In the past few months I've learnt a lot about the maternity system here in Bosnia. This is because I met some Bosnian ladies who are interested in natural birth and these women shared with me their birth stories as well as their knowledge about the system here. I have also gone around asking quite a few ladies I meet in everyday life about how they felt about their births. I would have loved to know so much of this stuff when I was pregnant, so that's why I'm sharing it now. I guess it should be taken with a grain of salt, since it's based on second hand information in some cases.
Midwifery in Bosnia
Midwives aren't very well thought of in Bosnia. The word used to describe them, "babica" also means "grandmother", so it's not surprising that people associate homebirth with poor families who can't afford to go to hospital and just get a 'grandmother' to help. Such midwives quite possibly still exist in the countryside, but in the city, it seems that midwives only practice in hospitals. There is a course available for training midwives, but it is only a highschool degree from the medical highschool in Jazero (maybe there are others in other parts of the country). Beyond this highschool qualification, there are some short courses offered by the Centar Fenix and that is about it! I spoke to a girl who I know who goes to the medical highschool. She will become a midwife only if she doesn't fulfill her dream of becoming a footballer! None of her friends want to be midwives either if they can help it. It seems more like a low-level job that they will do if they can't find anything else. (As a side-note, I asked her if she had witnessed a birth and she said, not yet, but she had seen an abortion. Hmmm...) Not surprisingly, those that do decide to work as a midwife finish their training in the hospital by watching doctors (obstetricians) practice and being instructed by them. They end up being like obstetric assistants who are probably very out of touch with what it means to a woman to have a baby (especially when starting out fresh from highschool).
Apparently, the training for midwives before the war was more complete and so the older generation of midwives are more skilled, for example with breech birth and twins. Despite this, even they don't have much autonomy within normal hospitals. They supervise the labor but aren't able to administer medications or perform medical procedures and must call in the doctor (who works in shifts) for the birth. Apparently, there were some midwife led birthing units in the countryside, but these have been progressively closed in accordance with a policy of closing smaller maternity hospitals to redirect women to larger, more "equipped" hospitals in the so-called interest of safety. I say "so-called" because, actually, by sending women to centralized units and closing down local ones, you are making it more likely that women may give birth on the way to the hospital, which is probably the least safe option.
Birthing Options
The only real option women have is to go to their local public maternity hospital. There are no private hospitals in the capital, but I've heard there is one in Pale (Republika Srpska) and also one other private hospital in Banja Luka (also Republika Srpska). Homebirth is commonly thought to be illegal. It is probably not actually illegal, maybe just a grey area, but perhaps there was a push to discourage it at some point because it seems like it used to be common but isn't anymore. It is now considered an uncultured thing only peasants would do. This combined with the minimal training of midwives and obstetricians' general preference for hospitals and that leaves you with a situation of no homebirths. In any case, no one I know has found a health care practitioner based in Bosnia who will assist them in a homebirth. It may be possible to bring in a midwife from another country, but it would be difficult to get back-up from the hospital. Birthing centres do not exist either. Apparently midwife-led maternity units used to exist. Maybe a couple still do, but I'm not sure how they would compare to what I would think of as a birth centre. I think they would really be more like a normal hospital, only without obstetric back-up.
Prenatal Care
Pregnancy is rather medicalized. There are only two options for prenatal care - seeing the doctors in the public system (in a clinic known as Dom Zdravlije or the hospital) or seeing a private obstetrician-gynecologist. Women, even those in the public sector, are advised to have an ultrasound at least once a month for the entire pregnancy. Doctors do not palpate the belly to examine the baby's position or growth, they rely exclusively on ultrasounds. They have short appointments with their patients where there isn't much time to talk about diet or lifestyle, but they do quite a number of tests and examinations. Some women are given additional medications which seem excessive to me, such as hormonal medications to "keep" the pregnancy or prevent contractions. At 36 weeks, the woman books into the hospital and starts having weekly examinations, including CTG, ultrasounds, vaginal examinations and possibly more. If a women reaches her due date, she is sometimes encouraged to have an induction immediately or if she prefers to wait, more frequent (even daily) monitoring is done and in a friend's case, amnioscopies were ordered frequently to check for meconium staining. The last is quite an invasive and risky procedure that has little benefit in helping the outcome. This isn't all bad by any means, some of these things can be quite useful, but what I'm noting is lack of the continuity of care midwifery model as well as excessive use of technology and tests.
Hospital Birth Practices
Based on listening to the birth stories from a few women, it appears to me that doctors in Bosnia prefer to "actively manage" labor and birth. That is, there is a specified time-frame within which a woman must dilate and also push out the baby before which time they will intervene to speed things along. In accordance with this view, and other beliefs (many of which are not evidence- based), the following interventions are common:
Water birth is supposedly available in the national hospital, but few (if any) women have been actually allowed to give birth in water. Probably because of a general mistrust of water birth and their belief in the need for episiotomy. The C-section rate is about as high as in western countries - approaching 30%. Doctors work on shifts and you can't know who will be on shift when you go into labor, but I have heard of women bribing doctors to give them a non-medically necessary C-section when their preferred doctor is on shift. This is probably because of the (in my opinion) terrible vaginal birth option that hospitals offer as the only alternative. By the way, C-sections are usually done under general anesthesia, rather than epidural. I also heard of one woman who was offered an induction (as a favor) when her doctor was on shift so that she could birth with her doctor. Further, although some of the older midwives and doctors have skills in things like breech birth, the newer doctors are trained to opt more frequently for C-sections, so I hear often about women having c-sections for 'big babies', twins, VBAC and breech. In terms of breech, apparently only one doctor offers external version (to externally flip a breech baby).
It goes without saying that in such a medicalized environment, doctors would likely be incredibly "cautious" when it comes to premature rupture of membranes and presence of even lightly stained meconium in waters.
There are probably exceptions to the list of interventions I have given. Maybe some doctors are more liberal in allowing different positions for labor or birth and so forth. I have read one positive birth story in which a woman who was having her second child did not have an episiotomy and the doctor massaged her perineam instead. I'd tend to think that that is the exception rather than the rule, sadly.
Conditions in Hospitals
Generally only one person can be with the birthing woman. When I first wrote this article, there was one doula in Sarajevo, apparently. She could only attend births by pretending to be a cousin but eventually was recognized and not allowed to come anymore. Since then, in 2016, a number of women trained to be Doulas with Dona International - the first training session of this kind in Bosia-Herzegovina. It remains to be seen whether they will be allowed into hospitals. Fathers are allowed under certain circumstances I'm not so clear about. Perhaps you have to be in a special room because generally there aren't single rooms. The national hospital has rooms for two people (though it's not so busy, so often the room is to oneself), and Jazero hospital has rooms for four. So, not so sure about the rules for participation of men, but I've heard a few stories which make it seem like men are not welcomed as they should be.
The large hospitals are quite well equipped. I think that they probably okay at managing genuinely complicated births... but then again, there was one comment from a friend that indicated that some high tech equipment that was donated is just sitting there not being used because staff don't know how to use it.
Finally, and I think this is the most serious problem, women are not treated in a way that respects their right to informed consent. Routine procedures are administered without asking the patient or explaining what they are for. If the woman protests, she is seen as challenging the doctor's authority and is labelled as uncooperative. Most women see the hospital policies as laws and don't feel like they have the right to go against hospital policy for example to decline an episiotomy or request to nurse their baby immediately after birth. I have also heard stories that amounted to abuse, such as not allowing a woman to see her baby for many hours or scolding a woman for wanting to birth in an unconventional fashion.
How Women Feel
Many of the things I've said about the situation here are not very encouraging when it comes to my personal perspective. I think what they are doing is far too medicalized and many of their procedures (not to mention their attitudes towards patients) are genuinely harmful. Having said that, I have asked some women around the neighbourhood how they felt about their birth and most seemed kind of okay with it all. I think that's partly because they don't know anything else. Popular culture tells us birth is scary and painful, so when that's what they get, they're not surprised. Its also in some cases because they genuinely believe that what the hospitals offer is great care. Once again because of cultural conditioning, they believe that a short labor is better (since it's painful and difficult anyway, using drugs to speed it up must be good, right?). And, those who have means are happy they can bribe a doctor for an elective C-section and skip all the horror. Some of those who are poor may simply be happy to have any access to maternity care, since the alternative would be an unassisted birth.
What can be done?
If a woman wants to have a natural birth in Bosnia that doesn't include many of the standard hospital practices, what can she do? I believe women need to inform themselves about the situation, about their rights and make their choices known to their caregivers, ideally before the birth. People should realize that hospital policies are not laws they have to obey. Also, just because they sign something upon admission that says they consent to what the doctors will do does not mean they can't withdraw their consent. It should be possible to make a signed statement withdrawing consent if necessary. In other countries, patients have sued hospitals for assault if a doctor performed, say, an unwanted episiotomy or coerced someone into an unnecessary C-section. Both hospitals in Sarajevo have nice sounding patient rights published on their websites, so being aware of these rights could be helpful.
But, as I say, it's probably better to make your preferences known before the birth, as having to argue during labour isn't going to be easy (or helpful for the progress of your labour). Since it's not necessarily known who will be on staff when you go into labour, maybe it's worth preparing a written document that you can ask as many doctors as possible to read and sign, before the birth. I really don't know if it would work, but it's worth a try!
Beyond that, the other option is a systemic change - there needs to be a reviving of the midwifery profession here with proper tertiary education and training, there needs to be safe homebirthing options with back-up from hospitals and there needs to be midwife led birthing centres set up. I focus on midwives because the midwifery profession is about understanding and supporting normal birth. Obstetrics is a branch of surgery that is needed for complicated pregnancies and births, but when obstetrics takes over all births, it makes normal birth unnecessarily medicalized.
Conclusion
In a country where government services are under-resourced, it seems surprising that a rather expensive, overly medicalized maternity system exists. The midwifery continuity of care model, including homebirths and birth centres for lower risk pregnancies, would be significantly cheaper. Perhaps the system reflects a desire not to be backwards - having a lots of ultrasounds and having a C-section are sometimes seen as symbols of sophistication. Moving towards a new model would take a major cultural change - it would take a greater humility from hospitals that another way is valid and it would take women believing that a less medicalized birth is possible, safe and even enjoyable and progressive.
Midwifery in Bosnia
Midwives aren't very well thought of in Bosnia. The word used to describe them, "babica" also means "grandmother", so it's not surprising that people associate homebirth with poor families who can't afford to go to hospital and just get a 'grandmother' to help. Such midwives quite possibly still exist in the countryside, but in the city, it seems that midwives only practice in hospitals. There is a course available for training midwives, but it is only a highschool degree from the medical highschool in Jazero (maybe there are others in other parts of the country). Beyond this highschool qualification, there are some short courses offered by the Centar Fenix and that is about it! I spoke to a girl who I know who goes to the medical highschool. She will become a midwife only if she doesn't fulfill her dream of becoming a footballer! None of her friends want to be midwives either if they can help it. It seems more like a low-level job that they will do if they can't find anything else. (As a side-note, I asked her if she had witnessed a birth and she said, not yet, but she had seen an abortion. Hmmm...) Not surprisingly, those that do decide to work as a midwife finish their training in the hospital by watching doctors (obstetricians) practice and being instructed by them. They end up being like obstetric assistants who are probably very out of touch with what it means to a woman to have a baby (especially when starting out fresh from highschool).
Apparently, the training for midwives before the war was more complete and so the older generation of midwives are more skilled, for example with breech birth and twins. Despite this, even they don't have much autonomy within normal hospitals. They supervise the labor but aren't able to administer medications or perform medical procedures and must call in the doctor (who works in shifts) for the birth. Apparently, there were some midwife led birthing units in the countryside, but these have been progressively closed in accordance with a policy of closing smaller maternity hospitals to redirect women to larger, more "equipped" hospitals in the so-called interest of safety. I say "so-called" because, actually, by sending women to centralized units and closing down local ones, you are making it more likely that women may give birth on the way to the hospital, which is probably the least safe option.
Birthing Options
The only real option women have is to go to their local public maternity hospital. There are no private hospitals in the capital, but I've heard there is one in Pale (Republika Srpska) and also one other private hospital in Banja Luka (also Republika Srpska). Homebirth is commonly thought to be illegal. It is probably not actually illegal, maybe just a grey area, but perhaps there was a push to discourage it at some point because it seems like it used to be common but isn't anymore. It is now considered an uncultured thing only peasants would do. This combined with the minimal training of midwives and obstetricians' general preference for hospitals and that leaves you with a situation of no homebirths. In any case, no one I know has found a health care practitioner based in Bosnia who will assist them in a homebirth. It may be possible to bring in a midwife from another country, but it would be difficult to get back-up from the hospital. Birthing centres do not exist either. Apparently midwife-led maternity units used to exist. Maybe a couple still do, but I'm not sure how they would compare to what I would think of as a birth centre. I think they would really be more like a normal hospital, only without obstetric back-up.
Prenatal Care
Pregnancy is rather medicalized. There are only two options for prenatal care - seeing the doctors in the public system (in a clinic known as Dom Zdravlije or the hospital) or seeing a private obstetrician-gynecologist. Women, even those in the public sector, are advised to have an ultrasound at least once a month for the entire pregnancy. Doctors do not palpate the belly to examine the baby's position or growth, they rely exclusively on ultrasounds. They have short appointments with their patients where there isn't much time to talk about diet or lifestyle, but they do quite a number of tests and examinations. Some women are given additional medications which seem excessive to me, such as hormonal medications to "keep" the pregnancy or prevent contractions. At 36 weeks, the woman books into the hospital and starts having weekly examinations, including CTG, ultrasounds, vaginal examinations and possibly more. If a women reaches her due date, she is sometimes encouraged to have an induction immediately or if she prefers to wait, more frequent (even daily) monitoring is done and in a friend's case, amnioscopies were ordered frequently to check for meconium staining. The last is quite an invasive and risky procedure that has little benefit in helping the outcome. This isn't all bad by any means, some of these things can be quite useful, but what I'm noting is lack of the continuity of care midwifery model as well as excessive use of technology and tests.
Hospital Birth Practices
Based on listening to the birth stories from a few women, it appears to me that doctors in Bosnia prefer to "actively manage" labor and birth. That is, there is a specified time-frame within which a woman must dilate and also push out the baby before which time they will intervene to speed things along. In accordance with this view, and other beliefs (many of which are not evidence- based), the following interventions are common:
- routine shave and enema upon admission (expectation that shave should be done before going to hospital)
- frequent artificial breaking of waters
- frequent chemical augmentation through artificial oxytocin drip
- artificial rupture of membranes
- pushing lying on back (lithomy position) on birthing table
- panic if baby is not pushed out in a few pushes
- use of fundal pressure to increase speed of birthing (doctor or nurse pushes on the top of the uterus to increase the force of pushing putting extra pressure on the vaginal wall muscles and increasing the likelihood of perineal and pelvic floor damage)
- routine use of episiotomy for first time mothers (and frequently otherwise)
- immediate cord clamping
- a quick cuddle and picture with mum and then off to the nursery baby goes to be weighed, measured, vaccinated, given vitamin K injection, quite possibly fed formula or sugar water before being returned.
- actively managed delivery of the placenta - use of injection to initiate contractions and control bleeding
- mum gets her episitomy sewn up and rests while baby has his or her examinations with strangers
- mum gets to breastfeed her baby a few hours after birth (maybe 4 or more).
- The baby is quite possibly full of formula when it comes time to be nursed. (The national hospital, Abdullah Nakas hospital is supposed to be a baby friendly hospital, but according to one woman who had an insider's view of it, she found that the baby friendly standards were not being adhered to as they should be.)
Water birth is supposedly available in the national hospital, but few (if any) women have been actually allowed to give birth in water. Probably because of a general mistrust of water birth and their belief in the need for episiotomy. The C-section rate is about as high as in western countries - approaching 30%. Doctors work on shifts and you can't know who will be on shift when you go into labor, but I have heard of women bribing doctors to give them a non-medically necessary C-section when their preferred doctor is on shift. This is probably because of the (in my opinion) terrible vaginal birth option that hospitals offer as the only alternative. By the way, C-sections are usually done under general anesthesia, rather than epidural. I also heard of one woman who was offered an induction (as a favor) when her doctor was on shift so that she could birth with her doctor. Further, although some of the older midwives and doctors have skills in things like breech birth, the newer doctors are trained to opt more frequently for C-sections, so I hear often about women having c-sections for 'big babies', twins, VBAC and breech. In terms of breech, apparently only one doctor offers external version (to externally flip a breech baby).
It goes without saying that in such a medicalized environment, doctors would likely be incredibly "cautious" when it comes to premature rupture of membranes and presence of even lightly stained meconium in waters.
There are probably exceptions to the list of interventions I have given. Maybe some doctors are more liberal in allowing different positions for labor or birth and so forth. I have read one positive birth story in which a woman who was having her second child did not have an episiotomy and the doctor massaged her perineam instead. I'd tend to think that that is the exception rather than the rule, sadly.
Conditions in Hospitals
Generally only one person can be with the birthing woman. When I first wrote this article, there was one doula in Sarajevo, apparently. She could only attend births by pretending to be a cousin but eventually was recognized and not allowed to come anymore. Since then, in 2016, a number of women trained to be Doulas with Dona International - the first training session of this kind in Bosia-Herzegovina. It remains to be seen whether they will be allowed into hospitals. Fathers are allowed under certain circumstances I'm not so clear about. Perhaps you have to be in a special room because generally there aren't single rooms. The national hospital has rooms for two people (though it's not so busy, so often the room is to oneself), and Jazero hospital has rooms for four. So, not so sure about the rules for participation of men, but I've heard a few stories which make it seem like men are not welcomed as they should be.
The large hospitals are quite well equipped. I think that they probably okay at managing genuinely complicated births... but then again, there was one comment from a friend that indicated that some high tech equipment that was donated is just sitting there not being used because staff don't know how to use it.
Finally, and I think this is the most serious problem, women are not treated in a way that respects their right to informed consent. Routine procedures are administered without asking the patient or explaining what they are for. If the woman protests, she is seen as challenging the doctor's authority and is labelled as uncooperative. Most women see the hospital policies as laws and don't feel like they have the right to go against hospital policy for example to decline an episiotomy or request to nurse their baby immediately after birth. I have also heard stories that amounted to abuse, such as not allowing a woman to see her baby for many hours or scolding a woman for wanting to birth in an unconventional fashion.
How Women Feel
Many of the things I've said about the situation here are not very encouraging when it comes to my personal perspective. I think what they are doing is far too medicalized and many of their procedures (not to mention their attitudes towards patients) are genuinely harmful. Having said that, I have asked some women around the neighbourhood how they felt about their birth and most seemed kind of okay with it all. I think that's partly because they don't know anything else. Popular culture tells us birth is scary and painful, so when that's what they get, they're not surprised. Its also in some cases because they genuinely believe that what the hospitals offer is great care. Once again because of cultural conditioning, they believe that a short labor is better (since it's painful and difficult anyway, using drugs to speed it up must be good, right?). And, those who have means are happy they can bribe a doctor for an elective C-section and skip all the horror. Some of those who are poor may simply be happy to have any access to maternity care, since the alternative would be an unassisted birth.
Those who know more about the situation from family or previous births may just accept whatever the hospital does and live with it. They may know it's bad but they take an attitude of non-resistance as a way to get through. For example, if you know delayed cord clamping just isn't an option, you don't trouble yourself to make a fuss and ask for it. Just like I don't usually bother asking the taxi drivers at the airport to use the meter. I know they aren't going to do that and they will charge about four times the normal rate and if I argue with them, I'll just end up stressed and anxious, so I can't be bothered causing a fuss. However, I have heard from some women who are really passionate about natural birth. They really argued for what they wanted and made it happen. I suppose that's what it takes. As sad as it is, that's probably what's needed to make a change in the hospitals' attitude.
Of course, I should say that some women may have had a good experience - perhaps they ended up with a more compassionate doctor or they had some kind of social standing and were treated better because of that.
Of course, I should say that some women may have had a good experience - perhaps they ended up with a more compassionate doctor or they had some kind of social standing and were treated better because of that.
What can be done?
If a woman wants to have a natural birth in Bosnia that doesn't include many of the standard hospital practices, what can she do? I believe women need to inform themselves about the situation, about their rights and make their choices known to their caregivers, ideally before the birth. People should realize that hospital policies are not laws they have to obey. Also, just because they sign something upon admission that says they consent to what the doctors will do does not mean they can't withdraw their consent. It should be possible to make a signed statement withdrawing consent if necessary. In other countries, patients have sued hospitals for assault if a doctor performed, say, an unwanted episiotomy or coerced someone into an unnecessary C-section. Both hospitals in Sarajevo have nice sounding patient rights published on their websites, so being aware of these rights could be helpful.
But, as I say, it's probably better to make your preferences known before the birth, as having to argue during labour isn't going to be easy (or helpful for the progress of your labour). Since it's not necessarily known who will be on staff when you go into labour, maybe it's worth preparing a written document that you can ask as many doctors as possible to read and sign, before the birth. I really don't know if it would work, but it's worth a try!
Beyond that, the other option is a systemic change - there needs to be a reviving of the midwifery profession here with proper tertiary education and training, there needs to be safe homebirthing options with back-up from hospitals and there needs to be midwife led birthing centres set up. I focus on midwives because the midwifery profession is about understanding and supporting normal birth. Obstetrics is a branch of surgery that is needed for complicated pregnancies and births, but when obstetrics takes over all births, it makes normal birth unnecessarily medicalized.
Conclusion
In a country where government services are under-resourced, it seems surprising that a rather expensive, overly medicalized maternity system exists. The midwifery continuity of care model, including homebirths and birth centres for lower risk pregnancies, would be significantly cheaper. Perhaps the system reflects a desire not to be backwards - having a lots of ultrasounds and having a C-section are sometimes seen as symbols of sophistication. Moving towards a new model would take a major cultural change - it would take a greater humility from hospitals that another way is valid and it would take women believing that a less medicalized birth is possible, safe and even enjoyable and progressive.
