In the first days after the birth of the child, especially with the first birth, mothers have many questions about breastfeeding, bathing and the overall regimen of the baby. They doubt how to act in one or another situation and more than ever they need competent advice and support. To help mothers during this period, many countries have home patronage programs, in which nurses and midwives visit them at home and give them valuable guidance on proper care for the newborn.
Over the years, there have been various programs for similar home patronage in our country, both of non-governmental organizations and with state and European funding, but in general there is no established sustainable model of such care. From June 2022 the service “A visit to provide health care for a newborn up to 6 months after discharge from the medical facility” is financed by the Health Insurance Fund.
However, only 2 home visits in the first 6 months, and the NHIF pays BGN 14 per visit. Apart from the low pay, this service is hardly performed because of the absurd bureaucratic procedure for performing it. The reason is that The NHIF does not directly contract with nurses and midwivesto go to the homes of newborns and consult the mothers.
NHIF contracts only with general practitioners, who in turn can employ a nurse or midwife.
The so-called NHIF-funded service remains almost entirely on paper. As a result, in 2022, the NHIF concluded contracts with only three jeeps for this service in Blagoevgrad, Montana and Plovdiv, and 81 visits were made, for which the NHIF paid a paltry BGN 1,134. For 2023, the NHIF has financed 153 visits, which are again insignificant against the background of the annual number of children born in the countrywhich is between 56,000 and 60,000. This cost the NHIF a total of BGN 2,185 in 2023, according to Health Fund data provided to Mediapool.
If someone thinks that there is simply no interest on the part of mothers in such a service, the practice abounds with examples in the opposite direction. Not one or two public and private hospitals offer a paid service for home patronage for newborns, at 10-12 times higher pricesfrom those of the NHIF.
In Sofia, a private hospital offers such a service at a price of BGN 170 for a single visit and a package price of BGN 470 for three visits. A similar service in Plovdiv costs BGN 150 for a single visit and BGN 380 for three visits.
Why the publicly funded neonatal foster care service is currently broken and how this can change – we asked Maria Evgenieva, a midwife with many years of experience in similar programs.
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Maria Evgenieva is an economist and a midwife. She underwent specialized medical and psychological training in Bulgaria, England, Scotland, Norway and the USA.
He works in the non-governmental sector and has been the clinical manager of a program for home visits to high-risk mothers for 8 years.
He trains expectant parents, but is also a frequent speaker at medical forums and congresses for professionals.
She says that the optimal number of visits should be tailored to the needs of the woman herself. “In general, during normal birth and development of the baby, it can be started with three visits in the first month after birth or the discharge of the baby. However, there are cases in which the mother has increased anxiety, postpartum depression, the child may have some problem and illness, and then more intensive consultations are necessary.”she tells Mediapool.
Evgenieva is convinced that it is the midwives who are best prepared to perform this activity, but considers the lack of enough specially trained personnel who are up to date with the most modern guidelines for newborn care to be a problem. “GPs do not have the capacity to provide this service as they are busy and cannot devote enough time to a quality consultation that should last 60-90 minutes“she says.
“Very often, the personal physician simply gives a printed sheet with instructions for feeding and raising the newborn. While a doctor’s examination lasts about 15-20 minutes, a midwife’s consultation is on the order of an hour, sometimes more.” explains Evgenieva.
That is why the price paid by the NHIF for the service of BGN 14 is extremely insufficient for the labor, even more so when the transport costs are added. “Of course, a nurse or midwife can also give a simple printed sheet at their visit and leave after 10 minutes. That’s why it’s important to have standards that the service meets“explains Evgenieva.
One of the big problems at the moment is precisely the lack of a standard for nursing and midwifery care, which it also makes the work of independent practices of nurses and midwives difficult and is one of the reasons why they are not financed by the Health Fund. The independent practices of nurses and midwives were regulated by law a few years ago, but due to the lack of a uniform standard and methodology for their work, the requirements for opening an office vary widely in individual areas of the country. “Midwives are sometimes charged exorbitant costs for equipment that is not necessary for the purposes of their practice“says Evgenieva.
Thus the services offered by nurses and midwives remain only in the private sector, but not all women can afford them, while the publicly funded service is practically unusable.
This “vacuum” is currently being filled by private academies and courses for parents. The problem with them, apart from some of them being paid and not available to everyone is, and another part which is bigger is heavily influenced by the baby industrywho wants to sell her products, and therefore these courses do not always provide the most correct advice and guidance for raising children, says Evgenieva.
An example in this direction is the intrusive advertising of formula milk and baby food. Add to this the adherence to outdated nutritional recommendations by a large proportion of GPs in the country and a lack of organized and accessible breastfeeding support for mothers, it is not surprising that our country has a low share of exclusively breastfed babies – 18.6% at 4 months, compared to 41% on average in Europe(note ed. based on data from the National Survey of Health Risk Factors among the Population in the Republic of Bulgaria 2020, NCSOZA).
The service would be much more accessible and convenient if the NHIF contracts directly with nurses and midwives, but there is resistance to this from the medical community. It would follow to each DCC there should be a group midwifery practice for home visits for newborns, which would serve all the patients of the GPs working there.
According to Evgenieva another option for the operation of publicly funded services for high-risk pregnant women, mothers and newborns (and not just for children with disabilities) could be organized around maternal and child health centers, which were created years ago at the hospitals in the regional cities and financed by the state. However, these centers are not functioning effectively at present. “The idea is that the nurses and midwives will be employed by these centers but will work and provide services in the field.”she explains.
Evgenieva herself has extensive experience in programs for home patronage care for newborns. Such is the “Together-Healthy Baby, Healthy Future” program of the Trust for a Social Alternative, which is financed by the “America for Bulgaria” Foundation. Under it, home visits are made to young mothers from the initial stages of pregnancy until they reach the age of 2. their children are covered in the program socioeconomically disadvantaged mothers under the age of 22, some in their early teens. The focus of the program is on the first 1000 days from conception to the child’s 2nd birthday, as this period is key and has an impact on his further development, habits, health status.
Evgenieva gives an example that under this program are carried out by 50 to 64 visits to a mother during the period of pregnancy to the first 2 years of the child. The results are impressive: a longer period of breastfeeding compared to other mothers of similar socio-economic status who are not covered by the program; improved child nutrition, reduced levels of depression and maternal social isolation. “The best thing is that after the support provided to the mothers, they manage to get back on their feet and midwives and nurses are heroes in their eyes and serve as role models. So some of these girls later decide to study to be midwives and nurses to help other women.”she says.
