90% of the county and municipal hospitals in Romania do not have clear policies regarding abortion on demand. The service is legal, but, in practice, doctors can refuse to conduct this procedure.
“A barbaric gesture.”
This is the phrase used by a doctor in the Obstetrics – Gynecology Department of Fălticeni Municipal Hospital, Romania, to describe an abortion.
When we talk to him further about the medical procedure, he says that what we are proposing is “killing a person”.
“Wouldn’t it be a barbaric gesture if I killed you?” the doctor says rhetorically.
To help us understand this issue, he offers what he calls “a joke”.
Let’s say a woman has a baby at home and comes to the hospital, 12 weeks’ pregnant, and wants an abortion, he explains. The doctor would reprimand her, saying, why not kill the one at home? Because he is consuming more, while the “little one” inside her is less of a consumer. He would then tell her that it is “illegal” to request a voluntary termination of pregnancy. The doctor states that abortion on demand is banned in public hospitals in Romania.
But the doctor in Fălticeni is wrong.
Abortion on demand was decriminalized in Romania almost 22 years ago, by decree-law no. 1 of 26 December 1989. At the dawn of modern democratic Romania, this act cancelled a series of laws from the years of communist regime. Among them was decree no. 770 of 1 October 1966, which restricted access to abortion in almost all cases. Now, there is no law prohibiting a woman’s right to voluntary termination of pregnancy in state hospitals. However, the refusal of many doctors to provide this service leads, de facto, to a severe restriction of access to abortion on demand in the public health system.
Infographic: Edit Gyenge
It has been 55 years since Ceausescu’s decree outlawed the right to request an abortion. By 1989, the ban had resulted in at least 10,000 illegal abortions ending with the death of the woman undergoing the procedure. Unofficial estimates suggest the real figure is double this number: 20,000 victims of the decree, between 1966 and 1989. This ban on abortion was a tragedy not just for people, but also for society, and the trauma can be felt in public systems such as healthcare, social care, and maternity care.
As Romanians, we are still heirs to the anti-abortion decree of 1966. Because of this, our team of journalists set out to investigate abortions in the coming weeks and months, approaching the subject from multiple perspectives. Here, at The Decree Chronicles.
Firstly, we open with a journalistic series about women’s access to voluntary termination of pregnancy in public hospitals. In recent years, press reports have revealed the denial of this medical service in many public health units in the country. In 2019, investigative website Să Fie Lumină(Let There be Light) published the case of Neamț County Emergency Hospital in east Romania, where the hospital sent women requesting an abortion to a priest for counseling. Following the discussion with the priest, if these women wanted to continue with the medical procedure, they also had to obtain a document, signed by the priest.
Women needing abortions no longer go through this process at Neamț County Emergency Hospital. Since 2015, doctors have no longer performed abortions on demand in this public health unit. The hospital has even adopted an official act stating it no longer undertakes this activity. This is rare, as the vast majority of hospitals who fail to provide on-demand abortions have not issued a formal decision about this withdrawal of services.
116 Hospitals Investigated
116 Hospitals Investigated
Theoretically, voluntary termination of pregnancy is legal and offered in the public health system in Romania. In practice, doctors in almost a third of public hospitals in the country – whether county, municipal or maternity hospitals – reject requests to perform abortions on demand. If we add medical units that have ceased providing this service during the COVID-19 pandemic, this reaches a total of over 40% of public hospitals that have not performed voluntary abortions since the beginning of 2020.
Probably no other medical service permitted by law, regulated (by some hospitals) through procedures and available to patients, at least on paper, suffers in practice from such a limitation of access, coming, moreover, from within the medical system, from the doctors’ refusal to carry out such procedures. The doctors’ justification for their refusal is related to ethics and, most often, religious views.
Voluntary termination of pregnancy is currently one of the most disputed public issues in Romania, and mirrors similar debates in Italy, Poland or the USA. For years, it has been the subject of increasingly heated debate. There is talk of the right of women to benefit from such a medical service, if they request it. There is talk of the right of doctors to refuse to provide the service of voluntary termination of pregnancy. But there is less talk about the obligation of the medical system to ensure the provision of this service.
A doctor has the legal right to refuse to perform on-demand abortion for a patient. But the public hospital that hires him has the obligation to provide that patient with an alternative. In most situations, in today’s Romania, the alternative is another hospital, often in a different county, tens or hundreds of kilometers away.
Photo: George Călin / Inquam Photos
In July 2021, we sent requests for access to information of public interest to 116 public medical units – county hospitals, municipal hospitals and maternity hospitals. We selected them using a simple principle: that of the medical standard offered. In other words, we did not include smaller city hospitals in our investigation because most of them provide minimal medical care – and, in practice, most patients looking to access an abortion would go to larger public health units, at municipal or county level.
After almost two months of gathering answers, documents and statistics from 116 hospitals, the picture is that of a medical system in which on-demand abortion is often offered without the guidance of written procedures or, in almost a third of the units, it is denied, because the doctors object to this service, although they have not issued a formal declaration on this refusal.
Documents that Do Not Exist
Documents that Do Not Exist
There are counties in Romania where neither the municipal hospitals, nor the county unit perform abortions on demand. One such case is Neamț County, where the four public hospitals with obstetrics-gynecology departments investigated reported zero abortions on demand between 2017 and 2021. During this time, almost 2,000 interruptions in pregnancy were performed in private clinics in the county, according to the data obtained by The Decree Chronicles from the National Institute of Public health. In a future article, we will investigate how private businesses benefit from pregnant women who are refused abortions by the state sector.
The lack of procedures and clear policy governing the provision of medical service for voluntary termination of pregnancy is flagrant, according to data compiled by The Decree Chronicles. Less than 10% of the hospitals surveyed in this investigation have specific medical protocols, i.e. written rules that standardize the provision of on-demand abortion services. More precisely, out of 76 municipal, county and maternity hospitals that perform voluntary abortions, only 11 have adopted such documents.
Buftea Maternity is among the few hospitals that have a protocol regarding abortion. Click on the image to see the document.
As for the 34 hospitals included in the investigation that do not offer abortion services (unrelated to the limitations imposed by the pandemic), only two can present administrative decisions in this regard.
We did not only ask the 116 hospitals included in the investigation whether they perform abortions on demand or not, but also requested the official documents on which the hospital base the decision to offer or not the services for on demand abortions.
In many cases, however, the papers do not exist. Paradoxically, although only three of the 116 hospitals investigated have administratively registered reports of medical staff requesting the cessation of abortions on demand, the actual lack of service is to be found in many more health units. Eleven times more.
Reports sent by my the medical staff ale to the managemet of SJU Neamț and Hunedoara Municipal Hospital.
Why did we insist on looking at the fundamentals of paper, and on receiving the papers in question from the hospitals? Because when we formulated the requests for access to public information, we imagined that we would be able to get a clearer image of the bureaucratic context in which on-demand abortion services are offered or refused in Romanian public hospitals.
Instead, we obtained a statistical landscape that describes a contradictory situation: in most municipal, county and maternity hospitals in Romania, a legal medical service is available if the doctors in the obstetrics-gynecology department so desire. If they don’t, the service isn’t available, and the hospitals defend themselves by saying it was their voluntary decision and there’s no need to justify it.
Back to Communism, on the Kitchen Table
Back to Communism, on the Kitchen Table
The absence of written papers regarding the cessation of on-demand abortions, although a reality in dozens of Romanian public hospitals, can undermine a possible applicant’s right to sue the health unit that refuses to provide her the requested medical service.
“Any case in court or administrative complaint must be based on evidence. And, of course, a written piece of evidence remains the best piece of evidence you can show in front of a judge. But even hospitals that do not have a decision in this regard are not absolved of legal liability if there is a case against them,” explains lawyer Iustina Ionescu, a specialist in legal cases that raise issues concerning human rights.
The lawyer considers that a patient who is denied an abortion on demand in a public hospital could consider a lawsuit against the health unit. Such a case may not be successful, but it would send a message. It is very important to document these cases and it is worth starting somewhere, believes Ionescu.
“We have to consider the stigma associated with patients who need an abortion. Somehow this explains why there have been no cases in court so far,” she adds. The association of abortion with personal shame may account for the absence of lawsuits, despite the large number of hospitals that refuse to grant voluntary terminations.
“The fact that women have to pay for these medical services out of their own pocket and that the hospital must issue a receipt does not mean that it is optional for the hospital [on demand abortion is a medical service not covered by the National Health Insurance House]. Where would that take us? Where are we going to get treatment? On the kitchen table, like in communism?”
Iustina Ionescu, lawyer
How can a woman’s right to decide whether to have a child or not be reconciled with the doctor’s right to refuse to perform a medical act if the request violates his or her moral values? I asked this question to Nicolae Voiculescu and Maria Berna, two academics (at the Faculty of Law at Titu Maiorescu University in Bucharest) who have written about reproductive rights.
Their answer leaves no room for interpretation: “the doctor’s refusal to perform an abortion on request cannot generate legal repercussions”. But the doctor denying the service should redirect the patient to a fellow doctor, or to a nearby healthcare facility.
However, Voiculescu and Berna point out in their response that “abortion can be provided as long as the refusal to perform abortion based on the violation of the doctor’s moral values does not become generalized at the level of the society.”
In Romania there are dozens of public hospitals where all doctors in the obstetrics-gynecology department refuse to perform abortions on demand.
At Marghita Municipal Hospital in Bihor County, on-demand abortions have not been performed in years. Nobody knows exactly when the service ended. There is no administrative paper to enshrine this fact. The manager of the unit does not even consider it necessary, and he has a simple explication for the situation: “It is customary for us not to have abortions”.
The head of the Obstetrics-Gynecology Department at the hospital defends himself by saying that there are simply no material conditions necessary to provide this medical service. Asked whether the refusal to terminate pregnancy might also be based on religious reasons, he admits that there are “colleagues who have these notions” in the section he leads.
“In any case,” concludes the doctor, “it is anachronistic to perform curettage on demand when there is contraception.”
Doctors’ Views Can’t Limit Patients’ Rights
Doctors’ Views Can’t Limit Patients’ Rights
In Poland, women are unable to access abortion on demand except in very strict conditions. Due to these limitations, in the lastdecade, there have been two cases against the Polish state before the European Court of Human Rights (ECHR) questioning the provision of on-demand abortion services.
The legal argument used in the ECHR decisions may provide a relevant framework for discussion for the Romanian situation, highlighted by our investigation.
An ECHR decision from 2011, issued in the case of R.R. versus Poland, puts forth, among other things, the argument of the Special Rapporteur on the right of everyone to the enjoyment the highest attainable standard of physical and mental health (the Special Rapporteur is based within the Office of the UN High Commissioner for Human Rights).
According to him, “if a state has allowed providers to consciously oppose the provision of health services, it must ensure that it has other appropriate procedures in place to protect the ability of women to effectively exercise their rights under article 8 of the Convention, including the right to abortion, if it is legal, and the right to information regarding their state of health”.
The case of R.R. versus Poland was precisely about this: a woman had been denied access to medical investigations and abortion.
In the same decision, ECHR explains: “For the Court, the states are obligated to organize the system of medical services in such a way as to ensure that the effective exercise of the freedom of conscience of doctors in a professional context does not prevent patients from gaining access to medical services to which they are entitled under the applicable law”.
In a second case, P. and S. versus Poland, brought forth after a raped girl was denied medical access to abortion, the Court noted that the Polish Government had referred in its defense to the right of doctors to refuse certain services on grounds of conscience, in accordance with Article 9 of the Convention (freedom of thought, conscience and religion).
However, according to ECHR, states are obliged to organize their health care system in such a way that the exercise of this right does not prevent patients from gaining access to services to which they are entitled by law.
So far, the Romanian state has been exempt from court actions by women who are, by law, guaranteed the right to on-demand abortion services, but whose right is limited by the malfunctioning procedures and lack of predictability of the public medical system.
In the event that a case concerning the provision of abortion services will be filed against Romania at the ECHR, the Court’s judges would probably follow the established philosophy: even if doctors have the right to not perform medical procedures that they consider contrary to personal values, the state is obligated to ensure that such decisions do not limit the right of women seeking an abortion.
In Romania there are 34 county, municipal and maternity hospitals (first-line health units) that do not perform voluntary terminations of pregnancy. The cessation of this on-demand service had nothing to do with the pandemic. Some of these hospitals have not provided such on-demand medical services for more than ten years. Among the health units investigated, only two have an administrative decision in this regard, Neamț County Emergency Hospital and Hunedoara Municipal Hospital.
Click on the image to see the full document.
Among clinics specialized in obstetrics-gynecology, out of the nine national ones, two do not perform interruptions of pregnancy on demand. At Brașov Maternity Hospital, the procedure has not been available since 2015. At Cuza Vodă Maternity Hospital in Iași, the procedure has not been available for at least six years.
At the Maternity Hospital in Galați, only medical abortions are offered on request, not surgical ones.
Among county emergency hospitals, there are six units that do not carry out interruptions of pregnancy. These are the hospitals in Neamț, Vaslui, Călărași, Olt, Dolj and Satu Mare.
Out of the 61 municipal hospitals, 25 units do not perform abortions on demand.
Among the five emergency hospitals in Bucharest to which we sent requests, one does not perform abortions on demand. It is the Central Military Emergency Hospital “Dr. Carol Davila”. The Bucharest University Emergency Hospital only offers medical abortions (those with prescribed drugs for early stage pregnancy).
În județul Sălaj, pe lângă SJU Zalău care ne-a spus că face întreruperi la cerere, dar a raportat 0 cazuri în 6 ani de zile, mai este un spital orășenesc care are secție de obstetrică-ginecologie. Însă și acesta a raportat tot 0 cazuri în ultimii patru ani și jumătate. Practic la nivelul județului Sălaj nu s-a făcut niciun avort la cerere în ultimii ani. Datele obținute de noi arată că se fac însă la privat. 260 în ultimii patru ani și jumătate.
În județul Olt, din cele 4 spitale cu secții de obstetrică-ginecologie, două nu fac întreruperi la cerere. Spitalul Municipal Caracal nu mai face avorturi la cerere din 2016. Iar SJU Slatina nu mai face această procedură din 2009, din lipsă de spațiu. Începând cu 2018 un singur avort la cerere a fost raportat la nivelul spitalelor publice din județ.
În județul Hunedoara, SJU Deva spune că face întreruperi voluntare, dar nu are niciun avort la cerere raportat în ultimii șase ani. Spitalele Municipale Hunedoara, Orăștie, Lupeni și Brad nu fac întreruperi de sarcină la cerere. Spitalul Municipal Vulcan spune că oferă procedura. A raportat însă 0 cazuri din 2015-2020
In Sălaj County, in addition to Zalău County Emergency Hospital, which told us that it does perform interruptions of pregnancy on demand, but reported zero cases in six years, there is also a city hospital that has an obstetrics-gynecology department. But it also reported zero cases in the last four and a half years. Basically, no on-demand abortion has been performed in Sălaj county in the last years. However, data obtained by us shows that they are done privately: 260 in the last four and a half years.
In Olt County, out of the four existing hospitals with obstetrics-gynecology departments, two do not perform interruptions of pregnancies on demand. Caracal Municipal Hospital has not performed abortions on demand since 2016. Slatina County Emergency Hospital has not performed this procedure since 2009, due to lack of space. Only one on-demand abortion has been reported in public hospitals in the county since 2018.
In Hunedoara County, Deva County Emergency Hospital claims that it carries out voluntary abortions, but has not had any registered in the last six years. The Municipal Hospitals in Hunedoara, Orăștie, Lupeni and Brad do not perform abortions on demand. Vulcan Municipal Hospital claims it offers the procedure. However, it has registered zero cases between 2015 and 2020.
In Botoșani, according to the answer provided by the local county hospital, the on-demand abortion service is offered strictly based on the doctors’ “motivation by conscience”. In fact, the hospital has two obstetrics-gynecology departments; only the doctors of the second department honor the requests for voluntary termination of pregnancy.
In Ploiești, the county emergency unit states, as part of the answer they provided in response to our request, that it does not offer on-demand abortion services because they can only be provided by a monospecialty hospital. The assertion is, at best, questionable, since dozens of county hospitals in Romania perform abortions. Ploiești County Emergency Hospital claims that patients refused by the hospital can go to Ploiești Maternity Hospital or to a private practice. During the pandemic, the applicants were left with the option of a private clinic, as the local maternity hospital stopped on-demand abortion services, due to COVID-19.
Some of the hospitals explained in their answers that abortion is not a financially sustainable procedure; others underlined that abortion means murder. Here are two examples.
Finally, a special mention goes to Ilfov County Emergency Hospital. Although the statistics provided indicate that the hospital offers on-demand abortion services, the unit refused to provide any requests from hired healthcare professionals regarding cessation of service. The hospital administration considers that such requests are NOT OF PUBLIC INTEREST and do not concern the medical activity of the hospital.
Abortion on Request Is a Medical Emergency. Or Is It Not?
Abortion on Request Is a Medical Emergency. Or Is It Not?
In 2020, some recommendations regarding the interruption of pregnancy reached public hospitals in Romania.
The document had been prepared by the Obstetrics-Gynecology Commission of the Ministry of Health and signed by Elvira Brătilă, the President of the commission.
It is important because, at the onset of the coronavirus pandemic, it formulated several points of view to guide hospitals in their efforts to provide on-demand abortion services.
The document from the Ministry of Health notes that “patients who opt for abortion on demand are an emergency due to the nature of the biological evolution, being conditioned by the time limit in which the procedure can be performed.” As a result, the Ministry of Health commission advised “they will receive the proper healthcare”.
“Women who request the termination of pregnancy will have unrestricted access to consultation and specialized assistance,” said the paper issued by the Ministry of Health.
In addition, medical abortion was recommended as a possible alternative to surgical abortion, where hospitals could not provide separate access and treatment areas for Covid and non-Covid patients).
We questioned Elvira Brătilă, to understand the significance of the recommendations issued by the Obstetrics-Gynecology Commission at the Ministry of Health under her presidency. At present, the doctor no longer leads the ministerial body, and is only a member.
Although she had indicated in the official paper from 2020 that abortion on demand should be treated as a medical emergency, Brătilă adopted a much more nuanced position when speaking to us.
– If, at the ministry level, abortion on demand is seen as an emergency, how do you see the situation of public hospitals that refuse to offer it? – Well, they [the patients] can look for another service. After all, there is a service in that county that can get the job done. In the end, it doesn’t even have to be in a public hospital because the medication can be prescribed, and the patient can buy it from the pharmacy. Medical abortion is not performed in the hospital. The woman gets a prescription, she buys it and takes the pills home. Only if the bleeding becomes abundant and requires curettage, which sometimes happens, then she can come to a hospital, and no one can deny her since she is coming to the emergency room.
– What about surgical abortion on demand? – It’s the doctors’ right to refuse. If the hospital doesn’t do it, you can’t impose it. If it doesn’t have a contract with the House, if it doesn’t have I don’t know what circuits, if… It’s related to how each place is organized. That is why medical abortion is an alternative.
– Has it been discussed in the Commission, this situation in which more and more public hospitals refuse to perform interruption of pregnancy on demand, if it is a problem or if it constitutes a violation of rights? – There’s no violation and we didn’t send anyone to ask around “do you?”, “don’t you?” I told you, it’s all about the way the hospital is organized. If they don’t have the necessary circuits to do this… you can’t force them.
Human rights researcher Romanița Iordache makes a comparison with the doctors refusing abortions due to their own views: a comparison. “If I specialize in surgery, am I allowed to tell my patient ‘I don’t do blood transfusions because I’ve become a Jehovah Witness’?”
Iordache believes that doctors in the public system who refuse to perform abortions due to religious reasons should turn to private clinics for employment.
“You can choose to offer limited services in your private clinic. The problem is that when you work in a public hospital, you should fulfill the mandate of the public hospital. And at this moment, in Romania, it is still legal to terminate a pregnancy on demand. I said ‘still’. I think that if you don’t understand your rights and you don’t live by them every day, you lose them,” adds Iordache.
Some of the doctors in the public hospitals targeted by this investigation would vehemently challenge the researcher’s opinions. Some have also expressed their disapproval of us, as journalists, asking questions about the (often limited) access to on-demand abortion services.
“We do not perform uterine curettage or medical abortions,” the obstetrics-gynecology staff from Pașcani Municipal Hospital told us, under the signature of the Head of Department. “It is the free decision of the doctors in the ward, based on their moral and religious beliefs.”
Eventually, the writing turns into an accusation against journalists: “We do not understand why you do not put pressure on the Ministry of Health to reactivate family planning programs in order to obtain free contraception, as it would be logical, rather than to exert unjustified pressure on gynecologists”.
We will also be writing about the family planning system, as part of The Decree Chronicles.
A Problem for the State to Solve
A Problem for the State to Solve
“There is an obligation to provide a public service,” considers Radu Vlădăreanu, President of the Romanian Society of Obstetrics and Gynecology (SOGR). “You can’t afford to suddenly have everyone having problems of conscience. If abortion is not offered on demand, you will end up with induced abortion. Few go to other counties or look elsewhere.”
He also believes that, as long as the law allows it, the public health system should provide this service on demand. “If you can’t offer surgery, then offer medical abortion”, says the SOGR President.
– We have also had these discussions in the board meetings,” continues Vlădăreanu.
– And the conclusions were.. – Medical abortion must be encouraged if they [the doctors] do not want [to perform the surgical one], and that it must, at least in theory, be accessible in every big city.
“We are discussing the individual, the doctor who claims to be a conscientious objector,” says researcher Romanița Iordache. She believes we should be discussing who is responsible for ensuring that patients’ rights are respected. The main responsibility belongs to the national health system, according to the researcher, and remains the obligation of the hospital to provide the medical service.
Iordache continues: [For a doctor or a hospital]to say that there is someone offering the service 200 km away or that there is someone across the road who offers the service for a fee is a failure to ensure the right to health and women’s rights to decide about their own body”.