Parteneri
Chapter 6. Access to Services
Chapter 6. Access to Services
6.1. Access to Contraceptives. Services and supply
Findings
Generally speaking the access of the population in the Republic of Moldova to contraception services is satisfying. Chemists offer a large number of contraceptives of different types and mechanisms of application. The population considers the prices to be accessible. Contraceptives are freely available in chemists, without prescriptions, including pills for urgent contraception.
It is clear that for adolescents and some social groups contraceptives price is not accessible. Contraception access is also limited due to confidentiality non-observance within the distribution system, namely for the young, and lack of information about places where contraceptives can be obtained.
In general the evaluation team has noticed that family planning services do not correspond to population necessities, a fact proven by unsatisfactory information of population, consultation low quality, a limited range of gratis contraceptives and a confusing system of distribution from humanitarian aid.
The evaluation team aimed to investigate how the system of family planning services and contraceptives distribution works.
Contraceptives for gratis distribution are acquired by MHSP from humanitarian aid donated by UNFPA and other sponsor-enterprises. They are deposited at Dalila Health Centre, since MHSP does not own a warehouse and it is forced to rent one. NSPCRHMGFP distributes contraceptives further to republic municipalities and regions, transporting them from Dalila Health Centre to another regional localization pointed by local hospital administration. The decision regarding the number and type of contraceptives is made on the basis of application form that is filled in by region family planning manager. The latter submits the form on the basis of data about contraceptives used last year. In regions contraceptives are distributed to local hospital chemists, to voluntary chemist’s of regional hospital, from where they are further dispersed to family planning centers. In some regions there has been established the fact of contraceptives further distribution to rural health centers. Sometimes contraceptives were distributed to consultation departments, gynecology and confinements, at the insistence of local medical specialists.
Family planning centre gynecologist decides on contraceptives gratis distribution basing on his personal knowledge about women of socially vulnerable groups, on lists presented by rural family doctor or his assistant who know better women of social or medical risk from the community.
Women from rural areas or regional centers, who ask for gratis contraceptives, are referred to the nearest family planning centre. In case contraceptives are available, women that correspond to gratis criteria receive contraceptives immediately.
The evaluation team has found out that some family planning centers did not have gratis contraceptives either because of their distribution only to chemists or due to full lack of deliveries for a long time.
In case family planning centers do not have contraceptives, the woman is referred to voluntary chemist’s or regional hospital chemist’s of family doctor Centre with a prescription signed by family doctor, the head of family doctor Centre and gynecologist.
Sometimes family planning doctors or gynecologists visit villages and bring contraceptives destined for distribution to women of these groups.
In its attempt to estimate the level of satisfying the necessities of rural population, the evaluation team has also found out that contraceptive distribution system either works inadequately or does not work at all.
Thus, there have been no contraceptives in the attended health centers for a long time (for several months or years), and women did not visit planning centers because they did not have money or did not want to go there.
A gynecologist and a family doctor had sporadic or no visits at all, although these were planned and registered in the corresponding books. Usually gynecologist visits only those villages that he is in charge of.
There were no women found that had received gratis contraceptives, although they were registered in family planning centers books.
In some rural areas, even in private chemists, there are no contraceptives but for condoms, and sometimes even these are short (and they motivate with lack of demand on behalf of the population).
In Chisinau, in family doctor centers, in family planning centers, those who render these services have declared that they always have contraceptives available for gratis distribution.
Family doctors do not play practically any role in offering family planning services and distributing contraceptives. This was motivated by lack of knowledge on this field, training deficiency, and doctors’ exclusion from contraceptive distribution system. But the interviewed family doctors have displayed their interest in having a greater family planning role, and their assistants, namely the former “midwives”, seemed to be well instructed in the field of contraceptive methods and even willing to offer contraceptive coil services. It also seemed that the assistants knew much more about the situation in rural areas and the necessities of women of socially vulnerable groups.
Many representatives of regional hospital administrations have expressed the opinion about the necessity to re-introduce “midwife” specialty in public health system; some of them presented concrete training and local budget financing plans.
At the same time there has been noticed a great necessity of family doctors (the personnel constitutes only 20%). A family doctor receives up to 60 patients per day, treating different types of problems. Sometimes several doctors consult patients simultaneously. Thus they hardly find time for family planning. The doctors think that their efficient involvement in IEC implementation is only possible through creating or re-vitalizing health centers, cultural centers, having full support of mayors.
There have not been found any community groups (adolescents from schools or students) which have systematically received gratis contraceptives. The interviewed group representatives declared that they knew nothing about their rights and where to ask for assistance.
Those who render these services could not also name the criteria that define a group to benefit of gratis contraception.
Post-abortion contraception (see chapter Abortion)
Recommendation
- To maximize the working process of contraceptive gratis distribution system destined for population: to train a logistic management system, to improve distribution monitoring
- To enrich the types of contraceptives. To distribute contraceptives on the basis of population necessities and not on the number of inhabitants.
- To improve the efficiency of condom and contraception supplying program, including a partial distribution from public sector; to organize condom gratis distribution to adolescents and groups of the young placing contraceptives in accessible areas (MFC halls, schools and other institutions toilets, cafes and bars…).
- To form a logistic system of contraceptive acquisition and distribution and to cover the costs from insurance.
- To create adequate conditions in order to enlarge the number of family doctors and their assistants in the process of rendering family planning services, active contraceptive distribution through primary medical aid, especially in rural areas.
- To provide contraceptives for institutions that render abortion services, and their distribution should become an indispensable component of abortion services.
- To standardize social-vulnerable criteria, and to inform about them the population and those who render such services
6.2. Access to Abortion. Services and supply
Abortion services are mainly rendered in Moldova by public medical-sanitary institutions, such as: gynecology and pregnancy pathology departments of regional, municipality and city hospitals and some family doctor centers in Chisinau. There several private clinics and centers that render abortion services; the latter being performed only by obstetrician-gynecologists.
Managers and those who render such services have noticed that just recently services have been rendered in out-patients clinics and forbidden at present. The administration explains this fact by its concern to reduce the number of non-registered abortions and complication threats. But those who render these services do not agree and are inclined to think that the reasons for it were personal likes and dislikes, guarantees of occupying hospital beds for a whole day and financial benefits from services fees. When being performed in out-patients clinics, on the contrary, the whole number of abortions have been registered, confidentiality and service quality have been respected, and doctors took greater risks in some complication cases.
Hospital directors consider that ban on abortion has contributed to its secret performance that leads to much more complications.
In general women know where they can resort to for abortion services. But the information on abortion access (place, cost, medical personnel etc.) is obtained within community framework, among women, from non-medical sources.
It should be mentioned that women from rural areas have to drive to regional centers every time, sometimes oftener; they should also pay the road fee and it takes them 2 or 3 hours to get there. Thus services access in rural areas is more difficult than in urban areas where there are more medical institutions concentrated in one sector. Services access is much more difficult for poor women, from socially vulnerable groups. Lack of money necessary for both the trip to the regional centre and abortion result in criminal and self-induction abortions and infanticides, according to a village family doctor assistant, “they have proved at USG that she was pregnant 30 weeks ago, but now she has got rid of the baby and does not want to say what she has done with it. I think that she has buried many corpses in her garden”.
Sometimes women consult family doctors or gynecologists of MFC to make investigations and to receive an abortion referral. Often they resort directly to a gynecologist who performs the necessary investigations and, a bit later but on the same day, the abortion in gynecology department. It is evident that this method is used by those women who pay for these services.
Although the mechanism of gratis abortion access for women of socially vulnerable groups and from rural areas is developed, practically, it does not function. It has been proven that those who render these services are not informed about the introduction of a Combined Abortion Program, of medical-social indications and abortion complication cases, and about the fact that in such situations the hospital can reimburse the abortion cost from CNAM. The doctors do not know how to do all these things and insist that women of these groups should pay even for a spontaneous abortion or of abortion-related complications.
Services access is practically impossible for these women. In case a woman with no livelihood asks for gratis services, she is to resort to family doctor or his assistant, to take a certificate from mayoralty and consultative board of MFC that issue a referral. Sometimes a woman receives this referral when she is already waiting in the department, and medical documents are being filled in on the spot, thus the necessity of having many roads for a woman disappears. This method is often used by those who think that the consultative board activity violates confidentiality, especially when speaking about adolescents and first abortion.
None of interviewed woman knew the mechanism of obtaining gratis abortion services and contraception and where to resort to.
There has been noticed from interviews with health managers and with those who render these services that the criteria of defining socially vulnerable groups are still vague and are often misinterpreted. There have been appointed the following:
- Women with many children
- Poor women (with a document from mayoralty)
- Spinsters with children
- Imprisoned Husbands
- Minors
- Women having a reversible effect
- Women with somatic diseases
There is expressed an opinion that these criteria have been established by a board whose members should indispensably be supplied with a lawyer .
The evaluation team also failed to find out from specialists of corresponding institutions (MHSP, NHIC) these criteria and their demonstrative requirements and to see the regulatory documents which settle the exact mechanism of rendering gratis services.
Another important fact noticed by team members is a complete absence of cooperation among abortion and other types of services: like in many other cases, women, after having an abortion, are not offered contraception means and do not benefit of social assistance; all these maintain the vicious circle of their social problems and of reproductive health as well.
During a visit to a medical institution the evolution team has interviewed some patients in gynecology departments admitted for abortion services, and adolescents, several of whom without any income, who were to pay off services in full. They have not been informed about the possibility of having abortion services and contraception gratis.
True Life Stories:
A woman of 23, admitted to the gynecology department for a third abortion. 12 weeks pregnancy. She is from a village but works in a city bar for a salary of 300 lei; she is often exposed to sexual violence at work. She paid 260 lei for abortion, the money taken from her mother who also brings up two schoolchildren. In order to help her, her mother sold apples. She knows nothing about contraception but cannot afford to buy any. Nobody discussed the matter with her in the department or offered her any means of contraception.
She plans to go to Russia to stay with some relatives in order to earn more money.
An adolescent of 16, admitted to the department for the first abortion with her sister. Her boy-friend does not know anything about her pregnancy, she was ashamed to tell him. Her parents work abroad. Her sister has a baby; on hearing about her sister’s pregnancy, she borrowed some money and took her to the doctor whom she herself had consulted previously. They wanted to pay 160 lei for abortion. They knew nothing about the possibility of being released from payment. Nobody offered them any means of contraception after abortion.
Recommendation
- To evaluate the function and the quality (or explanation) of social-vulnerability criteria and of their demonstrative mechanisms as well by persons responsible for gratis services. To study the experience of other countries in the field of establishing criteria of socially-vulnerable groups (e.g. in Romania).
- To implement the experience in this field in order to define the degree of vulnerability not only according to quantity criteria (the number of children in a family etc.), but also to that of quality (the peculiarity of the group for which it is worked out).
- To develop the mechanisms of involvement of social assistants in cases when women of socially vulnerable groups resort to reproductive health services for social assistance.
- To train social assistants in the field of public health
- To maximize the mechanisms necessary to obtain gratis abortion services for socially vulnerable groups and to reimburse the institution the abortion costs for non-insured persons from CNAM reserve fund.
- To render gratis contraception, to cover the costs from insurances, after abortion, to women of socially vulnerable groups and adolescents.
- To train a permanent informative system for population, especially for socially vulnerable groups, concerning gratis services (by means of notices, advertisements, booklets, Mass-media announcements, family doctor information)
- To initiate a close cooperation among abortion services, family planning services and other reproductive health services (a comprehensive assistance).
6.3 Training Suppliers
Findings
Since “access” is closely related to the capacity of health workers to render quality services that correspond to modern scientific achievements and both EU and WHO standards, the evaluation team has set the task to examine the situation of university and post-university doctors training and of colleges as well, but after graduation – medical assistants and midwives in the field of family planning and contraception.
There have been noticed some changes in student curricula since 2002 at “Nicolae Tesetmiţan” Medical and Pharmacy School, for 4 and 5 year students; due to cooperation of “Reproductive Health Training Centre” NGO, there has been initiated a course (2 hours) of contraception with 6 practice hours destined to family planning and abortion. The theme on “Abortion modern technologies. Pre and post abortion advice” is included in curricula. Practice hours are held in a clinic where the MVA method is implemented and where students can make acquaintance with this method.
Curricula for obstetrician-gynecologist residents lasts 4 years, 4 seminars reveal precocious abortion, 4 seminars – Late abortion, and 3 courses inform about abortion.
Curricula lacks training in entire period abortion care and care quality. Pre- and post-abortion advice is paid little attention to.
There are no books that reflect peculiarities of these theme.
The residents learn to make abortion when they are on duty, practicing on patients who ask for spontaneous abortion.
According to statements of men in charge at medical colleges, training and retraining programs for medical assistants and midwives contain a sufficient number of classes concerning family planning and abortion. But in the process of evaluation it has been found out that there is a disparity between the courses written curriculum and the real facts, as well as between the assistants little knowledge and their will to enrich it. The assistants expressed their dissatisfaction at holding the retraining course only every five years. In fact, only the institution appointed midwives attend these courses. Hardly any assistant from a rural area can attend a retraining course. Midwives are motivated to take more responsibilities on conditions of taking a corresponding training course. There has been expressed the opinion that those who want to attend retraining courses can do it for a fee.
The retraining course for family doctors does not cover the abortion theme at all, mentions casually the contraception theme within the frame of 30 minutes, and is presented sometimes in Russian.
There have been held sporadic courses for family doctor training in the field of family planning.
Retraining programs for obstetrician-gynecologists do not contain abortion theme at all, and the training in this field often comes to halts. Questions on this subject are not included in exams for medical categories. There are no definite abortion performing criteria.
Some health workers declared that they had practically not been trained in the abortion subject for several years. The training is mainly a matter of self-instruction, on the basis of materials borrowed from their colleagues who have attended the respective courses. Some of them spoke about their participation in training courses at MVA and medicinal abortion in Chisinau. But not all of those who have attended these courses render abortion services.
On analyzing the information presented above, the evaluation team has come to the following conclusions: there is no systematic training for health workers, the under-level quality of training program and inadequate selection of course attendees in the field of fertility regulation services cause low level of knowledge of health workers at any level, limited access to such services and low quality of abortion and family planning services.
Recommendation
- To adjust the training curricula for health workers in the field of abortion and contraception, according to EU standards and WHO recommendations.
- To revise and adjust the training curricula for health workers: to include module in abortion and contraception at all training levels for health workers (in colleges, institutions, post-university, retraining course)
- To hold at national level training seminars for health workers who nowadays render abortion services regarding the entire period abortion care and to develop abortion methods recommended by WHO (to train organizers capable to instruct health workers at national level and to retrain them regularly). To restrict the selection methods of persons appointed to ICA training courses.
- To monitor and evaluate the implementation of training courses. To carry out evaluation studies on the impact of curricular changes.
6.4 Illegal abortion
Findings
In Moldova an illegal abortion is considered an operation performed out of a medical institution, by untrained persons or one that exceeds 12 weeks pregnancy, without any necessary dispositions stipulated in MHSP regulatory documents.
Though safe abortion services are available in private and public facilities, there still exist a number of unsafe, illegal abortions (18 registered in 2003, according to the statistics of the Ministry of Health). There are no statistics on illegal abortions performed out of clinics or lawsuits against persons without respective medical training. Nevertheless the data available demonstrate that quite a big number of admissions to gynecology departments are related to abortion complications, revealing a big total number of illegal and risk abortions (but according to health workers illegal abortion complications happen seldom). The exact percentage of illegal and unregistered abortions is not known, still it is estimated at about 2-50%.
People, local administrative authorities and doctors know about illegal abortion, but think that nowadays women resort to it not so often as for the last few years.
The methods that women use to interrupt an unwanted pregnancy are the following: exceeded dose iodine usage, utilization of veterinary medicine that induces animal birth. There have been found out some cases of using home self-induction with Misoprostol by women who worked at a private factory and by those who were refused II semester abortion.
True Life Stories:
Director of perinatal centre: There has appealed a woman that was 22 weeks pregnant, she returned recently from Moscow where she had been working. The board rejected her because of her long-term pregnancy. A week later an ambulance brought this woman, with the uterine cervix 6 cm opened.
The persons interviewed named the following barriers to legal abortion access: the requirement to present a special board resolution permitting II semester abortion, which violates women’s confidentiality and postpones the abortion until illegal resort; poor information distribution and limited access to contraception, lack of information about the population rights, possibilities to obtain gratis or long-term services, illegal abortion risks, poverty, high prices.
Quotation, health worker, hospital director: Forcing a woman to appeal to different committees violates her rights.
There is an opinion that barriers to legal service access present a good source of benefit for some health workers since the cost of Late abortion varies from 300 to 500$.
The “waiting period” between the first consultation and the abortion procedure is also classified as “a barrier” by health workers, the reason for this being useless investigations.
The other reasons that force women to resort to illegal services are lack of support on behalf of husbands or partners, and of the whole of society.
Recommendation
- To develop IEC system for population concerning its rights, access, information about service prices, illegal abortion risks, abortion prevention.
- To simplify the procedures destined to abortion during the II semester of pregnancy