The uncovered cost of motherhood

The simplification of motherhood as an individual need with which the state does not deal has made the market of private gynecological hospitals flourish. Public centers in regional hospitals employ gynecologists, but they mainly treat women with low economic income, but they are not the first choice of most women in their process of becoming mothers. However, they are often the last stop when private hospitals fail to complete treatment

The cost of motherhood in Kosovo is often considered as a matter that belongs to individuals and that the construction of health policies for them is unnecessary.

The simplification of motherhood as an individual need with which the state does not deal has made the market of private gynecological hospitals flourish.

Public centers in regional hospitals employ gynecologists, but they mainly treat women with low economic income, but they are not the first choice of most women in their process of becoming mothers. 

However, they are often the last stop when private hospitals fail to complete treatment.

And in the public system, gynecological services are often clearly unstructured. 
Combined with a low degree of trust and not very enviable hotel industry, this sector in many dimensions fails to compete with the private system.

The cost of a pregnancy is high. The state does not make the slightest effort to provide women in this condition with safe services in the public sector where they would receive these services at no cost.

The Minister of Health, Arben Vitia, says that there are several reasons that in the pregnancy phase, a large part of women spend large sums of money to monitor the condition of the fetus that they will bring to life. 

One of them also mentions the lack of gynecologists, but also the interest of professionals of this profile to deal with routine checks in the public system.

"Besides the University Center, we have gynecology wards in regional general hospitals in the Republic of Kosovo. But in addition, we also have primary care centers for the provision of these services. Unfortunately, if we start from the last thing you said, these primary care centers do not have, so to speak, the full working capacity for many reasons. One of the reasons is that a large part of women, due to the possibility of financing, do not go to these centers but go to general hospitals or the private sector where they think the services are better. Another problem is the challenge in these centers to employ gynecologists. In some municipalities there have been competitions several times, but the gynecologists, because they do not want to work only in the ambulatory part of the routine visits of pregnant women, have not expressed interest in being employed in these centers and consequently their idea has been to either be employed in regional hospitals or in the KKUK", said Vitia

These and other problems, but also what Minister Vitia calls decisions and free choices of women, make women look for doctors in their private offices even for routine visits.
But an administrative instruction issued in 2017 by the Ministry of Health and then amended in 2020, does not allow primary level Medical Centers to hire gynecologists.

Article 14 of this legal basis mentions the medical profiles that are foreseen at the primary level of health. 

Gynecologists are not mentioned there. However, the continuation of professionals in this field was allowed until their retirement.

"Specialists from other fields can continue to work at KPSh as consultants to family doctors until retirement," says the Administrative Instruction.

Exceptions to this administrative instruction are Family Medicine Centers that have maternity hospitals, of which there are currently several throughout Kosovo.

This administrative instruction was attacked in the Constitutional Court by the Municipality of Pristina, but this court had declared the request inadmissible.

The cost of a pregnancy is often unaffordable for a large proportion of women.

The mindset created for even routine visits to be carried out in the private sector puts those who do not have them in a disadvantageous position.

Difficulties of women

Kaltrina Rexhepi Dragusha is a researcher at the Institute for Research and Human Rights.

It shows the difficult path of a woman who wants to become a mother and who in most cases, in the main stages of health, does not have the support of the state or public institutions.

"Visits are very expensive. The minimum for such a medical visit is 20 euros, and as we have heard, a visit to a private clinic costs up to 50 euros. This is very expensive for our budget since it is known that most families have below average economic income and without including the additional tests, the medications that are expensive can reach up to 100 euros for a visit, which is very expensive. Therefore, the Ministry of Health should create as much public health promotion as possible and enable women to make these visits to Family Medicine Centers. Likewise, when women go to give birth at the KKUK, then they have better relief and hospitality because this impression is created that if we have the private doctor where we performed the visits, then he could influence us to have better treatment in Gynecology and KKUK and not if we don't visit these doctors", said Rexhepi.

Within a year, about 22 children are born in Kosovo.

About 19 thousand of them, according to official statistics, are born in public hospitals.

Minister Vitia says that this statistic shows that women still entrust the birth process to the public sector.

"However, regarding visits, we can say that it is lame because a large part of women choose to make these visits in the private sector, while regarding births, I can say that the public sector is still the most reliable sector. Somewhere around 92-3 percent of all births are in the public sector. Of these, 40-45 percent in general hospitals and somewhere around 45 percent in KKUK", said Vitia.

However, the director of the Gynecology Clinic at KKUK, Zef Ndrejaj, admits that the high statistics of public births are also related to their high cost in private hospitals. 

His hope that such a high percentage of births will also have routine visits is related to one of the biggest health projects in Kosovo that has been promised for at least a decade and a half, but which has failed to be realized.

"A private intervention is very expensive. A caesarean section costs thousands of euros. While at Gynecology it is free of charge. It's completely free. The other reason is that why checks are carried out in private but come to be born here is probably just the frequent access to private while here is the big flow. There are a lot of patients, a lot of flow, and you get a little ambushed. She is the biggest reason. But this is also related to the lack of Health Insurance. Because if we have Health Insurance and it starts with systematic pregnancy follow-up checks, then it is a good way to go to routine, regular checks in the public sector. But the large influx is due to the lack of time, they cannot wait too long and go privately", stated Ndrejaj.

Promotion of public services related to health and care for pregnant women is often almost equal to zero.

Large number of private hospitals

In Pristina, the capital of Kosovo, the largest number of private hospitals is in the field of gynecology and the number of private gynecological clinics for routine services is high.
But the director of Gynecology does not agree with the fact that a number of women choose the private sector even for very simple services that under normal conditions the public system has no problem performing.
"We strongly disagreed with this thesis, with this conclusion because not many are fleeing from the public sector, but there are several reasons why some patients or family members are oriented towards the private sector. One can say that the Health Insurance that someone has probably the best economic conditions, does not want to wait in line too much wants to do work quickly. For medical treatment, let's not even talk about the fact that medical treatment cannot be had in the KKUK, but there are other procedures, perhaps the speed of the intervention, then the postoperative treatment, because the number of patients is very few in the private sector, and the opportunity for patient care it's a little bigger. All these are that some family members or some women are private oriented. For the public, speaking from the medical point of view, there is no alternative. I do not believe. We have been here for 25 years. We have many cases that come from the private sector to the public. When there are any complications in the private sector, then they come here, the treatment continues. This is a very big reason for the family members to convince that the treatment is done here and works with standards. In terms of conditions, we can say that we are improving. In gynecology, we have 4 wards that have only completed the works", added Ndrejaj.

The lack of communication of the Ministry of Health and its subordinate institutions with women during pregnancy makes them isolated from safe health services. 

According to Rexhepi Dragusha, this is the main problem that up to 80 percent of pregnant women receive services only in the private sector. 

They do this even if they have a lot of other expenses, but they are forced to think that private checks are the best thing they can do to take care of the fruit they bear.

"It is known that every pregnant woman needs systematic checks, so 8 or 9 and they are mandatory. This is not a luxury or pleasure, but to see how the pregnancy process is going, how the fetus is developing and everything related to pregnancy. Therefore, I think that the state should promote this health aspect of public institutions for the measure. We never see systematic screening of pregnant women in Primary Care. These services are promoted only for the private sector and most women, I can say up to 80 percent, only visit doctors privately, even though most of them work in the public system but after hours they work in the private sector", Rexhepi emphasized. .

Lack of promotion of public institutions

Minister Vitia agrees that the institution he leads has not done enough to raise public awareness about this issue.

According to him, they have already started to increase the promotion of these services.

However, on the official websites of the Ministry of Health and other public institutions, you don't see any call or notification or guide for pregnant women to ensure that they can get these services easily without additional expenses and costs.

"I agree with you in this part that we need to do more to strengthen maternity centers in Primary Health Care. Last year, we started an evaluation of these centers both in terms of infrastructure and supply of more adequate equipment for monitoring pregnancy. Now they all have, but an additional promotion of these centers, matinetites, as far as the ambulatory part is concerned, is needed. As for births, not only complications, now in this number of 92-92 percent are not only complications that come in the public sector. This shows that when it comes to births with thoughts that this process can be dangerous, it can be seen that our citizens continue to trust the public sector more than the private sector", said Vitia.

Pregnancy and women's reproductive health in recent years has become an issue with a commercial basis.

Advertisements of packages for basic health services and offers with discounted prices for childbirth are published every day on social networks.

This booming business has caused caesarean deliveries to increase significantly.

For such births there must be medical indications. But nobody in Kosovo controls this aspect.

Almost every birth that takes place in private hospitals is by operation. The motive for this, according to the KKUK, is the high financial cost that these centers require in relation to the cost of a normal birth.

"The number of sections is very high in private for various reasons, but the biggest reason is probably material. I am saying that a private birth costs more than 1600 euros. Then they have it in hand. Somewhere up to 80 percent know that cesarean births take place in the private sector", Ndrejaj stated.

But even the public sector does not stand well with statistics.

Large number of cesarean deliveries

Only the center led by Ndrejaj has about 40 percent of births by operation. He says that the reasons for this are different.

"There are many reasons. It's a lack of protocols. We have no protocols. We are working on protocols. The protocols were not done within the month, but we are working. When you have the protocols, it is very easy to work. Another is the pressure of family members. Then there are the serious cases that come from the Regional Hospitals. It increases the number of cesarean births," he added.

However, these figures are much higher than the figures in developed countries.

A study published in a specialized health website operating in the USA shows the increasing trend of these cases.

“Over the years, global caesarean section rates have increased significantly from around 7% in 1990 to 21% today, exceeding the ideal acceptable rate of CS, which is around 10%-15% according to WHO. However, not all caesareans are currently performed for medical reasons with the rate of non-medically indicated reasons and so-called "maternal caesareans" increasing rapidly. These trends are projected to continue to increase during this current decade, with both unmet need and overuse expected to reach a projected global rate of 29% by 2030," the study said.

But Kosovo has exceeded this forecast for years.

The not entirely natural coexistence between the public and private sectors, especially for gynecological services, has led to the fact that sometimes private treatment serves as a prerequisite for more qualitative treatment in public hospitals.

Researcher Rexhepi Dragusha says that sometimes women choose a private doctor who also works in public just to have easier access to the public system during the birth process. 
Director Ndrejaj says that he has already taken concrete steps to prevent doctors from changing regular custodianships just to give birth to their patients who come from the private sector.
"Private hospitals have created an increase in the attendance of those who have the opportunity to attend these hospitals because they offer greater comfort. For marginalized groups, for those who do not have opportunities, it is very difficult to afford. First, it is difficult to afford even a visit which is a minimum of 20 euros for a doctor, and the doctors who have many names are around 30, 40 or 50 euros. This can then also create distrust for public medical centers. Irritation also because a belief is created that only those who have not gone public while those who have gone private. It is a belief that if you are not treated by a doctor in private then you do not receive good treatment from the health staff. Then you have to find a connection, a well-known doctor to get the best treatment. When I went to give birth to my daughter, the first question was which doctor did you follow the pregnancy and not where did you follow it or was it natural that we should follow it in the state sector", Rexhepi said.

Ndrejaj also spoke about the demands of the patients, which according to him, some cannot be fulfilled.

"No no. I can't say they don't interfere because they do. Without a doubt, if a doctor works in both the public and private sectors, the patient can obviously choose the doctor she wants. I have the problem in the public sector as well, the patient insists on choosing a doctor or insists on a private doctor. But we have stopped or improved that possibility by giving you the right to all patients. So the patient who is referred to the private sector by a certain doctor should not have priority in the public sector. We have improved it", he said.

The management of the Ministry of Health and SHSKUK is proud of the investments and renovation of the clinic that is in progress.

With this, according to them, the provision of advanced services related to the early diagnosis of the fetus will also begin. 

Until now, those women who had the financial means have provided these services in the private sector.

"During this year, the Ministry of Health is in the final stages of some processes, while others will be completed by the end of the year, starting with services such as medically assisted fertility where some administrative problems have already passed. The subject and the economic operators who have competed for the supply of the Gynecological Clinic with the equipment has been in the PRBO for a relatively long time. All deadlines have already passed and the case has been signed. We expect that within a month and a half or two months these devices will arrive at the Gynecology Clinic. Something else of importance is the amnicentesis, which by the end of the year it is expected that the Gynecology Clinic will be equipped with the necessary equipment, but also with the training of the health staff, since this procedure has not been done in the public sector before, but only in private clinics and outside Kosovo. it can be performed at the Gynecology Clinic", said Vitia.

The purpose of the KKUK

And KKUK believes that with the advancement of these services, KKUK will become one of the most advanced centers in terms of services. However, there is no exact date when these services can start.

"All these are items that are expected to be started and to continuously improve the diagnostic conditions, not to compete, but to be convincing above all others in the region", emphasized Ndrejaj.

Women from marginalized groups have been and are the biggest victims of this health system that has never prioritized women's reproductive health. 

He has not done this either in the public discourse or by investing in these basic services.

Women and families with low income often did not know the state of development of the fetus until the moment it was born. And this should be the basic right of every person.

"One of them is the deprivation that during pregnancy you cannot have a diagnosis of the fetus and its situation in the early or late periods. So, until the birth of the fruit, they do not know how the condition of the fruit is. Most of the very important tests, especially those for women over 35 years old, are not performed in Family Medicine Centers. They are not even carried out in KKUK. All these women are deprived that if their fetus may have health problems, with various anomalies, they are deprived first to know and then to decide whether they want to abort or not", stated Rexhepi.

Fighting and arguing with numbers often overshadows quality.

Public health institutions boast of the record number of births in this sector. 

But despite numerous complaints about the quality of services and the indecent behavior towards them during the birth process, this issue has never been addressed seriously by the management. 
It has often been promised for "staff education measures in relation to pregnant women".

Director Ndrejaj also promised such a thing, but he linked this with limited human capacities that would have to serve these women.

"We have a slight lack of staff of nurses, midwives, you waited very soon for the competition to open for the admission of new nurses and midwives. We need about 20. The lack of communication with patients and the improvement of communication will be done with the hiring of staff and training, I believe it will improve. But it is a big problem because there is a large flow of patients and a small number of nurses because it is impossible for 40-2 midwives to deal with 3 patients, to meet every request and to be close to the patients as it should be", said Ndrejaj.