"I was being treated as if it were reprehensible that my body was doing its job"

In 2021, Patrícia Balogh-Tóth was seven months pregnant when Hungary passed a new law effectively making the practice of choosing one's obstetrician impossible. Her OB-GYN indicated that he would not sign a new contract, leaving her in a predicament: either her doctor would see her through her pregnancy, but she would have to give birth with someone else, or she would have to follow her doctor to a private clinic, where she would have to pay. "My baby is only born once, so I thought I would make the financial sacrifice so that I would be familiar with my doctor."

One May evening, she was experiencing intermittent Braxton-Hicks contractions while her doctor was examining her. "Try not to give birth until tomorrow," the doctor implored, as he was on call at another hospital until 6am. But at ten o'clock her water broke, and she had to go to the delivery room. So even though Patrícia had a medical contract, a doctor of her choice, and had paid for the health services out of her own pocket, she was nevertheless unable to give birth with the doctor she trusted. "I felt like the rug had been pulled out from under me."

To make matters worse, when they arrived at the hospital as she was experiencing strong contractions 2-3 minutes apart, someone in the delivery room – who later turned out to be the midwife – without any greeting or introduction, asked Patrícia how she could imagine to give birth in the hospital without her doctor. "Sweetie, is this your first baby?" she asked 27-year-old Patrícia. She then proceeded to repeatedly question her credibility: “I'll believe it when I see it,” she said, when the mother claimed that her water was clear.

While proceeding with the cervical examinations during the contractions, the midwife was talking to her assistant over the mother's body as if she were not even there. And she did this with the door open, in a room that faced an elevator, putting Patrícia on display, who was scantily clad and in an exposed position.

In vain, the expectant mother asked how things were progressing, the midwife kept her in the dark, only shooting back now and then with a "fine". But the midwife was all the more enthusiastic in her disparagement of Patrícia's doctor ("He must have done something to induce her labor", or "He's hardly on call – why can't he find a way to come here?"). If the young woman made a sound during the contractions, the specialist grimaced and expressed her disapproval by leaving the room. "I was being treated as if it were reprehensible that my body was doing its job."

As Patrícia was having problems adapting to the labor, they decided to opt for a cesarean section. Patrícia was told that her baby's heart rate had dropped, which justified the operation, but the CTG readings did not confirm this. In the final report, the baby was found to be disproportionate for parturition, even though he was born at 3350 grams with a head circumference of 34 cm. During the cesarean section, the woman said she was in a lot of pain, but she was not taken seriously. There was no golden hour or skin-to-skin contact – the baby was immediately taken from the mother to the neonatal unit. During the next day's visit, the chief doctor delivered the final blow:

"What's the matter, mum, couldn't deliver the baby?"

Patrícia's case is not unique. For decades, obstetric violence has been a serious and unresolved problem in Hungary's healthcare system. "We are often asked if women could have more awareness or do something better to avoid obstetric violence, but this story also demonstrates that it is not the women but the system that needs to change," says Viktória Keszler, founding member of Másállapotot a Szülészetben! Movement [a movement dedicated to bring about change at multiple levels in order to achieve women-centered care].

"In the case of obstetric violence, we are not talking about perpetrators and victims, but about institutional problems, about how the fundamental rights of women and newborns are being repeatedly violated, along with the Health Act. This institutional violence is characterized by a hierarchical relationship. Healthcare workers often communicate, give orders, and make decisions from a position of power, infantilizing the expectant mothers and calling into question their competence in the midst of a physiological process where the task is not to diagnose or cure disease, but to support mothers in the functioning of their own bodies. Verbal repression and humiliation, shaming, downplaying the concerns and feelings of women, disregarding their needs, punitive behavior, unjustified pressure, referring to the danger to the baby in case of disagreement, and raising the threat of possible death are commonplace in obstetric practice."

Another fact not helping the situation facing woman is that

it is still not possible to choose an obstetrician-gynecologist to oversee the childbirth, which means that mothers often have to rely on specialists who are complete strangers

– all in a setting where it is well known that trust is what fosters a complication-free outcome. This is further illustrated by the glaringly high rate of cesarean sections in Hungary: in 2021, 40.63% of mothers in Hungary underwent the operation to help deliver their baby. Meanwhile, the World Health Organization says that a cesarean section rate of more than 10 percent is not associated with reductions in maternal and neonatal mortality rates. And that's not to mention the "husband stitch" (a post-episiotomy 'suturing meant to tighten the affected area'), which is an extremely harmful practice and can lead to permanent sexual problems.

Hungarian women don't feel as healthy as their male counterparts

When we talk about women's health, the focus most often centers on problems related to their sexual and reproductive organs, or childbirth. But women's bodies not only differ from men's in terms of reproductive organs. Further, based on societal customs, women also approach health care differently from men: for example, they make greater use of health services. Of course, the fact that women live longer also plays a role in this (79.3 years on average for Hungarian women compared to just 72.9 years for the men), as they are more likely to suffer from age-related diseases. On top of this, because of gender role expectations held by society, it is more difficult for men to admit when they have a problem. So it comes as no surprise that Hungarian men feel healthier on average than women.

Women are also often accused of being unduly dissatisfied with their health and health care. Whether it's the way they are handled during childbirth or the treatment that they receive, they are often judged for it: they "exaggerate" their pain and feelings, and they act "hysterically". It is not surprising then that they are often not taken seriously when seeking medical attention.

In her book Unwell Women: Misdiagnosis and Myth in a Man-Made World, Elinor Cleghorn uses a simple example to illustrate how women's problems in the health sector are perceived differently from men's. During the COVID-19 outbreak, there was public outcry that the AstraZeneca vaccine could cause blood clots, but no one was upset that the risk of a fatal thrombosis was significantly higher when using hormonal contraception – what's more, millions of women continue to be prescribed the pill every day without the active substance undergoing review or being declared unsafe.

Tamás Farkas is a sociologist of health and illness who has been working in the field for the past ten years. "Most of the drugs currently on the market have been tested exclusively on white men without considering their effects on other races or the female body," he says. "Because healthcare is a male-dominated profession, it has not been part of the research narrative to test them on people of other genders or races. The same is true of medical devices used on a daily basis, which have been tested and optimized for male bodies: in size, ergonomics, and even sensitivity. Such is the direction of abstraction:

when we're talking about a patient, we are essentially talking about a man.

It is only in the last ten years that this has started to change. So there are still healthcare instruments that are uncomfortable for women."

Heart disease: the research focuses mainly on men although the disorder doesn't spare women

Even though when it comes to diseases affecting women, the most common problems mentioned are generally those typically associated with female organs, the leading cause of death for women – as well as men – is cardiovascular disease. And yet, a US study found that chest pain in women was misdiagnosed in 5% of cases. One cardiologist proposed the idea that this could be because heart attacks often play out differently in women than we expect – not according to the "textbook". It may be completely asymptomatic, or it may be marked only by atypical symptoms (such as jaw pain, sweating, fatigue, abdominal discomfort, dizziness), and it may not be accompanied by its widely known symptom: chest pain. Diagnosis is not made easier by the fact that much of what is known about heart disease comes from research on men. Women make up only 20-25% of participants in clinical trials on heart attacks and preventive treatments.

"Medicine doesn't really know what to make of the research results. As reported in the Economist, three years ago a major discovery was made in orthopedic surgery: women are many times more at risk of tearing their ACL because of their hormonal and anatomical make-up. But this is still only a research finding, and medical science does not yet know how to address such differences. The problem is that, even if a statistically significant correlation has been demonstrated that is specific to women, it's still not guaranteed that it will bring about an effect because, as a mere research result, it cannot yet have any practical impact on care. The question of how and when the differences in females (anatomically and biochemically) can be incorporated into daily care and diagnostic practice – or whether it ever will – is a very complex and open question. The transfer of knowledge within hospitals and wards contain many incorrect, ossified practices. These mindsets are not easy to change. Improving infrastructure and proposals to develop family-friendly institutions will not bring results in changing such mentalities. This requires a generational change," says Tamás Farkas, expressing his concerns.

There are also diseases that are specific to women. The so-called "broken-heart" or Takotsubo syndrome is significantly more common in women than in men. Because of their hormonal fluctuations, women are not only more likely to develop oral cavity problems but they are also more at risk of osteoporosis after menopause. But it is also surprising to learn that women are the most at risk of autoimmune diseases. Depression is diagnosed roughly twice as often in women as in men. However, research has shown since the 1990s that 30-50% of women with depression are misdiagnosed – this is because anxiety can often be a symptom of another, often undetected, illness. According to Farkas, this is no wonder, as female patients communicate differently from men, which is difficult for health professionals to accommodate.

"The majority of women tend to have more awareness as patients: they are more thorough, more attentive to detail, and generally more inclined to understand and have an overall picture of their own health. They are also more likely to make a greater effort to solve problems for the sake of their own health and that of their environment. This, in turn, has an impact on what extra information they ask the doctor for, how much time they spend unpacking it, what sort of explanations they require, how many times they read the outpatient card and the final report, and to what extent they read up on the medication. Men are more inclined to cut this short: they listen to the doctor, nod, and agree to the instructions. However, due to the information asymmetry in healthcare, after a while, it becomes burdensome for the doctor to explain their approach to the patient. When women ask more questions, they increase the time of care, and doctors with finite resources become impatient with them more quickly."

What might the solution be? There are several studies showing that women's health can benefit from a higher level of education. In Hungary, this has been confirmed by KSH data, which shows that women with the lowest levels of education are up to five or six times more likely to die from circulatory, endocrine, nutritional, and metabolic diseases (most often diabetes) than those with the highest levels of education. Of course, women's aspiration to further their education alone does not solve the problems in health care. It is important to recognize that women and men should be handled differently when it comes to doing tests and making diagnoses – after all, a personalized approach is what really improves the quality of patient care. Improving doctor-patient relationships can also bring us closer to the goal.

But this is not the direction we are currently heading in. Given international trends, it is worrying that an anti-abortion MEP has been elected President of the European Parliament. And in Poland, a country which has served as a model for Hungary's government on many issues, abortion can only be performed on women whose lives are in danger (no exceptions are made for rape or incest victims). Hungary's parliament has also recently witnessed a rather extreme discussion, according to which children are regarded as a common good – a remark that hints at the further erosion of the right of women to self-determination.

This article is the fourth in a series of Telex articles on the situation facing women in Hungary today. You can find the first article here, the second here, and the third here.