Women’s Health, Changes and Challenges in Health Policy Development in Lithuania

Abstract

Health is a sensitive mirror of social circumstances. This paper looks at the situation of women’s health in Lithuania in the context of the social, political and economic transition in the country following independence in 1990, and reforms to the health system. Data since 1990 show that considerable social and demographic inequalities in the health of women exist in Lithuania, with low-educated women and those living in rural areas in the most unfavourable situation, including in relation to reproductive health. Reproductive health issues have received some recognition in recent years, with the main attention and resources directed to the development of a Maternal and Child Health Programme, especially perinatal care and the organisation of neonatology services, which has resulted in a notable decrease in maternal, perinatal and infant mortality. Services for family planning, abortion, infertility, cervical and breast cancer, and violence against women are under-developed. Non-governmental organizations are beginning to be formed to advocate for increased resources and services for reproductive health. Improvements in the health status of Lithuanian women can be expected if attention is paid to social determinants of health.

Résumé

Cet article examine la situation sanitaire des femmes en Lituanie dans le contexte de la transition sociale, politique et économique après 1990, et les réformes du système de santé. Depuis 1990, les données révèlent des inégalités sociales et démographiques considérables dans la santé des femmes, les célibataires, les femmes peu instruites et les rurales étant les plus défavorisées, notamment par rapport à la santé génésique. Les questions de santé génésique ont commencé à être reconnues ces dernières années; l’essentiel de l’attention et des ressources s’est porté sur la création d’un programme de santé maternelle et infantile, particulièrement de soins périnatals et l’organisation de services de néonatologie, ce qui a permis de réduire la mortalité maternelle, périnatale et infantile. Les services de planification familiale, d’avortement, de traitement de la stérilité et des cancers du sein et de l’utérus, et d’aide aux femmes victimes de violences sont sous-développés ou assurés principalement par le secteur privé. Des organisations non gouvernementales commencent à se former pour demander un accroissement des ressources et des services de santé génésique. On peut s’attendre à des améliorations de la situation sanitaire des Lituaniennes si une attention est accordée aux déterminants sociaux de la santé.

Resumen

Este artı́culo examina la situación de la salud de la mujer en Lituania en el contexto de la transición polı́tica, económica y social desde 1990, y las reformas del sistema de salud. Los datos muestran considerables desigualdades sociales y demográficas en la salud de las mujeres en Lituania. Las solteras, las mujeres de bajo nivel escolar, y aquellas que viven en áreas rurales son las más desfavorecidas, inclusive en relación a la salud reproductiva. En los últimos años se ha prestado cierta atención a la salud reproductiva, principalmente hacia la asignación de recursos al desarrollo de un Programa de Salud Materno-Infantil, con énfasis en la atención perinatal y la organización de servicios de neonatologı́a, los cuales han resultado en un descenso notable en la mortalidad materna, perinatal e infantil. Los servicios de planificación familiar, aborto, infecundidad, cáncer cérvico-uterino y de mama, y violencia en contra de la mujer están menos desarrollados o existen mayormente en el sector privado. Están empezando a formarse organizaciones no-gubernamentales dedicadas a abogar a favor de mayores recursos y servicios de la salud reproductiva. El nivel de la salud de las mujeres lituanas puede mejorarse si se pone atención a los determinantes sociales de la salud.

Key Words:

• health inequalities
• social determinants
• reproductive health services
• health policy and programmes
• Lithuania

Lithuania was an independent state from the end of World War I until it was absorbed into the Soviet Union after World War II. Health care in the Soviet Union was government-controlled through central planning. Lithuania’s health system was relatively well funded and the population’s health status better than in other parts of the Soviet Union. Health care was virtually universally accessible, and the state supported an extensive array of public health care facilities. For several decades, the Communist Party bureaucracy of the Soviet Union claimed that there had been substantial improvement in health under this centralized system, according to broad socio-economic indicators. However, this claim was not reflected in demographic and health statistics. Given the contradiction, Soviet officials did not allow publication of official data after the mid-1970s; it was only available for restricted circulation.

At the beginning of Gorbachev’s perestroika in the 1980s, guidelines for the development of health care and rebuilding of the health care system up to the year 2000 were drawn up. However, no radical change in the health care services actually occurred. Instead, only Gorbachev’s anti-alcohol campaign of 1985-1987 had a positive impact on mortality in the Lithuanian population. In March 1990 Lithuania declared its independence from the Soviet Union, and in 1991 became a member of the United Nations. Since then, there have been a series of reforms both of the national economy and the health system. Severe recession and hyper-inflation marked the structural crisis of the first phase of economic transition. Economic recovery and positive economic growth first began to appear in 1995. A continuing low inflation, growth in GDP, increased foreign investment and favourable changes in the balance of payments and privatisation of the economy reflect the transformation of the Lithuanian economy [1].

The population of Lithuania, which is relatively homogeneous in terms of cultural factors such as religious affiliation, is gradually decreasing. At the beginning of the last decade this process was mainly determined by emigration, more recently by a negative natural population growth rate. At the end of 2000 the population of Lithuania was 3.7 million. Numbers in urban and rural areas were nearly stable in 2000, in comparison to 1990, with 2.5 million in urban and 1.2 million in rural areas. As in numerous other European countries, the Lithuanian population is ageing; in 2000, people aged 65 and over made up 13.4% of the population [2].

Health sector reform and health policy since 1990

Since 1990, the health sector has been undergoing extensive reform, to renovate and create a financially sustainable modern health care system that can provide high quality services. Public health services are being re-organized with the aim of protecting, promoting and monitoring health, educating the public and strategizing on how to improve service delivery. The development of a primary health care network is considered a crucial aspect of these reforms. The health care system is also being decentralized, with management devolved to various government levels – in descending order by the Ministry of Health, County Governors, Municipal Councils and specialized supervisory institutions. Ownership of and responsibility for health care institutions has passed from the Ministry of Health to the municipalities.

The Ministry of Health has overall responsibility for the public health system’s performance. With the decline in direct administration of health care institutions, the maintenance and development of tertiary health care has become the administrative focus of the Ministry. At the regional level, most health care providers (provincial hospitals and specialized health care facilities) are governed by the provincial administration. The municipalities are responsible for providing primary health care to their local populations. They have been granted property rights for outpatient facilities and nursing homes, and they also run small and medium-sized hospitals in their localities. In 1998, the Ministry of Health initiated a debate on the privatisation of general practice. No hospitals have been privatised, and there are no official plans to privatise polyclinics or larger hospitals. Primary health care services are delivered in primary health care centres, general practitioners’ surgeries, school and community paramedical centres, outpatient facilities and polyclinics, women’s consultancies and the practices of private physicians. Private primary health care is still not very widespread, although there are some private gynaecologists, internists and dentists.

Statutory Health Insurance finances primary health care services on a per person basis, that is, there is a flat rate of compensation for primary care providers for each patient who is on their list of registered patients. According to the Health Insurance Law, all permanent residents must participate in the statutory health insurance scheme. Unemployed people and those belonging to certain vulnerable social groups are covered by the State. However, equity in accessibility of health care by socio-economic status, as well as public vs. private health services, has not been sufficiently studied in Lithuania [3].

Formulation of Lithuanian health policy started with the preparation of a National Concept of Health in 1991, which was a vision of the future Lithuanian health system. This document set the following priorities: steady improvement in population health, prevention of disease, development of primary health care, restructuring of medical education according to European standards, and concentration of highly specialized care in university hospitals [4]. This policy is considered one of the most progressive in Europe and has been cited by the World Health Organization (WHO) as an example for other post-socialist countries [5]. Lithuania does not have an effective, rationally functioning health care system as of yet – it is still problematic in many ways. However, the National Health Concept, which is based on solid scientific information and international experience has a clearly defined vision. During the difficult transition period, it ensured that the restructuring of the health system was not an irrelevant process of destruction.

The development of a National Health Programme, adopted in the Lithuanian Health Law of July 1994, was another important step for Lithuanian health care [6]. Largely influenced by WHO, the National Concept of Health and the National Health Programme were based on “Health for All” principles of equity in health, community participation, multi-sectoral approaches and balance in health care provision. Furthermore, gender considerations have constituted a key reference for analysing and understanding the significance and effects of certain social inequalities on population health.

Health is an exquisitely sensitive mirror of social circumstances. This paper looks at the situation of women’s health in Lithuania in the context of the social, political and economic transition in the country. Based on data on inequalities in health, it focuses on sexual and reproductive health issues and the challenges for health policy and programme development for improving the health of women.

Inequalities in women’s health

Tackling social inequalities and inequities in health has been identified as a major challenge in reforming health systems both in developed and developing countries [6]. Problems related to inequalities in health are of particular importance in countries undergoing social, economic, and political transition. For a fuller understanding of factors leading to inequalities in health it is necessary to consider the cultural context of the country. Health inequalities become “unfair” when poor health is itself the consequence of an unjust distribution of the underlying social determinants of health [7]. However, the mechanisms giving rise to inequalities in health are still imperfectly understood, and evidence remains to be gathered on the effectiveness of interventions to reduce such inequalities.

Inequalities in health are avoidable to the extent that they stem from identifiable policies, such as tax policy, regulation of business, welfare benefits and health care funding. Women’s economic situation, for example, a prerequisite for health, is generally less favourable than that of men in Lithuania. Even though unemployment among women is lower than for men (10.8% vs. 12.3% in 2000), women’s average monthly gross earnings are lower than men’s [8].

Level of educational attainment is a composite socio-economic variable, reflecting a number of influences on health status and mortality. It is closely associated with occupation, income, and many other characteristics related to social support systems affecting access to material resources, and health care services. The relevance of educational attainment to health is well documented in Lithuania. In comparison with the group with university education, the life expectancy of women with primary education is 4.3 years shorter [9]. In recent years, there is a noticeable increase in the number of young people seeking education at all levels in Lithuania. During 1998–1999, women comprised 50.7% of all students enrolled in educational institutions, and outnumbered men at higher educational levels, comprising 65.2% of college students, 57.8% of university students and by 1999, 51.8% of all doctoral students [8].

Thus, certain health inequalities are, in principle, amenable to policy intervention and change. There is a solid research database that provides information on demographic and social inequalities in health in Lithuania and has served as an important component in national health policy formulation. Furthermore, there are ongoing projects providing the opportunity to monitor inequalities in health at national and regional level in the future.

Main causes of mortality in women and healthy life expectancy

Causes of death in Lithuanian women are characteristic of many developed countries and have not changed for many years. Across all ages, the most frequent causes of death in 2000 were cardiovascular diseases (64.0%) and cancer (18.4%). Suicide and accidents were responsible for 6.3% of deaths among women, and respiratory diseases for 2.8%. The major causes of death vary with age. Accidents and suicides are the main causes for women under 44 years of age, while breast and cervical cancer are the main causes of death for women aged 45–64. For women aged 65 and older, diseases of the circulatory system account for most deaths [2].

A mortality analysis performed by residence of women clearly demonstrates that considerable inequalities in mortality and life expectancy exist within the country. Age-standardized, overall mortality rates of the rural population superseded those of the urban population in the past two decades. In 2000, the difference in mortality between urban and rural women reached 23.7%. The greatest differences are found in the age group 15–30, where probability of death is about twice as high in rural areas.

Trends in major causes of death also differ in urban and rural women, with mortality from many causes higher in rural than in urban areas. The greatest differences are found in the rate of cervical cancer (1.7 times higher) and suicides (1.5 times higher) in rural women compared to urban women. Especially huge inequalities are observed in cervical cancer mortality trends: in urban areas the rate has been stable since 1990, while in rural areas it is increasing statistically significantly by 4.4% per year. The same is true for suicides, which are increasing significantly among rural women by 4.1% per year though fairly stable among urban women [10].

Life expectancy in Lithuania, after a dramatic decrease in 1991-1994, gradually started to increase again from 1995 and reached 67.6 years for men and 77.9 years for women in 2000. After independence, the decline in life expectancy of rural women was significantly higher than in urban women. Since 1995 the life expectancy both of rural and urban women is increasing, however, and this increase is significantly higher in urban areas. The greatest difference observed between life expectancy of urban and rural women was in 2000, reaching 2.8 years.

Middle-aged men are generally considered the most vulnerable population group, given this differential. Nevertheless, analysis combining both objective and subjective health indicators (indicators of healthy life expectancy) demonstrates a different situation. Although total life expectancy for women is higher than for men at all ages, healthy life expectancy does not differ significantly. Healthy life expectancy at birth for men is 52.7 years and for women 52.6 years. The proportion of healthy life expectancy in total life expectancy is 79.8% at birth for men and 68.4% for women, i.e. lower for women than men for all age groups up to the age of 80 [10].

The reasons why women report such poor health and at the same time quality of life are complex, associated both with health, psychological and social problems. Approximately one-third of women’s life is spent in post-menopause. For many years the problems of ageing women were under-estimated. The health care system has mainly focused on young women during the childbearing years. In the past decade, some efforts have been made to raise awareness in society and change the attitudes of health care professionals regarding the needs of older women, but a multi-sectoral approach has not yet been implemented.

The reasons for inequalities in the health of urban and rural populations are multiple. Social and economic changes that occurred during the period of 1990–2000 exacerbated the already existing social problems of the rural population. Inequalities in the health of urban and rural populations grew because of rapidly deteriorating health in the rural population, caused by greater social and psychological stress, unhealthy life style (e.g. smoking, high alcohol consumption), inequities in accessibility of health care and absence of preventive programmes in rural areas. Since 1995, when economic development became positive and more stable, inequalities in health between urban and rural women continued to increase due to the fact that the health of the urban population was improving more significantly [10].

Reproductive health: demographics and policies

As yet, there is very little information on the impact of health sector reforms on women’s reproductive health in Lithuania. Reproductive health issues have received recognition in Lithuania since the International Conference on Population and Development in Cairo in 1994. Nevertheless, much remains to be done to improve our understanding of the concept of reproductive health, support reproductive rights and provide good quality reproductive health care within basic health services. Doing so will necessitate the involvement of the public, private, non-governmental and community sectors.

The birth rate in Lithuania has been decreasing for many years, but the greatest decrease has taken place during the last decade. In 2000, the birth rate was 9.2 per 1000 inhabitants. The population growth rate has been negative for seven years; in 2000 it was –1.3 per 1000 population [2].

Families are relatively small in Lithuania – the average household size was 2.74 in 1997 [1]. The average age at first marriage is 24.6 years for men and 22.8 years for women, but the number of marriages has fallen dramatically among those 20 to 24 years of age. The rate of marriages has decreased from 9.8 per 1000 population in 1990 to 4.6 in 2000. In 2000, there were 64.4 divorces for every 100 marriages.

The total fertility rate in Lithuania was 1.27 in 2000. Most deliveries are currently to women aged 20–29 (64.5%). Not only is maternal age increasing, but the number of single mothers is also growing – 23% of children were born to co-habiting or single women in 2000 [8].

There are no specific sections of the National Health Programme that comprehensively address reproductive health, although it does include sections on maternal health, sexually transmitted diseases, equity, accessibility and appropriateness of women’s health care [6]. Since 1992 there has also been a Maternal and Child Health Programme in Lithuania, which includes several multi-sectoral sub-programmes where close collaboration with the Ministries of Labour and Social Care, Science and Education, as well as with family support and social care organizations is essential. Care for pregnant women, birthing mothers and newborns is regulated in accordance with the principles of the Perinatal Care Programme. The Ministry of Health adopted a Perinatology Programme for 1997–2000, which ensured continuation of the Perinatal Care Programme.

Reproductive health services

Reproductive health services, when provided as part of the “basic package” of general primary health care services, are provided free of charge to insured persons. There is no specific provision for reproductive health services in the primary health sector. In urban areas, primary health care centres, where gynaecologists work with general practitioners, also provide obstetric and gynaecological services. In rural areas, these services are often not available, and a midwife provides care. Primary health care providers and qualified midwives deliver ambulatory care to pregnant women and postpartum care. High-risk pregnancies can only be seen by an obstetrician-gynaecologist (Ob/Gyn); care can be obtained at both public and private clinics. Highly specialized obstetric and neonatal services are provided in university hospitals.

Family planning services are available in both public and private health care settings, including primary and specialized health care institutions, such as women’s clinics, the State Family Planning Centre, and private Ob/Gyn offices. Other specific reproductive health services, including abortions, obstetric and gynaecological care, are provided on a fee-for-service basis in public hospitals to all women who need them. Specialized reproductive health services are provided on a fee-for service basis in the State Family Planning Centre in the capital Vilnius, which was founded in 1993 to provide a broad spectrum of specialist tertiary care. This facility is dedicated to seeing patients for family planning, infertility treatment and training providers in reproductive health and family planning.

Because of the lack of an organized programme, the level of reproductive health services that is provided in the primary health care system is inadequate for the population’s needs; however, it is not possible to quantify this, due to a lack of data [11]. Health education materials and other communications addressing women’s health issues are not sufficient, particularly in sex education and family planning.

Maternity care

A decade ago, antenatal wards, labour rooms and nurseries were under a strict, closed “hygiene” regime. Routine enemas and pubic shaving in preparation for delivery were still used, and routine episiotomies for preterm births were encouraged. After delivery, nursery care for babies in hospitals was the norm, and visits from family members after delivery were restricted. Tremendous changes have taken place in maternal and newborn health care in the last decade. Huge attempts have been made to change the attitude of medical staff, improve practices and create an atmosphere of normality, sensitive to mother’s and newborn’s needs and ensuring quality of care according to evidence-based practice.

Since the 1980s, maternal mortality has halved. In 2000, it was 11.8 per 100,000 live births, which is still about twice the EU average [12]. Obstetrician-gynaecologists and midwives attended 95% of births in 2000. Nevertheless, maternal deaths during pregnancy and delivery indicate the need to improve antenatal care, the functioning of emergency referral systems and the management of complications during pregnancy and childbirth.

Perinatal care

From 1992, with financial support from the Swiss government, the Perinatology Programme was established in all three Baltic Republics, and a birth registration system began functioning in January 1993. Funding of the Programme was taken over by the Lithuanian Ministry of Health from 1997 to ensure its continuation. Due to the re-organization of perinatal services and the establishment of modern, well-equipped neonatal intensive care units in Perinatal Centres and of a neonatal transportation system, perinatal mortality improved remarkably from 14.1 per 1000 live births in 1992 to 10.3 in 2000. The infant mortality rate has declined in recent years to a relatively low level – 8.5 deaths per 1000 live births in 2000 [2]. Breastfeeding has been highly encouraged.

Family planning services

According to the only survey of family and fertility in Lithuania, conducted in 1994–95, most Lithuanians start having sexual relations at the age of 17–19. In spite of the low fertility rate, the prevalence of modern contraceptive use is far below that of western European countries, however. Only 48% of urban and 44% of rural women, and 51% of urban and 43% of rural men surveyed were using a contraceptive method in 1994–95, and of those, a high proportion were using a traditional method (Table 1)

Table 1 Contraceptive methods used by women, 1994–1995 [13]

Method	%
Oral contraceptives	4
Intrauterine device	23
Condoms	25
Abstinence/rhythm methods	21
Withdrawal	24
Other (e.g. spermicides, breastfeeding)	36

Note: Several methods may be used at the same time.

Choice of method was associated with level of education and rural or urban residence. 17% of respondents said they did not use contraceptives because of medical considerations, which illustrates the widespread lack of access to accurate information [13]. Myths regarding the supposed harm caused by hormonal contraceptives remain prevalent. Family planning centres are, in fact, often used only as centres for diagnosis and treatment of infertility [14].

The low prevalence of effective contraceptive use greatly contributes to the high number of unplanned and unwanted pregnancies. Data from a study conducted in several Eastern European countries in 1996–97 to find out why women of fertile age were not using effective contraception demonstrated that in most cases the reasons were subjective: confidence in partner to avoid pregnancy, lack of concern about or no interest in contraception, or not considering the risk of becoming pregnant. The majority of women knew that contraceptives were available and where they could be obtained. The main reason given for low use of the Pill was the high price all over the region. As the main source of information about effective contraception, women mentioned gynaecologists, midwives and general practitioners [15], though this may now be changing.

In Lithuania, hormonal contraceptives, though available, are relatively expensive and there is no system for reimbursing high-risk groups. In addition to negative public opinion and negative attitudes of doctors towards hormonal contraception, there are few dedicated service providers in the primary health care system and little reproductive health education in schools. It is still mainly gynaecologists who carry out educational work on family planning.

Sterilization without any medical basis is not available for either women or men. The 1996 first Draft Law on Family Health Care included a section legalizing and regulating voluntary surgical sterilization as a method of family planning, but in later drafts this section was deleted after pressure from anti-choice groups. Most often, sterilization is performed for women only on medical grounds [16].

Of late, however, promising changes are being observed in the field of family planning. The use of contraceptives is increasing due to better information and youth-friendly centres have been set up in some cities. Since 1995, pharmaceutical companies have reported a consistent rise in the sale of oral contraceptives, which have increased in popularity. The use of condoms is also increasing because of awareness of AIDS [17].

Abortion services

Before 1990, modern contraception was little known or used in former Soviet Union countries. Traditional methods of birth control were most popular and abortion was accepted and used as a main method of fertility control. In the Soviet Union, medical termination of pregnancy on request up to the 12th week of pregnancy was legalized in 1955, but data on abortions became available only after 1990. There is no abortion register in Lithuania so abortion data are not systematically collected. It was estimated in 1990, however, that there were 82.8 abortions per 1000 women of reproductive age [1]. Ten years later, in contrast, 25.1 abortions were performed per 1000 women aged 15–49, or 69.6 abortions per 100 live births, according to existing data for 2000 [2]. However, not all abortions are recorded. Although the number of abortions is decreasing with increasing contraceptive use, and Lithuania has a lower rate of abortions than other Central and Eastern European countries and Newly Independent States, the number of abortions remains high [18].

National policy is to keep abortion legal, since banning abortion would increase the incidence of illegal abortions, entailing a high risk of maternal deaths. All abortions are done in medical institutions by trained gynaecologists, but induced abortion is not covered by national health insurance, and women must pay themselves, with fees determined according to number of weeks of pregnancy. Most terminations are carried out early, up to five weeks after a missed period. Only surgical methods are permitted. Recent attempts to introduce mifepristone+misoprostol for early medical termination have failed due to an active campaign by the Catholic Church.

Sexually transmitted diseases

Since 1990 a dramatic increase in reported cases of sexually transmitted diseases (STDs) has been observed. The incidence of syphilis reached epidemic levels, rising from 5 per 100,000 population in 1990 to 100 per 100,000 by 1996, and then gradually began decreasing to reach 31.7 per 100,000 in 2000 [2]. These figures have been the most reliable indicator of trends of STDs, because these patients are usually treated in public health services. Syphilis is generally considered by society as a dangerous and serious disease. For other STDs, patients are more likely to seek treatment in the growing private sector, or to treat themselves. The reasons for the increase in STDs in the last decade have not been adequately investigated in Lithuania. Although the incidence of clinically diagnosed AIDS has increased during last few years, it is significantly lower than the European Union average [18].

Infertility services

There are very few official data on infertility available in Lithuania. Epidemiological estimates suggest that nearly 50,000 couples are infertile, but it is difficult to comment on the most prevalent causes of infertility, because no representative studies have been carried out. The only available data come from private infertility clinics providing modern assisted reproductive technologies, which show that among those actively seeking treatment, the main cause of infertility in women in 2001 was damage to the Fallopian tubes, reflected in the high rates of STDs.

Today, a wide range of private medical services is offered to infertile couples in Lithuania, including hormonal treatment, intrauterine insemination, microsurgery and laser surgery, as well as in vitro fertilization (IVF) and intracytoplasmic sperm injection. The first IVF procedure in Lithuania was performed in 1998. In January 2002 the first baby from a frozen embryo was born.

Because these procedures are available only in private clinics, only a fraction of those who could benefit, those who can afford them, actually do. There is no health insurance reimbursement or any other kind of health insurance available to cover them.

Infertility treatment causes real dilemmas for health care providers, not only because of the costs but also to do with whether infertility treatment constitutes “health care” and how important it is in comparison to other high-cost treatments such as chemotherapy for advanced cancers or organ transplants, where the patient is very ill. Lithuanian society also seems ambivalent about whether infertility is a legitimate health problem. The use of donor eggs or sperm and of surrogate mothers has aroused great concern and heated debate. “Pro-life” organizations are striving for the prohibition of all methods of assisted reproduction. Few other medical procedures have been subjected to such intense religious, moral and social scrutiny as assisted reproduction.

Cervical cancer prevention and treatment

The incidence of cervical cancer was 24 per 100,000 in 2000, with women being diagnosed only at an advanced stage in 44.9% of cases. Mortality from cervical cancer started to increase gradually and statistically significantly in the 1990s, rising on average by 2.1% per year. In 2000 it was 13.3 per 100000, which is among the highest in Europe [2][18], again related to the rise in STDs.

In all the former Soviet republics, a wide network of cancer services was created, and cancer specialists were present in almost all out-patient departments of hospitals, working under the supervision of specialist cancer centres. However, they put greater emphasis on diagnosis and treatment of advanced cases than on early detection and prevention efforts among high-risk groups. Screening was occasional and only covered women attending Ob/Gyn services for other health problems. The importance of preventive programmes is now recognized by government and health professionals and the first steps towards the organization of a national screening programme, with involvement of family doctors, will be taken in the very near future.

Breast cancer

Mortality from breast cancer has declined in recent years and in 2000 was 28.1 per 100,000 women – slightly below the EU average [2]. Mammography screening programmes for breast cancer, financed by the local municipalities, have been implemented in three cities of Lithuania. Data from a pilot study of mammography screening for breast cancer in Kaunas among more than 4000 women of different ages found that the incidence of a diagnosis of “probably malignant”, based on the mammograms, was almost 2%. There was no difference in the rate of abnormalities in the age group 41–50 and 51–60. The incidence of malignant abnormalities was most frequent in women over 71 years of age [19].

Advocacy work on the part of health professionals and NGO’s, directed to government officials and policymakers, aims to place breast cancer on the national health agenda, encourage the development of systematic policies and breast cancer detection and treatment protocols, and educate health professionals and the public on the importance of checking for breast lumps and seeking early diagnosis. Decision-makers must carefully weigh the public health benefits of investing resources in breast cancer screening and treatment programmes against the cost and benefits of addressing other pressing health problems.

Violence against women

The problem of violence against women has received limited attention as a public health issue in Lithuania, and data on the incidence and type of violence are lacking. Homicide deaths of women increased from the mid-1980s to the mid-1990s and then started to decline, but are still among the highest in Europe. A campaign “Stop violence against women” was carried out by NGOs in 1997–98. Data from a large scale study in 1999 estimated that 42% of women had suffered physical, sexual or psychological abuse at least once from their current male partner, 63% of women over 16 years old had experienced physical or sexual violence at least once in their life, and only 11% of victims had reported violent incidents to the police [20]. Prosecutions in cases of rape are not common, primarily because the judicial system does not accommodate the needs of rape survivors who report a rape. Many women change their testimony after threats by relatives or friends of perpetrators. However, women who report domestic violence can now receive assistance from law enforcement authorities and from the active women’s movement. NGOs and a handful of police stations have opened Women’s Crisis Centres that offer psychological, medical and legal assistance to women who have experienced violence.

Non-governmental organizations involved in advocacy for women’s health

Since the mid-1990s, a number of NGOs have been formed to carry out educational and advocacy work on reproductive health issues. The Family Planning and Sexual Health Association, founded in 1995, works on the development of legislation, reproductive health policy and programmes and sexual and reproductive rights. Very active in advocacy for women’s health is the Lithuanian Society of Obstetricians and Gynaecologists, founded in 1958. It is working in the field of continuing medical education for specialists and the implementation of evidence-based knowledge in daily practice. In 1998 it started publishing a quarterly journal Lithuanian Obstetrics and Gynaecology. The Society of Contraceptology was founded in 2000; its main purpose is the promotion of effective methods of contraception. Finally, there are several NGOs such as the Lithuanian Organization for the Protection of Children’s Rights, Save the Children, National UNICEF Committee and others that defend the rights of children, and could have great influence as well.

Concluding remarks

Preparation and discussion of a new Reproductive Health Care Law is in process, and has to be ratified by the Parliament. It emphasises reducing the rate of abortions by increasing the prevalence of effective contraceptive use; primary and secondary prevention of STDs; development of youth-friendly information and policies; creation of an infertility register and treatment policies; screening strategies for gynaecological cancers; continuation of the Perinatal Care Programme; and development of an older women’s health care programme. An abortion register also needs to be set up by the Government.

Nevertheless, the process of the further development of health policy in Lithuania in relation to women’s health faces considerable difficulties, associated mainly with inflexibility and resistance on the part of the medical profession and a medicalized perception of health, a legacy of the health service model of the former Soviet Union and the complicated economic situation. Low community participation and insufficient involvement of sectors other than the formal health sector in planning and implementation of health strategies is also a serious problem. Networks and active groups of women in the community that might facilitate collective action to address problems are not well developed. It would have been almost impossible to achieve such action during the period of social and economic change in the 1990s. Now, as we enter a more stable period of development, this task becomes more realistic. Improvements could be achieved if considerable pressure were put on the Government, municipal authorities and health services to take action on women’s health, particularly reproductive health.

Dramatic political, social and economic changes in Lithuania in the last decade of the 20th century have had a significant influence on women’s health, and on the considerable social and demographic inequalities in women’s health since 1990. Low-educated women and those living in rural areas are in the most unfavourable situation, including in relation to reproductive health. Among the many opportunities to achieve greater equity is investment in human capital, redistributive policies and ensuring comprehensive access to health care. Lack of attention to primary preventive programming during the period of transition has resulted in insufficient development of reproductive health services, and some reproductive health problems have increased. A comprehensive approach at primary health care level should identify conditions such as cervical abnormalities and breast cancer at earlier stages. Reproductive health challenges should receive serious attention in health policy development in Lithuania, not only statements that women’s health deserves priority but real and constructive action. Special attention should be paid to the social determinants of health. Improvements in the health status of Lithuanian women can be expected to occur if these efforts are made. A country like Lithuania, despite limited economic resources, can improve the health of women, not only through health care services, but also through social reforms. It depends greatly on political will.