, they are psychologically ‘torn apart’ by senior management,” the obstetricians tells me privately.
All this is not helped by a shortage of medical staff and a lack of potential measures to prevent professional burnout, not to mention limited access to information about new research and evidence-based medicine.
“Doctors who are responsible for women and children’s lives earn a very low salary for such responsible work, which lowers their desire and opportunities for professional development,” says senior neonatologist and Doctor of Medical Sciences Alyna Dunayevska.
“Attendance at EBCOG's European Congress of Obstetrics and Gynaecology costs around €2,000-3,000 in fees plus travel and accommodation, which is impossible on a Ukrainian doctor’s salary. And unfortunately, few of my colleagues speak English. Often, the only source of information for doctors is pharmaceutical company reps who are mainly interested in selling their products, and many lectures at Ukrainian professional conferences are paid for by pharmacy firms keen for orders. The result is a reliance on non evidence-based medicine.”
Caring is the most important thing in childbirth. Photo CC BY 2.0: 40weeks_ua/Flickr. Some rights reserved.
Gynaecologists’ low professional level is obvious even to their patients. After Maria had her baby, a local gynaecologist diagnosed her with cervical erosion (which according to the latest research requires no treatment) and suggested treating her using methods found online. “When I heard the doctor say: ‘Have you decided on your treatment? Did you look on Google?’ I thanked him and left – I wouldn’t visit a specialist like that again!”
Situations where a woman with a locomotor disability is having a baby are still a big problem, since most well-women clinics have no experience of taking such a woman through pregnancy and childbirth. Elena, a wheelchair user, is one of the few disabled women in Ukraine to decide to have a child with her husband. It was a conscious decision and they spent a long time coming to it.
“At first, the doctors tried to dissuade me,” Elena tells me, “as they had no idea what the consequences might be and admitted that they had no experience of taking a disabled woman though a pregnancy. One of the doctors told me that it would be a ‘state of emergency’ for our whole town. I was scared to begin with, and became even more scared when I saw the doctors’ reaction, as I had no one to support me. I met with similar incompetence from the obstetricians and gynaecologists while I was in labour. There were moments when I felt insulted: a gynaecologist told me at some point to ‘sit on the operating table’ – as though I could do that myself!”
The lack of special equipment and gynecological examination chairs for disabled women in most women’s health centres means that women with spinal impairment have to be examined in their wheelchairs. Some perinatal centres specialising in services for disabled women will provide more appropriate facilities, but most women’s health centres are not equipped for them.
Members of the medical profession often make a woman feel guilty for any complications with her pregnancy, and try to persuade her that it is all her fault and that she doesn’t care about her unborn child. If a woman has a miscarriage, some gynaecologists are more likely to reproach her than to offer emotional support (for which they have had no training). And in the Ukrainian maternity hospital system, the stillbirth or perinatal death of a child is still as much of a taboo subject as it was in Soviet times, and only a few hospitals have psychologists on their staff to provide appropriate support for a woman in this situation. Late terminations on medical grounds are another area that is insufficiently regulated by law: only a regional expert commission can take a decision on the subject.
Ukraine also lacks openly accessible figures on the number of live births (vaginal with and without complications, caesarean sections) delivered by a given obstetrician, midwife and maternity hospital, as is standard in EU countries, to allow women to choose where to give birth. Ukrainian women mostly resort to word of mouth, as well as searching for information on various internet forums created by women for themselves.
All these issues are a real challenge for the health service reforms recently initiated in Ukraine. The reforms offer real progressive and positive changes in medical services and how they are financed. The issue of obstetric aggression, however, has is still to be targeted as a focus area, says specialist Yevhen Kubakh.
According to the experts, the solution to the problem may lie in the introduction of the three-stage model of delivery that has been successfully implemented in the Netherlands, UK, Germany, Israel, Canada, New Zealand, USA and other countries. The distinctive feature of this system is the choice a woman can make between midwife-centred and doctor-centred antenatal care (provided that she is in a low risk group). In Ukraine, however, midwives are not trained to work independently, delivering babies on their own in normal circumstances. A volunteer working group, including lawyers, practising doctors, activists and members of the public, is at present engaged in developing a legal framework for such changes.
As well as legislative changes, there’s also a need for changes in medical workers’ in-service training: access to recent research in evidence-based medicine; monitoring of compliance with existing regulations; improvements in communication between women and medical staff, and a new approach to funding healthcare. Other elements of change are equally vital: a proper review of medical staff’s working conditions; the introduction of a system to avoid burnout; the appointment of staff psychologists in all maternity hospitals and high quality training for them; the introduction of clinical investigations into medical errors instead of punitive measures. Otherwise we shall just have to continue relying on doctors’ conscientiousness and a fair amount of luck.
All the mothers quoted in this article asked to be quoted anonymously.