Appeal for compliance with healthcare standards in childbirth during the COVID-19 pandemic

CDA/ODZ + ŽK, 30. 3. 2020

An open letter to relevant government & public authorities, institutions and health care facilities

Non-governmental organisations Ženské kruhy (Women’s Circles) and Občan, demokracia a zodpovednosť (Citizen, Democracy and Accountability) have for several years been documenting violations of women’s human rights during childbirths in Slovak hospitals. Health care provided to women in connection with childbirth is emergency medical care and its provision must be in line with the relevant standards, even at a time of epidemics. Pregnant and birthing women represent a specific group of vulnerable population which deserves special attention. However, the relevant government institutions and the measures they have adopted so far pay almost no attention to the situation of pregnant and birthing women.

The reports we are receiving from individual women as well as from some of the hospitals indicate that the violations of the women’s human rights have become even more profound across the Slovak birthing facilities with the spread of the novel virus COVID-19. These violations also take the form of non-compliance with medical standards and of decreasing the quality of childbirth-related health care. There have been numerous reports of caesarean sections and forceps deliveries being ordered without proper medical indications, as well as of medically unjustified separation of newborn babies from their mothers.

Such practices are in direct conflict with the recommendations of the World Health Organization (WHO) for treatment of pregnant and birthing women with confirmed or suspected COVID-19 infections. “If a woman in childbirth, with or without the COVID-19 disease, undergoes an unnecessary intervention, she is exposed to an increased risk of developing a severe course of this disease and, at the same time, to other adverse and long-lasting impacts on her and her baby’s health. No intervention during childbirth may be indicated arbitrarily, and where interventions are performed, their benefits must always prevail over their risks,” says Miroslava Rašmanová of Ženské kruhy.

Also, some women have been denied the option of adequate pain management by means of epidural analgesia on grounds that it is necessary to reduce the workload on the anaesthesiologists. Pain relief is one of the primary tasks of the medicine and one of the quality indicators in the provision of childbirth care. “On one hand, the birthing facilities call for such measures as forceps deliveries or C-sections that put higher demands on anaesthesiologists and on postpartum care for women and, thus, require that more medical personnel are present. On the other hand, they say that they need to spare the medical personnel, which is in a direct contradiction with the previous argument. The same applies to the separation of newborns from their mothers; it does not only require that more personnel is involved, but it also increases the risk of the newborn contracting infection from that personnel,” adds Rašmanová.

In addition, a number of the hospitals are implementing general restrictive measures, such as the ban on having a birth companion. Birth companions represent emotional and psychological support for a woman giving birth and, demonstrably, their presence mitigates the risk that the birth will have to be terminated by a caesarean section. Professional organisations, therefore, recommend enabling the presence of birth companions as part of properly provided health care, and it is also recommended by WHO in connection with the COVID-19 pandemics.

 “Moreover, the possibility to have a birth companion is a human right and women cannot be deprived of this right by a unilateral and arbitrary decision of a hospital or people who work there. The personnel’s fear of infection is understandable, but the primary means of its elimination is not to deny the women their rights, but to implement adequate hygienic and epidemiological measures – for example, strictly wearing face masks and protective clothing whenever necessary, avoiding that women are transferred from one room to another during labour and delivery or preventing that more women meet in a delivery room at the same time, or making sure that the birthing woman and her companion are attended by the least possible number of medical personnel. When addressing the current situation, the State should make sure that this type of measures is complied with and ensure that sufficient supply of protective and disinfectant equipment is available while women’s rights are respected,“ says Janka Debrecéniová, a lawyer with Občan, demokracia a zodpovednosť.

In connection with the COVID-19 pandemics, WHO issued recommendations on the provision of healthcare in relation to pregnancy, childbirth and breastfeeding on 18 March 2020. The WHO recommendations emphasise that all women have the right to a safe and positive childbirth experience and to high quality health care regardless of whether COVID-19 has been confirmed in them. According to these recommendation, the health care provided to the women giving birth must continue meeting the following requirements:

All pregnant women, including those with confirmed or suspected COVID-19 infections, have the right to high quality care before, during and after childbirth. This includes antenatal, newborn, postnatal, intrapartum and mental health care.

A safe and positive childbirth experience includes:

• being treated with respect and dignity;
• having a companion of choice present during delivery;
• clear communication by maternity staff;
• appropriate pain relief strategies;
• mobility in labour where possible, and birth position of choice.

At the same time, the WHO emphasises in its recommendations that diagnosed or suspected COVID-19 infection in a birthing woman is no indication for caesarean section and that caesarean sections may only be performed when medically justified.

According to WHO, the medical personnel should be protected through appropriate use of protective equipment and clothing designed for this purpose.

As human rights organisations, we are seriously worried that the women’s right to appropriate health care during and after childbirth and related rights may be violated in some Slovak health care facilities during the pandemic through implementation of arbitrary and inappropriate counter-epidemic measures, or under cover of such measures. “We note that any human rights limitations occurring in a democratic society may only be applied in exceptional cases, must pursue a legitimate aim and have to be necessary and proportionate. This test has to be applied particularly strictly in situations which affect the especially vulnerable group of women and their newborn babies, all the more so under circumstances when women have to rely solely on health care facilities and are fully under control of their personnel,” adds Debrecéniová.

The consequences of harmful practices and violations of the rights of women and children at childbirth may be long-lasting and devastating, affecting both their physical and mental health; apart from the women and their children themselves, they also affect their families, wider communities and society as a whole. Therefore, we urge the government and competent authorities and institutions, including the specific health care facilities and their personnel, to take all efforts, especially with respect to the current situation, to make sure that the women who give birth during the COVID-19 pandemic receive high-quality childbirth care respecting their human rights and applicable medical standards. Isolating women in childbirth from their closest persons, the lack of feeling of safety and control, medically unjustified interventions during childbirth, the absence of support in breastfeeding, and separation of mothers from their babies, have too many negative implications that need be avoided.

We urge the Slovak Government, the Ministry of Health of the Slovak Republic and other relevant State authorities and institutions (for example, the so-called “Crisis Staff”) to take the following measures during the COVID-19 pandemic:

• To ensure sufficient supply of protective and hygienic equipment for childbirth facilities and hospital staff whose appropriate use will prevent the spread of infection in maternity and postnatal wards. It is necessary to protect the hospital staff themselves, as well as the delivering women and their companions.
• To ensure that the rights of women and children to appropriate birth-related health care as described by the World Health Organization are fulfilled and that the human rights standards in the provision of such care are complied with.
• To provide pregnant women, health care facilities and the public with sufficient, quality information related to the provision of childbirth care at the time of pandemic.

Further, we urge the managements in hospitals, maternity wards, neonatal wards and postnatal wards across Slovakia to:

• Keep in mind, constantly and with due care, the implications childbirth has on the physical and mental health of women and their babies, and, with respect to every single woman in childbirth, take all efforts to fulfil her right to a positive childbirth experience.
• Allow women to have a companion (who is not a visitor) present during childbirth. Their presence has a demonstrably positive impact on the course of childbirth.
• Not harm women’s health by surgical interventions and by speeding up the childbirth where it is not medically indicated.
• Provide women with appropriate pain relief options during and after childbirth.
• Avoid such restrictions and interventions in childbirth that increase the risk of it ending in caesarean section, surgical delivery and serious harm during vaginal birth.
• Encourage women, in line with the WHO recommendations, to bond skin-to-skin with their newborn babies immediately after birth and enable them to begin breastfeeding within the first hour after birth, even if they had a C-section delivery.
• Not separate women from their newborn babies during their stay at a postnatal ward and provide them with all necessary support to start breastfeeding and taking care of their baby.
• Provide women with all necessary information before and during childbirth, including in light of the fact that their access to information about health care provided in birthing facilities is currently restricted even more than usually.
• Always keep in mind that any intervention performed as part of childbirth care may only be made with informed consent of the woman affected, and that such informed consent may be revoked at any time.

 

Further information related to the COVID-19 pandemic:

• WHO recommendations on pregnancy, childbirth and breastfeeding

• WHO interim guidance (full text)

• Relevant information and the appeal of the NGOs Ženské kruhy / Women’s Circles & Občan, demokracia a zodpovednosť / Citizen, Democracy and Accountability (SK)

 

Download:

• The appeal of the NGOs Ženské kruhy & Občan, demokracia a zodpovednosť

 

Contact:

Janka Debrecéniová – debreceniova@odz.sk
Miroslava Rašmanová – zenskekruhy.oz@gmail.com
Zuzana Krišková – zenskekruhy@zenskekruhy.sk
Šarlota Pufflerová – pufflerova@odz.sk