Power dynamics in Hungarian birthing care
The leader is slain but the war is won: after 60 years of illegality and decades of persecution, home birthing is now legal in Hungary, in large part due to Ágnes Geréb’s advocacy and activism. Yet Geréb herself remains disbarred and still faces numerous charges related to her medical practice before the change in the law. And the medical regime affecting birthing is evolving only very slowly in a women-friendly direction. The stone wall that blocked Geréb’s path for exactly 40 years – the rubble of which continues to hamper her progress – was built from bureaucratic rocks: a regime of patient bribes; a strict biopolitical demands for the mechanization of births, and the historical process of midwives’ subordination to doctors. The original sin of the “child bed fever” epidemic, the tragedy of Ignác Semmelweis, and the unaccounted deaths of the mothers he didn’t manage to save, are the mortar that cement it together.
Hungarian home birth protagonist Ágnes Geréb had one of her convictions revoked in May 2017, yet she remains disbarred from practising as a midwife or a gynaecologist, is forbidden from being present around pregnant persons, and is still facing prosecution in a plethora of cases.
Geréb was arrested in 2011 and kept in pre-trial custody after the police were called to post-natal complications at a birth which was unplanned and at which Geréb happened to be present. At the time, home births were illegal in Hungary. She has faced trial for perinatal complications for which hospital obstetricians are not prosecuted. International experts in the field state that Geréb seems not to have made any professional mistakes. Instead, her prosecution is widely recognized as a witch hunt against home birth activism.
Her cases are obviously problematic, have a strong political touch and are surrounded by intense debates about whether she is a saviour or a charlatan, an activist or a criminal, a professional or a hippy on a loose leash. Authoritative figures in obstetrics and midwifery have taken her side and campaigned for her release, pointing to Geréb’s professional qualities – a point which even her opponents acknowledge. Yet these international experts were not admitted to testify in her trials. In court, only Hungarian medical expert witnesses and institutional doctors were called, people who themselves have never seen a home birth. Geréb has, in any case, very few allies among fellow Hungarian medical professionals. She is the only doctor who openly opposes and takes a risk standing up to the highly hierarchical regime of birthing care; as such, she is clearly the “black sheep” of obstetrics in the country.
‘So I went along’
Ágnes Geréb was a university student in training as a general doctor when one day, as she describes it, she was wandering around in the hospital looking for a task. That was when she stumbled upon a woman in labour with her already-dead baby, left totally alone in a room. She stayed there with the mother through her birth, which she later described as a transformative moment: at that moment, she decided to become an obstetrician. In the birthing regime typical of the 1970s, this was an odd and sad, yet unique opportunity for her to see an undisturbed birth, basically because a dead baby being born was of less interest for the already-overwhelmed doctors at the clinic.
Geréb graduated in 1977 and started to work at the Szeged Women’s Clinic as a medic. She observed patients’ wishes, silently disobeying some hierarchical rules of the medical discipline which she regarded as pointless. From the start, she would let fathers be with their wives when they gave birth, an especially big no-no at the time. She was temporarily disbarred from the clinic for this activity in 1978, and at other times later on. In 1984, seven years after she had started the practice, hospitals began admitting fathers at births. Geréb was not pardoned, neither compensated for the disbarments. By then, she was already advocating a holistic model of birthing – as distinct from the practice of seeing birth as merely the process of delivery – as well as home birthing.
One of her patients had just returned to Hungary after having lived in the US, where she had given birth at home. This patient suggested to Geréb that she entertain the possibility of extra-institutional births, and even helped organize a study trip to a birthing centre in Livermore, California, run by independent midwife Bea Haber. By the time of this six-month study trip, Geréb had already had clients from the clinic whose births she had started to oversee in their homes. In 1992, she organized an international conference in Szeged and set up the Alternatal Foundation. She organized several public talks and translated and published literature on alternative methods to the contemporary medical regime. She got to know internationally renowned advocates of the free birth movement, such as Sheila Kitzinger, Ina May Gaskin and Michel Odent. She promoted the advancement of midwives in the duties around birthing, a profession that at the time was – and mostly still is – completely subordinated to doctors in Hungarian hospitals. But neither doctors nor midwives in Hungary were infected by Geréb’s enthusiasm. After giving birth to her fourth child in 1994, she interrupted her clinical career. ‘I felt unwelcome. I just didn’t go back,’ she says.
By that time her clientele had started to grow and without much set-up she started to work as an irregular freelancer, providing a service for home birthing which was neither clearly criminalized nor yet entirely legal. Medical assistance to extra-institutional births were not allowed, but birthing outside a hospital itself wasn’t banned. Geréb appealed multiple times for a professional licence to legalize her work but was never granted a permit.
By the second half of the 1990s her movement grew in terms of clients and colleagues, and she became known in Hungary as the kind of strange unorthodox figure doctors hate, many people are suspicious about, yet whose followers praised highly. Home births would be talked about on national television, often times labelling it as a fad for well-off women who do not recognize the importance of hospital regimes and put their babies at risk. Suspicions were voiced about this being a well-paying business. From the second half of the 1990s, whenever Geréb or her team would call an ambulance to any birthing complication, most often a police car would also automatically arrive.
In 2000 a baby was born without any complications, but suffered post-partum brain damage due to lack of oxygen and died a year later in what may have been a case of Sudden Infant Death Syndrome. Geréb was prosecuted and in 2007 sentenced to three years’ disbarment from practising as an obstetrician. Due to the prosecution, she had already begun qualifying as a midwife, partly because she was promoting a midwifery-based model anyway, but in large part because she spotted a loophole in the professional regulations. If she could not practise as a doctor, she still could be active as a midwife, she suggested. The courts never acknowledged this logic and never took into consideration that midwifery could be a different profession, with different protocols from those of medical doctors.
In 2003 and 2007 more babies died, the first a twin who suffered from lack of oxygen, the latter from shoulder dystocia. This latter complication is a topic of concern in hospitals as well: in the process of delivery, the baby’s head emerges, but their anterior shoulder gets stuck in the mother’s pubic bone. C-sections are no longer an option at this stage. Geréb tried a procedure known as the Gaskin manoeuvre, but could not save the baby. The parents pressed charges and the case resulted in a national scandal, with Geréb depicted as a child murderer and many medical doctors condemning her publicly.
Strangely, even these scandals attracted attention to the horrors present in institutional birthing care and a discourse was started on the changes needed. The Obstetricians’ College of the Chamber of Doctors clearly rejected the issue of home birthing in 2002. But the tide had turned by 2007, and they agreed to possible legislation to legalize it when liberal Minister of Health Ágnes Horváth initiated a series of negotiations. Final agreement was never reached: the doctors blamed Geréb and her colleagues for being insistent on their demands, they rejected over-regulation of their work and both parties rejected the minister’s ideas on ambulance protocols. Not much later, the government fell into crisis and the issue sank from public view.
On 5 October 2010, Ágnes Geréb was visited by a pregnant woman whom she had formerly turned down and had advised to give birth in hospital based on her unfavourable test results. The subject came back with new results to prove she was eligible for home birth, and her labour started during her visit. It was a “storming birth”, meaning that it happened very quickly and powerfully and, as a result, the baby had trouble breathing. The midwives called an ambulance and the police arrived, arresting Geréb without obvious legal grounds.
She was held in pre-trial custody for almost three months, in scandalous circumstances: official visitors were not allowed to meet her, she was driven to court in handcuffs and leg shackles that caused open wounds to her legs; she was subjected to strip searches and allowed only a single monthly visit from her family. Protests were organised, and international professionals appealed to the Hungarian authorities to free her.
Two months later, in December 2010, an unforeseen event helped turn the tide: Anna Ternovszky, a private citizen who at that time was pregnant and was a client of Geréb, appealed to the European Court of Human Rights in Strasbourg. The court condemned Hungary for violating women’s right to choose where they give birth. Shortly afterwards, Geréb was transferred to house arrest and a flurry of legislative action began. Within only four months, a newly appointed secretary of health, Miklós Szócska, pushed through a law, which came in effect on 1 April 2011, legalizing home births and ending a 61-year ban.
Since 2011, independent midwives have been granted licences and now working in Hungary in growing numbers and. They report growing acceptance of their work from institutions. One might think, Ágnes Geréb at last won the war. The truth is, as usual, more nuanced than that. Home birth activists are dissatisfied with the law since they think it overregulates their work, while public medical insurance doesn’t finance their work. Geréb is no longer under house arrest, yet she cannot leave the country and is forbidden from practising her profession. She appealed for a presidential pardon but was refused, with the argument being given that, despite the importance of her work and her achievements in advancing the cause of free birth and women’s rights, disobeying the law must still be punished. She herself suspects she will never be allowed to work under to the new law. She has lost the work which provided her with a sense of personal identity and an income. She now works as a typist.
The Semmelweis lesson
Despite Geréb meeting international standards and receiving professional and moral support, she is clearly on the losing side. To see why the Hungarian obstetrics profession has refused to bend, one needs to look into the history of this profession in Hungary and, in a wider context, across the former Austro-Hungarian Empire.
The founding moment in modern obstetrics has a lot to do with a Hungarian physician, Ignác Semmelweis, who earned his doctoral degree and diplomas as an obstetrician and a surgeon in Vienna in 1844 and 1845. He then started to work as an assistant to a Professor Klein at the Obstetrics Clinic at Vienna’s Allgemeines Krankenhaus (General Hospital).
This period marked the latter phase of the anatomical revolution, an important movement of the Enlightenment since the 16th century. Having gained legal access to human bodies, medics started to map up the organs and the processes within the human body. It took approximately another century for doctors to gain access to the business of birthing. The discovery of the uterus itself involved experiments on enslaved women, used as research dummies without anaesthesia. With the anatomical mapping of the uterus, medical doctors demanded and gained access to the process of birth, a highly personal and intimate yet physiologically completely normal process.
Tremendous advances, and along with a plethora of unjustified interventions ensued. The history of modern obstetrics is the history of benevolent advancement as well as abuse of power and disrespect for women. The progress of medicine brought essential life-saving methods, but many of these were developed at the price of patients being hospitalized, catalogued and drawn into the biopolitical machinery of the production of manpower.
At this stage when Semmelweis started to practise in Vienna, the anatomical revolution was in its prime, and omnipresent. Autopsy reports were published in newspapers. That is exactly how Semmelweis discovered the correlation between internal poisoning and puerperal fever, also known as childbed fever. Semmelweis was mourning the death of Jakob Kolletschka, a friend and colleague of his in a quite morbid, yet at the time very average fashion: by reading his autopsy report. That is how Semmelweis recognized that Kolletschka’s symptoms, resulting from poisoning he suffered during an examination, were identical to those birthing mothers displayed in institutionalized circumstances.
Two maternity clinics were operating in parallel in Vienna, one run by midwives and one by medical doctors. The training of these professionals was regulated by Empress Maria Theresa in her order Generale Normativum in re Santiatis in 1770 and institutions set up according to Ratio Educationis in 1777. Midwifery was gradually regulated as a profession to be practised only by those who had a diploma. This demand for professional training was enforced gradually, as most midwives in rural areas could not go to school, in part due to their duties in their communities, partly because many of them were illiterate, and also because some of them did not speak German. Hungarian and Slovak language education was introduced some years later, and midwifery started to became a middle-class profession across the Empire.
Seventy years later, by Semmelweis’s time, midwives and doctors underwent theoretical schooling together at medical universities, but their vocational training happened at two separate clinics. At this time, institutional births were still a novelty, and these maternity clinics were set up as free-of-charge institutions for urban women who could not afford midwives. Most of them were very poor urban dwellers, many of them unmarried and/or prostitutes. As a return for the service, women were used as subjects for training purposes.
Semmelweis observed that the midwifery clinic had a mortality rate of 4%, whereas doctors produced a mortality rate around 10%, which nonetheless compared well to clinics elsewhere in Europe. In birthing institutions, the mortality rate could reach up to 30%. Studying the statistics and the practices Semmelweis concluded that doctors dealing with corpses were themselves causing childbed fever, since they performed autopsies and then examined mothers without cleaning their hands. He then introduced a strict regime of handwashing with chlorine at the clinic, and maternal mortality drastically decreased.
It should be recalled that this happened three decades before the microbiological revolution started, so people did not know about pathogens. Semmelweis himself concluded that toxins were transmitted from dead bodies.
After taking part in the 1848 Viennese revolution, he did not get his position extended at the Vienna hospital and returned to Pest in Hungary to work as honorary professor at Saint Rokus Hospital, where he managed to decrease mortality to below one per cent. Yet he only published his findings a decade later in his book Die Aetiologie, der Begriff und die Prophylaxis des Kindbettfiebers in 1860. He is often talked about as the Cassandra of his time, a misunderstood protagonist, which is something of an overstatement. Semmelweis was applauded for his work and established quite a reputation for himself in England and in many places throughout Germany, and his regime of asepsis was established and maintained in Pest. His peers and the upcoming generations of students understood and subscribed to his theory. Yet it is true that he had very painful debates with professors of higher merit, especially in Vienna, where many former colleagues rejected him. His participation in the 1848 Vienna revolution did not help him politically, nor were his chances helped in the aristocratic medical community by his origins as the son of a grocer.
A threat to a new profession
More seriously, Semmelweis’s theory threatened obstetricians on multiple grounds. First, it placed life-and-death responsibility in the newly established profession, which had gained access to the formerly forbidden phenomenon of birthing less than a century before. Second, it reinstated the individual integrity of birthing women, and not just poor and morally compromised women, who doctors otherwise tended to view as undifferentiated masses for them to perform on. Semmelweis separated these corpuses from the dead corpses and also from each other, demanding an understanding for the individuality and the personal boundaries of a birthing body. Third, it reprimanded gentlemen, pointing out that they should have paid more attention to midwifery, previously regarded as a female profession.
These were painful lessons that many highly ranked figures rejected. Meanwhile, Semmelweis himself was developing serious mental problems, partly due to an infection that damaged his brain, and party due to his ever-growing sense of guilt about the deaths of mothers he himself caused before his breakthrough, and the deaths of those who he couldn’t save from his self-absorbed colleagues. In a cruel irony, his life was cut short by sepsis, the condition he himself had identified, after he suffered a severe beating while attempting to escape from a mental home.
Within two decades from Semmelweis’ death, Lister started to experiment with antiseptics and Louis Pasteur published his first works on pathogens. The microbiological revolution not only proved Semmelweis observations, but even provided them with a now visible cause.
Nobody was ever held accountable for his death. Nor was anyone held accountable for the deaths of thousands of women across Europe. This original sin is a crypt in the founding myth of modern obstetrics.
Disinfection and the handwashing regime has become a hospital ritual, and rightly so, but crucial parts of Semmelweis’s lesson were ignored.
Midwifery was not rehabilitated as a profession, and a tremendous corpus of accumulated knowledge was lost. Nor did the integrity of the birthing woman become any more important to obstetrics. In fact, medicine grew more and more into a disciplining authority over the years, in part due to rapid urbanisation, and lack of resources and manpower in institutions during the world wars.
In the meantime, since we abandoned poor old Semmelweis, many changes have happened in Hungary. Cities grew all around Europe and the world at an astonishing speed. Budapest for instance grew from fewer than 400,000 dwellers to over a million in only thirty years. The education of midwives changed: college training was available not only for independent midwives but also institutional professionals, who gradually became subordinated to doctors. Yet the profession that has provided women with agency and independent means of living for thousands of years, still did exist, especially in rural regions.
This ended in 1950, when the Stalinist regime in post-war Hungary forbade birthing outside of institutions. For more or less another decade, village midwives would still see through births eventually, calling an ambulance afterwards, relying on the lack of infrastructure. By the end of the 1950s, this ended.
But not only did the Stalinist leadership forbid reproduction outside the control and discipline agencies of state health institutions, but they also abolished college education for midwives. In 1968, vocational schools were launched to train future healthcare workers, and the higher education of independent midwifery was discontinued. Vocational schools trained nurses, and whoever wanted to specialize in birthing care had to complete a further one year of training and obstetrics nurses were explicitly subordinated to obstetricians, that is to doctors. The formerly independent and for a long time partner profession of midwife was finally conquered and directed under the control of medical doctors. Which in this case most often means men.
Since 1980, women have earned over 50% of all new doctoral degrees in Hungary. Right now over half of practising doctors are women. But among obstetricians and gynaecologists, 88% are male.
College education of midwifery was reinstated in the early 1990s due to professional pressure and advocacy, but the independence of midwives not restored, reinforcing their subordination to doctors and forbidding them from performing any medical assistance outside of hospitals.
The industrialization of birthing care, excessive use of oxytocin and other interventions, and lately an ever growing number of caesarean sections happened quite smoothly, in large part because midwifery as a profession was sidelined.
The situation today is not much brighter. Despite the WHO suggesting that 5-15% of births via caesarean is an acceptable ratio, institutional births in Hungary end up with caesareans in over 35 out of a hundred cases, and the ration has been continuously on the rise for over a decade now. This places Hungary at the top of the list among OECD countries, behind Italy and the Turkey, where over a half of all births result in surgery.
Here we should mention another important phenomenon that Ágnes Geréb confronted, and thereby threatened the obstetrics community. This is, at last, about money.
Geréb represented worrying competition to fellow obstetricians when it came to the Hungarian habit of tipping medical professionals in hope of better treatment, using cash in envelopes. This phenomena we call hálapénz (‘gratitude money’ in a mirror translation), or more often paraszolvencia. This latinizing formula you won’t find in the dictionaries, since in this form this word is a uniquely Hungarian development, culturally situated somewhere between ‘tip’, ‘gratutity’ and ‘bribe’.
Obstetrics as a field thrives on these tips, since the gradual development of their clientele, and the regularity and the rituals of pricing otherwise state-financed medical services (monthly check-ups or CTGs for instance) allow obstetricians to benefit from and even plan on these payments, which in other medical fields occur far more sporadically.
Tips are a means of buying the benevolence of a given medical professional, who in return is supposed to treat the patient with extraordinary care. Yet, since these agreements are completely informal, the patient gains no actual rights or entitlements through the transaction. These are verbal contacts not penalized but neither regulated by law, so nobody can go to court or turn to any other authority if the tipped professional does not treat them accordingly, or may not even show up at the time of the birth. Many doctors may perform devotedly or simply decently, but what actually happens at the given time, is a matter of pure chance.
Extraordinarily, this phenomenon is rooted in the formulation of health care in Hungary in the 1950s. When the governing Stalinist party, the Hungarian Workers Party collectivised agriculture in Hungary (a process which amounted to confiscation), a decision was made to compensate agricultural workers by declaring universal health care for all citizens. Yet this service was not covered by the appropriate resources, staff or even hardware. So in 1952 the government agreed to make it a ‘tipping profession’, to compensate doctors for the extra duties. Even though state health care income gap was closed within 20 years, the surplus income was never spent on developing health-care infrastructure accordingly, but was spent on other projects of the socialist state instead. Paraszolvencia was here to stay and has been an unchangeable national practice ever since.
It is worth noting that despite the widespread argument that gratitude money was supposed to compensate doctors for their unfairly low incomes, these tips show a negative correlation with the financial needs of the actual medical professional. In short: the higher the rank, the more a doctor receives. Tips are not, therefore, an efficient way to compensate for underfinancing, and have nothing to do with professional fairness.
Had one wished to deal with the lack of resources in health care, one would better campaign for transparent financing of state institutions, organize fund-raising campaigns or, even better, demand a fairer and more sustainable tax and insurance system. Tipping is rather about sustaining a highly hierarchized regime of power, on top of which are the highest ranked medical professionals. These decision makers have a vested interest in not abolishing the habit of tipping since it benefits them excessively, despite harming both patients and lower-ranking medical workers. The state itself has a counter-interest as well, since this system places tensions between the health care workers and the patients instead of the state and its concerned agencies, who are responsible for the conflicts in the first place.
Ágnes Geréb did not accept tips in her clinical years, and as an irregular freelancer she and her colleagues developed a pricing regime that was well below average tipping rates.
Hospital doctors would explicitly ask for sums of between €200 and €500 or more. Six years ago, when I gave birth, the average Budapest tip was around €320, while Geréb and her team asked for €160, but any patient could ask her for a lower price or state how much they could actually afford to pay. It is worth remembering that with hospital tips, you get no receipt, nobody pays any taxes and you get no guarantees. Also, it happens in a medical environment that was already financed by your public health insurance contributions.
A stereotype enforced by the law
After Geréb was arrested in 2010, a legislation for extra-institutional births was introduced very quickly. Her fights are over: free birth is now legal and possible. Institutional birthing care seems to evolve very slowly, if at all. But it is not compulsory any more. One might say, the leader has been slain, but the war won. Geréb suspects she will never be allowed to practise again. But she also draws attention to another important barrier: money, again.
Ever since Geréb gained popularity, home birthing has been accused of being a fad of the wealthy. As detailed before, Geréb’s colleagues tried to make sure that people who did not have a lot of money were not be excluded from their services. But the legislation that was introduced six years ago demands so many technicalities, accessories, insurance and the like, that the cost of home birthing has ballooned. Furthermore, home birthing is not financed by public medical insurance.
So now home birthing has been legalized, but in such a fashion that it is, ironically, becoming the reserve of the wealthy, a privilege only for those who can already afford it. So while the original stereotype was untrue, now it is being enforced by the law.
This article is based on a presentation by the author at a seminar held at the Institute for Human Sciences (IWM) in Vienna on 16 May 2017. Réka Kinga Papp is currently a Milena Jesenská Visiting Fellow at the IWM.