Commentary by Nicky Grace, ARM Website Editor and Independent Midwife practising in the UK
The international community concerned with childbirth and human rights has been shocked by the two-year prison sentence handed to Hungarian midwife Agnes Gereb this week. Gereb has spent years attempting to appeal against the sentence but all the appeals have finally come to an end and it now appears that she will go to prison.
While it is legal for women to give birth at home in Hungary, in reality Hungary’s public health authority refuses to issue licences to independent midwives who would attend the births and successive governments have supported this stance. Any midwife who does attend a home birth risks police investigation and arrest.
Midwives like Agnes Gereb are investigated and charged for matters which would not be regarded as crimes in any country with a professional governance structure to support women’s choices.
Gereb qualified and practised for 17 years as an obstetrician but gained much of her very extensive home birth experience working as a midwife. She founded the Napvilag birthing centre in Hungary and it is said that she has attended 3,500 births. Internationally Gereb is held in high esteem as a home birth expert and human rights advocate. She has acted with courage and integrity throughout her long career, first putting her medical license on the line by allowing partners into birthing rooms back in 1978. However, campaigners say that the Hungarian authorities have relentlessly persecuted Gereb and other midwives in their bid to criminalise home birth and make hospital deliveries the only option for women in Hungary.
Like many ARM members, I am outraged and stunned by the inhumane treatment and loss of liberty of this dedicated midwife. But while our hearts go out to our colleague on both personal and political grounds, we need to acknowledge the wider implications not only for the human rights of childbearing women, but also for the professions of both midwifery and obstetrics. There are matters of principle at stake here.
No one wishes to have an adverse outcome whether at a home birth or a hospital setting, indeed it is the aim of our practice to avoid such outcomes. However, everyone acknowledges that childbirth is, by its nature, unpredictable. As a mother bereaved of a newborn myself, I am only too aware that it is simply not possible to guarantee a perfect outcome for every birth however effective the midwife’s or doctor’s practice. It is possible to minimise adverse outcomes and improve safety in all settings with a range of measures – in my book, the most important of which is to listen to the woman – she usually knows what is best for her and her baby.
However, the Hungarian authorities don’t appear to be listening to their citizens who want home birth provision attended by midwives. Nor do they take into consideration research evidence that shows that for many women the safest place to give birth is out of hospital, as long as the right infrastructure is in place for transfer to hospital if complications arise. For Hungarian women, it is almost impossible to choose to give birth at home and any midwives who do attend them risk imprisonment.
Let’s stand by Agnes Gereb. One thing that we can all do is to sign this petition which is gaining momentum https://www.change.org/p/everyone-freedom-for-agnes
In addition to signing the petition, Gereb’s supporters have asked members of the international community to write directly to the Hungarian President, Janos Ader, asking for clemency. Legal expert, midwife and mediator, Paul Golden, has written a letter which can help give guidance on communication with the President. Paul’s comments and his letter follows. Below this I’ve reprinted an article by ARM member Dr Irene Walton who visited Gereb in 2012. This case has been dragging on a long time but let’s all make some noise and stand by our colleague to let her know she’s not alone. There but for the grace of God …
Paul Golden gives advice (see below) for those who wish to write and provides a draft of his own letter. Please don’t directly copy the letter which has been provided to give you some ideas. Messages will be far more effective if you draw on your own personal views and experience.
Paul’s advice and draft letter:
Clemency letter to János Áder the president of Hungary.
Regarding the two year jail sentence for Ágnes Gereb.
Notes and suggestions for an effective letter writing campaign.
Please Plan the letter before writing.
The aim is to create global justification for the president to grant clemency.
Keeping to brief facts rather than emotion.
Introduce yourself and your relationship to Ágnes Gereb and her work with birth and human rights.
Please Mention which country and any organisation you represent.
Give your reasons: Why it is important that Ágnes be granted clemency.
Dear President Áder
Clemency Request for Agnes Gereb
We, members of the international community respectfully request that you provide clemency for Agnes Gereb.
I am a human rights advocate, lecturer & midwife working in the UK Australia and New Zealand. I work with The Global Midwifery Council (GMC) who endorse this letter to you. The GMC is an organisation of leaders in midwifery and childbirth education.
I have visited Agnes in Hungary whilst researching this case.
Reasons to consider for granting clemency
- Time Served – The time be considered to already have been served due to the lengthy legal proceedings that started in 2010.
- Ágnes has already spent periods in jail and many years under house detention.
- These court actions have placed restrictions on Ágnes from being free to travel, work or live her life with respect to private and family life. (These are the very values she sought to uphold).
- The lengthy proceedings have had a significantly negative impact on Ágnes’ health and wellbeing.
- The restrictions preventing Ágnes from working have caused great financial hardship.
- Ágnes’ family and friends have suffered distress during this lengthy process and now again with the jail sentence.
- Ágnes provides help to her large family caring for her grandchildren and others.
- Ágnes provides dedicated care for her aged and unwell mother at home.
- The local, national and international community benefit from Ágnes who gives her support to many causes for the benefit of others.
- Ágnes’ family friends and the communities will lose this valuable loving support if she goes to jail.
- Ágnes was meeting the international law requirements of Article 8 and the judgement laid down by the European Court of Human Rights in Strasbourg (Ternovszky v Hungary 2012), when she provided her care to families choosing out of hospital births.
- Ágnes has demonstrated her deep understanding from the proceedings, learning and reflecting greatly on the findings by the court.
We urge you to use your Presidential powers for the benefit of Ágnes,Hungary and the global community.
Excerpt from Irene Walton’s article from Midwifery Matters, 2012.
(Reprinted with permission.)
In support of Agnes Gereb
I went to Budapest at short notice on Thursday 9th February 2012 at the request of Nick Thorpe, BBC correspondent for Hungary and the East of Europe, and the rest of Agnes Gereb’s support campaign organisers. I went there to give support to Agnes and the other midwives personally but also to do my small bit for the women of Hungary. The links I have attached give the background and gist of it in a clear way so I will just describe what I did and what I thought at the time. http://www.szuleteshaz.hu/en/hungarian-state-injustice-caused-to-dr-agnes-gereb/
Immediately on arriving Elizabeth Prochaska, an English barrister, and I went to meet some of the support team. Agnes had been on house arrest from March 2011 until her appeal was heard. The decision had already gone against her and the next day Friday 10th February the trio of judges were going to announce the verdict. As you can imagine everyone was feeling down (but not out). After the meeting when all the possible outcomes and options were explored Elizabeth and I were taken by Nick to meet Agnes.
I was quite shocked when I met her because I knew her only from photographs and videos such as the links attached here. She is taller than me so about 5ft 5 ins and although normally slim she is now extremely thin ……and pale, so ,so, so pale, but with a luminosity that is so beautiful and charismatic. Does she have a vitamin D deficiency due to her house arrest and lack of sun light? She did not rail against her fate, and did not display anger or resentment in any way, just a quiet shrug of the shoulders, not resignation but an unspoken communication to a fellow midwife who would understand the senselessness of it all. After being in her presence for only a short while I can imagine how calming and comforting she must be to a woman in labour. She gave us tea and then we sat until quite late discussing the midwifery and legal aspects. All I can think of in these cases is that if they had occurred in the UK we have the structures in place to give the midwives involved our full support not our condemnation. I can and will go into the utter stupidity of some of the charges at a later date – for example a woman who haemorrhaged (500ml) was transferred by Agnes and her team (using their clinical judgement) to hospital where she was fine (I don’t think but am not sure whether or not she was given a replacement) and both went home the next day. This is one of the supposed criminal acts!! Is there any community or independent midwife who would have done differently? When you see the rest of the charges the saga is the same. A baby died due to shoulder dystocia. There is no accurate and reliable screening test for this and it is everyone’s nightmare, in hospital as well as in the community…
… Agnes lives in a third floor flat built round a courtyard with trees and grass. There is a walkway outside and her daughter lives two floors down and to one side so Agnes can stand at her front door and wave but not go down either to sit in the sun (Budapest can get up to 35oC in the summer or kiss
her grandsons good night. She is deprived of a basic right afforded most prisoners, that of taking outdoor exercise and is under a more restrictive confinement that a terrorist in the UK. Whilst we were there the police made one of their random phone calls to check that she was in. These begin at 6am every morning and occur without a pattern during the day with last being at 11pm. So in effect she is only allowed at maximum seven hours undisturbed sleep. She did chance a quick visit to her twin grandsons’ eighth birthday party and was caught out by a police phone call. However when they came to take her back to prison the chief took pity on her and gave her a second chance.
I went back to the hotel and planned what I would say at the rally the next day. After much consideration I thought it would be along the following lines
I am sure I am speaking for hundreds if not thousands of midwives and women when I say I
1. Strongly and urgently call for the immediate release of Agnes Gereb and all charges to be dropped
2. Join with professional colleagues and members of the public from around the world in condemning the appalling, unjust, unprofessional and inhumane treatment of Agnes and the breach of her human rights.
3. Deplore the unscientific and negative information from the witnesses for the prosecution.
4. Suggest the Hungarian authorities establish a professional self regulating body for midwives that will set and regulate professional standards and support midwives and women.
5. Applaud the Hungarian Government’s recent action in putting measures in place to make out of hospital birth possible.
6. Urge the Hungarian authorities to take notice of the rigorous and credible international evidence regarding the safety of out of hospital birth.
7. Enable women to have the right to make informed choices about place of birth, care practices and carers.
8. Call upon the Hungarian authorities to put protocols and legislation in place that will enable midwives to fulfil the WHO definition of the midwife as an accountable practitioner who works in partnership with women and the EEC directives.
The following morning the summing up took place. I have never had experience of the press in full flow before and I found it horrible and overwhelming. Agnes and her midwife colleagues were surrounded by about thirty people shoving television lenses and microphones on booms in their faces and their families were elbowed out of the way. The court was opened and then adjourned for two hours. Then the verdict was given by the female senior judge and then she gave a long talk about why the verdicts had been reached. I didn’t get a full translation but one point was that originally the sentence was two years prison and five years removal from practice. Under appeal the prosecution had asked for an increase to seven years for removal of registration but the judges took it upon themselves to increase it to ten years. The four midwives were fined and their license to practice revoked for a varying length of time. I need to write this up later because in itself it was an indication of the thinking in that because Agnes was originally a doctor she took accountability whilst in such a paternalistic professional set up midwives were deemed unable to take responsibility and accountability. Following the judgement Agnes had to go straight back to house arrest and is to be summoned to prison in the next two weeks to two months. There will be no account of the previous 77 days she has spent in prison or of the eleven months house arrest. I do not know too much about European law in general only how it is translated into the midwifery directives but I am assured and believe she was not given a fair trial. For instance she was not allowed to present expert witness testimony from abroad in her defence because they were not on the expert witness register in Hungary and they were not present at the births. This was despite the fact that there were no expert witnesses with home birth experience on the register. I always believed that an expert witness was an impartial professional with particular expertise. This is evidently not so in Hungary because whilst the case was concluding an expert witness for the prosecution, a doctor, was standing on the court house steps saying the most appalling things about Agnes to the TV cameras.
The court case was followed by a rally where several people including myself and Elizabeth Prochaska gave a speech. There were several hundred of her supporters present and various television crews despite the temperature being minus 20oC.
The link to the rally is here http://www.youtube.com/watch?v=ahvFGaeekkU&feature=related
Later that afternoon I was taken to do a live television appearance with MTV. On the way I was informed that it was a question and answer session with my opponent being one of the doctors who had given evidence against Agnes and that he was going to say I was wrong in that it couldn’t happen in the UK because it had happened in the UK to Wendy Savage and that she had been put in prison. The incident had occurred nearly 30 years ago and I was 99.99% certain that Wendy had not been sent to prison, was cleared and made a Fellow of the RCOG immediately after. However the rest of my journey was spent checking the facts with Lesley Page and Sheila Kitzinger and I was correct. In the event I considered the TV programme to be quite successful. The obstetrician was not the one who had spoken on the steps and he even concurred that the sentence was too excessive. Also the points about professional self regulation support and accountability of midwives, choices for women and safety of planned out of hospital birth for low risk women and the benefit of a culture of birth without fear were made. After the show the obstetrician seemed reluctant to home and we had a long talk and I think he was beginning to realise the damage that has been done to out of hospital birth in Hungary. He said that no obstetrician or midwife would have the expertise or fearlessness to attend women at home. Nor would they have anyone to teach them because Agnes and her colleagues were the only ones with any experience and expertise.
Elizabeth and I attended a meeting later that evening to discuss the way forward now. The only short term option left is an appeal to the President for clemency and a pardon. Long term there can be appeals to the European courts. However none of these will be of much comfort to Agnes in the coming weeks and months because she is facing another trial on several lesser charges which may carry a prison sentence. The President can only give one pardon so even if she is pardoned for these ‘offences’ she would be arrested once more for the next ones. The European courts grind very slowly so it is possible she will have served her sentence before they hear her case.
The next morning we went to see Agnes again and say goodbye. After the TV programme the evening before the translator asked me what does the midwife do at a home birth and I explained the role. Then she said she had stayed at home until just before her babies were born and would like to know who pushed the baby out. I said the woman of course and she looked puzzled and asked why didn’t the midwife do it? When I mentioned this Agnes said it is routine in hospital for the midwife to deliver the baby whilst the doctor applies fundal pressure and she gave me a photograph of it being done. If this is so then one can understand why women don’t want to go in hospital to give birth and why Agnes and her colleagues have been so fearless in their determination to help.
We all had a discussion regarding on camera about the structure, regulation and practice of midwifery. We were conscious that her family were all gathered in other rooms so did not stay too long. My heart strings were tugged when she showed me a child’s cut out drawing of a mobile phone. Her little grandson had said that when she is sad and lonely in prison she can phone him on it. He has made himself one to ring her when he misses her. Her mother was there looking sad, frightened and how you would expect a frail and sick woman of 85 to look when her daughter is going to be in prison for two years. She asked me to ask the midwives in the UK to help Agnes and I am doing so now. Also a pregnant woman and her husband were leaving in tears when I got there. The husband turned back and asked me to help them and Agnes.
I think the issue here is not whether or not Agnes made any clinical errors and personally I think she did not. It is about a system that offers women and their partners a harsh old fashioned system and denies them choice by frightening and victimising the midwives and doctors who wish to work outside it. In the end it is of course about power and money, control and paternalism.
Please help me to help Agnes and enable women’s birth choices.