How We Give Birth in Romania

What the medical birth system in Romania looks like, criticized by mothers, doctors, and midwives alike, without any of them listening to one another.

This story was originally published in Romanian in March 2018. Read the Romanian version.

After I became a mother, I often asked myself if I will have the courage to tell my daughter the truth: I would have liked her birth to be different. I would have liked to feel more in control, less alone, less guilty. Not a piece of flesh about to explode.

All the people gravitating around me in the delivery room were strangers. The nurse I liked had finished her shift and the one who had replaced her kept telling me it’s time, I’m going to be a mom. I have to be responsible. My child needs me. I have to focus and push. I grumbled because I couldn’t articulate words. Had I been able to, I would have probably asked why it hurt so much, even though I was given anesthesia. I would have asked how my child was doing and how affected she was after 14 hours of labor. But all I could do was scream. I felt like an animal. And the words of the people next to me sounded like verdicts and commands.

Then came the guilt.

My doctors, the one who had monitored my pregnancy and the one on call, were looking on me from a distance, like observers in a committee, and I heard them say: ‟[Women] no longer want C-sections, but not everyone can do it, look at how she struggles.”

The on call doctor came closer and explained I had to breathe on his signal: ‟1, 2, and…”, and then push. He stuck an elbow in the corner of my belly and said: ‟Good job. One more push and you’re done!” It was as if someone had punched me hard in the back and then told me an encouraging ‟Good job”. However, I felt like it wasn’t long now, and I almost had a smile on my face, when my doctor happily told her colleague: ‟Gooood job, you!” I was giving birth and I felt like I was taking an exam and not doing well.

This is how my daughter came out. The neonatology nurses quickly took over and I remained there, looking at her. They told me she was well, wrapped her up in a cocoon and held her close to my face. Then they took her away, while she was crying, the sound of her powerful voice moving farther away stuck in my mind forever. I stayed on the table where I had given birth because I was bleeding, and the doctor who had monitored my pregnancy started stitching up my perineum.

I could tell she was displeased and a bit stressed out. She asked me why I bled so much because she couldn’t stitch me up properly. Then she repeated her colleague’s earlier remark: ‟On top of it all, you come unprepared for birth.”

I thought I was ready to deliver naturally: I had read numerous articles about it, I went to a breastfeeding class, I had asked my doctor how I can prepare, and she had told me, smiling, not to go to classes with midwives because they will make me think I can give birth on my own, and, anyway, no matter what I read, I would forget everything that day because of the pain. It felt like a rather weak plan considering my need for control, but I decided to fully trust the person I had chosen to monitor my pregnancy. I admit the main reasons for my trust were that she was a woman and the same age as me.

I wasn’t afraid of the pain, that’s why I chose to give birth naturally. I knew that the recovery was easier than after a C-section, I knew it was healthier for both me and the baby. Both my mom and my sister had given birth that way. Towards the end of my pregnancy, I intended to read about breathing during labor and to plan more with my doctor, but I never got the chance. One night, somewhere between the 36th and the 37th week, my water broke.

Although I knew what had to be done with a baby because I had taken care of others since I was a teenager, I spent the first months with my daughter crying. I was crying because I hadn’t known how to give birth, because I didn’t know how to breastfeed, because I didn’t know how to take care of my child. It wasn’t just the sadness that many mothers feel after giving birth; there was something in my clash with the medical system that made me sense a failure. The first week at home, when I found myself thinking that maybe she’d be better off with another mother, I realized I needed help.

My doctor’s remark that ‟I had come unprepared” stuck with me for a long while and I turned it semantically inside out for a month, especially in my therapist’s office, where I ended up healing what was diagnosed as depression following trauma at birth.

Almost obsessively, I read about giving birth, breastfeeding, the connection between a mother and the newborn in the first hours, trauma, and most of all about how people give birth in other countries. It was as if I wanted to ‟prepare” myself not for another birth but for the one I could have had. To find out if it really could have been different.

Soon enough, reading on my phone while my little girl slept on my chest became insufficient. Because I had hundreds of questions, a year ago I began documenting how we give birth in Romania.

I had a shock right from the beginning, when I found out that the birth system has much more serious problems than the lack of medical empathy. Almost half the births are C-sections. There are women in the rural areas who do not make it to a doctor during their pregnancies because they cannot afford it. Ours are the most women in the European Union who die in childbirth and the most babies who die in the first month after they are born.

Then I spoke with dozens of mothers, more or less educated, who gave birth in public or private hospitals, from cities and villages. I read dozens of stories on online mothers’ groups. I went to childbirth, child-rearing, and breastfeeding classes to meet future parents and find out about their questions and fears. In maternity wards, I interviewed obstetricians about how they see their work in a system where pregnant patients have become dependent on them and in coffee shops I interviewed modern midwives about how they plan on working in a system that forbids their independence. In a state hospital, I put on a white hospital gown and observed a birth incognito. I saw mothers pumping and crying. I spoke with midwives from Sweden, Britain, and Denmark. I attended parliament conferences where they debated what we are missing in order to have a birth system that’s equal for everyone.

I found out that we could give birth more humanely and be better informed in Romania, but in order for this to happen we need not only medical empathy, but many changes in a rigid and improvised system, where the involved parties don’t listen to one another.

Empathy for the mother

Since I moved to Bucharest, I have been to 15 state hospitals, as a patient and with family. I went through many emotions, from anger to horror, when I saw dirty toilets, unending lines, envelopes stuffed in pockets, and remarks lacking any common sense from nurses or doctors. I was one of the patients who judged the weak system and its people. I often asked myself why so many doctors are rigid and expeditious, why they talk about us patients like we aren’t there.

I found out I was pregnant at the end of 2015, two months after the fire in Colectiv, between scandals – the one about the system that couldn’t handle the injured and the one about the disinfectants diluted by Hexi Pharma. Influenced by previous experiences, scandals but also by my doctor, I chose a private maternity unit. I wanted the nurses to treat me nicely, to not have to worry about infections and to not have to give bribes.

A few hours after I arrived at the hospital, they induced labor with a substance called oxytocin, which was supposed to speed up the onset of contractions. But that didn’t happen. The nurses watched me with disappointment, telling me my contractions weren’t good. I spent my labor tied to a machine that was monitoring the pulse of the child in my belly and the rhythm of my contractions. I asked if I could move more, but I was told I couldn’t be disconnected because the baby’s pulse had to be monitored at all times. I was hungry, but the nurses told me it would be better if I didn’t eat because, who knows, we might end up doing a C-section and it’s not wise to eat before surgery.

When the nurse I liked told me her shift was over, a few hours before I gave birth, I told her: ‟Such a pity.” She jokingly said that if I wanted to give birth with her, I should come to the state maternity, where she was hurrying to start another shift because she wouldn’t make ends meet without two jobs.

I don’t know if there were more than two nurses per shift. They checked my cervix dilation about once per hour, they smiled at me, but they were always in a hurry. They sometimes talked about me as if I weren’t there and said ‟I was a good girl”. The truth is I didn’t question anything that was happening then, even though I was starving. I felt alone, I was scared, and I didn’t want to give birth. So, when the on call doctor told me at some point that every other woman who had come that day had given birth, I let myself get carried away. I had to handle it without complaining.

I spent the following days in the hospital crying because I didn’t have any milk – that was what the nurses were calmly telling me. In flashes of reason, I was desperately browsing the internet for advice and breastfeeding consultants. When I told a nurse that I couldn’t get my child to eat if she’d already been fed formula, she firmly told me to stop reading nonsense because she managed to breastfeed at the age of 40.

I remembered all these moments of frustration when I met Diana Lazăr, a mother who had just given birth at the public maternity Giulești in Bucharest. Three days had passed from her emergency C-section and she was in a room with four other mothers, with a half-full recipient of breast milk on the bedside table. The obstetrician introduced her to me and asked her how she was doing. She told him she was fine, but that her ‟boy doesn’t want to suckle, doctor, Sir”.

‟Don’t worry, I never drank breast milk, I was on formula, and look how big I am now,” he answered.

Diana is 30 years old and lives in Râmnicu Vâlcea. Both her and her husband work at a transportation company delivering for the chemical producer Oltchim. They wanted the pregnancy so badly that they went to pray at the grave of Arsenie Boca. They invested as much as they could from their savings for the little boy they were expecting. She doesn’t know exactly how much, but she vaguely remembers a calculation her husband made one night: about 6,000 RON spent on consults at a private office, blood tests at private laboratories, and ultrasounds at private clinics in Bucharest, and about 1,500 RON in informal payments for giving birth and staying for over a week in the maternity unit.

Under no circumstances did she want to give birth in the hospital in Râmnicu Vâlcea, which she knew was unsanitary. So she was thrilled when a friend recommended a doctor from the maternity in Bucharest who also did consults in Râmnicu Vâlcea. Her most important needs were that her doctor answer her questions and be present at the birth. The fear of an unprepared, unknown emergency system that we hear has malpractice issues makes us hold on tightly to this portrait of a doctor willing to make an appearance at the birth and to answer texts when you have an emergency. (The doctor’s presence is a practice we encourage and is part of the reason why the system is broken, I found out later.)

When I spoke to Diana, her little boy was in the neonatology ward, same as the other babies in the maternity who don’t share a room with their mothers. Once every three hours, the women leave their rooms, go into the breastfeeding room, sit on rigid chairs, take their children in their arms, and place them at their breasts. Diana was sad because her little one was grabbing neither the breast, nor the bottle, and the nurses were feeding him formula through a tube. When she went to breastfeed, she held him for half an hour. She was surprised one day when she told him ‟come to dada”, the same thing she tells her nephews. As if there wasn’t yet a connection between her and the baby, because they were apart. ‟This child doesn’t know I’m his mother, I don’t know he’s my child.”

A night before, he seemed so lethargic, as if he were dead. She cried for hours when she got to her room. I remembered my little girl, also born at 36 weeks, and all the fears I had. She rarely opened her eyes and the best way for her to calm down and fall asleep was on my chest. In the maternity ward, I had seen a baby born the same night but at 40 weeks, who looked at the persons or the objects in the room. During my first week home, a friend who had given birth in Belgium explained that some babies born at 35–37 weeks, even though they have a good weight and their lungs function correctly, have trouble adapting to the new environment, fall asleep while eating, and get easily tired by the surrounding stimuli. They are like fetuses who want to curl up like they did in the uterus they came out of too early.

Diana wasn’t told this in the hospital and couldn’t have been told something like this in a maternity ward where mothers are separated from their babies. When I asked her if her baby was fed the milk she was pumping, she teared up. She told me she was throwing it away, same as all the other hospitalized mothers. The maternity unit’s policy is that babies who cannot suckle directly from the breast will not be fed breastmilk but formula from the bottle. Diana whispered what a nurse had told her: ‟This is how we do it here, at home you do what you want.”

An obsolete medical system

Same as the overall medical system it’s a part of, the birth one doesn’t respect caregiving protocols either. Every hospital has its own rules and some of them are old-fashioned and do not respect new research in the field, nor legal regulations in the country.

This happens because the system’s organization, from infrastructure to education, has many breeches. For example, part of our anguish would diminish if we had our babies with us or if we got more help with breastfeeding. Only things aren’t that simple.

In the ’90s, when UNICEF and the World Health Organization started a global campaign to make breastfeeding a norm in every country, the concept of a baby-friendly hospital was introduced. Such a maternity or neonatology ward had to meet 10 criteria to get the UNICEF accreditation, among which: helping the mother breastfeed in the first half hour after birth, the rooming-in system (the mother and the baby stay in the same room for 24 hours a day), training the staff in breastfeeding, and forbidding the use of other nourishment besides breast milk, with the exception of cases with medical indication.

In the 2000s, UNICEF accredited maternities in Romania under this concept, the organization’s goal being that the pilot project would then be adopted by national authorities, like it happened in other countries. Maternities wanting to get this accreditation received support in the form of staff training as well as advice on what to change in the hospital. Anemona Munteanu, the project’s coordinator for more than 10 years, says that, at the time, many people in the system were wondering what they got out of it. Munteanu answered that if they applied the rooming-in system, they would have a child to a mother, when otherwise they had a nurse to 30 children. ‟They complained that they had to talk to the mothers, but we explained that of course it’s an effort to learn communication skills and have patience, to accept that every mother is at a different stage and has her own anxieties, but who better to watch over a child than its own mother?”

The UNICEF accreditation lasted for two years, precisely in order to create a continuous process of change in hospitals, where human resources naturally fluctuate and always have to be trained. The Ministry of Health states that nowadays 32 out of 182 maternities and obstetrics-neonatology wards meet the 10 criteria for the UNICEF accreditation, covering 40% of the total births. However, practically no hospital has the UNICEF accreditation because the organization wrapped up this project in Romania five years ago, as the project’s purpose was to implement a good practice that would then be undertaken by the system. The ministry says a periodic evaluation isn’t necessary because hospitals maintain the concept once implemented.

But why is a baby-friendly hospital important? Because the rate of exclusive breastfeeding until six months is 12.6% in Romania according to a 2011 study by The National Institute for Mother and Child Health. The same institute showed that only 19% of women held their child on their belly immediately after giving birth, 10% initiated breastfeeding in the first half hour after birth, and 38% of the mother-child couples stayed in a rooming-in system. (A 2017 global analysis by UNICEF and WHO calculated that the rate of exclusive breastfeeding in the baby’s first six months is 16% in Romania, while the European average is 30%.)

The maternity building where Diana gave birth, renovated after the fire eight years ago, when six babies died, was built in the ’20s as a school for Romanian Railways’ apprentices. Its construction doesn’t allow for the rooming-in system, neonatologists told me, because the rooms are small and scarce. They can barely fit in four, five mothers. Where would they hold their babies too? For that to happen, another building would have to be built.

Then there’s the issue of the lack of staff, which makes it difficult for the mother and her baby to be in the same room. Even when the rooming-in system is implemented on paper, in practice – either in a state hospital or a private one – it doesn’t really work. The nurses either encourage the mothers to get some rest and leave the children in the neonatology ward or don’t provide the necessary support for them to take care of their children in their rooms.

Even though I was in a maternity ward that allowed for the baby to stay with me, that first night I couldn’t get out of bed. The rooming-in system that the private maternity prides itself with didn’t come with a nurse because that would have meant a further cost. I had confessed my concern for not being next to my child after giving birth to my gynecologist and my nurse and both looked at me with astonishment. Eventually, one of them told me: ‟You’ll have all your life to be with her.”

‟If you want rooming-in, you need staff, because you cannot put the child directly with the mother, and ‘goodbye, farewell’,” Marcela Șerban, a neonatologist at the Giulești maternity, told me, because the mother needs help, especially after a C-section, where the hospital protocol is to keep her up to 24 hours in the intensive care unit. Another doctor, from a maternity in Bucharest that doesn’t allow mothers to stay with the babies, told me they had had situations where mothers accidentally rolled over their babies in their sleep. The hospital did not want to take the chance, so they gave the system up.

Nurses would have to go from room to room to make this accommodation, while, in the current system, they watch over all the children in a single place. In maternities where they also care for premature babies, hospitalized in intensive care units, it seems like the organizational scheme is to minimize risks, not to please both mothers and babies, and eventually their families too.

European recommendations, doctors told me, show that a nurse should have four babies delivered on term or two delivered prematurely in her care. The staff regulations are similar in Romania: according to a ministry order from 2010, between one and three nurses should look after a newborn per shift.

Only, in practice, there are times when a nurse looks after 30 children. Amalia Stănescu, neonatologist at the Cantacuzino maternity, told me that in her team, at night, 47 babies, the maximum number of spaces, are in the care of a single doctor and only four nurses. They not only look after children delivered on time, some of whom stay in their mothers’ rooms, but also premature babies or those in the intensive care unit, who need permanent observation. Stănescu says that in order to provide more help with breastfeeding, they would have to hire another nurse just for that.

A nurse with 20 years of experience earns around 3,000 RON. It’s a job that’s always on the run, between emergencies, paperwork, problem-solving, like when an incubator breaks and you need a quick solution, other than the official one where you make a request and a technician comes after three to four days.

In such a structure, it’s difficult for mothers to receive more empathy or more support. Of course, there are nurses and doctors jaded by the day to day conditions, who seem to no longer care about patients. But most of them are just overwhelmed by an exhausting rhythm, in an organization lacking resources, in which we ask them for – and rightfully so – something they cannot deliver: a birth that belongs to the mother and the child, and not to the medical system.

Childbirth, a painful heritage

Childbirth did not belong to women 50 years ago either. After the communist regime’s decree from 1966 which banned abortions, giving birth became a patriotic duty, traumatizing women who delivered babies in a row, like in a factory.

My mother first gave birth in March 1977, after a two-day labor, without anesthesia, helped by midwives because the on call doctor didn’t wake up. Seven years later, she gave birth to me in a newly-built hospital, praised in a Romanian Television reportage. She spent her labor in a crowded room, with a female doctor who told her ‟she liked keeping her legs up in the air”, and who told another woman ‟to stop screaming like a cow”. C-sections were limited to a certain percentage per hospital, up to 5%, and had to be approved by the hospital’s manager, recollections from back then say. Screams were not tolerated and were stopped with more or less obscene versions of the question: ‟You liked conceiving it, why are you screaming now?”

Most women were not allowed to leave the hospital without breastfeeding, my mother told me. When they left, they received their children from nurses, to whom they gave a bottle of champagne or a box of chocolates. Some mothers hoped to never return to a maternity ward. In a time when birth control pills or condoms were difficult to find and an abortion came with a criminal record, women paid for their success of not giving birth again through furtive abortions at home, sometimes with knitting needles stuck in their vagina. Some women were helped to illegally abort by midwives, whom they offered coffee or a carton of cigarettes, and above all the promise that they will not tell a soul until their deathbeds, like my mother did when she went through it.

After the Revolution, this legacy led to both doctors and women adopting a way of giving birth that was safer and more controllable: the C-section.

At first, C-sections were only used to save the baby, when the mother was dying or already dead. American journalist Tina Cassidy, author of the book Birth: The Surprising History of How We Are Born, writes that the first historically documented C-section happened around 1500 in Switzerland, when a pig-gelder, desperate to help his wife, cut the woman’s belly because she couldn’t give birth after several days of labor and help from 13 midwives. The operation was a success: both the baby and the mother survived.

Defensive medicine

Centuries later, with the progress of medical education and the discovery of anesthesia, C-sections became a safe, almost infallible procedure in many parts of the world. According to WHO, the number of C-sections has overwhelmingly risen in the last decades. It’s a phenomenon with many factors involved and in some societies the causes are national and cultural. For example, in Brazil, most women give birth by scheduled C-sections and the phenomenon is based on trauma endured in hospitals, trying to give birth naturally. It is possible that here too, in a post-communist society, women have sought to gain control.

When I got pregnant, I read that doctors push you towards a C-section, but I didn’t know why they were doing this, nor if it was a phenomenon. I couldn’t know a clear number because we have a non-transparent, even faulty statistical system. The National Institute for Public Health (NIPH) calculates the number of vaginal births and C-sections, numbers received from public hospitals affiliated with the Ministry of Health. The Institute has no numbers from private hospitals, from those that belong to the Ministry of Internal Affairs, and about home births. According to these incomplete numbers from NIPH, the C-section rate is 48%. Because the National Institute of Statistics doesn’t keep track of the number of births but of the number of babies born alive, which is larger in the case of twins and multiples, we don’t have a relevant total either.

Yet specialists’ estimations tell us that the rate of C-sections is larger in the private system than in the state one. Putting all this data together, we can expect that half the births in Romania are C-sections.

WHO says that a healthy rate of C-sections should be lower than 15%, because a C-section is an emergency, life-saving surgical intervention and it shouldn’t be perceived as a choice of birth method. The difference between the WHO recommendation and the Romanian reality is a story with multiple nuances.

First of all, part of the C-sections in Romania are elective, scheduled, and with no medical recommendation that would require them. The doctor and patient agree beforehand upon the date of birth, which means that the woman doesn’t go through labor anymore, but ends up directly in an operating room, where she is given an incision in her abdomen and uterus, and her baby is taken out. The way statistical data is collected makes it difficult to know how many are truly elective.

Second, a C-section is a way of maintaining the doctor-patient relationship which has become vital for pregnant women who, fearing the weak health system, don’t want to end up giving birth with on call doctors. ‟Patients place their trust in a doctor the whole pregnancy,” a practician told me, ‟so they can feel safe with him during delivery.”

Births can happen anytime, even when, as a doctor, you come home after two other births, or you’re during consults, or at night when maybe you don’t have anyone to leave your children with, or simply when you’ve reached a level of exhaustion, after hundreds of on call nights, that you can no longer cope with it. There are slim chances that all your patients will give birth only during on call days. So some doctors who monitor pregnancies choose C-sections because the emergency system can’t work as a backup plan.

Sometimes, this relationship during pregnancy comes with informal payments in the public system or with monthly consults in private offices, a profitable situation on both sides. In the public system, an informal C-section payment is up to 2,000 RON in Bucharest, compared to a vaginal birth, between 1,000 and 1,500 RON, but which can last up to ten times longer. It’s a reality we all contribute to. Families offer money, but in return ask the favour of having the doctor available at all times.

Thirdly, for obstetricians, the decrease in the natality rate in the last decades means less practice. If you’re a doctor and during your residency you haven’t seen vaginal births but mostly C-sections, you can’t become a doctor who prefers vaginal births over C-sections.

‟You had nowhere to learn,” Celus Tarpan, one of the ‟vaginist” doctors, how obstetricians pro-natural birth are labeled in the field, told me. In order to know how to assist a birth, you would have had to have seen at least 200 labors and births during your residency, Tarpan thinks. In Bucharest, however, there are teaching hospitals where C-sections are more common than vaginal births, so the future doctors’ training is also lacking.

I noticed myself that C-sections are default, when the doctor asked me, when we first talked about childbirth: “C-section, right?”, when my ophthalmologist told me: “You want my approval for the C-section, right?”, when my ultrasound doctor told me I should get a C-section, otherwise I run the risk of having a Virgo baby and it’s not a very good sign, when the nurse who admitted me in the maternity unit at five in the morning disappointedly told me: “Natural? Aww, only naturals tonight!”

C-sections are not only unhealthy for women – because they’re surgical interventions with a hard recovery, the chances of breastfeeding could drop, the risk of infections could rise –, but they’re also costly for the state budget. A C-section is, on average, two or three times more expensive than a vaginal birth because it’s a surgical intervention that requires anesthesia, more days of hospitalization, and even intensive therapy.

Furthermore, several doctors I spoke to told me they feel completely exposed when something unforeseen happens during labor. Even if in theory there are care protocols, they are not applied at hospital level or they’re obsolete and unrevised.

Nor is updating the patient about what is happening to her one of the strengths of the Romanian medical system. And the medical alphabetization they speak of in other countries is a faraway concept.

The truth is doctors fear families will accuse medical decisions. The trust in doctors and in the system is low and the patients’ suspicions high. If complications occur at birth and you get subpoenaed, “you’re completely exposed,” a doctor told me. So the solution most of them found is to practice the so-called defensive medicine, which includes C-sections.

Maybe it’s because of this stress they are not taught to manage that the doctors who assisted my birth, young ones, for that matter, complained they find pregnant women unprepared. Maybe that is why the resident doctor whose case I observed incognito reprimanded the mother, minutes after birth: “You didn’t push at all, if it wasn’t for the midwives’ help –”, but how fair is it that doctors place responsibility on patients, even in stressful situations?

Changing the doctor’s role

‟Obstetrics is like a thunderstorm,” a doctor told me. Something unforeseen can happen anytime. This is the philosophy doctors learn in college too because they’re trained to foresee negative things; to see the pathological to the detriment of the physiological. ‟It’s like the aeronautical industry,” Ilinca Gussi, an obstetrician and head of works at the Medical University in Bucharest told me. ‟Is it right to state that if we take all precautions and we all pay attention and we’re not tired, and we look after both mother and child, nothing will ever happen to us? It’s not true. Planes crash, although it’s a well-established industry; everyone is trained for any kind of catastrophe.”

Ilinca Gussi, obstetrician, 42, thinks that doctors should only take care of pathological births which involve risks and midwives should be the ones who take over the cases with no problems, the way it happens in other countries.

She says that the difference between the aeronautical industry and obstetrics is that in the former, when a plane crashes, there’s never only one person punished, and what prevails is not placing blame but finding what happened so that another catastrophe doesn’t happen again.

Gussi is 42 years old, is an obstetrician specialized in maternal-fetal medicine, trains residents, and works at the Cantacuzino maternity in the morning and at her private clinic in the afternoon. She’s the mother of three, aged 12, 10, and 3, which she delivered naturally, a rare thing, she says, in the world of our female doctors, because ‟when you know how many things could go wrong you have to put a lot of faith in destiny and the team you place your care with.”

Each time, she tried to be an obedient patient. At her last birth, her doctor was a friend, and she still feels guilty that she kept her standing all night, after she had worked until 10 P.M. During each of her labors, she also had her best friend next to her, who had given birth before her and who, ‟not being a doctor, was calm, had an amazing clarity in understanding when there’s a hard medical situation and an outstanding resilience.”

She chose her, and not her partner, like other women prefer, because she trusts la sagesse des femmes (the wisdom of women). ‟I think a woman who weathered a birth and then remained serene can help you much more in labor. There’s a reason why, in traditional communities, women gathered around someone when she went into labor.”

When she was a resident, Gussi learned how to help women give birth from the midwives in the hospital, who had a lot of experience from communism. She spent her fourth year of residency in a hospital in Paris. One day, she was called by a team of midwives at a birth where the mother couldn’t get the baby out. In France, where physiological births with no risks are assisted by midwives, the procedure is to call the doctor only when there are no other options left. She went into the delivery room, where the patient’s husband was present, took a scalpel, cut open the perineum to help with the baby’s delivery, took out the baby, cut the umbilical cord, put the baby on the table, and then handed it over to the mother.

When she glanced at the stunned husband and midwife, she didn’t understand. On the hallway, the midwife stopped her and told her: ‟This isn’t how we do things here, but we’ll teach you how to do it.” It was then that she found out that the father was supposed to cut the cord and that’s what he was waiting for, and the baby should have been placed on the mother’s belly.

Her experience in France taught her to see a different childbirth process, where doctors handle the pathological cases and the midwives are those equipped to assist physiological births. Because, in time, she trained to find solutions for problems that come up in a risky pregnancy, either for the mother or the fetus, Gussi is one of the doctors for whom assisting births is no longer a career priority.

‟Midwifing is a thing that became exotic, but it shouldn’t be like this. We’re going to lack people who do this and who should be the midwives, with their heads there, doing only this. I get a much bigger satisfaction from handling who knows what operation or a sick child than waiting 14 hours for someone, doing the grand effort of not doing anything.”

Ilinca would like midwives to be included in the Romanian system, because it would take over some of the pressure from doctors. When obstetrics nurses on her ward asked her what good would a degree from the college of midwives do them, she told them: ‟In a future life we will have our offices next to one another, and I will oversee only the complicated cases and you will oversee the simple ones and we will shake hands, and I will never go to the hospital at night ever again.”

Doctors who seek change in the birth system, like Gussi, say that there are few solutions because what’s more urgent now is the lack of staff. With doctors that go abroad starting with their second year of residency, you don’t have many resorts to do things differently. She also says that midwives should organize themselves to regulate their profession and experts in public policies should draw up strategies to include them, only ‟just like there aren’t doctors in hospitals, there aren’t experts in ministries. The central and social health system doesn’t fulfill at all its vocation of catalyst in such simple and obvious public health policies as supporting giving birth naturally and in comfort, in optimal conditions.”

Modern midwives

Before, my definition of midwives was rather confused, between my mother’s stories about the midwives who made house calls after deliveries and today’s midwives, who help you give birth at home, a sort of premium product through which you can bypass the hospital system if you’re afraid.

Midwives’ history had its ups and downs, writes Cassidy. At first, midwives were the women in the community: mothers, grandmothers, aunts, who helped the pregnant women give birth at home, offering advice from their own experience. In many languages, ‟midwife” means grandmother, in Jamaica it’s ‟nana”, in France she was called ‟sage femme”. In Ancient Greece, the law said that midwives must have had children and be over the period of menopause so they can always be on call. At first, midwives weren’t schooled because women didn’t have access to education. However, because most pregnant women had no other alternatives, the profession continued to grow and, in some places, educate itself. But the change didn’t happen overnight, because there were neither enough doctors, nor enough hospitals. It was the poor women who ended up in hospitals, under doctors’ observation, while those from the middle class still gave birth at home, assisted by midwives. Afterwards, in some countries, things turned.

There was a coming and going between doctors and midwives, both men and women, according to the mentality of each ward. In Sweden, a country with a feminist history, midwives had continuity and nowadays still share a complementary role with the doctors. In 1839, the then queen decided by law that all communities in Sweden would hire midwives in order to decrease the high maternal death rate. Today, midwives have university degrees and assist births in hospitals. This happens not only in Sweden but in France, Great Britain, Norway or Denmark.

These are the modern midwives. From the time they find out they are pregnant, women are seen by midwives in their offices and are referred to doctors only if there’s a risk. Labor and delivery happen with midwives, as well as postpartum care, and all these services are accessed through the public health system. If a patient wants a C-section, she is sent to talk to a psychologist, who assesses if labor or childbirth might affect her mentally. In these countries, the number of obstetricians is up to ten times lower than the midwives. (Of course, in such a context, vaginal childbirth is encouraged. According to an international report from 2015, the C-section rate in Norway is 16%, in Sweden 17.3%, in Great Britain 26.2%.)

In Romania, women also gave birth with midwives. During communism, midwives from clinics were in charge of women during their pregnancies, at birth (if they didn’t make it to a hospital), and during childbed or, illegally, when they wanted to have an abortion. When the system medicalized, some of them migrated towards hospitals, and the nurses nowadays are traditionally called ‟midwives” in the obstetrics ward in hospitals, even though many didn’t graduate from dedicated schools but a sanitary high school, and they trained on the job, under doctors.

Before accession in 2007, the European Union urged us to regulate the midwife profession. Since 2005, midwives colleges began opening within medical universities in Bucharest, Iași, and Cluj. Three years later, Romania had to transpose in its own legislation the European directive through which midwives were acknowledged as medical staff capable of monitoring pregnancies, assisting birth, looking after the mother and child postpartum in cases with no pathological risk, as it was already happening in other countries. Only the law did not receive application norms, which meant that midwives had no way of exercising their profession. They had no work autonomy in hospitals, nor could they settle their services through the National Health Insurance House.

It was only in 2014 that a ministry order with the independent practice norms was published, which truncated the midwives’ responsibilities that the European directive itself had given. In evasive terms, the norms stated that midwives could physically and mentally prepare the pregnant woman, monitor her every time she went to the bathroom, and look after her during childbirth and childbed. All the other tasks that should have been included in a midwife’s job description, like the European direction stated, would have been done only at the doctor’s indication or in his presence. Basically, the midwife would have done the same things as an obstetrics nurse. After graduating from a four-year university course – created as part of the profession’s revival process – they were allowed to do almost nothing.

Nobody knows for sure how many midwives with degrees there are today in Romania. But there are talks about a number of 1,000 or little over. Of these, 761 work in the medical system. In 2013, a group of midwives with degrees founded the Independent Midwives Association (IMA), an organization meant to convince authorities to repair the legislative gap that excluded them from the medical system. IMA estimates that, in fact, only 300 graduates work within the system, although they are practically still nurses subordinated to doctors. The rest work as stewardesses, receptionists, saleswomen or they are housewives.

Because the profession wasn’t regulated in the medical system, the demand reduced. By 2014, nine midwives colleges had been opened in the country but because the profession wasn’t growing, there are only three left today: in Galați, Craiova, and Bucharest. In Galați, 24 students graduated in the last class, out of the 40 places available. In Bucharest, where there are 15 places, 12 graduated.

IMA continues to fight to change the legislation. In 2016, they convinced the ministry to create a work group composed of doctors, midwives, NGOs, and ministry experts in order to find legislative solutions to put them back to work. The group met in February 2018, after the change of another minister. A year before, the association tried to introduce a law in parliament that would have filled the legislative gap from the past years. Midwives would have earned revenues settled by NHIH, just like general practitioners, would have assisted physiological births in hospitals, without the presence of a doctor, would have had a College separate from nurses. Initially, some members of parliament said they’d support the project, but things soon stalled here too.

One of the project’s objectors was the very president of the Order of General Nurses, Midwives and Nurses of Romania, Mircea Timofte. He says that IMA’s endeavor is just a maneuver for midwives to legalize home births and that the doctor is the midwife’s boss in the hospital anyway. ‟What does the midwife want, to kick out the medical professor and assist herself in the hospital?”

Irina Popescu, midwife, 35 years old, thinks that every woman has the right to an informed, empathetic birth with no trauma and that midwives are the ones who can help women earn this right.

Irina Popescu, one of IMA’s founders, graduated from the Midwives College in 2011. I met her a few weeks after I gave birth, when she helped me breastfeed and took out some stitches from my perineum. She asked me in detail about my birth, why the doctors made this or that decision. The truth is I had no idea because I had not asked them. After she became a midwife, Irina met a lot of confused women when it came to their births. Some had gone through trauma and they ended up seeing her because they wanted the next time to be different.

Irina thinks that every woman has the right to an informed, empathetic birth with no trauma, and that midwives are the ones who can help women earn this right. She is 35, has the stature of a handball player and crosses Bucharest almost exclusively on bike, on which she has painted the message ‟Give birth how you feel”. In the city, almost anyone who has a small contact with the childbirth world knows who she is. She monitors pregnancies in her office near the Circus Park, she assists births in a private hospital, and she teaches classes on childbirth and childrearing.

When she was a student, she interned with a midwife from Switzerland, whom she assisted with home births and in public maternities where, through a volunteering program, they were trying to teach women breastfeeding techniques on plastic bottles because at the time babies mostly stayed in neonatology wards, and not in their mothers’ arms.

She knew the mothers in state hospitals well because she had also been there. She was 21 years old when she got pregnant with her first little girl and the doctor who monitored her pregnancy suggested a C-section, telling her that her placenta’s position will not allow her to give birth naturally. She was scared of the operation and saw another doctor who made the opposite diagnosis. During labor she stayed in a room with 15 other women, each one with her own pain. The nurses were scolding her for throwing up, were not allowing her to move, and even though she felt the need to push asked her not to do it because the doctor had not arrived. When she came, the doctor told her to hurry up because she had to pick up her child from school and cut open her perineum, even though Irina protested. She remembers a single nurse; a woman who held her hand when, after a contraction, she pushed for the first time.

It seems like everything Irina did afterwards was to become that helpful woman for future mothers. Up until now she assisted 300 births, 80 of which were in the mothers’ houses, before the regulation that dictates that home births should be assisted by midwives only in the presence of a doctor. That is where she gets her label of ‟the midwife who assists births at home” from, a label that kind of hinders her when she publicly speaks about the association’s effort to regulate the profession. (IMA members, including Irina, don’t support home births because they don’t think the Romanian emergency service is prepared to take over complicated cases in good time.)

Most women who come to Irina’s classes are educated, often have financial power, usually look after themselves in the private health system, can afford a 5,000–8,000 RON birth, and want to spend much of their labor at home with her, and not at the hospital. For example, Alexandra Oniceanu-Becuț, one of the most well-documented and organized mothers I met.

Alexandra is 29 years old and is a communications manager in a bank. When she got pregnant, she knew she wanted to give birth in a private hospital and to breastfeed by all means. Ever since she started working, in her second year of college, she had medical insurance at a private hospital included in her salary package, so she did not want to go through the public system’s uncertainty. Along with her husband, she attended Irina’s childbirth and childrearing classes, a four sessions module that costs 400 RON, she decided to also monitor the last four months of pregnancy with a midwife, and to give birth with both a pro-natural birth doctor and a midwife. Her chosen hospital has a banner on the building promising that if you give birth there you’ll get ‟the magic hour,” the skin-to-skin contact between mother and baby in the first hour after birth. This is what she included in a birthing plan she sent to the maternity, but also that she doesn’t want the little one to get formula, that she wants anesthesia only if she cannot stand the pain anymore, that she wants her husband to be present during delivery.

In October, she gave birth to a baby boy, after a 12-hour labor and a C-section that couldn’t be avoided. She never felt like the doctor or the midwife was rushing her, she received support in breastfeeding and took care of the little one with her husband in the three days they stayed in the hospital. She felt safety and control, the things she had sought by thorough research during her pregnancy months. For this normalcy and for avoiding the rushed system they were afraid of, Alexandra and her husband payed almost 11,000 RON.

It’s an outrageous sum with which to buy the normalcy I had wanted myself; an outrageous sum for a care service that women from other countries receive free of charge. As the president of the midwives association in Sweden told me, ‟Don’t you think it’s terrible that they make money from something that should be as it should be?”

A real need for midwives

It sometimes eats at Irina that her work doesn’t bring about change on a large scale because the services she offers are private and only reach a small segment of women who are already informed anyway.

I spoke with doctors who claim that such a package in the private system is the result of dishonest marketing because it misleads women into thinking they can control their birth and can prevent any negative thing that might happen. I’ve heard women say that giving birth with a midwife is a trend for those who can afford it because no midwife can take the pain away, and childbirths are painful moments, not moments of spiritual connection. I’ve read opinions of other women on the Internet claiming that the ‟traumatic” adjective associated with giving birth in hospitals is exaggerated because people have been giving birth since the beginning of time, our mothers have done it too, and they didn’t complain.

Adina Păun, 40 years old, also a graduate of a midwife college, thinks that only a collaboration between doctors and midwives will change the current situation. Adina, an ex-manager of a real estate company, had a professional reconversion and is among the most recommended breastfeeding consultants on online groups of mothers in Bucharest, where many women say she changed their lives. Because she wanted to get her international certification as a consultant, for which she thought she needed a medical degree, she applied at the Midwives College in 2012. What convinced her to apply to college was the day she saw a doctor cursing at a woman whose baby was in a complicated position during expulsion: ‟Push, you fucking cunt, you’re killing the baby.”

Adina went on call voluntarily in the Cantacuzino maternity, under Ilinca, and she also did prenatal consults with her in the private system.

During these years, she learned that childbirths that end up being traumatizing for women aren’t necessarily the doctors’ fault but that of a poorly managed system. For the time being, she isn’t ready to take the step and get hired in a hospital because she doesn’t think that she could handle the on call system. She’s divorced and has two pre-teen daughters she wants to spend as much time as possible with. Even though she was a good student in college, she feels she needs to see hundreds of births before practicing herself. Furthermore, because the midwife profession isn’t regulated yet, she doesn’t know if she can handle the hospital system where she has no freedom to practice. ‟I don’t think I can push my elbow in someone’s belly if I’m asked to.”

Adina, also a member of IMA, thinks the midwives’ role in Romania should be a balanced one, far from the extreme ‟we don’t have bathtubs in maternities so that women can spend their labor in water” and closer to looking after women in communities and offering contraception ‟which is badly needed”.

Ilinca, whom Adina joined in the Save the Children caravan these past four summers, believes this too. In hard-to-reach villages, a team of doctors led by Ilinca gives consults and ultrasounds to pregnant women who cannot make it to the gynecologist.

In 2016, according to the National Institute of Statistics, 51,942 children were born from mothers who never went to a prenatal check-up. In a year, almost a quarter of all pregnant women don’t make it to a doctor.

Vali Angelica Matei, 20 years old, lives in the Podoleni village (Galați) and couldn’t visit her gynecologist regularly during her pregnancy because she doesn’t work and her husband is a day laborer.

There are women like Vali Angelica Matei from the Podoleni village near Tecuci. She got pregnant at 20 years old, with a boy she met on Facebook. Her parents had kept her on a tight leash, always at school or at home, so a month after she met Iosif she decided to move in with him because they had chemistry. She was ashamed to introduce him to her parents. At the in-laws, who have three more children and a house with only three rooms, they live a bit cramped but ‟when you’re in love, you can live in a matchbox”.

She was stunned by the news that she was pregnant, because she never thought it could happen so fast. She felt sick from the beginning; she was getting dizzy and throwing up anytime she took a bite. She told me that the general practitioner gave her a referral, but neither she, nor her husband, who’s a day laborer, have the means to pay for a consult. I asked her why the doctor referred her to a private office and she told me she doesn’t know; ‟maybe because it was urgent”.

Same as Vali, with no education or money, there are women who go to the doctor sporadically or not at all. They live in villages and barely make it to the general practitioner, where they often press to get an appointment, same as all the ill people from the community. They don’t make it to the ultrasound in the nearest town.

There are villages where there isn’t even a general practitioner, like Urși in Vâlcea County, left with only a nurse after the last doctor died. One day, the nurse from Urși helped a woman give birth at home, because there was no time to wait for the ambulance, nor for the doctor from another village.

There are women who never went to a gynecologist before they got pregnant, either because that’s the way things were done before or because they were ashamed. There are pregnant underage girls for whom notions of sexual education do not exist because their mothers don’t tell them anything and neither do the schools. A monitored pregnancy means not only a medical consult, but also blood work and fetal ultrasounds. In theory, a pregnant woman receives them free of charge, even if she never worked and was never insured before her pregnancy. But some women don’t know they can benefit from free consults, tests or ultrasounds.

On the other hand, even if they do know and want to benefit from free health care, they have to make an effort because bureaucracy is not easy to navigate. For example, the gynecologist’s recommendation is to get your blood tested in a certain week of the pregnancy. With this request you have to go to the general practitioner, who offers you another document, valid for a month, through which you can settle your tests through NHIH. With this paper you will go to the analysis laboratory, but if you have bad luck and the period when you have to get the tests done is in the second half of the month, you’ll have difficulties finding a laboratory that hasn’t reached its sum limit. In Bucharest, most laboratories reach it in the first ten days of the month, so you have no option left but to pay for the tests or, if you can’t afford it, wait another two weeks or give up on doing them.

Every week, Romina Sima, doctor at Bucur Maternity, consults women who are far along when they make it to a consult and, from what she can tell, education is the greatest problem of the childbirth system. Sima says a patient whom she told had to terminate the pregnancy because the fetus had a serious cerebral malformation kept the pregnancy and returned after a few months to the hospital to give birth. When she told her the baby had no brain, the mother asked her: ‟But other than that is it well?”

Pregnancies that aren’t medically monitored are important because they can create complications in pregnancy and at birth, both for the fetus and the mother. In Romania, one in 10 children is born prematurely and needs emergency medical intervention, while there are only 23 specialized intensive care units at national level. Premature births are considered the main cause for neonatal mortality, which occurs in the first month of life. Romania comes first in this area in the European Perinatal Health Report, with a rate of 5.5 per thousand deceased babies, double compared to northern countries or France. According to the same report, Romania comes second in the percentage of maternal death rate, with 21 deaths per 100,000 births. However, the European report data was published in 2010, and Euro-Peristat, a European project monitoring perinatal health in the European Union, will publish a new analysis in 2018. It’s possible that Romania’s position in this ranking has changed, but the numbers from the National Institute of Statistics, even if lower, show that we still have a problem. (In 2016, the neonatal death rate was of 3.8 per thousand and the maternal one of 8.4 per 100,000 births.)

Ilinca thinks that midwives could reduce these numbers in the long run, if the system would give them the power. ‟If the system is afraid to allow midwives to help with births independently, it can begin doing prenatal, when you have tens of thousands of women who don’t see doctors. This way they don’t take the bread out of anyone’s mouth.”

It’s a potential solution for pregnant women who, many times, both the system and part of the medical staff consider second-class patients; a version that few would disapprove of and with which doctors would feel comfortable.

Aida Petca, obstetrician at the Emergency Teaching Hospital Elias and professor at the Midwives College, also spoke to me about the option where midwives would look after women in these areas pre- and postnatally. She believes that for the present time midwifery students get minimal practice when it comes to childbirth, and this is something the doctors who don’t see their presence in the system in a positive light know too. On the halls of parliament, this was hastily confirmed by Ioan Suciu, senior vice-president of the Obstetrics and Gynecology Society, who told me that the midwives’ role should be in primary care, meaning alongside general practitioners, who aren’t medically or emotionally trained to monitor pregnant women. Only, he told me at the time, we need 11,000 midwives for this, not the 1,000 we have now.

In 2007, the law on community health care was passed, which states that alongside every practitioner in the 2,800 rural communities there should be a midwife with a university degree, who would handle pregnant women and new mothers, just as it was before the Revolution. In some of these counties there is a community nurse or mediator who looks after vulnerable people, those who are uninsured or have difficult access to health services, and the midwife completes this team. They are all hired by town halls, and their paychecks come from the Ministry of Health.

Only, even if they found the money, the problem still remains. Where will they find the midwives to move into rural communities in need, when there are just over 1,000 graduates? It’s a question that also eats at the midwives’ representatives, who believe that it will be even harder for them to show they exist and want to work if there aren’t midwives who will go into rural areas.

Women should ask for us as they would a right that isn’t observed, midwives say, as a last resort in a system they can’t seem to change. It’s just that, apart from big cities where a modern midwife like Irina works discreetly, most women don’t know that such midwives exist, and it will take some time for women to get to trust them in a system where doctors have the power.

Epilogue

After more than a year, I still haven’t found a more hopeful answer to the question I asked myself when I started documenting births in Romania. Could have I given birth differently? Maybe, if I had been luckier, more prudent or if I had spent more money. The way the birth system is currently organized, I could not have done something better myself and, even more terrifying, the medical staff around me probably couldn’t have done things differently.

During my research, I’ve seen an incredible gap between the needs of pregnant women, doctors, midwives, and authorities when we talk about the system’s issues and what an ideal birth means.

Mothers would like the system to change on its own because they don’t feel they are a part of it so as to help with the change. Furthermore, they are the ones giving birth and that is why they ask to be in the center of the system. In order for them to achieve this, the easiest way is still to cling to a doctor, whom they consider a god, and then criticize when he acts accordingly. Many doctors and nurses find it hard to put themselves in the mothers’ shoes because they never learned to practice empathy. Moreover, many feel trapped in a system where they have no space to make decisions, have no resources, and are fewer and fewer. In these conditions, it’s no wonder they can’t respond to families’ demands. Modern midwives – although it seemed they would take some of the load off – were left voiceless or maybe they never had a voice. Many doctors, especially the old-fashioned ones, don’t consider them necessary, and many women don’t know they exist and even have medical abilities. Then there are those who aren’t in the delivery rooms every day: hospital managers, authorities, and politicians – those who should make the breaches in the system public, but oftentimes choose to preserve the status quo.

I wish that doctors would read this text, especially the young ones, from the generation of those I gave birth with. They could change something; if not in the system, then at least in the attitude with which they regard their patients. And the midwives whom I barely knew existed when I gave birth and who could bring empathy and workforce in the system if they banded together better. And those who run wards and hospitals, and who could find the financial solutions to restore the patients’ trust in the system. And members of parliament, especially women, who could be a force for change; and statistical institutions who collect obsolete data; and the minister, and those in the opposition who want to be ministers, so they can see we can change the way children come into the world. We just have to listen to one another, not blame one another, in the hope that maybe we can succeed in building a dialogue starting from the minimum we all agree upon.

Now, everyone’s voices echo loudly from the sides. I hope this story will fill the empty space between them just as, more than a year later, it filled the emptiness I felt a few days after my daughter was born.

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