site.btaPerinatal Mortality Rate in Bulgaria Three-Fold Higher than EU Average, Audit Shows

The Bulgarian National Audit Office Tuesday published the findings of an audit into the implementation of the National Programme for Improving Maternal and Child Care 2021-2030 in the period from January 1, 2021 to December 31, 2022. According to the audit, Bulgaria is yet to achieve the average indicators for mother and child care in the EU. The national goals are for that lag to be overcome to a large extend by 2030.

The audit shows that the mortality rate for babies aged up to six days is three-fold higher than the average in the EU. For children aged under one, the mortality rate has been experiencing a downward trend since 2014 but is still higher than the EU-average.

The high perinatal mortality rate is the result of the low number of medical check-ups during the pregnancy, the quality of obstetric-gynaecological care and the low level of health and  reproductive knowledge. There are clearly unresolved problems in obtaining adequate health care for all pregnant women, regardless of their health insurance status, and in carrying out prenatal diagnosis (procedures that allow a diagnosis of fetal harm to be made during intrauterine development). In Bulgaria, the programmes for neonatal screening (testing of newborns for a series of diseases before the symptoms occur) as a preventing health practice are limited to only three diseases, compared to 49 in Italy and 16 in Germany.

In 2022, nearly 250 of new mothers were aged under 15, and for some of them that was their second or third birth.

There has been a lasting downward trend in births in the 20-29 age group and an increase for those aged over 30. Birth at a young and older age result in a high rate of stillbirths: 5.67 per 1,000 total births in 2022.

More than half of women in Bulgaria who have a health insurance give birth with a cesarean section, compared to 25% in Europe, and that is a lasting negative trend in this country, the audit reads.

The National Programme for Improving Maternal and Child Care provides resources for health and medical care for health insured persons, but no effective campaigns have been planed and held to make the population better informed, particularly in villages and among vulnerable groups. 

There is a need for more effective care for pregnant women and children, implementing primary prevention after birth and during child rearing, together with effective secondary prevention and treatment after the onset of disease to bring infant and maternal mortality to lower levels. 

A total of 70 activities for 17 measures are included in the Action Plan 2021-2023 for the implementation of the identified five main priorities of the National Programme for Maternal and Child Health. The National Centre for Public Health and Analyses, the Regional Health Inspectorates, the Centre for Comprehensive Services for Children with Disabilities and Chronic Diseases, and medical institutions with established Maternal and Child Health Consultative Centres have been identified as responsible institutions. 

Activities with various initiatives and commitments have been planned by the mentioned responsible institutions, but only in 2023 did the Minister of Health issue orders for the assignment of 9 activities under the national programme.

It is difficult to get an idea of the overall implementation of the measures under Priority 1, "Health promotion, including reproductive health, family planning and child health", from the reported data. There is a lack of information what territory in the country is covered, which segments of the target group are targeted by the measures, and an assessment of their effectiveness. There is no communication strategy, the audit reads.

The annual analyses prepared by the National Centre for Family and Child Health lack an analysis of the impact of the actions taken under the national programme - of the reasons that led to a decline in some indicators and an increase in others.

Regional health inspectorates in most cases do not periodically publish materials on the information, training, consultation, medical and social activities, psychological consultations for pregnant women, mothers and children with disabilities and chronic diseases implemented under the programme. The activities of the programme are insufficiently promoted, the audit also found.

Children aged 0 to 1 year

For the period from 2014 to 2022, infant mortality declined from 7.6 to 4.8 per thousand live births in 2022. However, the indicator still deviates from the EU average of 3.3 per thousand in 2022, and Bulgaria ranks among the top EU countries for infant mortality after Romania, Slovakia and Malta. 

The neonatal mortality (number of children dying between day 1 and 27) was 3.1 per thousand in Bulgaria, close to the EU average of 2.5 per thousand in 2021.  

Perinatal infant mortality rates are still high, at 7.3 per thousand in 2022 compared to 2.5 per thousand for the EU in 2021. The high figures indicate that the activities implemented under the National Programme and other strategic and programme documents are not sufficiently effective, especially in terms of ensuring satisfactory coverage of antenatal check-ups for uninsured women. 

In 2021, antenatal checkups performed on uninsured women by an obstetrician account for only 40% of all uninsured women giving birth, dropping to 37% in 2022. In 2023, they reach 63%, indicating that many have not had a single antenatal check-up. 

The mortality rate of children in their first year is two-fold higher in villages than in cities.

The highest number of deaths in children occur between day 28 and one year of age.

Not a single home visit for newborn care was registered by general practitioners in 2021. The number was 81 visits in 2022 and 168 in 2023.  

The declining number of general practitioners and their uneven territorial distribution, the existence of vacant medical practices in small and remote settlements and in neighborhoods with minority populations is currently not adequately addressed, the audit reads.

The main cause of death in children under 1 year of age is conditions occurring during the perinatal period. The other leading causes of child mortality are congenital anomalies, malformations and chromosomal aberrations, diseases of the respiratory system, diseases of the circulatory organs and external causes of morbidity and mortality. These four classes of diseases account for nearly 80% of deaths in children under 1 year of age. 

Children aged up to 18 years

The cause for the doubling of the under-18 mortality rate compared to 2014, is due to symptoms, signs and abnormalities detected in tests that can relate to the cardiovascular, respiratory, digestive and other systems in the body. Other causes of death in this age group that show an increase are neoplasms, which account for 12% of deaths. Diseases of the nervous system accounted for 10%. Respiratory diseases and circulatory diseases are decreasing in number. 

Bulgaria is among the countries in the EU with the lowest level of disease prevention and, consequently, the highest levels of morbidity and mortality from diseases preventable with good prevention or treatment. This finding is fully applicable to children as well.

Regular and quality preventive check-ups are essential for early detection and reduction of mortality in children in all age groups, which has not been achieved. Data on reported preventive examinations show that in all age groups, the actual number of examinations is below the annual target. In the 0 to 1 year age group the average is just over 9 per person, compared to 13 per year. For children aged 1 to 2 years, they are about 2.8 per person with at least 4 examinations per year planned. For children aged 2 to 7 and 7 to 18, it is also below the scheduled preventive examinations. 

Births and abortions

The fertility rate in Bulgaria, as in the EU, shows a steady downward trend: from 9.4 in 2014 to 8.8 in 2022. The exception is the period from 2020 to 2022, when Bulgaria registered an increase from 8.5 to 8.8.  

The fertility rate is affected by the problems associated with the decline in the number of women of childbearing age, from 1.58 million in 2014 to 1.28 million in 2022. 

Another factor is delayed childbirth, infertility, and abortion. The data show a steady decline in births between the ages of 20 and 29 and an increase in births after the age of 30, with the average age of women giving birth to their first child rising from 26.7 years in 2014 to 27.6 years in 2022. 

Still, the number of births under the age of 20 is high, with births under the age of 15 being observed. In 2022, there were 248 cases, including 8 cases with second birth and one case with third birth.

The data show a very high proportion of caesarean deliveries for insured women, despite actions taken to incentivize normal birth by increasing the cost of the clinical pathway. Their relative share to total births reported and paid for by the National Health Insurance Fund for insured women was 55% in 2021, 53% in 2022, and 55% in 2023. 

Caesarean sections are considerably less frequent for uninsured women, with their relative share to total births by uninsured persons being 27% in 2021 and 2022, and 28% in 2023.  

The largest number and proportion of abortions is in the over-30 age group: nearly 10,000, accounting for 53% of all abortions in 2022. Of these, nearly 7,000 were therapeutic abortions and about 3,000 were miscarriages. There were 100 abortions performed on persons under 15 years of age.

Premature births

Annually, premature births account for around 9% of all childbirths in Bulgaria. In the 2014-2022 period, a positive trend is observed: there were 6,340 premature births in 2014 compared to 5,258 in 2022. At the same time, the number of deaths of premature newborns dropped from 353 in 2014 to 216 in 2022. Factors that influence this indicator are the quality and coverage of care in the healthcare system, the availability and development of neonatal care, and the availability of highly skilled and experienced health workers. 

Data on morbidity and late complications in this group of newborns is not collected and analysed. The number of premature infants requiring rehabilitation and other healthcare is also not tracked, the audits says.

Maternal mortality

The UN Sustainable Development Goals set a maternal mortality coefficient in the world below 70 per 100,000 newborns by 2030. Bulgaria has achieved that goal, with a coefficient of 12.4 in 2022, but is yet to fall below the EU-average, which was 6.35 in 2020.

The Bulgarian National Audit Office gives the Health Minister nine recommendations to be implemented by end-May 2025.