The Committee has placed the issue on its agenda and held a hearing on 25th November. We were assured of the support of the Committee and they decided to keep the question open and get in contact with the Hungarian government in order to transpose the directive properly.
We would like to represent what the core regulations of the directive are and why Hungary failed to comply to them.
Firstly, the Directive refers to the professional competence of midwives and in abroader sense to their professional autonomy and independence. Secondly, it has relevance to those women who, based on exhaustive and objective information, would like to decide autonomously on where, how and with whom they want to give birth. This is absolutely important so that self-autonomy and the right to private life can prevail. In a former decision in a Hungarian case – known as the Ternovszky case – the European Court of Human Rights claimed that the choice of circumstances of giving birth is an essential part of the right of private life. The European Convention of Human Rights also declares the right to private life.
In the Hungarian healthcare system the real choice cannot be ensured because of the following facts:
The obstetric system is doctor-driven, medicalised and expensive. Although there is a state healthcare insurance which finances the cost of delivery, if a woman chooses her own doctor she has to pay a so-called „call charge” fee which is in fact gratitude money. Not to mention the fact that in such a case women have to pay several times for the - sometimes unnecessary – examinations during pregnancy.
- The general attitude is that pregnancy and birth is a process that needs the presence of a doctor and involves a series of interventions, in respect of which the decisions are mainly taken by the doctor, and women are pressed to accept them. This is a very important point, because informed consent should be the pillar of the modern healthcare system. It means that the care recipient can decide which interventions she accepts or rejects.
The survival of many children and mothers is due to the development of science and better hygienic and infrastructural circumstances. At the same time it has toemphasised that these interventions have not only lifesaving effects, but also risks and the possibility of complications. During labour, routine interventions are applied to the majority of women. According to the 2012 data some 6 in every 10 women are subject to episiotomy during vaginal deliveries, while the proportion of c-section is 35,1%. These data clearly show that this practice is well over the recommendation ofWHO.
Several international professional organizations have called attention to the importance of the profession of midwifery. I would like to cite two of them: the United Nations Population Fund (UNFPA) in its 2011 report declared that ”the service of midwives is extremely important for a healthy and safe pregnancy and delivery”. The World Health Organization (WHO) attributes special significance to the profession of midwifery in decreasing mother and infant mortality. Several research studies support the fact that a proper midwifery service entails less routine interventions, leads to higher mother contentment, and is less expensive.
In accordance with the above, article 42 of Directive 2005/36 states that the competence of midwives includes – among others – the following activities: diagnosis of pregnancies, and monitoring normal pregnancies, carrying out the necessary examinations, recognising the warning signs of abnormality which necessitate a referral to a doctor, conducting spontaneous deliveries, and examining and caring for the new-born infant. It means that the profession of midwives shall have autonomy, its own competence, and liability system.
In our petition we claim that Hungary does not recognise fully the activities of a midwife listed in Article 42 of the Directive and does not provide for the independence and autonomy of the profession. Both the regulation and the practice is at fault because a midwife practising in hospital has the possibility neither to monitor pregnancies nor to deliver babies within her own autonomous competence and liability. Independent midwives may attend deliveries which take place outside hospitals, but they may not monitor pregnancies at all – according to current regulations which are to be modified.
In Hungary 99% of women give birth in hospital, and therefore for the majority of women the right to choose is infringed upon as their pregnancy and delivery must be exclusively monitored by a doctor.
Although the Government has regulated home birth, allowing midwives to attend deliveries out of institutions, midwives cannot practise independently in hospitals.
To show the current approach the healthcare government considers midwifery as patient care.
Professions are given numerical codes, and midwifery activity both in and out of hospital is not considered as obstetrics and gynaecology but patient care.
This spring the Hungarian government has initiated professional debate regarding the modification of the current regulations on maternity care. All three organizations signing the petition have submitted detailed professional material based on this EU Directive. According to the Directive, the following shall fall within the competence of midwives: diagnosing pregnancy, monitoring normal pregnancy, and prescribing or advising on the examinations necessary for the earliest possible diagnosis of pregnancies at risk (Article 42 2. a)). On the contrary, the proposed decree rules that the obstetrician-gynaecologist shall make the diagnosis of pregnancy and determine whether the pregnancy is normal or at high risk. (The Hungarian law distinguishes pregnancies of low and high risk. Low risk pregnancies equal the category of normal pregnancies under the Directive.) We highlighted that as the doctors have the right to decide whether a pregnancy is high or low risk, it is the doctors who determine who can receive midwifery led pregnancy monitoring. This results in women not having the real choice. There is also a lack of informed consent ensured by the draft, although that should be the core of modern and professional healthcare.
The draft was published in spring 2013 it has not come into force yet.
Our expectation is that the autonomy and independence of the profession of midwives will not depend on the risk level of pregnancy. It would be desirable if midwifes were trusted so much that they can recognize if a pregnancy needs the intervention of a doctor.
Our petition was received with great interest. The Committee claimed that the creation of healthcare systems is the responsibility of member states. At the same time there are minimum standards, which have to be insured by all member states. This also means that the recognition of midwifery has to be automatic.
Hungarian member, Kinga Göncz highlighted this is about basic human rights issues which go beyond of the competence of midwives. So she asked the Committee to broaden the examination. She also pointed out that it is the right time to make changes because the decree about maternity care is under revision at present.
Danish member Margrete Auken emphasised that pregnancy is not an illness. It is the common interest of the whole society to leave room for midwives.
Romanian member Victor Bostinaru suggested that the Committee should evaluate the situation of midwives and ensure coherent frames for their activities. He stated that the strong financial orientation is characteristic of several other countries as well. He confirmed that everybody would win with a well working system.
Everybody agreed that the Hungarian government should contact the Committee in order to apply the Directive properly.
Based on the speech delivered by Bea Bodrogi, Szuleteshaz Assosciation on Brussels, 25th November, 2013.