Jana has been a midwife for many years in both hospital and community settings. Having faced numerous challenges in her profession, she decided to contact the Ministry of Health in an open letter explaining the current issue of unavailable homebirth care. This letter exchange illustrates the difficult situation for women and midwives in the Czech Republic.
The first letter
Original letter can be found here: https://www.vlada.cz/assets/ppov/rovne-prilezitosti-zen-a-muzu/Pracovni_skupina_k_porodnictvi/Priloha-c–3a.pdf
Open letter to the Ministry of Health, Czech Republic, to the Health Secretary Mgr. et. Mgr Adam Vojtech and to the leading representatives of the Czech Obstetric and Gynaecological Society
Dear Health Secretary Mgr. et Mgr. Adam Vojtech and other representatives of the Ministry of Health, Czech Republic and representatives of the Czech Obstetric and Gynaecological Society.
I have worked as a community midwife for the last 7 years. Since the beginning, I have faced oppression from the state towards my profession. However, what has been happening in recent years is no longer sustainable and is unacceptable in a democratic society.
I would like to inform the Ministry of Health and also the public about the real situation around midwifery care at homebirths.
The real situation is that the Ministry of Health refuses to provide healthcare to the women who in their freedom make an informed decision to birth at home. Every woman has an unquestionable right to choose the place of birth according to the Charter of Fundamental Rights and Freedoms. However the state refuses to provide care to these women.
How? The local licensing authorities do not grant a full licence to independent healthcare providers, they limit the licence so that midwives are not allowed to assist homebirths under the threat of CZK 1,000,000 (GBP 33,500) fine. Midwives are not even allowed to look after a woman who wants to deliver in the hospital but wishes to remain at home for the first stage of labour. Even in this case the midwife would risk a 1 million CZK fine.
The women who opt for a homebirth often decide to birth unassisted or with a doula, who has no education in providing healthcare. A doula therefore cannot assess blood loss, cannot resuscitate a newborn or mother, cannot assess and suture a perineal tear, cannot assess the risks during a homebirth.
The women who choose to birth at home will not disappear just because the state is oppressing midwifery care at homebirth. The numbers will remain more or less stable. We can see in the numbers from most countries where homebirth is an available choice within the system. They represent between 2% and 4% of all births. By legalising midwifery care at homebirth, setting clear rules, educating community midwives – homebirths will become safer than they are under current conditions.
I am asking you, Health Secretary and other responsible representatives of the Ministry of Health and representatives of the Czech Obstetric and Gynaecological Society, whether this state of things seems acceptable to you. The fact that for the first time in history you are leaving some women entirely without healthcare during childbirth. That you are leaving this 1-2% of women without any support of a trained healthcare professional.
I am asking the Ministry of Health for an explanation, why are midwives in the Czech Republic receiving limited licences? Why isn’t there a single midwife in the Southmoravian region who could attend a homebirth without the threat of receiving a fine for doing so? Who is going to look after these women?
I am asking the representatives of the Czech Obstetric and Gynaecological Society to cooperate with professional midwifery organisations to create a safe functional system of care, where women are free to make an informed decision about the place of birth. Together, let’s create a safe care strategy for women birthing at home.
Below I have attached the response of the Southmoravian local authority to my request to extend my so far limited midwifery licence.
Kind regards, Bc. Jana Riedlová, community midwife from Brno, 5th April 2018
The attachment mentioned in Jana’s letter can be found here. In short, in this letter the local licensing authority is refusing to provide a full midwifery license to Jana.: https://www.vlada.cz/assets/ppov/rovne-prilezitosti-zen-a-muzu/Pracovni_skupina_k_porodnictvi/Priloha-c–3b.pdf
The first response
Jana did not receive a response from the Ministry of Health, but she did receive a reply from one of the members of parliament who is also a emergency medicine doctor. The wording was actually shocking and many individuals as well as organisations criticised such communication. However, there were no consequences for this MP, until this day, he remains in his position.
Transcript of the original response in Czech can be found here: https://www.vlada.cz/assets/ppov/rovne-prilezitosti-zen-a-muzu/Pracovni_skupina_k_porodnictvi/Priloha-c–3c.pdf
You probably think that the topic of childbirth is somehow special. It simply isn’t! Millions of years women are giving birth and it’s actually the best role. Why do you still spiel about it? What do you want. Give birth to your own children and be a great mum. What do you want. What do you need. Nothing. A fertilised woman can come to her doctor by herself, leave her to it. Don’t poke her and everything will be OK by itself. And if not, I, as an emergency doctor, will arrive and manage somehow. The best you can do is to give birth to your own children and leave other women alone and they will manage, just like you all do!
Have a nice day,
MUDr. MILAN BRÁZDIL
Member of Parliament
Member of the Healthcare Committee
Memeber of the Security Committee
Chair of Subcommittee for Emergency Healthcare Services
Sněmovní 1, Prague
The second letter
In 2020, after waiting almost two years for the response, Jana decided to send another open letter.
The original letter can be found here: https://m.facebook.com/liga.lidskych.prav/posts/10157588073496273
To: Mister Mgr. et Mgr. Adam Vojtěch, MHA, The Health Secretary of the Czech Republic, Palackého nám. 4., Prague
Subject: Information request according to no. 106/1999, Free Access to Information Act
Dear Health Secretary,
I am contacting you with this letter for a second time, because you never replied to my first open letter sent in 2018 despite promising you would.
I am a community midwife, also contracted to work in a maternity hospital. I accompany my birth-giving clients to a maternity hospital. The Southmoravian local authority issued a limited licence to me even though I have never requested a limitation of services provision.
Despite that, women contact me all the time, requesting midwifery care at homebirth. Abroad it is usually 1-2% of women who for various reasons decide to birth their baby outside of a hospital. Even though after the revolution* midwives were legally granted same competencies as their foreign counterparts, the interpretation of the Ministry of Health limits our competencies by creating additional regulations and refusing to provide care to this group of women. At the beginning of this year an experienced midwife Lucie Kasova received a fine of 100 000CZK (3300 GBP) for having assisted homebirths.
We could have been working together to create a safe framework for midwifery practice for the past 20 years, but instead the Ministry of Health chooses to pursue a path of oppression.
I am therefore asking you, mister Health Secretary, do you really think that these women will stop birthing at home? The reality proves the opposite. I would like to know who is going to provide care to these women and how is the Ministry of Health planning to guarantee professional healthcare which they have the right to receive.
How is it possible that you keep using arguments such as safety for mothers and saving babies lives while you are leaving these women without any professional healthcare whatsoever? Instead of trained healthcare professionals – midwives, these births are being attended by lay people, doulas and others. Who in those cases is going to provide resuscitation to the newborn, who will assess postpartum blood loss, who will administer medication to stop postpartum bleeding, who will assess the risks during first and second stage of labour and transfer the woman to hospital if needed or call an ambulance? Who will maintain clear documentation about all events in labour, documentation so important for providing appropriate subsequent care?
I am interested to hear whether the Ministry of Health has a statistic about these unassisted births and how safe are they for mothers and babies. Studies from abroad are very clear on this. Homebirths are safe when planned, for low risk women and when the risks are continuously being assessed by at least one attending midwife and when they are integrated in the healthcare system.
Mister Health Secretary, do you really believe that these women and babies do not have the right to receive professional care from a university trained midwife? And have to therefore undergo the risks of unassisted births?
I am asking you and professional medical and non-medical societies to give your comments on whether it is acceptable for you, when a women who decides to birth outside the hospital is not allowed to call a midwife to assist her with the birth.
Midwife Bc. Jana Riedlová, Brno, 22nd January 2020
*This is a reference to the Velvet revolution – end of communist regime in 1989
The official response from the Ministry of Health
The reply with redacted names can be found on the Ministry of Health official website: https://www.mzcr.cz/wp-content/uploads/wepub/18487/40223/18_2020_A.pdf
A response issued by the Ministry of Health to the request for information according to no. 106/1999 Free Access to Information Act, as amended
We provide the following comments in response to your letter received on 22nd January 2020, in the subject of healthcare provision by midwives during homebirths:
Healthcare provision in the Czech Republic is regulated by no. 372/2011 Healthcare Services and Conditions of Provision of Health Services Act, together with further regulations, regulation no. 99/2012 About Minimal Staffing Safety for Healthcare Services and regulation no. 92/2012 About Minimal Technical and Material Safety in Healthcare Institutions and in Community Care.
Regulation no. 99/2012 About Minimal Staffing Safety for Healthcare Services, as amended, clearly specifies the requirements for providing safe healthcare including healthcare provided by midwives in outpatient settings according to appendix no. 1 of said regulation, part I., subparagraph 2.11, in the following way:
2.11.1. Healthcare without intrapartum care provision
a) a midwife licensed to provide care without supervision
b) a specialist midwife licensed to provide care without supervision if the services provided are regulated by a different regulation
2.11.2. Healthcare including providing intrapartum care for physiological births
a) a midwife licensed to provide care without supervision,
b) a specialist midwife licensed to provide care without supervision if the services provided are regulated by a different regulation
c) gynaecologist/obstetrician – physical presence in the workplace within 5 minutes.
If providing a caesarean section or providing an operation leading to delivery is not guaranteed within maximum of 15 minutes from the identification of complication in a healthcare institution, the care must then be organised in an inpatient setting according to the rules of subparagraph 15 part 3 of said regulation and also with presence of a neonatologist according to the appendix 3, part II., subparagraph 1.7. This applies to care provided within a healthcare institution setting.
The above implies that midwives are allowed to provide intrapartum care in physiological labour as long as all the requirements for solving intrapartum complications are met accordingly. These requirements are set in a way to maintain care quality and patient safety for both mother and baby.
Since January 2014 women can give birth in maternity hospitals without a doctor’s presence, only attended by midwives. This concerns uncomplicated cephalic births with a prior doctor’s approval. A midwife who is responsible for intrapartum care must have a contract with the healthcare institution or be an employee. There is also a second option and that is a so called outpatient birth, which allows the mother and newborn to leave the hospital prematurely.
The above mentioned options guarantee to birthing women, who for personal reasons do not wish to have a doctor present during labour and birth, the required level of privacy. On the other hand these allow immediate provision of medical care to both women and newborn, should the need arise, which is in compliance with the requirements of quality and safety of the healthcare provided.
Your statement that the Ministry „is leaving women to birth without any healthcare provision,“ in other words that the Ministry refuses to provide professional healthcare must be denied. The Ministry of Health is a central body of the state administration and is not therefore in any case a provider of healthcare services. The healthcare services for pregnant and birthing women and newborns are fully covered by the system of public insurance and are being provided by the healthcare providers that hold a licence to provide such care, which means that they comply with the set requirements. The accessibility of these healthcare services and the network of healthcare institutions which provide such care is absolutely sufficient in the Czech Republic.
Currently this type of healthcare services is arranged well in all aspects. In its content (including a guarantee of quality and safety of the services provided), organisation and insurance coverage. The Ministry together with professional organisations want to go forward by cultivating the current system in way of continually increasing the quality and safety of care while making efforts to satisfy women and their families. Therefore we do not support homebirths or freestanding birth centres, we always unequivocally stand on the side of the unborn baby and we promote birthing with the presence of professionals within maternity hospitals.
The birthing woman has the right to chose the healthcare provider with a friendly environment (see patients right to chose healthcare provider in accordance with provision § 28, paragraph 3, subparagraph b) of no. 372/2011 Healthcare Services and Conditions of Provision of Health Services Act. Nobody is denying women in the Czech Republic this right.
In accordance with the World Health Organisation (WHO) and The International Federation of Gynaecology and Obstetrics (FIGO) recommendations and above all in accordance with the doctors who are responsible for health and lives of newborn babies and women, the Ministry of Health supports creation of Midwifery Centres within hospitals. These should fulfil the wishes of women to birth in a private friendly environment with individualised care while maintaining the safety, high standard of care and minimising the risk of care delays.
The term Midwifery centre is understood as a separate area within maternity hospital where the intrapartum care for physiological births will be provided solely by midwives. The doctor does not have to be present at the birth unless the situation requires their presence for either a maternal or a newborn factor. Birthing in such centres will be maximally close to the way in which women wish to give birth to their children while maintaining maximum safety for mother and baby. The midwifery centre has to be connected to a standard obstetric-led unit, so that the continuity of care is guaranteed in cases where the so far physiological birth suddenly complicates.
The first midwifery centre in the Czech Republic was established at Bulovka Hospital ObGyn and Neonatal department. This is a pilot project which has been launched upon the request of the Ministry of Health. The project will subsequently be analysed and the implementation of such care across the Czech Republic will be considered. The General University Hospital in Prague is also interested in establishing such centre and is preparing its launch.
The essential priorities for the Ministry of Health are life, health and safety of the mother and newborn. 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 while maintaining absolute safety for them and their children.
With regards to the rest of your letter, we have to state that the questions presented do not fall under the information request according to no. 106/1999 Free Access to Information Act, considering the fact that these do not lead to obtaining objectively existing information but are aimed at the opinions of the Ministry or more precisely at the opinion of the Health Secretary (e.g. see „I am asking you, mister Health Secretary, do you really think that these women will stop birthing at home?“ or „Mister Health Secretary do you really believe that these women and babies do not have the right to receive healthcare from a university trained midwife?“ and so on). According to provision § 2 paragraph. 4, Act no. 106/1999, obliged entities do not have an obligation to provide information regarding their private opinions amongst other things.
Kind regards, –
The Ministry of Health, Health Secretary’s Office
Palackého náměstí 4, 128 01 Praha 2, http://www.mzcr.cz, 6th February 2020
More information on the state of midwifery in Czech Republic can be found here