Eastern Europe and Central Asia Caucus Consensus Statement
The Eastern Europe and Central Asia Caucus was convened as part of Women Deliver 2016. The caucus was financially supported by PATH and organized by Roda, a Croatian NGO. The goal of the caucus was to bring together diverse stakeholders to discuss regional priorities and strategies for strengthening girls' and women's health and wellbeing; and to serve as a catalyst for momentum in participants' home countries. This caucus in particular, focused on quality in reproductive healthcare as a way of upholding women's dignity and autonomy.
In preparation for the caucus, organizers consulted 30 individuals and organizations from the region to identify the most pressing reproductive rights concerns in their countries. These concerns were broken into three broad categories: health education for youth, increasing safety in pregnancy, childbirth and postpartum, and disrespect and abuse in pregnancy, childbirth and postpartum. During the caucus, break-out sessions were held for each of the three categories to further identify priorities and possible solutions. Based on these discussions, the following list was compiled. It highlights the priorities for the region for reproductive health issues impacting women especially in pregnancy, childbirth and postpartum.
The document was discussed at the caucus, with over 90 representatives from 20 countries in attendance, and the consultation process continued afterwards with ten experts in the field who provided feedback and helped shape the final outcome document.
Consensus Values and Human Rights Framework
We, the signatories of this consensus document are a diverse group of advocates, activists, service providers, policy-makers, and other stakeholders. This document reflects the work we did at the caucus and our ongoing commitment to improve the quality of reproductive health care for all women.
At this caucus, we proposed that the definition of adequate reproductive health and safe motherhood be transformed to include thriving before and after pregnancy and childbirth, recognizing that pregnancy and childbirth especially are crucial for the health of women, children, families and societies at that moment and for the future. This work was done within a Respectful Maternity Care(1) and human rights framework. Although some of the issues listed may not be direct human rights violations, they all contribute to a healthcare environment in which the rights and dignity of women are systematically violated.
1) Gender Stereotyping
Gender stereotyping limits the roles and rights of women in both healthcare settings and society. As a reproductive rights concern, gender stereotyping encompasses a wide range of problematic issues arising from women being perceived as not competent to make decisions about their bodies and babies. These perceptions of lack of competence interfere with women's abilities to exercise their autonomy and dignity. These issues include:
- Lack of respect for reproductive health choices throughout a woman's lifecycle that negatively impacts her right to decide freely and responsibly on the number and spacing of her children. This includes:
- lack of respect for the right to access abortion and contraception (2);
- forced abortions due to fetus defects or preterm birth (3).
- Lack of respect for the right to informed decision-making. This includes the lack of understanding by health professionals of the basic principle that decisions connected to reproductive healthcare (and to all other healthcare) are ultimately taken by the clients and beneficiaries of the care and not by health personnel (4).
- Disrespect, abuse and other violations of rights in reproductive healthcare settings, be it psychological, verbal or physical (including shaming and social stigma regarding "bad" choices). This also includes the normalization of abuse and disrespect which affects women's and society's expectations of care.
- Harmful stereotypes about women including the stereotype of a woman as a mother and as an incompetent decision-maker that contribute to violations of sexual and reproductive rights of women and girls, including in childbirth; social security systems and employment and social policies that perpetuate the roles of women as mothers and hinder women from a balanced exercise of their parental responsibilities and paid work.
- Lack of assisted reproductive care. Includes: insurance companies' limitations on how many couples per year can have treatment or how many cycles a couple (or woman) can go through; limitations to extent of coverage of treatment, lack of availability of sperm donations.
2) Access to Information and Education
Access to Information and Education underpins the effective exercise of all other rights. Without awareness, education and understanding of a rights based framework for healthcare by health professionals, legal advocates and consumers, no lasting sustainable improvements can be made. Lack of access to information and education can lead to rights violations, even when the parties involved have the best intentions of providing good care. Examples of access to information and education issues include:
- Lack of awareness and access to information about reproductive health: including lack of formal or informal information dissemination about reproductive health, contraception, abortion, pregnancy, birth and postpartum, especially among youth; religious influence on the content of sexuality education classes; lack of open discussions of menstruation; lack of education of health professionals and policy makers on reproductive health. Comprehensive sexual education is presented as taboo or propaganda, and needs to be presented as a life-skills tool.
This lack of awareness and access to information impedes women's abilities to make safe, informed decisions about their reproductive health care and to exercise their right to decide freely and responsibly on the number and spacing of her children. It also contributes to an environment where women do not feel safe or able to discuss their reproductive health options and decisions.
- Informed consent: The obligation to provide adequate information in understandable form to patients is often neglected by providers, compromising users' active participation in care planning. Informed consent is often obtained by providing only partial information; there is no chance to pose questions or ask for alternative methods from health care professionals. These barriers to informed consent impede women's abilities to make their own reproductive health choices, and as such violate women's autonomy and dignity.
- Documentation of interventions and/or events occurring during the care process is often deficient. This encumbers the review of the care process (e.g. during supervision or in court proceedings) later on. Lack of documentation and lack of access to the documentation and data hinder women's abilities to seek redress for rights violations and to make safe and informed choices about future care.
Discrimination and Inequality in reproductive health care lead to direct rights violations. Discrimination and inequality particularly harm segments of the population who are the most disadvantaged and/or marginalized. Differential access to quality health care is itself a violation of rights and can seriously compound the impact of other rights violations. Examples of discrimination and inequality include:
- Inequality in access to reproductive health services, including maternity care, for minority, disadvantaged and marginalized groups (including: rural, poor, ethnic minorities (including Roma), migrant women or transgender people.).
- Substandard quality of reproductive care provided to minority, disadvantaged and marginalized groups (5) as compared to majoritarian population, as well as segregation in maternity wards.
- Restrictions on access to assisted reproduction for disadvantaged groups: same-sex couples; women living without a male partner; minority women and women with disabilities.
- Lack of knowledge and understanding and/or discrimination or coercion by health care providers against minority, disadvantaged or marginalized groups seeking sexual and reproductive services including lesbians, people with disabilities, transgender people, ethnic and religious minorities.
- Lack of holistic care that meets the needs of people with disabilities, or sicknesses requiring specific approaches to sexual and reproductive healthcare.
- Forced sterilizations and/or forced contraception, particularly of ethnic or religious minorities, disadvantaged and marginalized populations (e.g. Roma women, women with disabilities, transgender people).
- Women with mental disabilities – particularly those living in institutional settings – are often under full or partial guardianship, meaning that all their reproductive decisions are made by their guardian.
4) Lack of Accountability
Lack of accountability was one of the main themes of the caucus discussions. Lack of accountability makes seeking redress for violations very difficult. It also impedes any push for effective and lasting improvements to the healthcare system. Lack of accountability also makes it harder for women to access information about their health and reproductive rights options. Examples of lack of accountability issues include:
- Lack of accountability for healthcare providers and decision makers; lack of mechanisms and procedures providing adequate remedies and systemic improvements to the functioning of health care facilities, practitioners and systems. Such mechanisms are crucial for providing redress to women who have experienced violations and for encouraging best practices in medical settings.
- Lack of channels and procedures for gaining meaningful feedback from mothers/families to providers in person or in writing (particularly focusing on general treatment and respect).
- Fees for service in the field of childbirth: including, out-of-pocket or informal payments that have to be made to doctors, midwives or health care facilities; fees for a companion at birth; fees for epidurals. Such fees for service demonstrably negatively impact the quality of care received by women and incentivise increased interventions. Fees for service also impact accessibility of care.
- Lack of good-quality data collection systems: including for information on mortality, caesarean, episiotomy, all labour and delivery practices including interventions (6), abortion rates, unmet need for contraception etc.; also lack of gender, ethnicity, disability, sex orientation and age aggregated data on SRHR indicators. This lack of data makes it difficult for women to make safe, informed choices about care, and hinders effective reform efforts.
- Poor political support for reproductive health including pregnancy, childbirth and postpartum care and lack of financing. Lack of gender sensitive approaches to public budgeting. Without political support and gender sensitive budgeting and financing, it is impossible to effect change to healthcare systems.
- Guidelines/standards of care are not developed jointly with all stakeholders, including the potential beneficiaries of care and their advocates or representatives. Without consultation, such guidelines may not take into account the needs, rights and preferences of the potential beneficiaries of care or alternative care provider options (e.g. midwifery practices).
5) Lack of evidence based care
Evidenced based care ensures that women receive the highest quality of safe, medically appropriate care. Lack of evidence based care can lead to unnecessary interventions and other medical decisions that violate the rights and dignity of women and contribute to a less safe healthcare environment. Some examples of lack of evidence based care include:
- Lack of evidence-based protocols for handling pregnancy, birth and postpartum (e.g. no continuity of care during pregnancy; lack of homebirth protocols); and lack of awareness, on the side of healthcare providers of internationally accepted standards of care in the field of childbirth, reliance on outdated and harmful practices that negatively affect women and newborns.
- In most systems, medical protocols are not regularly reviewed by competent authorities to ensure that they reflect current evidence and best practices. Care given in accordance with such protocols is therefore not high quality, safe, respectful care.
- Increasing rates of caesarean section across regions and hospitals, with no accountability mechanisms.
- Lack of parenting support and access to the newborn after birth. Includes: Lack of continuous contact with the newborn after birth (7); lack of access to a sick newborn; and lack of support and empowerment focused on the exercise of confident parenting (e. g. lack of support in breastfeeding).
- Lack of choice of provider (midwife or doctor) and/or place for birth (birth centre, hospital or home birth).
- Lack of awareness of psychological impacts of childbirth, including of birth trauma and ways to address it; no psychological support available to women and families after birth. This affects women's long term experiences of care and cultural understandings of childbirth.
6) Provider Barriers
Provider barriers contribute to unhealthy work and care environments and make it more difficult for providers to give high quality, safe care. When providers are unable to practice in healthy and sustainable ways, the whole system suffers. Providers who are experiencing barriers may find it more difficult to advocate for their clients or to engage with them in respectful, healthy ways. Examples of provider barriers include:
- Frustrating working environments for providers of care, lack of respect for and fulfillment of their personal and professional needs and rights connected to exercising an occupation.
- Gender imbalances among health professionals providing care in childbirth and designing systems of care in childbirth.
- Restrictions of midwifery including: lack of access to quality education programs and the ability to open private, independent practices for midwives who work outside the hospital system. Add,Severe restrictions on the work of midwives who work in hospitals.
7) Violence against Women
Violence against women including sexual violence and intimate partner violence has significant interconnections with and impacts on the sexual and reproductive rights of women, including in connection with pregnancy, birth and postpartum. Violence against women can affect how women experience care, their access to appropriate, safe respectful care and their access to reproductive choices. Specific violence against women issues that were raised in the caucus include:
- Lack of awareness about violence against women, including how it impact care, pregnancy, childbirth and postpartum.
- Lack of data on the prevalence and effects of violence against women, particularly its intersections with pregnancy, birth and postpartum.
- Lack of appropriate systems of intervention for women who have or are experiencing violence.
Calls to Action:
1) Gender Stereotyping
We call for an end to gender stereotyping, particularly the treatment of women as not being competent decision makers. This requires increased access to and respect for reproductive choices; effective informed decision making that is grounded in the decisions of the clients; the elimination of disrespect and abuse in reproductive healthcare settings; an end in both society and economic and political systems to the stereotype of a woman as a mother; and increased assisted reproductive care.
2) Access to information/education
Access to information and education are some of the most significant ways of combatting all of the other reproductive rights issues listed in this document. Greater access to information about reproductive choices, quality of care and choice of providers, medical interventions and normal reproductive health issues including menstruation, sexual education, and childbirth empower women to be able to make safe, informed choices about their health care. Women also need to be educated about their rights and how they impact their reproductive choices.
Education is also crucial for providers. Ensuring that providers have training in rights based, respectful care and in evidence based care. Ongoing education should be given to care providers who were trained in earlier styles of care that are not compatible with respectful, evidence based care. Providers also need to be educated about power dynamics and client centered decision making.
We call for the elimination of discrimination and inequality in reproductive healthcare. Combatting discrimination and inequality requires recognizing its impact on safety and quality of care and the rights of women and families. Improving access to high quality reproductive health care options for minority, disadvantaged and marginalized populations must be a central priority for healthcare reform. Other reforms must include the elimination of segregation in maternity wards; elimination of restrictions to access to assisted reproduction for disadvantaged groups; effective education for providers about respectful, non-discriminatory care for minority, disadvantaged or marginalized groups; increased access to holistic care that meets the needs of people with disabilities or sicknesses requiring specific approaches; the elimination of forced sterilization/contraception particularly for ethnic or religious minorities and other disadvantaged and marginalized populations; and a reevaluation of decision making for women with mental disabilities, ensuring that their reproductive choices are respected.
Along with education, the need for accountability is a central call to action. Strong, effective, women and community oriented accountability mechanisms would provide for redress in cases of rights violations and would force healthcare systems, providers and decision makers to improve the quality of care. Increased channels and procedures for women and families to give meaningful feedback about experiences of care would improve patient-provider relationships and power dynamics. Additionally, developing guidelines and standards jointly with all stakeholders including potential beneficiaries of care, would ensure that care is client oriented and give women greater access to accountability mechanisms.
Eliminating informal (cash) payments in childbirth would improve quality of care and access and reduce unnecessary interventions. Governments must play a more active role in eliminating informal payments by making sure that providers are adequately compensated and not in need of informal payments to subsist. Additionally governments must conduct investigations into those providers who continue to take informal payments, while ensuring protections for whistleblowers.
Accountability also requires high quality data collection systems and a mechanism for making this data readily available. Access to this data is crucial for seeking redress, making informed choices and pushing for reforms. Developing accountability mechanisms will require political and financial support but would also give advocates and women mechanisms for encouraging greater political and financial support, particularly when grounded in high quality data.
5) Evidence Based Care
Education for providers, particularly about evidence based care is central to developing high quality, safe health care systems. Requiring regular review of medical protocols to keep them consistent with current evidence would encourage providers to also keep up to date with evidence. Along with specific accountability mechanisms, evidence based care would also help combat the increasing rates of caesarean sections, and other interventions. Evidence based protocols about parenting support and access to the newborn would empower parents to be more confident. Evidence based care could also be the basis for increasing access to choice of provider (midwife or doctor) and/or choice of birth place. Along with these benefits of evidence based care, data collection and education about the psychological impacts of childbirth for women, families and providers must also be a priority as it affects women's long term experiences of care, pregnancy and parenting.
6) Provider Barriers
We must also ensure that providers work in safe and healthy work environments. Respect for providers and ensuring that their needs and rights are met will empower them to be positive advocates for women and respectful care. Particularly in professions such as midwifery, provider's abilities to practice and support women's decision making can be severely hampered by the power dynamics in their work environment. One area for improvement would be to address the gender (and profession) imbalances among health professionals providing care and designing systems of care.
7) Violence Against Women
Violence against women must be recognized as a sexual and reproductive health problem. Women, communities and care providers must be educated about its intersections with pregnancy, childbirth and postpartum. Providers, in particular, must be trained in how to give care in ways that are sensitive to the experiences and needs of women. High quality data must be gathered about the prevalence of violence against women and its effects on reproductive health; and appropriate systems of intervention must be put in place to support women who have or are experiencing violence.
(1) See "Respectful maternity care: the universal rights of childbearing women." White Ribbon Alliance (2011).
(2) (due to various barriers, e. g. lack of subsidisation from the public health insurance, exercise of conscience-based refusals on the side of health professionals, religious and social pressures)
(3) (preterm birth abortions: pregnancy was wanted, birth started early, forced - non-consented abortion/birth. Non-existing palliative care in hospices;)
(4) (also, lack of legal provisions enabling supported but autonomous decision-making by persons with disabilities)
(5) See issue 11.
(6) (e.g. pushing and laboring position, Kristeller, what is done exactly to babies etc.)
(7) (e.g. separation of the child from the mother, after vaginal birth for few hours, after C-section also for few days)
Regional / International Organisations and Networks
Human Rights in Childbirth (HRiC), http://humanrightsinchildbirth.org
YouAct, European Youth Network on Sexual Reproductive Health and Rights, http://youact.org
YSAFE (Youth Sexual Awareness for Europe), www.ysafe.net
International Planned Parenthood Federation European Network, www.ippfen.org
Alliance for Maternal Health Equality, http://www.maternalhealthalliance.eu/
El parto es nuestro (Childbirth is ours), www.elpartoesnuestro.es
COST Action IS1405: Building Intrapartum Research Through Health - an interdisciplinary whole system approach to understanding and contextualising physiological labour and birth (BIRTH), European wide organization, funded by the EU, https://eubirthresearch.eu/
International MotherBaby Childbirth Organization, www.imbci.org
National / Local Organisations
Roda - Roditelji u akciji (Roda - Parents in Action), Croatia, www.roda.hr
Asociatia Mame pentru Mame (Mothers for Mothers Association), Romania, www.mamepentrumame.ro
ENCA Hellas (European Network of Childbirth Associations, Greek Branch), Greece, www.encahellas.eu
EMMA Közhasznú Egyesület (EMMA Hub - Women's Association for Birth Rights in Hungary), Hungary, http://emmaegyesulet.hu, http://emmahub.hu
CESI - Centar za edukaciju, savjetovanje i istraživanje (Center for Education, Counseling and Research), Croatia, www.cesi.hr
Udruga za ljudska prava i građansku participaciju // PaRiter (Association for Human Rights and Active Citizenship), Croatia, www.pariter.hr.
Ženské kruhy (Women's Circles), Slovakia, https://zenskekruhy.sk
Сдружение "Родилница" (Rodilnitza Association), Bulgaria, www.rodilnitza.com
Másállapotot a szülészetben! Mozgalom, (M)Othernity Movement, Hungary, https://www.facebook.com/masallapotot/?fref=ts
The Medical Women's International Association, Secretariat in Canada, www.mwia.net
Centar za majku i dijete "Fenix" (Mother & Child Center "Fenix"), www.centar-fenix.com, www.bhmama.org
Občan, demokracia a zodpovednosť (Citizen, Democracy and Accountability), Slovakia, www.odz.sk
Правозащитное движение: Бир Дуйно-Кыргызстан (Human rights movement: Bir Duino-Kyrgyzstan)
Kyrgyz Republic, www.birduino.kg
Fundacja Rodzić po Ludzku (Childbirth with Dignity Foundation), Poland, www.rodzicpoludzku.pl
Български хелзинкски комитет (Bulgarian Helsinki Committee), Bulgaria, http://www.bghelsinki.org/en
Mother and Infant Research Unit at the University of Dundee, United Kingdom, http://nursingmidwifery.dundee.ac.uk/mother-and-infant-research-unit
Liga lidských práv (The League of Human Rights), Czech Republic, www.llp.cz
Česká ženská lobby (Czech Women's Lobby), Czech Republic, www.czlobby.cz
This document should be cited as: Reproductive Health Issues that Impact Women During Pregnancy, Childbirth and Postpartum. Eastern Europe and Central Asia Caucus, Women Deliver. Copenhagen, May 2016. Available from: http://www.roda.hr/udruga/projekti/women-deliver/reproductive-health-issues-that-impact-women-during-pregnancy-childbirth-and-postpartum.html.
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