A glimpse of childbirth in Bulgaria: time to ROAR

Dr. Tracey Cooper is a consultant midwife, who works in Lancashire, England. Tracey is probably the most courageous midwife I have ever met, her strength and courage fuelled by compassion.  

Tracey won a COST research grant from the European Union with Bulgarian midwife Yoanna Stancheva, at the Zebra Midwifery Practice (ZMP) in Bulgaria. The project involved Tracey's travel to Bulgaria to work with the practice for 10 days, to help improve the midwives' decision-making and confidence in providing quality antenatal care within the current legal framework. This research project represents a first attempt to describe and optimise midwifery competencies, as well as to define a strategy for moving towards midwifery-led care in the future. It is a component of a long-term commitment, which members of international midwifery alliances have made in order to improve the organisation of care in the country.

Tracey said: 'My observations are that Bulgarian midwives have very restricted competencies in comparison to other midwives in the EU, and that maternal and neonatal outcomes ranked Bulgaria low compared to the rest of the EU.  By observing the prenatal consultations taking place at the Zebra Midwives practice, I could assess their level of comfort when using essential midwifery skills, such as abdominal palpation, fetal auscultation with a Pinnard and a Doppler, blood and urine test reading, diet recommendations, etc. The midwives at the Zebra Midwifery practice had difficulties recognising these skills as solid clinical evidence for the woman and baby’s wellbeing. These results were congruent with the restrictive legislation and medicalised culture of birth prevalent in the country'.

Photo: Midwife Iona Nashkova learning new skills, with Tracey 

Photo: Midwife Iona Nashkova learning new skills, with Tracey 

The Zebra Midwifery Practice is the only registered midwifery practice in the country. It is a surprising fact that although midwives have been legally allowed to open midwifery practices since 2011, it took five years before the newly graduated midwives from Zebra were able to take advantage of this opportunity.

Midwives are not interested in opening their own practices because they are not allowed legally to provide the full spectrum of midwifery services required for basic antenatal care, such as prescribing tests and making clinical decisions. These elements of antenatal care are only within the obstetricians’ capacities even in physiological pregnancy and birth.

The ZMP provides severely restricted midwifery care by UK standards. Moreover, midwives cannot get contracts with the national insurance company, and women have to pay for this restricted version of midwifery care.

The number of registered midwives in Bulgaria is 5897. The majority of midwives are at a retirement age, average age of midwives is 52 years. A  large number leave the country for other places where they can practise autonomously and have opportunities for professional growth. The vast majority work in 2 places, having at least 2 jobs.

This is midwifery crisis as midwives are leaving, and many will come to a retirement age within the next 10 years. Because of this, action needs to be taken to make the profession attractive for midwives, so they want to stay and work in Bulgaria, and for midwives from other countries to want to work in Bulgaria, too. 

In the photograph below, Tracey attempts to influence decision making about the issues surrounding maternity care in Bulgaria, with the WHO, the British Embassy, the union and midwifery leaders, birth activists, women and their families at a Round Table meeting. The obstetricians union and the Department of Health were also invited, but did not attend. 

Tracey found during her short visit the following issues:

  • Pregnancy and birth viewed by current care providers as risky and a medical event for all women and not a normal life event.
  • Reliance on technology and not on midwifery care and relationship based skills - many interventions performed unnecessarily for no clinical reason:

 - during pregnancy - medication, scanning
 - during birth - enema, shave, fundal pressure, routine use of oxytocin and episiotomy.

Babies are separated from their mothers, and kept in a nursery. The mother only has access to her baby twice a day, for two 30 minute periods.  There are no guidelines for rooming in, and a three day stay following a normal birth is compulsory.

Photo: Nadezhda Chipeva

Photo: Nadezhda Chipeva

Tracey told me: 'Many women only have one child, and some I spoke to said this was because they felt they could not go through the childbirth experience again. Others were considering freebirthing at home alone, as they were too scared to go back to the hospital for birth.  Care is not based on evidence but routine, outdated practices'.

In Bulgaria, there are no unified, nationally applicable guidelines for quality midwifery care.

During antenatal care, midwives are not allowed to:
- prescribe routine urine and blood tests. This is basic care for pregnant women and midwives cannot prescribe the tests even though they are trained to do so and it is part of their competencies
- perform vaginal examinations or recognise onset and progress of labour using behavioural cues. By national law, midwives are not trained and allowed to perform vaginal examinations, which is a breach of the EU directives on midwives’ competencies;
- assess CTG monitoring;
- work outside hospitals and without supervision of obstetricians;
- make contracts with the Bulgarian national healthcare service which puts them at a disadvantaged position.

During birth, midwives are not allowed to:
- Make clinical decisions for physiological birth;
- Make vaginal exams to assess dilation in labour;
- Repair vaginal tears and episiotomy.

Although directive 1 of the national law describing the midwifery scope of practice allows midwives to assist birth with a cephalic presentation, the midwives’ role during birth is limited to supporting the perineum which is a completely technical detail at the end of birth and does not reflect the meaning of the phrase “assisting birth”.

Midwifery care during the postpartum period was practised until 20 years ago. Nowadays, postnatal care is not part of state sponsored maternity services. Even in Bulgaria, postpartum care has always been an essential element of midwifery work, but at the moment there is a troubling gap in the care for mothers and newborns. Midwives need to be able to offer breastfeeding support, to assess the mother’s physical and emotional recovery, as well as the newborn’s health. The national insurance company does not consider it an element of basic maternity care.

Women have to attend the hospital on their own when they are in labour, with no support persons. Babies are taken away from them following birth. The baby is kept in the nursery, the woman only has access twice a day for two 30 minute periods. This increases the potential for mental health issues, problems with breastfeeding and emotional attachment issues for woman and baby.

Tracey found the situation very disturbing. 'Women were extremely anxious, as told everything that can go wrong, with no reassurance during consultations with obstetricians. The intervention and the obstetrician being the lead care provider has not reduced intervention or helped mortality rates. The caesarean section rate is 42%, Perinatal mortality11/1000, compared to EU mean average 7.14/1000, Stillbirth 8%, compared to EU mean average 5.27%, Neonatal mortality 4.5%, compared to EU mean average 2.74%'.

A delivery in Bulgaria.  Photo: Nadezhda Chipeva 

A delivery in Bulgaria. Photo: Nadezhda Chipeva 

Tracey asked you to think about this: 

'Can you imagine being in labour, with no birth partner,  in a room full of people? You are in lithotomy and a midwife is lying across you, pushing on your fundus (abdomen) with all her weight, while a routine episiotomy is performed. Then, when your baby's head is born, an obstetrician pulls out the baby without a contraction. Your baby is taken away, and you can’t see him or her for at least two hours? This goes on all day every day! It has to stop!

We have to find some way of supporting our midwifery colleagues in Bulgaria to end this inhumane practice'.

I asked Tracey what we could do to help: 

'Be aware of the suffering both women and midwives endure in Bulgaria, and keep this highlighted on social media. We must try to persuade the government in Bulgaria to remove their law that birth is a medical emergency, and to recognise the value of midwifery led care to improve quality and therefore the future wellbeing of Bulgarian women and their families, and also reduce unnecessary costs'.

Yoana Stancheva and colleague IIona Neshkova are dynamic midwifery leaders, who are working hard to influence maternity care in their country.

Here is Yoana, speaking up at the Young Midwife Symposium at Women Deliver Global Conference, Copenhagen 2016

Yoana feels Tracey's visit to Bulgaria has been invaluable: 

'Tracey's visit provided the most comprehensive review of the state of midwifery in Bulgaria that an independent observer has ever done. What's more, Tracey was immensely involved in understanding the motives behind the system of maternity care that we have deemed "working" for us. These motives are difficult to comprehend for people who don't belong to the general culture of institutional responsibilities and personal involvement of caregivers with the concept of care. Tracey was committed to grasp it all, with patience and compassion which the system of abuse does not deserve. Her observations were like a large, inspiring breath of fresh air that promised hope for a hopeless situation.'

You can find Tracey Cooper on Twitter , IIona Neshkova on Twitter  and Yoana Stancheva on Facebook