(originally published in March 2020)
After the Second World War and during the communist era (1948-1989), all births were gradually moved to hospitals, midwifery was renamed and treated as “female nursing” (1965-1993) and health care started to be provided universally and paid for by public funds. Midwifery community care was suppressed until it almost disappeared and started re-appearing again after the Velvet Revolution (end of the communist era in 1989).(1)
Currently midwifery education in the Czech Republic is in line with the EU directive 2005/36/EC which defines midwifery as an autonomous profession. After three years of university education, a midwife can start practising. There used to be a register of non-medical health care practitioners that all midwives had to join. A fee had to be paid to join the register and the registration needed to be renewed every few years after fulfilling certain criteria. This register is no longer in place.(2)
The majority of midwives work in hospital settings, either on maternity wards, gynaecology wards or neonatal units. Some midwives work in private IVF centres or private gynaecology surgeries in a nursing capacity. All maternity care is doctor-led and the insurance and hospital management systems prevent midwives from exercising their autonomy. In the hospital hierarchy, midwife is always below all doctors. Midwifery care is covered by insurance only when previously indicated by a doctor. Very few midwives work in community and their care is not covered by public insurance. All community midwives are practising independently. A few independent midwives have a contract with a particular hospital where they can look after their clients during labour.
A pregnant woman (whether healthy or high risk) will typically have all her antenatal care with her private gynaecologist (this is covered by insurance) and around 36 weeks her care is taken over by the local hospital or the hospital where she wishes to give birth. If the woman wishes to be looked after by a midwife during her pregnancy, she has to pay for the care directly. Postnatal care is virtually non-existent in public sphere, women spend a few days in hospital and when discharged, care of the baby is taken over by a private paediatrician and the woman has no care until her six weeks postpartum check up with her private gynaecologist. Postnatal community care is provided only by independent community midwives if the woman pays for it directly.
There are no freestanding birth centres and homebirth, while in theory being legal for women, is discouraged by all available legal and practical means. Midwives in the Czech Republic are not allowed to attend homebirths and when they do, they face penalisation. The regional authorities which are responsible for licensing independent midwives restrict their autonomy by excluding provision of care during labour from their licence.(3) There are two recent cases when homebirth attending midwives were fined for doing so. The fine was 100 000CZK and 120 000CZK which equals £3400/£4000.(4) To frame this – an independent community midwife will usually ask for a payment of around 10 000CZK ~ £340 for attending birth and being on call, this fee can sometimes also include some antenatal and postnatal appointments.
There were also two court cases in recent history during which midwives were judged for attending homebirths. They faced charges for causing serious harm/being negligent by providing care in homebirth. However, the charges were not proved and they were both acquitted after many years and numerous appeals. It became obvious during these processes that the main problem was the mere fact that these midwives attend homebirths. This is because the Czech medical societies view assisting homebirths as inappropriate practice.(5)
Freestanding birth centres are practically impossible to open and manage due to a regulation which orders that planned birth in a health care institution is only allowed if there is a doctor available within five minutes and urgent caesarean section can be performed within fifteen minutes.(6)
In 2019 a trial alongside midwife-led unit was opened in one hospital in Prague.(7) In the same hospital where a midwife-led unit was opened twenty years ago but its functioning was made impossible by the hospital management after a few years of its existence.(8) Opening of a midwife-led unit is a very welcomed step towards providing more choice to women. But because there is only this one midwife-led unit in the whole country, it is only available to a small number of women. Furthermore at this point, the women have to be seen and deemed low-risk by a doctor on admission in order to be allowed to give birth in the midwife-led unit. There are some hospitals in the Czech Republic in which midwives are allowed to look after low risk women more or less autonomously, but this is subject to local agreements and the will of the leading doctors, due to the hierarchy system.
See the attached picture of the midwifery-led unit ceremony opening, where the prime minister and health secretary were present. This picture was chosen for official presentation of the topic on the health secretary’s social media page.(9) It was widely criticised in Czech midwifery community as there are no midwives nor any women in the picture and also the language used in the description is not appropriate – the health secretary using expressions such as “mummies and their wishes” as if they are not equal partners in the debate about the care available to them. I think that the picture describes the current situation of Czech women and midwives very accurately.
Translation of the health secretary’s message:
HEALTH and SAFETY of mother and baby during childbirth is our priority. These principles are non-negotiable. Nevertheless we accept at the same time that MAXIMAL COMFORT and being responsive towards the birthing woman are important. That is particularly key in such a private and intimate event as childbirth is. That is why we are taking the path of improving the quality of the services in maternity hospitals and opening midwifery centres. We want that the WISHES of mummies are responded to. In midwifery centres that means that the birth will be managed by a midwife but a doctor will always be ready to step in if needed. And that is key for us.
Manuál: Jak se stát komunitní porodní asistentkou