After frequent questions about gynaecological examinations, keeping and terminating pregnancy in minors and doubts regarding when you need the consent of parents / guardians and when not, we bring this article taken from the Analysis of the situation and recommendations for dealing with cases of minor pregnancies and parenthood jointly created by Parents’ Association “Step by Step” and the UNICEF Office for Croatia.

As an introduction, it is necessary to point out that the relevant regulations in force in the Republic of Croatia, in the field of health care, the Health Care Act, the Medical Treatment Act, the Health Care Quality Act, the Patients’ Rights Protection Act and the Act on Health Measures for Exercising the Right to Free Decision-Making on Birth of Children.

The Patients’ Rights Protection Act is based on the principles of humanity and accessibility and protection of patients’ rights. The principle of humanity of protection of patients’ rights is achieved by ensuring respect for the patient as a human being, ensuring the right to physical and mental integrity of the patient, protection of the patient’s personality including respect for patient’s privacy, worldview, and moral and religious beliefs. The principle of accessibility implies equal possibility of protection of the rights of all patients in the territory of the Republic of Croatia. According to the provisions of the Patients’ Rights Protection Act, the patient expresses the acceptance of an individual diagnostic or therapeutic procedure by signing a consent form. For an unconscious patient, for a patient with a severe mental disorder and for an incapacitated or minor patient, the consent referred to in Article 16, paragraph 2 of this Act shall be signed by the patient’s legal representative, i.e. guardian.

If the interests of the patients referred to in paragraph 1 of this Article and their legal representatives, i.e. guardians are opposed, the healthcare professional is obliged to immediately inform the competent social welfare centre. 

The Act on Health Measures for Exercising the Right to Free Decision-Making on Birth of Children of 1978 is the only regulation that regulates the issue of pregnancy termination. This law recognizes the right of an individual to freely decide on the birth of children. This is a right that is not explicitly recognized by the Constitution of the Republic of Croatia as a constitutional right, however, since it is an important part of private life, Article 35 of the Constitution of the Republic of Croatia, which protects the privacy of citizens, is fully applicable in relation to situations related to pregnancy termination. The right guaranteed by the cited law is not absolute but is subject to restriction determined by the Act itself, and it is a matter of health protection. Pregnancy termination is defined by law as a medical procedure.

Apart from the Act mentioned above, the term medical procedure can be found only in the Criminal Code of the Republic of Croatia, in the legal description of the criminal offense of arbitrary treatment, while the Patients’ Rights Protection Act uses the terms diagnostic and therapeutic procedure, and the Act on Medical Fertilisation uses the term medical procedure, so that the terminology of the Act on Health Measures for Exercising the Right to Free Decision-Making on Birth of Children is not in line with the laws that have entered into force in the last few years. The Act contains provisions on pregnancy termination and on the procedure that precedes the medical procedure of pregnancy termination, and it begins with the request of a pregnant woman. 

In addition to a request for pregnancy termination submitted by a minor under the age of 16, the consent of a parent or a guardian with the consent of the guardianship authority (social welfare centre) is required. This means that minors over the age of 16 will not need consent, but the question is whether the provisions of this Act conflict with the provisions of the Patients’ Rights Protection Act, according to which the consent of a minor patient is required to accept a particular diagnostic or therapeutic procedure. Therefore, the question can justifiably be asked which of these legal provisions doctors will give priority to in practice, i.e. whether they will apply the Patients’ Rights Protection Act, as a law that later entered into force (lex posteriori), or the Act on Health Measures for Exercising the Right to Free Decision-Making on Birth of Children, which is a special act in relation to pregnancy termination (lex specialis). In such a situation, it would be difficult for a doctor to advise how to proceed, however, bearing in mind that the Family Act prescribes that parental care lasts until adulthood, it would certainly be more appropriate to apply the law that came into force later (Patients’ Rights Protection Act) and which prescribes consent in a more restrictive way. It should not be forgotten that the terminology of the two acts is not harmonized, and while one speaks of a medical procedure, the other speaks of a therapeutic procedure, which opens the door to further doubts. The implementing regulation to the Patients’ Rights Protection Act is the Ordinance on the consent form and the form of statement the refusal of an individual diagnostic or therapeutic procedure.

However, if a doctor acts in accordance with the provisions of the Patients’ Rights Protection Act, it is not excluded that in civil proceedings he/she could be liable for damages for violating the personal right to privacy of a minor who requested pregnancy termination. 

Experience from practice shows that the treatment in such cases is not completely uniform, and that a larger number of health care institutions require the consent of parents when it comes to pregnancy termination in minor patients. 

Consequently, the legal and institutional framework relating to minors’ pregnancies and parenthood needs to be improved as a matter of priority.

The rule is that pregnancy termination can be performed until the expiration of ten weeks from the day of conception, and after the expiration of ten weeks from the day of conception only with the approval of the commission, under the conditions and according to the procedure established by the Act. Experience from practice shows that often pregnancy in minor girls is determined after ten weeks from the day of conception. Late detection of pregnancy is mainly associated with insufficient information in young girls, non-recognition and denial of signs of pregnancy. In addition, girls sometimes hide the fact that they are pregnant and postpone the moment when they will inform the family.

If it is determined that ten weeks have elapsed from the day of conception or that pregnancy termination could seriously impair the woman’s health, the pregnant woman is referred to the commission of the first instance, and in the case of a minor who has reached 16 years of age, but did not marry, the parents or guardian of the minor will be notified about the referral of the minor to the commission of the first instance. Notification to parents in such situations will not affect the pregnant woman’s decision to terminate the pregnancy, as she can make her own decision at the age of sixteen, but it will certainly be interference in her intimate life and possibly have far-reaching consequences for her future relationship with the family.

Experience shows that in the moments after the discovery of pregnancy in underage girls, family relationships are disturbed the most, and in such cases, it is necessary to provide help and support that the family needs to overcome difficulties and responsibly accept the new situation.

The calendar-based or rhythmic method (the Knaus-Ogino method) is one of the natural methods of contraception (periodic abstinence) in which the fertile period is estimated according to the length of previous menstrual cycles and the time of ovulation. It has a high failure rate because the length of the next cycle is predicted based on the length of the menstrual cycle from the past. The calendar method calculates fertile – “dangerous days for pregnancy” and infertile – “safe” days between two menstruations. Sexual intercourse should be avoided during fertile days.

How to calculate fertile days?

A woman’s fertile period lasts 5 days before and 3 days after ovulation, which always occurs 14 days before the next menstruation. The time of ovulation is calculated by subtracting 14 days from the number of days of the menstrual cycle. Then, from that calculated day of ovulation, we subtract 5 days and add 3 days from the day of ovulation. Thus, the time of the fertile period or fertile days is obtained. During fertile days, sexual intercourse should be avoided because there is a high possibility of fertilization and conception. 

Calculation examples:

• If the menstrual cycle lasts 28 days, then subtract 14 from that number and get the day of ovulation = 14th day of the cycle (the 14th day from the beginning of menstruation). If ovulation is the 14th day of the cycle, then the fertile days will be from the 9th to the 17th day of the cycle. The other days in that cycle are infertile. 

28 – 14 = 14th day – OVULATION 

14 – 5 = 9th day (beginning of fertile days) 

14 + 3 = 17th day (end of fertile days)

• If the menstrual cycle lasts 30 days, then we subtract 14 days from that number and thus get the ovulation day = 16th day of the cycle (the 16th day from the beginning of menstruation). If ovulation is on the 16th day of the cycle, the fertile days will be from the 11th to the 19th day of the cycle. The other days in that cycle are infertile. 

30 – 14 = Day 16 – OVULATION 

16 – 5 = 11th day (beginning of fertile days) 

16 + 3 = 19th day (end of fertile days)

• If the cycles are unequal, then it is necessary to establish the duration of the shortest and longest cycle for the previous year. Then 18 is subtracted from the shortest cycle and 11 is subtracted from the longest cycle. Thus, a period of fertile days is obtained when one abstains from sexual intercourses.

Example:

If the cycles vary from 25 to 32 days, then 18 days are subtracted from the shortest cycle (25 days) and the 7th day is when fertile days begin. From the longest cycle (32 days), 11 days are subtracted and the 21st day of the cycle is when fertile days end. According to the calculation, sexual intercourse should be avoided during fertile days, which is from the 7th day of the cycle (calculated from the beginning of menstruation) to the 21st day of the cycle.

25 (shortest cycle) – 18 = 7th day (beginning of fertile days) 

32 (longest cycle) – 11 days = 21st day (end of fertile days)

See if you agree with any of the following statements:

• A person who experiences violence is often to blame for the violence to which he or she is exposed.
• Persuasion to have sex is a sign of love. 
• There is no true love without jealousy. 
• Men cannot be victims of sexual violence. 
• One slap can happen and is unlikely to happen again. 
• He / she will treat me differently than others.

These statements are WRONG BELIEFS that seek to justify violence.

 THE TRUTH IS:

• There is no justification for violence, the victim is never guilty for the violence experienced and the perpetrator is always responsible. 
• Persuasion to sexual intercourse is manipulation to realize one’s own desires. Love is expressed by respecting partner’s desires and personal boundaries. Sexual intercourse without the consent of another person is a criminal offense.
• A relationship between two people should be based on mutual respect, trust, and tenderness. Jealousy and controlling a partner are not an integral part of the relationship, but a reflection of insecurity, mistrust, and a desire to establish power and control over the other person. 
• Men can be victims of sexual violence. In these cases, the perpetrators are also mostly men. 
• A person who behaves violently in this way tries to gain power and control in the relationship, but in fact thus shows his / her inability to solve differently the problems he / she feels exist in the relationship. Therefore, it is very likely that such person will behave violently again in a situation where he / she does not know how to solve a certain problem. 
• A person who is violent towards others is unlikely to treat you differently. Violence is that person’s answer to problems (the only one that person knows) and it is very likely that such person will start using it to “solve” problems in your relationship as well.

Every child needs a model of acceptable behaviour in order to grow and develop. This means that parents need to instil family values ​​in their children, take on parental responsibility and set boundaries, i.e. say no when they consider it necessary.

Children learn the rules from infancy

Even an infant can notice parental reactions and draw conclusions regarding his/her own behaviour. Whether it is an infant, a small child, a pre-schooler or a schoolchild – children learn the rules from the experience they have with their parents day by day. 

Parents choose the rules for their children
In doing so, they can be guided by their own experiences or expert advice. Choosing rules is the first step in teaching them effectively. Neither too many nor too few rules are good. Wise choices are fair rules that respect a child’s personality but require respect for parents and other people. The rules, which are firm, reliable and predictable, do not vary on the emotional state of the parents and are appropriate to the age and developmental state of the child. In doing so, we must know what we must never say “no” to, and these are the basic children’s needs for food, clothing, footwear, health, sleep, love, and social relationships.

How to enforce the rules?
To begin with, the messages we send to the child should be formulated clearly instead of vaguely, positively instead of negatively. Pay attention to your child’s positive behaviour so that the child does not get your attention only when he or she is behaving inappropriately. If you criticize, always criticize child’s behaviour – never the child as a person. Encourage your child. Always point out exactly what you like about the child. Be consistent – establish family rules about sleeping, eating, watching TV and apply them consistently because your child needs to know where it stands. If you once allow your child to eat on the couch, and once you insist that it must sit at the table, the child will be confused and will not know where the boundaries are, what is allowed and what is not. In addition, your words should follow your deeds. Deeds that must not punish, rather set boundaries. Punishments have something arbitrary and hostile. However, your child can learn from the logical consequences. By doing so, you are sending your child a message that you love him/her and that he/she is important to you. That is why you cannot be indifferent towards how your child behaves but must offer the child the help to adopt the necessary rules. It is always better to determine incentives instead of announcing unpleasant consequences. Although the same has been said, the message is quite different. Incentives are not based on the child’s fear of parental punishment, but rather allow the child to take responsibility for his/her actions.

Avoid corporal punishment!
Remember to serve as an example to your own child. By corporal punishment, you teach your child that physical violence is acceptable if we are stronger. By doing so, you are indirectly teaching your child that he/she can also beat his/her younger siblings or other children in kindergarten. In addition, physical violence has a negative effect on a child’s self-esteem and can cause fear and a desire for revenge. Just imagine how you would feel if one of your loved ones, physically stronger than you, hit or beat you. Your child feels similarly: deeply hurt and humiliated. Thus, physical violence has a devastating effect on your relationship with your child, so it is completely inappropriate as an educational tool.

Sleep is a part of our lives. All living beings need sleep because in this way we rest both physically and mentally. Adult sleep is regulated by the internal body clock, which scientists call the biological clock or circadian rhythm. A child is not born with the circadian rhythm of an adult, its biological clock begins to form at the age of 6 to 9 weeks, and even sleep cycles are established after 3 to 6 months. The child gradually reaches a stage where it is mostly awake during the day and mostly asleep during the night. 

Babies go through the same sleep cycles as adults but spend more time in light sleep and have more frequent phases of brief awakenings. This sleep pattern is biologically conditioned and is important for your child’s growth and development.

Regular visits to a gynaecologist are important for every woman.

This is all the more important for adolescents because at the beginning of sexual activity, the exposure to the risks of sexually transmitted diseases and unplanned pregnancies is high, especially if they lack information on these topics.

Ideally, young people should see a gynaecologist before sexual activity to discuss contraception, sexually transmitted diseases, the menstrual cycle etc. However, since there are no ideal situations in life, it is recommended to visit a gynaecologist at least or no later than one year since starting sexual relations.

Adolescents often have a fear of the first gynaecological examination, but this is not necessarily an examination as such, but counselling on various topics, and through several visits to the clinic, the fear of a gynaecological examination disappears. The first examination, in addition to counselling, also includes an examination with gynaecological specula and taking a PAP smear. It is a swab that, in addition to signs of inflammation, also shows the possible presence of various bacteria and viruses, including HPV. This smear or test is done at least once a year. However, experience shows that people report to the doctor primarily when they have a health problem (temperature, pain, etc.) while regular, preventive examinations are often “skipped”. Regular visits to a doctor to prevent diseases are extremely important (for example, a check-up once a year, despite not experiencing any health problems at that time).