© Translated by Maria Stoilkova
On International Women’s Day, we focus on human rights in childbirth. Rarely discussed, the issue touches the lives of over 60,000 women in Bulgaria and their families every yearл
As a topic that remains unspoken mainly, women’s birthing rights should speak to everyone!
The rights of the woman giving birth[i] comprise a separate domain of reproductive health rights. As such, this field has been systematically neglected and misunderstood in Bulgaria, both in the hands of institutions that must ensure the compliance of these rights and in the hands of professionals, who are expected to observe them as part of their professional responsibilities.
The Bulgarian Helsinki Committee has been monitoring the field surrounding birthing for years in Bulgaria. We are pressed to acknowledge the lack of significant positive development in this sphere.
As part of the review of the topic in the Annual Report on Human Rights for 2020, the organization encountered an alarming discrepancy in maternal mortality data that official institutions have reported for 2019.
Maternal mortality
The official data, published by the National Statistical Institute (NSI) in April 2020[ii], indicates that out of 61 882 births recorded in the period under review, zero maternal mortality was registered. However, according to the National Health Insurance Fund (NHIF)[iii], medical institutions have reported seven deaths in the category related to pregnancy, childbirth, and the postpartum stage during this same period. The Medical Surveillance Executive Agency (IAMS)[iv] states in an official letter that six inspections of such cases were carried out in 2019. Furthermore, the Ministry of Health has requested the expert council on obstetrics and gynaecology to analyze the reasons that have led to these cases of maternal mortality.
If we assume that the NHIF’s data is accurate, then the maternal mortality rate in Bulgaria for 2019 reaches up to 11.3 per 100,000 live births. Compared to the moderately stable trend of declining maternal mortality rates from the previous years, the latter is a worrisome jump as indicated by the previously recorded rates of 6.4 for 2018 and 7.8 for 2017, respectively. Furthermore, the insurer’s data would not reflect the births and deaths of patients for whom the Fund did not pay for treatment, which makes this advised rate a conservative estimate.
The BHC sent a request for clarification to the NSI concerning the published data and received an affirmative response that “in 2019 there were no cases of deceased mothers.” Clarifying how the data gets collected is instructive here to understand the discrepancy. The NSI draws information on the causes of deaths from medical death records. The form and content of the death notice are defined by Ordinance № 42 from December 8, 2004, by the Minister of Health, and the section that indicates the causes of death and other medical information is standardized following the recommendations of the World Health Organization (WHO). The medical personnel that ascertains death draws up the notice by filling in the part “medical death certificate.” The coding of the causes of death itself can only be completed by a physician working under the Regional Health Inspectorates.
Reflecting the above, the BHC submitted a signal to the Minister of Health, the Inspectorate of the Ministry of Health, and the Inspectorate of the NSI to investigate the reasons that had led to the omission to register or incorrect registration of deaths of mothers in 2019. Nevertheless, we also recognize that the lack of self-correction, pending today, and the inclusion of this data in official documents by the Ministry of Health, signal negligence of women’s birthing rights and lack of respect for the right of the highest rank – that of life itself.
Access to health care for pregnant women from vulnerable groups
For a consecutive year in 2020, the systemic problem concerning access to medical care for pregnant women from vulnerable groups failed to be reported. By law, uninsured pregnant women in Bulgaria are afforded access to health care under two regulations – the National Program for Improving Maternal and Child Health (NPIMCH)[v] and Ordinance 26/ 14th of June 2007[vi]. According to the Activity Report of the Ministry of Health[vii], in the first half of 2020, 2590 medical consultations and home visits were performed in the health counselling centres (HCCs) operating under the NPIMCH. The comparable number for the same reporting period in 2019 was 3 271.
Relative to the total number of HCCs and the number of workdays comprising the reporting period, each centre has carried out approximately 0.66 consultations or visits per day. This figure indexes a decline in the number of consultations performed by almost 25% compared to the previous year.
According to the National Health Insurance Fund[viii], 5837 uninsured women gave birth in the period between January 1 and October 31, 2020, under Ordinance 26, 2,412 women received the available by right obstetric and gynaecological examinations, and just over 1,200 women received one exam for blood and urine tests. What transpires from this record is that every second uninsured woman in Bulgaria gives birth without having had a single exam during her pregnancy, and 4 out of 5 women have not received a single test. The relative share of women covered by the activities under Ordinance 26 has not changed compared to the previous year in 2019. Accordingly, the data suggests that in 2020 on average, 8 to 9% of all mothers could not exercise their right to medical care during pregnancy.
Segregation
A 2016 study by the BHC showed that segregating mothers based on ethnicity is a standard practice in birthing institutions across Bulgaria. Hospital stay data revealed that the segregated mothers had a shorter average hospital stay than others. The BHC has filed a lawsuit against one of the medical institutions where this practice was recorded. In February, the Supreme Court of Cassation (SCC) prevented a cassation appeal[ix] against the decision of the Pazardzhik District Court (PDC), which confirmed the first-instance court’s rejection of the lawsuit on behalf of the BHC and the European Roma Rights Center.
Medical standards and quality of care
At the end of 2020, a draft Medical Standard in Obstetrics and Gynecology was proposed[x] to fill in for the missing document, previously repealed by the court in 2017. For the first time, the proposal introduces to regulate several long-established, internationally recognized, and scientifically proven good practices in maternal health care. Unfortunately, the proposal also appears shortsighted on the requirements and guidelines for achieving these goals, and if not all of them, at least some of the internationally recommended practices in the field.
The draft proposes the introduction of “viability criteria” for premature births. At the same time, fetuses born at an earlier pregnancy stage are registered as abortion if they do not survive for at least 72 hours. This requirement violated the rights of the newborn and was repealed by the SAC[xi] in 2016. Furthermore, there are no guidelines for overcoming the high proportion of invasive procedures occurring in the clinical practice in Bulgaria – oxytocin infusion, episiotomy, cesarean section, etc. – all classified as “violence” in a special report[xii] by UN Special Rapporteur on Violence against Women, Dubravka Simonovic. For reference, published in the summer of 2019, the report focused on the various forms of abuse endured by women during childbirth. Among them, in addition to the long-defined problems of verbal, psychological, physical, and sexual abuse against pregnant and childbearing women, a number of medical interventions were also highlighted, precisely procedures that are medically unnecessary or introduced without the informed consent of the mother. Characterized as abuse were a number of procedures considered controversial in their safety and effectiveness, such as the Kristeller manoeuvre and the needless and painful manipulations like the surgical suturing without anaesthesia.
Unfortunately, available records in Bulgaria show that in many maternity wards, practices and procedures in use often contradict the medical recommendations for safe and respectful care and the recognized definitions for violence during childbirth.
According to the NHIF, about 51% of singleton births paid by the NHIF in 2020 included cesarean sections. The WHO’s recommendations on using cesarian sections dictate that the method may benefit mothers and babies in up to 20% of deliveries. In all the rest of the cases, the risks associated with surgical delivery do not justify its use. Accordingly, this reveals that more than ¼ of all women in Bulgaria giving birth during 2020 have been subjected to unnecessary severe surgeries that carried medical risks for mothers and their babies and thus can be characterized as mistreatment. The absence of public record on how frequency other similar procedures are used, outlined in the report as abuse, hinders the proper assessment of the proportion of mothers affected. However, anecdotal data shows that it possibly exceeds 50%.
The financial incentive introduced in August 2020, which increases the cost of the clinical pathway for vaginal births over that for deliveries using cesarean section, is a step in the positive direction. However, it also raises the troubling question of why the scientific recommendations and the consensus on how women’s care addresses mistreatment during pregnancy and childbirth are not sufficiently respected in most Bulgarian medical institutions unless they are financially enthused.
Access to medical care and quality of maternity care in the conditions of COVID-19
The COVID-19 pandemic has confused the organization of medical care, including that for pregnant and postpartum women and children under one year of age. During the first wave of C-19 infections for the period from March 13 to April 21, 2020, immunizations and planned operative and therapeutic activities of health care providers were limited, following an order from the Minister of Health[xiii]. At the peak of the infection period, there were repeated signals that hospitals were turning back birthing women[xiv] or requiring them to have a recent PCR test.
The right that a woman in childbirth has not to be subjected to unnecessary invasive procedures, recognized as violence, was invalidated by public recommendations, coming from key health officials that demanded that all women give birth by cesarean sections during the epidemic. Such recommendations stood entirely at odds with the established scientific consensus on maternity and neonatal care[xv].
The analysis of the available data invites the general conclusion that the rights of women giving birth are not well recognized in Bulgaria neither by the institutions and clinicians in the field nor by the women themselves and their families. Bulgaria has a long way to go to offer this segment of women’s rights a worthy place in its legislation and practice.
[i] Human rights in childbirth https://www.bghelsinki.org/bg/articles/prava-na-rajdashtata-jena
[ii] NSI, published at 13. 04. 2020 г. https://www.nsi.bg/sites/default/files/files/pressreleases/Population2019_XE8MEZL.pdf
[iii] National Health Insurance Fund, information received under the Access to Public Information Act , issued number РД-19-51/ 31. 01. 2020 г.
[iv] Executive Agency “Medical supervision” information received under the Access to Public Information Act , issued number 93-00-6/04.02.2021 g.
[v] National Program for the Improvement of Maternal and Child Health 2014 – 2020, published at https://ncpha.government.bg/bg/2019-02-19-23-15-35/2014-2021
[vi] Ordinance № 26, June 14, 2007 On the provision of obstetric care to uninsured women and on the performance of research outside the scope of the compulsory health insurance for children and pregnant women, (OG – SG, issue 9 of 2014., in force from 31.01.2014), available at https://lex.bg/laws/ldoc/2135556407
[vii] Report on the implementation of the program budget of the Ministry of Health as of 30.06.20, published at https://www.mh.government.bg/media/filer_public/2020/09/01/otchet_mz_programen_30062020-2. pdf? fbclid = IwAR2cqRviVvP6RwAymgbSxac8iaTszBn4RC1ekrucybLNTGCyjzuKBdOX1w0
[viii] National Health Insurance Fund, information received under the Access to Public Information Act , issued number RD-19-489 / 29. 12. 2020.
[ix] Supreme Court of Cassation (2020). Definition № 80 of 14.02.2020, c. № 3932/2019
[x] Draft Ordinance for approval of the medical standard “Obstetrics and Gynecology”, published at https://www.mh.government.bg/media/filer_public/2020/11/10/akusherstvo_i_gunekologia.pdf
[xi] Supreme Administrative Court, Decision № 12295 / 15.11.2016 under Adm. Case № 6657/2016, First Chamber, available at http://www.sac.government.bg/court22.nsf/d6397429a99ee2afc225661e00383a86/0b945d77a4b74c5dc2258069004fe4cd?OpenDocument
[xii] Simonovic, Dubravka (UN. Human Rights Council. Special Rapporteur on Violence against Women) (2019), A human rights-based approach to mistreatment and violence against women in reproductive health services with a focus on childbirth and obstetric violence. Достъпен на https://digitallibrary.un.org/record/3823698?ln=en&fbclid=IwAR3COAA0-SSjqvZuGkO15yQx7RCWDJmD7TAW4GTdUBWrygT5T6y8PXbv9Sk
[xiii] Order of the Minister of Health, March 13, 2020, available at https://www.mh.government.bg/media/filer_public/2020/03/13/rd-01-124-vuvejdane-protiepidemichni-merki.pdf
[xiv] To visit four hospitals in three cities to give birth,” published on 16. 12. 2020 by news.bg – https://news.bg/regions/da-obikolish-4-bolnitsi-v-3 -city-to-rodish.html ; “Hospitals request negative PCR from mothers to accept them,” published on November 6, 2020 by dnes.bg – https://www.dnes.bg/koronavirus/2020/11/06/bolnici-iskat-otricatelen- pcr-ot-rodilki-za-da-gi-priemat.468674
[xv] Briefing of the National operational headquarters (NOH) of March 18, 2020, published by BNT on March 18, 2020 – – https://bntnews.bg/news/brifing-na-nacionalniya-operativen-shtab-8-chasa-nyama-novi-sluchai-na-zarazeni-s-covid-19-u-nas-1044131news.html
