The Moralities of medicine and birth care in the Czech Republic

The moralities of medicine and birth care in the Czech Republic

The case of the arrested mother

Ema Hrešanová, University of West Bohemia, Pilsen

[email protected]

http://www.dur.ac.uk/anthropology.journal/vol17/iss1/hresanova.pdf

Abstract

In this article I deal with key moral principles and logics permeating the post-socialist birth care system in the Czech Republic. In particular I analyse a case of a woman who was arrested for leaving a maternity hospital with her healthy newborn several hours after the delivery. I identify two competing ‘regimes of morality’: one defending health care workers’s standpoints, and the other defending the rights and decisions of the arrested mother. My findings indicate that both of these regimes eclectically employ moral claims that are consistent with socialist as well as capitalist ideas of the market and money in birth care.

Keywords

Morality; Czech Republic; birth care; postsocialism; market

Introduction

In the autumn of 2007 I was finishing my long-term ethnographic fieldwork in two

maternity hospitals in the Czech Republic when my attention was caught by the scandal

related to birth practices in a small maternity hospital, which flooded the mass media for a

few days. The main figure in the ‘story’ was a 30-year old woman Eva H., who decided to

leave this maternity hospital with her healthy newborn several hours after her delivery.

Ema Hrešanová DAJ 17(1) 2010

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mailto:[email protected]?subject=



Though she was allowed to leave, a social worker under police escort, equipped with a

preliminary court order, came to her house late in the evening of the same day, and forced

her to return with her child to the hospital.

But the story is more complicated. The doctors originally released the mother with her

child eight hours after the delivery without any objections although this is a very unusual

practice. After giving birth women are supposed to stay with their babies at least three days

in Czech maternity hospitals. It was after they got a call from a private pediatrician who

should have been responsible for the newborn’s subsequent healthcare that they decided to

contact the Municipal Department for Childcare and Children’s Social and Legal

Protection as they believed that the Department should know about the baby being kept

outside the hospital. Several hours afterwards the social worker contacted the hospital

again and requested information about potential risks to the baby’s health. After hearing

from the hospital the head pediatrician that there are always some perils to a newborn’s life

in the first 24 hours after the delivery, the social worker decided to approach a local judge

with a request to intervene. The judge acted quickly and issued a court order to bring the

mother and her child back to the hospital. The outcome – a mother arrested for leaving a

hospital with her healthy newborn – naturally aroused intense interest among a number of

various actors who commented on the situation. Besides journalists and media

commentators these included a Ministry of Health spokesperson and the Minister for

human rights and national minorities, lawyers, non-governmental organizations and others.

Each of these actors employed their own reasonings about what and who was wrong and

right, and blamed different figures in the case.

In this paper I focus on the contradictions in the moral judgements of different social

actors involved in this case. My aim is to identify different ‘moral logics and principles‘

hidden in this case, and point to the most crucial moral principles permeating particular

birth care practices and the Czech health care system as a whole. I use Heintz’s concept of

moralities in order to grasp and understand different systems of ‘moral logics’, which are

competing in the Czech birth care system. Heintz defines morality as a ‘set of principles

and judgements based on cultural concepts and beliefs by which humans determine

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whether given action is right or wrong’ (Heintz 2009:3). Building on these judgements

people adopt a certain posture and act accordingly. I suggest to think about these sets of

moral principles and standpoints as constituting wider ‘regimes’ of morality, which are

shared by a certain group of people. They are always contested, too, and therefore they are

often contradictory.1

My focus on moralities in birth care may be seen as a part of a new anthropological

endeavour to develop the anthropology of moralities, which could enable ‘the recognition

of the plurality and creativity of moral discourses and practices all over the world and

simultaneously keep them in dialogue’ (Heintz 2009:2). I believe that in the case of Czech

birth care this is especially needed because such a plurality of moral discourses is far from

being acknowledged. I want to show that the analytical perspective focusing on moral

dimension of existing arguments may offer us a new way of approaching the crucial binary

opposition of natural versus biomedical model of childbirth, which dominates public

debates as well as the social science scholarship on birth care. It can also help us

understand why this dichotomy persists so much in spite of an effort to deconstruct it

(Annandale and Clark 1996). It is the different moral rationale and contradictory moralities

underlying these two perspectives which nourish their essential irreconcilability.

This analytical perspective also highlights changes, which have occurred in people’s

thinking about health and health care in the post-socialist context. It points to a rising

diversity in various actors’ moral standpoints, judgements and values throughout the

entirety Czech society. But as Verdery (1996:184) points out, it would be misleading to

relate different moralities with either socialism or capitalism. She argues instead that

‘diverse discourses about morality are crucial loci for defining the social order’ (Verdery

1996:184). Following Verdery we can also note that the study of moralities may be a

valuable contribution to our understanding of wider societal changes and ways of

establishing new social orders in post-socialist contexts.


1 My understanding and interest in morality and related concepts was fundamentally shaped by the Moral Economy of Medicine working group at the Department of Anthropology, University of North Carolina, Chapel Hill (led by Michele Rivkin-Fish), whose spring sessions I regularly visited in 2009 thanks to the Fulbright Commission in the Czech Republic. I also thank the reviewer who significantly pushed my understanding of anthropological concepts related to morality further.


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My paper is about postsocialist contexts, as it is about changes in moral thinking related to

birth care and health. In particular it deals with two distinct regimes of morality, which I

identified in the media coverage of the scandal and in informal interviews with three health

care workers employed in the maternity hospital concerned. 2 I call the first regime of

morality the medical because it defends the positions of the medical personnel in the

particular maternity hospital and emphasises their reasonings as the (only) ‘right’ version.

In comparison the second regime of morality, which I label as the alternative, puts the main

emphasis on the rights of the woman arrested after giving birth, and her perspective. It

generally highlights parental rights and birthing women’s subjectivity and individual needs.

This paper has two main parts. The first part presents my findings related to the

perspective of the hospital’s employees on the scandal. I point to the most important issues

in their morality of birth care. This analysis allows us to better understand the details of

their decision-making. The second part deals with the media coverage of the scandal. It has

three sections, first focusing on the medical regime of morality. The second discusses issues

related to the alternative regime of morality. And the last section addresses a question: who

is most ‘at blame’ for the mother’s enforced return to the hospital? This quandary is

repetitively raised in a number of media contributions and seems to define the overall

media coverage of the scandal.


2 I was able to contact these people and talk to them about this scandal thanks to the acquaintances I gained during my ethnographic fieldwork in previous years. I also conducted an ethnographic content analysis of the media coverage of the scandal (Altheide 1996). I used three different sources of the media contributions (first, the media database run by the ANOPRESS Information Agency, which monitors all Czech mass media content; and the Czech News Agency database; and my own, consisting of the newspapers I bought during two weeks following the scandal). I applied several keywords in order to get all the media messages related to the scandal; these included the Czech words for hospital, a birthing woman and the name of the town where the scandal happened. As the scandal occurred at the very end of October 2007, I searched for texts published from 25 October until the end of the year. In this way I gained 28 mass media articles in total; these were from various genres, including reports, talk shows, interviews, essays, news, commentaries, etc. (The list of analysed media contributions is available on request at: [email protected]).


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The morality of birth care in the maternity hospital concerned

Building on the interviews with persons employed in the hospital I identified three domains

as crucial for their morality of birth care: firstly, the responsibility for a newborn’s health;

secondly, the legal regulation of this primary responsibility; and thirdly the issue of money.

My informants generally stressed the responsibility for the newborn’s health as an essential

issue. For instance, a Mrs Novakova told me:

‘...you also can’t know what sort of person this woman was. She gave us one address here but you can find a different one in newspapers. Well, you can’t really know how it is…and (we can logically ask) does she live anywhere at all? And then you could read somewhere that a dead newborn was found under a bridge or in a garbage can…Well, you can’t really know what conditions she is taking her baby to...’

This quotation reveals the health care worker’s doubts about the mother’s competencies to

care for the child, thus raising the question if it is really the mother who should be

exclusively and primarily responsible for a newborn’s health. This way of thinking about

the mother’s responsibilities, competencies and moral duties naturally determined

subsequent actions of the health care providers in the hospital. As this health care worker

explained to me in a further conversation, the health workers told the mother that they

could not hold her in the hospital against her will, but that they were going to alert the

police. So in case a dead newborn was found somewhere in a garbage can, the policemen

would know where to go first.

In Mrs Novakova’s perspective, the responsibility and competencies to care for the

newborn’s health are also closely related to expert knowledge. In our interview, she

emphasised that the highest number of heart disease incidents evolve in the first 24 hours

after delivery, and these are not detectable by any ultrasound or other technologies. She

asked: ‘Is a lay mother capable of recognising that the baby is going blue because of heart

problems?’ In her opinion, the hospital personnel obviously play a key role in being the best

protectors of a baby’s health and life.



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While Mrs Novakova’s comments point to the question of who should be primarily

responsible for the newborn’s health, Mrs Svobodova’s comment shows that the newborn’s

health is of highest value and a key point in her morality of birth care. She told me:

‘For example, this scandal, I understand that they [mothers] don’t like it here, we touch their bellies and so on, but as the midwife told that lady, it is the baby who is the most important figure here, and the baby doesn’t care if he sleeps here or at home those three days’.

This phrase highlights at least two points: firstly, that she considers a hospital to be the best

location for the newborn. Secondly, it implies that in her opinion the mother acted selfishly

because she went home, and ignored the doctor’s opinion that hospital care is the best for

the child’s health. These moral judgements play a crucial role in the way these health care

workers approach women with different perspectives on birth care.

All of these three informants also pointed to gaps in legal regulations, which do not specify

who is primarily responsible for a newborn’s health. There is only one ‘Methodical

instruction’ issued by the Ministry of Health, which says that obstetricians should follow lege

artis, and release the newborn 72 hours after the delivery at the earliest. As Mrs Novakova

explained to me, the personnel acted with regard to this fact. Being aware of potential legal

actions against them, in case ‘something terrible’ would happen, they wanted to make clear

that they cared and were doing something in order to protect the newborn’s health. As

pointed out by several authors (cf. Lowton 2005:99), the emphasis on ‘action’ and active

interventions is consistent with the practice of ‘defensive medicine’, which has become an

important aspect of contemporary biomedicine.

In the current situation, health care professionals and providers have only one way to

protect themselves legally from potential lawsuits for malpractice. They can release a

birthing woman from hospital in the case that she agrees to sign a special waiver document

which would confirm that after their release, it is she who takes all responsibility for herself

and her baby. However, there have recently been several lawsuits from the medical

establishment, in which the validity of these documents was substantially questioned. Thus



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my informants do not believe that these special documents would provide them sufficient

legal protection in the case of a potential lawsuit. Besides that, as they remarked, the

doctors and nurses usually lack appropriate education to formulate these documents

correctly from the legal point of view, and unlike large teaching hospitals, the smaller

hospitals (including their own) cannot afford to employ their own lawyers either. These

complicated legal conditions further intensify the health care workers’ suspicion of the

women willing to leave hospital earlier than required.

Money is the last key point which these health care workers used as a basis for moral

judgements of individual actors as well as the system as a whole. It was mostly Mrs

Novakova who emphasised that the health care system is the only sector in which

significant reforms have not been carried out after the fall of communism. She argued that

hospitals and health care providers are the only ones in contemporary Czech society who

continue to be restricted from participating in the market economy. In her opinion this is

not fair because it prevents people from learning how much health care costs, and leaves

them with the idea that health and health care is ‘for free’. Such a system enables patients

to act without considering any of the extra financial costs that they may cause by their

behaviour. This is especially true for women who decide to give birth at home or – as in the

case of the arrested woman described in this article – leave the hospital earlier than

recommended and put their newborn at ‘unnecessary’ risk. According to the health care

worker it should be explicitly stated: ‘Alright, you can give birth here or there but this is

how much money it costs’. Referring to the scandal she explained:

‘...if there were any complications, the childbirth and subsequent care would not cost 100 crowns but 100,000 crowns, and it is not clear if health insurance companies would pay it. But in case they would refuse to cover it, you have some budget and when it comes, why we should spend money from the sum which is for the whole ward’s salaries and rewards to cover something which is not our own fault...?’

Attitudes like these harm not only individual practitioners, who have very low salaries, but

the health care system as a whole, she argued. In Mrs Novakova’s opinion the absence of



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market-driven environment in the health care system has such consequences as that in

health care there have still not been implemented any quality standards. In this respect, her

conception of what is unfair in terms of the Czech health care economy corresponds to

moral judgements made by Russian midwives who saw paid birth care services and market

principles implemented in Russian health care in the 1990s as a means to get a higher

quality of care (Rivkin-Fish 2009:172).

In the second sense, Mrs Novakova also used money as a measure of the morality of

others, particularly private midwives and doulas3 promoting natural and home childbirth.

She states that these private midwives and doulas do not accompany these birthing women

because they feel ‘pure love’ or compassion with the birthing women but because they are

paid very well for that. She compared their wages with the salaries of midwives employed

in the delivery wards, and pointed to significant gaps between them as well as to differences

in their responsibilities and workload. While the poorly paid midwife on duty at the

hospital has to care for three other birthing women and is (also legally) responsible for their

health, the private midwife or doula has no legal responsibility at all.

She also pointed out that the maternity hospitals cannot ‘sell’ any ‘extra’ services. So if a

woman wants, for example, individual one-to-one care, she is not allowed to ‘buy’ it in the

hospital. This relates to the way this health care worker perceives the morality of the

private midwives and doulas. In her opinion these women are not really moral persons

acting according to ‘higher moral principles’; they are not really interested in the woman’s

empowerment or health. The real reason why they accompany a birthing woman to the

hospital is money. In this regard Mrs Novakova seems to connect their immorality to their

ability to act according to market principles, which is, however, not distributed justly in the

Czech health care system; only some providers can adopt them fully while maternity

hospitals are excluded from most of the ‘market’ opportunities.


3 A doula is ‘an experienced woman who offers emotional and practical support to a woman (or couple) before, during and after childbirth’ (http://www.doula.org.uk/content/duk/about/default.asp, accessed February 2, 2010).


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http://www.doula.org.uk/content/duk/about/default.asp


Regimes of morality in the mass media

After reading the media texts several times from the morality perspective it became evident

to me that the authors explicitly or implicitly advocated moral positions and actions of

either the maternity hospital personnel or the affected birthing woman. The texts led me to

ask several questions which seem crucial for delimiting the two competing moral regimes in

birth care and identifying principles and ideas belonging to them. In particular I asked

which of these two sides in the ‘dispute’ was depicted as acting morally more correctly;

who was in the author’s opinion to blame the most, and who should bear the largest

responsibility for the result of this event. I describe the medical and alternative moral

economies of birth care in response to these questions, but first I present most the

significant issues raised within their frames.

The ‘Medical’ regime of morality in media messages

Most of the contributions strived to provide a balanced point of view and presented the

reasonings of both sides. I was able to distinguish four contributions clearly defending the

maternity hospital’s moral standing. In case the author did not discuss this issue explicitly, I

paid a close attention to the meanings of particular formulations and an overall

structuration and sense of the text in order to understand who seemed to be the more

moral actor in their opinion. As obvious from the emphasis placed on potential dangers to

newborn’s health, the core principle in this regime of morality consists of the perceived

moral duty to protect the newborn’s health and the health of his or her mother, although

the health of the newborn is conceived as that which matters most. There are several issues

related to this basic value in the analyzed contributions. As we shall see, they overlap with

the issues raised by my informants I interviewed in the concerned maternity hospital.

The first is the notion of doctors as experts who are the most capable of recognizing and

dealing with potential risks to the newborn’s health, against which they should intervene.

These risks seem to define an overall birthing situation – childbirth is all about health risks

(cf. Contribution [hereinafter also ‘CN’] 7). In the contributions adherent to this moral



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regime Mrs Eva H., the ‘arrested mother’, is depicted as an immoral woman who does not

really care about her newborn’s health but is rather selfish and promotes her own freedom

at the expense of her newborn’s health. On the other hand the doctors from the given

maternity hospital are implicitly described as the only moral actors genuinely interested in

the newborn’s health, which they are supposed to protect, and because of which they want

the newborn to stay in a hospital. The hospital is presented as the most suitable place

where postpartum care should be provided, which is consistent with the health care

workers’ standpoints discussed in the previous section. As the ‘home’ of these newborn

health experts it is a setting providing ‘security’ (CN4, 5). That is, it is perceived as a place

where health risks can be most efficiently reduced.

And this is reflected in the case of the birthing woman’s health as well, which is also best

protected in a hospital. This becomes most apparent with regard to the issue of postpartum

psychosis. Concerning this problem, birthing women are depicted as persons in potential

danger of these psychiatric problems – persons who are in need of expert control. It is

morally right to persuade them to stay in the hospital after their deliveries because leaving

the health care institution could be potentially very dangerous for them (CN5). In this

regard several obstetricians are quoted to give evidence of how dangerous this condition

may be. For instance, Contribution 19 quotes Mr Sip, a gynaecologist, who states:

‘I’ve already had to take ‘fresh’ mothers down from the windows several times [as they wanted to jump out of it because of the postpartum psychosis]. During my 30 year career this has happened ten times or so.’

The way in which the postpartum psychosis issue is raised and discussed in these

contributions also reveals significant beliefs about health and its conception. This is

especially evident in Contribution 19, in which the main protagonist states that maternity

hospitals should make ‘mothers’s health safe but in doing so their psyche should not suffer’.

In this contribution, the main speaker defines health primarily in physical terms while the

psyche is conceived as something separate and different from health, something that is not

health itself. Neither is it something crucial for sustaining health. But this view contradicts



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the WHO’s stated definition of health, according to which it is ‘a state of complete

physical, mental and social well-being and not merely the absence of disease or

infirmity’ (World Health Organization 1948). What is remarkable here is that the WHO’s

definition of health is crucial for the proponents of the alternative moral regime of birth

care, as I will show later. Such a conception of health seems to refer to the Cartesian

conception of the body, which separates physiological and mental states from each other

while it is only the physiological domain which is the object of physicians’ professional

interests and activities.

The threat of postpartum psychosis also highlights legal aspects of birth care. As Dostal

points out in his legal analysis of the scandal published in Medical Tribune (CN8), basic legal

principles do not only include the protection of health but also the protection of privacy

and parental rights. Nevertheless, within this morality of birth care the first duty is depicted

as superior to the others. Doctors should first protect health and intervene in its name,

especially the newborn’s health, because babies cannot speak for themselves, unlike (sui

juris) adults who can freely decide to refuse health care (CN21). But is a woman shortly after

the delivery really taken as a person sui juris?

According to at least two analysed texts, doctors doubt that these women would be judged

like that in court if ‘something wrong happens’ (CN19, 21). They emphasise a potential

legal defensibility of any written statement proving a mother’s informed refusal of health

care because it would be difficult to prove that she was conscious while signing it (CN19).

They believe that the potential existence of postpartum psychosis may always work as a

good legal excuse for refuting the informed refusal, thus putting them at risk of neglecting

their medical duties. Thus these doctors believe that this written form could not protect

them from potential lawsuits for malpractice and that it has ‘no legal value in protecting

health care providers’ (CN21). In their view, their moral duty is to act and to provide health

care to the newborn (which means her or she should stay in hospital), whether his or her

parents wish it or not. As this is the same reasoning employed by my informants from the

maternity hospital concerned, we can assume that this issue expresses one of the most

important moral positions related to the medical regime of morality in Czech birth care.



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But interestingly, this moral urge to act because ‘something wrong could happen’ does not

only concern the hospital personnel but it is also shared by the judge and social workers

employed at the Municipal Department for Childcare and Children’s Social and Legal

Protection. Bartova, one of the journalists criticising the state institutions’ procedures in the

case, summarises it aptly as ‘the fear of authorities from “what if ”’ (CN17).

Alternative regime of morality in media messages

This morality of birth care generally defends moral positions and decisions made by Mrs

Eva H. when she left the hospital with her baby after her delivery. There are several

significant topics characteristic for this moral economy. One of the most remarkable one is

the emphasis put on the perspective of the arrested woman and her rights. In most of the

contributions, which I identified as a part of this moral regime, it is repetitively stressed out

that Mrs Eva H. – as any other woman - had the right to leave the maternity hospital

whenever she wanted. But it was exactly this right, which was violated in Mrs Eva H.’s

case. As she said to the journalist who wrote Contribution 14: ‘When they were taking us

back [to the hospital], I felt like I had no rights at all’.

Within this regime of morality this right is framed within a basic human rights discourse.

In this context, ‘repressive’ interventions of state authorities are interpreted as extremely

immoral and illegitimate as they violate these rights and limit individual freedom.

Paradoxically it is the Municipal Department for Childcare and Children’s Social and

Legal Protection, which employed one of the most interventionist approaches; the social

workers from this state institution threatened the mother with taking her baby away from

her if she did not follow the court orders and return to the hospital (CN23).

The authors of most contributions usually condemned the conduct of the social workers as

totally inappropriate, immoral and bureaucratic in nature. In particular, the author of

Contribution 17 argues that the social workers uncritically followed the impersonal rules

and ignored particular needs and interests of the family and the baby. The predominant

sentiment in these contributions is the resentment of the fact that the state authorities dare



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to intervene into private lives of individuals, especially if it concerns such an intimate issue

as the mother-newborn relationship.

As Mandel and Humphrey (2002:3) point out, anger directed at the state is a common

phenomenon in post-socialist countries. According to these authors such negative

sentiments and complaints usually refer to the economic differentiation and the fact that

the state does not provide services, which used to be granted in socialist times (ibid.). While

the complaints directed at the role of the ‘state’ may be related to this issue as well, I

hypothesise that this excessive sensitivity to the state’s interventions in private lives may be

related to the repressive character of the previous political regime, in which the state

frequently restricted individual rights and freedom (cf. True 2003:130).

There is another moral issue linked to this ‘individual–state authorities’ relationship. As

apparent from the interview with the arrested woman and other articles about the case

(especially CN 3, 6), Mrs Eva H. finds it particularly immoral that the hospital personnel

decided to contact the Municipal Department for Childcare and Children’s Social and

Legal Protection instead of calling her personally and asking if she had any alternate plans

for her newborn’s care in case her paediatrician was not available. In Mrs Eva H.’s

perspective it is immoral to contact the ‘organs of power’ first, instead of trying to solve the

problem with the individual of concern. In her view, it is polite to find the solution with the

person involved first. Only if this fails, the third party – for instance state authorities –

should enter the dialogue (CN 3). This morality also highlights the feelings of the birthing

woman as something essential (especially CN4, 9). The authors of the analysed texts

criticise maternity hospitals for ignoring the feelings of many birthing women. For instance,

Contribution 9 refers to the birth experience of a woman who argues that ‘doctors don’t

try to understand the feelings of birthing women. They don’t try to understand that psyche

significantly influences the birthing process and they often perceive them as hysteric’ (CN9).

Similarly Mrs EH in Contribution 3 stated: ‘The staff did not understand that I felt it in a

different way. I didn’t agree with the routine procedures, and from the psychological point

of view I wouldn’t cope.’



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Although she pointed out further on that she received perfect birth care accommodating all

her wishes related to her birth, she wanted different care for her newborn than the hospital

offered (CN17) and therefore decided to leave. In her opinion this was the best way to

achieve the most appropriate care for her baby and support his wellbeing. The moral

imperative presented here stems from different health beliefs than those promoted by the

medical moral economy; different ways of maintaining good health are then a natural

result. Contribution 9 offers a further explanation of why this matters so much. Describing

three cases of women who decided to give birth at home, the author points out that for

these women the childbirth process itself and especially the first moments of the newborn’s

life are an essential basis for their parent-child relationship. As quoted in Contribution 6,

Mrs Eva H. originally also planned to give birth at home. (She changed her mind because

of renovations to her house.) These contributions also point to her ambivalent approach to

modern medicine and to her preference for ‘natural and herbal medicine’ (CN3). As these

contributions argue, she was strongly against the separation of her child from her and such

procedures as cutting the navel of the newborn (which is usually conducted several days

after the delivery) etc. Although not explicitly stated, we can assume that Mrs Eva H.

shares similar views and takes childbirth and the first moments of her newborn’s life as a

crucial point in her parental role.

These contributions include frequent quotations of Mrs Eva H. who highlights her

individual approach to children (she is a primary school teacher). She wants to approach

her newborn son in the same way, and therefore is ready to protect him from impersonal

hospital routines and rules, which would force her to wake her baby just because of

medical check-ups (CN3). In her perspective the best way to protect her son’s health is to

take him away from this setting, in which baby’s personal needs must be subjected to the

institutional regime. One way that the birthing woman may be able to ‘protect herself ’

against the hospital routines is to prepare a birth plan for the hospital personnel. The birth

plan includes a list of her wishes and demands on birth care and a description of her ideas

about such care. As several contributions argue (cf. CN3, 17), Mrs Eva H. did exactly this

and followed the practice recommended by the World Health Organization. In

Contribution 17, the WHO is taken as an international authority that the Czech state



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authorities should respect and follow. Its name and statements are used in the struggle

against the Czech state and medical authorities.

To summarise, this morality of birth care stresses the importance of the birthing woman’s

perspective, the need to protect her rights and freedom in decision-making about herself,

her baby and the health care received. In relation to this it first highlights the psychological

aspect of childbirth and neonatal care as something integral and inseparable from good

health. This is in contradiction to the previous regime of morality, which tended to banalise

the role of psyche. Secondly, it points to individuals’ fights for their personal rights and

needs against the bureaucratic and impersonal formal rules urged by the state institutions.

Within this regime of morality, Mrs Eva H. is primarily depicted as a highly educated

woman with an active approach to her pregnancy, childbirth and parental role who wants

the best for her baby and promotes an individual approach in care and education. Her

decision to leave the hospital is not depicted as something ‘irresponsible‘, as it was within

the opposite regime of morality. Rather it is her way of achieving the best care for her son

fitted to his individual needs (CN3). The construction of health risks and ways to avoid

them are in severe contrast to the ‘medical’ morality of birth care. While in the medical

regime of morality, the health risks consist of leaving the hospital, in the alternative it is

exactly the opposite. In the alternative regime of morality it is the impersonal hospital

regime which jeopardises health by ignoring the individual needs of the baby.

Who is most ‘to blame’?

In the mass media texts analysed different authors and actors agreed that it is wrong to

force a new mother and child to return to the hospital. After reading the texts several times

I realised that the media coverage of the scandal is predominantly determined by the

question, which I phrase as ‘who is to blame the most for arresting the mother?’ Different

actors focused on finding the greatest culprit and each articulated different ideas as to who

this could be and why. Some writers find the maternity hospital personnel to be ‘the

guiltiest’. In the view of some of these authors the medical authorities of this maternity



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hospital did something ‘unbelievable and inadmissible’ when they contacted the

Department of Childcare just because they believed that the newborn could be jeopardised

if not under the ‘doctors’ care’ (CN27). In these articles the doctors are blamed for

imposing their ‘natural authority’ and power over the birthing woman. This interpretation

is confirmed from the highest positions. Mr Cikrt, the Ministry of Health Affairs

spokesman, who would be expected to defend the health care practitioners, literally said:

‘They privileged the medical view and their longing for the absolute perfection of the

process, over the free decision of the mother’ (CN13). The hospital personnel strictly

followed the instructions issued by the Ministry of Health Affairs as this would be the ‘law’,

which matters more than the laws protecting basic human rights and individual privacy.

From the human rights’ perspective the way that the maternity hospital proceeded was

completely unacceptable. Mrs Eva H. shares this view although she calls for a further

investigation of the event in order to find out who bears the most responsibility for the

matter. After initial reluctance, she finally decided to bring a suit against all the institutions

involved: the hospital, the Department of Childcare, as well as the court. As she said, it is

her moral duty to find out whose fault it was, so she could prevent such things from

happening again to other women (CN3).

According to Contributions 23, 2 and 8, the court is to blame for issuing the order and

sending the Departmental social workers with police for the mother. These authors refer to

the expertise of several lawyers and human rights’ organisations, who find this practice in

contradiction with current laws. Contribution 8 presents the most persuasive argument.

According to the author, the judge failed the most because he was not able to distinguish a

given hierarchy of valid legal enactments. According to him it is the court’s responsibility to

identify just limits: ‘where it is still possible to accept the parents’ decision-making power

and where it is needed to break medical secrecy and permit the state’s hand to

intervene’ (CN8). It was the judge who had to recognise the ‘illegal nature’ of the

Methodical Instruction issued by the Ministry, which is in contradiction with constitutional

law. In this author’s view it is understandable that the doctors followed this ambiguous

instruction, as they do not have juridical education and thus they are not capable of

assessing the legacy and potential illegality of this document. Therefore it is the Ministry of



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Health Affairs, which should bear a political responsibility for the results of the case, as it

did nothing in abolishing this incorrect instruction.

There is also one contribution (CN17), in which the author argues that the social workers

from the Municipal Department for Childcare and Children’s Social and Legal Protection

are most at blame. Similarly as in Contributions 6 and 23, the author quotes Mr Olejar, the

president of the Patients’ Association and shares this view, too. From their perspective, the

main fault of social workers was that they acted upon insufficient evidence, the validity of

which they did not even check. They are most at blame because they had no real interest in

the baby’s well-being; they just followed formal impersonal rules, which is in contradiction

to the institution’s mission. But the head of the department defends his employees and

states: ‘If we get such a report, we must act’ (CN17). He assumes that he would proceed in

the same way, too, while he explains further why the social workers contacted the court:

‘The local investigation would slow down everything, and these people wouldn’t let us in

anyway’. This sentence reveals much about the morality of this institution, which puts

emphasis on speed and interventions in the name of children’s wellbeing. It also points to

the implicit assumptions that the ‘clients’ of this institution are a priori problematic persons

who oppose the institution’s employees. It seems that these social workers perceive

themselves as a part of the repressive state power.

According to many authors the scandal pointed to deeper problems within the entire

system of birth care. Contributions deploying both moralities criticise the state, embodied

by the Ministry of Health Affairs, for ignoring systematic gaps in the birth care system and

doing nothing in order to correct them. As one reader expressed in his newspaper

contribution: ‘The state creates no conception of health care, neither has it prepared any

comprehensible professional and legislative conditions for those families who want the

alternative birth care’ (CN21). Thus it is this ministry – those people ‘above’ – which is to

blame for doing nothing and ignoring the need to conduct systematic reforms in birth care.

This argument is raised within both moralities of birth care. The proponents of both agree

on the need to conduct systematic changes in birth care. While the medical regime of

morality highlights the need to protect the health care providers who need clear



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instructions on what to do in such situations, the alternative morality proponents want the

same reforms to set up such conditions, in which women could leave the maternity

hospitals whenever they want.

Discussion and conclusions

Mrs Eva H. stayed in the maternity hospital two more days. On Sunday she was released

with her newborn at her own request. Fifteen months later the media referred to her case

again, announcing further progress in the lawsuit. But since then there has not been any

news on its outcome, which probably indicates that nothing important has happened or

that the media has lost their interest in the case. Anyway the scandal may become a test

case and therefore its outcome will certainly attract attention of anybody interested in the

Czech birth care system.

In this paper I suggested approaching this particular event as an entry point to study

explicit as well as implicit moral standpoints, principles and judgements related to Czech

health and birth care. My aim was to identify the core principles and key themes in these

two moralities. In particular I analysed two competing regimes of morality in birth care. I

based this on the informal interviews with midwives and obstetricians from the concerned

hospital, and on the analysis of the media coverage of the event. The first regime, which I

called the medical, defended the moral standpoints of the concerned maternity hospital staff

while the other – the alternative – regime of morality focused on moral positions and rights

of the arrested mother Eva H. Both regimes of morality emphasised different moral

principles and raised distinct issues of relevance.

Contribution 4 offers an apt summary of the main contrasting issues. It presents opinions

of women randomly questioned by the journalist of a local newspaper. Those women who

took the view of the medical morality generally emphasised the medical risks and the

security of the hospital. On the contrary, women holding the alternative morality point of

view stressed the importance of the mother’s subjectivity and feelings after the delivery.

They also pointed to the problematic nature of the hospital procedures.



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While the medical morality puts emphasis on the doctors’ expert role, the alternative

morality highlights the individual right to receive or refuse the provision of health care.

The individual perspective and rights as well as independent decision-making are generally

stressed, which I see as closely related to liberalism and the market ‘philosophy’. The point

where both moralities intersect is the criticism directed at the state. The state is criticised

for failing to implement suitable reforms which would correct the imperfections of the

system as a whole. The state is represented by various institutions which participated in the

scandal. But it is the Ministry of Health Affairs, which is considered to be the ‘guiltiest’ and

most responsible, although its particular representatives (the Minister, the spokesperson)

defended the rights and positions of the arrested woman against the hospital personnel.

And this is exactly the point where I see that further investigation is needed. What does this

tendency to blame the state indicate? How much is it specific to Czech post-socialist society

as a whole, and to what extent is it specifically linked to the domain of health care? I

suggest that these negative attitudes could be a repercussion of the socialist state

paternalism and may be related to a relative lost of social benefits, which used to be taken

for granted.

My analysis also indicates that the medical as well as the alternative regimes of morality

eclectically employ moral claims, which are consistent with both the socialist as well as the

capitalist ideas of the market and money in birth care. That means that these two

moralities are not mutually exclusive, as it might seem at the first sight. This is especially

apparent in the reasonings of Mrs Novakova, a health care worker from the maternity

hospital. Her statements demonstrate all the moral paradoxes which the post-socialist

health care system embodies. It is she who condemns the other actors (private midwives

and doulas) from pursuing pure profit only. As Mandel and Humphrey (2002:1) point out,

‘market penetration’ is often linked to morality, which is radically different from the

socialist. And it is still she who finds the current system unfair as it is the only domain in

which the ‘market’ has not been properly implemented, and the hospitals are significantly

disadvantaged in comparison to other participants in the economy. Similarly as in other

post-socialist countries (e.g. Russia), for her the ‘market’ represents the more just system of

awards and re-distribution. But her standpoint could be also related to the observation



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made by True. True (2003:130) remarks that the ‘free’ market economy was perceived as

closely associated with the newly acquired ‘freedom to express’ in the Czech Republic in

the first half of the 1990s, and in this sense the capitalist market economy had positive

appeal.

I find the analysis of birth care moralities illuminating for one more essential reason: it

aptly demonstrates how the conception of biomedical risks relates to the politics of birth

care, and how ideas about what is right and moral relate to social action. Obviously people

also act, make decisions and approach others with certain moral evaluations in their minds.

Their actions are often related to their ideas about what they believe is right or wrong, and

the practitioner-mother relationships is no exception. This perspective also highlights how

much it matters whose moral principles are dominant. The study of moralities of birth

care thus seems to be an interesting entry point which also provides us better with

understanding of the politics of birth care in post-socialism.

References

Altheide, David. 1996. Qualitative media analysis. London: Sage.

Annandale, Ellen, and Judith Clark. 1996. What is gender? Feminist theory and the sociology of human reproduction. Sociology of Health and Illness, 18(1): 17–44.

Doula UK. 2005. About doulas. http://www.doula.org.uk/content/duk/about/default.asp (accessed February 2, 2010).

Heintz, Monica (ed.). 2009. Anthropology of moralities. Oxford: Berghahn.

Lowton, Karen. 2004. Practitioner-client relatioships. J. Gabe, M. Bury, and M. A. Elston (eds), Key concepts in medical sociology. London: Sage, pp. 96–101.



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Mandel, Ruth, and Caroline Humphrey. 2002. The market in everyday life: Ethnographies of postsocialism. R. Mandel, and C. Humphrey (eds), Markets and moralities: Ethnographies of postsocialism. Oxford and New York: Berg, pp. 1–16.

Rivkin-Fish, Michele. 2009. Tracing landscapes of the past in class subjectivity: Practices of memory and distinction in marketizing Russia. American Ethnologist, 36(1): 163–179.

True, Jacqui. 2003. Gender, globalization, and postsocialism: The Czech Republic after communism. New York: Columbia University Press.

World Health Organization. 1948. Constitution of the World Health Organization. http://apps.who.int/gb/bd/PDF/bd47/EN/constitution-en.pdf (accessed February 2, 2010).



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http://apps.who.int/gb/bd/PDF/bd47/EN/constitution-en.pdf




The Moralities of medicine and birth care in the Czech Republic

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