On November 20 last year, with her baby due the next day, Dajana Petric was admitted to the maternity ward of the local hospital in Doboj, a town in northern Bosnia and Herzegovina. All was well, she thought, until the contractions began.
In increasing pain, Petric, 25, called the nurse. She was taken for a CTG scan, which measures the baby’s heart rate and monitors contractions in the uterus. The results did not reflect the pain she was experiencing and, according to Petric, a nurse told her she was making things up.
“They take me back to the room and the nurse says that they will go to sleep and that I should not call them unless my waters break,” Petric told BIRN. “I couldn’t sleep because of the pain. At one point I was screaming into the blankets and pillow so they wouldn’t hear me.”
Petric called the nurse again but was told to go back to bed. In the early hours of November 21, she had diarrhoea, was vomiting and began bleeding. At 6 a.m., the doctor arrived and Petric’s waters broke. “The doctors listens to my stomach and say they have to deliver the baby immediately because it was choking,” she said.
The child was born at 6.20 a.m. Petric said she did not even have the strength to push out the placenta.
Her account is one of 523 submitted to BIRN via a questionnaire about the experience of childbirth in Bosnia and Herzegovina, Albania, Croatia, Greece, Hungary, Kosovo, Montenegro, North Macedonia, Romania and Serbia, with a focus on the process of delivery, the attitudes of medical staff, health complications and consequences and legal fallout.
More than 80 per cent alleged ‘medical negligence’, many complained about the attitude of medical staff but barely three per cent filed an official complaint or sued. Petric said it was probably only the midwife’s apology that stopped her from suing.
Daniela Drandic of ‘Parents in Action: Roda [Stork]’, a Croatian NGO that lobbies for the protection of women’s rights in pregnancy and parenthood, said the accounts reflect a widespread failure to listen to and trust women, as well as a lack of confidence among women in the efficiency and fairness of the courts.
“When they come to the maternity ward, women are in a vulnerable position, the institution expresses its power over them and they simply do not have a voice in the whole process,” Drandic told BIRN.
“Who is more qualified to talk about what is happening to her body than that woman to whom it is happening?” she said. “I’m afraid it will be a long time before we start trusting women, not only in this sphere.”
According to the results of the questionnaire,
- 84.13 per cent of respondents believe the cause of the complications they experienced during childbirth was medical negligence
- Only 3.06 per cent filed a lawsuit or complaint
- 85.47 per cent said they had no pre-existing conditions that might have caused complications
- 6.5 per cent reported that their baby or babies died during labour
‘In the end, they lose’
Illustration. Photo: EPA/PAULO CUNHA.
In 2018, after a Croatian MP shared her own traumatic experience of childbirth, Drandic and the Roda NGO launched a social media campaign under the banner #BreaktheSilence [#PrekinimoSutnju], inviting women to submit written accounts of their experiences with the Croatian health system.
Within days, more than 400 letters had flooded in. Roda submitted them to the health ministry. The campaign resonated in neighbouring Serbia and Bosnia too, where women also began speaking out.
Drandic said that much more needed to be done to change healthcare practices in the Balkans.
“Such a change is possible either through education or through court proceedings that have some kind of epilogue that affects the way the institution or profession behaves,” Drandic told BIRN.
She lamented the fact that so few women felt able to file a complaint or launch a lawsuit.
“First and foremost… women are traumatised, they need space from that event so that they can process the trauma before they are ready to talk about it,” while also caring for a newborn and dealing with the “huge change” that has happened, Drandic said.
Then there are the courts. Women, Drandic said, do not have a transparent, reliable or efficient complaints process they can turn to. “Nor is a court process something that is a possibility for them at all, because these court proceedings are usually long and certain and, in the end, they lose,” she said.
“Women are in a very vulnerable position in this whole story, while doctors and hospital institutions are in a very powerful position.”
‘Complete reform’ necessary
Graphic: BIRN/Igor Vujcic.
For their part, medical professionals say a lack of doctors and poor organisation might be to blame.
Snezana Rakic, a gynaecologist at a private clinic in the Serbian capital, Belgrade, said maternity hospitals in Serbia were simply too big.
“There are maternity hospitals that are very large and have 6,000-7,000 births per year; in these maternity hospitals the frequency of births is very high and logically you cannot expect the same kind of service as you might get in smaller maternity hospitals,” Rakic told BIRN.
“Across the world, maternity hospitals for 1,500 to 2,000 births are being made, where you have practically five births a day… you have more staff and fewer patients who require care. So the main problem is organisational.”
Rakic said Serbia could learn a lot from elsewhere.
“A complete reform is needed,” she said. “Experiences from Austria and Germany are different: midwives, who are well trained, lead a physiological birth and the doctor comes only in case of complications.” In Serbia, a doctor is required to be present, but doctors are in short supply across the region.
Another doctor questioned the definition of ‘complications’.
“The concept of complication [in childbirth] differs between doctor and patient,” said Aleksandra Dimitrijevic, a professor at the Faculty of Medical Sciences in the Serbian town of Kragujevac and director of Gynaecology and Obstetrics at the local hospital.
“It is not a complication if the birth lasts longer because the final result is a healthy woman and a healthy child,” she said.
Of the roughly 2,200-2,300 births carried out at the hospital, “when we talk about severe complications we are at less than one per cent,” Dimitrijevic told BIRN.
‘I never saw the baby’
Photo: EPA-EFE/IDREES MOHAMMED.
Thirty-four respondents to the BIRN questionnaire reported the death of the baby or babies during labour. One respondent, a family member of the pregnant women, said the mother had died. In another case, both mother and baby died.
One of those who said she had lost her baby was Dina Angelova, who is of Russian origin but lives in North Macedonia.
Angelova told BIRN that her waters broke at home and she was taken by ambulance to the general hospital in the northern town of Kumanovo.
“I started bleeding there, it lasted for three hours,” she said. “But the staff was extremely rude and shouted at me for making a mess in their premises. I was told that I was open, but that the baby was too high so I could not give birth.”
“The agony lasted for several hours. I asked for a caesarean section, but I was told that everything was fine.” A doctor whom Angelova described as older and more experienced shouted at the medical staff, telling them they were “losing both the woman and the child.”
Eventually, the baby was delivered but was placed in an incubator and transported to the capital, Skopje. Angelova was kept in Kumanovo. She later received a phone call saying that her baby had died and Angelova discharged herself from the hospital.
“I never saw the baby,” she said. “So every time I go to church I light two candles, one in case the baby is alive somewhere and one in case it’s dead.”
An autopsy indicated that the baby had swallowed too much amniotic fluid. Angelova said that other doctors she consulted told her the child would have survived had a C-section been performed.
Angelova reported her case to public prosecutors in Kumanovo, who told BIRN that it had asked the police to investigate and sought the opinion of an expert at the Forensic Medicine Institute in Skopje, which had still to be submitted.
“I just want to know where the guilt lies, for the culprits to be punished so that other mothers do not suffer as I did,” Angelova said.
Many other mothers do suffer similar experiences in North Macedonia, which has one of the highest rates of infant and maternal mortality rates in Europe.
Infant mortality dropped to its lowest ever rate in 2018, at 5.7 per 1,000 live births, but was still higher than the European Union average that year of 3.5.
According to a UNICEF report from February 2018, North Macedonia has the second-highest rate of infant mortality in the first month of life in Europe, behind only former Soviet Moldova.
The report said the performance of health systems could not alone account for high mortality rates, which it blamed also on economic development, poverty, social welfare, disease rates and the state of the environment.
Dr Borjan Pavlovski of the Association for Emancipation, Solidarity and Equality of Women, ESE, said infant mortality rates were worse within North Macedonia’s large ethnic Albanian minority and in rural areas.
The National Roma Centre, NRC, an NGO that works on rights of the Roma community in Kumanovo, said it regularly encountered cases of complications during labour.
“Let’s not forget the women who don’t have [ID] documents due to various administrative problems,” said NRC head Ashmet Elezovski. “They do not have the right to healthcare and free-of-charge childbirth.”
Violence and verbal abuse
Jolka Nathanaili Penotet, a psychologist and head of the Albanian NGO Child and Family Unit, gave birth to her daughter in 2015 at Queen Geraldine Hospital in Tirana.
There were no major complications, but Nathanaili Penotet said she suffered for weeks afterwards from the “unprofessional” and “careless” incision made to her perineum to make room for the baby, a common procedure but which women say is frequently performed without asking for consent, informing the woman or offering an alternative.
“I will never forget my condition during the first month after labour, even though I had a natural childbirth,” she told BIRN, saying that a doctor she subsequently visited in France was shocked by the damage done.
“The way new mothers are treated, the lack of care… leaves an indelible mark on all of us and make us think twice before undertaking another pregnancy.”
Some 7.5 per cent of those who responded to BIRN’s questionnaire reported problems with episiotomy.
A 2019 report by Croatian lawyer and UN Special Rapporteur Dubravka Simonovic said that “mistreatment and violence against women in reproductive health-care services and childbirth in health facilities happen all around the world and affect women across all socioeconomic levels”.
Obstetric violence includes physical abuse, compulsory medical procedures or procedures carried out without consent, the refusal to give painkilling medication or anaesthesia, violations of privacy, but also humiliation and verbal abuse.
Drandic said that “outdated practices” were still being used in Central and Eastern Europe. She cited the Kristeller manoeuvre, or fundal pressure, a practice in which a midwife or doctor presses hard on the mother’s stomach during contractions. In developed countries the practice is discouraged due to the risk of broken bones, organ damage and other complications.
A woman from the Bosnian town of Foca said that without warning she was subjected to episiotomy and the Kristeller manoeuvre.
She said the baby suffered a broken collarbone while she was left with severe bruising around her stomach and ribs and suffered from an infection when the stitching on her perineum broke.
She complained of verbal abuse too, with staff telling her to “Stop acting up” and accusing of her of behaving “like you’re the only mother in the world.”
Some 16 per cent of respondents complained about the way medical staff spoke to them or physically handled them.
“I was insulted by the doctor over my body weight, [called] derogatory names,” wrote a woman from Serbia.
Another, in Montenegro, said she was subjected to “violence”, “shouting” and “jumping on the stomach”, an apparent reference to the Kristeller manoeuvre.
She quoted the medical staff as telling her, “Suck it up” and “Do you think this is a hotel?”
The woman in Foca said she felt partly to blame for not knowing her own rights.
But Drandic said that pregnant women and mothers are often not “in a position where they can fight for their rights”.
“Quite simply, a woman, when she is at the end of her pregnancy, or when she gives birth… she simply has more things to do than analyse the articles of the law or quarrel with someone,” Drandic said.
“Women, in general, do not know they have the right to say ‘No’. This is the elementary thing that we don’t even teach girls. You have the right to say ‘No’. And the person to whom you say it has an obligation to hear it and respect it.”