Wholesome Care in Support of Early Childhood Development: The Role of a Cross-Sectoral Approach in Improving Maternal and Child Health and Development in Bulgaria.
Research shows that the period from pregnancy to the age of 3 is crucial for every child. This is when 80% of the brain is formed. The building process is the interaction between neural connections that occurs at the speed of light in the early years, and then declines and never repeats. Early life experiences determine whether or not this process is a stable foundation for children's later emotional, cognitive, intellectual, and social development.
Driven by the importance of the wholesome development and proper growth of children, the experts of the We Care network explore the challenges faced by pregnant women, mothers, nursing mothers and children up to 3 years old in Bulgaria. They identify serious systemic challenges to meaningful care for child development and recommend a solution based on the Nurturing Care for Early Childhood Development framework, addressing the areas of health, nutrition, early learning, responsive parenting and safe and secure environments. Interrupted health insurance entitlements disrupt women's access to antenatal care; the uninsured are entitled to one examination as well as a package of tests, which is woefully inadequate to anticipate and prevent potential complications. Consequently, every year in Bulgaria, nearly 7 000 children are born following untraced pregnancies, which is a risk to the health of the baby and the mother. At least one-third of severe illnesses in preterm infants are due to preventable complications from untreated maternal infections during pregnancy.
A Cure for Money
Although children under 3 have free access to medical care and specialists, and the NHIF covers some medicines partially or fully, the funds available to cover medicines are proving insufficient. Only 11-13% of the NHIF budget is for child health, of which 5% is for medicines. According to a 2019 survey by the Bulgarian Pediatric Association, "for health care for a child under 1 year, about 100 BGN extra is given monthly, half of which is for medicines." Accordingly, due to financial barriers, many families cannot afford to fully treat their children.
Hungry Brain
A study of the legislative framework in Bulgaria related to child nutrition shows that there are various services in the field. However, they are not comprehensive and integrated in away that builds parenting skills and provides nutritional support simultaneously. Families that are located in segregated and isolated areas have limited access to such services, so the number of malnourished children there is substantial (47.2% of children of Roma origin do not receive at least one meal a day including meat, fish or chicken compared to 9% of children of Bulgarian ethnic origin). Additional factors, such as insufficient information, insufficient support from health care providers, and societal attitudes, make it difficult to implement and expand the reach of existing nutrition and feeding models to children from these families.
(Un)Developed parenting skills
Early learning and care services for the 0-3 age group are offered by the health, social care and education sectors. Due to the early age, such services are most effective when provided in the family home. However, there is as of now no government-funded national service that supports the development of responsive care and early learning skills with regular visits by health or social care workers to the homes of families with children under 3. This is a precondition for the lack of skills of parents, especially from vulnerable groups, to stimulate early learning and provide responsive care. Further long-term consequences for some children could be developmental delay and difficult adaptation in the education system.
Valid health and social care
Around 250 thousand people in Bulgaria do not have ID cards and over 80 thousand are without a permanent address. Of these, 1,686 women with children aged 0-3 don’t have a valid ID card by 2021, and 25,998 aged 14-30 have never had ID cards. Their basic civil, political and social rights are restricted – they are unable to access health insurance, education, training, property, marriage, voting, family life and inheritance – this is how they remain 'invisible'.
The role of cross-sectoral work
Without a change in the structure of sector programs and services in Bulgaria, there will be no substantial, effective and equitable reform of early childhood development policy. The We Care Network organizations support this reform by laying the foundation for stakeholders to take on additional responsibilities and calling on all families, institutions and organizations to work together to achieve a better future for children.
It may seem that the health sector has the greatest responsibility, as well as the greatest potential, to contribute most to improve early childhood development, but it is essential that it also works with other sectors - education, social assistance, finance, water and sanitation, child protection, etc. This requires a cross-sectoral, holistic approach where policies, programs and services work in a coordinated and systematic way. This approach takes into account different communities, responds to their needs, enriches their knowledge of parenting and meaningful care, and provides resources to help with the raising and the development of the child. In addition, it must take into account all parties that have a role in the care of the youngest – the government, civil society, academic institutions, the private sector, families - because the input of all stakeholders is necessary.
Suggestions for improving maternal and child health and development
For all mothers and babies to have a fulfilling life, equal access to checkups and pregnancy follow-up tests is needed for every woman, regardless of her insurance status. In addition, services and care for wholesome nutrition, early learning, responsive care and a safe and secure environment are also key.
Nutrition plays an important role in child development. Therefore, support is needed through nutrition education and counselling for children aged 0 to 3, as well as regular nutritional and material support for families at risk.
Early learning starts at home. When parents maintain eye contact, talk, sing and play with children, they develop their social and emotional skills. Interaction with the child, moreover, develops the structure of the brain. If the family cares for and responds to the child's needs - feeding him or her on time, protecting him or her from accidents – the child will get to know the world better, learn about people, relationships, communication. This stimulates connections in the brain. Having responsive parenting services in the safe environment of the home will support families in building the knowledge and skills needed to stimulate children's early learning.
A safe and secure environment at an early age is important in preventing illness and developmental delays that can otherwise negatively impact a child's cognitive, social-emotional, and physical potential for life. Therefore, all pregnant women, mothers and children aged 0 to 3 should be legally empowered with equal access to health and social services. In order to make this a reality, facilitated procedures for the issuance of identity documents and address registration need to be introduced.
This article is part of the series "Nurturing Care to Support Early Childhood Development". The series aims to present the interrelationship between the domains of health, nutrition, safe and secure environments, early learning and responsive caregiving, enhancing maternal and child development. It supports the need for synchronized work on each of the themes through measures to establish the most appropriate setting for children. It justifies the work of the advocacy network We Care for equal access to health services for every child and antenatal care for every pregnant woman, regardless of her health insurance status; improving opportunities for wholesome nutrition for children from poor families through the introduction of a specialized nutrition program; opening up integrated services and programs to support the building of parental capacity to care for the child at an early age; accessible procedures for issuing identity documents and address registration for women and children without valid documents; the provision of universal access to medication for all children aged 0-3.