Dr. Laszlo Abraham, expert in the field of malpractice in obstetrics and in general medical practice, was interviewed here not long ago. After his lines appeared in the blog, the idea of interviewing Agnes Gereb, the emblematic figure of home births in Hungary, was a just request since sadly her name is also linked to malpractice in obstetrics. Agi never gives interviews. But for the blog 'Bezzeganya' (’uppity-mother’) she decided to make an exception, and she now shares with us her opinion on home birthing, malpractice and the double standards surrounding the profession.
The blog published an interview about medical malpractice a short time ago. In connection to this topic, the question of double standards has come up. In relation to the tragic events in your practice I would like to ask your opinion about double standards, i.e. injuries and deaths in hospitals vs injuries and deaths at home births. Would you tell our readers when and why you were made responsible?
It appears that the punishments I have been given have become increasingly severe. First, it was around 1978 that I was forbidden for half a year to attend to births at the hospital which I worked for due to the fact that I allowed husbands to be present at their baby's birth. In this case neither the sin nor the punishment was tragic.
My membership of the Hungarian Medical Chamber was suspended for half a year in the early nineties - which at the time meant that I was not allowed to practice as a physician for that time - because I took a bleeding woman to hospital in a country town where she was given medical support, after the initial struggle for co-operation with the staff. She left the hospital in a day or two in healthy conditions (http://szules.hu/index.php?option=com_content&view=article&id=541:nyiregyhaza-blues&catid=69:writings&Itemid=89 ). This was not a tragic event either but the punishment affected me greatly, especially since the execution of the sentence started with immediate effect even though the case was not yet closed. The six month ban was completed by the time my lawyer's appeal was accepted and consequently the charges were dropped against me. There was no acknowledgement of the lost six months from any official body...
In the early nineties further incidents of persecution took place including one, two, three house searches. Once, for instance, a well-wishing neighbour saw my daughter's nappy in the bin, soiled with poo and milk, and thought that it was a nappy soiled with meconium and amniotic fluid. The consequences were less severe this time: my daughter could undisturbedly, without the threat of another house search, poo in her nappy from then on.
In 2000, however, after eleven years of attending home births, a tragedy occured. The same kind of tragedy took place not much later at the hospital MAV and more recently at a Hungarian clinic of obstetrics and gynaecology (http://szules.hu/index.php?option=com_content&view=article&id=535:about-a-little-baby-girl&catid=69:writings&Itemid=89 ). The difference, however, was that our tragedy was widely accessible through the media while the event at the hospital and at the clinic was not reported in the news as far as I know. For this incident, after seven years of criminal procedure, I was in 2007 sentenced to three years of suspension as an obstetrician-gynaecologist. (Surely there was an inquiry, an in-house inquiry among the professionals at the hospital MAV, too, but it did not become a matter involving the police or the criminal court and I did not hear of anyone being made responsible for the incident. The more recent, strikingly similar incident at the clinic was not followed by a police inquiry either.)
There was also a tragedy in 2003 (http://szules.hu/index.php?option=com_content&view=article&id=536:this-happened&catid=69:writings&Itemid=89 ). A twin baby, after the birth of the sibling, became unwell in the womb so I administered an injection of oxytocin into the vein of the mother (to speed up the process of birthing). As a result, the baby was born immediately (which was the aim of the exercise, in order to give the best chance for the baby to be born quickly. Even the best-equipped hospitals would have been unable to perform a caesarean faster.) This was followed by immediate attempt at revival. Nevertheless, after having suffered anoxia, the baby died at home at the age of seven months. While the newly born was in hospital, in the next incubator there was a twin baby with the same post-natal problem which occurred during labour at the hospital. We do not know who was present at the birth of this baby. I was sentenced to two years in prison and a ten year suspension for this and for the birth in which a baby died due to shoulder dystocia (http://szules.hu/index.php?option=com_content&view=article&id=534:a-tragedy-happened&catid=69:writings&Itemid=89 ). The damage that the twin baby suffered due to anoxia was attributed to the administration of oxytocin. Apparently this mistake would have never happened in a hospitalised birth. Meanwhile, in that same year, a televised series dedicated to birth was running. One of the head physicians invited to the program proudly explained the case when he administered oxytocin in the vein of the mother during birth and it did not occur to him that it might cause problems if he so openly talks about this particular topic in front of the viewers (http://www.youtube.com/watch?v=iTrBpxiP3L0 ). (What he was actually saying also appeared in subtitles because it was difficult to hear him describing the case.) Shoulder dystocia had never resulted in a court sentence in Hungary before. In England a report was written about the 56 cases of shoulder dystocia that resulted in death at hospital-administered births over the period of two years, in order to examine the causes. This document was submitted to the Hungarian court during the case. During the hearings one head physician claimed that shoulder dystocia had never been the cause of death in Hungary. It appears that the practice of English obstetrics has a long way to go.
According to your knowledge after homebirth is there a follow-up of birthing accidents and injuries from the point of view of the mother or the child? Is there any statistical data relating to birth with anoxia or with more severe injuries to the vagina, or about the frequency of any other problems (incontinency, fissura anii)? (As far as I know this data does not exist in hospitals.)
Luckily there have not been any serious incidents to the mothers during homebirths assisted by me or my colleagues. Even if we were not inclined to follow the life of the newly borns and their families it would be impossible not to know about them thanks to the interest from the media. We maintain contact with every family after the birth, so there are only a small number of families that we have no information about. There is a mother whose child, although not the one who was born at home, already has a child. Every year there is an event linked to 7 April, the Day of Homebirth, when we meet with the children who were born at home and their families, and the stories of their homebirths are being collected on the site www.tortenetek.szules.hu . There have been very few perineal injuries – less than half a dozen – that were deemed to receive attention in hospital. Owing to the hospital care they have fully recovered.
Have you had the opportunity to say sorry to the parents of the disadvantaged children or the deceased baby? Have you tried? Have they accepted the apology?
The only baby we have lost during birth was the little girl with shoulder dystocia. Unfortunately I could not speak with the parents since. On the day after the tragedy my fellow helpers and I went to the hospital to visit the mother, but the father sent us away. With the mother we only saw each other, only looked at each other. We were not able to hold her. For this reason, on our website we started a section where the family could read - if they wished to - the compassionate messages which were written by families who gave birth with us, and by families who did not (http://szules.hu/index.php?option=com_content&view=article&id=162:egyutterzo-levelek&catid=53:egyeb-irasok&Itemid=76 ). Since that day, 15 September 2007, every year we light a candle for the little girl. For her and for the others too, on 4 March (2000) and 24 December (2003). Also, on 4 September (2009) and 5 October (2010) we commemorate and the parents commemorate (I wouldn't like to say more about the last two dates.) These are very important relationships. One set of parents invited us to the farewell of their baby's ashes, while with another family we walked the path together with the baby through suffering to death. These friendships have developed to be very meaningful and they are for life. I love them. They love me, us, and with us they shared their most difficult moments. Our position cannot be compared to theirs, but it was very difficult for us, too and will remain so forever.
What do you think an optimal model for home birthing could be? Would you for example support “birthing house-like” units in hospitals where it would be possible to give birth undisturbed?
I do not think a birthing house inside a hospital is possible. My colleagues and I invented the idea of a birthing house and the meaning of this expression refers to giving birth outside a hospital. But to set up a unit inside a hospital where work goes on following the midwife model is absolutely possible and a very good idea. I do not think that everybody must give birth in a birthing house or at home. It is possible to give birth well anywhere: in hospital following the midwife model, in hospital traditionally, at a clinic with the help of the most well qualified obstetricians, surgeons, most developed monitors, at home, in a birthing house or in birthing centres; since the safer the mother feels in a place the fewer complications will occur at birthing. If a woman who in all likelihood is facing a complication-free birthing feels that for her giving birth is the safest in a hospital, she would not be able to have her child at home - or if she would, it wouldn’t be a good experience. The acceptance of home birth and setting up units working according to the midwife model would only make the range of choice wider and after getting all the necessary information all the women can chose the one that seems to give them the greatest security, and thus the smallest chance for complication.
Is there any statistical data about deaths during homebirth (either in your praxis or in general, perhaps internationally) and in hospitals?
There isn’t. But you can make your own calculations. Only one baby died during birth – we do not even know if the poor baby died in the birthing house or on the way to hospital or in the hospital, but this is not important. The two other babies we have lost during the 22 years suffered oxygen deprivation and one of them was 7 months old and the other 14 months old when they died. In Petö Institute a lot of children are being treated who suffered oxygen deprivation – none of them was born at home.
How many cases have you had where birthing started at home and was finished in hospital? How does this rate compare to the international average?
About 10 per cent of women who start giving birth at home end up in hospital and this complies with the international average.
If the woman starts giving birth at home but has to go to hospital do you consider it a home birth in your own statistics or a birth in hospital?
Ten percent of home births are finished in hospital. This is a normal part of homebirth. In most of the cases we have to take the mother to hospital because we get exhausted, because the loss of energy is greater than the energy gained. In these situations help from outside is needed so that the mother can find the strength to be joyful after giving birth...
How much do you think the attitude of hospitals towards child birth has changed since you worked in a hospital at the beginning of your career? (As far as I know it has changed a lot and for the better.) Do you think the direction of the changes is good? If not (completely), what do you think the reason is? In what other ways do you think they should change?
The attitude of hospitals has changed a lot, so have the midwives, but the professional routines have unfortunately not changed. Naturally we should not generalise in the field of attitude either. In the professional routines, however, a gynaecologist-obstetrician who is bold enough to change professional routines is very rare even if they are ready to admit that some examinations, processes or treatments are unnecessary, useless or even harmful.
Women who choose homebirth are often accused of neglecting the safety of their baby because of their own interests. What do you say to this?
A woman’s interests cannot be separated (either legally or biologically) from those of the baby inside her. It is unquestionable that childbirth has the least complications if no medical intervention takes place, and if no medical intervention is needed. The ’balm’ that makes childbirth run smoothly is oxytocin, a hormone that is released in the body of the mother during the process of birth. If the mother feels bad or unpleasant physically or psychically the release of oxytocin gets hindered. So everything that helps the comfort of the mother and facilitates inside processes flow freely (dim light, warmth, scents, touches, movements, sounds, etc.) helps the health of the baby as well. It is evident that the mother changes the position of her body while giving birth whenever she feels uncomfortable or whenever she experiences excessive pressure on a certain part or her body. This happens because the baby pushes their mother from inside during the difficult journey and it signifies that they have not got enough room. The mother, by seeking her own comfort, changes her position and by ceasing the uncomfortable pressure she brushes aside the obstacle in the baby’s path; thus she gives way to the baby and so the physical burden on the baby during birth is significantly diminished. In short if the mother is free to change her position she will feel more comfortable and the baby will be born more healthily.
Some say that the image of those supporting home birth has been damaged by the fact that you are identified with home birth. Wouldn’t it be better for the cause if another face and another name could be associated with it? Is there a “change of image” among your plans?
If I had not been identified with home birth then somebody else would have. This is inevitable. I did not need this. I hate the role of Jeanne d’Arc. I am not a heroine, nor am I a martyr or a child murderess. I have never wanted to fight or become famous. I would have preferred to attend births simply and quietly giving my best and continually learning from the mothers and teaching successors so that I could hand down the relay baton. I wanted to give and get joy and remain a mother, wife, grandmother, sister and daughter and share my joy. Just like midwives in other countries where not hierarchy but democracy dominates around childbirth as well. I have not succeeded in reaching many of these goals. Let me quote from a great American book (Penny Armstrong, CNM and Sheryl Feldman: A Wise Birth. Bringing Together the Best of Natural Childbirth with Modern Medicine) that was published in Hungarian in 1995. “How strange it is that those who think that giving birth is about love, affection, human dignity and taking care find themselves outside and they must demand that their voices be heard. How incomprehensible it is that they are condemned radicals and militant. How impossible it is that they must gather all their strength, they must organise, deliver speeches, raise money and negotiate to make others realise the human dimensions of childbirth and motherhood”.
As far as I know home birth is not supported by health insurance. How much is it exactly if somebody wants to give birth at home?
Exactly? It is exactly as much as mothers give to the doctors as a tip these days: UF150, 000. It was different in our days. These days only the wealthiest can afford to legally give birth at home. In our days home birth was there for everybody no matter whether they were rich, what colour their skin was, what party or denomination they belonged or did not belong to. Home birth only depended on the decision the woman made on the basis of her information and not on money.
There is another common image of those choosing home birth: they are wealthy women dressed in fine linen who are all faithful worshippers of the method. Is this true? Who are the women who choose home birth?
For a few years in the beginning it was only intellectuals who chose home birth but later there were a lot of unskilled workers too and women from all walks of life: a lot of talented artists and many outstanding professionals. Are they dressed in fine linen? Some of them are. But if there is one single person dressed like that in a crowd of demonstrators she is sure to be photographed. I do not know who are the ones who choose home birth now but in my time these women had a common feature: they liked to choose freely, their inner freedom was important to them, they liked to be informed and they liked to take the responsibility for themselves and for their children. Very few real extremists joined us, but there were some.
What do you think of women who choose programmed Caesarean? Does the freedom of birth as you mean it refer to them as well? What advice would you give to such a woman?
I would do what my mother has always done. She always told me what she thought and then she let me take my own decision and she supported me even if my decision was different from what she suggested.
Whom would you strongly dissuade from giving birth at home?
There are professional reasons, of course. But I would only say that I do not suggest that she should give birth at home and give her my reasons. The decision lies with the mother – she can decide that she does not wish to get information or take part in the professional decision and leaves the decision to the midwife (this does not usually happen). But it has happened that I suggested another midwife because of personal reasons. When I got to the point that I could make my choice, and could also be chosen, i.e. I was not the only independent midwife in the country like during the first ten years, I never went to people I did not have a good feeling about. Whenever it was possible we cleared up the cause of a bad feeling, antipathy, misunderstanding or other problems but if we could not do it, somebody else went to the woman or none of us did. This is at least as important with attending birth as the professional part. How could a midwife be present at an undisturbed birth if she feels repugnant towards the mother? How could she protect her, care for her lovingly? Attending birth does not bear lies...
Thank you for the interview.Center