Πέμπτη, 20 Οκτωβρίου 2016

HRiC Europe Summit Report - Greece

1            General Information

The information in this report is based on a Survey on Maternity Practices conducted on women living in refugee camps in Greece in the period of September/October 2016. The interviews were collected by a group of volunteers acting on behalf of Pleiades. The questionnaire, prepared by Pleiades and included in Appendix of this document, was defined in context of the international law, excerpts of which are included in section 3.
The number of women who could be reached by the survey is fairly limited due to circumstantial difficulties including, among others, the lack of female translators (desirable if not critical, given the sensitivity of the matter), the lack of professional translators (and resulting potential inaccuracies), and finally the reluctance of women to entrust private information to strangers, often as a result of experienced situations of shame and humiliation.
All information is reported to the best understanding of the surveyors, given in good faith, and collected from trusted sources.

2            Credits and References

This report is the result of the work of Electra Leda Koutra, founder and president of Pleiades, and of volunteers, like Iphie Intze, Simona Bonardi, Omaira Gill, Milena Zajovic Milka and her team in Are You Syrious?, as well as Dr.Dina Kamba.

3            Interviews

At 3am my bleeding started. I didn't have emergency contact information. No one did. I had to wait until the camp manager came to the camp the next morning. At 10am the camp manager came to the camp, and my sister-in-law spoke to her. The camp manager said that the ambulance would not come to the camp because it was Saturday. She suggested that I go to the MDM clinic, which is 10 minutes walk from the camp. I was bleeding and she did not offer me a means of transportation at least to reach the clinic, which is 2 minutes away by car. I went to MDM. No gynecologist was there that day. A general doctor visited me and injected a serum. They returned me to the camp after my serum finished. They said "We have no ambulance to take you to the hospital and you should go back to the site where you live and be picked up from there." I was at the office from 2pm until 9pm when the manager left. I was in pain and I was screaming but she didn't care. I left the office and went up the stairs to my tent. My pain got worse. I went to the washroom and miscarried. Ambulance came at 7pm the next day.
[M.S., 35 years old, from Afghanistan, Elliniko airport terminal reception site]

I have such a bad pain in my head sometimes I feel like banging my head against the wall. But the doctors told me it's normal and it will pass.
[Y.S., 19 years old, from Afghanistan, Elliniko hockey stadium reception site]

I had a powder to drink to facilitate going to the bathroom. I stopped having that because I was scared to go to the bathroom at night, when single men were awake and around.
[Z.R., 32 years old, from Afghanistan, Elliniko airport terminal reception site]

The other women at the camp tell me I am foolish to become pregnant. They say "Why did you do this? How will you provide for these children?" 
[A.S., 24 years old, from Afghanistan, Elliniko hockey stadium reception site]

3.1        General Remarks

29 women were interviewed in total who live in refugee camps and squats in or around Athens. From them, 23 are from Afghanistan, 5 from Syria and 1 from Iraq. 8 of them are pregnant, 1 had a miscarriage, 20 gave birth and 1 of them lost her child after birth. Their average age is 26 years old. For many of them, this is their first child or have another one or two children.
All of them report being malnourished during pregnancy, which lead to anemia and low blood pressure. Less than half received supplements (vitamins and iron) and the ones who did had to pay for them. In their majority, they only visited a doctor once or twice during their pregnancies and some of them did not visit one at all. The routine tests were ultrasounds, blood pressure check and blood check.
The main problems they face in the camps is low quality of food (cannot be eaten), lack of privacy and unsanitary conditions.
The most common issues reported are listed in the following table.

Issues reported
Inadequate accommodation
Lack of safety
Lack of sanitation
Lack of hygiene
Inadequate food
Insufficient medical support / services
Lack of female doctor personnel or uncertainty about availability
Lack of information or inability to access information (denied access or lack of translator)
Delayed access to key information (delay of one month or more)
Inconsistent information received (assistance and support, access to medical services including exams and child vaccinations)
Faced discrimination during gestation or birth
Lack of financial means to provide for themselves (food, medicines, necessities)
High-risk pregnancy
Potentially life-threatening complications (mother or child) resulting from living conditions (including journey to reach Greece) or denied/insufficient assistance
Miscarriage resulted from denied assistance
No legal assistance

3.2        Women who gave birth

The bad nutrition and condition of the mothers affected the children and 6 out of the 20 ended up in the Intensive Care Unit. They suffered inter alia from yellow fever, meningitis, lack of vitamin D and tuberculosis. One of them died.
The major problem of the women who gave birth was the complete lack of State translators. The women could not understand what was happening to them or their babies and that made them anxious. Also, the diagnosis were not explained to them and did not know how to follow-up.
In average, there were 4 or 5 doctors in the labor room and always some of them were men which was problematic for the women since in their countries gynecologists are only women
No husband was allowed in there even if they women wanted him.
Normally the child was given to the mother immediately for skin-to-skin and breast-feeding and stayed in the room with her unless there were medical reasons.
Clothes were sometimes given for the time in the hospital, nappies were always given for hospital time.
From the 20 women, only one did not make it in the hospital on time for the labor because the ambulance was late. 12 (60%) of them had to have a Caesarian section because of emergency reasons or after trying for hours to give birth. We cannot assess the findings of the doctors because we do not have access to the medical files of the women. However, the women did not feel that they were being bullied into a C-section.
Afterwards there were allowed to stay for at least 3-4 days to the hospital, if not more for medical reasons but they were not explained how to take care of their wounds from the surgery. Most of them monitored their physical health in medical NGOs but none of them had access to psychological or emotional support.
They were given vaccination cards but it was in Greek and there was no explanation for follow-ups. They could only find the vaccines in NGOs, especially the clinic of Doctors of the World in Omonoia.
They were not asked for money in the hospital and they did not receive their medical files 55% (11/20 women) of the women report a positive hospital experience.
The problems they face in their place of accommodation after birth remain the same as above with the addition of a lack of provision for milk and specialised food for their children and a sanitary environment for them and their kids.

Average age of women: 26 years old

Average= 3 Children per woman.

3.3        Living Conditions

Open fire to warm water for tea in Vasilika camp. Camps do not offer any facility for self-preparation of food.

Taps at Vasilika camp

In rural areas and open buildings, snakes are common. They are found indoor and outdoor.

Crowded tents inside Elliniko airport terminal

 Numerous families (including Yazidis) live in camping tents in the area surrounding Elliniko airport terminal. They have occasional, limited or no access to the camp’s services.
Large UNHCR tents hosting people at Elliniko baseball stadium. Tents are outdoor exposed to the sun all day where temperatures may exceed 40 degrees Centigrade.

In Vasilika camp, tents are mounted inside hangars. The problem of rats and cockroaches is common throughout all reception sites. In rural areas and open buildings, snakes are common. 

Warming water in the sun for use to shower. The solar panels in Vasilika camp in Northern Greece make the hot water too hot for use and there are no controls to regulate the water temperature in the showers. In Elliniko reception sites, hot water is not available.

Air ventilation system?

Elliniko airport terminal

Poor hygienic conditions of bathrooms and occasional flooding

In general, there are not enough toilets, showers and water taps in the camps, on average 1 toilet for about 100 people, 1 shower for about 200 people. 

Throughout camps, promiscuous use of toilets, showers, bathrooms is reported. Women feel generally unsafe to use the facilities at night.

 Living spaces divided by blankets and curtains at Elliniko.

3.4        Food

In most camps three meals are distributed, however the quality is extremely poor. Food is neither varied nor nutritious. Furthermore, cases of expired food and food poisoning were reported over six months in camps throughout Greece.
Pregnant women report being unable to consume the food distributed due to both quality and nausea caused by bad smell.
It is constantly reported that not enough baby food (including milk) is available or distributed. Parents refer to the not-for-profit organization running the medical services also for the provisioning of baby food. Special dietary needs (allergies and food intolerance) are fully neglected.

In many camps/reception sites/shelters, food is reported of poor quality, not nutritious, occasionally old / with mould 

Self-catering at Elliniko terminal

3.5        Access to Medical and Health Services

3.5.1Children Vaccinations

During the months of July and August, it was announced that vaccinations would be carried out in camps throughout Greece. The following remained unclear: 1) how it could be ensured that all children requiring vaccination be identified/reached (and the procedure for those not reached or unable to attend); 2) the procedure for children missing medical records; 3) the operation was once-off, therefore no sustainable, regular process was put in place for children born after the appointed dates; 4) how to apply for additional vaccinations.

4            Law Context

 A. Convention for the Protection of Human Rights and Dignity of the Human Being with regard to the Application of Biology and Medicine (Convention on Human Rights and Biomedicine)
32. The Convention for the Protection of Human Rights and Dignity of the Human Being with regard to the Application of Biology and Medicine was opened for signature on 4 April 1997 and entered into force on 1 December 1999. It has been ratified and entered into force in respect of twenty-nine Council of Europe member States, namely Albania, Bosnia and Herzegovina, Bulgaria, Croatia, Cyprus, Czech Republic, Denmark, Estonia, Finland, France, Georgia, Greece, Hungary, Iceland, Latvia, Lithuania, Moldova, Montenegro, Norway, Portugal, Romania, San Marino, Serbia, Slovakia, Slovenia, Spain, Switzerland, The former Yugolslav Republic of Macedonia and Turkey.[1] The Russian Federation has not ratified or signed the Convention. Its relevant provisions read as follows:
Article 5: General rule
“An intervention in the health field may only be carried out after the person concerned has given free and informed consent to it. This person shall beforehand be given appropriate information as to the purpose and nature of the intervention as well as on its consequences and risks. The person concerned may freely withdraw consent at any time.”
B. General Recommendation No. 24 adopted by the Committee on the Elimination of Discrimination against Women (CEDAW)
33. At its 20th session which took place in 1999 the Committee on the Elimination of Discrimination against Women adopted the following opinion and recommendations for action by the States parties to the Convention on the Elimination of All Forms of Discrimination against Women (ratified by all Council of Europe member States):
“20. Women have the right to be fully informed, by properly trained personnel, of their options in agreeing to treatment or research, including likely benefits and potential adverse effects of proposed procedures and available alternatives.
22. States parties should also report on measures taken to ensure access to quality health care services, for example, by making them acceptable to women. Acceptable services are those which are delivered in a way that ensures that a woman gives her fully informed consent, respects her dignity, guarantees her confidentiality and is sensitive to her needs and perspectives. States parties should not permit forms of coercion, ... that violate women’s rights to informed consent and dignity.
31. States parties should also, in particular:
(e) Require all health services to be consistent with the human rights of women, including the rights to autonomy, privacy, confidentiality, informed consent and choice.”
C. A Declaration on the Promotion of Patients’ Rights in Europe
34. The Declaration was adopted within the framework of the European Consultation on the Rights of Patients, held in Amsterdam on 28-30 March 1994 under the auspices of the World Health Organisation’s Regional Office for Europe (WHO/EURO). The Consultation came at the end of a long preparatory process, during which WHO/EURO encouraged the emerging movement in favor of patients’ rights by, inter alia, carrying out studies and surveys on the development of patients’ rights throughout Europe. In its relevant part the Declaration stated as follows:
“3.9 The informed consent of the patient is needed for participation in clinical teaching.”

D. Article 8 ECHR
“1. Everyone has the right to respect for his private and family life, his home and his correspondence.
2. There shall be no interference by a public authority with the exercise of this right except such as is in accordance with the law and is necessary in a democratic society in the interests of national security, public safety or the economic well-being of the country, for the prevention of disorder or crime, for the protection of health or morals, or for the protection of the rights and freedoms of others.”

Lack of information and consent during the delivery, as is the case with lack of interpretation, constitutes “an interference” with  women's Article 8 rights. This interference is not lawful, neither necessary nor proportionate.
The European Court of Human Rights has reiterated that under its Article 8 case-law, the concept of “private life” is a broad term not susceptible to exhaustive definition. It covers, among other things, information relating to one’s personal identity, such as a person’s name, photograph, or physical and moral integrity (see, for example, Von Hannover v. Germany (no. 2) [GC], nos. 40660/08 and 60641/08, § 95, 7 February 2012) and generally extends to the personal information which individuals can legitimately expect to not be exposed to the public without their consent (see Flinkkilä and Others v. Finland, no. 25576/04, § 75, 6 April 2010; Saaristo and Others v. Finland, no. 184/06, § 61, 12 October 2010; and Ageyevy v. Russia, no. 7075/10, § 193, 18 April 2013). It also incorporates the right to respect for both the decisions to become and not to become a parent (see Evans v. the United Kingdom [GC], no. 6339/05, § 71, ECHR 2007‑I) and, more specifically, the right of choosing the circumstances of becoming a parent (see Ternovszky v. Hungary, no. 67545/09, § 22, 14 December 2010).
40. Moreover, Article 8 encompasses the physical integrity of a person, since a person’s body is the most intimate aspect of private life, and medical intervention, even if it is of minor importance, constitutes an interference with this right (see Y.F. v. Turkey, no. 24209/94, § 33, ECHR 2003‑IX, V.C. v. Slovakia, no. 18968/07, §§ 138-142, ECHR 2011; Solomakhin v. Ukraine, no. 24429/03, § 33, 15 March 2012; and I.G. and Others v. Slovakia, no. 15966/04, §§ 135 - 146, 13 November 2012).

Under the Court’s case-law, the expression “in accordance with the law” in Article 8 § 2 requires, among other things, that the measure in question should have some basis in domestic law (see, for example, Aleksandra Dmitriyeva v. Russia, no.9390/05, §§ 104-07, 3 November 2011), but also refers to the quality of the law in question, requiring that it should be accessible to the person concerned and foreseeable as to its effects (see Rotaru v. Romania [GC], no. 28341/95, § 52, ECHR 2000-V). In order for the law to meet the criterion of foreseeability, it must set forth with sufficient precision the conditions in which a measure may be applied, to enable the persons concerned – if need be, with appropriate advice – to regulate their conduct. In the context of medical treatment, the domestic law must provide some protection for the individual against arbitrary interference with his or her rights under Article 8 (see, mutatis mutandisX v. Finland, no. 34806/04, § 217, ECHR 2012).
The absence of any safeguards against arbitrary interference with patients’ rights in the relevant domestic law at the time constitute a serious shortcoming (Konovalova v. Russia, §45, V.C., cited above, §§ 138-142)
A woman giving birth should have received prior notification about any arrangement interfering with her private life and be able to foresee its exact consequences (Konovalova v. Russia, §46) so as to be capable of making an intelligible informed decision (Konovalova v. Russia, §§ 37, 46).
 In order for the requirement of lawfulness of Article 8 § 2 of the Convention to be fulfilled, sufficient procedural safeguards should be in place against arbitrary interference with women’s Article 8 rights in the domestic law and practice, like sufficiency of information provided to the pregnant and birthing woman, in a language that she understands, consideration of refugee women’s vulnerable condition during the procedure, availability of alternative arrangements in case the woman decides to refuse the proposed medical arrangement.

5          Appendix – Pleiades Questionnaire

5.1       The interview

1.     Where is the interview collected?
2.     In which format? E.g. mother is interviewed in person, or the questionnaire is filled in privately by the mother.
3.     If in person, was a (female) interpreter used?
4.     If by a facilitator/cultural intermediator/other professional (please specify), was a female one used?

5.2       Mother’s information

5.     Name/Surname/Asylum Seeker Card No (and Copy)
6.     Date of Birth/Age
7.     Country of origin
8.     Number of children (excluding the pregnancy subject of this interview)
9.     Family situation (mother’s marital status, father’s domicile, if pursuing reunification how long since last time husband and wife met, etc.)
10.  Vulnerability:
11.  Contact number (specify if Whatsapp/Viber available)

5.3       Pregnancy subject of this interview

Section A. Gestation is ongoing at the time of the interview
12.  Describe the mother’s health at the time of the interview
13.  Are you aware of any health condition affecting you (mother) or the child associated to high-risk pregnancy/birth?
14.  Have you received any healthcare advice since learning about your pregnancy?
15.  Have you received any medical assistance and/or services (diagnostics, monitoring, check-ups) since learning about your pregnancy?
16.  When was the health status of you or your child last assessed?
17.  Describe your living conditions during pregnancy:

Section B. The interview is conducted after the birth date
Answer all questions of Section A.
Answer questions 12-17.
Baby’s information
18.  Date of Birth
19.  Sex
Baby’s health
20.  Weight of the baby at the time of birth
21.  Weight of the baby at the time of the interview
22.  Health of the baby at the time of birth
23.  Health of the baby at the time of the interview
24.  Was it a premature birth?
25.  Were there any birth complications?
26.  Were there any post-partum complications?
27.  (Refer to following subsections for baby’s vaccinations)

Mother’s health after birth
28.  Describe the mother’s health at the time of birth
29.  Were there any birth complications?
30.  Were there any post-partum complications?
31.  Have you received any post-partum healthcare support/medical assistance?
a.     Baby’s physical health monitoring
b.     Mother’s physical health monitoring
c.     Mother’s psychological health support
d.     Mother’s emotional support, e.g. under high stress and/or difficult family circumstances
32.  Do you have access to community support groups and additional counselling services? E.g. contraception, family support, family planning.
33.  Did you have access to breastfeeding education and/or practitioners for professional guidance/advice?
34.  Were you referred to any breastfeeding support groups for the duration of the lactation period?
35.  Did you feel safe during birth?
36.  Did you or your child face any threats before or after birth?
Living conditions after birth
37.  Describe your living conditions after birth:

Ø  Go to section B1 if it was “free birth” (mother’s decision to give birth at home or elsewhere without the assistance of a healthcare professional)
Ø  Go to section B2 if it was a case of “born before arrival” (mother gave birth at home or elsewhere before the planned arrival of a healthcare professional)
Ø  Go to section B3 if birth happened at hospital’s premises

Section B1. Free birth
38.  Where did the birth occur?
39.  Was it a safe environment?
40.  Was it a clean environment?
41.  Was a family member or friend with you during labor and/or at the time of birth?
42.  If no, was it your choice?
43.  Which healthcare professionals were present at the time of birth?
44.  Did you have access to clean baby clothes and nappies?
45.  Did you have access to pain-relief measures during labor?
46.  If yes, were you made aware of benefits and risks?
47.  Did you undergo any procedure or treatment that seemed potentially harmful to you or to your child?
48.  Are you informed about the compulsory vaccination prophylaxis for your baby?
49.  Do you have a vaccination card?
50.  Were you able to obtain information and instructions regarding the compulsory vaccinations?
51.  Did your baby face any medical condition before or after vaccination? If so, describe what and when.
52.  Did you or your baby face life-threatening complications before, during or after birth?
53.  Did you seek/receive prompt assistance?
54.  Were you or your baby hospitalized after birth?
55.  Were you asked to pay money at any stage?

Section B2. Born before arrival
Answer all questions of Section B1.
Answer questions 38-55 of section B1.
56.  Summarize events that led to OOH (Out-Of-Hospital) birth. E.g. late arrival of ambulance, hospital too far, etc.

Section B3. Birth at hospital
38.  Was an interpreter available in all critical phases, including hospital admission, labor, birth, post-partum procedures?
39.  Was a family member or friend with you during labor and/or at the time of birth?
a.     If no, was it your choice?
40.  Which healthcare professionals were present at the time of birth?
41.  Were you allowed to be with your baby after birth?
a.     If yes, how long after?
42.  Were you allowed to be skin-to-skin with your baby after birth?
43.  Was the baby with you the whole time? E.g. Baby bed in mother’s hospital room 24 hours.
44.  Did you and your baby have to be separated for medical reasons? If yes, for which reasons and for how long?
45.  How long after birth were you allowed to breastfeed?
46.  Was your baby given any artificial teats, pacifiers, food, drink without your previous authorization? If yes, were you clearly communicated any medical indication requiring that?
47.  Did you have access to clean baby clothes and nappies?
48.  Did the personnel conduct themselves in a professional manner? Were they kind? Respectful of your privacy? Did you feel uncomfortable about specific behaviours by the hospital personnel?
49.  Were you explained at each stage what was about to happen?
50.  Were you normally offered options?
51.  Which birth procedure was carried out?
52.  Were you offered options regarding the possible birth procedures?
53.  Were you recommended a specific birth procedure?
54.  If yes, were you explained the reasons?
55.  Did you feel that you were being put under pressure or bullied into choosing a specific birth procedure or treatment by any healthcare professionals?
56.  Did you feel that you were being put under pressure or bullied into choosing a specific birth procedure or treatment by any family member?
57.  Were you allowed to ask questions?
58.  Were you provided answers?
a.     If not, were there specific reasons? E.g. unavailability of interpreter, unavailability of information, lack of promised follow-up, etc.
59.  Were you asked for authorization about the selected birth procedure?
60.  Were you offered pain-relief measures during labor?
61.  If pain-relief measures were provided, were you asked for authorization before proceeding? Was the procedure explained to you? Were benefits and risks explained to you or to your birth partner?
62.  Did you undergo any procedure or treatment that seemed potentially harmful to you or to your child?
a.     If yes, did you raise your concerns?
b.     If you raised your concerns, was the response adequate? Reassuring? Evidence-based?
c.     If no, why? 
63.  Were you illustrated the vaccination prophylaxis for your baby?
64.  Were you provided a vaccination card?
65.  Were you given information and instructions regarding the following vaccination appointments?
66.  Did you or your baby face life-threatening complications before, during or after birth?
67.  Did you receive prompt assistance?
68.  Were you and/or your birth partner explained what was happening?
69.  Did you or your baby undergo surgery?
70.  Were you and/or your partner asked to provide written authorization?
a.     If so, was that in a language that you understood?
71.  Were you asked to pay money at any stage?
72.  Were you granted access to your medical/maternity records?
73.  Was your overall hospital experience positive in terms of assistance, support, professionalism?
a.     If no, did you make a complaint?
b.     Were you offered the option to formalize your complaint?