Petition to promote active birth policies and practices and to improve the quality of maternity care services



Dr. Evgeny Zhelev, Minister of Health
Dr. Rumiana Todorova, Director the National Health Insurance Fund
Shirin Mestan, Chair of the National Agency for Child Protection
Georgi Pirinski, Chair of the National Assembly
Borislav Kitov, Chair of the Health Care Commission at the National Assembly

National Centre for Public Health
National Association of General Practitioners in Bulgaria
National Association of Pediatricians in out-of-hospital Care
Bulgarian Association of Obstetricians
Bulgarian Association of Pediatricians
Bulgarian Association of Health Care Professionals
Bulgarian Association for Patient Rights
Bulgarian media

Ladies and Gentlemen,

We would like to appeal for your support for the initiation of changes in maternity and child health care. In the last decade we have witnessed how midwives, obstetricians and women giving birth are increasingly dependent on technology in monitoring pregnancy and during labour. We are concerned about the increased proportion of medical interventions in low risk births and also by the high number of Cesarean section deliveries. Another cause for concern is the fact that the potential risk of medical interventions in normal birth for the mothers, babies, families and society has not been systematically studied. Current practices in child birth and post birth care in Bulgaria are not in line with the findings of modern scientific studies and practices in developed countries, as well as with the recommendations of the World Health Organization (WHO) and other health care organizations. And finally, it is worth mentioning that if the changes we demand are implemented they would decrease the cost for medicines, unnecessary interventions and hospital stay.

We would like to express the following demands:

1.    Medical standard. The adoption of a medical standard which is based on best practice around the world in prenatal care, birth and post birth care and is agreed with representatives of the parent associations [25]. The medical standard should include measurable criteria for the quality of maternity care. Its leading principle should be: 'The mother and child are at the centre of the maternal care provided. The main objective of maternal care is to guarantee the health of the mother and the child with the least possible intervention in the process so that safety is not compromised'. There should be an annual independent audit of the quality of services in maternity and neonatal wards with the results made publicly available. There should be regular surveys of parent satisfaction from the services provided, including parents from the minorities, whose results should be made available to the public.

Every maternity ward should meet at least the following criteria for the quality of services:

•    Induced labour in no more than 10% of all births [11], [30].
•    Episiotomy is carried out in no more than 5% of all births [3],[11],[18].
•    C-section is carried out in no more than 10-15% of all births [8],[11],[18],[30].
•    Vaginal birth after c-section (VBAC) is carried out in at least 30% of all births after prior c-section delivery [7],[9],[12],[13],[14],[15],[16],[17], [21],[23].

2. Prenatal health care. It should include special training to prepare the pregnant woman physically and emotionally for giving birth. It should be guided by the understanding that the process of child birth is something normal, natural and healthy [5, p.22]. Women should be encouraged to have a natural birth, including if they have had c-section before, unless there are specific circumstances that rule out vaginal birth.

3. Birth plan and informed agreement. Parents should be encouraged to prepare in advance a birth plan which reflects their decisions on a number of issues related to giving birth. The informed agreement should be given in advance to future mothers as part of the document pack needed for hospital admission. This will allow the woman to study it   carefully instead of being rushed to sign it when she is admitted into the maternity ward. If there are any deviations from the normal process of pregnancy, birth and postpartum that require medical interventions (including tests and monitoring) they should be  explained in detail so the couple can be an active side in decision making and take responsibility after being fully informed [1],[6],[20]. All standard procedures administered to the baby (vaccines, antibiotics, blood tests, etc.) should be explained to the mother and performed only with her agreement [1],[6].

4. Place of birth. Pregnant women should be able to choose the place of birth – in hospital with the assistance of an obstetrician, in a birth centre with the assistance of a midwife or at home assisted by a qualified caregiver. The possibility for giving birth in a birth centre or at home should be legalised.   There needs to be relevant infrastructure for referral of deliveries with complications so that the risk is minimised. There should also be appropriate training for medical staff and caregivers.

5. Conditions in maternity wards. The atmosphere in maternity wards should make the woman feel comfortable and safe [2, pp.12-13]. If the woman wants the father and a companion to be present during birth and the post birth period for emotional and physical support this should be made possible without extra payment. The number of medical staff present should be brought to the minimum. Their attitude towards the woman in labour should be kind, well meaning and respectful [2, pp.13]. Qualified psychological support should be available in all maternity wards. Students of medicine and trainees should be present during labour only with the woman's agreement. Nonpharmacological pain relief methods should be applied if the woman wishes so [2, pp.13-14]. During all stages of labour, including the pushing stage, the woman should be encouraged to take positions in which she feels most comfortable [2, pp.14]. Various support mechanisim and objects that assist women in taking different positions should be supplied.

6. Start of labour. Labour should be assessed as low risk if it starts between 37th and 41st gestation weeks and there have been no complications during pregnancy. Inducing labour should be considered only after 41 full weeks of pregnancy have passed [5, p.238],[20, p.38],[32, p.31].  If the woman refuses labour induction she should be offered intensive monitoring which includes cardiotocography and ultra sound assessment of the amniotic fluid at least twice a week [20, p.38]. If the waters break spontaneously labour should be induced no earlier than after a 48 hour monitoring period [2, p.20], [5, p.205]. Before the induction of labour the woman should be offered a vaginal examination for membranes stripping [5, p.235].

7. Minimal interventions. If labour is proceding in a normal way the routine procedures listed below should not be performed. Their effectiveness and/or safety is not supported by scientific research. They should be applied only if there are medical reasons or if the woman asks for them [2, p.8], [19, p.24], [25, p.6 (2.4.)]:

  • cleanliness procedure (pubic shaving, enema) [2, pp.8-9], [4, p.33S-34S], [5, ch. 29, p.258-259], [10, ch.5, par. “Initial assessment”], [30, p.D3];
  • obstaining from food and drink [2, pp.9-10], [4, p.36S-38S], [5, ch. 29, p.259-262], [10, ch.5, par. “Nutrition and Hydration”], [19, p.18], [26, p.63-66], [30, p.D6];
  • frequent vaginal examinations [2, p.21], [5, ch. 31, p.285], [19, p.27], [26, p.46-47], [30, p.D8],;
  • pain relief medicines [2, pp.14-16], [4, p.65S-73S], [5, ch. 34, p.323-328], [10, ch.”Pain during labor”], [19, p.20-21], [26, p.36-38];
  • continuous electronic monitoring of the fetus [2, pp.16-18], [4, pp.39S-42S], [5, ch. 30, pp.270-275], [10, ch.5, “Fetal heart rate surveillance”], [19, p.28], [26, pp.40-43];
  • amniotomy [2, p.22], [4, p.38S-39S], [10, appendix 2], [19, p.27], [26, p.50-53];
  • induction and augmentation of labour, including in the third stage [2, pp.22-24, 29, 31-32], [4, p.42S-45S], [5, ch. 32, pp.292-294, ch. 33, 305-306], [10, ch.5, “Birth and Immediately Following”], [19, pp.27, 34 (1.8.6.)], [26, pp.74-76];
  • episiotomy [2, pp.27-28], [4, pp.45S-48S], [5, ch. 32, pp.295-297], [10, ch.5 “Episiotomy”], [19, pp.31 (1.7.13)], [30, D10];
  • directed pushing [2, pp.24-26], [5, ch. 32, pp.290-291], [19, p.31(1.7.8-9)], [26, pp.68-69], [30, p.D10];
  • fundal pressure shortly before delivery or from the beginning of the second stage [2, p.25].

8. Emphatic attitude towards the mother and the baby. Provided that the state of the newborn does not require urgent mediacl intervention or the mother speciafically asks for different treatment we would like to demand the following to become standard procedure:

  • clamping the umbilical cord afer pulsation ceases [26, pp. 32-33];
  • routine aspiration of the new born should not be applied. In the presence of meconium in the amniotic fluid endotracheal intubation and aspiration should not be done routinely [5, pp.421-422], [27];
  • the vernix should not be washed out [26, D19];
  • the baby should be given to the mother immediately after delivery and breastfeeding should be initiated  as soon as the baby wishes to feed [5, p.441], [10, p.7.13], [24], [28], [29], [31, p.32];
  • mothers should be encouraged to breastfeed whenever the baby wishes to feed, not at given intervals [5, p.445], [10, p.7.13], [24],[28],[29];
  • mothers who have had an operative delivery should receive support, including physical, to initiate breastfeeding as early as possible [24],[28],[29];
  • formula milk and water should not be given to the babies unless prescribed for medical reasons [5, p.445], [10, p.7.22], [24],[28],[29];
  • maternity and child care wards should get certified by UNICEF's 'Baby Friendly hospital' programme;
  • babies should not be separated from their mothers during any part of the postpartum hospital stage, including in cases of operative delivery [5, pp. 429-430],[10, p.5.24] [31, p.33];
  • the requirement for a 3 day hospitalisation post delivery should drop out; women should have the choice of оutpatient delivery [5, pp. 434], [31,p.53].

Parents should be encouraged to get to know and accept their babies with disabilities.

Parents should be allowed to part with their still born or deceased babies and to bury them according to their customs.

9. Modernising education and training. We insist that the current curriculum is assessed and revised in line with best practice around the world and the latest scientific achievements; there should be regular training and qualification courses for medical staff (e.g. every 2 years); new courses such as communication skills, psychological support and nonpharmacological methods of pain relief should be introduced. Internation exchange programmes with hospitals, univercities and birth centres should be considered.



Questions, comments, support

We would welcome your comments and support. Please send all questions and comments to If your comments concern the content of our demands please quote the source you are using. You can support us by signing the active birth petition. If the subject does not concern you personally it may be very important for your relatives or friends. Please send the petition to any one who may find it relevant and ask them to do the same.

Main sources:

1.    National Health Insurance Fund, Patient's Rights and Obligations, National Framework Agreement 2006

2. World Health Organisation (WHO), 1996, Normal Birth Care: Practical Guide

3. Albers, L. L., Sedler, K. D., Bedrick, E. J., Teaf, D., & Peralta, P. (2005). Midwifery care measures in the second stage of labor and reduction of genital tract trauma at birth: A randomized trial. Journal of Midwifery & Women’s Health, 50(5), 365–372

4. Coalition for Improving Maternity Services (CIMS), 1996, The Mother-Friendly Childbirth Initiative

5. Enkin, M.W., Kierse, M.J.N.C., Neilson, J., Crowther, C., Duley, L., Hodnett, E. et al (2000). A Guide to Effective Care In Pregnancy and Childbirth,(3rd ed.). Oxford: Oxford University Press

6. The European Charter of Patients' Rights, Rome, 2002

7. Gonen, R., Nisenblat, V., Barak, S., Tamir, A., & Ohel, G.(2006). Re sults of a well-defined protocol for a trial of labor after prior cesarean delivery. Obstetrics & Gynecology, 107(2, Pt. 1), 240–245

8. Gould, J. B., Danielsen, B., Korst, L. M., Phibbs, R., Chance, K., Main, E., et al. (2004). Cesarean delivery rates and neonatal morbidity in a low-risk population. Obstetrics & Gynecology, 104 (1), 11–19

9. Guise, J. M., McDonagh, M., Hashima, J. N., Kraemer, D., Eden, K., Berlin, M., et al. (2003, March). Vaginal birth after cesarean (VBAC) Report/Technology Assessment No. 71. (AHRQ Publication No. 03-E018). Rockville, MD: Agency for Healthcare Research and Quality

10. Health Canada, 2000, Family-Centred Mate rnity and Newborn Care: National Guidelines

11. Johnson, K. C., & Daviss, B. A. (2005). Outcomes of planned home births with certified professional midwives: Large prospective study in North America.BMJ, 330(7505), 1416

12. Landon, M. B., Hauth, J. C., Leveno, K. J., Spong, C. Y., Leind ecker, S., Varner, M. W., et al. (2004). Maternal and perinatal outcomes associated with a trial of labor after prior cesarean delivery. The New England Journal of Medicine, 351(25), 2581–2589

13. Landon, M. (2004). The MFMU cesarean section registry: Factors affecting the success of trial of labor following prior cesarean delivery. American Journal of Obstetrics and Gynecology, 191(6, Supp. 1), S17. Abstract.

14. Lieberman, E., Ernst, E. K., Rooks, J. P., Stapleton, S., & Flamm, B. (2004). Results of the national study of vaginal birth after cesarean in birth centers. Obstetrics & Gynecology, 104(5, Pt. 1), 933–942

15. Locatelli, A., Regalia, A. L., Ghidini, A., Ciriello, E., Biffi, A., & Pezzullo, J. C. (2004). Risks of induction of labour in women with a uterine scar from previous low transverse caesarean section. BJOG, 111(12), 1394–1399

16. Loebel, G., Zelop, C. M., Egan, J. F., & Wax. J. (2004). Maternal and neonatal morbidity after elective repeat Cesarean delivery versus a trial of labor after previous Cesarean delivery in a community teaching hospital. Journal of Maternal-Fetal and Neonatal Medicine, 15(4), 243–246, Abstract.

17. Macones, G. A., Peipert, J., Nelson, D. B., Odibo, A., Stevens, E., Stamilio, D., et al. (2005). Maternal complications with vaginal birth after cesarean delivery: A multicenter study. American Journal of Obstetrics and Gynecology, 193(5), 1656–1662. Abstract.

18. Maternity Center Association. (2004). Harms of cesarean versus vaginal birth: A systematic review. In Childbirth Connection, What every pregnant woman needs to know about cesarean section (booklet; 2nd edition 2006, revised; pp. 20–27). New York: Author. Also, retrieved December 17, 2006

19. National Collaborating Centre for Women’s and Children’s Health (NCCWCH), 2007, NICE clinical guideline 55: Intrapartum care: care of healthy women and their babies during childbirth, RCOG Press, London

20. National Collaborating Centre for Women’s and Children’s Health (NCCWCH), 2008, NICE clinical guideline 62: Antenatal care: routine care for the healthy pregnant woman

21. Rosen, M. G., & Dickinson, J. C. (1990). Vaginal birth after cesarean: A meta-analysis of indicators for success. Obstetrics & Gynecology, 76(5, Pt. 1), 865–869.

22.Royal College of Midwives, 2005, Evidence-based guid elines for midwifery-led care in labour

23. Smith, G. C., Pell, J. P., Cameron, A. D., & Dobbie, R. (2002). Risk of perinatal death associated with labor after previous cesarean delivery in uncomplicated term pregnancies. The Journal of the American Medical Association, 287(20), 2684–2690

24. Ten steps to successful breastfeeding

25. UK Department of Health, 2004, National Service Framework for Children Young People and Maternity Services Standard 11: Maternity Services

26. World Health Organization. Pregnancy, Childbirth, Postpartum and Newborn Care. 2003

27. World Health Organisation. Basic newborn resuscitation: a practical guide, 1997

28. WHO/Unicef. Protecting, promoting and supporting breastfeeding: the special role of maternity services. A Joint WHO/Unicef Statement. Geneva: WHO, 1989

29. World Health Organization. (1998) Evidence for the Ten Steps to Successful Breastfeeding. Division of Child Health and Development, Geneva

30. World Health Organization. (1985). Appropriate technology for birth. Lancet, 2(8452), 436–437. Summary.

31. World Health Organization. (1998). Postpartum care of the mother and newborn: a practical guide.

32. World Health Organization. (2002). WHO Antenatal Care Randomized Trial: Manual for the Implementation of the New Model.