Case: Pojatina v. Croatia
Judgement date: 4 October 2018
Topic: Reproductive rights
Aspect: Home birth

Summary of the facts:
This case concerned Croatian legislation on home births. The applicant in the case was a mother who had given birth to her fourth child at home with the help of a midwife from abroad. She alleged in particular that, although Croatian law allowed home births, women such as her could not make this choice in practice because they were not able to get professional help.

Summary of the Court's findings:
The Court held that there had been no violation of Article 8 (right to respect for private and family life) of the Convention. It accepted that at first there might have been some doubt as to whether a system for assisted home births had been set up in Croatia. It therefore called on the authorities to consolidate the relevant legislation so that the matter is expressly and clearly regulated. However, it found that the applicant had clearly been made aware, through the letters from the Croatian Chamber of Midwives and the Ministry of Health which she had received while she had still been pregnant with her fourth child, that the domestic law did not allow assisted home births. It further found that the authorities had struck the right balance between the applicant’s right to respect for her private life and the State’s interest in protecting the health and safety of mothers and children. It pointed out in particular that Croatia was not currently required under the Convention to allow planned home births. There was still a great disparity between the legal systems of the Contracting States on home births and the Court was sensitive to the fact that the law developed gradually in this area.

The facts:
I. THE CIRCUMSTANCES OF THE CASE
5. The applicant was born in 1976 and lives in Zagreb.
6. She gave birth to her first three children in hospital. In 2011 she became pregnant with her fourth child and had a due date in February 2012.
7. In November 2011 she sent a letter to the Croatian Chamber of Midwives ( Hrvatska Komora Primalja ), enquiring about the possibility of having professional assistance with a home birth. She explained that her first three hospital deliveries had gone normally, without the need for much medical intervention, but that she had not felt fulfilled afterwards. She therefore wanted to give birth to her fourth child at home.
8. On 1 December 2011 she received a reply that according to the relevant domestic legislation health professionals, including midwives, were unable to assist with home births. In particular, although the Act on Midwifery allowed the setting up of private practices by midwives, the Healthcare Act, as the general Act in the sector, still did not expressly provide for such a possibility. Therefore, since the matter was not clearly regulated, no midwife had set up a private practice or officially assisted with home births. The letter also cited a statement from the Ministry of Health and Social Welfare ( Ministarstvo zdravstva i socijalne skrbi Republike Hrvatske - hereinafter “the Ministry of Health”) issued in August 2011 and published on the Croatian Chamber of Midwives ’ website:
“Having regard to the current circumstances, where the requirements for organising a system of professionally conducted home births do not exist (education and training of personnel) and where the other accompanying elements (availability of emergency transport and proper admission [ to a medical facility ] in the case of complications) which would enable safe delivery at home are lacking, we are of the opinion that in this area of healthcare the lawmaker has ensured, as far as possible, all the conditions for the care of mothers and the right of children to life and health. Considering the above, we are of the opinion that the protection of children, who do not choose the circumstances of their coming into this world, takes precedence over respect for a woman ’ s right to freely choose to give birth outside a medical facility .”
The Croatian Chamber of Midwives thus declined to assist with the applicant ’ s planned home birth. It noted that home births nevertheless occurred in Croatia, and for that reason it had urged the Ministry of Health to clearly regulate the matter as soon as possible.
9. On 15 February 2012 the applicant gave birth to her child at home, assisted by a midwife from abroad.
10. After the birth a paediatrician and a gynaecologist allegedly declined to examine the applicant and her baby but she eventually managed to find doctors who examined them both.
11. On 23 February 2012 the applicant registered the birth and obtained a birth certificate.
II. GENERAL INFORMATION PERTAINING TO HOME BIRTHS IN CROATIA
A. Statements by the Ministry of Health and the Ministry of Administration
12. On 11 May 2011 the Ministry of Health sent a letter in reply to an enquiry from the Ombudswoman for Children ( Pravobraniteljica za djecu ), which stated that the relevant domestic law provided that babies were to be delivered in medical facilities. The question of home births had not been regulated by law and medical assistance in such procedures was considered as quackery. It further stated that home births were the personal responsibility of the mother and the person assisting with the delivery. In the event of a delivery outside a medical facility and where a woman claiming to be the mother did not have any medical documentation, the doctor carrying out the first examination of the child was obliged to make note of the absence of such documents. The doctor was not allowed to register data which he or she was not able to verify.
13. On 25 August 2011 the Ministry of Administration ( Ministarstvo uprave Republike Hrvatske ) sent a letter in reply to an enquiry from the Parents in Action - Roda NGO ( Roditelji u Akciji – Roda ) stating that the law provided for the possibility to register the civil status of a child born outside a medical facility. It further stated that officials were obliged to verify data reported to them before putting anything down in the State register. Consequently, a person reporting the birth of a child born outside a medical facility was required to submit proof that the woman reported as the child ’ s mother had indeed given birth to the child. The medical documentation required for proving such circumstances was a matter for the health administration authorities.
14. On 31 May 2012 the Ministry of Health replied to an enquiry from Parents in Action – Roda NGO by saying that it had never instructed doctors not to examine children born at home. On the contrary, having regard to the increased frequency of situations in which doctors were faced with having to examine children born at home without any medical documentation, it had consistently held that doctors were obliged to examine such children but were not allowed to register any data that they were not able to verify. It added that home birth was still not regulated by law and that therefore there was no mechanism for registering requests for home birth or regulations on the duty to report them.
B. Report of action against midwives
15. On 24 January 2012 the Croatian Chamber of Midwives reported on a case in which, according to the media coverage, a woman who had given birth at home had been separated from her child for two days. In particular, the hospital had called the police and social workers in order to establish that she was indeed the child ’ s mother after she had refused to be examined by a gynaecologist in a hospital. In addition, several midwives suspected of having taken part in the birth had been questioned by the police.
16. According to information submitted by the Government, no health professional has ever been prosecuted in criminal proceedings or sanctioned for assisting with a home birth.
III. REPORTS ON HOSPITAL BIRTH PRACTICES IN CROATIA
17. In the Concluding Observations on the combined fourth and fifth periodic reports on Croatia issued on 24 July 2015, the Committee on the Elimination of Discrimination against Women expressed concern regarding the lack of oversight procedures and mechanisms for ensuring adequate standards of care, the protection of women ’ s rights and their autonomy during deliveries and the lack of options for giving birth outside hospitals.
18. A survey on maternity practices in Croatia undertaken by the Parents in Action - Roda NGO in March 2015 noted situations of women ’ s wishes being disregarded by medical staff during childbirth, of a lack of consent for procedures conducted during labour, and limits on the presence of an accompanying person during childbirth.
19. The Gender Equality Ombudsperson ( Pravobraniteljica za ravnopravnost spolova ) issued a research report in 2013 which noted inconsistencies in hospital practices regarding the presence of an accompanying person during childbirth.

Relevant law and the Court's assessment:
IV. RELEVANT DOMESTIC LAW
A. The Constitution
20. The relevant provisions of the Constitution of the Republic of Croatia ( Ustav Republike Hrvatske, Official Gazette no. 56/1990 with subsequent amendments ) read as follows:
Article 57 § 2
“ Rights concerning childbirth, motherhood and childcare shall be regulated by law.”
Article 59
“Everyone has the right to healthcare in accordance with the law.”
B. The Healthcare Act and corresponding bylaws
1. Healthcare Act
21. The Healthcare Act ( Zakon o zdravstvenoj zaštiti, Official Gazette nos. 150/2008, 155/2009, 71/2010, 139/2010, 22/2011, 84/2011 and 154/2011 ), as in force at the material time, provided that healthcare measures included, inter alia, ensuring the full healthcare of women, in particular in relation to family planning, pregnancy, childbirth and motherhood (section 17 ( 10 ) ). Healthcare measures were provided in accordance with a plan and programme drawn up by the Ministry of Health (section 18).
22. Healthcare services were to be provided by healthcare facilities, companies and private health professionals, under the conditions prescribed by law (section 35 ( 1 ) ). Exceptionally, healthcare services were also provided by other legal entities and physical persons in accordance with the law (section 35 ( 2 ) ).
23. The Act expressly regulated the private practice of health professionals such as doctors, dentists, dental technicians, pharmacists, nurses and physiotherapists (sections 146 and 147). It did not expressly regulate midwives in private practice.
24. As regards foreign health professionals in private practice, the law regulating the work of foreigners in Croatia was applicable. Foreign health professionals had to meet the same conditions as national health professionals in private practice, save for having Croatian citizenship. They also had to have relevant knowledge of the Croatian language ( section 145( 4) and 147(7)).
25. Private health professionals who performed in private practice without meeting the conditions provided by that Act and those who worked in private practice in an area which was banned by that Act, could have been punished for a misdemeanour and ordered to pay a fine of between 5,000 and 10,000 Croatian kunas (HRK) (sections 204 ( 2 ) and 204 ( 9 ) ).
26. The Act was subsequently amended several times (Official Gazette nos. 12/2012, 35/2012, 70/2012, 144/2012, 82/2013, 159/2 013, 22/2014, 154/2014, 70/2016 and 131/2017 ), but it still did not expressly regulate midwives in private practice.
2. Bylaw on minimum conditions for space, workers and medical equipment for providing healthcare services
27. The Bylaw on the minimum conditions for space, workers and medical equipment for providing healthcare services ( Pravilnik o minimalnim uvjetima u pogledu prostora, radnika i medicinsko-tehničke opreme za obavljanje zdravstvene djelatnosti, Official Gazette no. 61/2011– “the Bylaw on minimum conditions”), as in force at the material time, provided that the performing of midwifery services required an examination room measuring at least twelve square metres, a room for an assistant midwife of at least nine square metres, a waiting room measuring at least nine square metres, and toilet facilities for staff and patients. It also regulated which appliances were required for performing midwifery services and which members of staff had to be present during each eight ‑ hour shift (section 31).
3. Bylaw on the conditions, organisation and functioning of urgent outpatient medical assistance
28. The Bylaw on the conditions, organisation and functioning of emergency outpatient medical assistance ( Pravilnik o uvjetima, organizaciji i načinu rada izvanbolničke hitne medicinske pomoći, Official Gazette no. 146/2003 – “the Bylaw on emergency medical assistance”), as in force at the material time, regulated the measures and procedures to be followed in the event of an emergency at the place of the emergency, during transport in emergency medical assistance vehicles and on the premises of medical facilities (sections 2 and 3). The Bylaw provided that plans and programmes for the basic education of medical nurses and medical technicians working in urgent outpatient medical assistance had to include, inter alia, assisting with births outside a hospital, dealing with newborns and transporting mothers and newborns ( annex no. 3).
C. Compulsory Health Insurance Act and Plan and program of the compulsory health insurance healthcare measures
1. Compulsory Health Insurance Act
29. The Compulsory Health Insurance Act ( Zakon o obveznom zdravstvenom osiguranju, Official Gazette nos. 150/2008, 94/2009, 153/2009, 71/2010, 139/2010 and 49/2011), as in force at the material time, provided that guaranteed healthcare was provided through health measures established on the basis of a corresponding plan and programme drawn up by the Ministry of Health (sections 15 ( 2 ) and 15 ( 3 ) ). Insured persons were entitled to obtain guaranteed healthcare at the expense of the Health Insurance Fund ( “ the Fund ” ) in healthcare facilities and from private healthcare professionals who had concluded an agreement with the Fund on providing healthcare services under the conditions prescribed by law (section 15( 4 ) ). Obtaining guaranteed healthcare services related to the monitoring of pregnancies and childbirth was paid for in its entirety by the Fund (section 16 ( 2 )( 3 ) ).
30. On 1 July 2013 a new Compulsory Health Insurance Act ( Zakon o obveznom zdravstvenom osiguranju, Official Gazette nos. 80/2013 and 137/2013) came into force. It still provides that guaranteed healthcare is provided through health measures established on the basis of a corresponding plan and programme drawn up by the Ministry of Health (sections 18(2) and 18 (3)).
2. The Plan and programme of healthcare measures under the compulsory health insurance system
31. The Plan and programme of healthcare measures under compulsory health insurance ( Plan i program mjera zdravstvene zaštite iz obveznog zdravstvenog osiguranja, Official Gazette nos. 126/2006 and 156/2008 – “the Plan and programme of healthcare measures”) provides that healthcare measures include, inter alia;
- the examination and vaccination of children born at home (section 1(2)(1)( 14) );
- emergency transportation of endangered pregnant women, women giving birth and newborns in situations of urgent illnesses and conditions (section 1(4)(1)(4));
- professional assistance of a doctor and a midwife in home birth and transportation to a maternity ward (section 1 ( 5 )( 2 )( 2 )( 1) );
- the examination of a woman in her home after giving birth there and an examination in a medical facility six weeks later (section 1 ( 5 )( 2 )( 3 )( 1) ).
D. Act on Midwifery
32. The Act on Midwifery ( Zakon o primaljstvu, Official Gazette nos. 120/2008 and 145/2010) provides for the possibility of performing independent midwife work. Approval for performing such work is given by the competent body of the Croatian Chamber of Midwives (section 15).
33. The Act also provides for the possibility for midwives to set up a private practice if they have completed the relevant education and have obtained approval for performing independent work (section 24 ( 1 ) ). The Act refers to the provisions of the Healthcare Act (section 24 ( 2 ) ) for the procedure for setting up and closing a private practice.
E. State Registers Act
34. The State Registers Act ( Zakon o državnim maticama, Official Gazette, no. 96/1993), as in force at the material time, set down which persons were obliged to report the birth of a child to the registry of births when the child was born outside a medical facility (section 11 ( 2 ) ). It also laid down a general obligation for officials to verify data before entering it in the State Register if there was a reasonable suspicion that the data was incorrect (section 25 ( 3 ) ).
35. The State Registers Act was amended in 2013 to expressly provide that a person reporting the birth of a child born outside a medical facility must submit medical documents related to the birth or proof of motherhood (section 11 ( 3 ) ).
F. Criminal Code
36. The relevant provision of the Criminal Code ( Kazneni zakon, Official Gazette no. 125/11), as in force at the material time, read as follows:
Refusal to provide medical assistance in emergency situations
Section 183
“ A doctor of medicine, a dentist or other health professional who declines to provide immediate medical assistance to a person in need of such assistance owing to the existence of a risk of permanent damage to his or her health or life shall be punished by imprisonment of up to three years.”
Quackery
Section 184 ( 1 )
“ Any person who provides medical treatment or other medical assistance while lacking the necessary professional qualifications shall be punished by imprisonment of up to one year.”
G. Medical Assistance Act
37. The relevant provisions of the Medical Assistance Act ( Zakon o liječništvu, Official Gazette nos. 121/2003 and 117/2008) provide that a doctor is only allowed to refuse to provide medical assistance when a person is making threats or demonstrating physical aggression towards him or her or another health professional, save for in emergency situations (section 18 ( 4 ) ). In the event of an unlawful refusal to provide medical assistance a doctor can be punished for a misdemeanour and ordered to pay a fine of between HRK 5,000 and 10,000 (section 59).
V. RELEVANT INTERNATIONAL AND COMPARATIVE- LAW MATERIAL
38. The other relevant international and comparative- law material is set out in paragraphs 62-68 in the case of Dubská and Krejzová v. the Czech Republic ([GC], nos. 28859/11 and 28473/12, 15 November 2016).
THE LAW
I. ALLEGED VIOLATION OF ARTICLE 8 OF THE CONVENTION
39. The applicant complained that Croatian law had dissuaded healthcare professionals from assisting her when giving birth at home, in violation of her right to a private life, as provided for in Article 8 of the Convention, which reads:
“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.”
A. Admissibility
1. The parties ’ arguments
(a) The Government
40. The Government maintained that Article 8 was not applicable to the case since the issue at stake was only the personal comfort of the applicant, who had wanted to give birth at home, which could not be part of her right to respect for her private life. There was no scientific proof that giving birth in a medical facility could in any way damage the physical or psychological integrity of a mother or child and thus the legislation concerning home birth as such could not be the subject of an examination by the Court under Article 8 of the Convention.
41. The Government maintained further that the circumstances of the applicant in the present case should be distinguished from those of the applicants in Dubská and Krejzová (cited above). In that case, one of the applicants had eventually given birth at home alone while the other had had to abandon giving birth at home altogether and have her child in a hospital. The applicant in the present case had given birth at home with the assistance of a midwife from abroad. Furthermore, there was no indication that the applicant would not have had emergency medical assistance if the home birth had gone wrong. Also, the applicant had been able to properly register the birth of her child and neither the applicant nor the midwife concerned had been prosecuted. Against that background, the Government deemed that the applicant could not be seen as a victim of the violation alleged.
(b) The applicant
42. The applicant replied that the Court ’ s case-law made it clear that the circumstances of giving birth incontestably formed part of a person ’ s private life. That had been confirmed in Ternovszky v. Hungary ( no. 67545/09, § 22, 14 December 2010 ) and in Dubská and Krejzová (cited above).
43. She further submitted that she had decided to give birth at home as her first three hospital deliveries had been stressful as she had felt that her wishes had not been respected and that she had not had control over the procedures that had been followed. However, not being able to find any midwife in the Croatian healthcare system to assist her, she had hired one from abroad, which had caused her feelings of uncertainty and anxiety. In particular, she had feared the criminal sanctions that she or the foreign midwife could have faced. Also, since the foreign midwife had not been licensed to practise in Croatia, there had been no guarantee that the midwife would have been able to arrange emergency transport and admission to hospital if the delivery had gone wrong. Finally, her decision to give birth at home had led to her and her child being denied postnatal care, which had been a common situation for women in Croatia who had decided to give birth at home. She could therefore certainly be considered a victim of the violation complained of.
2. The Court ’ s assessment
( a ) Applicability of Article 8 of the Convention
44. The Court held in a recent Grand Chamber case that although Article 8 could not be interpreted as conferring a right to give birth at home as such, the fact that it was impossible in practice for women to be assisted when giving birth in their private home came within the scope of their right to respect for their private life and accordingly of Article 8. It found that issues related to giving birth, including the choice of the place of birth, were fundamentally linked to a woman ’ s private life and fell within the scope of that concept for the purposes of Article 8 of the Convention (see Dubská and Krejzová, cited above, § 163 ). The Court sees no reason to depart from that view in the present case.
( b ) The applicant ’ s victim status
45. The Court has consistently held in its case-law that the Convention does not provide for the institution of an actio popularis and that its task is not normally to review the relevant law and practice in abstracto, but to determine whether the manner in which they were applied to, or affected, the applicant gave rise to a violation of the Convention (see, among other authorities, N.C. v. Italy [GC], no. 24952/94, § 56, ECHR 2002 - X). Accordingly, in order to be able to lodge an application in accordance with Article 34 an individual must be able to show that he or she was “directly affected” by the measure complained of. This is indispensable for putting the protection mechanism of the Convention into motion, although this criterion is not to be applied in a rigid, mechanical and inflexible way throughout the proceedings (see Roman Zakharov v. Russia [GC], no. 47143/06, § 164, ECHR 2015).
46. In the present case, the Court notes that the applicant complained that the domestic legislation concerning home birth was not consolidated and that therefore she could not obtain assistance of a health professional from the Croatian healthcare system when giving birth at home. The Court further notes that in the above-cited case of Dubská and Krejzová the Grand Chamber assessed a situation under Article 8 of the Convention where domestic legislation did not in practice allow for medical assistance during home births. The Court sees no reason to depart from that view in the present case. The fact that the applicant eventually gave birth at home with the assistance of a midwife from abroad does not prompt the Court to conclude that she cannot claim to be a victim of a violation of her rights under Article 8. Consequently, it dismisses the Government ’ s objection as to the applicant ’ s lack of victim status.
( c ) Conclusion as to the admissibility
47. The Court notes that this complaint is not manifestly ill-founded within the meaning of Article 35 § 3 (a) of the Convention. It further notes that it is not inadmissible on any other grounds. It must therefore be declared admissible.
B. Merits
1. The parties ’ arguments
(a) The applicant
48. The applicant submitted that the domestic legislation concerning home births had placed her in a state of uncertainty as regards the legality of her actions during the vulnerable period of her pregnancy. Moreover, after the delivery she had faced problems such as the denial of postnatal care to her and her child and had still felt anxiety about a possible criminal prosecution. The Government could therefore not claim that there had been no interference with her right to respect for her private life.
49. The applicant submitted further that the legislation on the matter was not foreseeable. In particular, the Act on Midwifery envisaged private practices for midwives (see paragraph 32 above), while the Bylaw on emergency medical assistance and the Plan and programme of healthcare measures guaranteed professional assistance during home births (see paragraphs 28 and 31 above). Such factors tended to support the conclusion that professionally assisted home births were permitted. However, the Healthcare Act did not provide a procedure for midwives to set up a private practice (see paragraphs 21 -25 above). Moreover, the Ministry of Health had expressed a view that assisting with home births would be considered as quackery (see paragraph 12 above).
50. The applicant maintained that the interference at issue did not pursue the legitimate aim of protecting the life and health of women and their new ‑ born babies since by allowing home births – but at the same time making it impossible for women to receive professional assistance – the State de facto exposed women and children to increased risks to their health and life.
51. The applicant did not consider that the State had a wide margin of appreciation on the matter. The issue at stake was a particularly intimate and important aspect of the right of pregnant women to respect for their private life. She also respectfully disagreed with the Grand Chamber in the above ‑ cited case of Dubská and Krejzová that there was no clear common ground regarding skilled attendants at home births. The applicant was of the opinion that there was a clear trend among Council of Europe member States towards a liberal policy on the matter. She added that the consensus on the issue among those States was supported by international expert opinion on the issues of maternal health and the importance of skilled attendants at birth.
52. The applicant added that the prohibitive and punitive approach adopted by the Republic of Croatia could affect women ’ s enjoyment of other fundamental rights, such as the right to life and health. By making it less safe for women to give birth at home, the State could put those other rights at risk. Unlike the Czech Republic, which had tried to initiate an open discussion on the matter of home birth with a view to adopting certain policies and laws, the Croatian Government had entirely failed to deal with the matter.
53. The applicant noted that hospital births in the Republic of Croatia were associated with a high risk of procedures that did not respect women ’ s choices. In her argument she relied on the reports of the Committee on the Elimination of Discrimination against Women, the Parents in Action - Roda NGO and the Gender Equality Ombudsperson, which noted situations of a lack of respect for women ’ s wishes in maternity wards during childbirth (see paragraphs 17-19 above).
54. The applicant contested the Government ’ s argument that Croatia ’ s geographical characteristics and a lack of financial means meant it was not possible to set up an adequate transport system which could ensure the speedy transfer of a mother and child to the nearest hospital in case of an emergency during a home birth (see paragraph 59 below). There was no difference between providing transport for an emergency situation during a home birth or for any other kind of emergency situation. Moreover, the Government did not submit any evidence to demonstrate that the State would face financial constraints if allowing professionally assisted home births.
55. Lastly, the applicant submitted that her situation should be distinguished from that in Dubská and Krejzová (cited above) as she had been refused postnatal care, which had been a common situation for women in Croatia who had decided to give birth at home. Moreover, women who gave birth at home in Croatia often experienced difficulties registering their children in State registers since the relevant law obliged them to submit medical documents to prove their motherhood. Furthermore, midwives were not free from harassment. The Ministry of Health had expressly held that their assisting with home births was considered as quackery (see paragraph 12 above) and they had also been submitted to police questioning (see paragraph 15 above). The applicant thus argued that her situation was more akin to Ternovszky (cited above), in which the Court had held that a lack of legal certainty and threats to healthcare professionals had limited the choices of the applicant in that case when considering home delivery. For the Court, that situation had been incompatible with the notion of “foreseeability” and hence with that of “lawfulness” ( ibid., § 26).
(b) The Government
56. The Government firstly argued that there had been no interference with the applicant ’ s right to respect for her private life because she had given birth at home, as she had wished, with the assistance of a midwife from abroad.
57. Were the Court to find that there had been an interference owing to the fact she had not been able to have the assistance of a health professional from the Croatian healthcare system, the Government maintained that it had been based in law since the relevant legislation regulated births in medical facilities only, which implied that planned home births with the assistance of health professionals were not permitted. That was confirmed by the Ministry of Health letter (see paragraph 12 above) to which the applicant had referred in her application to the Court. The possibility to set up private midwife practices was still not regulated by law. Such interference also pursued the legitimate aim of protecting the health and life of mothers and their new-born children.
58. As to the proportionality of the interference, the Government maintained that even though home delivery might be more pleasant for women giving birth, it still represented, in the light of all the scientific findings known to them, an option that was less safe than a full hospital delivery. They noted that the Commission for Perinatal Medicine of the Ministry of Health was of the view that hospitals were the safest places for child deliveries, providing the best guarantees for the preservation of the health and life of both mothers and babies. As such, the question of whether the State should allow its medical staff to participate in such deliveries fell within its margin of appreciation, meaning that each Contracting Party should be absolutely free to decide on its own, on the basis of its own assessment of numerous factors which needed to be considered, whether or not to provide that alternative to its citizens. The Government asserted that the Contracting Parties should not be compelled to make provision for home delivery and that the spirit of the Convention did not require that legislative measures or practices to that effect should be implemented in every Contracting Party. That, however, did not mean that a Contracting Party should entirely disregard the fact that a substantial number of women did not feel comfortable in a hospital environment and that certain adverse effects in relation to child delivery could be linked to that particular feeling of discomfort and fear.
59. The Government submitted that apart from the capital and several other bigger cities the Republic of Croatia consisted mostly of large and sparsely populated rural areas and islands and mountainous terrain that was difficult to access. In such circumstances it was virtually impossible to provide an effective transport system which could ensure the speedy transfer of a mother and child to the nearest hospital if a home birth went wrong. Furthermore, the Republic of Croatia did not for the time being have sufficient financial resources to set up a home birth system which could guarantee the same level of medical services as in medical facilities.
60. The Government submitted that 99.2% of deliveries in Croatia took place in public maternity wards. There were currently thirty-one public maternity wards and one private ward in Croatia. In line with the available space and other capacities, maternity wards allowed women to choose between several possible delivery positions and to have a spouse or other close relative present during giving birth. Mothers -to-be were free to choose the maternity ward in which they wished to give birth. The Government further submitted that in 1993 Croatia had joined the Baby-Friendly Hospital Initiative (BFHI), a programme launched by the WHO and UNICEF. Currently all maternity wards in Croatia were BFHI accredited, that is certified for their excellence in maternity care and support for breastfeeding. In 2015 Croatia had also joined the Mother-Friendly Hospital Initiative and in 2016 it had initiated a pilot programme to comply with the guidelines set down by the International Federation of Gynaecology and Obstetrics.
61. As to the applicant ’ s allegation that she had been denied postnatal care, the Government submitted that doctors were not allowed under the relevant law to refuse to provide medical assistance (see paragraphs 36 and 37 above). Even if her allegation was true, the applicant had never reported such an event to any relevant authority. Finally, there was no dispute about the fact that the applicant had received medical assistance and medical care after the delivery (see paragraph 10 above) and had managed to register her child in the State register (see paragraph 11 above). As regards the anxiety that the applicant had allegedly felt in relation to possible criminal sanctions, the Government maintained that there was no single provision in domestic law which could be understood as criminalising the actions of women who had decided to give birth at home. No woman had ever been punished for such an act. Moreover, no health professional, including the foreign midwife who had assisted the applicant, had ever been prosecuted in criminal proceedings or sanctioned for assisting with a home birth (see paragraph 16 above). The criminal offence of quackery could only be committed by persons who had provided medical assistance without having the necessary professional qualifications (see paragraph 36 above).
62. In conclusion, and having regard to the wide margin of appreciation that should be given to the Contracting States on this issue, the Government argued that the interference with the applicant ’ s right to respect for her private life had been proportionate to the aim pursued.
2. The Court ’ s assessment
(a) Whether the case should be examined from the standpoint of the State ’ s negative or positive obligations
63. In the above - cited case of Dubská and Krejzová the Court held that the matter involved “an interference with the applicants ’ right to avail themselves of the assistance of midwives when giving birth at home, owing to the threat of sanctions for midwives, who in practice were prevented from assisting the applicants by the operation of the law” and that “ in any event, as the Court has already held, the applicable principles regarding justification under Article 8 § 2 are broadly similar regardless of analytical approaches adopted” (see Dubská and Krejzová, cited above, § 165).
64. Accordingly, to determine whether the interference in this case entailed a violation of Article 8 of the Convention, the Court must examine whether it was justified under the second paragraph of that provision, that is whether the interference was “in accordance with the law” and “necessary in a democratic society” for the pursuit of one of the “legitimate aims” specified in Article 8.
( b ) Was the interference “in accordance with the law”?
65. The Court reiterates that an impugned interference must have some basis in domestic law, which law must be adequately accessible and be formulated with sufficient precision to enable a citizen to regulate his or her conduct, he or she being able – if need be with appropriate advice – to foresee, to a degree that is reasonable in the circumstances, the consequences which a given action may entail (ibid., § 167).
66. In the present case, there was no dispute between the parties that the domestic legal provisions providing the legal basis for the impugned interference were accessible to the applicant. The Court sees no reason to disagree on that point, and it must thus establish whether the provisions were also foreseeable.
67. The Court notes firstly that giving birth at home is not, as such, prohibited by the Croatian legal system. There are no provisions under domestic law criminalising the acts of women who decide to give birth in that way, and apparently no woman has ever been punished for such an action (see paragraph 61 above).
68. On the question of whether health professionals were allowed to assist in home births, the Court observes that, pursuant to the Compulsory Health Insurance Act, guaranteed healthcare was provided through health measures established on the basis of the corresponding plan and programme of the Ministry of Health (see paragraphs 29 and 30 above). The corresponding plan and programme included the professional assistance of a doctor and a midwife in a home birth as one of the healthcare measures involved (see paragraph 31 above). Such a regulation tended to support the conclusion that professionally assisted home births were permitted.
69. The Court further observes that the Act on Midwifery provided for midwives being in private practice (see paragraph 33 above). However, the Healthcare Act never expressly regulated the procedure for midwives setting up in midwife practice (see paragraphs 21-25 above). The Court notes that the Healthcare Act was amended several times after the Act on Midwifery came into force, and it remained silent on that matter (see paragraphs 26 and 32 above). Because of this, in reality, no Croatian health professionals, including midwives, officially assisted with home births (see paragraph 8 above).
70. The Court further notes that in its letter of 11 May 2011 the Ministry of Health stated that the relevant domestic law provided that babies were to be delivered in medical facilities. The question of home births had not been regulated by law, and medical assistance in such procedures was considered quackery (see paragraph 12 above). The Court does not find it necessary to assess the accuracy of the Ministry of Health ’ s conclusion that such medical assistance would constitute the criminal offence of quackery (see paragraph 36 above). In any event, it appears that no health professional, including the foreign midwife who assisted the applicant, has ever been prosecuted in a criminal case or sanctioned for assisting with a home birth (see paragraphs 16 and 61 above).
71. The Court also observes that in its letter to the applicant of 1 December 2011 the Croatian Chamber of Midwives, while noting that the matter of midwives in private practice had been regulated in an inconsistent manner, also informed her that, under domestic law, health professionals, including midwives, were unable to assist with home births (see paragraph 8 above). The letter also cited a statement from the Ministry of Health from August 2011, published on the Croatian Chamber of Midwives ’ website, which showed that no system of assisted home births had been set up in Croatia.
72. The Court therefore accepts that at first there might have been some doubt as to whether a system for assisted home births had been set up in Croatia. It therefore finds it appropriate to invite the Croatian authorities to consolidate the relevant legislation so that the matter is expressly and clearly regulated (see paragraphs 65 and 66 above). However, in the present case, it is of the view that the applicant was clearly made aware, through the letters from the Croatian Chamber of Midwives and the Ministry of Health which she received while she was still pregnant with her fourth child, that the relevant domestic law did not allow health professionals, including midwives, to assist with planned home births.
73. The Court therefore holds that the impugned interference was foreseeable for the applicant and in accordance with the law.
(c) Did the interference pursue a legitimate aim?
74. Contrary to the applicant ’ s arguments, the Court considers that there are no grounds for doubting that the Croatian State ’ s policy of encouraging hospital births, as reflected in the relevant national legislation, was designed to protect the health and safety of mothers and children during and after delivery (compare to Dubská and Krejzová, cited above, § 172 ).
75. It may accordingly be said that the interference in the present case served the legitimate aim of the protection of the health and rights of others within the meaning of Article 8 § 2 of the Convention ( ibid., § 173 ).
(d) Was the interference necessary in a democratic society?
76. The Court summarised the applicable principles in the case of Dubská and Krejzová (ibid.) as follows:
“174. An interference will be considered “necessary in a democratic society” for the achievement of a legitimate aim if it answers a “pressing social need” and, in particular, if it is proportionate to the legitimate aim pursued and if the reasons adduced by the national authorities to justify it are “relevant and sufficient” (see, mutatis mutandis, Fernández Martinez v. Spain [GC], no. 56030/07, § 124, ECHR 2014 (extracts)).
175. In this connection, the Court reiterates the fundamentally subsidiary role of the Convention system and recognises that the national authorities have direct democratic legitimation in so far as the protection of human rights is concerned. Moreover, by reason of their direct and continuous contact with the vital forces of their countries, they are in principle better placed than an international court to evaluate local needs and conditions (see, e.g., Maurice v. France [GC], no. 11810/03, § 117, with further references, ECHR 2005-IX).
176. It is therefore primarily the responsibility of the national authorities to make the initial assessment as to where the fair balance lies in assessing the need for an interference in the public interest with individuals ’ rights under Article 8 of the Convention. Accordingly, in adopting legislation intended to strike a balance between competing interests, States must in principle be allowed to determine the means which they consider to be best suited to achieving the aim of reconciling those interests (see Odièvre, cited above, § 49; Van Der Heijden v. the Netherlands [GC], no. 42857/05, § 56, 3 April 2012).
177. While it is for the national authorities to make the initial assessment, the final evaluation as to whether an interference in a particular case is “necessary”, as that term is to be understood within the meaning of Article 8 of the Convention, remains subject to review by the Court (see S. and Marper v. the United Kingdom [GC], nos. 30562/04 and 30566/04, § 101, ECHR 2008; Van Der Heijden, cited above, § 57).
178. A certain margin of appreciation is, in principle, afforded to domestic authorities as regards that assessment; its breadth depends on a number of factors dictated by the particular case. The margin will tend to be relatively narrow where the right at stake is crucial to the individual ’ s effective enjoyment of intimate or key rights. Where a particularly important facet of an individual ’ s existence or identity is at stake, the margin allowed to the State will also be restricted. Where there is no consensus within the member States of the Council of Europe, either as to the relative importance of the interest at stake or as to the best means of protecting it, particularly where the case raises sensitive moral or ethical issues, the margin will be wider (see Van der Heijden, cited above, §§ 55-60 with further references, and also Parrillo v. Italy [GC], no. 46470/11, § 169, with further references, ECHR 2015).
179. A wide margin is usually allowed to the State under the Convention when it comes to general measures of economic or social strategy. Because of their direct knowledge of their society and its needs, the national authorities are in principle better placed than the international judge to appreciate what is in the public interest on social or economic grounds, and the Court will generally respect the legislature ’ s policy choice unless it is “manifestly without reasonable foundation” (see Stec and Others v. the United Kingdom [GC], nos. 65731/01 and 65900/01, § 52 with further references, ECHR 2006-VI; Shelley v. the United Kingdom ( dec. ), no. 23800/06, 4 January 2008; and Hristozov, cited above, § 119).”
77. In the case at hand, the Court has to establish whether the fact that it was impossible in practice for the applicant to be assisted by a health professional from the Croatian healthcare system during her home birth struck a fair balance, on the one hand, between the applicant ’ s right to respect for her private life under Article 8, and, on the other, the State ’ s interest in protecting the health and safety of mothers and children during and after delivery. In addition to this, the Court has to verify whether the respondent State, by allegedly denying postnatal care to the applicant and her child born at home, and by making it difficult for her to register her child in the State register, overstepped the margin of appreciation afforded to it.
78. As to the respondent State passing legislation that did not in practice allow women to be assisted by health professionals from the Croatian healthcare system when giving birth at home, the Court notes that in the above - cited case of Dubská and Krejzová, the Grand Chamber held that the margin of appreciation to be afforded to the national authorities in that case had to be wide, while not being unlimited (see Dubská and Krejzová, cited above, §§ 182-184). In the light of those considerations, the Court must see whether the interference constitutes a proportionate balancing of the competing interests involved, having regard to the margin of appreciation. In cases arising from individual applications the Court ’ s task is not to review the relevant legislation or practice in the abstract; it must as far as possible confine itself, without overlooking the general context, to examining the issues raised by the case before it. Consequently, the Court ’ s task is not to substitute its own view for that of the competent national authorities in determining the most appropriate policy for regulating matters regarding the circumstances of giving birth. Instead, it must decide on the compatibility with Article 8 of the State ’ s interference in the present case on the basis of the fair-balance test described above (see Dubská and Krejzová, cited above, § 184).
79. The applicant in the present case wished to give birth at home with the assistance of a midwife. The Court accepts that as a consequence of the operation of the legislative provisions in force at the relevant time, she was put in a situation which had a serious impact on her freedom of choice: she was required either to give birth in a hospital, or, if she wished to give birth at home, to do so without the assistance of a midwife and, therefore, with the attendant risks that posed to herself and her baby. In the end, she gave birth at home with a midwife from abroad (see paragraph 9 above).
80. In that regard, the Court takes note of the Government ’ s argument that in the light of all the scientific findings known to them, and even though home delivery might be more pleasant for mothers-to-be, it still represented an option that was not as safe as a full hospital delivery. They noted that the Commission for Perinatal Medicine of the Ministry of Health was of the view that hospitals were the safest places for performing deliveries, providing the best guarantees for the preservation of the health and life of both mothers and newborns (see paragraph 58 above). In the case of Dubská and Krejzová the Court also noted that the risk for mothers and newborns was higher in the case of home births than in the case of births in maternity hospitals which were fully staffed and adequately equipped from a technical and material perspective, and that even if a pregnancy proceeded without any complications and could have therefore been considered a “low-risk” pregnancy, unexpected difficulties could arise during the delivery which would require immediate specialist medical intervention, such as a Caesarean section or special neonatal assistance. Moreover, the Court noted that a maternity hospital could provide all the necessary urgent medical care, whereas this would not be possible in the case of a home birth, even with a midwife attending (see Dubská and Krejzová, cited above, § 186).
81. The Court notes that the applicant could have opted to give birth in any maternity ward in Croatia which she considered likely to respect her wishes in principle (see paragraph 60 above). However, according to the applicant ’ s submissions based on her own experience (see paragraph 4 8 above), the wishes of mothers-to-be do not seem to be fully respected in maternity wards. Those remarks would seem to be confirmed in substance by the reports of the Committee on the Elimination of Discrimination against Women, the Parents in Action - Roda NGO and the Gender Equality Ombudsperson, which noted situations of a lack of respect for women ’ s wishes in maternity wards during childbirth (see paragraphs 17-19 above).
82. In the Court ’ s opinion, those concerns cannot be disregarded when assessing whether the authorities struck a fair balance between the competing interests at stake. At the same time, the Court acknowledges that in recent years according to the Government, various initiatives to improve the situation have been taken, notably by joining the Mother-Friendly Hospital Initiative in 2015 and starting a pilot programme in 2016 to comply with the guidelines set by the International Federation of Gynaecology and Obstetrics (see paragraph 60 above). On that background, the Court finds it appropriate to invite the Croatian authorities to make further progress in such matters by keeping the relevant legal provisions under constant review so as to ensure that they reflect medical and scientific developments while fully respecting women ’ s rights in the field of reproductive health, notably by ensuring adequate conditions for both patients and medical staff in maternity hospitals across the country (compare Dubská and Krejzová, cited above, § 189).
83. The applicant also complained that women deciding to give birth at home, as well as the midwives agreeing to assist them, had faced possible criminal sanctions for their actions. However, as already noted by the Court, there are no provisions under domestic law criminalising the acts of women who have decided to give birth in that way. Moreover, according to the Government, no woman has ever been punished for such actions (see paragraph 6 1 above).
84. The Court further notes that the Ministry of Health expressed a view in its letter of 11 May 2011 that since the question of home birth was not regulated by law medical assistance with home births would be considered quackery (see paragraph 12 above). As already noted by the Court, it does not find it necessary to assess the accuracy of the Ministry of Health ’ s conclusion that such medical assistance would constitute the criminal offence of quackery (see paragraph 36 above). Indeed, although it appears that several midwives suspected of having taken part in the birth had been questioned by the police, apparently no health professional, including the foreign midwife who assisted the applicant, has ever been prosecuted in a criminal case or sanctioned for assisting with a home birth (see paragraphs 15, 16 and 61 above).
85. Taking into account above considerations, the Court is of the view that by not passing legislation that would in practice allow women to be assisted by health professionals from the Croatian healthcare system when giving birth at home, the State did not overstep the wide margin of appreciation afforded to it on the matter (see paragraph 78 above). The Court reiterates that, while it would be possible for the respondent State to allow planned home births, it is not required to do so under the Convention as currently interpreted by the Court. There still remains a great disparity between the legal systems of the Contracting States on the matter (see Dubská and Krejzová, cited above, § 183), and the Court remains respectful of the gradual development of law in the sphere.
86. As to the applicant ’ s complaint that she and her child were denied postnatal care, allegedly a common situation faced by women in Croatia who decided to give birth at home, the Court firstly reiterates that in no circumstances should a child be deprived of his or her right of access to healthcare services on the grounds that he or she was born outside of a medical facility. The best interests of the child must be a primary consideration in all actions concerning children, whether undertaken by public or private social welfare institutions, courts of law, administrative authorities or legislative bodies (see Dubská and Krejzová, cited above, § 64).
87. In this respect, the Court notes that the applicant never reported the event of being denied postnatal care to any relevant authority. There is thus no document whatsoever to allow the Court to verify that allegation. The Court notes in that regard that under the relevant domestic law a doctor who unlawfully refused to provide medical assistance could be punished for a misdemeanour and ordered to pay a fine of between 5,000 and 10,000 Croatian kunas (see paragraph 36 above). Moreover, the refusal of medical assistance in an emergency situation constituted a criminal offence (see paragraph 37 above). Therefore, if the applicant and her child had initially indeed been refused postnatal care as she alleged and if she had reported the event the doctors involved could have been sanctioned. In any event, it was undisputed that the applicant and her child eventually did receive post-delivery medical care (see paragraph 10 above).
88. The Court further notes that the issue of the first medical examination of children born at home was a matter of discussion between the Ministry of Health and Parents in Action - Roda NGO. According to the Ministry of Health ’ s letter of 31 May 2012, situations in which doctors were faced with having to examine children born at home without there being any medical documentation were becoming more and more frequent. The ministry thus maintained that doctors were obliged to examine such children but were not allowed to register data they were not able to verify (see paragraph 14 above).
89. As to the applicant ’ s complaint that women giving birth at home experienced difficulties in registering their children in State registers as the relevant law obliged them to submit medical documents to prove their motherhood, the Court firstly notes that there is indeed such a requirement under the domestic law (see paragraphs 13, 30 and 34 above). However, the Court finds such a requirement understandable as it is clearly directed at avoiding possible abuses in situations where there is no official information on the birth of a child or its biological parents. As to the applicant ’ s particular situation, the Court notes that her child was born on 15 February 2012 and that she succeeded in registering the birth on 23 February 2012 (see paragraph 11 above).
90. In conclusion, and having regard to the particular circumstances of the present case, the Court is of the view that the interference with the applicant ’ s right to respect for her private life was not disproportionate.
91. Accordingly, there has been no violation of Article 8 of the Convention.
II. ALLEGED VIOLATION OF ARTICLE 13 OF THE CONVENTION
92. The applicant complained that as the matter of professional assistance with home births was not properly regulated she did not have at her disposal an effective domestic remedy for her complaint related to the violation of her right to respect for her private life. She relied on Article 13 of the Convention, which provides:
“Everyone whose rights and freedoms as set forth in [the] Convention are violated shall have an effective remedy before a national authority notwithstanding that the violation has been committed by persons acting in an official capacity.”
93. The Government reiterated their arguments submitted under Article 8 of the Convention.
94. The Court reiterates that Article 13 does not go so far as to guarantee a remedy allowing a Contracting State ’ s laws as such to be challenged before a national authority on the grounds of being contrary to the Convention (see, among other authorities, Vallianatos and Others v. Greece [GC], nos. 29381/09 and 32684/09, § 94, ECHR 2013 (extracts), and Roche v. the United Kingdom [GC], no. 32555/96, § 137, ECHR 2005-X). In the instant case, the applicant ’ s complaint under Article 13 is at odds with this principle. Consequently, this complaint is manifestly ill-founded and as such must be declared inadmissible in accordance with Article 35 §§ 3 (a) and 4 of the Convention.