Home-visiting nurse - reaching those most in need

"Initially I couldn't even think it would be possible, but it is now a reality" - Radostinka Penkova, a home-visiting nurse from UNICEF supported Center for Maternal and Child Health in Sliven

Патронажна сестра от Центъра за майчино и детко здраве в Сливен е на посещение на уязвимо семейство
UNICEF Bulgaria/2016
24 March 2021

Initially I couldn't even think it would be possible, but it is now a reality - Cristian already attends nursery, he adapts very well, speaks with syllables, feeds himself with a spoon ..." 

This is what Radostinka Penkova, a home-visiting nurse from the Center for Maternal and Child Health at the Medical Center “Dr. GV Mirkovich” in Sliven, explains, smiling with pride. She has been supporting two-year-old Christian and his mother every step of the way - since his premature birth to his placement in the nursery.  

This is also what the rest of the twelve home-visiting nurses and midwives in the Center do – they accompany the families in need, sometimes every day if necessary. 

Close to those in greatest need 

The Center for Child and Maternal Health was established in 2014 under a UNICEF project. Now its team will be reinforced and will expand its activities with funding from the European Commission (EC) under Phase III of the Preparatory Action for the Child Guarantee which is being piloted in Bulgaria*,  implemented with UNICEF support. Thanks to the financial support from the EC, the Center will be able to focus its efforts on early monitoring of child development through the additional training of specialists. Screening the development of children at certain key stages - 9 months and 18 months, will allow for the timely detection of any developmental delays or difficulties. It will also ensure timely referral of families to additional support services for overcoming potential problems. / Read more about the home-visiting care and the initial results under the "Child Guarantee" pilot project here

The Center and its team cover the entire district of Sliven and have satellite offices in Tvarditsa and Nova Zagora. It provides a wide range  of support from health information for quality baby care, social work and consultations, training, counseling and coordination of activities to address the  problems families are facing. All families with children aged 0-3 and pregnant women from Sliven dsitrict can benefit from the services.  

Services reach the sourrounding villages where there are no health services – including Mokren, Padarevo, Strupets, where the majority of the families are poor and may not have health insurance. While many people today can access all sorts of information about caring for a newborn baby with a few clicks online, there are some for whom healthcare is not accessible and access to information is limited. Many parents are simply unprepared, and there is no one to guide them.  

Патронажна сестра от Центъра за майчино и детко здраве в Сливен е на посещение при дете от уязвимо семейство от ромската общност
UNICEF Bulgaria/2016

The home-visiting nurses work in contexts where a baby's health problems are often not detected early  enough. In such cases, complications may occur, especially when there are  no reliable sources of advice and information for families with newborns. Even in terms of basic things, such as the baby’s weight gain,  breastfeeding, hygiene maintainance, bathing, etc., the nurses visit  the family’s home to be close to the parents and aware of all their concerns and problems. Being within the family’s environment helps them provide support to the family in the most prompt and adequate way. 

Support often begins before the birth - with advice to the pregnant women on how to care for their health, choose healty food,  and avoid bad habits. They also provide free check-ups for pregnant women without health insurance and a minimal package of clinical tests. After the birth, they support the parents in the first steps of caring for the newborn baby. In the first months they monitor the newborn’s weight, neuro-psychological and physical development of the baby, breastfeeding, nutrition and  hygiene. They also teach developmental games, including through song, for parents to learn how to communicate and also learn the importance of reading to their young babies.  They are united around one goal - building good parenting skills and a strong parent-child connections to empower families in providing the best care for their children during the first 1,000 days after birth. 

With understanding and trust  
Патронажна сестра от Сливен, Центъра за майчино и детско здраве, подкрепен от УНИЦЕФ, е на посещение при млада майка и нейата дъщеричка
UNICEF Bulgaria/2016

"It is not easy, we are dealing with changing mindsets and attitudes towards the baby," explains the director of the Center Lilka Koleva. 

- The pride in her voice is palpable, when she recognises that the first, most difficult step has been made - gaining the trust of the families. 

Trust is even harder to achieve in the remote and disadvantaged areas where the nurses work. But trust can save lives. Gradets is such a place – a village where working in the field is extremely difficult. The local people are extremely poor, many of them have not had proper livelihoods, and do not trust people outside the community, which makes access and communication very difficult. Although during the first visit to the newborn twins the family refused the home-visiting services, midwife Angelina Mihaleva did not give up and returned the next day, as  Lilka Koleva recounts. 

This time the mother allowed the babies to be examined. "At first glance, it was clear that both children were malnourished and in a poor state, they had not gained weight for almost a month and a half following their birth. One of the twins had fever. However, the Mother stated that the children were fine as she had not identified any problems, " the nurse recalls. The quick intervention of the nurse and her efforts to persuade the parents to seek immediate medical help in Sliven, were effective - the baby was urgently hospitalized. The day after, the other twin fell ill, and was also taken to hospital for a blood transfusion. "Throughout this time, the nurse kept in close touch with the children's ward, was informed about the children’s condition, and after their discharge visited them every week until she was sure that they were developping properly and out of danger. Now, they are a year and a half and everything is fine with them, " the Director of the Center explains. 

Each nurse covers a specific area where she visits families according to a preliminary schedule, tailored to the individual needs of the parents. The nurses keep in touch with the families, get to know them, and people know they can seek help from them. They become close enough to the families that parents open up about their problems and needs - information which is vital for the planning support to the whole family and the child,” says Lilka Koleva.  

"You have to choose the right moment,  if they are not willing to talk today, if they are anxious, if you see that they will not accept advice today, you will have to let it go and return the next day or day after…for as long as it takes," asserts one of the nurses.  

Early intervention 
Патронажна сестра от Центъра за майчино и детко здраве в Сливен е на посещение при майка с близнаци
UNICEF Bulgaria/2016

Often the nurses are the first to identify potential developmental delays and problems with the child. Many families do not have the knowledge and do not notice these issues. Sometimes parents do not even want to consider that their child may have a problem. Sometimes families give up quickly after the first rehabilitation or do not continue with the prescribed treatment. And in these situations the nurses are there to help. 

“We had a case, for example, when a healthcare mediator saw that a 15-month-old child did not walk steadily. But the parents had accepted it as something normal, and no one paid attention that such a developmental delay might be problematic,” says Lilka Koleva. In such cases, the nurse initially talks with the family and then with a team at the Center, they come up with a plan how to overcome the problems with exercises at home,  games, massages, and other techniques to stimulate the baby or refer the family to a specialized service, if needed. 

Overcoming administrative obstacles 

The support from the nurses goes far beyond health and social issues.They also assist  in administrative and legal issues. “One of the most serious problems in these communities is the lack of address registration and ID cards of the parents,” explains Lilka Koleva. It is not uncommon for a child not be registered for years. Not “existing” in the state register leads to lack of registration with a General Practitioner , lack of regular monitoring, examinations, measurements, vaccines etc. “We had a case when for one year we had to go from one institution to another until  we managed to arrange for all the documents for one baby to be registered. For one year, this child was monitored and examined only by the home-visiting nurse,” the Director of the Center recalls. 

Bozhidar from the village of Sotirya has a similar story - when he was 6 months old the nurse saw him for the first time and discovered that the child could not see. Although the mother was blind, no one in the family had previously noticed that the baby did not see or react with his eyes. “It was a “big battle” afterwards, not because of miscommunication or resistance from the family, but because of pure administrative obstacles - the child had no documents, no address registration and, therefore, no GP,” the nurse recalls. Thus, until the child could not be seen by a specialist, it was a major battle, mostly with institutions. But today, with the support of the nurses from the Center who helped through the entire process, Bozhidar went through eye surgery and now can see. 

The COVID-19 challenge 

The work of the nurses has not stopped because of the coronavirus pandemic, despite the risks. They continue to be in the field, on the front line, close to the families. 
"It is more challenging when you cannot visit the family in their  home as the contact is more difficult. But the strong relationship and trust built over the years help us and we have managed to adapt our work to the new challenges," says Lilka Koleva. The local organizations working with families at risk have already taken measures and, after a few meetings, they agreed on how to coordinate their work and support each other. 

Focusing on the main goal 

"Initially, when I started this work, I thought to myself – what is the purpose of this support that consists of visiting and talking with people," recalls one of the first nurses, Radostinka Penkova who was hired when the center opened. “But my very first case has changed my mind – I had to talk to and persuade  a pregnant woman to go for an examination, but she did not agree. Eventually, the case ended badly for the baby and the mother. Then I realized that convincing people, referring them to medical examinations so that the baby can be helped as quickly as possible, helping them do things that they are not used to, working for changing harmfull attitudes…those are all things that are very needed and extremely important," the home-visiting nurse ads. 

Cristian already attends kindergarten 
A patronage nurse from the Center for Maternal and Child Health in Sliven is visiting a vulnerable family
UNICEF Bulgaria/2016

"When it comes to a first child in the family, more support is needed, and especially if the child is not is showing developmental issues outisde the norm. The child is otherwise healthy, it just needs more support.”

- This is what Radostinka Penkova, a home-visiting nurse at the Center for Child and Maternal Health, says. For the past two years she has continuously supported Cristian and his mother in every step during their difficult journey after his premature birth.  
"We – me and his mother, talked about everything - nutrition, how to stimulate physical activity, massages, exercises. I advised her how to talk to him, how to engage him in play, taught her songs for him. This stimulates the development of the brain as well as motor activity ", explains Penkova. She added: “GPs simply do not have time for all this, they do not have the opportunity to pay as much attention to the child and the family. And today this connection between doctors and families is sometimes lost, especially when families live in small, remote villages. 
The nurse met Cristian and his family for the first time when he was nine months old and immediately noticed a delay in his motor development. This had not yet been observed  during consultations with the doctor or by theparents themselves. Even after rehabilitation in the municipal hospital, which was recommended by the home-visiting nurse, the child could not sit on his own unsupported.  
"Then we started with some exercises, different activities, games, new rehabilitation, and finally Cristian was able to stand up on his own. His mother had not  expected a positive change so quickly and  this encouraged her immensely," said the nurse without enthusiasm, as if talking about her own child. 
After this visible progress, she continued persuading the mother to let  child to go to the nursery - something quite unusual for their community. As a result, since the summer of 2020 Christian has been attending  the local nursery. 
"It was difficult even for me to imagine that we could achieve this together and prepare this little boy for nursery so that he can adapt and participate in life of the kindergarten. He needed special attention. But now this is a reality - it has happened,” the home-visiting nurse says with a smile. 

* Phase III is being piloted in Bulgaria, and 6 other Member States:  Crotia, Greece, Germany, Italy, Spain and Lithuania. 

This project is funded by the European Union. 
© UNICEF-Bulgaria, 2021 
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