The problem of obstetrics in Ukraine

Ludmila Sunprun
Ukraine - 05/01/2005
  Historically, the issues of reproductive health and reproductive rights of Ukrainian women have failed to garner significant popular interest. The societal perception of gynecological health, birth control, pregnancy and childbirth as personal matters pertaining to women alone and hence improper topics for public discussion has been detrimental to the health of women in Ukraine. As a result, there is a lack of information on such topics, the prevalence of misinformation and ignorance with respect to reproductive rights. Women are without the means to make informed choices, hence a negligent attitude towards one’s own reproductive health. This is exemplified by the common practice of using abortion as a means of birth control. Currently, 700,000 abortions are carried out annually, roughly 65-70 women of reproductive age per 1000, in comparison to 10 in Canada and 5.6 in the Netherlands.

The Ukrainian system of obstetrics is in particular need of extensive reform in terms of both management and methodology. The current system is a relic of the soviet health care services, comprising governmental institutions supported by inadequate levels of financial support. Soviet reproductive health practices continue to be followed which treat pregnancy as an illness rather than the beginning of a new stage of life and fail to take into account the individual needs of a pregnant woman that if attended to, would make the experience more enjoyable.

It has been found that, with respect to the current poor conditions of facilities and provision of care, financial limitations exacerbated by national policies that set requirements and limit management of individual facilities are for the most part to blame. In other words, given the continual problem of budget deficits, facility managers are powerless to implement policy changes that would alleviate the financial strain.

In Ukraine, there is a constitutional right to free services in public facilities but the funds allotted by the national government are insufficient to cover the annual costs of providing care for each individual. National laws have led to overstaffing of facilities due to capacity and staff requirements based on population, rather than patient inflows and managers have not been enabled to regulate staffing. More than half of a facility’s operational budget is spent on salaries and social insurance contributions, when some of this money could be used to increase the level of care. It should be noted also that doctors’ salaries are not enough to afford an adequate standard of living. Equipment purchasing and sustainability also greatly affects the quality of care provided. It has been observed that facilities often purchase the newest equipment without consideration given to the relative benefits. Consideration of financing for upkeep, employee training and related materials required for usage is not required as funds are most often allocated only for the purchasing of the equipment. Equipment donations can be problematic, as they also do not include financing for upkeep, training and supplies. An illustrative example was the donation of a mammography x-ray machine without the necessary films, which patients were subsequently required to supply.

Thus, patients are forced to pay for drugs and supplies necessary for their care such as syringes, sheets for hospital beds, and food during the hospital stay. Most facilities request “charitable contributions” from clients to help defray costs and some providers demand direct unofficial payments from patients to provide health care or to improve the quality of care. The financial constraints facing these facilities alter the doctor-patient relationship by sometimes causing friction between care-givers and patients and also negatively affect care-givers’ sense of responsibility to provide quality treatment. What should be a woman’s most memorable experience often turns into an unpleasant event she would rather forget. One woman commented on her experience due to her failure to provide medications and bed linens:

“A nurse came and in a loud voice commented on my lack of care for childbirth and how much medication I had forgotten to bring: 10 for myself, 10 for the child and 15 more medicines for the infant ward. Then, for five minutes I listened to a tirade on the absence of bed sheets. But I was already having contractions every 30 seconds and I listened to all of this while seated over a bedpan. No one was interested in the fact that I was not well and that some time before my water had broken…Luckily though, I was able to give birth quickly and without the help of medication.”

Another woman living in the countryside, although already in labor, had difficulties finding a maternity hospital that would admit her:

“The pain continued until morning. At that point, Ruslan grew concerned; we collected everything that was necessary and left for the maternity hospital where I was registered. They told us that it was closed for renovations. Reaching the neighboring town, we passed two maternity hospitals, but they appeared to be closed. Only at the third maternity hospital did they take me, and that with great difficulty. In short, money decides everything. We paid 300 grivne (60USD) only so that they would accept me.”

Methodologies currently being implemented in reproductive health need also be taken into consideration and modified so as to include modern western practices that emphasize the needs of the individual. While most medical professionals are well educated, they received their training within the Soviet education system, when standards of health care, considerations for patients’ needs and psychological state as well as doctor-patient relations were quite different from those of today. Seemingly endowed with excellent credentials, many of the doctors are in fact not providing care on par with the rest of Europe. Due to overstaffing, there is also the problem of highly qualified staff loosing their medical skills and qualifications without practice.

Many doctors in the field of reproductive health continue to dictate treatment for pregnant women without offering alternatives, order tests without explanation and prescribe medicines without discussion. Ordinarily, a woman upon realizing that she is pregnant is assigned to a women’s clinic for pre-natal care, a maternity hospital for childbirth, and a different doctor at each facility. The patient undergoes standard medical procedures and medical tests, is prescribed medicines, and given instructions for behavior during the prenatal check-ups. Often the results of medical tests are not shared with the patient and medication options are not explained, leaving an expecting mother uninformed and without control over her health and that of the baby. Over-testing is an issue, one study found that half of the laboratory exams ordered for pregnant women were unregistered in clients’ medical records, and although some were for reasons of urgency, for the most part it was shown that the exams had been unnecessary. Also little, if any, information is provided on nutrition, pre-natal exercises, common minor health problems or pre-term labor symptoms.

Maternity wards are often cold gray buildings with impersonal medical staff and overcrowded rooms, unpleasant environments for the birthing process. A woman enters the maternity ward alone and the father and family members are usually not allowed visitation rights. The only means of communication may be through the hospital windows. Up to 2/3rds of expecting mothers are hospitalized before giving birth and a significant percentage of clients are kept in the hospital too long due unnecessary delays in discharge. It may be weeks before a father is able to see his child. It has been found that much of the care given in inpatient facilities could be provided by outpatient clinics.

A woman gives birth alone in a room with another woman also in labor and is not offered a choice of birthing positions. If complications arise during the pregnancy there is no other family member present to be consulted on further actions. Although infant and maternal mortality rates continue to decline they are at the moment significantly higher that those in the rest of Europe. Identifying the factors relating to these high mortality rates has been systematically hindered by the fact that investigations are not anonymous and thus there is a tendency to fault with each individual case, and more importantly a tendency to find fault with the parents. One woman spoke of her experience:

“When I started to give birth, the midwife began to turn the baby in my stomach and another doctor was pressing on my stomach with their hands, as if to squeeze it out. When the head began to come out, the midwife grasped it and squeezed (there were the imprints of four fingers left on the crown of the head), and after that there was a brain hemorrhage. Basically, I gave birth to a boy and then fell asleep under anesthesia. When I came to, the doctors were sitting in the delivery room drinking coffee, where it should have been clean and hygienic. They had not expected I would awake from the anesthesia so quickly and said, ‘She has already woken up and we still have not stitched her up’. After this, as the baby had died, they started to look for a cause, any cause, provided that they found something that would prove it was not their fault, but my own and my husband’s. They started to check all the tests: for AIDS, syphilis, and everything else down to the littlest thing. And then they tested the baby, but they found nothing”.

A small number of women, dissatisfied with the level of care in maternity hospitals, choose to prepare for childbirth on their own and deliver at home. Unqualified practitioners are often entrusted to deliver the baby. Sometimes these homebirths are unsuccessful and the woman is forced to go to a hospital to be treated for complications and she is often neglected and humiliated by the medical staff due to her decision.

Patients living in the countryside rather than urban centers face even more obstacles. The conditions are necessarily worse, as they are living in regions with smaller populations and less funding. There are problems with communication, lack of transportation and travel distances can be great, particularly if a woman prefers to give birth at a well-run maternity hospital.

Although by law women in Ukraine today are entitled to make their own decisions about where they would like to give birth, who their doctor will be, which medicines they should take and in which position they would like to give birth, many are unaware of their rights and do not exercise them. Instead, women are pressured into following their doctor’s orders and feel uncomfortable and helpless which causes undue stress during the child-bearing period.

It is unfair to say that there have been no changes in the system of obstetrics since the end of the USSR. The Ukrainian government, concerned with the level of care under the current system of obstetrics, has issued a number of regulating documents aimed at the improvement of current practices and the enhancement of women’s rights. The Family Planning Program from 1995-2001 has been proceeded by the National Reproductive Health Program 2001-2005. As a result the organizational structures and laws needed to implement westernized practices have been outlined. If changes were to be accepted throughout the reproductive health care community and implemented by a majority of the women’s clinics, then the level of care would approach that of other European countries. The Ministry of Health of Ukraine has developed a broad reproductive health strategy but it lacks implementation plans and systems to monitor its implementation.

There is also a growing community of progressive obstetricians and psychologists focused on including innovative practices and methodology and private family planning centers are appearing throughout the country. The Ukrainian non-governmental organization “Family from A to Z” opened one such center in 2000 in the city of Kharkiv and is at the forefront of this movement. The center provides services such as: educational training programs for expecting couples based on a holistic approach, exercise classes, counseling for pregnant women, development classes for children six months to three years, and baby-sitting training. Other such centers and communities exist, but there is a need among Ukrainian medical professionals for increased exposure to current modern practices and support for their initiatives.

In order to achieve a good level of reproductive health care on par with those of the rest of Europe, changes in policy as well as financing will need to be made. Financial decision making should be decentralized and brought down to the local and facility levels so that managers can individually deal with staffing, payment mechanisms which are now largely unofficial, sustainability of equipment and responsibility for the quality of care. More women need to be made aware of their reproductive rights so that they are enabled to demand them. There also needs to be increased interaction between the medical community focused on implementing modern methodologies and practitioners still following soviet style practices. Already though, the foundation has been laid for improved reproductive health care through the initiative of the Ukrainian government and individual medical practitioners throughout the country.

Note: For more information on the organization “Family from A to Z” contact via email.

Women Rights | Ukraine | Reports