Para quem quiser como é a assistência ao parto na Bulgária, o texto abaixo foi enviado a mim pela minha colega parteira Olga Ducat, de Sófia. Existem dados bastante interessantes, como a queixa sobre a rudeza na atenção às gestantes, o número crescente de partos desassistidos, a extrema medicalização dos nascimentos e a proibição de partos domiciliares (até agora, mas depois do julgamento da corte dos direitos humanos da Comunidade Europeia as coisas tendem a mudar).
A small country by the black sea.
Democracy since 1994.
The population of Bulgaria is about 7.494.000 inhabitants
Babies born per year (2010): 76 000
There are about 130 maternity wards
There are no birth centers
The title “Baby-friendly hospital” is awarded to 12 hospitals.
Maternal mortality rates – 13 per 100 000 (2008)
Infant mortality rates – 11.0 (2010)
Neonatal mortality rate – 7 (2010)
The standard pregnancy care covered by national health insurance includes 9 free visits, some basic blood and other tests, and 2 ultrasounds – one during the first trimester and one between 16-20 weeks. Most women prefer to visit an ob-gyn during pregnancy but there is an option to visit a GP – some GPs implement the obligatory program “Maternity care”. However, many pregnant women choose to visit private consultancies despite the high expenses because of the special attention they are hoping to get. There is no practice for the obstetrician who takes care of you during pregnancy to attend your birth. Most obstetricians who work in hospitals also have private practice. So women who want a particular obstetrician to attend their birth are often forced to visit their private consultancies as well. Many women combine regular and private pregnancy care and visit two obstetricians in order to be sure that everything is all right. Every visit in a private consultancy includes ultrasound.
Preparation for birth
Some hospitals organize birth preparation courses or single lectures by a midwife or an obstetrician. The majority of hospitals have open door days once a month when future parents can see the delivery room, the neonatal ward, the rooms and ask questions. There are also privately run childbirth classes but most of them do not really inform women, they rather make them “fit into the system”. They describe the routine medical interventions but do not discuss their necessity or risks. There are also alternative childbirth classes – with focus on the normal physiology of birth, hormones during labour and delivery, alternative pain relief methods, routine hospital medical interventions and their risks, how to prepare your birth plan, how to communicate to the hospital personnel, etc. A lot of centers organize prenatal yoga or gymnastics. More and more women inform themselves from books and the internet.
With very little exceptions all women in Bulgaria give birth in hospitals. Homebirth is not regulated by Bulgarian law. There are no birth centers. There are only 3 hospitals in the country where water birth is available and there are very few doctors trained to attend water births.
The majority of hospitals charge for additional services such as birth in a private VIP delivery room, choosing a medical team, presence of the father. The cost of birth with the above extras exceeds the average monthly salary in Bulgaria.
There is a public and a private system. It is normal to pay in the public system too, under the table to doctors and midwives. By law you are entitled to have a person with you at birth, but many times you have to pay for that too.
The informed consent
The informed consent form includes description of the routine interventions that could be performed during birth, but the risks are not mentioned. Often there is no additional explanation by the personnel. Usually the woman signs this form while being admitted into the maternity ward when she has contractions and is unable to concentrate on the text. She can refuse signing the document, but it is very likely that this will affect negatively the personnel’s attitude. Birth plans are not commonly practiced yet. Parent attempts to make demands are usually not received well and they are often disregarded.
Childbirth in Bulgaria is extremely medicalised. Most people only make a distinction between cesarean and “normal” birth and a lot of women don’t even realize they have another choice. On the basis of anectotal evidence from women birth stories there is practically no natural birth without interventions.
The cesarean rates are constantly growing in the last years. According to the WHO data base the cesarean rate in Bulgaria in 2002 is 17%. In 2006 the rate is 24% (from 73 978 births more than 18 000 of them are c-sections). The official cesarean rate in the 3 major hospitals in Sofia is 45%, in private hospitals it is even higher.
Number of midwives – 3401 (2007)
Number of obstetricians/gynecologists -1356 (2007)
Midwifery has a longstanding tradition. The first midwives were taking their education in Saint Petersburg, at a school that was made after the Dutch model in the 18th century. Midwifery was given till the socialist regime was ending the home birth and every woman was giving birth in hospital setting. Midwives were no longer a freestanding professional but the assistant of the obstetrician. There was no midwifery organization till 2011.
Midwives were supposed to be member of the medical care givers organization. An organization, that only looks after the institutionalized caregivers interests.
Midwifes in Bulgaria are very dependent on the doctors, in fact they play the role of obstetric nurses. They are not allowed to work independently. Every birth in a hospital must be attended by an obstetrician. Compared with the obstetricians their salaries are extremely low.
The first Bulgarian doula started working in Sofia in the end of 2010. At the moment there are about 50 doulas in a process of a certification. 3 doula workshops were organized – one of them by DONA International, and two by European Perinatal School.
A lot of medical professionals have negative attitude to doulas. Another problem is that if you want to have a companion during birth, in the majority of hospitals you have to arrange an individual delivery room and to pay for all the VIP services. This is not accessible for most of the women. Besides that the attendance of more than one companion is not advisable/not allowed in most of the hospitals, so the woman has to choose between her partner and doula. Doulas usually charge about 100-150 EUR for their services.
Home birth was forbidden till Bulgaria became member if the EU and the directives can be mentioned. In fact it is not regulated by Bulgarian law and it is hard to find a doctor or a midwife who would attend homebirth. This stops mothers who would like to give birth at home. The idea of homebirth itself is revolutionary for Bulgaria; most people consider it terribly irresponsible, bordering on insanity.
The main arguments of doctors against homebirth are undeveloped infrastructure, heavy traffic and the impossibility to take the necessary equipment into the house. However there is an interesting tendency in the last few years – the number of planned unassisted homebirths has increased. The difficult situation in hospitals, the routine interventions and the rude attitude of the personnel force some parents to make this choice. Usually they inform themselves from the internet and order literature and home birthing sets from abroad. These births are usually assisted by the father. Sometimes doulas attend such births.
Women are very active for their rights in Bulgaria and are many times in the public eye with claims for change.
After discharge from hospital the mother and the newborn are visited by a pediatrician (the baby’s GP). They do a routine check up of the baby and offer advice about breastfeeding and how to care about the baby. (Usually the recommendation is breastfeeding on a 3 hour schedule). Two weeks after birth they usually weigh up the baby in the pediatricians consulting room, after that the mother and baby attend monthly pediatric appointments. There is a postnatal gynecological appointment for the mother 6 weeks after delivery.
Breastfeeding and maternity leave
The situation with breastfeeding in Bulgaria is changing for the better during the last years. Some hospitals already have breastfeeding support consultants.
As of January 2009 mothers in Bulgaria receive 90% of their salary during the first year of their maternity leave. The law allows 2-hour paid leave within the working day to breastfeed the baby until 8 months old and 1 hour on prescription after that, but very few women are aware of this possibility.
Olga Ducat, Sófia – Bulgária