“Our citizens do not trust the healthcare system, but believe in good doctors”

“In sociology it is customary to talk about the special ‘Soviet’ type of a patient: passive, delegating responsibility to doctors”

Katerina, what was the specifics of the Soviet system of childbirth?

The main factor is the significant influence of the state. The book by American researcher Mark Field of the 1950s says that in the Soviet Union, in contrast to the United States, the relationship between doctor and patient represented itself the triangle “doctor-patient-state”. The state always controlled the system of medical care, and this affected both the autonomy of medical decision-making and the experience of women. To date, in Russia, the doctor is not a fully autonomous professional, as, for example, doctors in Western countries. Russian doctors are often described as officials in white coats, a significant part of their work consists of filling in bureaucratic documentation. Even our medical associations are largely state-run.

Why in our state does the government seek to control the sphere of childbirth?

Because it is significant in terms of social policy. Both in the past and at the present time, the pronatalist discourse is of great importance, it is constantly said that we need to increase the birth rate. The state classifies women-mothers in a special category and cares for them more than for other patients. The Soviet tradition when doctors and midwives act as conductors of such state care remains to this day.

The very purpose of the appearance of maternity hospitals was that the woman did not hurt herself and the child and was under the control of specialists. Even before the revolution, hospital births were justified not only by that medicine reduced the risks to the health of the mother and child, but also by the need to supervise poor women. There were fears that when giving birth at home such women could then kill the unwanted baby. Doctors were to prevent it. That is, medicine in relation to women is always not only caring but also controlling.

In the Soviet Union, the state always controlled the system of medical care, and this affected both the autonomy of medical decision-making and the experience of women

Today we can see both sides of it. Thanks to the pro-natalist orientation of the state, obstetric aid has become a priority area of reforms and financial investments. This includes the birth certificate programme, which was launched in the mid-2000s, the healthcare modernization programme, which involves the construction of high-tech perinatal centres. Our state spends much more attention and money on medical care for women in childbirth than on the problem of high mortality of men. But health care, following the government policy, also disciplines women more. The most striking example here is the right to abortion and its implementation. Although medical abortion is allowed in our country, it has become less accessible in recent years. The list of the indications for termination of pregnancy has been significantly reduced, “the week of silence” has been introduced — the time before the procedure itself, when a woman who wants to have an abortion should once again think and weigh her decision.

How has it affected the women in labour?

In sociology, it is customary to talk about the special “Soviet” type of patient. To summarize, her portrait is the following: passive, delegating responsibility to doctors, not seeking to gain knowledge and make decisions about their health. It is not an active actor, but a recipient of paternalistic state care.

“When faced with reforms, doctors perceive themselves as victims — of optimization, modernization and other things”

Has anything changed nowadays?

There are the processes of liberalization and marketization taking place. In obstetrics, there are appearing new services, paid and free. Private clinics and entire private maternity hospitals are being established. Patients have a choice of where and how they give birth, in which hospital, one can choose a specialist. Under these conditions, a new type of patient is appearing. This is no longer a passive and ignorant patient, but a demanding and curious patient.

Although it should be borne in mind that not all women have the opportunity to choose a doctor, the conditions and format of childbirth. In general, it is highly educated and wealthy residents of large cities who have such opportunities.

Are doctors also changing?

We often read in the media materials about doctors who are poorly paid, overloaded with paperwork, exhausted by complaints of patients. Faced with reforms by the state, they perceive themselves more as the victims of optimization, modernization and other things. That is, they are professionals whose independence in decision-making and the potential for improving practices are severely limited by the forces of bureaucracy and the market.

However, not all modern changes are for the worse for physicians. Nowadays, there are niches where they can work more autonomously, borrow the best foreign practices and develop their own initiatives. There are appearing new professions in obstetrics. Let’s say, the profession of midwife itself not a new, but now a midwife in some cases can be not only technical assistant of a doctor but to be more self-reliant. In a number of maternity hospitals where I conducted interviews, contracts for childbirth are common not only with an individual doctor but also with an individual midwife. After all, it is the midwife spends most of the time with the woman in labour and often turns out to be a specialist who helps a woman cope with childbirth emotionally.

The profession of midwife itself not a new, but now a midwife in some cases can be not only technical assistant of a doctor, but to be more self-reliant

There are also appearing completely new specialists — doula, slingo consultants, breastfeeding consultants. All of them respond to the request of demanding clients for greater personalization of service, more comfortable experience of childbirth.

“I was surprised to find that all maternity hospitals in Russia are very different”

What can you say about the state of modern Russian maternity hospitals?

I have visited maternity hospitals in St. Petersburg, Moscow, Smolensk, Kazan, Volgograd and talked there with doctors, midwives and patients. Before I thought that, since we have the same standards, all maternity hospitals must be the same. But I was surprised to find that they are all very different. Some maternity hospitals are focused on natural childbirth, doctors there will avoid epidural anesthesia and cesarean section until the last. In others, serious medical manipulations will be carried out much faster and more willingly. In some maternity hospitals, midwives are the “hands” of the doctor, they cannot and do not want to make serious decisions in childbirth. In others, they are the main initiators of changes in the institution, create new departments at the hospital, introduce new methods of childbirth (for example, vertical childbirth). This diversity is, of course, a symptom of that our system of maternity care is being in the process of change, in a situation of constant reforms, when a single idea of good care in childbirth has not yet developed.

If we talk about the general trend, it is a noticeable trend towards the personalization of services. Maternity hospitals are rebuilt, large delivery rooms left from Soviet times are changed: if not even separate them with walls, then at least put partitions to create more intimacy. The creation of such delivery rooms is significant to implement the practice of childbirth with the partner.

They try to provide the wards with a more comfortable environment: fitballs and slings to facilitate contractions, a shower or even a bathroom in the ward. Finally, just a quality repair. Even Rakhmanov's beds no longer inspire terror as before — new models are reconfigured in different positions, and in the case of partner births, on some of them women can even be accommodated together with the partner.

Most often, paid childbirth is a payment for comfort: a comfortable room and more attention from medical staff

“Small maternity wards in small towns are left without funds, there are no necessary specialists”

In this regard, can you comment on the story that happened in the village of Kursavka, Stavropol Krai, where a woman in labour died right on the operating table due to that both the doctor and the nurse came out of the labour room?

It is difficult to comment on the specific situation. There are many problems in the system of childbirth in our country. I think it is important to deal with them on a more general structural level, rather than focusing on individual cases, even if they cause a strong emotional response. Somewhere it is the story of small medical institutions that lack resources. In fact, the result of the modernization programme in our country is the redistribution of resources towards large maternity hospitals and perinatal centres. And small maternity wards in small towns find themselves left without funds, there are no necessary specialists. Often, these departments are just closed, and women have to travel hundreds of miles to get medical care.

We can talk about bureaucratization, rigid standards and recommendations that do not always correspond to evidence-based medicine. The simplest example: the timing of labour induction after water broke. The question is, how long does the doctor wait for the birth to begin itself — 12 hours, 24, 48 or 72? The current trend, according to the midwives and doctors I interviewed — is to lengthen the waiting period so that the contractions begin themselves, and the body itself starts the mechanism of childbirth. But sometimes professionals have to insist in their maternity hospital on the possibility of longer time between membrane rupture and delivery without the use of the hormone oxytocin and antibiotics.

There is also a story about medical staff overload. This is night shifts, the duty to fill in mountains of documentation. With such a difficult daily schedule, they also try to earn extra money outside the main place of work. This inevitably affects the ability to concentrate, the staff just burns out.

What is more, the situation is not much better even in those large centres where patients are willing to pay for childbirth. The woman who paid for the delivery may arrive at a time when she is not the only patient at the doctor, and he will run between three different women in labour. It happens that the doctor or midwife ends the shift, the paid patient comes, the specialist remains, then the next one comes with paid births, and the change of the medical worker is extended to several days.

Now in Russia there have appeared doulas. I have recently attended their first all-Russian conference. Doulas do not provide medical care, their task is to help in terms of emotional care and support for both mothers and medical staff

“The supporters of home birth in Russia are not against medicine and scientific knowledge”

Is childbirth with the partner popular in Russia?

Childbirth with the partner is becoming more common in the middle class. Models of childbirth here can be different. It can be a joint choice of a family and a couple. When both the woman and her partner prepare for childbirth in advance, communicate with the doctor and midwife. This is ideal: all parties are ready for what will happen in the delivery room and all those present work as a team. There is another option: the partner is in the delivery room because it is accepted in his environment because it is so fashionable, but he may not be ready for this. Then there are difficulties. A professional has to take care not only of a woman giving birth, but also of a partner who does not really understand what to do.

Russia is characterized by the distrust of medicine and the trust in individual doctors. Since Soviet times, we have retained the idea of health care as a terrible and unfriendly system. In this picture of the world, a conditional maternity hospital appears as a terrible building without repair, where everything falls apart, and patients are rude. At the same time, it is expected that there are good doctors inside, and for the birth to go well, you need to find such a good specialist and make an arrangement with him.

In the conditions of such distrust, the partner, in addition to supporting the woman in labour, also tries to control the medical staff. Sometimes it is very unnerving for doctors and midwives.

Why do we have more and more supporters of home births, who are very strongly opposed to maternity hospitals? For example, Alena Sterligova says: “Now I have a clear idea, based on my own life experience, that it is impossible to give birth to a healthy child in the hospital.” What motivates these women who decide on home births?

It's the same story about the distrust of the health care system. If we compare the movement of home births in Russia and the United States, we see that the supporters of home births in Russia do not resist medical influence. They are not against medicine and scientific knowledge. People just doubt that hospitals provide safe and quality care. There is a fear that you may be physically injured: something is not sewn up, something wrong is transfused. And also hurt emotionally: be yelled at and rude attitude.

Some specialists with medical education go to take delivery at home because they believe that in the conditions of the hospital it is impossible to implement a truly personalized approach. In this sense, the choice of home birth is the doubt that medicine in our country is effectively organized

Our proponents of home birth often emphasize that home birth is more advanced medicine than you can get in the hospital. Some specialists with medical education go to take delivery at home because they believe that in the conditions of the hospital it is impossible to implement a truly personalized approach. In this sense, the choice of home birth is the doubt that medicine in our country is effectively organized.

The second point is related to that in home childbirth the birth of a child is not reduced to bodily experience. Those who share this view believe that hospital births are purely a medical manipulation. And it is as if separated from the daily life of women and families. The woman in labour is taken from her usual environment, placed in the hospital, the child is taken out of her and the two of them are brought back together. There are people who want to experience childbirth more holistically in connection with family intimacy. For them, childbirth has other meanings than physiology. It can be a spiritual experience or the experience of discovering your femininity during childbirth.

Such parents believe that these additional meanings and more multifaceted experience of childbirth are not compatible with the environment of the hospital. I saw a funny video, though, Spanish, showing a couple trying to have sex in a medical setting, and the message was that it would be hard to get pleasure when you are constantly distracted: the pressure is measured, something is injected, the doctor comes and checks something. Childbirth, according to supporters of home births, also cannot become a secret act in a medical setting.

In the media, parents who decided to give birth at home often appear in the image of ignorant, deceived and irresponsible people who, due to their stupidity, refused to go to the hospital. Is it fair?

In my research experience, I can tell that home births are, for the most part, the choice of an educated middle class that has read a lot of literature and makes an informed decision. But I don't want to sound like an apologist for home birth. In Russia, unlike, for example, the Netherlands, this area is not licensed, there are no standards and certification of professionals. In this situation, giving birth at home can potentially be very dangerous.

Have there been many such cases?

In Russia, there are no statistics on home births for the reason that it is a shadow sphere. The opponents of home births say that every home midwife has her own small cemetery where the victims of her activities are buried. There are ardent supporters of home births who would answer: “You count what mortality we have in hospitals, in home births there is nothing more terrible.”

None of the parties has reliable data. After all, for their collection, it is necessary that qualified physicians attend home births and systematically record whether there are complications and what exactly. Then this information could be compared with the statistics of maternity hospitals. But so far we have only speculation on the topic.