Parteneri
Executive Summary
Executive Summary
The present report includes the findings and recommendations of the strategic assessment of policies and access to fertility regulation services, carried out in September 2005 in the Republic of Moldova.
The WHO Strategic Approach to the Enhancement of Reproductive Health Policies and Programs is the methodology we used to identify and prioritize the needs for reproductive health services and technologies, test the necessary interventions on the priority needs, and apply the successful interventions at the national level.
The assessment was performed by a team of 25 people, representatives of the Ministry of Health and Social Protection, National Scientific and Practical Center of Reproductive Health, Medical Genetics and Family Planning, “Nicolae Testimiteanu” SUMP, the Republican Association of Obstetrics, Gynecology and Family Planning, NGOs dealing with women and young people, mass-media.
The team members interviewed hospital directors, chief doctors, service providers and patients, local public authorities, representatives of the National Health Insurance Company, community members, including students and pupils, teachers, NGO members, representatives of churches and businessmen…
This report contains opinions and perceptions of all aforementioned groups regarding the quality of and access to services, prices, used technologies and availability of family planning and abortion services.
The strategic assessment was initiated by the MHSP and the National Scientific and Practical Center of Reproductive Health, Medical Genetics and Family Planning, as an important component of the implementation of the National Strategy on Reproductive Health for 2005-2015, with technical and financial assistance from WHO, Ipas, East European Institute of Reproductive Health of Romania.
The assessment consisted of an initial stage, when a general presentation paper was developed, a national planning workshop was organized, which approached issues related to general problems and strategic fields, the interview guidelines were formulated, the team members were trained on how to take interviews and make field observations, collect and analyze data, develop recommendations and draft reports. During the next stage the key institutions and people examined the report; the findings and recommendations were disseminated at a national workshop; the suggestions and recommendations that came up during the workshop discussions were intgrated in the report, which was finalized.
Background
After being legally recognized in 1955, requested abortion became the most common fertility regulation method. This phenomenon was mainly upheld by the hard access to modern contraceptives, population low awareness of the family planning, lack of post-abortion contraception and low motivation of doctors to provide contraception. Ignorance and fatalistic attitude towards health, tolerance of pregnancy interruption coupled with accessible abortion services are additional factors that made abortion the main birth control method. Moral principles that blamed extramarital and before-marriage pregnancy, disapproval of sexual education in schools, dissuasion of open sex-related discussions and pleading for a blaming attitude towards sexuality have created an appropriate social environment that fostered this phenomenon.
Immediately before the collapse of the Soviet Union, the Republic of Moldova ranked the sixth (the highest position ever attained) among the other 15 soviet republics with about 75 abortions per 1000 women of reproductive age. Since than, the official statistical data reveal a gradual decreased from 75 abortions per 1000 women of reproductive age in 1990 down to 17.6 per 1000 women in 2004, on the background of increased general use of contraceptives from 45 % in 1992 up to 73.3% in 2003.
The decrease in the official number of abortions is accompanied by low quality abortion services and a high rate of abortion-induced maternal mortality. Due to social, economical and educational reasons, there is a great number of illegal and unregistered abortions.
Reproductive Health is the priority of the Ministry of Health and Social Protection of Moldova, which launched in 2005 the National Strategy on Reproductive Health. This priority was also mentioned by UN and during the recent international forums and conferences: International Conference on Population and Development (Cairo, 1994); XXI Session of the UN General Assembly (New-York, 1999); The European Population Forum (Geneva, 2004). The National Strategy for Reproductive Health of Moldova was developed in strict compliance with the provisions of WHO European Strategy on Sexual and Reproductive Health and with the documents passed by international consensus.
Safe abortion is one of the priorities of this Strategy. The Reproductive Health Strategy, upheld by the findings and recommendations of the Assessment, stresses out the comprehensive family planning services and safe abortion services as a priority for program interventions.
Knowledge, Perceptions, and Value about Contraception and Abortion.
Prevention, Education, Information, Communication
The field interviews and observations, carried out by the assessment team members, reveal that the population finds contraception necessary and consider using family planning methods rather than abortion. There is good knowledge about contraception among youth and teenagers, especially in the schools that have participated in the pilot testing of Life Skills course. However, the general knowledge level is pretty low, especially in villages, where certain “myths” and wrong ideas about contraception and unwanted pregnancy prevention tend to circulate.
It is also worth mentioning that there isn’t any permanent EIC system on reproductive health: the school curricula don’t include any sexual education classes, or this information is delivered on an occasional basis, by the gynecologist during the preventive examinations. In villages there is absolutely no such educational activity on this subject. Schools and medical institutions lack or have a limited number of materials, booklets and brochures on contraception and safe abortion.
Only a small part of the community knows about the possibility of getting free contraceptives at the family panning services. Teenagers tend to avoid this kind of services because the confidentiality in not respected.
The modern contraceptives are regarded as unaffordable because of their high prices in the drugstores.
The attitude towards abortion is contradictory: some people consider it something usual in a women’s life, others – “a very risky surgical intervention by curettage, after which many women risk to become sterile”. Abortion is a taboo topic that can not be openly discussed in the society. There is low awareness of abortion services, safe abortion methods, the laws and provisions on this subject, prices or the ways of getting free access to such services by means of social-medical indication. Non-observance of confidentiality was reported as an obstacle to safe abortion, especially by teenage girls and women from rural localities.
The community’s attitude towards abortion and contraceptives is strongly influenced by the attitude of church which regards contraception as “a sin” and abortion – as “a murder”.
Most service providers believe that abortion is a simple routine procedure that doesn’t require too much attention. Many people regard the abortion as an income source for doctors, this being on of the reasons why abortions are not registered and post-abortion contraception is not provided.
The assessment team concluded that in order to improve the population knowledge on reproductive health, it was necessary to establish an efficient, continuous IEC system, with involvement from all the local public authorities, mass-media, schools, drugstores, NGOs, HCs, FPCs, medical gynecological assistants. The Ministry of Health and Social Protection and the Ministry of Education, having the leadership and coordinating the development and distribution of educational materials, should also implement the IEC quality monitoring and assessment system, and carry out the IEC system impact assessment.
Access to services. Socially Vulnerable Groups with Special Needs. Young People.
Abortion is accessible to Moldovan people and is provided exclusively by obstetricians – gynecologists in public in-patient or out-patient health care facilities. According to the laws in force, private health facilities have no official permission to provide pregnancy-related services, although, according to some respondent’s opinion, in some of them pregnancy termination services are provided.
The facilities that offer pregnancy termination services and the family planning centers are mainly placed in the urban area. Thus, the rural population has a limited access to this kind of services, coupled with the higher price of the services, since they need to travel form villages to rayon centers or towns. Although developed, the mechanism of providing women from socially vulnerable and rural environment with free access to abortion does not work. The eligibility criteria, used to determine the belonging to a socially vulnerable or rural category are vague and usually misinterpreted.
The prevalence of modern contraception is still much lower than in European countries, and the “youth friendly” services have only started to be implemented.
The still high number of abortions indicates an unsatisfied need of high quality contraception. The assessment team has found that the provided family planning services are of low quality and don’t meet the population’s needs, this being confirmed by the small variety of free contraceptives and the muddled system of their distribution from humanitarian aid.
Thus, the visited health centers lacked contraceptives for a long time, women didn’t visits the gynecologist for a long time and are reluctant to travel to rayon centers to family planning centers, because of the shortage of money.
Family doctors play almost no part at all in providing family planning services and distributing contraceptives.
The worst access to family planning services have women from socially vulnerable layers that don’t know where they can get contraceptives, but don’t even want to, because of the utterly low level of information, thus finding themselves in the “vicious circle” of unwanted pregnancies that end with giving birth to unwanted children and no means to raise them or with stealthy, often fatal, trial to get rid of these pregnancies.
Although the state bodies, the international organizations, and NGOs are trying hard to improve this situation, the members of the assessment team noticed that the teenagers and young people, as well as the underprivileged groups, have a limited access to the reproductive health services, contraception and safe abortion. There are no contraceptive or abortion services targeted at the needs of young people. They especially report the violation of the confidentiality when accessing these services, what forces them not to use contraceptives or seek clandestine services of pregnancy termination.
The curricula of all categories and levels of service providers lack training in abortion care, quality care; pre- and post-abortion counseling is paid insufficient attention.
Even in case of large accessibility of safe abortion services, in public or private health care centers, there are still illegal abortions. Health providers believe that a pretty high number of gynecological hospitalizations are caused by abortion complications, suggesting a high number of risky or illegal abortions.
The main recommendations of the assessment team developed in order to improve people’s access to services, use of contraceptives and abortion decrease are the following: optimization of the existing free contraceptives distribution system, involving the abortion services providing facilities, greater involvement of family doctors in the family planning system, standardization of the criteria of social vulnerability and providers’ and population’s familiarization with them, optimization of the access to free services mechanism for this social layers, especially in rural areas, “youth friendly” contraception and abortion services development.
In order to improve the general access to quality services a revision and adjustment of the providers’ training curricula is required as to include modules on quality abortion care and contraception at all training levels (colleges, university, post graduate, advances training courses).
Service Quality. Abortion Costs and Funding. The Private Sector.
The assessment team has found that most abortions are still made by curettage, control curettage being performed even after electrical aspiration, general anesthesia is used for pain control , local anesthesia standards are not observed, and universal infection prevention precautions are not known and observed by all providers. Dangerous, not recommended by WHO methods are still used for second-trimester abortion. Most post-abortion complications, particularly those that lead to maternal mortality, happen especially in late abortions.
MVA is used by a limited number of doctors and facilities; medical abortion is not available due to high cost and lack of official use regulations. The assessment team noticed a low quality service especially in communication and contact with patients: no pre-abortion counseling provided, non-observed confidentiality and privacy at all stages of health care, no post-abortion and contraception counseling provided, patients leave the center as uninformed as they enter it. Not providing contraceptives immediately after an abortion fosters the phenomenon of repeated abortions.
The team members noticed better service quality in day in-patient units of the visited out-patient and private clinics.
Prices for abortion differ in facilities of the same health care level. Usually the prices are not displayed and people don’t know them. The official abortion cost doesn’t cover all elements of the service. The doctor’s work is not included. Doctors are not remunerated for the paid services they provide. This causes contempt among them and prevents them from registering all abortions. The informal payments made directly to providers is a widespread practice, consisting of an additional amount besides the official cost or fully for the unregistered abortion, avoiding the official payment.
The costs of abortions provided to women from socially vulnerable groups on a free-of-charge basis are fully covered by hospitals. Hospitals managers and doctors are not acquainted with the abortion-related modifications in the Single Program since 2005.
The assessment team recommendations at this point are targeted at improving the service quality by developing and implementing the concept of “patient centered service”, including:
- Develop and approve standards and protocols regarding abortion during the I and II trimesters of pregnancy, pain control and infection prevention
- Standards on counseling and informing patients, informed consents
- Provide contraceptive counseling and post-abortion contraception in all health care facilities, and monitor their fulfillment
- Develop a patient appointment system in order to observe privacy and confidentiality
- Implement WHO recommended abortion methods at the national level: MVA or EVA with tissue examination and no control curettage, medical abortion methods for early and second-trimester abortions
- Develop out-patient services with adequate equipment and personnel training
- Develop a national quality monitoring and assessment system, health care facilities accreditation in order to assure a continuous service quality
- Define and unify abortion costs and procedures correlating them with clinical standards
- Estimate the real cost of abortion, with all required elements and doctor’s work
- Improve abortion services financial management by using a part of the finances from abortions for equipment an remuneration of doctors
- Set the same requirements and responsibilities for private facilities providing RH services as for public facilities and provide them with the same rights, including the possibility to be contracted by NHIC
Future steps
Based on the findings and recommendations of the strategic assessment there can be drawn conclusions about the following measures that will be taken in order to improve access to family planning and quality abortion services, increase their quality and people’s level of education on RH and enhance the abortion and abortion-induced maternal mortality prevention measures , improve of the reporting system, implement the monitoring system and consider the functioning of these services.
Thus, of great importance is the establishment of standards and protocols in abortion services in accordance with the EU standards and WHO recommendations, implementation of the national monitoring system, compliance with standards, and continuous service quality. Training the present providers and establishing a continuous education system on quality contraception and abortion care is also very important.
At the same time, increasing efficiency of the IEC work on explaining the population the benefits of using modern contraceptives, providing them with informative and contraception materials, mandatory supply with post-abortion contraceptives will diminish the number of abortions and increase use of modern contraception.
Improving efficiency of and access to free contraceptives for women from socially vulnerable groups, developing “youth friendly” contraception and abortion services, developing quality services, including out-patient services, will lead to an easier access to services, removing the existing barriers and illegal abortion, abortion-induced morbidity and mortality.
Implementing the recommendations on improving the management of abortion service providers, including the financial management, will help provide health care facilities with better equipment and consumables and decrease the number of unregistered abortions and informal payments.
Suggested operational studies: Study on reproductive health funding, study on the impact of free post-abortion contraceptives offer to all women, on community perceptions and attitudes towards distribution of contraceptives in public places, on the causes why women that resort to abortion do not use contraceptives and on causes of unregistered abortions. These studies will generate additional information for the Ministry of Health and Social Protection and other stakeholders and help them design the main interventions in the implementation process of the Assessment recommendations at a national level, being oriented towards improving RH in Moldova.
The Assessment team recommendations are included in each chapter of this report.