HRiC Case Study: Greece, Part I


The Greek birth system has the highest cesarean section rate in the world, at around 70% of the birthing population. Evidence indicates that Greek doctors are performing cesarean section for reasons of financial profit and scheduling convenience. The 3 in 10 women who escape surgical birth are subject to routine episiotomies and other discredited interventions. The Greek maternity care system was criticized by the United Nations Committee for the Convention on the Elimination of Discrimination against Women(CEDAW) in 2013.

The way the Greek birth system is imposing surgical birth on a generation of women and babies is symptomatic of a disregard for women’s health and an imbalance in power and incentives. The international community has called on Greece to reduce its cesarean section rate and improve the dysfunctions in its maternity care. Meanwhile, what are the options for women giving birth in Greece today? How can they protect themselves from systems of care that send them home with surgical wounds and expensive bills? What are the mechanisms by which Greek obstetric providers are held accountable for care? What can the state do to ensure healthcare for Greek women, while protecting them from its current dysfunction?

Greek Maternity Care

Before the mid-twentieth century, when much of the Greek population moved from the village to the city, most Greek women gave birth at home with a lay midwife. Childbirth was a female affair managed by the women of the community. Doctors, if available at all, were only involved in the event of medical need or emergency. During the 1960s, Greek birth was “modernized” on the model of US obstetrics. (At this time, US obstetrics was dosing women with “twilight sleep” and tying them to their hospital beds under nets.) Birth moved into the hospital, under the control of the medical profession. Community midwives disappeared.

Meanwhile, Greek healthcare was moving into the private sector and becoming a commercial industry. An Investigation of Cesarean Sections in three Greek Hospitals, a 2005 article in the European Journal of Public Health, reports: “Greece has the highest proportion of private health care funding in the EU and one of the highest expenditures on health among OCD countries”. As Greek healthcare privatized, obstetrics commercialized, with most births moving into private, for-profit hospitals. By the late 1970s, the Greek cesarean section (CS) rate was 13.8%. As the rate of these expensive, convenient births rose to 29.9% by 2000, obstetrics became a profitable and attractive field; “between 1985 and 2000, the number of gynecologists increases by 34%, while the population grew by <10%.” The authors of this study hypothesized that “due to the recent commercialization of gynecology in health care,… increased pressure for financial growth in private hospitals is influencing physicians’ decisions to perform CS.” Their research confirmed that “physicians in the public and private hospitals examined in this study currently appear to be motivated to operate for financial and convenience incentives.”

Greek Obstetrics Under International Human Rights Law

In the last decade, the Greek CS rate has skyrocketed past 50% to claim first place in the global pandemic of cesarean section obstetrics. Greece is the only European country that failed to submit data for the EU 2010 Peristat Report on its rates of medical intervention in childbirth and mode of delivery. Anecdotal reports from women who have birthed in Greece indicate the routine use of episiotomy on those who deliver vaginally, as well as a lack of informed consent for scientifically discredited medical interventions during labor. Maria Andreoulaki of the European Network of Childbirth Associations reports: “Usually midwives can only work in collaboration with an ob-gyn, often acting as their secretary (booking appointments etc). Greek midwives are trained in very active, medical management of birth, and have little or no experience of physiological birth. There are some midwives who do independent study in order to learn how to support physiological birth or home birth. But even these usually feel unable to offer these services.” Hospital midwives can attend women during labor and assist doctors during surgery, but only doctors can “deliver” babies.

Despite all the media attention in recent years to the Greek economy, its financial inefficiencies, and their effect on the European Union, nothing has been written about its wasteful, expensive, surgical birth system. It is remarkable that Greek maternity care profits hospitals and doctors, through unnecessary surgical birth, at great financial cost to insurers and consumers, and immeasurable hidden costs in the short and long term for mothers and babies. The significance of the maternity care system to the Greek economy was even ignored in articles linking “austerity measures” to hospitals’ refusal to release newborn babies until their parents came up with the cash for their cesarean section.

Greece is a ratified signatory, along with every industrialized nation other than the United States, to the United Nations Convention on the Elimination of Discrimination Against Women (CEDAW). This year, CEDAW’s Committee for implementation of the treaty issued its Concluding observations on the seventh periodic report of Greece. The report stated the Committee’s concern “that the State party has a very high rate of abortions and a very low use of high quality, efficient methods of contraception, which means that women resort to abortions as a method of family planning. The Committee is also concerned at the extremely high rate of caesarean sections performed in public (40%) and private (up to 65%) hospitals without medical justification, the Greek rates being the highest in the world, way above the 15% rate considered by the World Health Organization as covering medical needs.” Although the Greek delegation argued that the cesarean rate had risen because Greek women were giving birth at an older age, CEDAW’s Committee urged Greece to “Reduce the rate of caesarean sections performed without medical necessity by training or retraining medical personnel on natural birth and introduce strict control of medical indications for caesarean sections in order to reach the WHO recognized rates.” The Greek government promised to investigate the proportion of normal births occurring at hospitals, and to work with “local medical boards” to “determine the terms and conditions under which cesarean sections are established as the most appropriate medical practice,” and that doctors would write in each baby’s Child’s Health Book how it was delivered, and the reason for its surgical birth.

Perhaps measures such as these will work to reverse the practice trends of the last 30 years and reduce the cesarean section rate. How far might that rate fall, and how fast? Most importantly, what are Greek women supposed to do in the meantime? What would you do, if you were pregnant in Greece? Would you feel safe, going to a hospital to give birth? What would your alternative options be?

Out of Hospital Birth: A Choice in Greece?

Women do want access to doctors and hospitals when there is demonstrated medical need during childbirth. But as the likelihood of an expensive, surgical birth rises around the world, more women choose to avoid turning a healthy birth into a costly medical emergency on the labor ward. Even in nations with hospital maternity care systems that are “safer” than the Greek system and have much lower rates of unnecessary interventions, a woman maximizes her probability of a physiological birth, a healthy baby, and an uncut body if she gives birth at home with a midwife. As bioethicist Elselijn Kingma has observed, “Home birth is safer for mothers. And not just a little bit safer, but massively so.”

If this is true in England, it is much more so in a birth system that is subjecting the majority of birthing women to an unnecessary major surgery that significantly increases their risk of dying in childbirth. The Greek maternity care crisis is playing out in a marketplace as much as a healthcare system. Given the private, for-profit nature of modern Greek obstetrics, women’s best ability to affect the way that they are being treated in childbirth is to “vote with their feet” and exercise their consumer power to walk away from abusive care.

The foundation is well established for women’s rights to request and receive information regarding the specific reasons for medical recommendations, to refuse medical interventions including cesarean surgery, and to choose whether to enter a hospital and when to walk out. Europeans have a human right to refuse medical treatment, and Greek women, like all Greek citizens, have an established healthcare right to informed consent. In 2010, the European Court of Human Rights (ECtHR) went beyond acknowledging that the state cannot force women to give birth in the hospital, a right that would be protected under the right to refuse medical treatment. In the case of Ternovszky v. Hungary, the ECtHR recognized a pregnant woman’s choice to have a planned home birth, with a midwife in attendance, as a reproductive right protected by the umbrella for other reproductive rights, the right to privacy. The Ternovszky case defined a woman’s human right to choose the circumstances in which she gives birth. It applied that right in the choice between giving birth at home or in a hospital, and with a midwife or a doctor. The Court held that European nations have a positive obligation to support the exercise of that reproductive choice. Every signatory to the European Convention on Human Rights (ECHR)—and Greece is one—has a positive obligation to acknowledge and support home birth as a legitimate healthcare choice through its laws and regulations. Furthermore, the Court declared that the human rights of birthing women are violated if “birth professionals” cannot attend them in the choice to give birth outside the hospital, without facing sanction for doing so.

What would it take to make the human right recognized in Ternovszky a reality in a country like Greece? When Greek birth moved into the hospital, home birth disappeared. The new licensed professional midwives did not offer to support women giving birth outside the hospital, but worked within it as assistants to the doctors. Home birth is perceived to have a murky “alegal” status of just the sort considered in Ternovszky; it isn’t forbidden, but it isn’t acknowledged or supported. The form to register a baby’s birth, for its birth certificate, requires a doctor’s signature in order to be valid.

[In Part 2 of our series on Human Rights in Greek Maternity Care, we will describe the legal treatment of home birth families, and their birth attendants, in 21stcentury Thessaloniki. The parties and lawyers involved in these cases spoke on the “Ternovszky Offense” and “Ternovszky Defense” panel of our “Birth Rights in the European Union: Mobilizing Change” Conference on November 4th, 2013.]

By Hermine Hayes-Klein. Hermine is a lawyer, Program Director of Human Rights in Childbirth, and Director of the Bynkershoek Research Center for Reproductive Rights.