Good Practices in the
Elimination of Discrimination against Women
with Regard to the Right to Health and Safety
Submission from non-governmental organization Rodilnitza, Bulgaria
Maternity Care – Overview
Maternity care in Bulgaria is provided exclusively in hospitals, which can be public, private or public-private partnerships.[i] The services are highly medicalized and provided only by obstetricians, with midwives being restricted to working mostly as nurses. There are no options for out of hospital birth, such as birth centers or home births attended by midwives. The law does not permit midwives to practice independently from obstetricians or negotiate reimbursements with the national health insurance agency. As a consequence, women are left with only two options – the rigid institutionalized care provided by obstetricians in the hospitals or giving birth at home without any medical assistance – an option that is taken by an increasing number of women.[ii]
The rate of C-sections has reached the alarming rates of 40% with the numbers expected to rise as subsequent births are also referred to C-sections and vaginal birth after cesarean is not recommended or practiced by doctors. In addition, practices which have been categorized as ineffective or harmful by the World Health Organization (WHO), are routine practices in Bulgaria. For example, enema, shaving of the pubic hair, intravenous infusion during delivery, back-lying position, instructed pushing during the second stage of delivery. At the same time, “practices that according to WHO are effective and should be promoted domestically are not widely available (following a birth plan prepared by the woman, taking into account her wishes to take in fluids, to choose a place for delivery, to be accompanied by a person of her choice, to have early mother-and-child body contact, and support for initiation of nursing within an hour after delivery).”[iii]
Although the Health Law provides for the right of informed consent,[iv] hospital staff rarely respect that fundamental right of the birthing woman. This has to be one of the most widely violated patient rights in Bulgaria, but it affects women especially because of their very vulnerable state during childbirth. Doctors have been found to have failed to inform women appropriately and to lack the direct communication with them necessary to obtain an informed consent.[v] Most providers believe informed consent is obtained when the pregnant woman signs a standard informed consent form upon admission and this is sufficient to satisfy the legal requirement. No refusals of procedures would then be permitted or documented. The form is often signed during contractions or as the woman is being wheeled to the operating theater for a C-section, even when the operation was planned days in advance.[vi]
As reported by the Bulgarian Helsinki Committee in 2013, “the right of the woman to give birth in circumstances chosen by her, and in a single room, to be accompanied by someone close to her is not guaranteed by law or in practice.”[vii] Even if the room is single, the family would have to pay extra money so the father can be present – charges for which he receives no services in return.
The Ministry of Health has not acted upon regular alerts from Rodilnitza in regards to the widespread violations of women’s right to informed consent and the requests for an informational campaign explaining to medical staff and the public what that implies .[viii]
Non-profit organizations advocating for the rights of women in childbirth are not included in the decision-making process on changing or amending laws and regulations that pertain to maternity care.[ix]
Maternal Mortality and Investigation
Maternal mortality has dropped significantly in Bulgaria, with the country reporting 5 maternal deaths per 100,000 live births.[x] Although this is commendable, there are problems with maternal deaths that still persist. Relatives have reported that they are having trouble requesting an independent autopsy.[xi] Even when autopsies are performed often the cause of death is not determined, which impedes investigation and creates a sense of lack of accountability among the relatives and the general public.[xii]
When maternal death cases are investigated and brought to court there are problems with expert witnesses. The expert witnesses are appointed by the court from a list of approved medical experts from different specialties, depending on the case. This creates problems with finding the facts of the case, as experts sometimes recuse themselves and leave the court with no options to proceed, as reported by a judge in Bourgas where the case was impeded for five years and on multiple occasions from proceeding due to lack of expert witnesses.[xiii] This severely impedes access to justice for women and their families.
Abuse and Disrespect in Childbirth
There is widespread abuse and disrespect towards women in childbirth. The following report was submitted to the CEDAW Committee in 2012 by the Gender Alternatives Foundation:
“Reports of verbal and physical abuse of women by hospital staff during abortion and delivery are very common in Bulgaria, albeit primarily oral. Therefore, they leave very little trace. Socially, the most typical and omnipresent ill-treatment of labouring women, such as shouting at them, making sarcastic and vulgar remarks, forbidding them to scream, and slapping them, is widely accepted as the natural way of birth. The birth “war stories” are shared, and the next generations are growing up with the expectation of suffering and abuse during childbirth. Intrusive, painful, and/or humiliating procedures, such as shaving, artificial rupture of membranes, episiotomy, and the forceful pressing on the abdomen, are applied primarily for speed and for the convenience of staff, rather than for the comfort and safety of the women, or only when it is really necessary. The labouring women are expected to be apologetic and docile. Disobedience may be punished by inflicting unnecessary pain by staff during delivery. Roma women are segregated and ignored.”[xiv]
In its concluding observations the CEDAW Committee wrote: “The Committee urges the State party to ensure that health-care providers are fully aware of the particular health-care needs of women, to adopt the patients’ bill of rights and responsibilities and to establish effective complaints mechanisms to enable women to seek redress in cases of health-care related discrimination and abuse.”[xv]
A campaign organized by Rodilnitza in November 2013 brought to light many of the stories that women usually share just among themselves. Social media was overtaken by women holding sheets of paper with the abusive words they had heard from medical staff while giving birth.
Over 60 women shared pictures with abusive words, there were hundreds of comments on each picture, with many more women sharing similar experiences. Some of the words women had heard while giving birth:
„Nobody is asking you if you want to,“ „Stop pulling your legs together!,“ „Babies have no business being with their mothers,“ “Why are you complaining? When you had sex it didn’t hurt, why are you hurting now?” “Stop whining like a bitch! You are going to squirt it out like a shit,” „Why did you move, I lost your vein, I am going to slap you,“ „Who are you going to complain to? I have witnesses, you have nobody.“[xvi]
The campaign was widely covered in traditional and online media, however, the Minister of Health completely dismissed all accounts as bogus. A letter writing campaign was organized so that individual women can report to the Ministry specific violations they had experienced. One year and one minister later, Rodilnitza received a reply from the Ministry of Health saying that the number of women reporting abuse and disrespect was very low, insignificant compared to the number of births per year, which is around 60,000.[xvii]
Homebirths, or possibly our awareness of them, have increased in the last 5-7 years. The subject has become a very contentious one in Bulgaria. Unfortunately, the position the government and the health care institutions have taken has been to the detriment of the birthing women.[xviii]
With the increased exposure to birthing practices overseas, more Bulgarian women have started to demand a higher quality obstetric care and especially one more humane and respectful of their rights. The system has not responded kindly and we have received numerous cases of women who upon requesting their patient rights to be respected have been physically and emotionally abused by the hospital staff. [xix]
Women who find the status quo situation in the hospitals unacceptable or psychologically unbearable have no other option, but to birth at home. Midwives are prohibited to practice outside of the hospital setting, which leaves women to birth unassisted. And still, a growing number of them choose to do so.
In cases when a homebirth has ended up in a hospital, the repercussions for the women have been enormous. The contempt of the medical staff for the mothers has proven to be only a small problem.[xx] Usually the hospital would invite the media and publicly shame the woman with complete disregard for her privacy. In a few cases, television crews were allowed inside to film the woman and/or her child. In one case, child protective services were called and the woman was threatened with the loss of her child and endured months of insecurity and stress following the birth.[xxi]
The dangers of this approach were raised by Rodilnitza with an open letter[xxii], namely how it will scare women from seeking medical help in the event that an inevitably unassisted homebirth requires it.
Further problems home birthing women face include difficulties with the registration of the newborn in the civic registers and refusal of doctors to provide postnatal care. The civic registry law does not specify who is responsible for registering a baby born outside of the hospital system – is it the obstetrician, the midwife, the pediatrician, or family doctor.[xxiii] This creates uncertainty among medical professionals, and coupled with the negative view towards homebirth, gives them room to refuse signing a newborn certificate.
Fathers are effectively denied the right to the 15 days of paternal leave as by law this time starts running after the mother is discharged from the hospital.[xxiv] This, of course, is to the detriment of women and their babies, who do not receive much needed support in the first days after childbirth.
Additional Payments for Maternity Care
The Constitution of the Republic of Bulgaria provides that women have the right to obstetric care free of charge.[xxv] The reality for women, however, is very different.
Women who have the state mandated health insurance still have to pay additional sums of money for basic rights, such as privacy, respect, and having their husbands present at birth or not being separated from their babies. These under the table payments were legalized by the Ministry of Health in 2006.[xxvi] The Ombudsman of the Republic of Bulgaria has commented on multiple occasions that such additional payments, especially for choosing a doctor or a team of providers, are unlawful as the patient is paying twice for the same service, once through the national health insurance and a second time out of pocket.[xxvii]
Rodilnitza is a non-profit organization in Bulgaria, dedicated to defending the rights of women during pregnancy and childbirth. We are a group of 20 women from different backgrounds and have been very active in advocating for respectful maternity care free of violence and abuse for the past 6 years. www.rodilnitza.com
[i] Medical Standard on Obstetrics and Gynecology, issued by the Ministry of Health, December 30, 2008, http://www.mh.government.bg/media/filer_public/c5/71/c571cbb3-b720-4c99-aa35-2f077de2f19b/meditsinski-standart_akusherstvo-genekologiya.pdf.
[ii] See for example, Annual Report of the Bulgarian Helsinki Committee, 2012, page 46-47, http://www.bghelsinki.org/media/uploads/annual_reports/2012_bhc_annual_report_en.pdf.
[iii] Annual Report of the Bulgarian Helsinki Committee, 2014, page 78, http://www.bghelsinki.org/media/uploads/annual_reports/annual_bhc_report_2014_en.pdf.
[iv] Health Law, Art 87-91, http://www.lex.bg/laws/ldoc%20/2135489147
[v] See a recent report from the Medical Audit Agency, stating that the informed consent forms are presented the patient by nurses or other personnel without an opportunity for discussion between the patient and the doctor. “Analysis of Medical Care Offered in Obstetric Units and Hospitals in the Period from 2014 and January-May 2015.” Ministry of Health, Medical Audit Agency, May 2015, http://www.eama.bg/images/NEWS/AG%20Analysis_Graf_Dima.pdf.
[vi] “The Principles of informed Consent are still not a Reality for Women in Labor,” Dnevnik newspaper, April 11, 2011, http://www.dnevnik.bg/bulgaria/2011/04/18/1076955_principut_na_informiranoto_suglasie_vse_oshte_ne/ See also, “The Trap of Informed Consent,” Argumenti BG, November 30, 2010, http://argumenti-bg.com/711/klopkata-informirano-saglasie/
[vii] Bulgarian Helsinki Committee Annual Report, 2013, page 62, http://www.bghelsinki.org/media/uploads/documents/reports/annual_human_rights_report/2013_bhc_annual_report_en.pdf.
[viii] Support Bulgarian Women’s Right to an Informed Consent, Press Release, November 22, 2010, http://www.rodilnitza.com/blog/news-events/support-bulgarian-womens-right-to-an-informed-consent/
Sample Letter of Support sent to the Ministry of Health outlining the problems with informed consent, November 22, 2010, http://www.rodilnitza.com/blog/wp-content/uploads/2010/11/International-Support-Letter.pdf;
Open Letter to the Ministry of Health on Urgent Measures Needed for Reforming Maternity Services, June 5, 2015, http://www.rodilnitza.com/blog/aktivnost/open-letter-mh-june-2015/ (Outlines the need for an informational campaign on informed consent among other urgent measures. No response received yet, although the legal period of 30 days for response has passed.)
[ix] There was a brief attempt in 2010 to form a working group on informed consent with the participation of non-profit organizations, but this attempt failed when the Minister of Health was substituted and the new minister did not continue the relationship.
[xi] “”We Want the Truth” – the Relatives of a Dead Mother,” May 18, 2015, Dnes Dir BG, http://dnes.dir.bg/news/konchina-rodilka-ulian-parvanov-19085983
[xii] “The Cause of Death of a Mother in Dobrich is Still Unknown,” May 22, 2015, Vesti Newspaper, http://www.vesti.bg/bulgaria/obshtestvo/vse-oshte-ne-sa-iasni-prichinite-za-smyrtta-na-rodilkata-v-dobrich-6036552 (Note: These are two separate maternal deaths within the same month).
[xiii] “Five Years after the Death of a Mother no one is Held Accountable,” May 18, 2013, BTV Novinite, http://btvnovinite.bg/article/bulgaria/pet-godini-sled-smartta-na-rodilka-v-burgas-vinovni-nyama.html
[xvii] Answer from the Ministry of Health Regarding Violence against Women in Childbirth, January 27, 2015, http://www.rodilnitza.com/blog/uncategorized/otgovor_na_mz/
[xviii] See for example Annual Report of the Bulgarian Helsinki Committee, 2012, page 46-47, http://www.bghelsinki.org/media/uploads/annual_reports/2012_bhc_annual_report_en.pdf.
[xix] Protest against the violence against birthing women in Bulgarian hospitals https://nenanasilieto.wordpress.com/violencebirhwomen/
[xx] See for example Annual Report of the Bulgarian Helsinki Committee, 2013, page 62, http://www.bghelsinki.org/media/uploads/documents/reports/annual_human_rights_report/2013_bhc_annual_report_en.pdf. (Describing the threatening and hostile environment women face when referring to a hospital after a home birth).
[xxii] Endangerment of the access to medical help and the doctor-patient privilege http://www.rodilnitza.com/blog/birth/medicinska_pomosht_lekarska_taina/
[xxiv] Labor Code, Art. 163(7), http://www.lex.bg/bg/laws/ldoc/1594373121. See also Annual Report of the Bulgarian Helsinki Committee, 2013, page 62, http://www.bghelsinki.org/media/uploads/documents/reports/annual_human_rights_report/2013_bhc_annual_report_en.pdf.
[xxv] Constitution of the Republic of Bulgaria, Art. 47, http://www.parliament.bg/bg/const
[xxvi] Regulation for Access to Medical Care, issued by the Ministry of Health June 2, 2006, http://lex.bg/laws/ldoc/2135527794/