Parteneri
Chapter 3. Abortion and Contraception Enviroment in the Republic of Moldova
Chapter 3 Abortion and Contraception Enviroment in the Republic of Moldova
Overview on Moldova Reproductive Health State and Indicators
The Republic of Moldova proclaimed its independence in August 1991, after the collapse of the Soviet Union. The country is densely populated; with 4.2 million inhabitants in 2000, that are about 124 persons on a square kilometer. About 54 per cent of country’s population lives in the rural area. Agriculture and food processing industry are the main sectors of the economy.
About 700000 people live in the country’s capital – Chisinau. Republica Moldova este constituită din 36 de raioane, unitatea teritorială – autonomă Găgăuzia (Gagauz-Yeri) şi patru municipalităţi (Chişinău, Tiraspol, Bălţi şi Bender.) Women average at 52.2% of the total number of inhabitants, with the men/women rate of 100 per 109.
The Republic of Moldova is one of the poorest CES and CIS countries with a GIP averaging $370 per capita, and 35% of the population is under the poverty level.
The following demographic indicators wer e develop don the basis of a combination of the decreasing birth rates, increased mortality and emigration. During this period of time, the birth rate decreased by 53,39%, from 22.7 per 1000 inhabitants in 1986 dawn to 10.6 in 2004. The mortality increased by 18.8% from 9.7 up to 11.5 inhabitants. The natural growth of the population has became negative, diminishing from 13.0 dawn to (–0.9) per 1000 inhabitants. The general fertility during the same period decreased by 55.2% from 91.0 dawn to 40.8 newborns per 1000 women of reproductive age. Thus, in 2004, the total fertility rate decreased dawn to 1.25 births per woman and is much lower than the 2.1 threshold necessary for people's reproduction.
There was registered a diminution in the fertility rate in all age groups, especially older than 30 years – by about two times; hence the number of children in families is limited to 1-2 and the population aging coefficient increases (number of people over 60 years per 100 inhabitants) from 11.7 in 1985 to 13.9 in 2002.
The emigration is significant, especially the illegal emigration to Italy and other EU countries. Over 14% of the population, mostly the young age group, are supposed to have left for abroad for a job since Moldova gained its independence.
The major decrease in life expectancy at birth also contributed to the decrease in the number of population. In 2004 the average life expectancy averaged at 67.75 %.
Moldova doesn't have any integral monitoring and evaluation system for the process, impact, and result indicators in the family planning and reproductive health field. At present, there are used only a few impact indicators, which allow only partial assessment of the family planning and reproductive health field, such as:. the fertility rate, birth rate, conceptive methods use rate, the abortion rate (per 1000 live births), syphilis incidence, HIV/AIDS incidence.
There have been conducted only two studies on family planning and reproductive health at the national level: The 1997 Study on Reproductive Health in the Republic of Moldova (MoH, MCHCRI, DSSM, Family Planning Association of the Republic of Moldova, CCD Atlanta, UNICEF); and the Multiple Indicators Study (MICS), 2000 (UNICEF, Moldovan Government, NSPCPM) More recently, the Health for Youth Association, supported by the UNICEF, conducted in 2004 the Youth’s Knowledge, Attitudes and Practices Assessment Study (KAP).
These studies provided the following data.
The number of women of reproductive age suffering of different diseases is continuously increasing. At present each second woman reaches the reproductive age with a severely modified maternal terrain. According to statistical data, in 2004 65.6% of the total number of pregnant women had extragenital conditions, if compared to 59,0% in 1995 and 13.0% in 1980. As a rule, every second pregnant woman suffers of anemia, every third woman – of urogenital system chronic infection, every fourth woman – of digestive and cardiovascular system diseases. In their turn, according to the data provided by the National Scientific Practical Center of Reproductive Health, Medical Genetics and Family Planning, these diseases cause sterility in 12-15.0% of cases, infertility - in 15.0 % of cases, pregnancy complications - in 70.0% of cases and delivery complications – in 80.0 % of cases. The study confirms that over the last decade there was registered a three fold increase in the number of pregnant women caring complex extra genital maladies, which are health and life threatening both for mothers and their potential children.
A series of statistical indicators prove that in the Republic of Moldova the reproductive health has been in a poor state over the last years, in spite of some positive trends. In 2004, of the total number of supervised pregnant women, 3.3 % delivered prematurely, 5.0% had late toxicity during pregnancy, 11.6% – labor anomalies, 2.3% intrapartum hemorrhages, 9.1% had a caesarean division.
Still, contrary to these factors, a reproductive health study, conducted in 1997, stated that during that year, almost all the women (9950) benefited of perinatal care, 77% of which was performed at an adequate or even higher level.
The newborn’s health is also alarming. In 2004, 251,3 out of 1000 babies were born with different maladies (111.7 in 1986), including 22.3 with congenital malformations (if compared to 10.3 in 1986). It is worth mentioning, that these diseases are caused by the mothers` reproductive health state.
Though there has been recently registered a positive trend in the mother, perinatal and infant mortality, there level is still much higher than the European indicators. Thus, in 2004 the mother mortality averaged at 23,5 cases per 100 thousand live births, perinatal mortality - 11.2 cases per 1000 live births and infant mortality - 12.1 cases per 1000 live births.
The health of teenagers and young people is a key problem for the time being. . Studies reveal that over 70.0% of those working in this field suffer from different diseases. .
Tobacco, drug, and alcohol addiction has become worrisomely spread among teenagers and young people. These phenomena foster high rates of HIV/AIDS infection and sexually transmitted diseases.
The incidence of sexually transmitted diseases reached an alarming level. In 2004 there were registered 357 (253 on the right bank) HIV positive people and 53 (51 on the right bank) people infected with AIDS. The share of sexually transmitted HIV increased from 14.9 % in 2000 up to 48.2% in 2004. During the same period the number of HIV/AIDS infected women increased from 24.3% up to 45.4%. In 2004 there were registered 52 HIV-positive pregnant women (37 women on the right bank), 17 of which received preventive antiretroviral treatment, 30 pregnant women gave birth to children with a high risk of infection. Unfortunately, the information, education, and communication about STD and HIV infection is not a countrywide process, it doesn’t reach the population and is neither promoted nor supported by the mass-media. As the emigration level and fertility level increased, the birth rate decrease drastically.
At present the maternal health in Moldova is also adversely influenced by the high incidence of abortions. Up to present, in the Republic of Moldova, the abortion keeps being one of the main family planning methods, or the main method of birth rate control. In 2004 the abortion rate amounted at 437 abortions per 1000 live births (if compared with 995.0 in 1995). The abortion-related complications are regarded as the main reason for maternal morbidity and mortality, and the expensive treatment is another problem, given the limited financial resources.
Reproductive Health Policies
3.2.1 History. Legal and Political Environment of the Reproductive Health
When the republic of Moldova gained its independence, it inherited the reproduction and control methods used on the territory of the former Soviet Union, when the fertility level got suddenly reduced below the substitution level, the induced abortion was the main method of fertility control, and the modern contraceptive methods were underused. The ignorance and the fatalist attitude towards health, tolerance for avortion coupled with the high availability of this method can be regarded as the main factors that turned the abortion into the main birth rate control method. These methods were also shaped by the strong moral principles that condemned pregnancy before marriage and extra-marriage pregnancies, disapproving the sexual education in schools, discouraging the open discussions about sexual intercourses and pleading for a condemnable attitude towards sexuality.
It was for the first time in Moldova that the Reproductive Health and Family Planning was given the status of specialized medical service via the order Nr.89 of the Ministry of Health dated 17.05.1994 “ On the Organization of the Republican Service of Reproductive Health and Family Planning”.
This order mainly stipulated the provision of consultations for women from rayons and towns at the Mother and Child Health Care Research Institute, the Republican Center of Reproductive Health and Family Planning, and in family planning centers that comply with respective personnel lists and regulations.
During the next years the Concept on Reproductive Health and Family Planning was developed and consolidated in a set of regulatory and legislative acts of the republic of Moldova, such as:
- Ministry of Health Order no. 132 dated April 29, 1988 “On the Improvement Measures for the Gynecological Health Care in RM”;
- Ministry of Health Order no. 58 dated February 18, 1991 “On the Permission to Provide Surgical Sterilization Services to Women”;
- Ministry of Health Order no. 58 dated August 03, 1994 “On the Protection of People’s Health”;
- The Law on Health Care of 28.03.1995, No.411-XIII:
- Art. 31. ;
- Art.32. Voluntary abortion;
- Art.33. Artificial fecundation and the implantation of embryo.
- Ministry of Heath Order dated 10.01.01, No.232 “On Approval of the Regulation on the Minimal Requests for a Consultation in the Family Planning Center”
- Criminal Code of the Republic of Moldova, etc.
The state of health care system of the early 90s, imperiously dictated the need to develop a National Program of Family Planning Services and Reproductive Health Protection in the Republic of Moldova for 1999-2003, approved via the Moldovan Government Decision dated 8 June 1999, no. 527, stipulating a range of measures intended to develop a responsible attitude towards the sexual behavior, prevent unwanted pregnancies or high-risk pregnancies, protect from sexually transmitted diseases.
On the 24 May 2001, in order to assure a legislative and regulatory framework to implement this Program, The Parliament passed the Law no 185-XV “ On Reproductive Health Care and Family Planning”.
Over the past years the Ministry of health developed the health care structure, the appropriate normative documents and protocols, approved the list of primary medical records in the field of reproductive health and family planning.
Thus, the measures of reproductive health enhancement, recently carried out in the Republic of Moldova insured the development of the legal bases in the reproductive health field and the development of the national programs in the field.
Current efforts. The National Strategy on Reproductive Health
The above measures helped decrease the number of unwanted pregnancies and unsafe abortions, pregnancy-related mortality and morbidity. Implementarea Programului Naţional de asistenţă în planificarea familială şi protejarea sănătăţii reproducerii a contribuit, în special, la reducerea numărului de avorturi în republică şi la micşorarea mortalităţii materne. The modern birth control methods are used more frequently and hormonal contraception method is becoming more and more popular.
Unfortunately, the reproductive health in the Republic of Moldova is still under the level of present possibilities and requests. Maternal, perinatal and infant mortality exceeds the level of developed countries.
Along this line, the Ministry of Health, via order no.197 dated July 02, 2004, set up 10 working groups that, on the bases of the national legislative regulatory acts and international recommendations on the issue, developed the National Strategy of Reproductive Health for 2005-2015. The Strategy was discusses at the Republican Conference from July 20, 2004, approved at the sitting of the College of the Ministry of Health from August 24, 2004, minute no.11, approved via Moldovan Government Order no. 913 dated August 26, 2005, and published subsequently.
The Strategy was developed in compliance with the National Concepts, Strategies, Programs and Projects existing in the fields of public health, social assistance, youth education, human rights, prevention of domestic violence, sexual abuse and trafficking in humans etc.
At present the Strategy Implementation Program is being developed.
The Reproductive Health Strategy of the Republic of Moldova was developed in strict compliance with the the WHO European Strategy on Sexual and Reproductive Health and the documents adopted via an international consensus:
The chapter on Elimination of all Forms of Women Discrimination;
The Program of the International Conference for Population and Development and Cairo-5 Program of Actions;
The WHO Declaration on HIV/ AIDS Infection;
Beijing+ Platform of Actions;
UN Convention on Children’s Rights.
By developing and approving this Strategy the Republic of Moldova alines itself to the recommendations of the World Health Organization and the United Nations in the field of reproductive health.
The priority areas in the Reproductive health care field of Moldova are as follow:
- Family planning. The right to realize the reproductive function. Contraceptive options.
- Safe pregnancy. Preconception care. Perinatal care and diagnosis. Prevention of giving birth to children with congenital malformations.
- Teenagers and young people. Sexual and reproductive health among teenagers and young people. Services friendly to young people. Education in school.
- Reproductive tract infections. The prevention and management of sexually transmitted diseases and HIV/AIDS infection. Prevention and treatment of reproductive tract infections.
- Abortion. Secure abortion. Pregnancy interruption services. Post abortion conceling.
- Infertility. Infertility prevention. Infertility prevention and treatment.
- Domestic violence and sexual abuse. Prevention and management of domestic violence and sexual abuse.
- Trafficking in human beings. Trafficking prevention. Migration.
- Genital and breast cancer. Diagnosis and management of genital and breast cancer.
- Aged people. The sexual health of aged people. Counseling for menupausal women.
- Men. Men’s sexually-reproductive health
The Present Strategy aims at improving the people's reproductive health and providing the Moldovan citizens with the opportunity to fulfil their sexual and reproductive functions for them to reach a healthy sexual development and maturation and have safe sexual intercourses, have as many children as they want under secure and healthy condition, avoid contacting any reproductive or sexual diseases, benefit from high quality services in case of sexual and reproductive dysfunction, not to be subject to or affected by violence and other sexual and reproduction abuses.
General Objectives of the Strategy:
- Support couples and individuals in meeting their reproductive goals;
- Prevent unwanted and high-risk practices.
- Assure safe and legal conditions for abortions;
- Reduce the maternal and perinatal mortality and morbidity ;
- Prevent and manage the sexually transmitted diseases and HIV/AIDS infection;
- Improve the sexual and reproductive health of teenagers;
- Prevent and manage efficiently the infertility;
- Reduce the violence and other abusive practices related to sexuality and reproduction;
- Assure everybody’s access to quality, affordable, convenient, and acceptable reproductive health services;
- Enhance the conciliation, information, education, communication on issues of sexuality.
Health Care Infrastructure and Public Sector Services
3.3.1 Family Planning Service Organization
The Ministry of Health is responsible for the implementation of reforms from the health care system of the Republic of Moldova and for the management of the entire system.
The Ministry of Health is managing the health care system at the national level. The Ministry is collaborating with a range of national public institutions, such as 4 National Institutions (Institute of Mother and Child Health, Oncology Institute, Heart Disease Institute, Phthisyopulmonology Institute and Pharmacy Institute) and Scientific Practical centers, such as: Public Health and Sanitary Management Center, Preventive Medicine Center, Reproductive Health Center, Medical Genetics Family Planning Center, etc.
These public institutions provide technical and strategic support in specific health care fields, as established by the Ministry of Health.
Till 1998, Moldova was divided into 40 administrative rayons. In 1999 there were set up 12 administrative regions (10 rayons, Chisinau municipality and Gagauz-Yery territorial administrative unit). In 2003 the administrative structure included 2 municipalities (Chisinau and Balti) 32 rayons and Gagauz-Yery territorial administrative unit. In 1999 the health care services were organized in a decentralized regional (rayon) system. This is a major change, if compared to the previous centralized health care system.
Primary health care (defined as the first contact point of the consumer and health care system) was insured through a net of institutions. Between 1998 and 2000 the number of these institutions decreased from 1200 to 800 health care clinics and family doctors centers, traditionally used as referral points at highers health system levels rather than primary health care providers.
The establishment of secondary health care facilities was based on territorial principles: those 191 rural hospitals served about 10 000-15 000 persons; 32 central rayon hospitals (one per each rayon) and municipal hospitals for towns and cities. Each hospital had an affiliated clinic.
The third level health care is provided by country-level hospitals and specialized clinics, research institutions and some municipal high quality hospitals and clinics, most of them based in Chisinau. These health care facilities provide health services to the patients referred from rayons or by municipal health facilities.
From 1998 to 2001 the number of hospitals in Moldova decreased from 305 down to 65, and the number of beds was reduced as well – from 14.4 down to 6.5 per 1000 inhabitants. 195 hospitals (mainly from rural localities) got closed down. Moreover, 670 obstetrics were also closed during the period between 1998 and 2001.
In 2001 the Moldovan Ministry of Health employed 14 000 doctors and 32 406 assistants (except for the transnistrian region), with 3.3 doctors and 7.6 assistants per 1000 inhabitants.
According to the data from the Sanitary Management and Public Health Scientific Practical Center, in 2004, there were registered 10737 doctors, that is 29.8 doctors per 10 000 inhabitants (the obstetrics and gynecologists share stand at 593 and 1.6 respectively).
In order to meet the perinatal care needs in an rational and efficient way, in terms of financial expenditures, a perinatal health care service, consisting of country-level facilities and as a well managed network of municipal, rayon, community units, was established in the Republic of Moldova. By the general scheme, the perinatal health care service consists of a countrywide network health care providers of three different levels, which assures people’s access to health care at all levels.
Thus there was established a new structure of the obstetrical and gynecological health care system, consisting of three different levels operating in a concrete geographical region.
This level includes health offices, family doctor offices, and health centers, sector (rayon) consulting offices and maternity centers, that will activate till the completion of the heath care reform. The counseling centers in obstetrics and gynecology, family planning centers, family doctors centers and obstetric divisions of the sector hospitals from Drochia, Donduşeni, Ocniţa, Camenca, Briceni, Floreşti, Râşcani, Glodeni, Făleşti, Sângerei, Rezina, Teleneşti, Călăraşi, Şoldăneşti, Aneniii-Noi, Ştefan-Vodă, Căuşeni, Criuleni, Străşeni, Nisporeni, Cimişlia, Basarabeasca, Ialoveni, Leova, Cantemir, Contrat, Vulcăneşti, Taraclia.
Usually a family doctor office employs a general practitioner and 2 assistants, one of whom is specialized in perinatal medicine.
The the obstetric and gynecological offices of the counseling centers employ an obstetrician-gynecologist consultant and a midwife, the pediatric offices employ a pediatrician and an assistant. The FDC family planning cabinets employ an obstetrician-gynecologist and a midwife.
The primary maternity centers employ obstetrician-gynecologists, neonatologists, midwives and assistants for newborns.
The secondary maternity centers include perinatology centers formed on the bases of Central Municipal Hospital No.l, maternity center of Chisinau, municipal hospitals of Balti, inter rayon centers from Edineţ, Soroca, Orhei, Ungheni, Hînceşti, Căuşeni, Cahul and Gagauz Yeri" Territorial administrative Unit (Ciadăr -Lunga).
These centers employ obstetrician-gynecologists, neonatologists, and other highly qualified specialists, selected on a competitional basis, according to the approved personnel list.
The third level maternity centers include: the Maternity Mother and Child Health Care Research Institute, which employs specialists, scientific workers, university professors in the field of obstetrics, neonatology, pediatrics and other health areas.
The third level perinatal center (MCHCRI) provides perinatal services to women with physiological pregnancy, at the level of Chisinau judetz.
The National Company of Health Insurance contributes to the implementation of the National Program of Family Planning, covering the expenses of reproductive health services via the compulsory health insurance system, based on the contracts concluded between the Company and service providers. The Single Program of Compulsory Health Insurances includes services, provided by family doctors and doctors from the free-of-charge family planning centers. family planning counseling, including the choice of appropriate contraceptive methods, consultation on the reproduction system for people who intend to get married.
The reproductive health services are financed from the Health Insurance Fund and the state budget. The National Program on the assistance for family planning and reproductive health protection benefits has the biggest budget, if compared to other national programs. The programs implemented and approved by the Government are financed both by the state (for instance, construction, functioning and maintenance of family planning offices) and NGOs (for instance plenty of programs for young people organized both within and outside schools, and in clinics for women).
The private sector has a very insignificant role both in commercialization of contraceptives and provision of family planning services.
At present there is a trend to introduce the family planning service into a wider reproductive health service, consisting of counseling, information and other reproductive health services.
The educational curriculum doesn’t include compulsory courses on sexual education and contraception, by there are some initiatives developed by non-government organizations in collaboration with the Ministry of Health and Social Protection and the Ministry of Education, Youth, and Sports, aimed at training teachers and developing a comprehensive curriculum in this field.
The Ministry of Health developed and approved the structure of health structure and the list of primary health forms on family planning.
In this respect, in the Republic of Moldova there exist: The republican family planning service with a wide range of family planning offices (47 per total) located at the primary health care level in Family Doctors Centers and the Scientific Practical National Center of Reproductive Health, Medical Genetics and Family Planning. The services are provided by skilled obstetricians-gynecologists.
There is a full geographic access, the offices being located in all rayons and municipalities all over Moldova.
The reorganization and reform of the health system, promoted and carried out by the Ministry of Heath over the past the last years helped organize in 1994 family planning offices in every rayon and municipaality of our Moldova, train the entire personnel of family planning offices during many seminars and training courses. With the the support of international organizations, a wide range of successful seminars for the health personnel were have been organized over the past years. During the seminars the national experts were trained in family planning and didactic materials for health workers were issued.
The reproductive health services are mainly provided by the public sector, but there exist a small number of offices under non-government and private organizations providing the same type of services.
Since 1998 the family planning system has been structured in three levels:
- The first level – family doctors;
- The second level – municipal and rayon family planning offices;
- The third level - The Scientific Practical National Center of Reproductive Health, Medical genetics and Family Planning
3.4 Use of Contraception
The Moldovan patterns of family planning have common features with Russian’s and other former soviet countries. The fertility level decreased suddenly, it is lower that the reproduction threshold, while the induced abortion became the main method of fertility control and modern contraceptives were under-used. The relative isolation of the Soviet Union from the progress in the field of contraception influenced both the knowledge about contraception and availability of quality contraceptive methods. Combined with ignorance and fatalist attitude towards health issues, the availability and high tolerance towards pregnancy termination, the induced abortion was regarded as the main birth control method (Remennick L, 1991, Popov A, 1996). These methods were worsened by the strong moral principles that condemned pregnancy before marriage and extra-marriage pregnancies, disapproving the sexual education in schools, discouraging the open discussions about sexual intercourses and pleading for a condemnable attitude towards sexuality.
According to the official statistical data, over the past decade the contraception use rate increased from 45% in 1992 to 73.3% in 2003. Since 1992 the prevalence of modern contraceptive methods increased from 35% to 41.8%. The use of Oral Combined Contraceptive Pills increased from 1.4 % in 1990 to 7.9% in 2004, 19.9% of women use intrauterine devices and 2.0 % of women had their tromps strung.
. from 18,8% in 1990 to 29,8% in 2004.
According to the Reproductive Health Study in the Republic of Moldova, conducted in 1997 among 4023 women of reproduction age, 73.7% of interviewed women use contraceptive methods and 50.0% use modern contraceptive methods. The unsatisfied needs of modern contraception averaged at 29.0%. 38.4% of women of reproductive age use intrauterine devises, 5.9 % - using condoms, 3.4% - tromp string, 2.1%- oral combined contraceptives, 21.6% - coitus interuptus, 2.0% - calendar method. Per total, the efficient contraception rate averaged at 46.4%. At the same time 26.3% of interviewed women were not using any contraceptive method.
According to the 2004 Knowledge, Attitudes, Practices (KAP) Study only 45.6% of young people used the condom during the first sexual intercourse. Only 50.1% of the interviewed young people aged 15-18 use condoms, -20.6% - use contraceptive pills, -1.6% - IUD, 11.9% - the calendar method, and 8.6% - don’t use any contraceptive method. Thus, only 70.6% of young people use the recommended contraceptive methods (condoms and hormonal contraceptives). And 29.4% of young people don’t use any contraceptive methods or use only inefficient methods.
The use of birth control methods is influenced by the reproductive behavior and goals. The potential demand for contraceptives increases with ages, from 34% among young adults, to 76% among women aged between 25 and 34 and 74% - among women aged between 35 and 44. The demand for contraceptives is estimated at 79% for women in couples and 60% of all women. (6) The uncovered demand for contraceptives averages at 16.5 % among women aged between 15 and 24, up to 26% among women aged between 25 and 34 and 29% - among women aged between 35 and 44. (6)
Contraception Sources and Costs
As reveled in the study, the public health sector was the most important source of contraception (72%). The outpatient facilities provided the present method of contraception to 41% of married women. Additionally, the maternities provided 21% of women with contraceptives, while the contraception clinics (from urban area) and health centers (from rural area) provided -10% of women with contraceptives. By importance, the drugstores may be regarded as the second source of contraceptives, providing about 23% of women with contraceptives. The Hungarian COCP cost about $2.00 a month, while the German ones - $4-6. The intrauterine devices can be purchased in drugstores for $2.00-5.00 Another sales points (shops, street markets) provide 1% of women with contraceptives. Other sources, as partners for example, provided 3% of women with contraceptives while partners and relatives provided 2% of women. Sterilization was performed in maternity hospitals. The cost of intervention is MDL 180.00 ($ 15.00 ).
3.5 Use of Abortion
3.5.1. The Legal Framework on Abortion in Moldova
The on-request legal abortion, before 12 weeks of gestation was legalized in 1995. This law is still in force, with minor amendments. Additional regulatory acts were issued to introduce vacuum aspiration as a method of early abortion (Order 757, June 1987, MoH of Russia ), to allow the induced abortion at 28 weeks of pregnancy on the medical, genetic, judicial and social grounds (Order no.1342 of December 1987 MoH of Russia) and to allow the charged abortion in private clinics (order no.250 of March 1988, MoH of Russia). The Moldovan Government ammended the previous Soviet legislation in August 1994 (Order no.152), and legalized the abortions before 28 weeks of gestation. 152), permiţând întreruperea sarcinii până la termenul de 28 de săptămâni. New stipulations were issued in 1995, when Moldova approved the World Health Organization definitions of live and still births, when the legal limit for late abortion (on medical, genetic, judicial and social grounds) was reduced to 21 weeks. The abortion up to 28 weeks of pregnancy is allowed only in case of congenital syphilis or severe congenital malformations.
As per the 1994 Ministry of Health Order No. 152, the abortion via vacuum aspiration or dilatation and curettage is allowed before 12 weeks of pregnancy, carried out only in public inpatient facilities (the patient is hospitalized and released from hospital on the same day, provided that there aren’t any complications) and only by obstetricians and gynecologists.
The patient can be hospitalized on the basis of the referral from the obstetrician gynecologist or the family doctor and written results of compulsory laboratory tests: fluorography, tests on syphilis, gonorrhea and other genital infections based on the vagina smear. All genital infections must be treated before abortion, and the abortion procedure is allowed only is the treatment is completed. Acute gynecological diseases or other acute diseases also may be a hindrance to abortion. The HIV test is compulsory, but for a period of time it was performed only at women from risk groups. Since 2004 HIV test became compulsory for all women applying for abortion.
The abortion is performed via curettage; with vacuum aspiration being preferred. But the electric vacuum aspiration method was allowed only at 5-6 weeks of pregnancy (mini abortions), on the bases of compulsory pregnancy confirmation via ultrasound test.
Ordinul mai recent al MS (nr. A new Ministry of Health Order (No 103 of 07.04.2004) additionally recommended the use of MVA (manual vacuum aspiration) for abortions during the first semester of pregnancy and approved the Clinic Instructions on Abortion via Manual Vacuum Aspiration.
3.5.2 Service Organization
According to the Law, all the abortions must be performed in hospitals by obstetricians gynecologists. At present only three large Chisinau-based outpatient facilities (near hospitals or obstetrics and gynecology divisions) are allowed to perform such procedures (without a MoH Official Decision ). As revealed by the Study, most of the induced abortions, reported in 1992, were performed in gynecological centers (93%). About 5% were performed in maternities, where the abortion usually is performed on medical grounds, and 2% were performed in outpatient facilities.
There exist 53 abortion services providers in Moldova. There are 34 institutions in the regions of the country (located in the rayon Hospitals of the second level) and three facilities are located in the clinics (level 1). Eight facilities are within gynecological divisions of Municipal Hospitals, five – (level 1) in the Family Doctors center of Chisinau and there are three national level institutions. (Level 3).
There are some private clinics that provide abortion services.
The consent of parents is required in case of teenagers under 18, but this fact is not stipulated in any regulatory act on abortion.
The National Statistics and Information on Abortion
For decades, the level of induced abortion in the former Soviet Union was very high, one of the highest in the world. Given to mass acceptance and liberal legislative acts, the induced abortion was often regarded as an alternative to contraceptives to limit the number of births or to make a larger interval between births. Immediately before the collapse of the Soviet Union, the Republic of Moldova ranked the sixth among the other 15 soviet republics with about 75 abortions per 1000 women aged between 15 and 49 (Popov 1991). Since than, the official statistical data reveal a gradual decreased from 75 abortions per 1000 women of reproductive age in 1990 down to 17.3 per 1000 women in 2003, the ratio of abortions / live births amounting at 0.5. During the last three years the official data show an average of 16 000 – 17 000. This can be regarded as a super estimation of the denominator, which may not take into account the intense emigration of reproductive age women from Moldova during this period of time. This estimation represents about half of the value registered in the official statistics, showing a significant underreporting in the medical report system.
The total rate of induced abortion is of 1.3 per woman. The figure varies from 1.7 in Chisinau to 1.1 in the rural areas.
Unwanted pregnancies are the main reason for abortion. The 1997 Reproductive Health Study reports a high rate of unplanned pregnancies (33% of pregnancies registered during the past five years were reported as unwanted; 90% of them were terminated via abortion), and this fact suggests that there exist an unsatisfied need for contraception. The same study reveals that the reason for most abortions (57%) was the precarious social and economic state, 28% - in order to limit the number of children, 7% - because of partner’s decision, and a very small number of abortions were performed because of the medical conditions (8%).
Table 4
The Frequency of Abortions in the Republic of Moldova
Indicii Years
1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004
Number of live births - - - - 51840 51217 46793 38924 37672 36452 36258 36509 38272
Total number of abortions 71430 64178 58777 57181 46010 37137 31293 26240 24647 16028 15739 17551 17965
“Mini” abortions (%) <7 weeks 27,2 29,5 26,6 22,6 21,3 25,4 27 30,5 37,2 30,5 32,2 35,1 36,6
Spontaneous abortions (%) 13,5 13,9 14,3 13,5 15,5 18,5 19,9 21,3 20,3 26,1 26,9 22,5 25,3
Legal” <12 weeks. (%) (%) (%) 55,8 52,8 55,3 59,8 58,1 51,5 47,8 42,1 36,8 36,9 34,3 34 31,7
Medical 24-25 weeks t. (%) (%) 1,8 2,3 2,2 2,3 2,8 3,2 3,8 4,5 3,8 2,3 2,5 2,4 0,41
Criminal (%) 0,1 0,05 0,1 0,1 0,1 0,1 0,1 0,2 0,3 0,02 0,03 0,04 0
No answer (%) 1,6 1,4 1,5 1,7 2,2 1,3 1,4 1,4 1,6 0,5 0,5 0,4 0,5
The early abortions via vacuum aspiration were approved by the Ministry of Health via Order no 152 of 1994 and were recommended as a strategy intended to reduce the abortion-related morbidity.
Terms used in the Ministry of Health statistics: mini abortion, legal abortion, medical abortion, criminal abortion are not described or specified in the regulatory documents.
3.5.4. Abortion-Induced Maternity Mortality in the Republic of Moldova
The maternal mortality decreased from 52.89 in 1993 to 23.5 per 100 000 live births in 2004, but still it is very high in comparison with other European countries.
Source: WHO, HFA Database (Health for All / Sănătate pentru toţi) , 2004
The main causes of maternal mortality are the following: abortion-induced complications (30.3%), hemorrhages (19.7%), septic complications (18.1%), and pregnancy-induced hypertension (11.2%). Most deaths occur in rural localities (75%) and each fourth death occurs at home (25.7%).
In comparison with the previous years, the rate of abortion-induced maternal mortality diminished in 2004:
Table 5
Maternal mortality per 100 000 live births
1996 1997 1998 1999 2000 2001 2002 2003 2004
Live births 51 840+ 51 217+ 46 793+ 38 924 37 672 36448 35705 36472 38273
Total number of deaths 40.2 48.3 - 28.6 27.1 43.9 26.4 21.9 23,5
Number of direct deaths 13.2 11.5 - 15.6 21.7 - - 19.2 18.3
Pregnancy/delivery-induced deaths - - - 13.0 21.7 - - 11.9 15.7
Abortion-induced deaths 11.5 8.8 - 2.6 0 8.23 5.6 7.3 2.6
Indirect maternal deaths 17.2 24.1 - 13.0 5.4 - - 2.7 5.2
Source: Personal discussions with representatives of the Ministry of Health and Social Protection, Republic of Moldova
However, this indicator is much higher than the EU and CIS average and doesn’t have any sign of improvement, as for instance in Romania, which has the highest rate of abortion-induced maternal mortality, and the CIS average (Figure 2 – a comparison between the average maternal mortality rate in Moldova with the EU, Romanian, and CIS average).
Figure 2 Abortion-Related Maternal Mortality per 100 000 Live Births
Source: WHO, HFA Database (Health for All / Sănătate pentru toţi) , 2004