Truth about home birth in Ukraine. What you need to know after the tragedy of a new mother's death in Rivne

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Alice Smahina

At the end of January, a 34-year-old woman died in Rivne as a result of home birth. The newborn baby and his seven-year-old brother remained orphans. During the pregnancy, the woman didn't visit doctors and wasn't under medical supervision. A person called a doula, or "spiritual midwife" accompanied home birth, at the request of the mother. Complications that occurred after her childbirth didn't worry the self-proclaimed midwife. A few hours after the unqualified "assistance," the woman was literally bleeding in front of relatives and her "assistant." Eventually, the woman's husband, also present at the birth, took her to the hospital, but it was too late. Despite the resuscitation, the doctors could not save the diminished woman. The heart can't pump blood through the vessels if it's not there. It simply has nothing to pump, and vital organs don't receive oxygen and stop their activity.

It's hard to say who wasn't affected by the powerful wave of hatred that arose almost immediately after this terrible event and which is still resonating in the media: blaming the dead woman, her relatives, doctors, maternity hospital staff, the doula, everyone who somehow, even hypothetically, could've been involved in the tragedy.

People in white coats caught the most. The real harassment of doctors broke out on social media because they were allegedly saving the unfortunate woman in labor not properly.

They called doctors on everything. Hundreds of subscribers, recalling their own experience and recounting others' experiences, talked about how mothers and children are abused in maternity hospitals, how a pregnant woman's right to natural childbirth isn't respected, how they "accelerate childbirth with harmful drugs" and how they "squeeze out children like horse doctors." Famous bloggers also added fuel to the fire in a frantic attack on medics, one of whom, by the way, actively promoted her own doula's services at one time. But none of the Instagram gurus has ever mentioned that now the expectant mother signs papers for every medical manipulation in the maternity hospital and no medical intervention is performed without the patient's consent. Those enchanted with "natural home births" don't mention that there are maternity hospitals in Ukraine, where safe births can take place under the supervision of qualified doctors. These gurus don't explain to patients their rights and the risk of complications from childbirth without the participation of doctors. And then…

Then, in the 21st century, another modern family will once again entrust the life of a mother and unborn child to a complete stranger without education, looking to posts on social media.

If there's demand, there'll be supply. Ordinary citizens' total distrust of any official institutions, including hospitals, a crisis of professional expertise, a large amount of incomplete, inaccurate, and biased information on the Internet and the media, leads to cognitive distortions such as the "true knowledge" illusion and a large number all sorts of swindlers who don't mind making a hand of this "knowledge." Every pregnant woman wants to give birth with a smile, without fear and pain, in a familiar, pleasant environment and surrounded by loved ones. And it doesn't matter what number of the birth is. Such comfortable conditions are offered by so-called "spiritual midwives." The positive moments of home birth are fondly explained on social media by mothers, whose experience turned out to be successful, while tragic cases mostly remain behind the scenes of this network euphoria.

The World Health Organization estimates that about 800 women die each year from complications during pregnancy and childbirth. Yes, medicine is not yet omnipotent, and doctors cannot help mothers in particularly tough cases, but obstetric care is recommended by the WHO for most births. For example, in the UK, obstetric maternity centers don't differ in safety from a hospital; often they're even located on its territory as a separate department. Home births are also safe, especially if it's possible to turn your home into a small hospital, as the British queen once did.

But in Britain, women in even the lowest risk group are usually advised to choose a maternity hospital because the risks to the baby are higher at home. However, the choice is left to women, after acquainting with the statistics for each place of birth: hospital, maternity center, home. Thus, both Princess Diana and Catherine, Duchess of Cambridge, gave birth to heirs to the British throne exclusively in hospitals.

There are countries where home births aren't uncommon and the law supports them, but they have a clear logistical care chain. Trained certified specialists are responsible for their recommendations and behavior, they can quickly transport the patient to the obstetric hospital within the limits of maintaining viability. Other countries (most of them) practice a "home birth under the care of a hospital."

This practice is already fully implemented in one of the maternity hospitals in Ukraine. It's the 5th Maternity Hospital in Kyiv. There are cozy, almost homely conditions, large baths for analgesia; childbirth in water is possible. A woman chooses a comfortable position during childbirth, she's not forced to give birth on her back, in a position that Ukrainian protocols don't recommend, because it often leads to complications. Within the "Childbirth without Restrictions" project of the 5th Maternity Hospital, the woman will be surrounded by qualified medical staff, taking into account all the wishes of the new mother, her vision of the childbirth, and most importantly, studying the personal plan of childbirth a pregnant woman envisioned.

Experienced doctors and midwives spoke about their attitude to home birth and about reasonable alternatives:

👩‍⚕️ Svitlana Halych, doctor of medical science, professor of obstetrics and gynecology, Odesa:

Regarding this practice in the regions, now almost every maternity hospital provides home birth. It means the following: with the informed consent of the woman, the medical staff does not interfere with childbirth, which takes place without life-threatening complications. However, in the event of such situations (bleeding, the threat of fetal death, decrement of the mother's condition), the staff provides qualified and emergency medical care. This approach is a reasonable alternative to home births without access to health care and inpatient deliveries according to the world's approaches and protocols.

This year the city's maternity hospitals did everything but greeted women coming to give birth with bread. Accordingly, they don't refuse those demanding not to interfere in childbirth, to give birth with a husband, a neighbor, an acquaintance, or a doula. Funding from the National Health Insurance Fund has done its positive work on the one hand and created the tendency to reduce childbirth on the other. We're successfully cooperating with certified doulas, and perinatal psychologists, who support the woman, if she wishes, during childbirth in the maternity hospital. It happens within a partnership birth. Because the purpose of such assistants is psychological support and help, not any interventions. Most of them are aware of their professional capabilities. Doula in the maternity hospital is normal. A doula at home is dangerous!

With the temporary ban on partner childbirth due to the coronavirus pandemic, the number of women who didn't go to the hospital but gave birth at home increased as projected. Women make such an untested decision, although no one will help them in case of complications. The ill-timed visit to the hospital for help can cost the mother's health, and sometimes (as with Rivne) life. Because none of the doctors has "Lord God" written in the passport when the human body has exhausted opportunities for compensation. And late assistance doesn't give a chance for life.

Doctors know that with bleeding, there are "platinum ten minutes" and "golden hour," when emergency care can increase the chances of survival. When this time is lost, the chances are greatly reduced.

We usually respect a woman's choice… we have to accept even unwise choices. There's nothing we can do about it. However, an even more heartbreaking thing is when society accuses doctors of it in the future. Don't believe that doctors don't care! Every such unfavorable case is a bloody wound in the soul of those who tried to save such patients and failed. Not only obstetricians-gynecologists, midwives, anesthesiologists-resuscitators, nurses, but also caring ambulance staff, multidisciplinary medical hospitals.

We must all remember that safe childbirth in Ukraine is possible only in an obstetric hospital. And if the doctors, in someone's opinion, didn't provide the necessary qualified assistance, there are law enforcement agencies. Otherwise, we'll all plunge into anarchy.

👩‍⚕️ Natalia Yaremchuk, high-level obstetrician-gynecologist, candidate of psychological sciences, Kyiv:

Once, a long time ago, when I was still an intern, they brought a pregnant woman with bleeding, placental abruption on the background of complete well-being. The obstetrician-gynecologist on duty struggled with bleeding in the operating room all night. Blood from the uterus usually flows as fast as from an open tap. And there is no rescue valve! There's only the mastery of a doctor, his/her iron will, perseverance and a mad desire to save a life, because to save is his/her job! The woman was rescued because the ambulance was driving in the oncoming lane, accompanied by police, and not a second of precious time was lost.

Then I couldn't go to the operating room, I was sick with fear, with the intoxicating metallic smell of blood mixed with the bitter smell of sweat spreading in a puddle under the surgeon's feet. The doctor sat next to the rescued mother for another day because decompensation could occur at any point. She approached the window and looked at the snow-covered city with her dry, inflamed eyes. I know what she was thinking.

At that point, she didn't think about what would happen to her patient if decompensation did occur. The doctor looked at two homeless stray dogs playing on clean snow, and wanted to run outside, to breathe clean frosty air… After inhuman nervous strain and daily stress, she wanted to become a homeless dog. She rescued the woman. It won't be shown on TV.

They also won't tell stories about thousands of daily feats in operating rooms and maternity wards. Her colleagues won't even mention it. It's their job.

And in twenty-five years, a completely diminished woman is brought to the maternity hospital after a home birth. But they bring it late. And she isn't saved, because the time for rescuing has gone irrevocably with the blood that flowed during the three hours in the house in front of the spiritual midwife. It turns out that the spiritual midwife, in front of whose eyes the mother of two children was bleeding, is not evil! Childbirth at home for women at high risk of bleeding is not evil! Giving birth online for big money is not evil, it's cool!

And what is evil then? As always, doctors…

The doctors' work is to save lives! It is impossible to save everyone and always.

Especially if the respect for the medical profession is destroyed at all levels, and human ignorance becomes endless.

In the photo above, you can see me, at six in the morning, when they brought twins with placental abruption and uterine bleeding. There were nine more of my colleagues in the operating chamber. Obstetrician-gynecologist, two anesthesiologists-resuscitators, two neonatologists, midwife, operating room nurse, anesthesiology nurse, and another attendant.

Nine people to save one life!

And do you still want a home birth?

👩‍⚕️  Lilia Levenets, high-level obstetrician-gynecologist, Ternopil:

Today, such a physiological phenomenon as childbirth is usually leveled to natural conditions as close as possible, and some women want to give birth at home because everything there is so familiar and comfortable.

Moreover, on the Internet, you can find a lot of examples of home births from bloggers and celebrities. The network is also full of ads about doulas, assistants in childbirth, but, unfortunately, these are often people without medical education, and they don't actually bear any responsibility after certain problems occur! Another thing is certified doulas, who have undergone special training and help you give birth in the hospital.

If you still decide to give birth at home, even with the most physiological and normal pregnancy, remember that there is ALWAYS a risk of critical and life-threatening conditions, such as soft tissue tears, risk of wound infection, fetal distress, weak labor development, and others. Particularly dangerous is obstetric bleeding, which is almost always certain death without the proper amount of blood for transfusion, anesthesiology, and other supplies at home.

No one can force a woman to give birth in a maternity hospital, but the expectant mother, when deciding to give birth at home, must realize that she's fully responsible for her health and the life and health of her baby.

Personally, I wouldn't like to give birth at home. When there's a doctor you trust, qualified specialists, who have all the necessary medicine and equipment at hand in an emergency, it's someway calmer.

👩‍💻 Ternopil Lawyer Olha Bondar comments:

There's no official concept of home birth in Ukraine, they're illegal. Moreover, the activities of persons accompanying home births can be considered a crime under the following provisions of the Criminal Code:

• For persons who aren't doctors: Article 138. Illegal medical activity. Medical activity without a special permit, carried out by a person who does not have proper medical education; if it has caused serious consequences for the patient, it is punishable by correctional labor for up to 2 years, or restriction of liberty for up to 3 years, or imprisonment for up to 3 years.
• For doctors: Article 140. Improper performance of professional duties by a medical or pharmaceutical worker. Failure or improper performance by a medical or pharmaceutical worker of his/her professional duties due to negligent or dishonest treatment; if it has caused serious consequences for the patient, a person shall be punished with deprivation of the right to hold certain positions or engage in certain activities for up to 5 years, correctional labor for up to 2 years, or restriction of liberty for up to 2 years, or imprisonment for the same term.

Therefore, doctors and any other person may not deliver birth outside of a medical facility. Any payment for such home births is also illegal because people who do it at home don't have a license and are also outlawed.

The exception is childbirth by ambulance doctors, but even in this case, the mother and child will later be taken to the maternity hospital for examination.

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• By law, according to the "Fundamentals of the legislation of Ukraine on health care," a pregnant woman has the right to:

✅ choose her own doctor.

✅ be registered in any women's clinic, regardless of the place of residence.

✅ ask her doctor any questions about prescribed medications and medical procedures and get a comprehensive answer to them.

✅ undergo psychological preparation for childbirth in the school of parenthood (order №417 of the Ministry of Health).

✅ choose the maternity hospital where to give birth (order №620 of the Ministry of Health).

✅ get information about her health and the child's health.

✅ have partner births (with the presence of no more than 2 trained persons).

✅ have de-medication of childbirth (i.e. have a birth with no drugs).

✅ freedom of action in childbirth (independently choose the position in which to give birth).

✅ breastfeeding.

• What's forbidden: ⠀

❌ Childbirth at home (or rather, agreement with a doctor for such a service, we don't consider spontaneous births). All unforeseen circumstances and complications are the sole responsibility of you and the participants of such births!

❌ Ordered childbirth (ahead of schedule).

❌ Cesarean section "on order", i.e. without indications.

Another aspect: the birth of a child at home requires certain evidence for its registration. Registration is difficult at the moment, it looks quite multi-level, and sometimes even requires genetic examination.

Home births are possible for a woman as a free citizen, but they're illegal for doctors and others who provide services for such births.

The person who called herself a doula and accompanied the dead woman from Rivne in childbirth disappeared. Currently, law enforcement officers have opened a criminal case under the article on premeditated murder (marked "accident").

The case in Rivne affected not only doctors but also real doulas who help women in childbirth. A doula isn't a medical professional. Nor is she a "spiritual midwife," whatever that means. So who are certified doulas and why are they needed?

💁‍♀️ Olha Horbenko, a perinatal psychologist, doula, co-author, and leader of the training program for doulas in the European Doula Network, co-founder of the "Natural Rights Ukraine" organization, Kyiv, explains:

Doctors, neonatologist Marshall Klaus and pediatrician John Kennell started and named this profession. In the late 70s, researching the first contact between mothers and babies, they accidentally discovered that when another woman was constantly present with a mother during childbirth, the results were better. It was these doctors and several specialists who were also involved in the perinatal field and founded the first doula organization "DONA" in the United States. A code and standards of practice for the new profession were developed, and the training of doulas began. Doula organizations now operate in most countries around the world. Doulas aren't medical professionals. They are in no way a substitute for doctors or midwives, as they're not responsible for medical safety and don't perform any medical actions. A doula is more of a professional partner during childbirth. She pays attention to the needs and wishes of women and fills that part of care during childbirth, lacking in medical systems even in developed countries: she provides continuous support, cares for the physical comfort of childbirth, and psychological safety.

Doula's activities also include informational, emotional, and practical support of women and families for the best health of mothers and children and a positive childbirth experience. A doula knows how to create the conditions for a natural birth and has methods of non-drug analgesia when it's possible. She also provides the necessary support to the woman when medical interventions are needed or when the woman wants to use medical anesthesia. Her job is to provide information for informed choice and to support a woman's decision. Doula as a companion for childbirth is repeatedly mentioned in the 2018 recommendations of the World Health Organization regarding childbirth.

Studies involving more than 15,000 women have shown that continuous partner support during childbirth reduces the risks:

• cesarean section by 33%
• drug anesthesia by 11%
• birth of a child in a state requiring help by 61%
• a woman's negative perception of her childbirth by 45%

WHO general recommendation is to have the partner of choice for all women during childbirth. By the way, this recommendation remained unchanged during the pandemic. A partner can be any person who a woman has chosen to provide her with ongoing support during the birth of a child: a husband, girlfriend, relative, or doula. Doula, as defined by the World Health Organization, is a woman who's been trained in childbirth support but isn't part of the medical staff.

A father can't be always present at childbirth; not every new mother wants him there. She may not have someone around her to support her during childbirth, so she may choose a doula for this. And even if a man was present, he usually perceives this new and emotional experience more positively if the doula is also present. The new profession is becoming increasingly popular in the world.

What can we say about Ukraine? A doula profession is only at the development stage.

The Semitsvit Center, which I represent, has been cooperating with the Perinatal Center in Dnipro for many years. 10 years ago we created a comfortable maternity ward; it's cozy, has a large bathroom. There's everything to make the mother and family feel comfortable. It's also an excellent example of combining women's needs and health security. The doula organizations of the European Doula Network, which includes the community of doulas of the Semitsvit Center, are unanimous that the doula cannot be present at labor without medical support. And since there's currently no official medical support for such births in Ukraine, our organization doesn't accompany births at home and has never done so. So it's unfortunate that absolutely all the doulas are being blamed now.

Regarding certification. In most countries, a doula is also not an official profession. There are usually doula organizations that adhere to a common code and standards and conduct training themselves. Since the profession is unofficial, the certificate isn't an official document. It shows what training the doula has undergone. Because training to be called a doula is mandatory. Also, the certificate is rather the reputation of the organization that conducted the training. But the doula is still in the legal field because according to the Order № 234 of the Ministry of Health of Ukraine, a woman can choose any person to support childbirth and even two persons. WHO emphasizes that women's free choice for such support is an important expression of respect for mothers and part of a human rights-based approach.

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And most importantly, how can a woman protect herself? Because there are people who call themselves doulas out of their own free will or violate the doula code.

• You should ask about the training that a person has undergone to be a doula, what organization has conducted it. It's easy to check.
• Ask about the code that the organization follows.
• Ask about the assistance experience she already has. As a doula, she won't promise to monitor your birth, even if she has a medical education. She won't give medical advice, cancel doctor's appointments, and perform any medical functions. She won't agree to support childbirth without medical support and won't say that it's absolutely safe with proper training. She won't incline you to a certain method of childbirth and promise to protect you in the maternity hospital from doctors, even if you ask for it. Because medical professionals are responsible for medical safety. A doula will ask about your expectations and will offer options according to your needs. However, only you will make the decision.

I've been fortunate to work with friendly doctors and midwives more than once, both in Dnipro and Kyiv. Everyone will benefit from such joint actions. Especially women and families. When everyone does their job in a way of mutual respect, a great result is usually a reward for everyone. And women have wonderful memories and a wish to give birth again.

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As a postscript

Homebirth is not evil, by any means. It's a choice. And like every choice, it has consequences, and those who made that choice are responsible for them.

We can't deny "obstetric violence" and traumatic medical care. This problem exists, those who've faced it understand it and know what terrible consequences it can cause. This problem has long been actively discussed in developed countries, where medicine is at a better level. There are still many problems in maternity hospitals in Ukraine: old delivery rooms and insufficiently equipped wards for 4-5 women, births without anesthesia, and staff's "Soviet" attitude. We need to talk about it. And also about the problems of medical education in Ukraine, the legal insecurity of doctors and patients, logistics and diagnostics in rural clinics, and the legal basis of "advice" on the Internet, who and how should be responsible for "treatment" on Instagram and forums.

If we want to avoid tragic events in the future, we should study the needs of women who make choices. In society, those who decide to give birth at home are often considered marginal or irresponsible, easily influenced, sectarians, fanatics of the naturalness idea. Do we really know their motives? The decision to give birth at home may be caused by a previous traumatic experience of childbirth in a hospital, a negative experience of someone in the family, the need to have support from loved ones in a vulnerable life moment, the desire to be an active participant in childbirth, not the object, the desire to avoid excessive interventions. That's what often worries pregnant women.

But we won't know what was most important for those mothers who decided to give birth at home until we begin to analyze the problem comprehensively. Until then, society will continue to turn the blind eye to home births and will explode only when another tragedy occurs.