Informal payments for maternity care in Central and Eastern Europe
MAASTRICHT. Informal (also known as under-the-table) payments in Central and Eastern Europe are higher and more frequent for maternity care than for any other type of medical care. This is one of the conclusions of a broader research project on out-of-pocket payments (both formal and informal) across Europe. Wim Groot, Tetiana Stepurko, Jelena Arsenijevic and Milena Pavlova from the Department of Health Services Research have written a European policy brief with recommendations to improve the situation.
The researchers became interested in maternity care when they came across contradictory figures. Although statistics indicate that prenatal care is widespread, a doctor is nearly always present for births and adequate emergency obstetric care is available, the proportion of mothers dying in childbirth remains relatively high in Central and Eastern Europe. In some countries, such as Hungary, Romania and Ukraine, this figure is three times the European Union average (20 per 100,000 births instead of 6 to 7).
“In Serbia all maternity care is free of charge”, says Jelena Arsenijevic, who did the research for that country. “Thanks to the old communist system there’s a good network of maternity wards and the doctors are well trained.” So far, so good. “But to get a prenatal scan, for instance, you have to wait a very long time. Obstetricians will tell you that if you go to their private clinic, you won’t have to wait. Also, in a public maternity ward you won’t know who’ll be monitoring you when you’re in labour. Delivery at home or in a private hospital is prohibited. If the statistics say there’s nearly always a doctor present at the birth, that means during the admission procedure and at the moment of the birth itself, but not necessarily in the hours before. Whereas if you make some sort of agreement with your obstetrician, she or he will be there. Sometimes people even plan a Caesarean to secure their investment (money from the mother, time from the obstetrician).”
Mothers-to-be agree to pay something extra to get the best care for their child. “It’s not just about you; that’s probably why it happens more frequently than with other medical care”, says project coordinator Milena Pavlova. Few Central and Eastern European countries have concrete legislation on under-the-table payments. “Doctors often receive very low salaries and government funding doesn’t always come through, so patients consider it okay to pay something extra. It’s like a tip in a restaurant.” Women who cannot pay the extra amount and who have no personal connections among the medical staff may be left without adequate care. “In Ukraine, you end up in the emergency room if you don’t have a personal obstetrician. You’ll have to either pay informally or be prepared to receive substandard care. Therefore, expectant parents search for a personal obstetrician in advance and openly negotiate with him or her about the delivery care as well as the informal payment. It is like signing a contract which in return assures you of reliable information before the birth as well as adequate treatment during it.”
The researchers not only recommend that governments take steps to ensure that medical care is better regulated and funded. They also feel that better communication would help. “There’s a strict hierarchy”, says Arsenijevic. “The doctor is the expert and doesn’t ask the patient for her preferences. The mother is often treated as an object instead of a woman. It would be good if communication training were implemented in the medical curriculum. Also, the position of midwives should be improved. And private providers should be included to promote competition – as it stands now, the public hospitals have a monopoly.”