 I'm very pleased to introduce Gargana Nikolova, who will tell us about Midwifery in Bulgaria with her talk, The True Story of the Campaign of Midwives, excuse me, Mothers and Midwives Together. Gargana completed her Midwifery degree in Bulgaria more than 25 years ago. She has worked as a midwife in three different countries and, in her words, had the privilege to support thousands of women and their families during one of the most important time of their lives, the birth of their babies. For a number of years she was a columnist for one of the biggest midwifery journals in Bulgaria. She is an international speaker who has presented in many different international forums, including ICM Congress 2017, the European Midwifery Association Conference, and National Midwifery and Students' Conferences. She received her Masters of Science from the University of West London in 2014. In 2016, she received the Mary Seacole Award for her project on antinatal education for Mothers from Black and Minority Ethnic BME Communities. In 2017, she became one of the first Royal College of Midwives Fellows. Currently, she is the Deputy Director of Maternity at Portsmouth Hospital University National Health Service Trust in the UK. She is a member of the Alliance of the Bulgarian Midwives, and although working in the UK at the moment, she is a passionate campaigner for re-establishing the integrity of the midwife in Bulgaria. Her presentation is a story of struggle, care, passion, and success for both mothers and babies. Excellent. I'm excited to hear your talk today. Gavgana, I will now make you presenter, and then you can take over the slides. Gavgana, you do need to unmute, though. Paula, good morning. Thank you very much for the lovely introduction. I'm really glad to be here, and I'm really glad to be able to talk to everybody who is online or to everybody who is going to look on that video afterwards. And without further ado, I would like to start the presentation. Dear colleagues and everybody else who is listening today, more than 2,000 years ago, Plato said that the greatest privilege of human life is to become a midwife, to the awakening of the soul in another person. Today, on the occasion of the International Day of the Midwife, the Alliance of Bulgarian Midwives and I wish you all to have the strength to accomplish all the professional and personal achievements you have ever wished for. And now, very often, when we talk about midwifery practice and motherhood, we wish to be part of the perfect world where the nature, the mother, and we, the midwives, are just part of the same soul, one soul. Sadly, more often than not, the reality is far from the dream. However, I will take you on a journey where a midwifery organisation from a very small country in Europe aims to come closer to the dream. The National Campaign, Mothers and Midwives Together, was born to fulfil the need for structured and consistent evidence-based midwifery care for every mother across Bulgaria. And so where is Bulgaria? So Bulgaria is a country situated in South-East Europe and occupies the eastern part of the Bulgarian Peninsula. The population of the country is just about 6.9 million and the main religion is Eastern Orthodox Christianity. The official language is Bulgarian and as a written South Slavic language dates back to the end of the 9th century. And just a couple of interesting facts about Bulgaria now. Bulgaria is the oldest country in Europe that hasn't changed its name since it was established back in 681 AD. And Sofia, our capital city, was found approximately more than 7000 years ago. Bulgaria is a vocation in Bulgaria, as a vocation in Bulgaria has its roots deep into the national history. One of the oldest birthing rooms still preserved is dated back to 1760, 1770. The first trained and practised midwife, Kristina Khranueva, the one who is sitting, started her practice in the distant 1881, enduring her long career, supported more than 3400 mothers. The first mother's home, which you can see at the bottom of your screen, Princess Maria Luisa, was built in 1903 and was the first in Bulgaria to accommodate assistant births and caesarean sections. It is not just one of the oldest vocations in Bulgaria, it's one of the most respected and celebrated. Since the 18th century, 21st of January is celebrated as the national day of the midwife, one of the happiest and joyful national traditions to celebrate the life and to acknowledge the midwife, the woman who was also seen as the guardian of both the life of the mother and her baby. The first Bulgarian midwifery association was established back in 1901 in Sofia by a midwife called Raina Knigine. The alliance of Bulgarian midwives is its successor, re-established by five, can you imagine, five midwives in February 2012. Now the members of the association are more than 300 and growing. And now, after so many years of history and tradition, it's not going to be our statement to say that the profession of the midwife in Bulgaria is on the brink of extinction. For the last 24 years, the midwives have lost a big part of their autonomy. Community midwifery care was dismantled. The antenatal and the interpartum care is now concentrated in the big cities, and it's almost entirely overtaken by the obstetric colleagues. Private obstetric care was introduced without carefully arranged insurance system or support system, fact which automatically denies the rights of or to equally care to equality of care for all women. All this, as you can imagine, led to devaluation of the midwifery profession and its status. This skill, they're already very experienced midwife and reduced the number of midwifery students and subsequently new midwives. Unfortunately, at the centre of this perfect storm stood our mothers and their families. As the midwives, we're losing their direct contact with the mothers and so vital communication and access to evidence-based information was lost. At the same time, a new phenomenon was building up. Internet was speeding up, providing access to any kind of care or information. As the community midwifery was lost, the opportunity to build up trust and confidence between the mothers and the midwives vanished. And just think about, don't we all know how important the trust is during the birth of the baby? Are we surprised that the rate of the caesarean section has plummeted? The midwifery guidance and regulations were somewhat somewhere forgotten never to be found or re-established again. Without regulations and strategy, no profession can function or provide the service required. After years of struggle to change the establishment in order to close the gap in the provision of the anti-natal intrapartum and postnatal care in different counties of the country and establish equal access to maternity care for all the mothers, no matter what or where they did. The Alliance of Bulgarian Midwives three years ago launched the campaign Mothers and Midwives Together. The first step was the establishment of face-to-face anti-natal classes led by regional midwives, members of the Alliance of Bulgarian Midwives and guest clinical speakers. This led to strong relationship and trust between the midwives and the mothers on a regional level. The role of the midwife become much more visible. Being a supporter or provider of evidence-based information and a trust figure during the most difficult time. The groups are set up on a monthly basis and provide free seminars with different topics and different discussions. As the groups are local, the mothers have access to the local midwives which provide information related to the local services and in some cases even the support during the birth. Well, for some of you listening now, this probably sounds, well, let's say strange. But the reality in Bulgaria is that the support provided by midwives during the intrapartum care is random and depending on many different factors, but the need of the mother. The next main focus of the campaign was to raise the mothers awareness of all the available options for anti-natal, intrapartum and postnatal care. I invite them to see the maternity units from inside. You may don't know, but the mainstream of the maternity units in Bulgaria are still closed units. And for the majority of the mothers, this was incredible to be able to see the unit from inside because the understanding for that was built up mainly or based on their party's opinion or from the internet. Arranging access to the birthing room and the postnatal area was not just important for the mother's preparation for the birth. It was a great opportunity for them to see the midwife and other staff working there. As a continuation, came the campaign Choose Your Midwife. Again, it might sound slightly unusual. However, this was the first database of midwives available to provide intrapartum care, as well as postnatal support, including breastfeeding support, smoking advice or maternal mental health support. This was the first time for many, many years when the mothers could have access to and choose a midwife. The campaign mother and midwives together took active part in the Ministry of Social Affairs project to work with the ethnic minority groups. Different seminars on teenage pregnancies, smoking or exercising during the pregnancy were developed and presented. Something which has either never been done before or has been led by non-clinical advisors providing random and very often contradictory advice. And I will dare to share, during one of the conferences arranged by the Alliance of Bulgarian Midwives, once I finished my presentation, one of the guests' mothers came and said to me, thanks to my midwife, which I met three months ago, three months before I gave birth, I had the most beautiful birth I could ever imagine. Now, can you imagine that was probably the biggest acknowledgement and thanks of our really hard work? One of the biggest problems in relation to midwifery practice was, and still remains, the absence of clear and structured midwifery guidance and regulatory protocols. Ensuring regulatory mechanisms and clear guidance for midwifery is one of the biggest aims of the campaign. In many conferences, meetings and consultations with the governance body, leading members of the campaign have presented reports and reports after reports, that the only way of safe and inclusive midwifery care can be provided is through structured and regulated midwifery profession, through midwifery guidance. The only way to be ensured that the mothers are not just given evidence-based information, but they can also make an informed choice is that different models of care, like, for example, a home birth or water birth, are controlled with clear and exclusive guidelines. A huge effort is directed to ensure that the maternity care will be included in the public health care system and independent midwifery practice can, at the end, become a reality. And finally, just two weeks ago, as from today we are speaking, Professor Diana Dimitrova, a lecturer in midwifery, published her first of its kind, postnatal community midwifery care guide. The first step to the successful return, we believe, to the community midwifery and door-to-door postnatal support for all our mothers. Implementing the antenatal glasses and providing evidence-based information, campaign for equal access to maternity services and regulations of the midwifery profession was always aimed to close the gap in the provision of antenatal and postnatal care for all mothers in all counties of the country. Regional, antenatal education sessions with the mothers, regular contact with the regional midwifery leads, local and national campaigns to support the mothers during COVID pandemic, local support groups, regular weekly online support, and as we speak, they are building more and more with up-to-date information available to every mother free of charge. Working with the ethnic minority groups, hundreds and hundreds of hours volunteer work by the members of the Lands of Bulgarian Midwives Board and members to ensure that the campaign is live even during the most difficult times through the pandemic. And now just to draw your attention to something equally very important, it was very clear from the very beginning of the campaign that without providing support to the midwifery colleagues who were providing the program and inspiring them, there will be no success. Therefore, the invisible part of the campaign was dedicated to provide as much support as possible to the midwifery colleagues nationwide. Face-to-face postgraduate training sessions, annual conferences and seminars to at least per year, midwifery notebook for community maternity care, online courses, continuing education of small groups of midwives, meetings with future potential midwifery students in order to raise the profile of the midwifery profession. And I have to confess, I really enjoyed that. All that with one aim, to ensure that midwifery care is available to every mother across the country and midwifery profession actually will survive. It has been a difficult journey. It has been a very difficult journey. There are still no regulations for the midwifery practice in Bulgaria. The antinatal clinics are still run almost exclusively by obstetricians. The midwifery profession is still significantly undervalued and unpopular amongst the potential new clinicians. There are still challenges where when recruiting new midwives or new students, the governance support is still very limited. The national public health care system still doesn't pay for medical advice provided by midwives. The national demographic crisis is still going and this is probably the most scariest of all of our problems. And to finish, approximately 40% of the practicing midwives are or close to retirement age, 40%. But the campaign mothers and midwives together has gained national acknowledgement against all the odds. Many more midwives have been involved and many more mothers too looked to have a midwifery support and they have been offered midwifery support. But most importantly, many more new mothers and their families have shared with us their happy stories just to say thank you. Last year, one of the midwives involved in the campaign has won the Kate Granger Award for individual midwife and compassionate care. And just a month ago, the president of Bulgaria has awarded three of the midwives involved in the campaign with a special certificate for their input into the development of the midwifery care in Bulgaria. And of course, a huge thank you and acknowledgement of her hard work goes also to the president of the Alliance of Bulgarian Midwives, Pavlina Gerina. Why are we so proud? Why are we so passionate? Well, because we are part of the journey. We are part of the story. Our happy story. Thank you. Indeed. Yes. You should be proud. That is an amazing testament to hard work. Thank you so much, Gergana. It looks like we have a question from Joanne Nieber. What is the situation of the midwifery schools in Bulgaria? Oh, Joanne, thank you very much for the question. Unfortunately, I can't see it on the screen, but that doesn't matter. Well, it's a high education. It takes four years. It is now very similar, if not almost the same, like any education in Europe, which means four years of studying where the last six or seven months are practicing. However, it's a blended model. So you have your lectures in the university, and then you have your practice in the hospital. Now, the problems are, as you can imagine, that the birth rate in Bulgaria is not great. Unfortunately, as I mentioned, I mean, the demographic crisis is horrendous. And sometimes the students unfortunately don't have much of an access to real births. But just to summarize, the education is still four years, and the midwives are coming out fully qualified. They can work anywhere in Europe, and they have full midwifery qualification. Did I answer your question? That is great. Joanne is typing right now. A couple of other comments. Informative presentation, the resilience to have midwives recognized as admirable. Joanne Roback said, yes, great answer. Lots of kudos coming your way. Best of luck. Congratulations. Wonderful presentation. Wonderful success. And one that I love too. I really loved looking at that old birthing room. That was really beautiful. Catherine Simochero also said the same thing. Really some great, yeah. Thank you. I think we're all hungry for those type of photos. It's really interesting to see that. And that's from 1760. That is amazing. Paula, I actually visited with one of our guests from UK two years ago, pre-COVID. I mean, obviously. And this, you can see at the bottom of your screen on the left corner of the bottom of the screen. This is the house. This is how the house looks like. And that small window on the top is the window where, which is attached to that room. It's amazing to see and actually almost feel how was that, I mean, at 1760, 1770. This was actually an active room, active birthing room. And perhaps interesting, if I may share, was that outside of this room, because in Bulgaria, the majority of, well, not the majority, but quite a good amount of time is quite cold, they had a special heating installation. So the woman would never be cold because they believe that during labor, during that transitional period, a part of God who obviously, and the midwife who was with you, the woman needed to feel very comfortable and very relaxed. Something which we are trying to build up now. Yes. Oh, that's so fascinating. Very, very interesting. How about anybody else? Any other questions or comments out there? You're welcome to put them in the chat box or raise your hand. I'm just kind of scrolling through to see if anybody has done that. So yeah, feel free to send a message or a question for Georgana. I do have one that I'd love to ask while we're waiting here. Does Bulgaria have freestanding midwifery led units now? And if not, what are the barriers? All right. Well, thank you for the question. Oh, I don't know whether to thank you or to think I have time to answer. Well, the answer to your question is no. The maternity care in Bulgaria is provided mainly in the hospital, the intrapartum care is provided mainly in the hospital. We don't have birthing centres because maybe isolated one, maybe one or two here there, but unfortunately, because the midwifery profession is not regulated, it's very, very difficult to establish what the rules should be for that birth centre. It's not because we don't have midwives who want to be independent midwives and set up birthing centres. It's because there is no support organised for that. Of course, there are, on the top of my head, there are two birthing centres, one in Sofia and one in Plovdiv, which are just on the infancy at the moment purely because it has been extremely difficult to maintain independence. But the majority, the majority, the vast majority of the intrapartum care is provided in the hospital. And again, unfortunately, the majority of the time is provided either entirely or majority by obstetricians. Yes, yes. Anybody else? Love to have any questions. I have one more. You mentioned the ethnic minority, minorities in your country are, is there an active campaign to recruit and train more ethnic minority midwives for culturally congruent care? What's happening in Bulgaria in that regard? Again, thank you for the question, Paula. Well, let me give you just a little bit of an understanding of the structure at the moment. We have approximately working, working, as we speak, 1,200 midwives or something along those lines. And 40%, if not more, are at retirement age or even retired. Now, because the profession has been so suppressed for the last 25, 30 years, it has been really, really difficult to recruit because as you can imagine, if you don't have regulations, if you don't have status, of course, the payment, the payrolls and everything else is important, then most likely then not you will have problems with recruiting midwives. And there has been a drive to to make sure that more young ladies from any kind of background in Bulgaria will apply and will complete the middle school. We have midwives from ethnic minority groups, students, even as we speak. But there's no national campaign, if that was your question, to recruit more midwives from ethnic minority background. They are there just because they want to be midwives. But unfortunately, at the moment, we don't have any support from the governance in order to arrange that. Yeah, yes, that's the case in a lot of places worldwide. Thank you so much, Gargana, for this excellent discussion about the status of midwifery in Bulgaria. We are all with you. We are so excited about your success, success of your campaign. This is such a beautiful example of families and midwives working collaboratively together.