History of abortion in Moldova

After the Republic of Moldova obtained independence in 1991, as in many other post-Soviet and Eastern European countries, abortion was utilized in large part as substitute for efficient contraceptive methods in order to regulate fertility. Abortion was carried out via dilation and curettage (D&C), not using safe methods that are recommended by the World Health Organization (WHO) and the International Federation of Gynecology and Obstetrics (FIGO) – medical abortion and manual vacuum aspiration (MVA).

Due to a lack of evidence-based guides and protocols and unsatisfactory quality and access to abortion and modern contraception services, around 30% of maternal deaths registered in Moldova between 1995 and 2005 were the results of complications from abortion. Consequently, the improvement of the quality and access to abortion and family planning services was included as a major priority of the National Strategy in Reproductive Health for 2005-2015, approved by the Moldovan government in 2005.

These priority areas were coordinated by the Reproductive Health Training Center (RHTC) and as a result, there was a reduction in the use of abortion for fertility regulation and the safety of abortion improved. The specific objectives of the National Strategy were to reduce mortality and morbidity due to complications following abortion; to reduce the rate of abortion and repeated abortion; to improve the quality of abortion services through providing new WHO-approved methods; to integrate abortion into other reproductive health services and improve accessibility to safe abortion services. The expected results included an abortion rate below 15 per 1000 reproductive-aged women; the reduction of complications following abortion; eliminating maternal mortality related to post-abortion complications; mandating post-abortion contraceptive counseling so that more than 70% of patients would select a modern contraceptive method following the abortion.

In the context of achieving these objectives, the RHTC team introduce safe, WHO-recommended abortion methods in Moldova; first MVA was introduced and then in 2005 – medical abortion. RHTC trained providers in both of these methods and developed standards for their implementation.

In 2015, the evaluation of the National Strategy, including the component related to safe abortion, alongside that regarding the reproductive health of adolescents and youth, was considered a great success. The implemented interventions aligned with the National Strategy obtained the established objectives.

The main recommendations of the evaluation were: the elaboration and approval of national clinical standards and guidelines; the modernization of the reporting system and the quality of abortion services; the revision of the curriculum for training abortion providers; the creation of a model for outpatient comprehensive abortion services and testing it in several medical institutions (Model Centers) where WHO-recommended methods are used, confidentiality is preserved, and post-abortion consultation is provided; and the scaling up this model at the national level.

During 2007-2011, with the support of the WHO and other international organizations, the RHTC team developed the Regulations for providing abortion in Moldova (2010) and Standards for the provision of safe abortion services (2011), revise and approved the training curriculum for abortion, and modernized and institutionalized a statistical reporting system of the number and quality of outpatient abortions. In addition, in two stages, six Model Centers offering comprehensive outpatient abortion services were created. Initially, this concept was tested in the perinatological centers in Chisinau and Balti. Later, the buildings were repaired, equipped with the necessary instruments, and medical staff from the consultative sections of the level II centers in Cahul and Orhei, the polyclinics in Cantemir, and the “Ana” Women’s Health Center in Drochia were trained. At the moment, according to data from the National Center for Medical Statistics, in these six institutions, utilizing the safe abortion methods of MVA and medical abortion, a third of all abortions in Moldova are provided.

A preliminary evaluation of the quality of abortion services in the Model Centers carried out in 2012 by the RHTC team in coordination with WHO and the MoH showed an extremely low rate of abortion complications, a high satisfaction among patients and providers, and large number of women who chose a contraceptive method following abortion. Based on the extremely positive experience of the Model Centers, the MoH recommended that other medical institutions in Moldova implement this concept of comprehensive abortion services, in conformity with the National Regulations and Standards that are in force.

Over the past years, more medical institutions in Moldova made modifications to abortion care, aligned with MoH recommendations and national standards, thus favoring safe abortion methods and disfavoring the use of D&C.

Hence, in 2017, the proportion of abortions via MVA and medical abortion rose to 80%. That being said, a considerable number of medical institutions in Moldova continue to provide D&C abortions (28% of all institutions) and use general anesthesia. Additionally, a large number of women are not offered a modern contraception method post-abortion.

Since 2005, the number of abortions has practically remained the same – around 14-15,000 annually. According to official statistics, the rate of induced abortion per 1000 reproductive-age women (15-49 years) decreased by a factor of three, from 51% in 1995 to 14.2% in 2016.

Over the past 10 years, abortion among young women (15-18 years) makes up 10% of the total number of abortions in the country.

Furthermore, over the past decade, similar trends have been seen in other Eastern and Western European countries, with the number of total abortions remaining relatively constant. However, in Eastern Europe the total number remains around 1.5-2 times larger than in Western Europe. This fact is proof that there is still a large unmet need for modern contraception.