The National Health Service of Ukraine explains that such a decision is solely in the interests of the child and the mother since doctors in departments with low fertility are losing their skills. But some doctors look at the situation differently: unofficially, they say that they simply decided to save money on the lives of little Ukrainians, as a result of which Ukrainian women who start premature birth risk not being able to get the necessary help.
Protecting Ukrainians from negligent doctors
Average Ukrainian infant mortality rates are twice as high as those for the EU. Over the past year, 1,469 newborn babies died in Ukraine. According to UN regulations, this demonstrates a low social level of the population and the state of national health systems. And in the National Health Service of Ukraine, infant mortality is associated with low qualifications of doctors. Therefore, it was decided to reduce those maternity wards (not maternity hospitals), in which less than 150 children are born per year. Now out of 70 departments that are planning to close this year, 30 take only up to 50 births a year.
For obstetricians, the daily delivery of labor is believed to be just as important as an ongoing practice for the surgeon. If a doctor is faced with difficult cases less often than once a month, for example, when a child needs resuscitation, he will not be able to act effectively in such situations, and the likelihood of a medical error will increase many times over.
A similar incident occurred in one of the small district maternity hospitals in the Lviv region. The media wrote that 35-year-old Valentyna K. died of bleeding because the doctor did not diagnose uterine rupture in time and left her alone for the whole night. By the time the case was considered in court, its statute of limitations had expired, so the obstetrician-gynecologist still continues to work in this maternity hospital.
It is not only cases of criminal negligence that occur in maternity wards, but also various interventions without the woman's warning or consent in order to speed up the natural process of childbirth, even if it is proceeding normally. Sometimes childbirth ends with broken ribs. Doctors are often unethical by not giving birth in a comfortable position for the woman, even though back birth can be unsafe for the baby. Of course, all this is typical for maternity hospitals in general, but in the outback, such incidents happen more often.
The problem is not only that doctors have little experience, but also that qualified personnel do not want to go to villages and small towns. Although, thanks to affordable education, the number of gynecologists in Ukraine is per thousand more than in other UN countries, there is a problem with the distribution of these doctors.
In addition, the country already lacks neonatologists, that is, specialists who are engaged in the adaptation of a child from the first minutes of his life. In total, there are about 1.5 thousand of them in Ukraine, so that primary resuscitation at the birth of a child has to be provided to obstetricians-gynecologists. Especially neonatologists are lacking in the northern regions bordering Donbas.
In Ukraine, we do not find data on the correlation of infant mortality with the distance from the capital, but Russian studies indicate a sad trend. For example, in the Chukotka Autonomous Okrug, three times more newborns die than in St. Petersburg. Taking into account that the protection of mothers and children is one of the priorities of the Ukrainian government for 2022, the authorities decided to reduce the number of maternity wards.
Tetyana Znamenska, chairman of the Association of Neonatologists, believes that 150 births a year is not enough to keep doctors' qualifications at the highest level. However, according to the director of the Kyiv City Center for Reproductive and Perinatal Medicine, Professor Vyacheslav Kaminsky, infant mortality is not at all connected with the staff of the maternity ward.
A similar practice works in the EU: maternity hospitals function on the condition that 300 babies are born there a year. According to the Estonian Society of Gynecologists, 400-500 deliveries per year are required to provide quality services. But there are nuances that distinguish Ukraine from Europe.
The professor emphasizes that the possibility of reducing the number of preterm births is primarily determined by the qualifications of the doctor leading the pregnancy. It needs to be constantly increased. In addition, in his opinion, a doctor leading a pregnancy should be deeply familiar with the married couple, all the features of not only the woman's health but also family circumstances, in order to be able to "feel" an unpleasant situation and warn it before objective signs appear.
Getting to the hospital
It must be said that not all 70 maternity wards will necessarily be closed. They will only lose funding from the National Health Service of Ukraine, and this is not the only source of income for medical institutions. Hospital owners - local councils - will have a choice: invest in their development or repurpose. For example, in hospices or social institutions. Most likely, they will actually be brought to the second outcome, since local budgets are limited in funds. Under the first option, most likely, in small maternity hospitals they will be forced to cut staffing, cancel round-the-clock shifts so that doctors will come for night calls from home.
“A maternity ward that does not fulfill the norm will receive less funding. This means that the remuneration and maintenance of buildings will not meet the requirements over time and will lead to unpopular decisions on the part of the administration of the department / institution. But the maternity ward, the only one in the region, in my opinion, cannot be closed without consequences, without providing a full replacement,” says the director of the Kyiv City Center for Reproductive and Perinatal Medicine.
The entire list of departments that would lose funding was not announced in the National Health Service of Ukraine, but they gave two examples: in the Melitopol central district hospital, only 15 births were taken in a year, in Krolevets - 4. And these examples clearly illustrate how the consequences for women in childbirth will depend on the specific case.
The Melitopol city maternity hospital is located 600 meters from the Melitopol central district hospital, where a sufficient number of women in labor - 832 a year - are received. But in Krolevets, women in labor who experienced the "demo version" of the innovations were not satisfied. At the height of the pandemic in 2020, when maternity wards were quarantined or redesigned to receive patients with covid, they had to go to the Shostka hospital, 40 km away.
For some women in labor, the need to travel such distances can simply be dangerous. The experience of Russia, where only for 2014–2015. closed at least 25 maternity hospitals and 16 maternity wards, shows that the territorial availability of medical care for pregnant women has fallen. A study titled "Difficult childbirth: What does the optimization of Russian maternity hospitals lead to" says that from Mozhaisk, where the obstetric department was closed, it is necessary to travel 67 km for childbirth, to Naro-Fominsk. And residents of the Kashyrsky district even wrote letters to the president stating that "it takes 3 hours to get to an alternative maternity hospital in the city of Stupino."
Doctors talk about a "threshold" of 50 km, which increases the risk of complications in premature birth. If in Europe most families have private cars, the roads have been repaired, and the ambulance arrives quickly, in our country the 10-20-minute timetable for the arrival of an ambulance is not always followed. A year ago, in the Odessa region, a newborn baby died in the snow-covered village of Novi Shompoly. The ambulance, which was called to the woman in labor, got stuck in the snowdrifts, and the child choked with amniotic fluid.
As for childbirth right in the ambulance, news about their successful outcomes appears in the media every month. But often doctors honestly admit that they do not know how to take childbirth at all.
Home birth is quite dangerous, especially in the absence of pregnancy diagnostics. A woman may simply not know about the wrong location of the fetus, multiple pregnancies, and everything can end in tears. Doctors could help women in labor at home if necessary, but this is simply prohibited by Ukrainian law. In the United States, by comparison, it is allowed to invite a professional obstetrician to home birth. However, foreign practice in Ukraine is applied quite selectively: at first they prefer to reduce something instead of creating it.
Childbirth is an expensive pleasure for the state
Unofficially, doctors say that departments are being closed due to the high cost of staff and equipment upgrades. The fact is that mobile X-ray machines are not available in all small maternity wards. This means that if such testing becomes necessary, the baby needs to be transported. If the baby is not transportable, this is actually a death sentence. The same applies to equipment for laparoscopic operations, video laryngoscopes. Often, small maternity wards do not have gynecological chairs for patients with disabilities. And the state does not want to deal with such an expensive provision of equipment.
As for the medical staff, the National Health Service of Ukraine assures that the closure of medical facilities will not affect him in any way. However, there are great concerns about what kind of "retraining" threatens the doctors. In Melitopol, for example, after the liquidation of the central hospital, some of the nurses joined the "cleaning group that deals with general cleaning." This is truly a worthy career growth!
But the shortage of doctors directly affects the degradation of medicine. Over the past two years, 66 thousand doctors have left the country. Hence the question: is there really no way for the budget to do without cuts? Especially considering that in 2021 it was overfulfilled by 4%.
The liquidation of the obstetric department of the same Krolevets hospital, which was remembered in the NSZU, was discussed back in 2019. The reason at that time was just the lack of funds to ensure work. It was reported that with a need for 1,5 million USD, the institution will receive only 80,000 USD of medical subvention from the state budget.
It was decided to fire about 40 workers, mainly junior medical staff. This partial reduction was supposed to save the hospital from a complete closure, but in the end, due to a lack of funding in October 2021, the local authorities decided to merge it with a primary health care center.
Local authorities have been reducing hospitals due to underfunding for several years now. Even once successful branches go under the knife.
If earlier, based on the logic of the medical reform, small departments could have at least 6,000 USD per year from the state and with the help of funds from local budgets somehow stretch, now this is not at all possible.
It is not too late to stop the healtcare reform
First, President Zelensky, and then Minister of Health Maksym Stepanov, criticized the medical reform and the new funding mechanism for hospitals. The reform was called "sabotage, which does not provide anything good for either doctors or patients and means the dismissal of about 50,000 medical workers and the closure of 332 hospitals." But it continues. Maternity wards are being brought to a close, even though this may constitute a narrowing of the constitutional right of citizens to health care.
Gynecologists say that if the problem of small maternity wards is only in the qualifications of doctors, then it is worth preserving their jobs, and spending part of the funding for Big Construction on equipping departments and good courses for doctors. Today, high-quality professional development is financially inaccessible to Ukrainian doctors. For example, participation in the European Congress of Obstetricians and Gynecologists costs about 3 thousand euros.
And, of course, in order to increase the motivation of doctors who are responsible for the lives of young Ukrainians, it is important to bring their salaries to a decent level. After all, haste and medical errors occur in conditions when doctors interested in remuneration from women in labor stimulate childbirth without a real need for that - just to have time to get this money on their shift. Those who do not demand "gratitude" are forced to get a second job. Here comes overwork, professional burnout, and, as a result, medical errors.
Zelensky promises that this year the minimum wage for a doctor will be 750 USD. It is very important that this really happens, but not at the expense of other fired doctors.
The National Health Service of Ukraine mentioned the prospect of lowering the "threshold" of 150 births to 75. However, it is hard to believe that this will actually happen. Partly because the requirement of 150 births per year is insufficient by European standards.