The term ‘obstetric violence’ refers to procedures performed during childbirth without a woman’s informed consent or medical necessity; they can involve violating her privacy, forcing her into positions, restricting her movement, denying her food or water, or subjecting her to humiliation or verbal abuse.
In some countries, such as Argentina and Venezuela, obstetric violence has been recognised in law since the 2000s as a distinct form of violence against women.
More recently, in March this year, Portugal adopted specific legislation protecting the rights of women during childbirth.
In Croatia, however, such violations only became a public issue in 2018 when the NGO Roda launched an online campaign under the slogan ‘Break the Silence’.
Hundreds of women came forward with harrowing accounts of childbirth; the following year, in response to the campaign, two UN special rapporteurs and a UN working group on discrimination against women submitted recommendations to the government and urged an independent investigation into alleged violations of sexual and reproductive rights.
In a joint statement, they said they were “appalled” by the testimonies, which included accounts of women being bound to their beds by their legs and arms; they called for the results of the investigation to be made public and for the drafting of national action plan for women’s health.
“We are deeply concerned about women being subjected to painful treatments without anaesthesia, including surgical miscarriage procedures, uterine scrapes, removal of placenta, stitching after birth, episiotomies being conducted against their will and disrespectful treatment of women by health personnel,” they said.
Seven years later, Croatia still does not have its own national guidelines for the care of women when labour is progressing normally.
“We believe that experts in gynaecology and obstetrics continuously monitor indicators, ensure the quality of care provided, and apply the relevant guidelines for childbirth care,” the Health Ministry said, without specifying what ‘relevant guidelines’ it was referring to.
Everything she didn’t want
When she was admitted to hospital, Marija’s birth plan was placed with the rest of her medical paperwork in the room where she was assigned a bed.
In it, she stated that she wished to be informed about every medical procedure to be performed – a right that is guaranteed under Croatia’s Patients’ Rights Protection Act.
She also wrote that she did not want medical students present; that she did not want to be shaved; and that she did not want an enema, a procedure in which fluid is injected into the anus to induce a bowel movement.
The WHO does not recommend shaving or enemas, saying there is no evidence to support their usefulness in vaginal birth.
Marija also stated she did not want her amniotic sac to be artificially ruptured – a procedure used to speed up labour – or an IV drip of synthetic oxytocin, a hormone the body naturally produces to trigger contractions, but which is often used to induce or intensify labour. The WHO does not recommend either procedure in births that are progressing normally.
She also ruled out an episiotomy, a surgical incision of the tissue between the vagina and the anus to enlarge the vaginal opening.
“The first doctor who examined me looked at my birth plan and asked, ‘Alright Marija, why are you refusing these interventions?’” Marija recalled.
“She didn’t even introduce herself; none of the doctors who came into the room after that introduced themselves either. They went straight to the birth plan. Obviously, they had been told I had one.”
In response, Marija told the staff that the birth plan contained her preferences, but that she them and was ready to discuss any procedure should it be deemed necessary.
Marija also specified she wished to be able to move during labour and to choose whichever positions felt most comfortable for pushing – positions known to reduce pain and open the pelvis more effectively than lying flat on the back, still the most common birthing position in Croatia.
According to WHO guidelines, in low-risk pregnancies, women should be encouraged to move freely and adopt any position that feels right to them.
Marija also hoped to use a birthing ball, which can relieve back pain and support the body in upright, active positions, and to be allowed to eat and drink in moderation if she needed to, given that labour can go on for hours.
Though she had heard from other mothers that maternity staff can be rough, Marija did not specify in her birth plan that they should be gentle, believing it would be inappropriate to mention; she also did not rule out the Kristeller manoeuvre, because she did not even know it existed.
In the end, none of the staff introduced themselves; medical students were brought in, before her husband asked the doctors to take them out; an episiotomy was performed without Marija being consulted; and her amniotic sac was artificially ruptured, which she consented to.
“Nobody asked me anything,” she said of the episiotomy. “I don’t know whether it was necessary or not.”
Marija said she is considering suing the hospital over her fractured ribs.
Stark contrasts in care
Maternity practices in Croatia veer wildly from WHO recommendations.
Since 1996, for example, the WHO advises that the rate of episiotomy should not exceed 10 per cent of all vaginal births.
In Croatia, however, the rate in 2023 ranged from 8.59 per cent at the General Hospital in Pakrac, in western Slavonia, to 75.8 per cent at the Clinical Hospital Centre in the northern coastal city of Rijeka.