Waiting for Justice:
A System That Has Failed Women
Vera and her husband Kristijan were expecting their first child in 2023.
But the pregnancy did not go as planned. The baby was showing signs of Down syndrome, and Vera’s doctor informed her that a miscarriage was likely. If she was planning to have children in the future, she was advised to terminate the pregnancy.
She waited for weeks to be admitted into hospital. When her turn finally came, she started bleeding during the night. She asked the nurse what she should do.
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She told me: "There’s a toilet. On the left side, there are bedpans. Take a bedpan and go to the toilet as often as possible, then push hard. Make sure the fetus falls into the bedpan and not into the toilet bowl, because if it does, you’ll have to retrieve it yourself. Once you're done, bring the bedpan with the fetus to me so I can send it to pathology, and then I will take you to the operating room for the final procedure. Don’t worry about the bleeding—it’s completely normal. You’ll bleed, and that’s it."
Vera refused to do it. She said that when she threatened to report them, she was told, “I don’t know who you think you’ll report me to at 4 o’clock in the morning.”
According to Vera, they explained to her that this was a daily occurrence—women miscarry in the hospital rooms as well, but since she was sharing a room with two other pregnant women, she had to go to the toilet.
Still, Vera did not comply.
Eventually, they transferred her to the operating room. She was bleeding, soaked because her water had broken. She said that no one came to change her clothes or her bed linens when she complained about being cold.
She was alone when she delivered her stillborn child.
She remembers that Dr. Aleksandar Dobrosavljević was a great help—he changed her clothes and explained the next steps in the medical process.
After leaving the hospital, Vera canceled her health insurance card. She never went back to any state hospital.
Vera reported the inhumane treatment, neglect, and verbal abuse to the Ombudsman and the Ministry of Health. These complaints remain unresolved.
The Narodni Front hospital refused to give an interview to CINS journalists.
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I believe that for the money I’m paying, I should be treated as prescribed by law—nothing more. Instead, I was humiliated, abused, and suffered the worst experience possible for a woman who was supposed to become a mother for the first time. Unfortunately, it is what it is. To stop this kind of thing from happening again, I decided to speak out and report it.
Vera is one of four women who reported obstetric violence and shared their stories with us. None of these complaints have resulted in any punishment so far. Documents analyzed by CINS journalists show that this is the rule rather than the exception.
Obstetric violence includes physical and verbal abuse during pregnancy and immediately after childbirth, humiliation, forced or non-consensual medical procedures, violation of privacy and confidentiality, withholding informed consent and pain medications, refusing hospital admission, neglect during childbirth leading to life-threatening complications that could have been prevented, as well as holding mothers and babies in hospital due to their inability to pay medical fees.
The World Health Organization
When we talk about obstetric violence, we talk about how women are treated.
"We are talking about a fundamental right—the absolute prohibition of such abuse. Abuse refers to methods that subject you to unnecessary pain and suffering."
Obstetric violence is not recognized as a criminal offense.
When cases of obstetric violence reach prosecutors or courts, they are usually classified as medical malpractice, endangerment of health, or negligent professional conduct.
CINS journalists requested documents related to such cases from 108 courts and prosecutors’ offices, covering the period between 2018 and February 2024. We also requested information about cases under the criminal charge of abuse and torture for the same period, but found none.
We’ve identified cases related to gynecology and, with the help of Sanja Radivojević, analyzed those that clearly indicated inhumane treatment of patients, or obstetric violence.
There were 27 such cases.
In most of these cases, someone died – the baby, the mother, and in some instances, both.
Only one doctor was convicted.
He received a suspended sentence and was prohibited from working as a gynecologist in a private clinic for three years.
One of the women who sued the doctors is Maja Simić Simeunović from Belgrade. She says she made that decision while still in hospital, lying in the intensive care unit.
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I don't want his death to be in vain and for him to become just another statistic for some doctors at Front. Every time they’re delivering another baby, I just want those doctors and staff at Narodni Front to hear my name, pause, and think ‘Well, maybe I should do my job properly this time.’ That they don't act so nonchalantly.
Maja had felt uneasy throughout her pregnancy. She remembered her first delivery as difficult, and this time, the COVID-19 pandemic didn’t help. She was due to give birth in early 2022, expecting another baby boy.
Several acquaintances recommended Dr. Dejan Dimitrijević, and when she looked him up online, she found many positive reviews. She decided he would be her doctor. However, things did not go as smoothly as she had hoped.
She attempted to express her worries to him, outlining the reasons why she should have a C-section this time, but he ignored her. She recalls the doctor telling her that the baby wouldn’t be so big if she ate less.
She was past her due date, and was admitted to the hospital for labor induction. The process did not unfold as it should. The doctor called another medical resident to assist him.
She heard them say it had to be a male resident so he could press down on her stomach more forcefully while the doctor monitored the baby's condition.
Then, in the middle of labor, the doctor left – Maja says he told her his shift was over. The pain became unbearable. She couldn’t endure it any longer.
She underwent an emergency C-section.
When she woke up, she learned that her baby had died.
Dr. Dejan Dimitrijević told CINS that he had provided a detailed explanation of the situation to the relevant institutions after the patient’s complaint and that they had followed protocol.
"Everyone has the right to doubt and seek further justice; I do not dispute that. As far as my role and our part are concerned, that’s where the story ends. I wouldn’t comment any further—there are institutions for that."
Maja was one of the first women to publicly speak about her fight for justice.
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What shook me the most, and I haven't mentioned this until now: on February 3rd, one day before my discharge, I was discharged on February 4th. I saw some commotion in the intensive care unit; everyone was running around. I asked one of the nurses, ‘What’s going on? What’s all the fuss?’ She replied, ‘They’re collecting signatures today,’ because presidential elections were being held that year. And then you realize something—you’re there in labor, screaming in pain, and no one even looks at you. But when it’s time to collect signatures, they all in a big rush.
Besides speaking to the media about her case, she initiated two lawsuits—one criminal and one civil.
For months, she searched for forensic experts willing to review the medical documentation impartially and provide an independent opinion.
Most cases of obstetric violence analyzed by CINS show that expert medical assessments are not conducted.
"In most cases where we determined there was obstetric violence, no forensic examination of medical documentation was carried out, or the prosecution relied on findings provided by the health inspectorate."
When she exhausted all options in Serbia, Maja Simić Simeunović tried with experts from Slovenia, Austria, and Germany.
Months later, she received a positive response from an organization in England. The documentation is now before the prosecution.
In addition, she reported the case to the hospital’s patient rights advocate, the Ministry of Health’s inspectorate, and the Medical Chamber.
So far, no one has been held accountable.
Lawyers Ivana Soković Krsmanović, Marina Mijatović, and Jelena Stanković conducted a study on obstetric violence in Serbia in September 2022.
They invited women to come forward and report their experiences. Around 200 women responded.
Among their reports were insults, denial of epidural anesthesia or pain relief, and the administration of labor induction without their consent.
Last year, we asked women who had experienced obstetric violence to fill out a questionnaire on our website. Within one month, over a thousand women reached out to us. Read their stories HERE.
Soković Krsmanović says that they sent the report to all relevant institutions within the healthcare system. The Medical Chamber responded formally, stating that they generally oppose all violence and degrading behavior. The Ombudsman said that they were already acting on previous complaints regarding the issue. The others said nothing.
However, Soković Krsmanović later found out that after receiving their letter, the Ministry of Health sent inspections to 38 hospitals across Serbia.
Ivana Soković Krsmanović provided those records to us, and CINS requested additional reports from the Ministry to complete an overview of inspection controls from early 2019 to February 2024.
CINS's analysis shows that most inspections concluded with just two words: no violence.
The inspections were mainly conducted by reviewing documentation. The inspectors did not speak with women who were in the hospitals at the time.
In some cases, the conclusions in the reports were nearly identical, with only the hospital’s name changed.
There were instances where inspectors simply sent emails to check if everything was in order.
For example, during an inspection at a hospital in Priboj, an inspector sent an email requesting answers to several questions about the treatment of maternity patients. The hospital responded within two days, stating that everything was conducted in accordance with the law.
Ivana Soković Krsmanović believes that the inspections were not conducted properly.
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I see that the inspection was carried out so superficially that, in my opinion, it sends a clear message that they have no intention or desire to actually address this issue. And to make matters worse, it seems like a mockery—literally—of the victims of obstetric violence. It’s outright denial. The fact that 200, 300, or even 5,000 people say they have experienced obstetric violence is simply dismissed. Here’s the inspection report—nothing was found.
The Ministry of Health did not respond to our request for an interview.
Ivana Soković Krsmanović explains that a health inspector has broad authority when conducting an inspection—they have the right to take statements from patients, officials, healthcare workers (including nurses, midwives, and gynecologists), to inspect rooms, equipment, devices, and review medical documentation.
"Of course, no one will write in a report, ‘Yes, this doctor acted against legal regulations, used offensive language, insulted me, yelled, failed to provide help, or left me alone.’ But that’s precisely why they avoid speaking with women—because they would receive information that, for some reason, they do not want to deal with. There must be a conversation, and not just a formal one. These women must be involved in the inspection process so that we can obtain official and accurate data on how and to what extent gynecological-obstetric violence occurs."
Danka Mihajlović was expecting her first child in 2021. After undergoing in vitro fertilization, her pregnancy was progressing smoothly—until the very end. A few days past her due date, Danka was admitted to the Betanija maternity hospital in Novi Sad due to bleeding. She said that initially she was told she would deliver immediately, but because the hospital was overcrowded, doctors decided to postpone labor until the next day during the first shift, while monitoring her condition overnight.
But the night brought complications.
She started bleeding again, and the CTG machine indicated that her baby's heart rate was dropping—something she only learned the latter from her discharge papers. The doctors opted for an emergency C-section, but complications later led to her son's transfer to a children's hospital.
Less than three days later, he passed away.
More than three years have passed, and Danka still does not know exactly what happened.
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As a patient, I expect to have the right not just to access my medical records, but to be informed about what happened to me and my child. When my baby entered that institution, that building—it was alive. Everyone kept assuring me that everything was fine. And then, two hours later, it was a disaster, and no one felt it necessary to tell me what happened, for what reasons, and whether it could have been prevented.
The Betanija maternity hospital declined to be interviewed by CINS journalists.
Danka Mihajlović sought answers from institutions. Shortly after being discharged, she contacted the Ministry of Health's inspection department, requesting both internal and external reviews of the hospital’s practices. At home, she kept replaying the events in her mind, feeling a deep sense of injustice.
In early November 2021, she received the internal commission’s report from Betanija, stating that there had been no misconduct. She says she had spoken with other women who had reported similar cases and that she had been expecting this outcome. Still, it wasn’t easy to accept.
"I felt humiliated, completely ignored. It was as if they were writing about someone else."
With her lawyer, she appealed the internal commission’s findings, highlighting several possible errors and requesting an external review—one conducted by doctors outside of Betanija.
The result was the same: no misconduct.
CINS journalists also obtained other reports from the Ministry following inspections conducted from early 2019 to February 2024.
The documentation contains only a small number of cases where reports explicitly mention women pointing out instances of obstetric violence. For example, in the inspection report on Betanija following a complaint by Danka Mihajlović, there is no indication that she reported neglect or that she signed the consent for transferring her child to the hospital only after the transfer had already taken place.
When inspecting a hospital, the Ministry can request both internal and external reviews. In the first case, a commission is formed within the hospital, while in the second, the Ministry assembles an expert commission. These commissions have almost never found any issues.
In addition, in over 100 inspections, routine checks were conducted to determine how a baby died during or shortly after birth. However, inspectors did not interview the women who had lost their children; they only reviewed hospital documentation. These inspections were repeated for months, primarily in the Nišava District.
Of the 49 reports analyzed that indicated obstetric violence, only one criminal complaint was filed—against a nurse who livestreamed a childbirth on TikTok.
In addition to prosecutors, courts, and the Ministry of Health, CINS journalists also sought data on reports of obstetric violence from the Medical Chamber and the Ombudsman. By the time this article was published, these institutions had not provided any information, prompting an appeal to the Commissioner for Information of Public Importance.
Katja Dragojlović Karović is one of the women who reported her case, among others, to the Medical Chamber. She complained that she was denied pain relief, that procedures were performed on her without anesthesia, that she was neglected, and that when complications arose during labor, the blame was placed on her.
She recalls feeling emotionally distressed upon returning home from the maternity ward, which affected her family, who didn’t know how to help her.
“We talked about it, and I think my mom suggested, ‘Maybe we should send a complaint letter or just reach out to someone.’ Then we spent a few days deliberating on where to send it and whether anyone would even listen to us.”
Her mother took the task upon herself because Katja was not in a condition to do so at the time.
Nearly eight years later, she shared her story with CINS.
Katja had planned to give birth at Dragiša Mišović Hospital, based on a friend’s positive experience. She had attended check-ups there and had chosen a doctor. However, when her water broke and labor began, she was told at the hospital’s reception that there was no available space and was redirected to Narodni Front Hospital.
She says that’s where her problems continued.
According to her, she was given labor-inducing drugs without her knowledge, left alone in a room to push, denied the epidural she had requested, and was attended to only when the baby became stuck in the birth canal.
At that point, she says, the Kristeller maneuver was performed, and the baby was delivered using a vacuum extraction device.
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I remember that vacuum being so painful, I mean, the instrument itself. When they pulled the baby out, I saw its head was completely elongated, and I started crying. I didn’t know if that was normal. Later, I learned that it is—because of the vacuum, their skulls get stretched like that—but at that moment, my baby looked like an alien, and it wasn’t crying.
After the delivery, she says, she underwent stitching for an episiotomy wound and other necessary procedures—all without anesthesia.
She told CINS that the pain was excruciating and that she heard a sentence that would stay with her until today.
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The doctor who was stitching me up—I could only see his head—while the tall doctor stood beside him. I said, "Can you please tell me how much longer this will take? I can't take this pain any longer. I just can't, it hurts so much." And that tall doctor told me, "Why are you complaining? You have the best plastic surgeon—he’ll fix you up beautifully." At that moment, I couldn't care less whether he was a plastic surgeon or how he would "fix" me—I just wanted the agony to stop. Then he said, "Besides, since you didn’t want to help your baby be born, now you just have to be quiet and take it." It felt like a slap in the face.
She never returned to Narodni Front Hospital. She says that she only once went down the street where the hospital is located, which was enough to make her feel sick.
Her mother reached out to the hospital on her behalf, as well as to the doctor from Dragiša Mišović Hospital who was supposed to deliver her baby and to the Medical Chamber. Only the Chamber responded, stating that they couldn’t do anything without names and witnesses. Katja says that two doctors’ stamps appear on her discharge papers, but she never saw them during her hospital stay, so she had no way of responding to that.
Attorney Ivana Soković Krsmanović explains that doctors, nurses, and midwives must introduce themselves to the patients and that the names of everyone involved in the delivery must be documented.
In the meantime, she completed training to become a birth doula. She did it to heal from her trauma, to understand what had happened to her, and to help other women have a better childbirth experience.
The stories of these four women reveal that cases of obstetric violence remain unexamined or unpunished.
Many women never even report what happened to them.
More than 1,100 women shared their negative experiences in maternity wards with CINS journalists. Out of those, only 33 reported them to the authorities.
Most women choose not to report such incidents due to a lack of information, a sense of powerlessness, distrust in institutions, fear, and the trauma they endured.
Those who did report had various reasons for doing so.
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Because my child is dead.
Biljana, Šabac
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If they had done their job properly, both my babies would be alive. I waited fifteen years to become a mother. Twice, I left the hospital empty-handed. (...) I don’t want any woman to go through what I went through—the pain that lasts a lifetime—or for hospital staff to treat patients like we’re cattle.
Vesna, Beograd
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Because I am a nurse, and it is shameful for anyone to treat a patient this way. I begged for help for five days, and all I received was neglect and an casual approach to my problem.
Milica, Sremska Mitrovica
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I think it’s time for this society’s attitude toward women to change.
Valentina, Beograd
Sanja Radivojević believes the key issue is that doctors are not informed about patients’ rights or their own legal and financial responsibilities. However, she says that this will have to change.
"I said they can’t ignore the fact that women will not stay silent. These are new women, these are young generations—I keep saying that."
At the beginning of 2024, a woman named Marica Mihajlović accused a doctor from Sremska Mitrovica of causing her baby’s death, as well as of verbal and physical abuse during childbirth.
Her case sparked an outpouring of reactions.
Thousands of women shared their experiences of obstetric violence on social media, and protests were held in Belgrade, Vranje, and Sremska Mitrovica. The doctor was taken into custody.
At the end of last year, the Higher Public Prosecutor’s Office filed an indictment against him, accusing him not only of medical negligence but also of abuse and torture of the mother, as stated in the indictment. The case is still ongoing.
In January, media outlets reported that a doctor from Zaječar was convicted in the first-instance court for the death of Bobana Momčilović Veličković, a national shooting champion. He was sentenced to four years in prison for gross medical negligence resulting in death. He was also banned from practicing medicine for five years. The verdict is not yet final.
The women we spoke to have since given birth again.
In the absence of systemic solutions, some "solved" the problem by giving birth in private clinics. Katja even took out a loan for her third delivery.
Although this does not guarantee a complication-free birth, they all agree that the treatment they received was incomparably better.
Shortly after speaking with us, Vera gave birth to her first child, a daughter. The same doctor from the public hospital who had previously helped her also oversaw her pregnancy this time. She says his attitude toward her was the same in both facilities.
Everything else, however, was much better.
CINS journalists investigated how institutions respond to reports of obstetric violence. We requested data from the Ministry of Health regarding inspections in gynecological and obstetric facilities from 2019 to February 2024. In addition, we collected documentation from over 108 courts and prosecutor’s offices on cases related to criminal offenses such as negligent medical care, failure to provide medical assistance, serious offenses against health, and abuse and torture from 2018 to February 2024. We focused on cases related to gynecology and, with the help of Sanja Radivojević from the Belgrade Center for Human Rights, analyzed those indicating inhumane treatment of female patients. We also requested information from the Ombudsman and the Medical Chamber, but as of publication, we had not received a response, so we filed a complaint with the Commissioner for Information of Public Importance.
Journalists: Teodora Ćurčić, Dina Đorđević
Editor: Vladimir Kostić
Illustrations and photographs: Zoran Miodrag, Envato, Leonardo.ai, Media Center Belgrade
Infographics and page design: Teodora Ćurčić, Zoran Miodrag
Production: Center for Investigative Journalism of Serbia (CINS)
February 2025.
Related
Stories from the maternity ward: Women who broke the silence
Last year, we asked women who had experienced obstetric violence to fill out a questionnaire on our website. Within one month, over a thousand women reached out to us. These are their stories.
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