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18 May 2014
Kafka in the Circus District
A Short History of Homebirth in Hungary
“In today’s world it can happen to anyone,” the Hungarian Penal Justice Authority proclaims helpfully on the opening page of its website, “that they end up in prison as a result of a bad decision or a momentary mistake...”
That would certainly be bad enough. But what if that bad decision or that momentary mistake is made by the Budapest Prosecutor, or the Budapest police?
“Someone must have been telling lies about Josef K...,” run the opening words of The Trial by Franz Kafka, “...for he was arrested one fine morning without having done anything wrong.”
On 5 October 2010, the celebrated Hungarian midwife and obstetrician Ágnes Geréb was arrested after helping at an emergency delivery at the small birthhouse she runs in the Hungarian capital. It was the culmination of many years of bitter dispute with the Board of Gynecologists and Obstetricians about the natural birth practices she champions. On 20 December, her fifty-eighth birthday and her 76th day in the maximum security prison in Nagy Ignác street in Budapest’s Fifth district, State Secretary for Health Miklós Szócska gave details of new regulations for homebirth which will come into force in the Spring. These break a thirty eight year doctor’s monopoly on birth, and finally allow births at home, attended by a skilled midwife. A crowd of around five hundred people gathered in the street outside the prison to sing to Ágnes on her birthday, while in the White House, the Parliamentary deputies building nearby, on the shore of the Danube, an exhibition of photographs of homebirth, many featuring Ágnes, was opened by the Fidesz deputy Ilona Ékes. On 21 December, Ágnes was released from prison into house arrest. At the same time, the government has promised a review of the entire system of remanding those under police investigation in custody. Both the new maternity care regulations, and prospective changes to the criminal code, owe much to the publicity around the case of one Hungarian woman.
When Budapest expanded rapidly in the late nineteenth century, the ever-informative Penal Justice Authority website tells us, and as the Hungarian capital began to run its own affairs after centuries of domination by Vienna, there was a pressing need for new administrative buildings, including courtrooms and prisons. The prison and court rooms in Markó and Nagy Ignác streets were built in the Lipótváros we are told, in fields until then used by travelling circuses.
Ágnes Geréb worked for seventeen years at the Albert Szent-Györgyi Clinical Center, at the University of Szeged in southern Hungary, after qualifying as an obstetrician in 1977. There was still something of a baby boom in Hungary at that time, as the women who were born in the first desperate years after the crushing of the 1956 revolution began to have babies of their own.
“I attended births day and night during that time, sometimes as many as four in twenty-four hours,” she told me. By the time she resigned from the clinic in 1994, by her own calculations, that added up to an astonishing 5,500 births in hospital. Two of them were her own.
As a woman in an overwhelmingly male-dominated profession, she was upset by the high degree of medicalisation of birth, by the forced passivity of mothers, and by the all-too-frequent result – that birth was a frightening, negative experience in women’s lives, something to be endured and then if possible, forgotten, and hopefully never repeated. Women were not allowed to walk around, eat or drink during their contractions, or find the position in which they felt most comfortable in which to give birth. As a doctor, she saw that the system was designed to make matters as easy as possible for the doctors, not for the birthing women. The compulsory shaving, the compulsory enemas when labour began, the administration of drugs like oxytocin and prostoglandin to induce or speed up delivery, the fact that women were expected to lie on their backs for an average of ten hours, in the most painful position, to give the doctor the easiest access, deeply disquieted her. As did the routine episiotomies (the cutting of the perineum) to ease the passage for the baby’s head. As did the practice of expecting all obstetricians to carry out abortions as well as births. And there were many abortions.
“Doctors often went into the room not knowing which it was to be next – death or life. That made them very cynical,” she said.
Ágnes Geréb began to fight for change – from the inside. She began by smuggling fathers into the clinic, to allow them to attend the birth of their children – against the rules of the hospital. When she was found out, she was suspended for six months. The director of the hospital would later claim credit for the fact that his hospital was the first to “allow” partners to be present at birth.
On visits abroad, Ágnes witnessed homebirths in Britain and the United States, and realised that birth could be a happy, empowering experience without endangering the mother or baby. She also realised that many of the complications in birth, which doctors are so proud of their skill at treating, are actually caused by their earlier interventions, like speeding up the birth with drugs, rupturing the membrane which surrounds the baby in the womb, and the position of birth. In the meantime, she also trained and qualified as a psychologist, and came to understand birth as a psychological process, as well as a medical one. If the woman is stressed, how can she give birth? In the United States, Ina May Gaskin, a lifelong champion of homebirth, told her how she often tells jokes to women in labour, to make them laugh and thus relax! It was all a world away from the clinic in Szeged.
In 1985 the World Health Organisation published ‘Appropriate Technology for Birth’ – a summary of the conclusions from a conference held at Fortaleza, Brazil.
“It is not recommended that pregnant women be placed in a dorsal lithotomy (horizontal) position during labour and delivery.(...)
Systematic use of episiotomy is not justified. (...) The induction of labour should be reserved for specific medical indications. No region should have rates of induced labour over 10%.” And so on.
Slowly, cautiously, and encouraged by the WHO and midwives and doctors she met abroad and corresponded with, Ágnes Geréb began to attend the births of her friends, at home. In May 1992, she organised the first homebirth conference in Hungary, in Szeged.
It was attended by homebirth practitioners from many countries, including Sheila Kitzinger from Britain, and Michel Odent from France. It was a time of hope, Communism had collapsed, and everything seemed possible, including natural childbirth. My wife was just a few weeks pregnant. In January 1993 our first child, Samuel was born in our living room in Budapest, with Ágnes’s expert care.
What do birth attendants actually do during childbirth at home, when there is no doctor to “lead” the delivery? My memories of that first birth, and of the four births which have followed it since, are intense. In the intimacy of your own home, with the phone turned off, the lamps turned low, by candle-light with scented oils, it is a time of massage and silence and soft words. Of hot compresses, of walking and dancing, of shouting and singing, but above all of waiting, and of resting between the waves of contractions. Ágnes listens regularly to the baby’s heartbeat. Sometimes she does an examination, to check on the baby’s progress. At one point, after many hours she asks my wife if she would like to go into hospital. Not, she explains, because there is any medical indication, but because she seems to be getting tired. We are shocked. What else could we do, we ask? Haven’t you got any wine in the house? A corkscrew is brought – not a usual aid at a birth. And the red wine with which we had intended to celebrate the newcomer’s arrival is breached. A spoonful of honey follows. And a few minutes later, her strength miraculously restored, the contractions start again in earnest. And the baby is born, wide-eyed, astonished, the most ancient as well as the newest being on the planet.
Agnes stays an hour or two, then disappears into the night, sometimes to her own family, sometimes to the next birth. My first son was her 25th homebirth, my fifth son her 2,500th. By the time of her arrest, in October 2010, the number had reached over 3,500.
And as in hospital, sometimes, though very occasionally, something goes wrong.
The hope and happiness of the early 1990s reached a peak on 30 November 1993 when the Hungarian Parliament voted by 260 votes to 4 that $300,000 be granted to Ágnes Geréb and her Alternatal Foundation, to establish the first Birth House in Hungary.
During the Parliamentary debates, the motion, introduced by two Free Democrat deputies, was praised by a Christian Democrat as “the best legislation” of the first Parliamentary cycle. The plan was for the Birth House to run training classes for pregnant mothers, and prepare women for natural birth, at home and in hospital. It was also designed as a place where women could give birth, if their home circumstances did not allow it – too many mothers-in-law, children, too thin walls, or if the birthing couple lived far from Budapest, and Ágnes was unable to travel because of her other birth commitments.
A spacious, beautiful flat was bought in Aranka utca, in the second district of Budapest, counting on the money voted by Parliament. But in 1994 as the months passed, no transfer was made. Initially, the excuse was a lack of documentation. Each document on the way the birthhouse would be run, the budget, exhaustive details of what would happen there, were sent to the competent authorities. Finally the true reason for the delays became apparent. “The Board of Obstetricians and Gynecologists... finds the establishment of a new birthing institution (Birth House) unjustified for professional reasons, and therefore cannot support expenditure from the state budget for health care on this project.” The letter is signed by Professor Jenő Egyed and dated 25th July 1994. Seventeen men, the majority gynecologists, not even obstetricians, had thwarted the will of the first democratically elected Hungarian Parliament.
In the absence of support from the all-powerful Board, the all powerful Hungarian National Public Health and Medical Officer Service (ÁNTSZ) refused to give a permit to the Birth House to operate. The money from the health budget was spent on other things. The house in Aranka street had to be sold. And Ágnes Geréb continued her remarkable, low technology, low cost work of attending home-births, without the support of any health institution. She continued to apply for a permit to operate a birth house. This was continually refused by the ÁNTSZ, for the same reasons. So she gave birth classes in her own home, and gave birth to two more children of her own in the meantime. She didn’t charge for births, but accepted donations from those who could afford it. Some women were so inspired by the experience of birth with her, that they studied, in hospital, to become midwives themselves, and once qualified, they began to attend home-births with her. Other women became “doulas” – female birth attendants with experience but no qualification, there to help the midwife, and the family. The homebirth movement, for that is what it was and is, grew steadily.
But the profession were not going to take this lying down. The first legal steps against Ágnes Geréb began in the mid 1990s, with individual hospitals starting court cases against her. Her house was raided one night by police, and documents taken away. Under a 1972 law, all medical staff who know of a woman about to give birth must make every effort to take her to the nearest hospital. By failing to do so, they were breaking the law – though parents were not. Homebirth was effectively a-legal for the parents, and illegal for the midwives. In 1998, the human rights ombudsman, Peter Polt ruled that women have a constitutional right to give birth where they please, and that Parliament has an obligation to resolve the legal nonsense that doctors and midwives are not allowed to help them.
Emboldened by this, Ágnes continued to attend homebirths, but the clouds were gathering. In 2000, the first death associated with a homebirth in Hungary occurred, several months after a baby, born without complications, stopped breathing in its mother’s arms, and suffered brain damage. The hospital – not the parents of the baby – sued Ágnes Geréb for negligence. She was acquitted in the court of first instance, but finally found guilty at the third, after prosecutors managed to remove one medical expert who spoke in her defence from the list of those accepted by the court. She was banned from practicing as an obstetrician for three years. Having requalified as a midwife in 2005, Ágnes continued to attend homebirths, as a midwife, not as an obstetrician. The demand was enormous – some two hundred births a year.
In 2002, the Board of Obstetricians issued a statement, explaining its continued opposition to home delivery. The conditions for it simply did not exist in Hungary, they argued. And in any case, it was unsafe elsewhere in the world, and there was a trend towards more hospital deliveries.
“The statement by the Board of the Hungarian Obstetricians and Gynecologists has no scientific validity,” wrote Marsden Wagner, the former director of Women’s and Children’s Health in the World Health Organization, “and is an attempt to use false statements and scare tactics to do what has failed in other countries such as Germany and would never even be attempted in the United States, to allow obstetricians to take away individual freedoms and dictate to families what they will experience in the birth of their own child.”
But the deaths of two more babies, including the first during birth in September 2007 in Budapest, gave the medical authorities the chance they were looking for, to rid themselves of a fellow doctor who challenged their power, and their income.
A series of prosecution cases were rolled into one, and the charge against her was increased to “manslaughter through professional negligence.” And as the court cases multiplied, the Hungarian media, initially sympathetic to what seemed to be a one-woman struggle against the old order, turned against her. Hungarian journalists, even at quality newspapers, public service media, and the state news agency, MTI, quoted at length from the Interior Ministry-approved experts marshalled by the prosecution against her. Despite the fact that the “experts”, in common with most obstetricians in Hungary, were completely ignorant of homebirth, having never witnessed one. Photographers from the tabloid press began arriving, mysteriously, at the same time as the ambulance, on the few occasions when one was called to a home delivery. Police cars were parked late at night outside the small flat where Ágnes gave birth classes and sometimes attended births in a quiet street in Buda. And the period of state and media harrassment continued, right up to her arrest.
The tide, however, was finally turning in her favour, to the dismay of her persecutors. We supporters of home-birth had not been idle, though we were disorganised. The joys and tribulations of bringing up our own children often took precedence over our desire to help others enjoy the same quality of birth that we were fortunate enough to receive. And Ágnes herself, and her growing group of helpers, were usually too busy attending births, to develop a strategy to win over a stubborn profession, and the misinformed political and legal establishments.
A succession of health ministers turned a semi-receptive ear to our pleas. Mihály Kökény as Socialist Minister of Health in 1996, István Mikola as Fidesz minister in 2002, Ágnes Horváth as a Liberal in 2008, all promised change. In 1997 we were even given a weekly page in the former Trade Union daily Népszava, paid by the Ministry, to encourage debate about maternity care, and the resulting first ‘Guide to Birth in Hungary’ was published in 1999. The campaign was modelled on a similar one, Rodzic po Ludzku, ‘To Give Birth in a Dignified Way’, which has run for many years in the former Solidarity newspaper, Gazeta Wyborcza in Poland.
And finally in 2010, even as the “martyrdom” of Ágnes Geréb intensified, the state secretary for health, Miklós Szócska, brought out his first draft regulations for homebirth. These include the right of women with low-risk pregnancies to give birth at home, attended by a qualified midwife, and establish a working definition of what low-risk actually means. At the same time, the newly established Semmelweis Movement announced plans to establish the first “reference ward” at a Budapest hospital, to be run entirely by midwives, and according to international protocols of midwifery practice – a truly revolutionary development.
Another important change has come from the Board of Obstetricians and Gynecologists itself. The high rate of maternal deaths in Hungary during birth – 15 per 100,000, three times the European figure of 5 per 100,000 – appears to have helped break the entrenched opposition of the medical establishment to more natural deliveries. The high rate of caesareans in Hungary – 34% – is increasingly recognised as a threat to maternal and infant health.
In early December 2010, the European Court of Human Rights ruled in favour of a Hungarian woman, Anna Ternovszky, and found Hungary in violation of Article 8 (right to respect for private and family life) of the European Convention on Human Rights by preventing health professionals from attending homebirths.
In the long run, the legalisation of homebirth and the establishment of midwifery as a separate profession with its own codes of practice, independent from, but working in close cooperation with the obstetric profession, promise a great deal. Ágnes Geréb’s martyrdom, and the campaign for her release, finally persuaded the politicians, the public, the profession, and perhaps even the prosecutor, that homebirth and independent birth houses should be allowed in Hungary, and might even help further humanise hospital birth. The debate, and even the trials continue.
On my eighteen year old son’s bookshelf stands an empty wine bottle, whose contents we drank with Ágnes in early January 1993 to ease and finally celebrate his safe arrival among us.