Ágnes Geréb

Natural Birth: The Long Struggle of Dr. Ágnes Geréb

The final part in our series on technology and birth. Read parts one, two, and three.

On June 28th of this year—nearly eight years after first appearing in court to answer scurrilous charges of negligent malpractice—the threat of jail was finally lifted from the shoulders of Dr. Ágnes Geréb, the obstetrician turned midwife who has been natural birth’s tireless advocate. Seven years since being sentenced to two years’ imprisonment, the prosecution of Geréb, with its cruel twists and turns, had come down to a final appeal for clemency from Hungarian President, Dr. János Áder. Previous petitions had been rebuffed, and had this one ended likewise, Geréb would have definitively returned to prison. But after decades of harassment and years of legal duress, including more than three years of strict house arrest, President Áder released Geréb from her sentence. Despite the deep sadness of seeing this noble woman beaten down over many years, and both the criminal record and ban from practice that this act of clemency preserves, her story is not only a case study in technological birth’s entrenchment and natural birth’s suppression. It is also a story of natural birth’s nascent resurgence.

In keeping with the postwar consolidation of institutionalized and interventionist childbirth, Hungary’s Soviet-sponsored Stalinist government made hospital birth compulsory in 1950. This was a difficult transition in rural areas, where traditions of natural birth stewarded by local midwives died hard. But die they did, especially since the undermining of midwifery accompanied and aided institutionalization (as it always does; see part one of this series, “The Attack on Natural Birth”). Midwifery ceased to be an independent and distinct vocation, with midwifes becoming no more than nurses with brief additional training and entirely subordinate to doctors. Two things became standard and immovable in a Hungarian woman’s child-birth experience: it took place in hospital with the (almost always male) obstetric doctor in charge.

It is no hyperbole to say that the mother was entirely powerless within this technocratic arrangement, in which the will of the professional and his commitment to intervention and impersonal “efficiency” held sway. Even to this day, journalist Réka Kinga Papp reports, women in Hungary are subjected to an episiotomy (in which the perineum muscle between a woman’s vagina and anus is cut) in more than 80 percent of first-time births and in 62 percent of births overall. Alongside this is the ongoing custom of hálapénz or paraszolvencia, an under-the-table cash payment to the attending obstetrician. This practice started before the war but came into its own in the nominally free healthcare system of the communist years. It became a symbol of the doctor’s power—both unofficial and compulsory, while guaranteeing the mother nothing. Hálapénz perverts the incentives of obstetricians and underlines the parents’ status as supplicants before the childbirth establishment.

A Calling Confirmed in Resistance
Graduating in 1977, Geréb was challenging this rigidly doctor-centered and institutional model almost as soon as she began work at the Albert Szent-Györgyi clinic in the southern Hungarian city of Szeged. According to Papp, “she observed patients’ wishes, silently disobeying some hierarchical rules of the medical discipline,” most notably flouting the prohibition on fathers attending births. This practice of including fathers initially earned her a suspension, but by the mid-1980s was becoming commonplace. She also inspired the animus of some in her profession by refusing to accept hálapénz. And as early as the 1980s, she began attending and assisting births outside of the hospital.

While this was a particularly egregious trespass against the hierarchy, it fit a pattern of popular resistance featuring wide participation in a flourishing “second society,” rather than overt political dissidence. This followed the emergence of a similarly parallel, unofficial “second economy” that had been winked at by a regime holding on with increasing desperation to its fraying economic legitimacy. In both the second economy and the second society, Hungarians increasingly provided for themselves what the system could not or would not provide. The hospitals in which Hungarian women were forced to give birth robbed them of any semblance of a care-driven experience, and so it was that, quietly, and for only a few women at first, Geréb entered homes and gave families what official society denied them.

With the downfall of communism, there was both hope and indication that what had returned in the shadows could become established in the light. Midwifery in general partially emerged from its degradation, with its status as a university discipline restored (although midwives remained under the authority of obstetricians). In 1992, committed to opening up the possibility of natural birth to women, Geréb established the Alternatal Alapítvány (Alternatal Foundation) and organized a conference in Szeged. The BBC’s Nick Thorpe, who has been a correspondent in Budapest since 1986, was one of those in attendance, along with his wife, Andrea. “When we attended the conference with Ágnes, we knew we were expecting our first baby,” Thorpe told me. “We liked her immediately, and began attending the classes she offered to prepare for a home-birth. Our first son Sam was born, safely, at our Budapest home [with Geréb] in January 1993.”

After the birth of her own fourth child in 1994, Geréb retrained and began working as a freelance midwife, making the countercultural decision to abandon formal obstetric practice entirely. The communist era regulation requiring medical professionals to transfer a mother in labor to hospital had not been replaced, placing Geréb outside of the law’s protection. But “the police, and prosecutors, were trying to shake off their reputation from the recently collapsed ‘police-state’ in Hungary,” according to Thorpe, “and were showing their kindest face. So there was little danger of prosecution.” Thorpe’s first child was only about the 25th home-birth with which Geréb had assisted, but the contrast with a “normal” institutional birth could hardly have been greater. “Ágnes was with us, in the same room, for almost all the 20 hours of Sam’s birth,” remembered Thorpe. “She did not hurry the birth. She massaged Andrea. She examined her when it seemed appropriate, but not in an invasive way. She reassured her that she knew how to give birth, in her own time.” After 17 hours, Andrea’s contractions seemed to stop. But after Andrea took a little wine and some honey, “her strength returned and the contractions started again, strongly.”

However, “the mystery then was why the baby, whose head was already in the birth canal, was still not born. According to Hungarian hospital protocols, if the baby is not born within 20 minutes [in this situation], he must be forced out. But as the heartbeat was fine, and there was no sign of meconium [which would indicate a baby’s distress],” Thorpe continued, “Ágnes was patient. After three hours, he came out suddenly. It turned out that he simply had ‘the shortest umbilical cord she had ever seen.’” Today no less than in 1993, this is a labor which would have been, in most hospitals in most countries, curtailed by interventions, some drastic. But with a skilled, experienced, and patient midwife—unhitched from the arbitrary schedules and doctor-centered practices of technological birth—the mother was allowed to give birth in her own time with the abilities of her own body.

For those who experienced a natural birth with Geréb, it revealed a way of bringing children into the world that changed their families’ lives. “I decided to have home births because I had seen my sister have a child in hospital and it was awful,” Mirtill Rackevei, who gave birth under Geréb’s care three times, told The Guardian. “My sister was reluctant to have any more children because of her traumatic experience but my home births were so lovely that she decided to try it.” As Rackevei continues, “the difference for her was so great that she went on to have third and fourth children, also at home. So now she has three children in the world who would not exist were it not for Agi [Ágnes].” It was also a seminal moment for the Thorpes, who would go on to have four more children with Geréb’s assistance. “Our experience with all the births was that she was a real expert,” Thorpe concluded, “able to read a birthing woman’s body, each bead of sweat, sound, movement, discomfort, pain. To sympathize, but without sentimentality. She was fully there with us, throughout. Such a degree of attention, and expert knowledge, is very rare in healthcare.”

Home Birth Under Attack
But the relatively acquiescent climate of the early 1990s did not endure. Although the institutional birth imposed on Hungarians was born of communist rule, its incentives and demands do not originate in or rely on communism. Even as Geréb’s practice expanded in the late 1990s, she came under increasingly hostile scrutiny, which gained strength within the medical establishment, but migrated to the state authorities. “The legally insecure situation got worse with the birth of each of our subsequent children [1995, 1997, 2001, and 2003],” Thorpe testified, “as the medical profession sought ways to discredit and persecute Ágnes.” A precedent was set in 1993 when, even though parliament allocated 32.6 million forints (about $300,000 at the time) to a new birthing center being established by Alternatal, the Hungarian Board of Gynecologists and Obstetricians effectively nullified the appropriation by refusing their support, and the funds were directed elsewhere.

Geréb’s spokesperson Donal Kerry noted in 2010 that the legal campaign against her is “rooted in the determination of a clique of obstetricians to maintain their own power and earning potential from hospital births.” Their persistent opposition, Papp told me, “is mainly embedded in the unbearable competition she posed for her colleagues who thrived in industrialized circumstances and…[on the] grey-zone incomes of [hálapénz].” Had natural and home-birth been what some of its critics alleged—a trendy fad for the wealthy—the medical establishment would likely not have reacted so defensively. But Geréb’s model was not based on profit. Thorpe relates that “there was no real system to pay her,” except “for a box, in the early days, in which couples were asked to put a small sum, but some forgot, and those who were poor simply didn’t. Later, there were attempts to formalize this,” but there was no financial model driving her care. In an enlightening piece on this topic in Eurozine, Papp similarly notes that, later in her practice, Geréb and her colleagues would ask for about half of the amount that was typically paid to doctors as hálapénz, “but any patient could ask her for a lower price or state how much they could actually afford to pay.”

Ágnes Geréb

Szabolcs Barakonyi / Index.hu

“If her model of mother-centered care, at home or in hospital, were to catch on,” Thorpe concludes, “doctors would only be needed if there were complications.” With Geréb assisting up to 200 natural births every year, there were soon thousands of grateful parents who could attest to the ability of a mother, under typical circumstances, to give birth safely and humanely without obstetric intervention. The obstetrician could again be what he or she had once been, a specialist applying unusual procedures in the event of an emergency, not the ruler of birth applying emergency procedures on a routine basis.

The Legal Assault
Since it was not the mother giving birth outside of hospital that contravened the letter of the law, but medical assistance rendered for the birth in the home, disrupting Geréb’s work meant pouncing in the rare event that a home birth needed to be transferred to the hospital. “From the second half of the 1990s, whenever Geréb or her team would call an ambulance to any birthing complication,” Papp wrote, “most often a police car would also automatically arrive.” In three instances, out of about 3500 births, a child died whom Geréb had helped deliver (the average number of perinatal deaths in Hungary for this number of births would have been around 17). Her safety record for both mother and child was exemplary, but even though every obstetrician and midwife experience occasional injury and death on their watch, prosecutors decided these incidents had been caused by negligence.

The first incident involved a child born in 2000, who died 14 months later due to postpartum brain damage, and it was this event that inspired the first criminal charges brought against Geréb in 2007, which resulted in a three-year (obstetrician’s) license suspension. In a 2003 case, a child died seven months after being born under Geréb’s care. As with the earlier postpartum death, the parents defended Geréb, insisting to The Guardian that “Agi [Ágnes] made no mistakes that night…. I don’t understand why Agi is being persecuted. We are prepared to go to the president and ask him to grant her clemency.” The third death occurred in 2007 as a result of shoulder dystocia, a highly dangerous situation in which the baby’s head is delivered but his or her shoulders remain stuck behind the mother’s pelvis.

According to a 2010 article on shoulder dystocia in the Journal of Prenatal Medicine, it is “the nightmare of obstetricians” that “remains an unpreventable and unpredictable obstetric emergency” and “represents a huge risk of morbidity for both the mother and fetus.” In a hospital birth, this situation is often exacerbated by either the prone position of the mother, which constricts the pelvis, or the epidural that prevents movement. “There can be a high perinatal mortality and morbidity even when [shoulder dystocia] is managed appropriately.” Geréb employed the Gaskin maneuver, which is one of the methods recommended by the American College of Obstetricians and Gynecologists, and involves moving the mother onto all fours. The Journal of Prenatal Medicine article not only comments that “moving the laboring patient to her hands and knees is often sufficient to the shoulder to dislodge” but “for a slim mobile woman without epidural anesthesia and with a single midwifery attendant, the all-fours position is probably the most appropriate.”

Nevertheless, these 2003 and 2007 cases were used to throw the book at Geréb after the bizarre arrest that launched the process which has dogged her since. It was on October 5th, 2010 that a pregnant woman, whom Geréb had previously advised to give birth in hospital due to complications, returned to Geréb’s birthing center and suddenly went into labor. An ambulance was called, and, 20 minutes later, Geréb was taken into custody. After a week, she was finally charged with negligent malpractice in relation to those two earlier (2003 and 2007) incidents. Never before had Hungary seen such a prosecution following a death in childbirth. In March 2011, she was found guilty and sentenced to two years in prison; after both sides appealed, her minimum term before parole was even increased from a year to 16 months. Appeals and pleas for clemency ensued, during which Ágnes’s house arrest far exceeded her original sentence. Complicating this process was that, in 2011, prosecutors initiated an odd collection of five new charges against Geréb, including two accusations related to operating as an obstetrician during her suspension, to which she responded, with the support of around 200 parents, that she had acted solely as a midwife in this time. Another conviction on these counts, this time suspended, followed in 2015.

Her convictions for negligent malpractice rested on dubious testimony from the ranks of the obstetric profession that regarded Geréb as their enemy. Few if any of them were more experienced than Geréb, who had attended around 9000 births. “She is not only a theoretical champion of less interventions,” Thorpe testifies. “She knows what to do, on a case-by-case basis, to help avoid them,” and “fully understands that every birth is different, in a world where institutions insist on treating them all as the same.” Revealingly, in every case bar the one involving shoulder dystocia, the parents whose children were involved in the accusations defended Geréb. The night after her arrest, hundreds of mothers, along with their children born under Geréb’s care, gathered outside the prison to bring her solace and show their support.

Her Influence
The sad irony of this legal persecution is that it has provided the impetus for a positive change from which Geréb herself has not been able to benefit. The anomalous nature of a law that penalized and helped stigmatize expert assistance for home births had long been recognized, including by Péter Polt (now chief prosecutor, then deputy ombudsman), who determined that women have a constitutional right to decide where they give birth and that parliament was obliged to correct the legal situation which obstructed them from doing so. Successive health ministers from across the political spectrum seemed poised to act, but it took the furor over Geréb’s arrest to spur Minister Miklós Szócska (of the currently ruling Fidesz party) to announce forthcoming regulatory reform on the 76th and penultimate day of Geréb’s initial detention in December 2010. The new regulations, which brought home births within the legal framework and allowed for the licensing of home-birth midwives, were put into effect just weeks after Geréb’s March 2011 conviction.

Though the regulations were still quite restrictive and financially burdensome on midwives, and did not allow home-births to be covered under Hungary’s universal medical insurance system, Geréb had helped inspire a landmark change. “After a long time the Hungarian state has finally recognized that people have as much right to give birth outside of institutions as within institutions,” Geréb commented in an interview with popular Hungarian news site Index.hu, “…women choosing to give birth at home [also] play not a small role in the humanization of birth within institutions.” Thus, even as prosecutors have ceaselessly sought to imprison Geréb, natural birth—albeit imperfectly and limitedly—has emerged as a legitimate alternative to the institutional model. And once so released, the false narrative that interventionist hospital birth is a requirement of safety and care can be progressively undermined. “It is not only home births, but a systemic change that is demanded,” Papp notes, “and it has to do with all the accumulated trauma…surfacing in the past years.” With the recent clemency, a lingering stigma has been removed from Geréb’s long career on behalf of natural childbirth, giving new hope for the few who have taken up her work, and for all the mothers who do and will seek an older and better way.

“She encouraged us to see childbirth as a natural experience, which women have been able to do throughout history, without the need for intervention, but very much with the need for a safe, caring, empowering environment,” Thorpe says, speaking for many. President Áder even conceded, while rejecting a previous plea for clemency, that Geréb had “done a great deal to broaden the rights of mothers to unmolested childbirth.” Much is left to do in Hungary as elsewhere across the Western world and everywhere the technological approach has spread, for, as Thorpe adds, “the state, most doctors, and most hospitals still regard birth as a problem only they can fix.” Every country’s precise situation differs, but in most of them natural birth remains marginalized and often maligned beneath the shadow of medical establishments, over a century of accumulated assumptions, and our pervasive and destructive technological way of thinking and living. “In any case, childbirth is trying,” Geréb muses in an interview with the Budapest Beacon. “It is in society’s interest not to add humiliation and trauma.” Reflecting on her journey, she concludes, “If my work has helped in any way in getting closer to a more just and person-friendly system, then there was some profit, positive contribution to this long, difficult period, this witch-hunt.”