TrustHLT/LaCour huggingface dataset:
GR1 (Government): But the very complex nature of the case, and in particular its health care policy implications, call for a wide margin of appreciation.
GR1 (Government): And let me now introduce Dr. Velebil,
GR1 (Government): one of the leading Czech experts in obstetrics, who will briefly present to you the medical reasons for the existing legal framework.
GR2 (Government): Mr. President, Honorable Judges, thank you for the word.
GR2 (Government): At the beginning, I would like to say that I'm sincerely convinced that the vast majority of pregnancies and deliveries are natural processes without any need for medical intervention.
GR2 (Government): I strongly believe that the interventions should be based on the need to protect the health of the babies and mothers.
GR2 (Government): And I also am – I consider it's very important to adhere to the patient's rights, especially to the right to respectful care and the right to choose a wide variety of circumstances at birth.
GR2 (Government): These are also some of the key priorities of the Czech OB-GYN Society and the principles which I teach my medical students and midwives.
GR2 (Government): In the previous presentation, we've heard that the natural process of birth could turn to a complicated one.
GR2 (Government): And assistance of a midwife at home birth may be insufficient.
GR2 (Government): Assistance of any health care provider, including the most experienced and most competent midwife or obstetrician, may be insufficient simply because that environment is insufficient to deal with all possible complications.
GR2 (Government): In life-threatening situations, threatening either or both the baby, the mother, the approximately adequately equipped environment, and availability of further qualified health personnel could make a difference between death and life.
GR2 (Government): The imperative requirement of a safe environment cannot be downplayed by the thorough medical checks throughout the pregnancy, by the excellent screening of all possible risk factors, simply because there are some emergency situations which they have no prior identifiable risk.
GR2 (Government): And those cases, they do occur.
GR2 (Government): And if you do not react immediately, you have no chance to protect life.
GR2 (Government): Contrary to some of the previous information, there is recent international research which is pointing out some risks related to home birth, regardless the attendant.
GR2 (Government): The government indeed submitted this research to the court.
GR2 (Government): When sudden abruption of oxygen supply to the fetus occur during labor, you have just few minutes to save life.
GR2 (Government): You don't have 10 or 15 or 20.
GR2 (Government): You have just few minutes to deal with that.
GR2 (Government): If profuse bleeding occurs during labor or shortly after that, when the baby was born, you may lose the mother, the baby, or both.
GR2 (Government): If the health status of a newborn changes shortly after normal birth, the appropriate measures must be taken immediately without a delay to minimize possible health consequences.
GR2 (Government): Such actions require not only presence of competent people, but it requires also, in quotes, competent environment to be able to exercise that competence.
GR2 (Government): Any unnecessary delay in such situations might have devastating health consequences.
GR2 (Government): Ability to provide health care in properly equipped environment, and therefore safer environment, in my opinion, is an achievement of particular society and comes from many resources, including organization, structure, content of care, together with economic tools to ensure the sustainability of the system and further improvements.
GR2 (Government): The Czech Republic has an extensive network of obstetrical facilities with excellent system of perinatal transport and referral system.
GR2 (Government): However, any accredited place of delivery must ensure timely help and quick referral, compliance with the requirements for the technical and material equipment and personnel requirements for safe provision of care.
GR2 (Government): They're postulated by the Czech Professional Society and agreed on by the Czech Medical Chamber and Czech Ministry of Health.
GR2 (Government): The repeated evaluation of the places of delivery is crucial and regularly evaluated, and this systematic approach clearly shows that it is productive and the Czech Republic belongs to countries with the best perinatal results in the world.
GR2 (Government): Let me to say that midwives are working closely and successfully with us obstetricians.
GR2 (Government): They are absolutely necessary and indispensable part of our healthcare system and our achievements would not be such as they are.
GR2 (Government): Without them, we could not really move things forward to the current achievements.
GR2 (Government): For example, in our hospital, midwives are independently attending physiological deliveries.
GR2 (Government): Part of our outpatient services is solely run by midwives themselves.
GR2 (Government): At the conclusion, I would like to say while considering the state's responsibilities and obligations to regulate certain aspects of private lives in many other fields to protect health and life of a person, we always should keep in mind that in case of birth, we safeguard at least two people at one time.
GR2 (Government): Thank you very much for attention.
Guido Raimondi (JudgeP): Thank you very much, Dr. Velebil.
Guido Raimondi (JudgeP): Now I turn towards my colleagues in order to know whether they wish to ask questions to the parties.
Guido Raimondi (JudgeP): And I see Judge Laffranque, please.
Julia Laffranque (Judge): I have a question for both parties, for the applicants and the government.
Julia Laffranque (Judge): And in the gender judgment, in paragraph 96, the court noted, thus a situation such as the one in the Czech Republic where medical professionals are not allowed to assist mothers who wish to give birth at home and where no specialized emergency aid is available may be said to increase rather than reduce the risk to life and health of the mother and newborn.
Julia Laffranque (Judge): And I would like the parties to comment on this, taking into account what we have heard, that the state has said that the standard and quality of healthcare is very important and the protection of life and health of mother and child as well.
Julia Laffranque (Judge): And on the other hand, that the applicants have in their observations and comments repeatedly questioned the absence of the regulatory impact assessment prior to the adoption of the relevant degrees in the Czech Republic.
Julia Laffranque (Judge): Maybe you could give us some more information about any statistics or research as to the cases of home birth without assistance or with unauthorized assistance in the Czech Republic and about the rate of complications that have occurred to have.
Julia Laffranque (Judge): It would be very fruitful for the answering of this question.
Julia Laffranque (Judge): Thank you very much. Thank you.
Guido Raimondi (JudgeP): Thank you very much Judge Laffranque.
Guido Raimondi (JudgeP): Your judge, Pardalos, please.
Kristina Pardalos (Judge): I have first a question for the applicants.
Kristina Pardalos (Judge): I would like to know that if there was an option to give birth in a home birth center, would this be an acceptable alternative for the applicant not to deliver at home?
Kristina Pardalos (Judge): Or even if the home birth center exists in practice, will they choose in any way to give birth at home?
Kristina Pardalos (Judge): And I have another question for both parties.
Kristina Pardalos (Judge): If you can describe a little bit more in detail the administrative procedure for issuing a technical license to a midwife or midwives who will create a home birth center, which authorities are involved in the issuing of the technical license, which are the administrative procedures?
Kristina Pardalos (Judge): Of course, the time to take in consideration is the respective time when the applicants gave birth.
Guido Raimondi (JudgeP): Thank you very much, Judge Pardalos.
Guido Raimondi (JudgeP): If there are no more questions, the court now will withdraw, and the hearing will be resumed at, say, 20 to 11.
Guido Raimondi (JudgeP): The hearing is resumed and I give the floor to Mrs. Candigliota.
AP2 (Applicant): Mr. President, if I may.
AP2 (Applicant): We decided as discussed to split our speech into two parts, one devoted to scientific issues, which Professor Janssen will answer in like five minutes, and then me, myself, will follow.
AP1 (Applicant): Mr. President, Honorable Judges, I'm a perinatal epidemiologist.
AP1 (Applicant): I was contracted by the Ministry of Health in the province of British Columbia, Canada in 1998 to evaluate the implementation and safety of planned home birth with regulated midwives compared to planned hospital birth and to make recommendations for the integration of midwifery as an independent profession under our Provincial Health Professions Act, including the provision of home birth.
AP1 (Applicant): Since then, I have published a number of studies of outcomes of planned home birth compared to planned hospital birth conducted by regulated midwives.
AP1 (Applicant): My studies have shown equivalent rates of perinatal mortality and morbidity and reduced rates of obstetrical interventions.
AP1 (Applicant): And this work has been supported in the international literature in the UK and the Netherlands.
AP1 (Applicant): While rates of transport from home birth to hospital overall have been about 15%, the rates of transport for emergency reasons range from about 1 to 3%.
AP1 (Applicant): The initial management of emergencies is the same at home as in hospital and involves the administration of intravenous fluids and medications and oxygens and is managed safely by our midwives while awaiting transport and during transport.
AP1 (Applicant): They manage the care in the ambulance and they carry extensive equipment with them to the home birth, which they also bring with them in the ambulance.
AP1 (Applicant): The equipment for home birth has been standardized across many countries in the world.
AP1 (Applicant): It's also true that even in hospital births, there's not a guarantee of immediate surgical intervention should it be needed.
AP1 (Applicant): And thus far in the international literature, having planned hospital births has not been a guarantee of reduced mortality and morbidity for low-risk healthy women.
AP1 (Applicant): In our experience, the implementation of planned home birth with regulated midwives has not incurred excess costs.
AP1 (Applicant): Rather, it requires implementation of communication protocols.
AP1 (Applicant): Our midwives inform the hospital when a planned home birth is beginning and when it has ended.
AP1 (Applicant): They have designated persons to whom they communicate with at the hospital to inform them of the progress of the labor and whether transport will be needed and if so, the care that will be required on admission to hospital.
AP1 (Applicant): We have recently conducted an extensive economic analysis of home birth published in 2015 in the peer-reviewed literature.
AP1 (Applicant): And our study demonstrated a cost savings of 50% to the healthcare system over the course of labor and birth and the first year of life for the newborn and a savings of 40% to the healthcare system over the course of labor and birth and the first eight weeks after birth for the mother.
AP1 (Applicant): These studies are important because if there was a hidden cost of home birth in terms of the baby's health, for example, a brain injury that showed up later during the first year of life, we would see this in our economic analysis in our costs and we haven't seen that.
AP1 (Applicant): In summary, our work has shown that planned home birth conducted by regulated midwives who are well integrated into the healthcare system is associated with equivalent rates of perinatal mortality and morbidity and with significant cost savings to the healthcare system and this work has been supported in the international literature.
Guido Raimondi (JudgeP): Thank you very much Dr. Janssen.
Guido Raimondi (JudgeP): Now Mrs. Candigliota.
Guido Raimondi (JudgeP): No, yes, please.
Guido Raimondi (JudgeP): As you prefer.
Guido Raimondi (JudgeP): Mr. Hořejší.
AP2 (Applicant): Mr. President, Honorable Members of the Court,
AP2 (Applicant): there are two groups of issues I will address in my speech.
AP2 (Applicant): There are, first, the questions to the additional queries of the Court, and there are also some matters within the government speech which I would like to address.
AP2 (Applicant): So, first, I will focus on answering the questions from the Court.
AP2 (Applicant): The first question concerning Section 96 of the Chamber Judgment, actually there were different priorities coming into play when assessing a fair balance between private rights and public interests, with a reference to some prerequisites.
AP2 (Applicant): Actually, there are three prerequisites which justify home birth as a viable alternative, and that is the existence of a low-risk mother, which is undisputed between the parties.
AP2 (Applicant): There is a second prerequisite of qualified midwife.
AP2 (Applicant): There is no dispute about this at all, as both parties are in concert that basically there are 3,000 to 4,000 qualified midwives already.
AP2 (Applicant): And there was the last prerequisite that related to emergency care assistance, due to inexistence of which the Chamber decided as it did.
AP2 (Applicant): I have to point out that the way that these questions were answered by the judgment, the Chamber judgment, is sort of tautological, because the Chamber did not answer the question whether the legislation that creates the impossibility of one of the condition precedent to be met is to be the issue, but they focused on the situation upon the implementation of the question.
AP2 (Applicant): So basically the merit of the case was effectively avoided.
AP2 (Applicant): So that's for answer to this question.
AP2 (Applicant): It's right also on the statistics on home birth in Czech Republic.
AP2 (Applicant): It has been repeatedly pointed out by both of the applicants that it is the state who does not have and who hasn't had any statistics on home births at all.
AP2 (Applicant): The government said today that it's 200 to 250 home births at all, while from the part of the midwives who are still carrying out attendances to home births, despite all the risks of being fined by the government, they still report over 1,000 home births per year, which represent 1%.
AP2 (Applicant): One may expect that if this option was fully legal, then the number of women who would use this option would actually be quite the same as in the surrounding countries.
AP2 (Applicant): Let's say in Germany this number runs about 2 to 3%, in Austria it's about 3 or 4%.
AP2 (Applicant): There was a second question, if there was a viable option of a birth center, if the applicants would opt for it.
AP2 (Applicant): The question is no, they wouldn't.
AP2 (Applicant): It's still the preference of a home birth being assisted by a qualified personnel, apparently having some backup options in case of sudden emergencies, which they would prefer, but it's still the option, it's still what they consider themselves to be the safest place and the safest option both for them and their children.
AP2 (Applicant): Apparently, if there was an option of a birth center, then it would be the birth center that we preferred against the hospital, which was evidence to evidence a great amount of obstetric violence.
AP2 (Applicant): I will use some words concerning the regulation of birth centers in the Czech Republic.
AP2 (Applicant): First of all, I would like to point out to our previous submissions concerning the secondary legislation, which points out the particular bottlenecks for this regulation.
AP2 (Applicant): In order to register a birth center in the Czech Republic, actually two prerequisites must be met.
AP2 (Applicant): One is that the birth center is run by someone who is qualified to provide this type of medical services, i.e. it must be a qualified midwife.
AP2 (Applicant): There are about 4,000 qualified midwives already in the Czech Republic.
AP2 (Applicant): However, there is a second condition, and that's, let's say, a technical license, which is to confirm that the spot of birth, the birth center premises as such, are the requirements which are imposed by the secondary legislation.
AP2 (Applicant): And they are technical prerequisites, and they are personal prerequisites.
AP2 (Applicant): As far as the technical ones, it is merely the criterion of 15 minutes' distance from a hospital, so to say, or upper level of care in case of emergency.
AP2 (Applicant): So it's the proximity to a higher level of care which matters.
AP2 (Applicant): In fact, it's fairly disturbing for both the applicants to find out from the last government submissions that after nearly five years of not regulating the interpretation of this 15-minute distance, after five years of interpreting this to be the effective ban for creating birth centers, shortening the distance to cover not only to door-to-door distance, but also then all the processes that happen within the hospital.
AP2 (Applicant): This has been confirmed judicially, and we have pointed it out in our submissions.
AP2 (Applicant): Now, after five years, after three days after the government's received the court's particular questions on this topic, at this point, the government comes up with a completely different interpretation, saying that the 15 minutes is actually the door-to-door distance.
AP2 (Applicant): I will not judge how purposeful this is.
AP2 (Applicant): This is up to you.
AP2 (Applicant): They are just bare facts.
AP2 (Applicant): I will also speak about the personal requirements, which is the second pillar for the inability to reach for the technical legislation.
AP2 (Applicant): Actually, there is a decree which the government omitted from their submission.
AP2 (Applicant): It's decree of Ministry of Health, number 99-2012.
AP2 (Applicant): We referred it to in our submissions.
AP2 (Applicant): And it requires a physical presence of a gynecologist and an obstetrician within five minutes on the spot.
AP2 (Applicant): You may see from the top of your head how incompatible these requirements are.
AP2 (Applicant): You cannot have, according to bar regulation of the Czech Medical Bar, who considers only an operation hall, a fully equipped operation hall, to be the only place where a lax artist principle may be practiced in childbirth.
AP2 (Applicant): You do not have it in birth centers, and you are not required to have it by the secondary legislation.
AP2 (Applicant): So actually, you cannot have a single medic, a single physician, who is a member of the Czech Medical Bar, to assist there.
AP2 (Applicant): So effectively, birth centers cannot be operated in the Czech Republic, and they can't be registered at all.
AP2 (Applicant): There is also a question of whether midwives may assist in hospitals to...
Guido Raimondi (JudgeP): If you want to leave some minutes to Mrs. Candigliota,
Guido Raimondi (JudgeP): you should come to a conclusion, please.
AP2 (Applicant): Okay, I will make one last conclusion.
AP2 (Applicant): That actually, this is not an option.
AP2 (Applicant): We have heard that midwives usually lead childbirth in hospitals.
AP2 (Applicant): However, the Czech Statistic Bureau says that this is not more than 20%, and it's always upon an indication and supervision of a physician, because there is a law saying that otherwise, this care wouldn't be paid by the public health insurance scheme.
AP2 (Applicant): Thank you for your time.
AP3 (Applicant): I would like to comment only the positive aspects, positive obligations in this case.
AP3 (Applicant): We don't think that this case concerns positive obligations of the state.
AP3 (Applicant): The main aspects are negative because we have qualified and registered midwives in the Czech Republic, and they have qualifications according to the EU legislations.
AP3 (Applicant): And on the other hand, we have women who demand their service.
AP3 (Applicant): So I think that it is only a civil relationship between the midwife and the woman.
AP3 (Applicant): And we don't need any service from the state.
AP3 (Applicant): So it's the question of negative obligations of the state.
AP3 (Applicant): And the only positive obligation is to ensure a legal framework to secure the possibility to meet the demand of women and offer of midwives.
Guido Raimondi (JudgeP): Thank you very much, Mr. Candigliota. I call now Mr. Schorm.
GR1 (Government): Well, I will speak first, and then I will ask you to give one more floor to Dr. Bellabile.
GR1 (Government): Well, there was a question by Judge Pardalos about administrative proceedings in order to get a license.
GR1 (Government): Well, this is an administrative proceeding based on a request, and you have to fulfill, obviously, the legal obligations.
GR1 (Government): And, for example, to document that you have the necessary equipment, et cetera.
GR1 (Government): Five years ago, there was a difference that the law thought of a local, how to say, check whether these conditions are fulfilled.
GR1 (Government): Now this is not required, so the procedure is somewhat easier.
GR1 (Government): Normally, you have to ask the regional authority.
GR1 (Government): Then there is a possibility of appeal to the Ministry of Health and then possibly, because it's a matter of right under administrative law, then you could lodge an administrative action with the administrative court.
GR1 (Government): There was no real request for running a Bell Center.
GR1 (Government): Therefore, there is no what we call application practice, nor an established interpretation even of the 15-minute condition.
GR1 (Government): As far as the so-called on-purpose reaction by the Ministry of Health, well, it was in reaction to a request for interpretation of the law, and the Minister of Health made it clear how this should be interpreted.
GR1 (Government): He did mention all the necessary secondary legislation in our written submission, so I would like to raise my voice against saying that we have been hiding something.
GR1 (Government): As far as the so-called labor artist approach for having an operation hall or a hall to carry out surgery, the applicants say obstetric surgery room.
GR1 (Government): Well, we think this is an inaccurate translation of the words porognizale, which look like birthing room, then obstetric surgery room.
GR1 (Government): Then there was a question about statistics by Judge LaFranca.
GR1 (Government): We saw some 20 planned home births.
GR1 (Government): Out of these 250 births carried out outside health care facilities.
GR1 (Government): We mentioned that in our speech, so I refer to it.
GR1 (Government): We don't have any information about having some 1,000 births outside health care facilities.
GR1 (Government): So there are some statistics available to the state.
GR1 (Government): I would also like to highlight what I've already said, that the system sends a clear signal to women that home birth is less safe, and that is also why there is only a few women in the Czech Republic giving birth to their children at home.
GR1 (Government): As far as paragraph 2696 of the Chamber Judgment, I would like to refer to Annex 5 to our memorial to the Grand Chamber.
GR1 (Government): And as far as the emergency arrival and departure is concerned, we have to think that if the legislation in case of a general emergency or ambulance foresees a 20-minute time limit, this means that the emergency, the ambulance has to come in 20 minutes, then it has to go.
GR1 (Government): So it means that it's a much longer period.
GR1 (Government): As far as the European Union legislation, it bears on qualifications of midwives, not about the way births or deliveries are carried out in the member states.
GR1 (Government): There is no consensus, there is no regulation, harmonization of the way deliveries are carried out.