Human Rights in Childbirth National Report: UKRAINE

General information on the data

This report is based on the following data:

(1) A survey spread among the Ukrainian women in February-March 2015 asking them to report on their childbirth experiences (‘The 2015 Survey’ hereafter). This survey has resulted in 3,526 responses from Ukrainian women who gave birth in Ukraine between 2009 and 2015.

(2) 20 women’s open letters on their experiences of childbirth sent to the Minister of Health Care in Ukraine and the Strategic Counseling Group on Health Care System Reform in Ukraine in 2015.

(3) Surveys conducted in October 2016 (“The 2016 Survey” hereafter) which was specifically crafted for the purposed of this report and circulated among Ukrainian women and midwives. This survey has resulted in 99 responses from women and 6 responses from midwives and obstetricians.

(4) We have also brought in personal and professional experiences of the contributors to this report, which includes experiences in childbirth education, and birth assistance to women for a number of years. Specifically, the report contains ideas from the Association of Professionals on Natural Parenting (that unites 35 doulas, medical doctors and midwives) and has been associated with over 1,500 cases of birth assistance since 2011. The data from those specialists have been collected orally in the course of the Association’s work.

(5) Finally, we have used women’s testimonies that came to “Miracle in the Heart” project by email or through social networks (Facebook and VKontakte). The number of such stories is hard to estimate since 2014. It exceeds 500 testimonies.

Maternity Care in Ukraine

Background Information

According to the Constitution of Ukraine, health care in Ukraine is free of charge. The official costs that women are to pay based on the legislation include only the prices for certain tests and the price of the private postnatal room at the maternity hospital. Nevertheless, it is usual in the Ukrainian healthcare system that pregnant women give informal payments to obstetricians in advance to be present at their labour and birth personally.

Vaginal birth at a state maternity hospitals cost about USD 100-1,000 [1] and a Caesarean section costs about USD 250-500. Specific price depends on the location with the capital being the most expensive. These costs are paid directly to an obstetrician to be present at birth on top of other costs for antenatal care of the postpartum private room. There are also some obstetricians who do not charge a specific price but rather accept “gratitudes” after the birth. These sums are paid directly to an obstetrician for a simple physiological birth. Complicated births cost 30-50% more.

In private maternity hospitals, the prices for birth vary from USD 600 to 3,200 depending on the complexity of birth and comfort level of a delivery room.

Midwife-assisted homebirth costs vary from USD 400 to 1,500 depending on a midwife’s qualification and experience (i.e. recommendations from other clients), city or village, birth complexity plus costs of the preparation for birth (about 150-200 US dollars) and postpartum consultations and care (about 150-200 US dollars). Some homebirth midwives work on a basis of donation, however.

Based on the Ukrainian legislation, a woman can be accompanied by up to two people during her birth in a maternity hospital [2]. However, it is also written in the legislation that the head of the maternity hospital regulates the quantity of accompanying persons, and most often only one person is allowed to accompany a woman, and in some cases, no partner is being let in due to such official reasons as renovations or quarantine. Moreover, a labour companion has to fulfill certain criteria. These criteria are sometimes written and known (for instance, a partner must be dressed in a certain manner, or provide his/her TB-screening etc.). Yet, sometimes maternity hospitals ask from 20 to 150 US dollars for allowing a birth partner in.

The structure of perinatal care in Ukraine includes:

• Regional perinatal centers – that administer 17.7% of all birth
• Maternity hospitals
• Maternity wards within general hospital in a smaller town
• Private hospitals: only 3 at the moment

Birth centers that would focus on physiological childbirth for low-risk women are not present in Ukraine. Home childbirth is not included in the public perinatal care system. As a result, low-risk women have almost no alternative to state maternity hospitals and perinatal centers.

In 2014 the national health care policy was reshaped according to the European standards making current protocols for normal birth in Ukraine identical to protocols of EU countries. The de facto implementation of those protocols remains problematic, however.

General perinatal care indicators are quite good in Ukraine as of 2014 as the following figures show:

Table 1: Indicators of Perinatal Outcomes in Ukraine

Perinatal mortality rate		8.5 per one thousand
Neonatal mortality rate		3.1 per one thousand
Survival rate of prematurely born babies in the first 168 hours of life	very low birth weight (less 1000 grams)	almost 82%
	low birth weight (1,000-1,499 grams)	93%
Maternal mortality rate		12.8 per 100 thousand
Cesarean Section		17.4% in 2014 (+7% compared to 2000)

Source: Official Ministry of Health of Ukraine site, www.moz.gov.ua, 2015

The data from the 2015 Survey shows that:

• Only 31% of women gave birth without medical intervention (active management of the third stage of labor was not considered an intervention) – thus labour is very medicated.
• Almost half of births at the second stage of labor have taken place in the position of women lying on their back.
• Only 49% of women were psychologically satisfied with their birth experience.
  
  

Part 1. Informed Consent and Refusal

1. What do women report being told about their rights to informed consent during antenatal care? Is there any standardized information available that helps women to exercise their right to make informed decisions during pregnancy and childbirth?

The 2015 Survey of over 3 500 women has shown that 76% of women said that they have been informed at the antenatal clinic on the matter of tests and monitoring procedures, while another 20% said that they were not. Moreover, 59% of women said that they had enough time and information in order to decide on informed consent, while 41% responded that they did not have enough time and/or information for doing that.

The 2016 survey among the mothers has, however, shown that 70-75% of women claimed to have not given their informed consent during antenatal, intrapartum and postpartum care. This discrepancy might be due to the difference in the responding audience in the two surveys, distinct formulation of the question or the dynamics that could have occurred in the social reality. In any case, even though the exact number of women who lacked proper exercising of their right to informed consent is not known, it is clear that a significant portion of women had their right to informed consent violated.

There is a standardized printed information about options and interventions in pregnancy and childbirth, provided as a “Consent Agreement Form” given in antenatal clinics. However, 40% of women in the 2016 Survey indicated that they did not face the procedure of being asked for consent or refusal, yet if they refused from some medical manipulations (for instance, hospitalization, physical examination) doctors asked them to write a written refusal. Thus providing women with choice and information is not the goal of the medical personnel; informed consent papers are mostly used by doctors in order to protect themselves from unwanted responsibility in case of a “disobedient” woman. 30% of respondents in our 2016 Survey admitted that doctors have not told or explained anything, and they just did what doctors prescribed.

Diagram 1

According to the law, medical facilities have to provide courses for pregnant women where they can get information about pregnancy and birth. And some facilities indeed have those courses. However, they present the information through the lens that women have to strictly follow their doctor’s instructions because they know best what is good for those women. The information in those courses is provided in a one-sided manner, according to the medical perspective on the process of birth. For example, they teach that amniotomy should always be done at 5 cm of cervical dilation. Psychologists often teach these courses, and even if they are aware of the alternative views they are supposed to teach the official perspective, otherwise, they might lose their job.

The majority of women have no idea of informed consent and the possibility to have an influence on their birth. When women hear about those things at non-hospitals based childbirth education events they are usually very surprised and no one knows the particularities of informed consent procedure. A frequent reaction is a doubt that they can make the right decision without education and knowledge. The second concern is that doctors may get offended if they (women) disobey and as a result, they are afraid to not be provided with the full amount of medical services.

Women participating in our 2016 Survey spoke on the following cases:

Svetlana: “I was asked to fill out a long questionnaire that gave me a choice of many different medical procedures and tests. At the same time, a chief midwife and the antenatal clinic head behaved in a pretentious and threatening manner after I refused from a vaginal exam and an ultrasound… The antenatal clinic head as she learned of my refusal from an ultrasound (especially given that it is free) has offered me psychological and psychiatric help. She has also invited an ob/gyn and, 2 nurses and birthing clinic head for them to talk to me”.

Olha: “No one has ever told me of such a right. The doctor just tells me what to do, which tests to undergo. No one explained me why and what for, as if it is self-explanatory that I just have to do it and that’s it”.

Kateryna: “To be frank, in the prenatal clinic most doctors dislike “conscious mommies”, they think that we have read and listened to some suspicious stuff on the internet and that we question their many years of practical experience”.

And Tatyana added that she faced medical personnel talking her into more procedures despite her unwillingness to do them with words like: “It is better to be on the safe side”, “Just do the tests, is that so hard after all?”, “Just do another ultrasound just in case”.

The 2015 Survey respondents shared very similar impressions and cases of informed consent violations. The most common themes were that doctors provided almost no information, answered no questions, or did so in a very formalistic way and/or humiliating or even threatening manner. Many women also report that along with some formalistic informing antenatal specialists used strong psychological pressure to still achieve the result that they want. While many women reported this being the case, one woman has shared a specific storytelling that “they were shown a horrible video after which she needed to seek a psychotherapists help”.

2. What have women reported about informed consent conversations or processes for the following interventions?

Episiotomy

Usually, doctors do not ask for consent in order to do an episiotomy. However, if a woman strongly expresses her stance against it, especially if there are witnesses with her, it is possible to have the right of refusal from episiotomy respected. Mothers’ reports in our 2016 Survey demonstrate that episiotomy is done routinely, without asking and usually in connection to other preceding or forthcoming interventions – whether necessary or not:

Marta: «They did an episio without even asking, pressed the baby out and put me on my back despite my will».

Myroslava: «At the check-up, my cervix was artificially dilated, it was very painful, during the following night it has fully dilated and contractions started, but no urge to push yet. So they gave me oxytocin, as I was still unable to push they’ve cut me, did not offer me any vertical position, just pressed the baby out. All this has happened during 3.5 hours... I still would like to hear from them why did I need all that; wasn’t it all unnecessary? And after the birth the baby has got a diagnosis due to all these stimulations...»

Valeriya: «I do not remember being told that I can refuse anything during birth. They just said – now we will check you, break the waters, add oxytocin, make an episiotomy. … When I was admitted into the maternity hospital, I was checked and told: now we will breakwaters and will birth is no time. There were no extensive answers. The doctor looked at me as if waiting for my approval and I probably looked approving, my timid attempts to ask, “Isn’t oxytocin harmful”, “Isn’t Analgin dangerous for the baby” were followed by the doctor’s “Surely not”. … By the time they made an episio I was already consenting to everything and just nodded».

Roksolana: «They constantly checked my dilation – afterwards I had a feeling as if I were raped by 5 people. They also cut my perineum, JUST IN CASE, so that there are no tears».

Amniotomy

Amniotomy is the most common medical intervention in childbirth (over 55% - the reference to be clarified) among all hospitals in Ukraine, as well as the limitation of freedom of movement/position and speeding labor up by oxytocin. Respondents of our 2015 Survey report that amniotomy was done in 47% of the cases, and in 18% of cases it was done without obtaining a woman’s consent.

Amniotomy is often done without prior informing about this procedure; often in the course of a usual vaginal exam. Doctors never speak of potential side effects, moreover, they consider this procedure as positive as it makes birthing faster, even if it’s done on 2-4 cm of cervical dilation, which is even against the official medical Protocol produced by the Ministry of Health of Ukraine. Often, amniotomy is considered mandatory if the amnion has not spontaneously broken at the beginning. Doctors consider birthing with amniotomy still natural. It is unique for an amnion to be allowed to stay intact by the stage of full dilation. Usually, amniotomy goes together with Nospanum injection to help soothe the cervix after an intervention, and it is rarely accompanied by fetal heart monitoring.

Many mothers in the 2016 Survey were willing to share on this procedure done to them:

Svitlana: “In the birthing room my question about what medication I am being given intravenously was followed by the answer: “A good one”. I was not asked whether I agree for an amniotomy, nor was I warned of their plans to start that procedure. When I asked to keep my husband near me, I was said that he cannot stay when they are doing a certain medical manipulation. The doctor spoke respectfully, but did not ask for consent and just did her own thing“.

Elena: “In the birth clinic I heard the following from my doctor: "These are no contractions, just precursors of birth, after all, it’s too early for you to birth" (as I disagreed saying that it was week 39 according to my calculations, she said that according to her calculations I was to birth in a month), "We will stop labour. Liuba (an obstetrician), start “Partusisten”. I said that I had an allergy for “Partusisten”, I was given it on week 26 as I had a threat of preterm labour and I got sick from ½ a tablet. The doctor has responded that she never saw an allergy for “Partusisten” and that I was to stop saying silly things. I was given “Partusisten” intravenously; an anaphylactic reaction has followed after which the doctors decided that I would birth. And then there was also: "Liuba, give me forceps, let’s break the sac", and "Liuba, start “Oxytocin” and “Parlodel”, enough waiting".

Viktoriya: “I clearly remember the moment when after a long labour I was given “Oxytocin” intravenously. As I asked, “What is that?” a midwife responded: “Vitamins”. Later I understood what that was”.

Olha: “They told me that since I agreed for one intervention (for which there were prerequisites) I had to agree to other interventions as well. “Because this is our protocol”, although there were no reasons for other interventions”.

Maryana: “No respect, blunt rudeness and an underlined attitude of superiority over a birthing woman. No answers to posed questions: "Don’t show off", "We know better", "Look at you, how smart!" [sarcastic], "This just has to be done".

Diagram 2

Labour induction

Induction is usually offered as the only option after the 40th week of gestation. The widespread argument is that “Your baby is suffering. He can die any moment”. No one is warning of the risks of this intervention, of the increased probability of C-section and complicated birth. As a result, an absolute majority of women consent for induction without doubting or giving it a second thought, as doctors only speak of expected benefits from induction. Among our Survey 2015 respondents, 14% of women report having their labour induced. Yet this data does not tell much about the level of labour induction in Ukraine as the survey audience could have been skewed towards pro-nature mothers given the features of our subscription base.

Freedom of movement and position

Fortunately, most maternity hospitals offer quite extensive possibilities for movement in the first stage of labour. Usually, doctors and midwives recommend moving more and offer a range of equipment to assist in that. However, it is normally not possible to move outside of the labour room, saying nothing of the birthing ward.

Freedom of movement in the second stage is usually very restricted. In addition, an absolute majority of midwives and doctors consider upright position a very bad idea for the pushing stage, even though official state documents provide for a woman’s freedom of position and mention upright positions as normal. Medical personnel uses a variety of arguments from “a greater risk of tears” to be unwilling to bend in order to catch a baby. The majority of maternity hospitals are equipped with birthing chairs but usually, women can use them only during dilation or only at the beginning of the second stage. As soon as the head is crowning the woman is being laid down on her back. Usually, this happens already at full dilation or at the start of pushing. Women’s requests to birth otherwise and their complaints about discomfort and pain are not being paid attention to. Women are usually forced to birth on their backs by arguments, threats or even physical force. Anastasiya reports: “I chose a hospital “friendly to mother and baby” and expected to birth on all fours. I was assured that in their hospital I can birth in any position when I came to register at that place at 34 weeks. When I came to birth I was again assured by a nurse that I may birth in a position of my choice. But when a doctor showed up she said that I can birth in any way I wish but if it is not lying on my back she is not responsible for anything”.

Overall, 49% of our Survey 2015 respondents report that they were on their back while pushing although it was not comfortable. The remaining 51% - was not necessarily in an alternative position, rather they have reported their position as “comfortable”.

In some cases, it is possible to negotiate a position on a side. In some maternity hospitals, a woman is allowed to be in a semi-sitting position, but her body is usually fixed with her legs against the midwife or the birthing chair. A kneeling position is a very rare case and it is often seen as a woman’s misbehavior.

Fetal heart monitoring

Fetal heart monitoring is usually done not continuously in Ukraine. Normally it is done for 10 minutes at arrival to the maternity hospital, and then from time to time as labour progresses. Some hospitals monitor the heartbeat every 15-20 minutes; others do it more often but for shorter periods. And yet in almost all the cases, a woman cannot move during this procedure. Sometimes the heart is not checked for several hours. And those diverse practices are usually not explained or at best it is said that such is the standard operating procedure in a given facility. Continuous fetal heart monitoring is rare, even after the medical labour stimulation.

Pain medications

In recent years, the propaganda of medical painkillers in birth is on the rise in Ukraine. Mass media is trying to convince women that this is a safe option that has no risks associated with it. During labour, doctors sometimes force women into an epidural if dilation is slower than what they would like it to be. Some maternity clinics require this manipulation almost universally and tell women that it is fully safe and good for their baby and for their labour, that there are no risks associated with it, that it is the highest achievement of contemporary healthcare and no adequate woman should be willing to suffer while epidural is available. If women ask about potential risks from anesthesia, doctors often laugh in response and tell that side effects are impossible. Yet, other birthing clinics, especially in less central locations do not suggest epidural and are less keen on using it. Along with the epidural, medicalized sleep (caused by Promedolum) is also sometimes used.

Among our Survey 2015 respondents, 9% of women used epidural at their own will and 5% of respondents used epidural based on doctors’ recommendation. Yet this data does not tell much about the level of epidural use in Ukraine as the survey audience could have been skewed towards pro-nature mothers given the features of our subscription base.

Labour augmentation

Labour stimulation is often offered and the potential side effects associated with it are rarely described. The only result that is being talked about is that a woman will birth faster. This intervention is often described as “the same hormone as the one in your body, you just don’t have enough of it so we will just add a bit more of it”, or that “the uterus is already tired”, “oxytocin is not produced well at night”, “you should understand that the baby is suffering, he needs help”. The underlying discourse is that this intervention is so necessary that there is even no point in talking of its potential side effects.

Planned C-section

In this case, the informed consent issue is taken seriously, doctors bring many papers that need to be signed, sometimes they also mention some of the risks, but more often just suggest reading about them. There is unfortunately not enough information on breech birth or VBAC, and therefore there is usually no one to inform a woman about a possibility to try a vaginal delivery. A participant of our 2015 Survey reports that she “...was not informed that natural birth after a cesarean is a possibility… In particular, they never told [her] to go through an intravaginal ultrasound on the 34th week”.

Most women in such conditions are just sent to a C-section by default, as it is considered necessary in such cases. The personnel and most of the parents see signing the informed consent papers in the case of planned C-section as a formality. Almost no one usually questions the necessity of an operation and seriously considers refusing it if a doctor recommends it. Among our Survey 2015 respondents, 8% has reported having a planned C-section.

Emergency C-section

Some maternity hospitals do C-section in extreme cases only, while others see it as a good alternative to natural delivery and operate as much as they catch babies naturally. In later cases, C-section is offered if a doctor does not like the duration of labour or if they are just “bored to observe”. Manipulations are also often used when it is being said that a woman “will not birth by herself” or “that baby suffers, he can die any moment”. And this is often done in cases where objectively there is no indication of baby suffering and no discoordination of labour or any other objectively concerning conditions. Among our Survey 2015 respondents, 7% has reported having an emergency C-section.

3. Information and Process

Are women provided with standardized printed information about options and interventions for pregnancy and childbirth? Is the information accurate?

Such information is not generally available, although some non-governmental initiatives try to produce such materials. Even though information about options and interventions during pregnancy and childbirth exists, antenatal clinics do not carry it in a printed form and rarely mention it to mothers.

The perspective on childbirth promoted in media and Internet forums is that a layperson is incompetent in matters of birth and only a doctor can tell what is good and what is bad. Only the information that is presented by doctors matters for the media. Even false information given by a doctor is seen as relevant. In contrast, even a valuable and proven information suggested by a non-doctor is seen as less important.

Diagram 3

In our 2016 Survey over 62% of respondents indicated that they got no printed information about their rights on Informed Consent either in antenatal clinics or in maternity hospitals. Some printed information was provided in antenatal clinics (24%), in sanitary inspection rooms (14%), and in the delivery room (11%).

Diagram 4

The largest percent (58%) of women that learned about informed consent did so from the documents supplied by obstetricians. 10% of respondents were provided with some printed leaflets where the right for informed consent has been clarified.

How is informed consent obtained antenatally? How is informed consent obtained during birth?

The Ukrainian legislation obliges doctors to obtain informed consent before conducting any medical interventions. In turn, pregnant and birthing women are granted a right to refuse to give their consent for such an intervention [3].

However, in practice, such informed consent is mostly seen as a formality, just as another signature to be obtained as the woman enters a maternity hospital.

Although the legislation presupposes 2 official kinds of consent forms to be given to women in labour, some birthing clinics offer the following unsanctioned form asking for a “blind and blanket” consent to everything that might potentially be done to her, which is obviously in violation to the very idea of an informed consent procedure:

Notably, the name of a doctor is often blank on this form. A doula reports that when medical personnel was asked how a woman can sign such a form if she neither saw a doctor, nor knows his/her name, the response was that “this is a standard form and the doctor for this woman’s labour is not assigned yet”.

It is also often practiced asking for woman’s handwritten refusal form during active labour. A doula reports being present at a breech birth where a woman was forced to write a text dictated by a doctor while she was pushing lying on her back if she wanted to birth without oxytocin. As she was managing this task, the doctor has cynically commented: “And please, write legibly”.

Many mothers in our 2016 Survey were willing to share on this, for example, Dasha who has shared: “They’ve thrown a pile of papers unto me and said: “Familiarize yourself and sign”. And this was when I was crunching from pain and cannot even hold a pen in my hand, saying nothing of reading. I’ve signed everything with my eyes closed. I can’t understand how one can give papers to sign to a birthing woman. She is busy with something else. At that time I could have signed anything without reading”.

Are interventions presented to women as an option that they get to accept or decline? Are interventions presented to women as decisions that the providers have already made?

Diagram 5

Diagram 6

Women are being told that doctors’ recommendations are mandatory and such that do not require any explanations. In private talks, doctors usually insist that it is them who are the decision-makers, not the patients.

What is the role of documentation and getting the woman’s signature in the informed consent process? Do women report feeling like informed consent is a signature on a form; it is the form a meaningful tool for ensuring that women freely consent to the intervention or treatment?

Women tend to view informed consent as another document needed at the arrival to the hospital. Usually, they are signed without being read. In addition, no one usually gives neither details nor explanations.

Have women reported being promised certain kinds of support during antenatal care, and then those promises are broken during labor and birth? (“bait and switch”)

Doulas report regularly witnessing that doctors declare certain things prior to labour, but then act differently and often differently on most of the agreed upon points during labour. Usually, this is justified by scaring women with phrases like “your baby is suffering and you are disobeying”.

Our Survey 2016 participants shared a lot on this, for example:

Nina: “My doctor was committed to his promise of natural birth, but the birthing clinic’s head has intervened and insisted on stimulation and episiotomy”.

Sofiya: “I signed a refusal from the active management of the third stage, but in reality, everyone was done as was most convenient to the doctors”.

Nadia: “Before birth, my doctor was nodding his head as I told about my plans for natural birth with no anesthesia and interventions. In fact – the amniotic sac was broken as soon as he came to check me. He told me of this as he was already doing it and gave me no options. He also prescribed the IV to stimulate contractions, they did it. He explained nothing to me. Before the IV contractions were bearable, and after – horrible, as if I was tearing apart”.

Natalia: “They promised me a vertical delivery, but in the birthing room they forbid me birthing like that. They said that I will have a huge tear if I do not climb on a chair so that they can control everything.”

Svitlana: “1. I asked the doctor (had an agreement on this 2 months prior to my due date) not to cut the cord during the first minutes, to let it pulsate – my request was ignored in the birthing room. 2. I was assured before birth (both my doctor and the doctor who turned out to be at my delivery) that the baby will be with me all the time since the facility had the “mother and baby friendly” status. However, when I was transported from the birthing room to a postpartum room suddenly my baby was taken away, I started yelling at them, but nurses did not pay any attention. I had to call the doctor who has already left by then and she said that she does not know why they took the baby and that they will return him soon. I never found out what they did to my newborn during those 10 minutes!”

4. Consent/ Right to Refusal

Are women told that certain interventions are “hospital policy,” and that they must accept them? (Examples can include electronic fetal monitoring, an IV, lying on the hospital bed, induction or augmentation with synthetic oxytocin, accepting a cesarean section if they have certain indications, etc.)

Diagram 7

This is constantly happening. This argument is often being used to refuse any of women’s right be it talking her husband or doula with her or sitting up during the fetal heart monitoring.

Have women reported any pushback, hostility, punishment or violence that occurred when they tried to exercise their right to informed consent by asking questions or refusing intervention?

Diagram 8

If a woman or her partner does not agree with a doctor, he can “get offended” and attend them less, give them less care, or become rude trying to punish them in response. A doula reports that a “frivolous” couple was forbidden to move with an IV because initially, they refused from stimulation. And even when they agreed for stimulation the woman was forbidden to sit up as she was “punished for disobedience”. Another reported case resulted in forbidding a father to enter the hospital and meet his child because his wife “was disobedient during labour”.

Our Survey 2016 respondents have also shared the following stories:

Luibov: “There were pressure and threats from the doctors: "you will not birth by yourself", "you do not know how to birth", "we will do a C-section now". They spoke to me as if were an object, a person who just does not comprehend anything and they spoke those things so that I can hear them”.

Anna: “The doctor was saying that I was birthing poorly. “You need to lie, not sit – you are sitting on the baby’s head” – even though it was just dilation and I could feel that the baby is still inside me. “Your husband will leave you if your birth so poorly and he will be right to do so” – this was said in the presence of my husband (he was with me at birth)”.

Vera: “Medical personnel kept humiliating me and friends who were with me in birth: I was “not walking properly”, “not lying properly”, “watched too much Youtube and tried to show-off”, they used curse words, did not allow me to birth vertically, as I tried vertical position they did not hold me and I have fallen on my back, they never offered me a birthing chair that was just there at the side, I just did not see it myself, I only noticed it after birth; I refused, but they still gave me “Oxytocin”, without my consent they treated and burned my babies eyes, I was against that ointments, but they said it was just in case; they’ve placed me in a very bad postpartum room even though I was healthy and in the hospital to which I was assigned. And they broke my sac without my consent”.

Ksenia: “In the hospital, in the birthing room there was yelling, I was treated as I were not adequate person (my husband was told in my presence: “she is inadequate, do not listen to her”, “you will either lose a baby or will get a disabled wife”, “why did you even come, you could have stayed at home”). They pressurized with their status and shamed me "A head of the department is in front of you and you behave like this” (meaning that I was not consenting for interventions). Manipulation - "we will now inject you with “Oxytocin” and you will birth in half an hour, why suffer?" They said that when … the shift was approaching its end”.

Maryana: “As I was pushing they threatened taking forceps a couple of times if I do not birth immediately. They pushed on my belly, pushing the baby out on contractions, paying no attention to my protests. And insisted on birthing lying on my back”.

Do women report having things done to them without anybody telling them first or asking for their permission? (e.g. breaking waters, episiotomy, C-section?)

Women complain that this is happening all the time. Most often, they mention amniotomy and episiotomy. In addition, this often happens right after birth, procedures with a newborn are rarely discussed with a mother. Our Survey 2016 respondents shared the following:

Anna: “A woman came in with some medications. I asked her politely what that was. And she replies: “Mummy, have you been born under the cart?", snorts and goes away. After another half hour, a doctor came and administered a medicalized sleep without asking neither the woman nor myself. A woman was in a quiet state, quite conscious. But the doctor under the conditions of this medicalized sleep started to manually detach placenta that would have come out naturally and to suture small tears that would have healed on their own. Money has been paid so he had to show that he has worked well for that money, even though it all looked like a big theater of absurd“.

Elena: “I have let the doctor know that I wanted to birth by myself (but I was answered that if I am an aircraft technologist I should deal with those issues, while birth – is their business). And my birth went normal (the overall length was 7 hours), and yet I received all the standard medical interventions: an IV in my vein (just in case), my amniotic sac was broken, they gave my “glucose” (I was never informed of what was that medication despite my constant questions. When I told that I felt cold, they added something the IV without any warning and I started having fever), the baby was being «squeezed out» before the pushing has started, the cord was cut right away, the baby was taken away from the mother for several hours after birth, I got an “Oxytocin” injection in the third stage, which is routinely done to everybody, again just in case”.

Yulia: “I was given injections without my consent, they’ve placed some receivers on me, many people were running around me and really bothering me. I did not have even a minute to be alone and I really lacked it. The birthing clinic did not help me with the birth in any way, on the contrary, they tried to speed the process up in anyways, as for the personnel it is a conveyor (my birth was 1.5 hours long). There were too many medical interventions and negative results from them afterward”.

Yevheniya: “I gave birth in three pushes and with no tears, but an intern at the birthing clinic made a very painful checkup after the placenta has separated, even though placenta came out nice and full. … My consent was not asked for. And I could not resist due to the special state of consciousness – my baby girl was lying on my tummy. So I just wriggled and cried in the process, and then remembered the wild pain (not from labour, but from that checkup) afterward”.

Yuliya: “A nurse was rude: when she was taking my blood for some test, I started having a contraction and I said “wait”, to which she has replied that she has no time to wait. It was good that the doctor has sided with me and asked her to wait. I do not remember what test that was but I think I had the same test results in my clinical files. Then I was given douche and in response to my shy “maybe I can without it”, they said, “You have to do it”. At the same time, they gave me the paper to sign consent for the active third stage management. And I had to sign it blank, without the doctor’s name indicated on it. But I objected and insisted on knowing the doctor’s last name. Back then I did not know yet that if I was asked to sign a consent I could have refused to do so. Otherwise, I would not have signed it. During the first days after birth, they took blood from a baby as well (put his blood on a piece of paper), in response to my question about that test they said, “Everyone does it”.

5. Accountability/Redress

What avenue for redress is available to women if their right to informed consent is violated?

To restore justice women can approach “a head of the medical department” who is usually charged with dealing with conflict situations. Besides it is possible to complain to the head of the maternity hospital, the Ministry of Health, President’s Advisor on the Rights of a Child, ombudsperson, mass media and international organizations. Yet the experience of women who did all that shows an extremely low efficiency of such methods. As Anna shared: “It is possible to appeal to the court, but a lawyer has told me that the probability of a positive result is 10-15%, while the emotional costs will be huge”.

Speaking of the internal control over informed consent matters like the maternity hospitals oversight of the doctors for them to respect this women’s right – it is only done formalistically. Head doctors care for the papers to be signed, not the women’s needs to be met. This is especially true when complicated interventions are planned – in those cases signatures are being collected meticulously, which nevertheless does not mean that information is given in a same careful manner. Thus maternity hospitals’ leadership is a very doubtful source for restoring justice in the case of informed consent violation. The intra-doctoral and intra-hospital loyalty is extremely high in Ukraine, and women have practically no chance to uphold their rights by approaching a head doctor with a complaint about his subordinate.

Does the legal system provide meaningful accountability for violation of the right to informed consent?

There is no direct sanction in the legislation to be used against the doctor who has violated the right to informed consent. According to article 43 of the Law of Ukraine “Fundamentals of Health Care Legislation of Ukraine” doctors have to comply with the patient's right to informed consent and thus this is part of doctors’ professional responsibilities. Failing to perform one’s professional responsibilities may result in disciplinary sanction such as a warning or firing according to Article 147 of the Labour Code of Ukraine. Yet, we know of no cases when a doctor would have been anyhow punished in the case of violating the informed consent right.

According to the law “On Citizens’ Appeals,” a woman has a right to appeal to an above-standing authority, for example, a chief doctor or the head of the department, with an oral or written complaint against the actions of a doctor responsible for her pregnancy or birth, or any other medical personnel. Such appeals have to be responded to within 45 days. Besides, according to the MOH of Ukraine Order No. 292 (from 10.04.2013), a woman has a right to appeal to the Ministry of Health directly using its official phone line that operated at certain hours.

Diagram 9

Does anything happen if their rights are violated? What?

Diagram 10

We do not know of any case when a doctor would be criticized or punished for violating a woman’s right. Therefore many women do not even try to seek justice restoration. As Olha shared: “I did not want to waste my nervous system”.

Other participants of our 2016 Survey add similar stories:

Yulia: “I tried to restore justice by at the level of complaints to the ob/gyn and the chief doctor. But since I did not have any negative health consequences, nor did my baby, I decided to not proceed with justice restoration as I probably saw all those people for the last time in my life”.

Tatyana: “Establishing justice is next to impossible in our country. And to prove doctor’s guilt is unrealistic. This requires a huge amount of money and effort”.

Elena: “I do not want to fight with medical institutions with a baby in my arms. Nothing will change. And stress can cause breast milk disappear”.

Anastasiya: “I have no idea how justice can be restored with respect to the sudden use of the forbidden Kristeller maneuver, or with respect to early cord clamping, since this is not recorded and therefore it cannot be proved. The same with respect to multiple vaginal exams on contractions (a very painful procedure), they’ve occurred during labour, it was late to change the birthing clinic, and there was no trust to other doctors”.

Liliya: “I wrote a letter to the regional department of health care and to the chief doctor of the birthing clinic. And I received formalistic answers that were in line with their regulations”.

Oksana: “I appealed to the chief doctor, but it turned out that it was all a unified system and it is supported by all the personnel”.

Marina: “I constantly explained my stance to the doctors and insisted on it. But at the end, I just had to flee the hospital with my kids (twins) when my strength to fight were over. I see the only solution – to birth at home”.

Part 2. Midwifery and Out of Hospital Birth

Midwives in the Hospital

Are midwives central to hospital maternity care? What is the role of the midwife in the hospital?

The official job description of hospital midwives contains numerous competencies and responsibilities:

Source: Ministry of Health of Ukraine. Order No. 620 “Organization of Inpatient Obstetric and Neonatal Care in Ukraine”, 2003

Thus the official status of midwives is quite high, yet in practice, they play a secondary role in a hospital setting. Midwives are working in Ukrainian maternity have little power and play a secondary role in childbirth. In practice, hospital midwives predominantly take care of filling out documentation, monitor fetal heart rate, help the head and body out after crowning, perform the episiotomy, and suture perineal tears of I-II degree, as well as monitoring a woman and a newborn in the delivery room.

In contrast, doctors play a major role in childbirth. They are responsible for pregnant women, birthing women and newborns according to the law.

Who provides the care in hospital births for low-risk women? Who is responsible for overseeing care for low-risk women?

According to Ukrainian protocols, low-risk births can be attended by either obstetricians or midwives. In reality, however, births are led by obstetricians in all cases regardless of the risks, with the exception of maternity wards of peripheral hospitals, or at nighttime when obstetricians may be absent.

Are midwives able to support women in physiological childbirth without any intervention in the hospital?

This is very rare, in exceptional circumstances, for example, if the doctor was not able to come: either in the case of a peripheral hospital, or a very fast labour, or a case when a doctor had to be elsewhere.

Does the woman know who will be attending her birth beforehand? Can she influence/ choose who attends her?

According to the legislation, a woman can freely choose her doctor, freely choose the method of treatment based on the doctor’s recommendations, to replace a doctor, to receive treatment abroad if such treatment is not available in Ukraine [4].

According to the 2015 survey, 67% of pregnant woman chose a doctor for the management of their childbirth.

Midwives out of Hospital

Is out-of-hospital birth a normalized and integrated healthcare choice in your nation?

Out-of-hospital childbirth is not part of the healthcare system of Ukraine. Midwives who help women in homebirths work outside the legal field. At the same time, there is no direct prohibition for women to birth outside of the hospital setting.

Homebirth midwives work under a constant threat of criminal responsibility in case of a complicated birth. If everything is fine with the mother-baby there is no one to sew them. Yet, if anything goes wrong, a homebirth midwife can be charged with responsibility.

Their professional activity is not licensed. This bears negative consequences both for the midwives and those they serve. Personal communication with Kyiv-based homebirth midwives reveals that at the current stage they are ready and willing to be openly registered and licensed. The bottleneck now is, therefore, the state’s willingness to cooperate.

If a midwife has medical education and works in a homebirth setting with no complications it is hard to make her criminally responsible. According to the Criminal Code of Ukraine (article 139), a midwife with medical education is obliged to help in childbirth if she finds herself near a birthing woman. On the other hand, she is not allowed to charge for that since in such case her activity can be seen as entrepreneurship without a license. According to article 164 of the Civil Code in the situation described, a midwife should be charged with a fine, payment confiscation and confiscation of her medical equipment.

If a homebirth midwife has a medical education but her actions during birth led to severe negative consequences for the mother or baby she risks being charged with a criminal responsibility according to article 140 of the Criminal Code of Ukraine, specifically imprisonment, freedom of movement limitation or correctional labor for the period of 2 years.

Homebirth midwives without a medical education risk being charged with the same civil responsibility according to the article 164 of the Civil Code, as well as criminal responsibility for unlawful medical activity. If a homebirth administered by a midwife without a medical education resulted in a poor outcome, the charge is correctional labor for the period of 2 years or freedom limitation or imprisonment for the period of up to 3 years.

At the same time, the medical system recognizes that homebirths do occur and in 2013 the Ministry of Health of Ukraine has legally defined the procedure of issuing birth certificates to children born outside of maternity hospitals [5]. According to this document, a medical committee consisting of 5 doctors considers the submitted documentation and attests the fact of birthing a child by a woman outside of a medical facility and issues a medical certificate needed for a state birth registration. Unfortunately, this new regulation has made the procedure of registering born at home children more complicated. Commenting on this new regulation Elena said: «…in order to register a homeborn baby I have to PROVE that I have birthed this baby. Even though I was registered at the prenatal clinic, had my pregnancy papers filled out, had a due date identified which coincided with the actual birth, even though I am breastfeeding this baby, there are dozens of witness that can confirm the fact of my pregnancy and even birth, existence of photo- and video-materials? I am obliged to go through a medical committee, tests, check-ups, which I consider unacceptable during a postpartum restoration period, in order to prove that my baby was born by me. And I have to do all this during a month after birth, otherwise, I will be charged with a fine. This is at the time when my baby needs my care so much during the first days of his life and that his health depends on mother’s state of mind».

There are no birthing centers focused on physiological birth for the low-risk women in Ukraine.

Do midwives work outside the hospital? In large or small numbers?

Since homebirth midwives do not work openly and do not cooperate with the state, it is hard to know the exact number of practicing homebirth midwives in Ukraine. The only data that is available to us is that there are about 20 homebirth midwives working in Kyiv – the capital of Ukraine and other location in Central Ukraine. There are also some homebirth midwives working in the East of Ukraine, but almost no such midwives in Western Ukraine. Among the midwives that took part in our 2016 Survey - to estimate the number of homebirth midwives in Ukraine to be up to 50 and two others as it being between 50 and 100.

The attitude of the official medical system is very negative towards the idea of homebirth and homebirth professionals and they often criticize homebirth in media.

The overall number of homebirths in Ukraine is estimated at the level of less than 1%. Our Survey 2015 showed that out of 3,500 participating women only 208 (0.2%) birthed at home.

Home birth support is conducted in a spontaneous manner and according to our Survey 2015 only 36% of homebirths were assisted by a midwife or a doctor, 12% were assisted by a person with no medical education, 46% were assisted by a woman's partner, and 6% of responding women birthed a child without anyone's assistance.

Do you know of any midwives in your system facing criminal sanction for charges associated with out-of-hospital birth? What has happened in their cases?

Elena, a midwife from Dnipro reports that a midwife Eleonora Groisman had to leave Ukraine after she was charged with a criminal accusation. Her case remains open at the moment. She has also shared that she knows at least 2 Kyiv-based midwives were called to the prosecutor’s office for interrogation.

And a Zaporizhzhia-based midwife Valentina describes two other cases:

(1) “On June 30th 2009 a birthing woman went to the maternity hospital #4 in Zaporizhzhia and mentioned that she had a homebirth midwife with her at home. The head doctor has demanded a phone number of that midwife and has made a written report on this to the police and the prosecutor’s office. That midwife was called to the police and the prosecutor’s office several times but eventually, the criminal case was closed as they lacked proofs of her guilt”

(2) “A midwife Elena, that worked in a birthing ward of the Cherkassy regional maternity hospital was de facto fired after a chief doctor has found out that she has helped a woman in a homebirth. She was forced to quit job “by her own will” under the threat of facing criminal investigation and having her medical degree annulled”.

Does health insurance or the state health system pay the costs of out-of-hospital birth?

There is no state coverage for out-of-hospital birth.

Safety and Integration of OOH Birth

Transparency and Communication

If a woman chooses out-of-hospital birth, can she count on open and respectful communication between her midwife and any hospital-based medical providers she may see during the pregnancy?

The medial system representatives have a strongly negative attitude to planned out-of-hospital birth. The friendly attitude at the arrival to the hospital is only possible in cases of unplanned OOH birth. Unfortunately, due to this expected unfriendliness, women try to transfer to the hospital as late as it is possible, only when a mother of a baby needs some very urgent help. This also leads to the reinforcement of the negative attitude to homebirth.

Can she count on them being able to openly share test results and communicate about her care?

This is only possible in very rare, exceptional cases.

In the event of transfer to the hospital during a home birth, is there usually open and respectful communication from the backup hospital team toward the midwife?

In the Ukrainian legal context even if a midwife accompanies a woman during a transfer to a maternity hospital she does not identify herself as a midwife, nor she informs that the was an attempt to give birth at home. Elena, a midwife from Kyiv shared: “In most cases, the medical personnel treats persons accompanying a birthing woman with no respect”. And another Kyiv-based midwife Svitlana also added that such open and respectful communication “is rare even with respect to the birthing woman and her husband”.

Do hospital staff listen to the midwife, share files and information and communicate respectfully in the event of a hospital transfer?

Elena, a midwife from Kyiv reports that “medical personnel does not share any information telling that that is not in their responsibilities. This is only possible if there is some personal connection between the homebirth midwife and the hospital personnel.” Sveta, an obstetrician from Dnipro reports the same information.

Serving OOH Healthcare Needs

Are emergency medical responders/ ambulance workers trained and equipped to assist a home birth transfer and/or to resuscitate a newborn?

Perinatal centers have special ambulance cars to transport newborns between hospitals. Medical personnel working on the general ambulance cars are not always ready to help in newborn resuscitation. They are not trained in newborn resuscitation and are not equipped, therefore they are afraid of homebirths.

Have women reported unequal, discriminatory, or punitive treatment after transferring to a hospital for care from a planned out-of-hospital birth?

Yes, women tell those stories regularly (Sveta, midwife, Kyiv, about 10 transfers in her experience).

Elena, an obstetrician from Dnipro shared that in her experience “the medical personnel is the most unhappy with the whole situation because for them such a patient is an extra «headache». For example, when I worked in a Dnipro maternity hospital and a woman came with severe bleeding after a homebirth, we were busy about saving her life first. Sure, in the process of saving, medical personnel could say unpleasant things to the father like "Why so late? What have you been thinking?" She has not met any blatant humiliation personally, although she remembers hearing about that” (2 transfers in her experience).

And a Kyiv-based midwife Olha shared that she has witnessed or heard of “psychological pressure towards the woman in cases of here refusal from procedures with the use of additional personnel, prescribing her antibiotics without any indication for that, misinforming a woman that a physiological arousal of the temperature postpartum is «because of the home-birth», ignoring the requests of a woman to make a loose stitch as she could not bend freely after an extra-tight stitch made after the episiotomy in the previous birth”.

Valentina, a midwife with 23 years of homebirth experience from Zaporizhzhia said that “Only once they treated a woman in a respectful and friendly manner, while in the rest of the cases she was met with aggression, humiliation, and threats that she will not be provided with medical care” (3 cases of transfer in her experience).

Regulation, Integration, and Safety

How does the state of regulation and integration for out-of-hospital birth affect the women’s choice for OOH birth? Do they still choose it?

Birthing women in Ukraine have no medical support outside of hospitals. Midwives are afraid to work at homebirths due to the risk of civil and criminal charges. In addition, many mothers do not feel safe for their children due to the lack of connection between homebirth midwives and maternity hospitals. This whole context infringes women’s right to choose the place of her delivery. All 6 midwives that took part in our 2016 survey agree that the existing policy forces women to birth in maternity hospitals, even though some women still opt for a home delivery.

Homebirth midwives cannot openly advertise their services, registering homeborn children is not very easy, homebirth is not integrated into the medical system overall and is seen negatively by the medical personnel.

For instance, Yulia shared that she had to birth in a maternity hospital, despite her desire to birth at home «because there were reasons to expect difficulties with registering a homeborn child at the place of residence, while there was no possibility to birth at home at the place of state residential registration. So birthing at home would mean the same war with the state system but after birth. I would have needed to explain my choice everywhere, collect a million of papers to register a child, maybe even hear some condemnation of my choice from strangers. The big money that we paid to the maternity hospital was not for medications, not for the personnel's work, not for comfort. These were the money paid for the paper that allowed me to register my baby easily».

Nevertheless, the number of planned home births has been growing in the recent years in Ukraine, even though still less than 1% of women choose to give birth at home.

Fortunately, according to the 2015 Survey out of 208 home birthing women, only 4 women (2%) had to go transfer to the hospital from their homebirth and they have received the necessary help over there.

Our 2015 survey suggests that 18% out of 3,500 respondents would prefer to birth their next child at home, accompanied by a certified, professional midwife, and given that homebirth was a part of a medical system.

How does the state of regulation and integration for out-of-hospital birth affect the safety of OOH birth?

Lack of legal framework and integration with the state health system does not allow reaching a high level of safety in home birth in cases of emergency. All six midwives that took part in our 2016 survey agree with this. The specific elements of this problem include:

• The lack of cooperation between homebirth midwives and maternity hospitals.
• The absence of ambulances equipped for transportation of mothers and newborns.
• The absence of midwives’ education control.
• The absence of necessary equipment and drugs for emergency treatment.

Why women keep on choosing OOH birth in Ukraine?

Despite the lack of integration with the medical system and lack of safety in relation to that, some women still choose home birth as the maternity hospital alternative has many significant faults.

A midwife from Kyiv, Olha, has shared that women still choose homebirth “because birth is a spontaneous, instinctive, physiological process. Birth does not require medical, and even less medicalized intervention. Birth does not need to be anesthetized, speeded up, helped etc. This is a process that belongs to the motherbaby”.

A Dnipro-based obstetrician Elena added that women a afraid of “unnecessary interventions, incompetent doctors, rude attitude on the part of the personnel, impossibility to influence the process, ignoring the parents' wishes regarding the level of medicalization, intervention, cord clamping, third stage management, and procedures with the newborn, as well as bad experience with a previous hospital birth and impossibility of a vaginal birth in a hospital (previous cesarean, poor eyesight, breech etc.). Women want comfortable conditions that would help labour and not jeopardize it”.

Sveta, a midwife from Dnipro:

“Because in a maternity hospital it is impossible to receive the same emotions, same joy and pleasure from birth because of a routine obstetric violence”

Alina, an obstetrician from Kharkiv: “Because of the fear of maternity hospitals and out the willingness to birth without medical interventions”.

Mothers provide similar reasons. For example, Julia shared: «There are many small moments that make up a picture of general misunderstanding. For, instance, in order to be discharged from the maternity hospital, a woman has to undergo a check-up. This check-up is done of a different floor of the maternity hospital and all the postpartum mothers go through it at the same time. So the line-up takes no less than 40 minutes. All this time the baby is alone on the other floor. … This is not normal. … A baby must always be with his mother».

Conclusions

Informed Consent

Ukrainian legislation presupposes the right to informed consent and refusal in line with international standards. Doctors are obliged to obtain women’s informed consent before any kind of medical interventions during diagnostics or treatment in pregnancy and childbirth.

This right has been proclaimed about 6 years ago and yet till now, the majority of doctors have not changed their practices to accommodate this new standard. At the moment this right is rather a formality, it has not yet become a meaningful instrument to promote women’s interests.

The practical realization of the right to informed consent and refusal is also jeopardized by a contradictory ruling with respect to women’s possibility to take a partner to be with them in birth. Partners can be potential witnesses of the informed consent and refusal violations, yet at the moment it is not always possible to take a partner into a birthing facility. Although according to the law a woman can be accompanied by 2 supporters, the law also allows space for the chief doctor to have a final say on who can attend, when and in which quantity [6].

Midwifery

OOH birth is outside of the medical system in Ukraine. Homebirth midwives constantly work under the risk of criminal charges in case of a complicated birth. In Ukraine, doctors hold the leading position in administering birth. Midwives that work in maternity hospitals are part of the medical system, but they have limited responsibilities and play a secondary role in the process of birth.

Doctors treat planned homebirths in a strongly negative way, they consider them dangerous and often criticize them in media and talking to women. Homebirth midwives cannot count on cooperation on the side of medical personnel, rather condemnation and appeal to the prosecutor's office and social service is more probable.

Today planned homebirth is unusual in Ukraine and according to our estimates, happens in about 1% of births.

And yet, Ukrainian women have a need for this kind of a medical service. A survey of over 3,500 Ukrainian women showed that every 3rd woman (35%) would like to birth her next child in a birth center where birth would be accompanied by midwives only. And almost every fifth woman (18%) would prefer a homebirth with a certified professional midwife.

Lack of legislative base and integration with the state health care system prevents achieving the highest possible standard of safety for homebirth in Ukraine.

This status quo represents a fertile field for human rights organizations in Ukraine to implement the midwifery model of administering birth.

In general, legal regulations with respect to patient’s rights and natural birth are in line with international standards and include the right to informed consent, non-medicated delivery, right of free movement and position during labour and many others. A more progressive perspective on obstetric care was reflected in the 2003 Ministry of Health Order, which ordained “to treat a woman, a birthing mother, not as an object of medical practice to execute delivery, but as an individual and the main participant in the important moment in her life – childbirth” [7].

Yet, an exception from quite extensive birthrights is the impossibility to choose one’s place of birth and the only official option being birth in a maternity hospital. The majority of those maternity hospitals are public, and three are privately owned in Ukraine. Yet, even those private facilities follow the same birthing philosophy and practices as the state-run ones. Thus, the women of Ukraine have a very limited choice.

Despite having many rights on paper, women, as well as the medical personnel are not aware of them and are not used to practicing them. Even those who know of some of those rights are not used to exercise them and those who dare to do so usually face resistance and humiliation from the medical personnel.

Some maternity hospitals in Ukraine that participated in the New Perinatal Technologies Project and bear the title of being “Mother and Child friendly” are committed to the principles stated in the more recent ministerial orders, and indeed they witnessed improvement of mothers’ and babies’ health outcomes as well as saw more women satisfied with their birthing experience.

However, in recent years, a certain backlash to obsolete, rigid, aggressive and medicalized obstetric technologies has also happened. The past experience of obstetric aid system reformation has shown that the absence of safe alternative to the delivery in maternity hospitals for a woman and inadequate load for doctors, who have to be on duty day and night and supplement their salaries by accompanying deliveries outside regular hours, lead to the return of a routine medicalized approach. Many physicians wish to accompany deliveries at a time, which is convenient for them, so they induce labor. Moreover, a woman at birth does not know about the medical interventions most of the time. Obviously, it is impossible to change such state of things without altering the whole system.

According to the modern research of different models of obstetric care systems in the world, it may be concluded that the most optimal model that allows preserving the health of the nation to the greatest possible extent, is the system that harmoniously combines the following three variants of obstetric care:

1. Hospital delivery for women of high and medium risk.

2. Delivery in birth centers within hospitals or close to them, accompanied by midwives only; in case of emergency, a woman at birth and a newborn can be transported to the hospital.

3. Home birth, accompanied by highly professional certified midwives for women at low risk (mostly subsequent childbirth) [8].

As of today, Ukraine has succeeded only with the first clause, creating large-scale, high technology perinatal centers, designed for women at birth at high risk. However, modern Ukrainian system of obstetric care cannot provide the majority of women with no contraindications, especially women with subsequent pregnancy, with proper conditions for their deliveries. Indeed, the majority of maternity hospitals have individual comfortable family-type delivery rooms. Nevertheless, normal deliveries are still accompanied by ob/gyns, initially trained to deal with pathological processes, and that often causes an iatrogenic effect and leads to groundless medical intrusions.

It is no wonder that the number of planned home births is growing in modern Ukraine. It is mainly conditioned by unwillingness of women to interact with the present rigid system of obstetric care that disrespects women at birth, their right of choice, regulating the interaction of mother and child during the period of their stay in the maternity hospital, but first of all, and endangers the health of mothers and children.

However, Ukrainian women have no safe alternative. In case of any complications during homebirth, a woman either faces an utterly negative reaction of medical staff at the healthcare institution, where she seeks assistance. Such situation infringes on the right of women to choose the place of her delivery, and one of the fundamental rights of a person – the right of women and children to receive emergency medical aid.

Afterwards, when applying for the certificate of birth after the homebirth, a woman has to spend the most precious time for being with her child and establishing child and parent relationship, on gathering the enormous amount of bureaucratic documents and undergo humiliating medical examinations up to DNA testing. All this can be changed for the better, if women have access to comfortable childbirth centers, where deliveries would be accompanied by midwives, as well as to homebirths, accompanied by highly professional certified midwives and supported by the state. In the post-Soviet realm, such system already exists in Poland and Latvia and we believe that Ukraine would benefit from following their example.

Some women also find the childbirth situation in Ukraine to contain elements of gender discrimination. Men statistically seek medical care less often and they are not pushed by the legislation to hospitalization related to fulfilling their reproductive functions.

Given the above-mentioned context, we are committed to working towards establishing the three-level maternity care system in Ukraine and invite international actors to mentor and support us in this work sharing the experiences that you have gained in your countries. We also invite supporters from within Ukraine to join us on this mission.

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• birth centres networks,
• sponsors/grantors, and 
• international organizations

for mentoring and investing into starting a Birth Centres Network in Ukraine

• 36% of mothers wish to give birth in a birth centre
• 18% of women strive for homebirth with a licensed midwife
• since 2014 a national health care policy has headed to European values (protocols)
• no alternative for a hospital birth

• scaling up of your activities
• prerogative in this pilot project
• significant contribution to support and protection of maternity and childhood
• considerable commercial potential

For fruitful collaboration, please contact us at proestrofest.info@gmail.com.

Miracle in the Heart project supported the flash mob “YES” to Birth Centers in Ukraine!” in Kyiv in 2015, and initiated and conducted the flash mob “Tell about your ‘Perfect’ Birth Experience in a Maternity Hospital to the Minister and Offer an Alternative!"

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References 

Civil Code of Ukraine

Criminal Code of Ukraine

Davis-Floyd, Robbie E., Lesley Barclay, Betty-Anne Davis. 2009. “Birth models that work”, University of California Press.

Labour Code of Ukraine

Law of Ukraine “On Citizens’ Appeals”

Ministry of Health of Ukraine (MOHU) 2003. Order No. 620 “Organization of Inpatient Obstetric and Neonatal Care in Ukraine” from 29.12.2003, available at http://www.moz.gov.ua/ua/portal/dn_20031229_620.html

Ministry of Health of Ukraine (MOHU) 2007. Guidelines on the Organization of Prophylactics with Respect to Intra-hospital Infections in Midwifery Departments, Order No. 234 from 10.05.2007, available at http://www.moz.gov.ua/ua/portal/dn_20070510_234.html

Ministry of Health of Ukraine (MOHU) 2008. Clinical Protocol of Midwifery Care “Normal Delivery”, Attachment 2, issued by Order No. 624 from 03.11.2008, available at http://www.moz.gov.ua/ua/portal/dn_20081103_624.html

Ministry of Health of Ukraine (MOHU) 2012. Guidelines for filling out the form of primary records documentation # 003-6/o, issued Order No. 110 from 14.02.12, available at http://zakon5.rada.gov.ua/laws/show/z0697-12

Ministry of Health of Ukraine (MOHU). 2013. «The order of confirming the fact of birthing a child outside of the healthcare facility», MOHU Decree No. 9, November 9, 2013, available at http://zakon2.rada.gov.ua/laws/show/9-2013-%D0%BF

Ministry of Health of Ukraine (MOHU). 2013. Order No. 292 from 10.04.2013

Verkhovna Rada Ukrayiny (VRU) [year to be added] The Law of Ukraine “Fundamentals of Health Care Legislation of Ukraine”, available at http://zakon2.rada.gov.ua/laws/show/2801-12/page2#n334

[1] … while the average monthly salary in Ukraine is 210 US dollars

[2] Verkhovna Rada Ukrayiny (VRU) [year to be added] The Law of Ukraine “Fundamentals of Health Care Legislation of Ukraine”, available at: http://zakon2.rada.gov.ua/laws/show/2801-12/page2#n334

[3] According to the Ukrainian legislation, doctors are obliged to obtain the oral consent of the patient before any diagnosing, treating or preventive actions, with the exception of the cases of danger to mother or baby's life or health. If a woman’s refusal may lead to severe consequences for a woman or a baby, a doctor has to explain that to a woman. If after that a woman still refuses the intervention a doctor has a right to obtain a written refusal from her, and if that is not possible – to ask witnesses of that refusal to document it (articles 34, 43 of The Law of Ukraine “Fundamentals of Health Care Legislation of Ukraine“). As a woman is admitted to a maternity hospital, she has her medical record opened containing the form «Voluntary informed consent of a patient to diagnostics, treatment, surgery, and anesthesia». According to the guidelines, a woman has to fill out that form herself in the presence of her doctor. During this time, a doctor is supposed to inform a birthing woman of a birth plan, various options of managing labour and consequePresented at the Europeans of woman's lack of compliance with doctor's recommendations (Guidelines No. 110). Also as the woman is being admitted to the maternity hospital for a planned vaginal birth she has to receive a form of informed consent to the active third stage management (Clinical Protocol No. 624). Medical personnel is also responsible to provide a woman with readily available information on her and her baby's health, explain the reasons for offered interventions and risks to life and health (article 39 of The Law of Ukraine “Fundamentals of Health Care Legislation of Ukraine“).

[4] Civil Code of Ukraine (Art. 284, part 2; 633); Law of Ukraine “Fundamentals of the Health Care Legislation in Ukraine” (Art. 6, part "d"; 34, part 1; 35, part 1; 36; 38).

[5] «The order of confirming the fact of birthing a child outside of the healthcare facility», Ministry of Health of Ukraine decree # 9, November 9, 2013, available at http://zakon2.rada.gov.ua/laws/show/9-2013-%D0%BF

[6] Ministry of Health of Ukraine (MOHU) 2007. Guidelines on the Organization of Prophylactics with Respect to Intra-hospital Infections in Midwifery Departments, Order No. 234 from 10.05.2007, available at http://www.moz.gov.ua/ua/portal/dn_20070510_234.html (Article 2.6)

[7] Ministry of Health of Ukraine (MOHU) 2003. Order No. 620 “Organization and Inpatient Obstetric and Neonatal Care in Ukraine” from 29.12.2003, available at http://www.moz.gov.ua/ua/portal/dn_20031229_620.html

[8] Davis-Floyd, Robbie E., Lesley Barclay, Betty-Anne Davis. 2009. “Birth models that work”, University of California Press.