Shaving, oxytocin, jumping on the stomach and vacuum extraction... that's what welcomes women in labor in Serbia. Gynecologists admit that they work like on a treadmill. Research DW exposes the failings of the health care system paid for by women.
"They say: when you go to Bethany, you say goodbye to your dignity. Is that normal?" says one woman about her experience in Novi Sad maternity hospitals. Another mother from Serbia says: "In my village, they take care of the cows more than the doctors took care of me."
"I have never shown anyone my first picture with a baby, because in that picture I look like a half-alive man. In my area, they would say - as if I ran away from the gravedigger under a shovel," says the third about her experience.
Shaving, an enema, then a dose of oxytocin to intensify contractions - this is the order that usually awaits women as soon as they cross the threshold of the maternity hospital in Serbia. These procedures are not recommended by the World Health Organization unless there is a clear medical reason or the express request of the woman.
DW spoke with more than twenty women in the past months. Their stories — which are very similar to each other — tell of inhumane treatment and the routine use of outdated and invasive procedures that speed up labor but increase pain and health risks.
"He just stabbed my arm"
"It was so intense and aggressive," remembers Stephanie Sh. from Novi Sad and how it looked today after she received her first stimulation with oxytocin.
"Yes, I opened it very quickly, but I didn't have any blood pressure because they forced it open. Then they came to examine me, one doctor after another, and finally one of them broke my water. But he didn't say anything to me, he didn't even warn me. He just stabbed my arm."
Oxytocin is used in maternity hospitals to increase contractions or to initiate labor in general. However, he can increase the strength and frequency of contractions so much that the pain becomes almost unbearable, without enough breaks for the woman to rest or prepare for the next wave.
Without oxytocin, labor may take longer, but the pain is usually more tolerable for the woman, as contractions progress at a natural pace with rest breaks, more movement, and less likelihood of additional interventions.
"They forced the birth that didn't start," says Nataša S. from Ruma. She was also given oxytocin, but since the birth progressed slowly with it, the doctors applied the Kristeler procedure, which is the official name for - lying on the stomach. Then the vacuum extraction of the baby.
"The doctor started jumping on my stomach, putting the baby down. After that, I had bruises under my breasts. She shouts: 'Tense', I tense up by heart, the capillaries in my eyes burst from the wrong tension. And then I hear the doctor say: 'Bring me a vacuum,'" Natasha remembers.
As a result of pulling out the baby with a vacuum, she says, the baby developed swelling on the head, and in the following days, Natasha feared more serious complications, including bleeding in the brain and cerebral palsy.
Water birth – schedule
"The use of oxytocin in our country often depends on organizational aspects - how many women are in the maternity ward who have not yet entered the delivery room," Jasmina Mihnjak, editor of the "World for Us" parenting portal, told DW.
Psychologist Biljana Stanković, who has been researching obstetric practices in Serbia for years, claims that the head of the maternity hospital in Novi Sad admitted to her that there is no capacity to give a chance to the natural course of childbirth, because it takes time. "He said, 'Honestly, even if I wanted to decide not to induce, I have nothing to do with the next women waiting to go into the delivery room'."
But that still shouldn't be the rule, says gynecologist Vladimir Weiss. "There would have to be clear medical signs that something inappropriate is going on, and then by stimulation or induction you try to prevent a negative outcome," Weiss explains to DW.
To check the extent of these practices, DW sent inquiries to all maternity hospitals in Serbia, as well as to the Institute for Public Health "Milan Jovanović Batut". The responses were full of statistical inconsistencies and holes in the records — suggesting carelessness in record keeping.
A prime example comes from the Loznica Health Center: their data states that lying on the stomach is used in about 90 percent of births. When asked why, the head of gynecology, Vladimir Đorđić, says that he does not know the origin or the author of that information. "It's shocking, brutal..." Djordjevic told DW.
He states that the documentation is often maintained by technical persons or less experienced doctors, so the data is probably unreliable. We heard similar remarks from other doctors in informal conversations, while "Batut" states that they do not check or analyze this data.
No empathy, no explanation
In addition to wrong entries, our interlocutors also recorded wrong words, ignoring, belittling, ridicule and insults. "I have never experienced that amount of insensitivity," says Natasha.
"We are so helpless in those moments - pregnant, about to give birth, contractions tear you apart, you can't do anything, you are literally at their mercy, and you experience some kind of relationship from them... I wouldn't even say like towards an animal."
"At some point I said, 'Please tell me what's going on, it will be easier for me.' And they laugh something in the style of 'what is this story, it won't be easy for you'", says Stefani. "The man who gave birth to me didn't communicate with me at all. He was nervous because he was woken up on the night shift."
Natasha also remembers the staff fighting over her body: "I'm asking for glucose to stay on my feet, and the midwife throws in: 'These are spoiled pregnant women.' The doctor comes in, doesn't talk to the midwife, everything goes through the obstetrician."
In the 2022 Report on the Treatment of Women in Gynecological and Obstetrical Institutions, which was compiled by three Belgrade lawyers, it is pointed out the big problem of verbal violence - insulting, cursing, humiliating, calling female patients derogatory names.
"Like on tape"
Why all that - our interlocutors ask themselves until one. Experts interviewed by DW peel back the layers of the problem that reveal a picture of an overstretched and tired health care system that the defense mechanism has found in – inertia.
Data obtained by DW show that a third of births in Serbia take place in the four largest maternity hospitals in Belgrade and Novi Sad, while smaller maternity hospitals are closing down.
"And because of that large number of births, women in large maternity wards are like on a conveyor belt," says Jasmina Mihnjak. "Hence the induction, speeding up labor, episiotomy and everything else - so that within 24-48 hours everything is over and the table is freed up for someone else."
Another factor is sociological, adds psychologist Biljana Stanković. She recorded cases of women admitted to the hospital just because they came from far away with things: "Then they send her to the ward, and there they say — the cervix is firm, the water hasn't broken. But since she's already admitted, they administratively 'go into labor' and then they put her on induction. Because of the initial miscalculation, the woman ends up on oxytocin."
A chronic shortage of people and low wages are on top of that, admits one gynecologist — but hardly anyone will say it out loud or to the management and authorities. And the administrations are mostly silent.
DW sent interview requests to the largest maternity hospitals, but they were turned down. The director of Novi Sad Betania, Dr. Dragan Stajić, initially agreed to the interview, but the director of the Clinical Center of Vojvodina, Vesna Turkulov, did not give his consent. "Not now, maybe sometime in the future," DW was told at the Clinical Center.
It can, but it won't.
"If you look at the number of maternity hospitals and the number of births in Serbia, I can hardly understand that it is overloaded," says, however, Dr. Vladimir Weiss. "We give in to the inertia of, 'Let's do the work during regular business hours,' or 'let's extend it to on-call,'" Weiss says.
While he was at the head of the maternity hospital in Pancevo, he initiated the pilot project of "unmedicated childbirth", which meant vaginal delivery without routine interventions.
"I managed to prove to myself and others that the state system can work. The staff I worked with initially reacted extremely positively. However, our work required greater commitment and as time went on, as people began to come to Pancevo more and more, they became - let's use that word - scared, and they started to position themselves differently," explains Weiss.
The project ended when the management told him one day that they "couldn't follow it", so he left the state system and moved to a private hospital.
Routine stronger than rights?
Inertia is recognized by other gynecologists DW spoke with. Data show that two-thirds of maternity hospitals have a maximum of three births per day. In such conditions, says one gynecologist, women could be given time to give birth naturally — but "habit" and "routine" prevail. "It's just how you do it," he says.
That argument should not help if women in labor fold the sheet, warns lawyer Sanja Radivojević from the Belgrade Center for Human Rights, because doctors can bear both material and criminal responsibility for their work.
"Most often, it is a violation of the patient's right to be informed about the procedure and to consent to it — or to withdraw consent." The blank consents that some maternity hospitals ask for at the reception are null and void, she adds.
"But we had a case of a woman whose labor was taking a very long time, and then the doctor on call said, 'I think we should do a vacuum.' She said: 'I don't agree to that, I'm aware of the risks of that procedure and that's out of the question,' but they still did it by holding four or five men," says Radivojević.
He says that the women's testimonies indicate a violation of Article 25 of the Constitution, which guarantees the right to inviolability of mental and physical integrity, and Article 137 of the Criminal Code, which prohibits abuse.
But none of the cases of so-called obstetric violence have yet received a judicial epilogue. Radivojević fears that the prosecution will deliberately run these cases into the statute of limitations.
Hopes in the guide – traumas in the drawer
The good news, our interlocutors agree, is that public pressure led to Serbia getting a national guide for natural childbirth. He notes the problems pointed out by women and recommends changing outdated routine methods, and pays special attention to the importance of communication with female patients.
"This is, on the one hand, an acknowledgment by the health workers that things have not worked so far, and on the other hand, an agreed position on what childbirth should look like," Mihnjak assesses. "We can now refer to the guide in the maternity ward, to say: 'I don't want my labor to be accelerated in any way if there is no need for it.'"
The bad news is that implementation will take time. "It can't be like that, you send us a guide and we realize it. Something that has been going on for 50 or 70 years, we have to rebuild it now with the resources I have," the head of the maternity hospital in Loznica, Dr. Đorđić, told DW.
Women in labor carry trauma from the maternity ward for a very long time. Stephanie says she is still healing from hers. "You know the fever you get afterwards, it was prolonged with me, and they had to give me an injection of benzedine to calm down. And every next time, when the doctor came into the room, I would start shaking. It's literally happening now," says Stephanie and breaks her hands that are starting to shake.
"I have an apartment on the street where Bethany is, and every time I pass by I have a terrible feeling. I just don't want to look there, on that side where I was, and I know exactly where I was when I gave birth."
Most women have never had the strength to confront their doctors. Jelena P. from Belgrade did - after two months she went, she says, "to look him in the eye".
"I didn't come to tell you how much it hurt, or what I went through. I'm just asking you: is it normal in 2023 for a woman to go through what I went through?"
The doctor shrugged, "As in your profession, there are those who go astray in ours. Best to lock that case in a drawer."
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