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After years of silence, hundreds of Croatian women have been speaking publicly about the traumatic experiences they suffered during childbirth in the country’s hospitals, putting obstetric violence on the political agenda.

When Croatian MP Ivana Nincevic Lesandric spoke out about her own painful experience of a cervical scrape carried out without anaesthesia, raising questions about the practices of the country’s hospitals and particularly about how women’s healthcare is treated, a debate about obstetric violence erupted.

The debate shattered years of silence on the issue as hundreds of women decided to share the horrific experiences they had endured in hospitals, and spurred civil society and Croatian media into action.

Parents in Action: Roda (Stork), an NGO that advocates dignified pregnancy, parenthood and childhood, launched an initiative on social networks, entitled #BreaktheSilence2018 (#PrekinimoSutnju2018), inviting all women who have had a bad experience with the country’s medical system to write it down on paper, together with the location and date.

This triggered an avalanche of similar stories. Over a period of just four days, Roda received more than 400 letters from women who have had traumatic experiences and sent them to the ministry.

“Year [19]92: after childbirth, stitches ‘live’ without anaesthesia… [at clinical hospital centre] KBC Rijeka,” read one of the women’s testimonies that was sent to the ministry.

“Dubrovnik, 2010: after childbirth, during which I didn’t make any sound, I was sewed up without anaesthesia. I screamed after every stitch. While tears rolled down my face, I begged the doctor to stop or to give me something for the pain. His comment was to hold on because he was sewing me up for my husband,” read another.

“Petrova hospital [Zagreb], 2018: half-hour of stitches after childbirth without any anaesthesia and painkillers with insolent comments from a [medical] resident who ‘had a bad day and now you are shaking while she is sewing’,” said another one.

In addition to these letters, numerous similar experiences from women who preferred to remain anonymous were published on social networks.

A critical moment for mothers’ rights

Doctors and nurses during the work of delivery of a baby. Photo: EPA/PAULO CUNHA

Danijela Drandic from Roda personally delivered the women’s letters to Croatian Health Minister Milan Kujundzic, who has frequently been criticised for numerous mistakes and omissions made by the healthcare system. Despite a recent no-confidence vote, Kujundzic remains in his position.

Drandic told BIRN that she hopes that these horror stories will help to improve country’s healthcare system.

“They [the government] realised that it is very important moment, that [the problem] can’t be swept under the rug,” she said.

Kujundzic promised he would send health inspectors to the hospitals mentioned in the letter. The inspections are still in progress, and after all the data that has been collected is analysed, the public will be informed about the conclusions, the Health Ministry told BIRN on Monday.

Obstetric violence includes physical abuse, humiliation and verbal abuse, compulsory medical procedures or procedures carried out without consent, the refusal to give painkilling medication or anaesthesia, and violations of privacy.

Anita Budak from Croatia’s doula (birth companion) association, whose role is to ensure a positive birth experience and support mothers during pregnancy, maternity and childbirth, told BIRN that although their role does not include the prevention of obstetric violence, if a mother feels she has been subjected to such violence, they support her in her decision to report it.

“I personally, as a doula, witness human rights violations. The most basic one is that informed choice does not exist in delivery rooms, or we only see it on rare occasions,” Budak said.

Experts say that every woman’s entry into motherhood naturally involves some level of pain, but there is no reason to make it even worse due to unpleasant or even violent treatment of women in hospitals during childbirth.

Budak said that some of the medical procedures, like uterine fundal pressure, a controversial manoeuvre used often in the second stage of labour, or episiotomy, a surgical incision of the perineum and the posterior vaginal wall frequently performed during second stage of labour to quickly enlarge the opening for the baby to pass through, are often carried out without asking for consent, without informing women about them, and without offering an alternative.

“I’m also witnessing cold and cruel behaviour towards women who are delivering, for which there is no excuse,” she added, although she said she also sees many caring and friendly health workers, albeit in smaller numbers.

A 19-year-old mother, who published her experience anonymously on a Facebook page entitled ‘Mums’ experience in Croatian maternity wards/hospitals’, told BIRN how she gave birth to her twins when she was only 17.

She also recalled the doctor insulting her throughout the process due to her young age, as well as the searing pain when she was sewed up after the delivery as the anaesthetics she was given did not work.

But her troubles did not end there. Because she has had problems with breastfeeding, as many mothers have, she was insulted by a nurse.

“The nurse answered roughly… asking me what kind of mother I am if I can’t feed my children,” she recalled.

“I didn’t talk about it so much because something [that is supposed to be] nice became a pretty bad experience that I find difficult to recall,” she said, adding that because of this trauma she decided not to have any more children.

Brain drain not completely to blame

A nurse holds a newborn baby Photo: EPA/PAULO CUNHA

When asked why Croatian hospitals do not use anaesthetics in procedures such as cervical scrapes or episiotomy, or why even if they do, the drugs often do not seem to work, some experts cited the lack of anaesthesiologists in many hospitals in the country.

The Croatian Medical Chamber said on October 15 that in the last five years, 620 doctors have left Croatia, most of them anaesthesiologists.

However, gynaecologist Jasenka Grujic points out that not all gynaecological interventions require general anaesthesia and the presence of anaesthesiologists.

“An episiotomy is sewn up with a local anaesthesic that is applied by the person who is doing the sewing – an obstetrician-gynecologist,” Grujic told BIRN.

However, she stressed that all patients need to be informed about a procedure and should give their consent, as prescribed by Croatia’s Law on the Protection of Patients’ Rights and the Code of Medical Ethics and Deontology, a codex that is part of the country’s Medical Law. She also urged compliance with the Respectful Maternity Care Charter produced by the White Ribbon Alliance for Safe Motherhood, an international NGO.

While providing the patient with the necessary information, doctors should also “calm the patient and ensure a sufficient level of privacy”, she added.

“For such things, there is no need for any funds, but it requires great dedication and time from the medical staff. Such dedication is the basis of the medical profession,” she said.

Ivana Skrnicki from the Croatian Association of Midwives said that a certain number of women who have experienced discomfort and pain due to the failure of hospital staff, but pointed out that each patient is different and that every woman responds to procedures differently.

“The number of staff is small compared to the number of patients. Patients come with different needs and demands, and employees are trying their best to work something out, but sometimes some things cannot be done in the way in which the patient wants,” said Skrnicki.

But Drandic from Roda argued that one of the problems of the healthcare system in Croatia is that pain in women’s reproductive organs is often not perceived as real pain.

“If someone had a traffic accident, they would give him or her some sort of anaesthesia before doing something [a medical procedure], but in reproductive health, that simply is not the case,” Drandic said.

Zeljka Jelavic, a sociologist and lecturer at the Centre for Women’s Studies in Zagreb, agreed that the Croatian health system – like the whole of Croatian society – is patriarchally dominated, and obstetrics mirrors this.

“The starting point is the fact that the doctor is the one who knows and who has the power of decision,” Jelavic told BIRN.

Prescriptions for better care

A nurse cleans a newborn baby Photo: EPA/PAULO CUNHA

Jelavic said that several changes are needed to improve the situation, starting from the education of doctors to the education of children so they will know how to use their rights when they reach maturity.

“This implies that it is necessary for us to have health education at the earliest age, that it is necessary to have citizenship education, and of course we need to strengthen institutions, but also to strengthen civil society organisations such as Roda that could contribute to changing the situation,” she said.

Croatia has been involved since 1993 in the ‘Baby-Friendly Hospitals’ programme, whose goal is to protect newborns and promote breastfeeding. By 2016, all 31 maternity wards in the country had been awarded the title of ‘Baby-Friendly Hospital’.

But only four have been involved in a new pilot project, launched in 2017 by the International Federation of Gynaecologists and Obstetricians and International Confederation of Midwives to make maternity hospitals mother-friendly.

“I think that in our society, especially with the strong rise of the Catholic conservative right in our society, the focus is put on the unborn child, not on the woman,” said Jelavic.

The public debate about the treatment that women get in Croatia’s hospitals has put the issue on the political agenda, however – and the honesty of those who have talked about their traumatic experiences has encouraged others to speak out, like the 19-year-old mother who told her story to BIRN.

“I sincerely hope this will [change the situation],” she said, “because the attitude that nurses and doctors have to pregnant women and women in labour is terrible, and this must definitely be changed.”

NOTE: This article was amended on October 2, 2018 to clarify that ‘Baby-Friendy Hospitals’ program started in 1993, and by 2016, all maternity wards had received the title of Baby-Friendly Hospital. It was also amended to clarify that the mother-friendly hospitals project was launched in 2017 by the International Federation of Gynaecologists and Obstetricians and the International Confederation of Midwives, not by UNICEF.

This blog was cross-posted from the Balkan Insight website.