In search of respect and continuity of care: Hungarian women's experiences with midwifery-led, community birth.

INTRODUCTION: To describe and compare intervention rates and experiences of respectful care when Hungarian women opt to give birth in the community. METHODS: We conducted a cross-sectional online survey (N = 1257) in 2014. We calculated descriptive statistics comparing obstetric procedure rates, respectful care indicators, and autonomy (MADM scale) across four models of care (public insurance; chosen doctor or chosen midwife in the public system; private midwife-led community birth). We used an intention-to-treat approach. After adjusting for social and clinical covariates, we used logistic regression to estimate the odds of obstetric procedures and disrespectful care and linear regression to estimate the level of autonomy (MADM scale). FINDINGS: In the sample, 99 (7.8%) saw a community midwife for prenatal care. Those who planned community births had the lowest rates of cesarean at 9.1% (public: 30.4%; chosen doctor: 45.2%; chosen midwife 16.5%), induced labor at 7.1% (public: 23.1%; chosen doctor: 26.0%; chosen midwife: 19.4%), and episiotomy at 4.44% (public: 62.3%; chosen doctor: 66.2%; chosen midwife: 44.9%). Community birth clients reported the lowest rates of disrespectful care at 25.5% (public: 64.3%; chosen doctor: 44.3%; chosen midwife: 38.7%) and the highest average MADM score at 31.5 (public: 21.2; chosen doctor: 25.5; chosen midwife: 28.6). In regression analysis, community midwifery clients had significantly reduced odds of cesarean (0.35, 95% CI 0.16-0.79), induced labor (0.27, 95% CI 0.11-0.67), episiotomy (0.04, 95% CI 0.01-0.12), and disrespectful care (0.36, 95% CI 0.21-0.61), while also having significantly higher average MADM scores (5.71, 95% CI 4.08-7.36). CONCLUSIONS: Hungarian women who plan to give birth in the community have low obstetric procedure rates and report greater respect, in line with international data on the effects of place of birth and model of care on experiences of perinatal care.

Examining obstetric interventions and respectful maternity care in Hungary: Do informal payments for continuity of care link to quality?

BACKGROUND: In Hungary, 60% of women pay informally to secure continuity with a "chosen" provider for prenatal care and birth. It is unclear if paying informally influences quality of maternity care. This study examined associations between incentivized continuity care models and obstetric procedures and respectful care. METHODS: This is a cross-sectional survey of a representative sample of Hungarian women (N = 589) in 2014. We calculated descriptive statistics comparing experiences among women who paid informally for continuity with a chosen provider with those who received care in the public health system. After adjusting for social and clinical covariates, we used logistic regression to estimate the odds of obstetric procedures and disrespectful care and linear regression to estimate the level of autonomy (MADM scale). RESULTS: Of women in our sample, 317 (53%) saw a chosen doctor, 68 (11%) a chosen midwife, and 204 (33%) had care in the public system. Women who paid an obstetrician informally had the highest rates of cesarean (49.5%), induction of labor (31.2%), and epidural (15%), and reported lower rates of disrespectful care (41%) compared to public care (64%). Paying for continuity with an obstetrician significantly predicted cesarean (aOR 1.61 [95%CI 1.00-2.58]), episiotomy (2.64, [1.39-5.03]), and epidural (3.15 [1.07-9.34]), but not induction of labor (1.59 [0.99-2.57]). Informal payment continuity models predicted increased autonomy scores (doctor: 3.97, 95% CI 2.39-5.55; midwife: 7.37, 95% CI 5.36-9.34) and reduced odds of disrespectful care. There were no differences in the prevalence of scheduled cesareans or inductions performed without a medical indication. CONCLUSIONS: Continuity models secured with informal payments significantly increased both women's experience of respectful care and rates of obstetric procedures. Intervention rates exceed global standards, and women do not choose elective procedures to preserve continuity.

Assessing quality of maternity care in Hungary: expert validation and testing of the mother-centered prenatal care (MCPC) survey instrument.

BACKGROUND: Instruments to assess quality of maternity care in Central and Eastern European (CEE) region are scarce, despite reports of poor doctor-patient communication, non-evidence-based care, and informal cash payments. We validated and tested an online questionnaire to study maternity care experiences among Hungarian women. METHODS: Following literature review, we collated validated items and scales from two previous English-language surveys and adapted them to the Hungarian context. An expert panel assessed items for clarity and relevance on a 4-point ordinal scale. We calculated item-level Content Validation Index (CVI) scores. We designed 9 new items concerning informal cash payments, as well as 7 new "model of care" categories based on mode of payment. The final questionnaire (N = 111 items) was tested in two samples of Hungarian women, representative (N = 600) and convenience (N = 657). We conducted bivariate analysis and thematic analysis of open-ended responses. RESULTS: Experts rated pre-existing English-language items as clear and relevant to Hungarian women's maternity care experiences with an average CVI for included questions of 0.97. Significant differences emerged across the model of care categories in terms of informal payments, informed consent practices, and women's perceptions of autonomy. Thematic analysis (N = 1015) of women's responses identified 13 priority areas of the maternity care experience, 9 of which were addressed by the questionnaire. CONCLUSIONS: We developed and validated a comprehensive questionnaire that can be used to evaluate respectful maternity care, evidence-based practice, and informal cash payments in CEE region and beyond.

Informal cash payments for birth in Hungary: Are women paying to secure a known provider, respect, or quality of care?

BACKGROUND: In Central and Eastern Europe, many women make informal cash payments to ensure continuity of provider, i.e., to have a "chosen" doctor who provided their prenatal care, be present for birth. High rates of obstetric interventions and disrespectful maternity care are also common to the region. No previous study has examined the associations among informal payments, intervention rates, and quality of maternity care. METHODS: We distributed an online cross-sectional survey in 2014 to a nationally representative sample of Hungarian internet-using women (N = 600) who had given birth in the last 5 years. The survey included items related to socio-demographics, type of provider, obstetric interventions, and experiences of care. Women reported if they paid informally, and how much. We built a two-part model, where a bivariate probit model was used to estimate conditional probabilities of women paying informally, and a GLM model to explore the amount of payments. We calculated marginal effects of the covariates (provider choice, interventions, respectful care). RESULTS: Many more women (79%) with a chosen doctor paid informally (191 euros on average) compared to 17% of women without a chosen doctor (86 euros). Based on regression analysis, the chosen doctor's presence at birth was the principal determinant of payment. Intervention and procedure rates were significantly higher for women with a chosen doctor versus without (cesareans 45% vs. 33%; inductions 32% vs. 19%; episiotomy 75% vs. 62%; epidural 13% vs. 5%), but had no direct effect on payments. Half of the sample (42% with a chosen doctor, 62% without) reported some form of disrespectful care, but this did not reduce payments. CONCLUSION: Despite reporting disrespect and higher rates of interventions, women rewarded the presence of a chosen doctor with informal payments. They may be unaware of evidence-based standards, and trust that their chosen doctor provided high quality maternity care.

Masked ball: ethics, laws and financial contradictions in Hungarian health care.

Corruption is a major problem in the societies of the post-communist Central European countries. Corruption in health care has some unique characteristics undermining the efficacy of and respect for Hungarian health care. One of the forms of corruption is tipping. This highly contested phenomenon is present in most of the patient/health professional's interactions in a sophisticated manner, raising serious ethical and legal dilemmas. The present paper analyzes tipping and other corruption-related factors, such as financial conflict of interest between industry and health care and argues that since ethical and legal considerations are often ignored in the country, patient care and clinical research are affected by these controversial issues to a great extent.