Organization preparing the report: Birth House Association (Születésház Egyesület)
I. Goals and activities
Goals and activities of the Birth House Association (BHA): to protect and represent pregnant mothers, women giving birth, newborns and families, to work towards ensuring that the right to undisturbed, natural birth is accepted in law and in society, to protect and represent health-care professionals who offer assistance in undisturbed birth.
II. Background information
Hungary is not the only country in the world in which only a very small percentage of women have the opportunity to experience a natural, undisturbed birth free of interventions. With a few exceptions, hospital births involve the routine administration of oxytocin, artificial rupture of the membranes, episiotomy and elective caesareans. In addition, contrary to the recommendations of the WHO (which state that a proportion of no more than 15% of births should be by caesarean), in Hungary, one mother out of three gives birth by caesarean section.
In Hungary, it is estimated that between 200 and 300 women choose out-of-institution or homebirth. The majority of these women choose out-of-institution birth accompanied by a midwife because, based on their experience, they know that this is the best way to ensure an intervention-free, natural birth. As in other European countries, homebirth has never been illegal in Hungary. However, up until April 2011, homebirth was also not regulated. This has caused and continues to result in serious consequences both for families choosing homebirth and for those professionals assisting in homebirths (midwives and doulas). Although women have the constitutional right to choose the location where and the manner in which they give birth, those who have attempted to exercise this right have suffered from numerous types of negative discrimination over the last 20 years. Meanwhile, the newly-enacted legislation does not provide any guarantee that this will change for the better.
Midwives who wish to assist at home births must hold a permit. However, as there is no legislation governing their profession, they are in violation of the law if they assist at a home birth. Because of the absence of appropriate legislation, in 2009 a pregnant woman submitted a claim to the European Court of Human Rights in Strasbourg, alleging that the Hungarian state had violated her right to privacy by making it impossible for her to give birth to her child at home and by threatening assisting midwives with sanctions. The Court upheld her claim and ruled against the Hungarian state.
A factor further complicating the matter is that criminal proceedings were continually launched against midwives – even in cases that would have been considered normal in a hospital setting, such as greater than normal post-partum haemorrhage. In Western Europe, the actions of midwives are reviewed by their own professional forums. In Hungary however, cases are only reviewed through the criminal justice system, with the midwife named as the accused. One of the victims of the criminalization of homebirth was the internationally recognized proponent of homebirth in Hungary, Dr. Ágnes Geréb, who in October 2010 was placed in pre-trial detention for three months as part of a criminal proceeding against her. Despite having been released from detention – apparently as a result of pressure from national and international human rights organizations – Dr. Geréb still remains under house arrest for an indefinite period of time.
After a 20-year hiatus, legislation on homebirth was finally enacted and came into force on April 2011. Although the legislation is certainly an important step forwards, many of its provisions have been severely criticized by experts. For the purposes of the present report however, we will limit our discussion to a single provision. The newly-enacted legislation does not provide any guarantee that the criminalization of homebirth will not continue in the future. In the following, we will explain this concern in greater detail.
III. Sources of the violations reported
The following report of the rights violations is based in part on the first comprehensive study of homebirth in Hungary supported by the BHA and carried out in autumn 2010 by sociologist Gabriella Varró and in part on the cases encountered by the BHA’s legal assistance service.
The first Hungarian study on homebirth sought to find answers to the questions of who chooses homebirth and why, as well as what were the experiences of these women and families with health-care institutions and various state authorities.
Women choosing homebirth felt that hospitals could not offer them a calm and natural birth. It says a lot about the state of the Hungarian health-care system that half of the women had had negative experiences with hospitals, which was a factor strongly influencing their decision, or they objected to the manner in which births are conducted in a hospital setting. Thus, 90% of these women chose homebirth in order to avoid unnecessary medical interventions.
Based on this study which covered a great part of homebirths in Hungary (1095 homebirths), it can be stated that although the right of a woman to choose the place and manner of giving birth is guaranteed in the Constitution, women choosing homebirth are frequently exposed to the harassment of authorities and the reprobation of health-care institutional staff. Given that there was no applicable legislation, homebirth had to be carried out in secrecy and families choosing it were subjected to condemnation on the part of the various institutions and authorities involved. For example, when learning that a homebirth was planned, a certain number of doctors refused to provide care: 1 in 8 obstetricians in the case of antenatal care and 1 in 6 paediatricians with regards to examining the newborn.
The study showed that homebirth is severely criminalized in Hungary. The numerous instances of condemnation and harassment seriously jeopardize the chances of women to have an undisturbed birth. In many cases, the health-care system and the authorities treated homebirth as though it were a criminal offence. This is clearly shown by the fact that, when an ambulance was called to a homebirth, it was accompanied by a police car.
- Legal aid service
Because of the increasing number of criminal and other proceedings against women and professionals affected by homebirth in recent years, it was necessary to create a legal assistance service for them. In the course of our work, we offer assistance primarily to women, ranging from simple information via telephone to providing legal representation services. In addition to the criminalization of homebirth, the fact that women having chosen hospital birth have also begun to use the legal assistance service – although it was originally advertised among women choosing homebirth – also points to the failure of the Hungarian health-care system to take women’s needs and rights into consideration. In addition to the above-mentioned study, our one-year experience has demonstrated that the following types of rights violations are typical:
- refusal to register the birth of children born at home or unnecessary complication of the procedure, harassment by the staff health-care institutions and family services institutions towards women having chosen homebirth;
- intimidation of women having chosen homebirth or their family members and requiring them to testify as witnesses in disciplinary actions and criminal proceedings launched against professionals assisting in homebirths;
- intimidation and harassment of women choosing short-stay hospital birth (i.e. where the mother and child leave the hospital within a few hours after the birth);
- not fully informing women in the course of obstetrical care provided in institutions.
IV. Violations of rights
The Birth House Association would like to particularly highlight the following serious rights violations affecting women in the context of obstetrical care in Hungary.
By the criminalization of homebirth, we primarily mean that whenever complications arise in connection with a homebirth – and as there is no appropriate professional forum – these are invariably reviewed within the criminal justice system. In practice, this has meant that even in the case of very minor complications, the police launch an investigation in which they would press charges against the midwives (exclusively women) assisting in homebirths and interrogate the women and families concerned. Criminal proceedings with regards to hospital cases are, on the other hand, extremely rare, and generally lead to a finding of the civil responsibility of the hospital (not the doctor) for the payment of damages, as sought by the family in question. The double standard is obvious.
Our study showed that in many cases, the health-care system and the authorities treated homebirth as though it were a criminal offence. This is clearly shown by the fact that, in 10 cases where an ambulance was called to a homebirth, the paramedics immediately notified the police as well.
The legislation that came into effect on April 1 2011 does not remedy the above problem. The law does not address the issue of responsibility, meaning that the review of complications arising in the course of obstetrical care will still be handled through the old, criminalization-based system.
Another form of criminalization of homebirth is where proceedings are launched against the mother herself, or where she is threatened with such proceedings as a way of frightening her into abdicating her right to choose. Based on the study, we found that in two cases a hospital reported a mother for having – at her own risk – left the hospital with her child after a complication-free birth without having been officially discharged. We will address the issue of short-stay hospital birth in the following.
4.2. Violation of the right to be informed – prejudiced attitudes in health-care institutional staff
Under the terms of the Healthcare Act, a patient has the right to be fully informed of his or her state of health, as well as the right to be informed of and to make decisions regarding the procedures to which he or she is submitted.
Contrary to this, in the course of the study we found that 60% of the respondents who were transferred to hospital did not know what was going to happen to them and received no information whatsoever as to what procedures the doctor would be performing on them Although the study did not bear on women having originally chosen a hospital birth, the majority of complaints received by our legal assistance service are, as reflected by the above, connected with the violation of the right to be informed.
Apart from a few exceptions, women having chosen homebirth met with negative and prejudiced attitudes towards homebirth as soon as they began receiving antenatal care. Respondents questioned for the survey said that as soon as they revealed their intention to have a homebirth, 40% of doctors and 30% of nurses immediately became hostile towards the pregnant woman. That obstetricians condemn homebirth is shown by the fact that one in eight refused to provide antenatal care to such women.
Among the cases encountered by our legal assistance service is one relative recent one (April 2011) in which a woman planning a homebirth was called upon near the end of her pregnancy by a district nurse and family protection service staff member, who proceeded to threaten her that if she did not change her mind about the homebirth, her child to be born could be taken from her and put into protective custody. The two healthcare workers had downloaded a document from the internet listing only the dangers of homebirth which they gave to the mother in her last week of pregnancy.
In summary: the criminalization of homebirth and the prejudices of healthcare staff and professionals represent a real threat and harassment to women choosing homebirth. Although it is without doubt that the recently enacted law helps home birth to gain some recognition, prejudices and conduct stemming from them will continue to affect homebirth mothers for years to come.
4.3. Short-stay hospital births
In most countries (in most of Western Europe), short-stay hospital birth is not considered a rarity. On the contrary, it is an option guaranteed by law, meaning that after a normal birth, insofar as the child is healthy, both mother and child may immediately leave the hospital.“I went home six hours after giving birth. I had a disagreement with the doctor, who didn’t want to let me go home with my baby. Then the police showed up at our home at one o'clock in the morning because the head physician of the maternity ward had called them.” Excerpt from the testimony of one mother having taken part in our study.
4.4. Unnecessary obstetrical procedures, high caesarean rates
Based on a study by the Health Insurance Supervisory Board, in 2009 shaving was compulsory in 30% of maternity wards, enemas were compulsory in 20% while in eight institutions mothers in labour were not allowed to consume fluids. Out of the 61 institutions reviewed, 42 hospitals performed routine episiotomies even on first-time mothers. In 35 institutions, the mother was only permitted to choose the position in which she laboured, but not in which she gave birth. A large proportion of births in Hungary today end in surgery.
One indicator of the quality of births is the frequency of caesarean sections. The rate of caesareans appears as a quality indicator of hospitals worldwide. In 2007, caesarean rates in OECD countries ranged from 14% to 40%. Hungary’s rate of 30% is high even against the OECD average of 26%, and very high compared to the WHO recommendation of 15%. According to the NHIF’s statistics, caesarean rates nationwide have increased by 4.5% since 2004. In 2009, 46% of hospitals (33 institutions) had a caesarean rate even higher than the national average.
It is characteristic of the practice of Hungarian hospitals that after mothers having had one birth by caesarean will have all subsequent births by caesarean too. The approach may be covert or explicit, but the procedure – albeit lifesaving in certain cases – will be administered automatically.
Budapest, 01 August 2011
Dr Bea Bodrogi
President of BHA
(Homebirth in Hungary). The study can be accessed on the following site (in Hungarian only): http://www.szuleteshaz.hu/category/tanulmanyok/
 Healthcare Act of 1997, sections 13-14.
 In the UK, in cases of spontaneous vaginal birth, over 70% of mothers and newborns leave the hospital on the day of the birth or on the next day.
 Based on data from the National Health Insurance Fund.