Parteneri
Chapter 7. Quality of Service
Chapter 7. Quality of Service
7.1. Pre abortion information and advice. Informed consent
Findings
Objective, complete and non-accusing information presented to a woman before the procedure, according to WHO recommendations, is an indispensable part of abortion care period. The notion of advice includes discussions and offers concerning all options of pregnancy, confirmation that the decision to resort to abortion is definite and consciously taken by patient, without compulsion on behalf of anybody, estimating feelings and taking into consideration patient’s fears and her spirit.
The evaluation of reality showed that patients, practically, did not receive any advice except in some rare cases when abortion was performed in a city clinic, by a doctor who had attended MVA courses.
If any discussion is held, it is often reduced to attempts to convince the woman to keep the pregnancy, using unjustified reasons and threatening her with risks of having no children.
On having abortion, a woman does not visit the doctor any more, and remains ignorant about normal post-abortion symptoms, fertility return or where to resort in case of ominous symptoms and which are they.
Written information or report after abortion is not offered,
Lack of information before abortion is motivated by the fact that none of the women interviewed could define the abortion method previously used or present any piece of information on discussion with doctor before abortion. Not a single woman was informed about contraception or utilization of a contraception method after abortion. “What are you going to do?”-asks the patient. “You’ll see”-answers the doctor.
Many women think that they had abortion-related complications which appeared as “hemorrhage and abdomen pain”, but which, actually, were normal post-abortion symptoms.
Health workers do not know the notion of advice, others think it is unnecessary; the attitude towards patients is very paternalistic, due to which the doctor imposes his own decision as being the best one, thus the woman does not have the possibility to choose the abortion method or anesthesia.
Some health workers consider that women should get advice from family doctors who make referrals and know those women better.
Medical assistants showed interest in their larger involvement in communication process with patients before abortion.
Health workers do not know that there is advice guide and The MoH Order no.103 of 2004 on advice and do not have any.
An informed written consent is used only in some clinics, but it does not specify the details related to abortion, and the patients often do not read it and sign it formally.
But even health workers do not understand the meaning and importance of this document and pay little attention to it.
Quotation, patient in a public institution, who resorted to abortion service :”people practice this way – they go to the doctor, give the money beforehand, then the doctor tells them to lie down, and only he knows what is happening”.
Recommendation
- To introduce obligatory standard advice as an indispensable part of abortion procedures. To organize training courses on the base of national financial support both for gynecologists who practice at present and for family doctors.
- To inform the patients about their rights to obtain pre abortion information and advice and post abortion contraception.
- To introduce the module Advice in training curricula for health workers at all levels.
- To draft, approve and issue a standard informed consent form for all abortion services and all institutions in the country.
- To draft, approve, and distribute systematically informative materials about abortion in order to have them always available and in all institutions. To consider advice as one of accreditation criteria for medical institutions which render abortion services.
7.2. Abortion procedure
7.2.1. General aspects
Findings
The evaluation team has revealed a great divergence in quality of abortion procedure offered in visited different public and private institutions.
The evaluation team has registered lack of standards, protocols and guides related to abortion care system. According to WHO, other organizations (Ipas), the concept “abortion care” includes:
- Relation, interaction with other services to which a patient resorts for the first time: with family doctor, family planning service, other reproductive health measures, service to combat family violence etc.;
- Information and possibility to choose abortion method – manual or electric vacuum, medicinal;
- Advice and rendering contraception methods immediately after abortion;
- Post abortion care measures, reference to other health services.
The evaluation team has noticed the lack of this concept in the Republic of Moldova, and a pressing necessity to establish an efficient monitoring system for structure function in order to guarantee basic quality standards of abortion care
7.2.1.2.Places. Flow of Activities
Abortions are performed in public health centers and private institutions.
As a rule institution facilities satisfy population requests, nowadays there is a smaller number of abortions. In general services are rendered without delay, there is no agglomeration and queues.
The general situation in gynecology departments of visited public hospitals varies from deplorable to quite good. The majority have been recently redecorated, cleaned and equipped satisfactory. Abortions are performed in procedure wards destined and equipped respectively, kept clean (not sterile) and held in accordance with stipulated regulations.
During evaluation there have been visited departments that have not been repaired for a long time, with worn out walls, partially torn linoleum, without running water, damaged toilets, etc.
Although the administration of these hospitals declares that mother and child’s health is of greater priority, the equipment for abortion procedure has not been changed or renewed for 20 years.
There has been registered a great divergence between general situation in obstetric departments and gynecological ones of the same hospital, that proved mainly to depend on the attitude of head department, without hospital administration involvement.
At the same time the department heads declared that redecoration and equipment purchasing in departments had been carried out exclusively by medical staff which had collected the money for this purpose, including some patients’ money.
The conditions of abortion procedures vary considerably, since there are no standard requirements for these institutions equipment.
There are no separate places destined for advice rendering, guaranteeing also to respect confidentiality.
As a rule patients take from home bedclothes and underwear, dressing-gowns and slippers, towels and sheets for gynecological table, sometimes gynecological gloves and syringes. Health workers accept these as natural things. Some institutions offer underwear and clothes, but worn or dirty. Only private institutions offer absorbents after abortion.
There are no separate beds destined for abortion in departments, they are of general use for all patients. Thus patients admitted for abortion are placed in wards with other women who receive treatment for keeping pregnancy. In some departments these patients are offered separate wards where they wait for the procedure, but here there are also women of post-abortion rehabilitation. All these lead to women anxiety growth and stress related to the procedure.
Many health workers have mentioned that patients admitted to abortion services do not represent a priority; doctors accept them after their daily routine: visits, operations. Sometimes women can wait for hours, until the anesthesia team discharges of other duties to offer general anesthesia to patient.
Only private clinics offer programming. Women are admitted when they appeal and if equipment is free. This leads to hours of awaiting, and sometimes women do not receive services in the same day when they appeal because sets of instruments are used up. Thus there can be performed 7-8 procedures in gynecology department of a city hospital, and none – in other departments. All these influence the procedures quality and universal cautions observance intended to prevent infections.
Recommendation
- To develop equipment and function standards for medical units which render abortion services, with obligatory facilities such as: waiting room separate from a rehabilitation one, rehabilitation ward with sufficient number of beds and chairs, underwear and bed-clothes and other necessary attributes, advice room, toilets in a satisfactory condition, contraception for distribution to all women. These requirements should form the accreditation criteria for all institutions.
- To establish a programming system for patients in order to avoid long hours waiting or refuses after women’s resorts
- To establish a system which helps patients to appeal to other reproductive health services, social and psychological assistance as well.
7.2.2. Personnel competence
Findings
Members of evaluation team have established the fact that although health workers’ knowledge does not correspond to modern concepts, general competence of doctors and medical assistants is quite good.
Residents learn to perform the abortion within the first surgical procedures. Obstetrician-gynaecologists consider abortion to be simple and routine. And generally speaking, doctors do not regard their patients’ information and advice as being a problem but rather as an indispensable and very important procedure. The most important criterion of a doctor competence, according to their own opinion, is lack of abortion-related complications cases.
During supervision of abortion procedures, members of evaluation team have found out that all health workers possess strong surgical abilities. Procedures are performed quickly, “non-contact” technique is respected, tissues are treated carefully. But at the same time it has been proven that almost every health worker has his own “standard” of abortion procedure which can be explained with good reasons, basing on his own ideas and believes. This is related to all procedure stages: patient admittance, technical details and post-abortion supervision. In fact, the variety of attitudes, perceptions, knowledge of medical personnel is linked, in general, to fertility regulation, contraception or abortion problems. “Myths” and retrograde ideas among health workers lead to underestimation of importance of contraception, limited usage of modern methods concerning prevention of unwanted pregnancy and abortion.
Health workers agreed that in this field standard training for unification of knowledge and ideas is imposed imperiously.
Thus it has been shown the urgent necessity to develop standards, guides and protocols, and health workers training, distributing modern and fact-proven information, but also in force standards, guides and protocols observance.
A great reserve for amelioration of the population access to family planning service, according to health workers’ opinion, is a larger involvement of medical personnel and family doctors in the process of service rendering.
Recommendation
- To enhance the time dedicated to family planning and abortion during training courses for health workers, focusing on non-technical procedures, advice, client and health worker’s interaction.
- To up-date the information on this field that is presented within the framework of training courses, basing on existing medical proofs.
- To standardize training courses and health workers examination in order to unify knowledge and inspect all abortion procedure stages, supervision and post-abortion contraception.
7.2.3 Patient and health worker’s interaction. Confidentiality and privacy observance
The evaluation team has noticed that the interaction between patients and health workers leaves much to be desired, especially in public institutions. Partially this is due to doctors’ lack of time and interest towards their patients’ problems, but also because of the misunderstanding of this communication importance and the priority of abortion technical side.
The communication is mainly reduced to the doctors’ attempts to convince the patient to keep pregnancy, to her unilateral information and “sermon”: why have you come to have abortion, I have told you that it was dangerous for your health, why have you come so late, but you’ll remain “sterile” – you’ll make me responsible?
As a rule the interaction is unilateral, only on behalf of the doctor while evaluating case history (anamnesis). The patient does not have the possibility to put questions, neither his fears and anxiety cause are analyzed. This fact and lack of corresponding places affect the possibility of giving advice in confidentiality or, in general, stifle it.
There are some health workers who consider that the majority of women, who have had abortion, are “fool” and do not use contraception methods because of their “retrograded outlook”. Patients are treated with the same attitude and communication.
Some doctors, because of religious believes, stopped practicing abortion. Some, when dealing with such patients, insist to convince her not to commit a sin and refer them to other doctors. But their believes do not prevent them from rendering medical health in abortion-related emergency cases or from making an abortion on medical orders.
The majority of health workers declared that they supported women, since they were in a difficult situation and needed help, including explanation and information.
Patients have mentioned that in private clinics, as compared to public sector, doctors paid greater attention to them, communicated more, and discussed with them more time. Many patients said that the problem for doctors of the public sector was in their attitude and respect towards them; the skills of public sector doctors are as high as private sector doctors. But this is the most important fact for patients, many of them will never return to public sector again.
In general women prefer to resort to their permanent doctor, judging not only their professionalism but also their general qualities – humane and able to give support and sympathy, respecting confidentiality in their having an abortion.
Confidentiality and privacy are hardly respected when rendering abortion services and violated at every stage. According to health workers and community members’ statements, the health care system neither promotes nor appoints a control board to respect professional ethics standards related to confidentiality and privacy values.
The examination and the abortion procedure with opened doors, or in a ward with other patients, where any medical assistant can enter at any time represent some examples of privacy violation, which have been noticed in the process of evaluation. Patients are not asked if they agree to being examined in the presence of students or residents, but, sometimes, are even forced to it.
Some gynecologists consider that confidentiality is not respected due to the necessity to produce patient’s identity card, or the diagnosis “abortion” written on medical certificate. Others – that confidentiality is violated due to obligation to have referral from family doctor.
Confidentiality is violated by the system which imposes reports presentation to primary abortion sectors from gynecology departments. Family doctor assistants have declared that they knew about all cases since they received data from regions about those women who had had an abortion, even if the women did not appeal to family doctor for referral. The whole village can find out about it (from family doctor, neighbor, clergyman…). The family doctor assistant regularly visits the gynecologist to collect data about abortions performed in the sector (names, addresses). This is a required MHSP statistical system and an efficient criterion of family doctor activity. Many of those questioned are not satisfied with this practice. For this reason, women often have to go to neighbor regions or Chisinau for the sake of their own confidentiality when resorting to abortion services. Quotation: “In Moldova a woman must buy her privacy”.
Some of those questioned think that one of the reasons to hide abortions is the desire to guarantee patient’s confidentiality.
It has been mentioned that keeping a woman in the same ward before and after the abortion, performing abortion in general gynecology or pregnancy pathology departments where there are women with other health problems from the same local area represent ways confidentiality violence.
Recommendation
- To include in training programs a module in values estimation exercises dedicated to the importance of health workers and patients interaction.
- To evaluate and take into account patients’ opinions about the quality of health workers and their interaction in the process of monitoring fertility regulation services.
- To improve the mechanisms of respect/guarantee concerning confidentiality and privacy in the field of reproductive health services:
- Abolishment of reports directed to family doctors by institutions that render abortion services (primary assistance)
- Codification of patient’s name
- Requirement not to indicate abortion diagnosis on medical leave
- Sanctioning persons who violated confidentiality
- Reorganization of places where abortion services are rendered in order to guarantee confidentiality, flux directing, patients programming…
- To inform and train health workers and patients about confidentiality and privacy
- To specify the necessity of confidentiality observance in labor contract between employer and employee and sanctions for violations
- To include abortion and contraception in the list of those cases when patients resorts to specialist directly.
7.2.4 Investigations
Findings
Nowadays patients’ investigation before abortion is regulated in the MoH Order no.152 of 1994 which stipulates: examination of group and rhesus factor, fluorography, syphilis test, vaginal smear for gonorrhea and other genital infections. It states that in order to make vacuum aspiration abortion at up to 20 days of menstruation pause, pregnancy should be proven by a pregnancy test or ultrasound test. These investigations are to be carried out in out-patients clinics, and the results should be indicated in referral.
The evaluation team has shown that these requirements are observed, with some changes, in the majority of cases. For example, substantial modifications within the framework of investigations are limited (only smear and syphilis), and are carried out in the department or institution which performs the abortion, immediately after patient’s resort, before the procedure, with results attached in the same or next day. As a rule, the group and Rh factor are indicated in identity card only. There are some cases when syphilis results are positive; consequently these patients are sought and invited to dermato-venereal institutions. For these reasons women are asked to produce obligatory identity card, and the number is registered in monitoring form.
USG is require only by several health workers; many of rely on clinic examination, pregnancy test and menstrual data. But in many cases, patients from urban area have already the USG result, since this method is very popular.
Patients pay from 45 to 65 Lei for investigations additionally, and the price varies considerably in all institutions.
Some clinics require in addition to them blood and urine general examination.
As a rule patients do not receive any explanation on the significance of these investigations. When carrying out the additional HIV-AIDS test, there is not any pre-test advice. Thus stipulations in MSPS Order on confidentiality advice and voluntary HIV-AIDS test are violated.
Many health workers who render abortion services prefer to rely on patient’s clinic exam and clinic signs of vaginal infection. They prescribe a treatment to these patients, irrespective of smear results and ask women to come in a few days.
Some of those questioned consider that it would be reasonable, when women resort to abortion services, to offer them cytology exam, if this was not carried out for a long time.
At the same time, when abortions are not officially registered, a phenomenon accepted both by health workers and community members, not a single investigation is carried out.
This forced team members to draw the conclusion that the importance of these investigations is overestimated, MoH Order is respected formally, and, actually, neither absence nor presence of these investigations influence the results of abortions and diminish the number of complications.
In private clinics all investigations are carried out according to the Order. The doctors declared that different committees control them thoroughly and can sanction them.
Recommendation
- To abolish investigations (tests) not related to abortion (HIV-AIDS test, vaginal smear, blood general exam etc.) and those not-recommended by WHO.
- To evaluate the necessity of additional investigations in laboratories or USG, on the basis of patient clinic evaluation.
- To introduce, in case they are available, optional screening test for sexually transmitted diseases, offering pre-test advice.
- Since many categories of patients receive surgical services without HIV-AIDS and other sexually transmitted diseases tests, the same method should be used for abortion procedures.
7.2.5 The procedure itself. Equipment
Findings
The evaluation team members have noticed that a range of aspects of abortion procedure require amelioration.
The prevailing abortion methods used in public institutions are dilatation and curettage (D&C). As to visited private institutions, manual or electric vacuum aspiration are used.
Curettage is practiced by older health workers who consider that they perform it at a high level quality and without complications, so that there are no reasons to use other methods.
Medical institutions are equipped with very old vacuum cleaners which are used with deteriorated nozzles, corroded and bent. There are not nozzles of different sizes, that is why nozzles of a big size are used for short-term pregnancies, which means a bigger dilatation, additional traumatism and longer procedure time. Aspiration equipment has not been verified and repaired for a long time. The hospital administration mentioned that the hospital had acquired very expensive anesthesia and ultrasound equipment. The apparatus for abortion has not been renewed for several years.
Some institutions use plastic nozzles which are adjusted to electric vacuum devices. But very often there are no nozzles of any kind or either the existing ones are bent and worn up. Such nozzles are not changed because of funds lack.
Perinatale centers are equipped with newer and more modern electric vacuums devices which were used before out-patient clinics abortion has been banned. Now they are out of use.
Control curettage is performed in any case, even after the electric aspiration abortion. Health workers say that they do this in order to reassure themselves about procedure completion, stating a wrong opinion of “the necessity to control all uterus corners”. Curettage devices are also are very old and worn up, and can increase the risks of uterus and cervical trauma.
Curettage is mainly used in those medical institutions which lack running water, even with an up-to-date aspiration device, because it is impossible to clean the aspiration tube otherwise.
Curettage is also preferred because the majority of health workers consider aspiration method more suitable for short-term pregnancies (6-8 weeks), while curettage is considered more efficient for long-term pregnancies. Perhaps, this is due to a long time practice of using aspiration vacuum only for the so-called “mini abortions”, which have been introduced in 1990s. Thus it has been established the fact that many health workers do not know MoH Order no. 103 of 2004 on MVA utilization for a 12 weeks pregnancy, while hospital administration does not try to ameliorate this situation.
Some evaluation team members could watch the abortion procedure. They have stated that although during MVA the procedures had been carried out according to all necessary standards, there still exist a lot of discrepancies.
When carrying out the procedure with local anesthesia usage, medical staff pay greater attention to the procedure itself and not to a contact with the patient, or to a necessary verbal support. During the procedure metal devices are thrown sometimes and make a lot of noise, but doctors do not pay attention to this and fail to take into consideration patient’s anxiety and pain. Instruments are handles roughly, patients startle and frown with every movement. The doctor does not explain what he is doing, how long it takes, what the patient can feel.
Doctors also exaggerate in their brutal and numerous vagina processing before and after the procedure. They do not carry out vagina palpitation before the procedure in order to estimate the size and the position of uterus. Instead they test the cervix – a dangerous and non-obligatory procedure.
Doctors practice many a lot of additional aspirations and curettages, although there are clear evidences that uterus is empty.
Doctors do not test the aspirated tissue – a simple procedure that replaces control curettage and proves the procedure completion, and even to trace out anomalous pregnancies.
Post-abortion supervision is carried out by anesthesia team for about several minutes. Often the patient leaves the institutions herself, without having a medical appointment.
7.2.6 Out- patient abortion
The evaluation team members have visited several MFC in Chisinau, which render abortion services on full day hospitalization. The quality of services in out-patient facilities corresponds better to the concept of cantered services for patients: general and sanitary-hygienic conditions are much better than in hospitals, but in some aspects even exceed them. The equipment is new, aspiration nozzles are in good condition, MVA method is used for abortion, local anesthesia is used according to standards, advice and post-abortion contraception is offered, and the service corresponds more to the family planning one.
A doctor who is responsible for out of patients clinic gynecology services and has been trying to implement electric vacuum aspiration for a long time, has declared that MVA method is more suitable for out of patients clinic practice.
Health workers from these institutions consider that abortion can and should be offered in out of patients clinic, where services quality is much higher, since “specialists from hospitals perform larger operations and have neither time nor desire to offer advice”
Some of those questioned have mentioned that there is a greater possibility to observe confidentiality in out-patient facilities that in hospitals. This is also referred to post-abortion contraception or other services of reproductive health.
In some areas illegal abortion is already performed in out of patients units. The doctors consider that their units have all necessary facilities and they would like to have an official permission for their activity.
In some other regions, doctors from out of patients units consider rendering abortion services quite possible, but if only these institutions were redecorated, equipped and specialists were adequately trained.
Many interviewed people think that abortions in out-patient facilities should be performed only with local anesthesia. Hospital doctors consider that abortions in out-patient facilities pose greater risks, but they do not present any real facts or cases of abortion-related complications, what would increase the risks of procedures in out of patients clinics.
An out-patient facilities manager does not agree on further development of abortion services in out of patients clinics, but, at the same time, he renders services of general surgery, such as appendectomia etc.
7.2.7 Late abortion
Abortion during II semester of pregnancy is performed in gynecology or pregnancy pathology departments, using intra- amniotic instillation of 20% NaCl, or antibiotic Gramicidin. In some cases, the abortion is postponed from 14 to 18 weeks in order to inject intra- amniotic Gramicidin.
According to interviewed doctors’ statements, misoprostol is being used more ofter for the last few years. Misoprostol doses and its administration regim vary a lot. Sometimes it is combined with intravenous oxytocine. On foetus expulsion, currettage is used to eliminate placenta. Some doctors consider misoprostol a very efficient and reliable substance for Late abortion and prefer it to intra- amniotic instillation. Doctors manifested concern regarding the absence of misoprostol in chemists.
The attended institutions showed a complete lack of immunoglobulin anti Rh factor and it is not administrated to women with negative Rh factor.
The institutions do not have protocols regarding abortion procedures and measures in cases of complications.
Recommendation
- To develop and approve standards and protocols regarding abortion during I and II semesters of pregnancy, according to WHO recommendations.
- To render services and assistance in out-patient facilities on condition that these units are equipped and the specialists are trained
- To develop monitoring mechanisms of these implementations and in force regulations observance
- To develop accreditation criteria for institutions which intend to render abortion services according to develop d standards. To accredit medical units which render abortion services. To introduce aspiration vacuum abortion and tissue examinations as obligatory accreditation criteria.
- To organize training seminars for managers and health workers on the aspiration vacuum method and tissue examinations.
- MHSP should develop the mechanism of institutions adequate supply with medicines, devices, equipment, and consumables.
7.2.8 Infections Prevention (Sanitary-Hygienic Norms)
Findings
Respect the universal warnings on infection prevention, recommended by WHO.
In general, the assessment revealed that health care facilities comply with the sanitary-hygienic norms.
They have protocols on the processing, disinfection, and maintenance of the sanitary-hygienic regime. The instruments and rooms are cleaned according to the requirements, most of the health personnel respect the appropriate rules (they wear gowns, bonnets, masks, eye-glasses, gloves).
But the interviews with service providers revealed that not all people are aware of the Universal Warnings; for instance some of them believe that all patients must make the syphilis or HIV test, in order to protect the medical staff. At the same time, they don’t wash their hands before and after the procedure, don’t wear masks and glasses during the procedure.
Not all facilities have liquid soap and disposable towels in the procedure room. Some of them even don’t have normal soap.
Some facilities have available sterile gloves, but the health personnel don’t put on both gloves. This is mainly true about the doctor's assistants and nurses.
We have also remarked some exaggerations: wearing sterile gloves during non-sterile manipulations, as for example vaginal palpation, non-sterile syringe manipulation, etc.
The external genital organs and vagina are many times treated with the same cotton wad, with rivanole or iodine, or chlorhexidine, without testing if the patient is not allergic to these substances.
The routine preventive intake of antibiotics, recommended by WHO and MoH Order no. 103 of 2004 is made by prescribing doxaciline, as this drug is not available for free-of-charge distribution. Some providers believe this drug is needed only in certain cases.
Recommendations
- Develop standards and protocols on prevention of infections during abortions, monitor their implementation.
- Include doxaciline, as a preventive measure, in the abortion service.
- Provide facilities with soap, disposable soaps, protection equipment for doctors.
7.2.9 Pain control
Findings
According to the WHO recommendations, during abortions the main must be managed. Verbal support, coupled with paracervical anesthesia with Lidocain are usually enough during the first semester abortion. The general anesthesia is more risky and is not recommended.
The assessment team members found out that during abortions all patients are offered anesthetics. But this is decided by the doctor, without explaining to the patient all available methods, their action, risks and advantages.
As there aren’t any protocols and standards, the methods of pain control differ in different institutions.
Most of the times they use general intravenous anesthesia with profound sedation. This usually includes calipsole, after a preventive medication. Short-term drugs, such as propofal, cannot be used because of their high price. Some providers prefer this method, as it is more efficient and comfortable, but claim that this is the patient’s wish. The general anesthesia is made by the anesthesiologist and his/her nurse, who evaluate the patient’s general state during several minutes before the abortion. Usually, they have Ambu mask and all the devices needed for complication management.
Some out-patient facilities also use the general anesthesia.
In some rare cases they use the local anesthesia, with Licodaine, complying with the relevant standards. It is worth mentioning that there is a wide range of local anesthesia methods. Thus, many times they use a higher percent than the recommended 0.5-1%. The Licodaine is infiltrated after the cervix is fixed with the tweezers, a procedure which is quite painful. During the Licodaine infiltration they do not control the vessel perforation.
We attested some cases when both intravenous and local anesthesia were used for the same procedure.
In other cases, the local anesthesia was coupled with dimedrol, or with intravenous introduction of analgin and dimedrol.
Novocain is sometimes used for the local anesthesia.
Some dangerous pain management practices where also mentioned: paracervical introduction of Calipsol by the person who performs the abortion procedure, in the absence of the resuscitation team. The doctor couldn't explain where he learned about this method.
There were also reported cases about the use of local anesthesia for late abortions, which women were forced to accept because of lack of money, as the general anesthesia is more expensive.
Some respondents declared that the control management methods depended “on the patient’s wallet”.
Some providers expressed such opinions as “the abortion should be made live to teach them a lesson”, “they have found what were looking for”.
Recommendations
- Develop protocols on pain management during abortion, train providers in local anesthesia.
- Counsel patients about pain control methods, risks and advantages of all methods for that the patient could decide on which method to be used.
7.2.10 Complications Maternal mortality
Findings
In Moldova the abortion-induced morbidity is quite high. The Reproductive Health Study reveals that 11% of women had abortion-related complications during the next first six weeks after the procedure. 5% of women reported complications six months after the abortion (on the bases of data on a small sample).
The official MoH statistics revelas the total number of complications (194 (1,1%) in 2003, including uterus perforations 9 (0,04%), genital tract infections 38 (19,6%), and others 147 (75,7%).
The team members tried to assess the opinions of providers and community regarding the post-abortion complications.
Many people believe that abortion has a very negative impact on women's health and may even lead to sterility. Most of the interviewed women, who had one or more abortions, declared they didn’t have any problems after abortion. Some of them reported such complications as pain and bleeding, but these are normal manifestations of the post-abortion period. This occurred, as doctors failed to inform women about the normal post-abortion signs and complications.
Several women reported inflammatory complications in form of fever and pain, that requested anti-bacterial treatment, sometimes repeated curettage. Some of them didn’t seek repeated care at the same doctor who performed the abortion, because of mistrust, but addressed to another doctor or cured by themselves.
They didn’t report any severe case, which requested lengthy hospitalization or led to sterility.
Providers believe that post-abortion complication occur in 2-3% of the cases. But, at the same time, most of them declare that they didn’t have many patients with post-abortion complications.
It is worth mentioning that not all complications are recorded, as doctors prefer to treat the patient without hospitalizing her or recording the case.
In case of complications during abortion or immediately after it, the care is provided by the hospital emergency team, that can arrive in 5 minutes.
The facilities don’t have any protocols on managing or referring and defining patients with complications. The providers acquire their knowledge during their undergraduate and graduate studies, and via self-training.
Most of the visited institutions didn’t have any case of abortion-induced maternal mortality over the past 5 years. This year a maternal death occurred in one rayon, caused by a hemorrhage induced by a spontaneous abortion during the first quarter of pregnancy.
However, providers admit that there exist cases of abortion-induced mortality, that they have heart that such cases occurred in other health care facilities and were mainly caused by illegal abortions and those performed during the second quarter of pregnancy.
Recommendations
- Develop standards and protocols on complications management and distribute the existing ones in all health care facilities
- Develop standard definitions for complications, include them in the MHSP statistical reporting system.
- Establish a well defined referral system to a higher level facility in case of severe post-abortion complications
- Train providers in defining, identifying and management of complications
- Carry out long-term studies to determine the rate of post-abortion complications in Moldova
- Use the results of confidential enquiry of maternal mortality and near miss analysis at the institution level in order to improve the quality of abortion service, implement the system confidential audit of maternal mortality.
7.2.11 Post-Abortion Contraception
Findings
Post-abortion counselling, focused on fertility maintenance and prevention of another unwanted pregnancy, and provision of contraceptives constitute compulsory components of the post-abortion care. This doesn’t only increase the level of women's information, and increases the rate of contraception use, but is also an important tool of breaking the vicious cycle of unwanted pregnancies. Abortion services are usually required by women who are “beyond” the family planning system, hence this is an appropriate time to improve the situation.
The post-abortion issue must be settled in Moldova. According to MHSP statistical data, the first abortion has a share of 12%; thus, it is obvious that the rate of repeated abortions is much higher.
During the assessment, the interviewed patients had a history of 2-4 abortions.
Usually women are not provided post-abortion counseling, IEC materials, and contraceptives.
Only several sections had contraceptives in their stock, which, according to the providers, were offered after abortion to women from socially vulnerable groups (IUD, condoms and COC).
Some providers believe that it is not recommended to use IUD immediately after delivery, as this might lead to serious complications. At the same time, according to the MHSP statistical data, 11000 IUDs were introduced in 2004 in in-patient health facilities, possible after abortion.
There aren’t any statistical data that would allow an accurate estimation of the number of women provided with contraceptives after abortion, or the impact of this phenomenon over the reproductive health or number of abortions.
The providers believe that contraceptives should be available in abortion wards, to be offered immediately after abortion. Most providers would like to have contraceptives at hand.
Though all women are referred to family planning offices, few of them visit these offices, while most of them “request another abortion in about 4 weeks”, as declared some providers.
The discussions with patients revealed that women are not aware of the fact that they may become pregnancy before the next period, none of them received post-abortion consulting on abortion, and only a few of them were prescribed microginon or logest, without receiving any pertinent explanations.
There is even an opinion t hat some doctors are not interested in providing women with contraceptives after abortion in order not to lose their revenues.
Recommendations
- Include the contraceptive counseling in the abortion-related set of services, and monitor their fulfillment.
- Provide facilities with contraceptives and IEC materials.
- Train all providers in contraceptive counseling, post-abortion IUD introduction.
- Develop the appropriate indicators to monitor the post-abortion contraception and include them in the MHSP statistical data.
- Carry out operational studies aimed at assessing the impact and cost-efficiency of the implementation of post-abortion contraceptive distribution system.
7.2.12 Interaction with other services
Findings
According to WHO recommendations, doctors should benefit to the maximum extent from the women’s request for abortion and settle all her problems related to the reproductive health, including the social one, violence, trafficking, etc.
During the assessment we realized that in Moldova the abortion service wasn’t interconnected with other reproductive health services. As mentioned above, there isn’t any collaboration even with the “closest” service – family planning; hence women are not counseled on contraceptive use.
During a request for abortion, doctors don’t check the state of cervix or mammary gland.
The sexually transmitted diseases are screened on the basis of compulsory syphilis tests and periodically HIV/AIDS tests. The patients are neither explained the significance of these tests nor counseled. Thus, the information and education component is again ignored.
Other sexually transmitted diseases is diagnosed on the basis of vaginal smear, a test regarded as insensible and not recommended by WHO.
Though working at perinatal centers, the social assistants, psychologists or jurists don’t get involved in the abortion service and counseling process. According to providers, they are dealing only with women in postpartum period. Many times the social assistants or psychologists are employed on a part-time basis, some of them don’t have the appropriate academic background.
There aren’t any mechanisms for identification of abuse victims, including sexual abuse, or trafficking in human beings, and referring them to the appropriate institutions.
There isn’t any collaboration with the police in this respect: the police doesn’t get involved in cases of suspected sexual abuse, they don’t know the legislation on domestic or sexual violence, don’t know how to fight this phenomenon.
Community members are aware of the existence of trafficking and abuse, and believe that these phenomena tend to increase, but they claim that these constitute local traditions, and the peculiarities of the Moldovan legislation in this field doesn’t seem to be able to settle such cases. Hence many victims are reluctant to seek legal help.
Young people are not explained what sexual aggression means, don’t know how to protect themselves against it and where to seek help.
Recommendations
- Develop the appropriate collaboration mechanism between the abortion service, FP service, other RH services, social or psychological assistance.
- Train people responsible of the social, psychological, and legal services in RH-related issues, get them involved in the abortion service, especially for women from socially vulnerable groups.
- Train the health staff how to identify victims of violence or trafficking, inform them about the specialized institutions so that they could refer women to them.
- Improve the collaboration with and train the police.
7.3 Manual Vacuum Aspiration (MVA)
Findings
Considerable efforts have been invested over the past years to implement VMA in Moldova. The MoH approved the MVA equipment, appointed the distributor, the gynecology department and Training center in reproductive health NGO, organized trainings for providers from Chisinau and other rayons. Ministry of Health Order no. 103 of 2004 approved the MVA and the Clinical Guidelines for this procedure and all elements of quality care in abortion. The obstetrics gynecology department of “Nicolae Testimitanu” SUMP and Training center in reproductive health NGO established a MVA center in the Perinatal Municipal Center of Chisinau. The newly established must monitor the implementation of MVA and of the patient-oriented care in abortion concept. As a result of this activity, the D&C was eliminated from the abortion practice, and the local anesthesia became the main pain control method.
As revealed by the assessment, the MVA extends very slowly at the national level and faces many barriers. As a matter of fact the service managers failed to comply with the aforementioned MoH Order and didn’t invest any efforts in MVA promotion.
In general, providers have a different opinion about MVA: the providers who were not trained declared they “didn’t believe in this syringe”, regarding curettage as a safer method.
However, those who participated in training or were trained by their colleagues bought these sets, regarding this method as excellent and don’t intend to give up In the out-patient facilities of Chisinau all standards are respected, local anesthesia is used, both providers and patients being satisfied.
Most of the gynecological divisions are not equipped with MVA devices. The providers who bought themselves the MVA sets use them for patients that approach them directly. Some directors claimed they didn’t buy the appropriate equipment because of the lack of money, others were practically uninformed about MVA, its prices and didn’t receive any procurement request from the specialized doctors. After our discussions many of them were genuinely interested in acquiring MVA equipment.
In one facility the providers declared that initially they were very satisfied with MVA, but later the deteriorated nozzles led to complications, incomplete abortions. The medical staff cannot dispose of the deteriorated nozzles, and the administration is reluctant to buy new ones, on the grounds that they are not disposable items.
The health staff of the visited private clinics use MVA successfully before 12 weeks of gestation, respecting all standards.
Recommendations
- Improve the MVA implementation mechanisms in all institutions that provide abortion services. provide them with equipment and consumables, train the specialists, monitor the implementation of MoH Order no. 103.
- Accredit health care facility on the basis of availability of MVA method and compliance with MoH Order no. 103.
7.4 Medical Abortion
Findings
In September 2004 the Pharmacy Company Şel Farma managed to register officially Mifepriston in the Republic of Moldova. It is about the Indian drug MtPill, produced by Cipla Ltd Company. Its ad notation, recommendations for abortions and the recommended regime of administration - 600mg of Mifepristone and 400mg of Misoprostol before 49 days of pregnancy, were translated into Romanian. After many negotiations with the importing company, the price was established at $12.00. Still, several months latter the price increased up to $20.00.
In 2005 the obstetrics gynecology department of “Nicolae Testimitanu” SUMP and CIDSR NGO organized training seminars in medical abortion, pre- and post-abortion counseling, supervision and management of adverse effects and complications. Service managers and abortion services providers from Chisinau clinics, resident doctors were included. Methodical instructions on medical abortion were developed and published. The evaluation study of appropriateness of using 200 Mg mifepriston and 400 Mcg misoprostol for termination of abortion before 56 days since the first day of the last period was completed in 2005. It was carried out by the obstetrics and gynecology department and CISDR team. At present, other two studies are being implemented: evaluation of different regimens for misoprostol for incomplete abortion and requested medical abortion. The new draft order on abortion, submitted by MHSP contains the medical abortion.
The assessment team concluded that in general doctors are familiar with the notion of medical abortion. A part of the interviewees reported using misoprostol for several years to terminate the pregnancy during the first and second quarter of pregnancy, regarding it as one of the most efficient and safe method. Some doctors reported that they had participated in training seminars on medical abortion or had informative materials from their colleagues. Most providers assert that the medical abortion is an important, necessary and welcomed alternative, mentioning that women are aware of it and request it.
In their opinion, for this method to be accepted, it is important to create the appropriate legal framework as soon as possible and develop the recording documentation by the MHSP. They also mentioned the need to provide additional training in this field, especially for family doctors who are practically unaware of it.
This is also confirmed by the fact that some doctors use wrong protocols, which are not evidence-based, regarding Mifepriston and Misoprostol, unawareness of counseling and contraception after the medical abortion.
The high price of Mifepriston – 240 lei – is a high barrier to medical abortion and makes it unaffordable for many women. At the same time, in some clinics the surgical abortion costs 260-280 lei.
Some interviewees expressed their concern for the disappearance of Misoprostol from drugstores. The team members were asked many times when it would be available again.
The out-patience providers are aware of this method and are ready to provide services of medical abortion, provided that they receive the appropriate training and equipment.
At the same time, some providers are against medical abortion, regarding it as an “experiment on women”, proving the need to organize more training courses in this field.
In some localities young people use Postinor, 2 pills, to induce abortion if the period is missed by up to 10 days.
At the same time the interviewed women, including the ones from rural localities, declared univocally that they would use this method if they knew where to address.
Both providers and community members talked about self-administration of Misoprostol by women, considering that this happened because of the failure to respect the confidentiality or the existent barriers to abortion.
Hence, it is important to improve the IEC methods and explain people all potential risks.
The dispensers need to be trained as well, as they don’t have the necessary knowledge as well, but they are usually the first people where community members seek knowledge about this method of pregnancy termination.
Recommendations
- Improve the medical abortion implementation mechanisms in all institutions that provide abortion services.
- Approve the method by MHSP, develop and approve protocols for pregnancy termination in the I and II semester.
- Develop the necessary documents for medical abortion recording, monitoring and evaluation.
- Develop the mechanisms of medical abortion provision: provide health facilities with Mifeprisotn and Misoprostol, and IEC materials for patients.
- Create a system of ongoing training for experts.
- Monitor the implementation of medical abortion in private and public health facilities.
- Accredit health care facilities depending on the availability of medical abortion.
- Establish a strict control system over the drugs for medical abortion and sell them only on the basis of the doctor’s prescription.
- Cover the costs of medical abortion for women from socially vulnerable groups and young women from NHIC funds.
7.5 Patient Satisfaction
Findings
The providers declared that patients were satisfied with the quality of provided services, as they usually return to the same doctor and recommend him/her to other patients.
However, they don’t have any mechanism of patients’ satisfaction monitoring, which could contribute to the enhancement of service quality and attitude towards women’s needs. Some units had special boxes for complaints and thanks, where we found only one thank-you note.
The patients reported general satisfaction with the received services, but regarded the lack of pain as the main evaluation criterion. They couldn’t say why would they like an enhancement of service quality. In one clinic of Chisinau the interviewed patients expressed their satisfaction with the MVA service.
This proves the unawareness of the notion of quality abortion service and low demands of people regarding the quality of provided services.
However, some patients reported dissatisfaction with the received services, because of pains during the procedure, lack of counseling, support, and respect from the personnel. Some of them declared they would not use the services of this facility any more, but would seek assistance elsewhere.
Patients’ satisfaction is not monitored via internal/external telephone; hence patients are not aware of this method. There isn’t any information about the hot lines, displayed on visible places.
Recommendations
- Implement the monitoring system within the facility and evaluate the patients’ opinion about the quality of services through anonymous questionnaires, periodical interviews, information about customer service telephones, placed on visible places.
- Make the monitoring and patients’ opinions evaluation system one of the main criteria for health facility accreditation.
- Use the patient satisfaction indicator in the MHSP official statistics to improve the quality of services.
7.6 Service Management. Quality Control Monitoring, Evaluation, Reporting
Findings
The abortion services are not managed and monitored separately from the health care facility general management, though the number of abortions exceeds considerable the number of other surgical interventions. Neither providers, nor managers of public health facilities regard the abortion services management and quality control as priorities, being preoccupied by routine management issues. Perhaps this opinion is grounded by the fact that abortion is a simple and low-risk procedure.
In general, the notion of “service quality” is not known, the issue of monitoring being regarded as the ratio of the number of abortions to the number of complications.
MoH collects data on abortion at the local, regional, and national level, using standard reporting forms, which include: Total abortion, mini-abortions, spontaneous, induced (legal), medical induced abortion up to 12 weeks, between 13 and 21 weeks, between 22 and 27 weeks, Other forms up to 12 weeks, between 13 and 21 weeks, between 22 and 27 weeks, without stating the reason, first abortion, number of complications (including uterus perforation, genital tract infection, others) and number of intrauterine devises introduced in laboratory and in-patient conditions.
These indices were developed quite long ago and haven’t been revised ever since, they are interpreted differently by providers, there doesn’t exist any definitions on the collected data.
No quality indicators have been developed. As mentioned above, there aren’t any indicators of patients’ satisfaction monitoring.
The use of abortion methods is not specified; hence it is not possible to estimate the share of medical abortion or MVAs.
As well, there isn’t any quality monitoring and evaluation system
During the assessment the team members didn’t find any sign of service quality monitoring.
The providers told that the control results, in form of ministerial commissions or from other accredited institutions, are mainly targeted at punishing the guilty people and identifying mistakes rather than promoting the quality in health care.
According to providers, neither financiers are interested in the quality of services: local public authorities and the National Company of Health Insurance check the expenditures on a periodical basis, but they fail to check the quality of provided services.
As for the abortion statistics, along the continuous increase in the official number of abortions, the assessment team concluded that there exist plenty of unrecorded abortions.
According to the local public authorities, service managers and providers, the real number of abortions is 2-3 times bigger than the official one. Here are the causes of this phenomenon:
- providers try to keep confidentiality of abortion;
- barriers to abortion services for women, high cost for the official abortion;
- barriers for abortion service providers (the prohibition to make the abortion in out-patient facilities, where it used to be allowed);
- abortions are a source of revenue for providers.
Recommendations
- Develop and implement a system of service quality monitoring.
- Develop quality monitoring indicators, based on the appropriate standards, develop patients’ satisfaction indicators.
- Modernize, standardize the definition used in the ministerial statistics, inform and train providers
- Modernize the services through the establishment by MHSP of inter-rayon commissions, including representatives of the Health Department and specialized experts that provide abortion and contraceptive services in rayon and municipal facilities.
- Develop quality standards for patients and inform, on compulsory terms, the patients about their rights.
- Evaluate and remove the existing barriers in the recording of the abortion number: Implement mechanisms of confidentiality observance, revise the service cost and develop a refunding mechanism for a part of the charged amounts, create the appropriate conditions for abortions in out-patient facilities.