Submission to the UN Working Group on the Issue of Discrimination against Women in Law and in Practice

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]

 

Homebirth

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]

 

About Rodil­nitza

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

 

Ref­er­ences

[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.

[x] http://www.who.int/gho/maternal_health/countries/bgr.pdf

[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

[xiv] http://www2.ohchr.org/english/bodies/cedaw/docs/ngos/GAFfor_the_session_Bulgaria_CEDAW52.pdf

[xv]http://tbinternet.ohchr.org/_layouts/treatybodyexternal/Download.aspx?symbolno=CEDAW%2fC%2fBGR%2fCO%2f4‑7&Lang=en

[xvi] http://www.may28.org/women-do-not-lose-their-human-rights-upon-entering-the-hospital/

[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).

[xxi] Ibid.

[xxii] Endan­ger­ment of the access to med­ical help and the doc­tor-patient priv­i­lege http://www.rodilnitza.com/blog/birth/medicinska_pomosht_lekarska_taina/

[xxi­ii] Civic Reg­istry Law. Art. 42 and 43, http://lex.bg/laws/ldoc/2134673409.

[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/

[xxvii] “Pay­ing to Choose a Doc­tor or a Team of Doc­tors at the Hos­pi­tal is Unlaw­ful,” Feb­ru­ary 8, 2012, Ombuds­man of the Repub­lic of Bul­gar­ia, http://www.ombudsman.bg/news/1720?page=10.

1 коментар »

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