Obstetric violence within pregnancy care is a pressing health issue in the country of Croatia. Over four hundred women have recently spoken out about their traumatic experiences during labor, but a history of this type of injustice institutionalized by the ministry of health has been culturally apparent for centuries now. By using the anthropological perspective of feminist theory, I have been able to pinpoint some of the causes of this particular health issue. That being said, there are three major determinants of health that affect the pregnancy care of women in Croatia: gender inequality, an inadequate relationship with policymakers, and low socioeconomic status.
“Obstetric violence includes physical abuse, humiliation and verbal abuse, compulsory medical procedures or procedures carried out without consent, the refusal to give painkilling medication or anesthesia, and violations of privacy” (Vladisavljevic). The use of heavy force or any kind of restraint is the most frequently encountered form of physical abuse. Acts of humiliation and verbal abuse coincide with the cultural assumption that a woman who decides to be a mother should be able to withstand the pain of pregnancy. Urging compulsory medical procedures–such as Cesarean deliveries–in non-emergency situations fosters unnecessary high risks for many patients during their pregnancy care.
The lack of consent received prior to invasive pregnancy-related procedures–such as biopsies, medically-assisted fertility, curettage, vaginal sewing repairs, and episiotomies–directly conflicts with the pre-existing Croatian Patients’ Rights Act (Survey on Maternity Practices in Croatia). Anesthetics are in contradictory high demand and low supply, so medical professionals use economic determinants to decide which patients will receive them. Violations of privacy will negatively affect almost half of Croatia’s pregnancy care patients in their decision to have more children (Survey on Maternity Practices in Croatia). It is critical for the health ministry to conduct further investigations while implementing protocols to eradicate these damaging patterns of medical assistance.
Gender inequality is a social determinant of pregnancy care in Croatia. Gender is often used in combination with other social characteristics to regulate a social hierarchy within a given society. Of the three waves of feminism that currently exist in academia, it is the second that furthers the concept of intersectionality by focusing on gender as it relates to class, the social relations of power, and changes in modes of production (Dominguez). When discussing gender, it is important to note that gender is cross-culturally divergent in its construction. Stereotypical assumptions of gender-based on physical observation, or in combination with personal cultural beliefs, can cause a patient to become anxious and uncomfortable.
“The problem lies with women’s experiences of reproductive healthcare being viewed through a different lens from men’s health” (Twigg). For example, symptoms of erectile dysfunction are addressed with pharmaceutical solutions at a much higher rate than symptoms of pain during pregnancy, although both are significant reproductive concerns. Feminist theory suggests that women must not only be seen in relation to men, but also in relation to one another (Leonardo). Advocating for a #BreakTheSilence campaign in regards to obstetric violence has allowed for numerous Croatian women survivors to unite in their experiences in an empowering and potentially healing manner. For the purpose of feminist analysis, women are often characterized as a singular social group based on shared oppression (Mohanty). Although women do not experience all of the same oppression, they do experience the same overarching layer of social oppression based on their gender.
An inadequate relationship with policymakers is a political determinant of pregnancy care in Croatia. The organization, Roda, or Parents in Action, submitted three complaints in regards to the overwhelming occurrence of Croatia’s obstetric violence to the United Nations, including a special rapporteur for violence against women, a special rapporteur for the right to health, and a working group on the issue of discrimination against women in law and in practice (Drandić). Similar claims were made public back in 2014, so with no governed resolution strategies or implementations five years later, it has become evident that the Ministry of health is ignoring these allegations.
“The main problem is that experimental studies [of healthcare] are generally infeasible and that observational studies of the effect of collective decisions [in reference to said healthcare] are liable to similar biases as observational studies of the effects of individual decisions” (Mackenbach). On a scientific level, researching into Croatia’s public health becomes limited, for the biomedical system in place has an inability to heal populations–only individuals. Also, pregnancy care may have been introduced on the political docket years ago, but policymakers are more often than not male, lack empathy for survivors, and/or initially respond with victim-blaming propaganda. Feminist anthropology critiques the social structures and cultural ideologies that shape women’s lives (Geller). Croatian culture still embodies traditional gender roles that promote the social structure of inequality for women, and this is emphasized through the country’s unwavering political stance on the matter.
Low socioeconomic status is an economic determinant of pregnancy care in Croatia. Poverty, along with a lack of quality medical care, is directly correlated to the use of violent and unorthodox methods. Women with little to no financial freedom resort to having babies in understaffed medical centers. They are not given the option of having a midwife to assist in alternative birthing methods such as water birth. Labor resources are scarce, so the use of any kind of medical aid such as anesthetics is economically determined. Having a low socioeconomic status can negatively affect both mother and newborn. Less than satisfactory circumstances during pregnancy can lead to weakened fetal development and maternal stress (Wilkinson). The postpartum stage is also greatly affected by socioeconomic status, for those who fall below the poverty line are at a higher risk for abusing drugs and alcohol as a coping mechanism when confronted with the stressors of having a new baby born into poverty.
The problem in reducing economic inequalities within health is the absence of developing health systems to provide poverty relief (Marmot). The circumstances in which people live and work should not affect their ability to receive sufficient health care as human beings. Croatia has a universal health care system that provides free pregnancy care to those who need it; however, the quality of this free medical treatment and assistance is less than average. Feminist theory pulls into question women’s financial ability to support themselves, as well as their children, in a culture that continues to follow traditional gender roles as regulation of economic power. In Croatia, it is less likely for a woman to obtain a career outside of the home, much less one that would allow them to be financially independent of the men in their lives.
From a cultural standpoint, women make up almost half of the population of Croatia, yet they are subject to gender biases and inequalities–particularly in the realm of healthcare–based on social, political, and economic determinants that they have little to no control over. The cultural norms regarding the treatment of women during labor have contributed to the apprehension that many women have towards maternity hospitals (Survey on Maternity Practices in Croatia). If multiple survivors from different medical facilities are coming forward with similar testimonies of mistreatment during their pregnancy care, the base of the problem is much larger than within the ministry itself. The problem ultimately lies in the foundations of Croatian society.
From a public health standpoint, such gaps in progress should show a clear pathway for sustainable improvement. If the intentions of public health are to provide benefits to the majority of people, women should have every right to be represented in the healthcare system. After all, it is women who give birth to all people. “In order to improve the structure of Croatian perinatal health care system, all maternities and neonatal units [need to be] organized in a network, regionalized according to the professional guidelines” (Survey on Maternity Practices in Croatia). Within these networks, healthcare professionals should be required to learn, at the very minimum, proper communication skills during their training, including those skills needed to reduce the infliction of trauma onto patients.
After divulging the individual ways in which gender inequality, an inadequate relationship with policymakers, and low socioeconomic status negatively impact the pregnancy care in Croatia, it has been brought to the surface that, within feminist theory, the social determinant of health most heavily intersects with both political and economic determinants, although they all intertwine with one another in some way. As more and more women come forward about their experiences with obstetric violence, I hope that some real change is not too far from happening. Roda is the first advocacy organization for this cause, and there is potential for similar growth of awareness and public protest. The long-term effects of this health issue will be felt slowly, for as more women feel scared of these conditions, fewer women will have the desire to procreate, and there will continue to be a drop in Croatia’s overall population.
References
Dominguez, Johnna, et al. (2017, April 24). “Feminist Anthropology.” Anthropology. Retrieved from https://anthropology.ua.edu/theory/feminist-anthropology/
Drandić, D. (2018). Complaints sent to UN Bodies on Obstetric Violence in Croatia. Roda. Retrieved from http://www.roda.hr/en/reports/complaints-sent-to-un-bodies-on-obstetric-violence-in-croatia.html
Geller, P. L., & Stockett, M. K. (2006). Feminist Anthropology: Past, Present, and Future. Philadelphia: University of Pennsylvania Press.
Leonardo, M. D. (2011). Gender at the Crossroads of Knowledge: Feminist Anthropology in the Postmodern Era. Berkeley (Calif.): Univ. of California Press.
Mackenbach, J. P., (2014). Political Determinants of Health. European Journal of Public Health. Retrieved from https://drive.google.com/file/d/1Ta6F0CX9dCURi9VW_-Bcc1HEIB-fhlmK/view
Marmot, M. (2005). Social Determinants of Health Inequalities. Public Health. Retrieved from https://drive.google.com/file/d/1bct-CtOGaE-NCBdQUDE11L9x1n4Riotk/view
Mohanty, C. T. (2007). Feminism Without Borders: Decolonizing Theory, Practicing Solidarity. Longueuil, Québec: Point Par Point.
Survey on Maternity Practices in Croatia (2015, March). Roda – Parents in Action. Retrieved from https://tbinternet.ohchr.org/Treaties/CEDAW/Shared%20Documents/CRO/INT_CEDAW_NGO_CRO_20903_E.pdf
Twigg, K. (2019, January 11). Croatian Women Challenge Brutal Pregnancy ‘Care’. Retrieved from https://www.bbc.com/news/world-europe-46803178.
Urelija Rodin, Boris Filipović-Grčić, Josip Đelmiš, et al., “Perinatal Health Statistics as the Basis for Perinatal Quality Assessment in Croatia,” BioMed Research International, vol. 2015, Article ID 537318, 9 pages, 2015. https://doi.org/10.1155/2015/537318.
Vladisavljevic, A. (2018, November 08). Violent Treatment During Childbirth: Croatian Women Speak Out. Retrieved from https://www.healthynewbornnetwork.org/blog/violent-treatment-during-childbirth-croatian-women-speak-out/.
Wilkinson, R. & Marmot, M. (2003). Social Determinants of Health: The Solid Facts. The World Health Organization. Retrieved from https://drive.google.com/file/d/1ubK2nSOuNnZS9X5vvt7C7rwqQq370tnh/view