A Project to Improve the Quality of Abortion Services in Moldova

Abstract

Abortion has been available legally in Moldova since 1955, and since then the abortion rate has gradually declined. The quality of abortion care remains low, however, and there is a high level of maternal mortality related to unsafe abortion. The goals of the 2005-2015 National Reproductive Health Strategy are to reduce unwanted pregnancy, reduce abortion-related morbidity and mortality, improve access to and quality of abortion care, including the methods of vacuum aspiration and medical abortion. This paper presents information on the current abortion law, policy and services in Moldova. It describes a project whose aim is to improve the quality of abortion services, including the introduction of medical abortion through training of service providers and community education. Manual vacuum aspiration has also recently been introduced. The drugs for medical abortion are officially approved, a clinical study evaluating the efficacy and acceptability of medical abortion in a low-resource setting has been completed, and training of providers has been carried out. However, institutionalisation of medical abortion faces many problems in relation to organisation of service delivery, the higher cost of medical than aspiration abortion, and doctors' reluctance to use new methods.

Résumé

L'avortement est disponible légalement en République de Moldova depuis 1955. Après la légalisation de l'avortement, le taux d'avortement a progressivement diminué. La qualité des services demeure faible, et le niveau de mortalité maternelle liée à des avortements non médicalisés est élevé. L'objectif de la Stratégie nationale de santé génésique est de réduire la nécessité d'avorter et d'améliorer l'accès à l'avortement et la qualité des soins, avec la pratique à plus grande échelle de l'aspiration par le vide et de l'avortement médicamenteux. Cet article présente une étude de cas sur la situation actuelle de la loi, la politique et les services en matière d'avortement en République de Moldova. Il décrit un projet, mené par l'équipe du Centre de formation en santé génésique, afin d'améliorer la qualité des services, avec l'introduction de l'avortement médicamenteux par la formation de prestataires et l'éducation communautaire. Le pays a récemment introduit l'aspiration manuelle par le vide. Il a officiellement approuvé les médicaments pour l'avortement médicamenteux, achevé une étude clinique évaluant l'acceptabilité de l'avortement médicamenteux dans des environnements à faibles ressources et formé les praticiens. Néanmoins, l'institutionnalisation de l'avortement médicamenteux connaît de nombreux problèmes en rapport avec l'organisation des services, le coût élevé de la méthode et les connaissances limitées des praticiens.

Resumen

En Moldavia, a partir de la despenalización del aborto en 1955, se vio una disminución gradual de la tasa de abortos. No obstante, los servicios de aborto aún son de baja calidad y un alto porcentaje de la mortalidad materna se atribuye al aborto inseguro. El objetivo de la Estrategia Nacional de Salud Reproductiva es reducir la necesidad de recurrir al aborto y mejorar la calidad y el acceso a los servicios de aborto, al practicar la aspiración endouterina y el aborto con medicamentos en mayor escala. En este artículo se presenta un estudio de caso de la situación actual de las leyes, políticas y servicios de aborto en Moldavia. Se describe un proyecto, realizado por el equipo del Centro de Capacitación en Salud Reproductiva, cuya finalidad es mejorar la calidad de los servicios de aborto, incluido el lanzamiento del aborto con medicamentos, al capacitar a los prestadores de servicios e informar a la comunidad. Recientemente se realizó el lanzamiento de la aspiración manual endouterina. Se han aprobado oficialmente los fármacos utilizados para el aborto con medicamentos, se ha concluido un estudio clínico para evaluar su aceptación en lugares con escasos recursos, y se han capacitado a los prestadores de servicios. Sin embargo, la institucionalización del aborto con medicamentos afronta muchos problemas asociados con la organización de la prestación de servicios, el alto costo y el conocimiento limitado de los proveedores.

Key Word:

• abortion law and policy
• abortion methods
• abortion providers and services
• training of service providers
• quality of care
• Moldova

The Republic of Moldova became independent in August 1991 with the collapse of the former Soviet Union. Since 1995, Moldova has been on the verge of a public health crisis and the country continues to suffer the negative consequences of political and economic transition. Moldova is one of the poorest countries in the Central and Eastern European region, with a per capita GNP of US$370; 35% of the population live below the poverty line.¹ Reduced allocation of funding for the social sector has led to the worsening of major social indicators and to deterioration in the quality of those services and access to them. Infant and under-five mortality rates are 16 and 20 per 1,000 live births, respectively, for example, reflecting this.

Moldova is experiencing a combination of decreasing birth rates, increased mortality and high out-migration to other European Union countries.² In 1997, the total fertility rate was estimated to be 1.8, below the threshold of 2.1 needed for a population to reproduce itself.³ A major decrease in life expectancy at birth (just under 68 in 2000) has also contributed to decreasing population size.⁴ In spite of falling fertility, however, there remains a substantial unmet need for contraception, as evidenced in the high proportion of unplanned pregnancies, the majority of them ending in abortion.⁵

The maternal mortality ratio, 21.9 per 100,000 live births in 2003,⁶ is likely to be associated in part with poor availability of medical equipment and drugs for emergency obstetric care,⁴ complications of unsafe abortion and more recently, increasing financial constraints for women in accessing services, caused by the fact that some reproductive health services, including abortion, became fee-paying and are no longer covered by the system of medical insurance.

Legal framework of abortion

Abortion on request up to 12 weeks of pregnancy was legalised in 1955. Since then, with some additions and modifications, this law has remained in force, essentially unchanged. Additional regulations were issued to introduce vacuum aspiration for early abortion in 1987, to permit induced abortion during the first 28 weeks of pregnancy on medical, genetic, juridical and social grounds, and in 1988 to allow abortions to be performed by private practitioners.⁷ There is neither a spousal consent requirement nor any mandatory counselling or waiting period. Parental consent is required for adolescents below the age of 18.

In August 1994 the law itself was modified (Ministerial Order 152) to allow pregnancy termination up to 28 weeks for medical, genetic, juridical or social reasons. New provisions were again issued in 1995, when Moldova subscribed to the WHO definitions of live birth and stillbirth, resulting in the legal time limit for abortion on those same indications being lowered to 21 weeks. Abortions up to 28 weeks are now allowed only in cases of congenital syphilis or severe congenital malformation. For second trimester abortion, approval from a special Commission is required.

Abortion service delivery

Today, because there are no guidelines or standards for abortion service delivery, practice is based on the 1994 Ministerial Order. Until that Order was passed, polyclinics and women's consultation centres were permitted to perform early abortions (up to six weeks LMP). Currently, only three large ambulatory units in the capital Chisinau (in close proximity to obstetric-gynaecology hospitals or wards) are allowed by the Health Department of Local Public Administration to carry out such procedures, even though this is not an official decision of the Ministry of Health. Since 1994, to reduce the number of complications, the Ministerial Order said that all abortions should be performed in hospitals by obstetrician-gynaecologists. This centralisation of services and their relatively higher cost has reduced the accessibility of abortion. In fact, the vast majority of induced abortions (93%) reported since 1992 have been performed in hospital gynaecology wards, with about 5% in maternities, usually only for medical conditions, and 2% in ambulatory units on an outpatient basis.⁵

Abortions in maternities are more prevalent in urban areas (7%) than in rural areas (3%), probably because complicated cases are referred to urban hospitals. Outpatient abortions were slightly more prevalent in Chisinau. Women who obtained outpatient abortions tended to be younger (15-24 years old), earlier in pregnancy (less than seven weeks LMP), and with slightly higher education and socio-economic status. There are 53 public institutions in Moldova where abortion services are provided, of which 34 are based in the regions in Level 2 regional hospitals and three in Level 1 polyclinics. Eight facilities are in the gynaecology units of city hospitals, five are in Level 1 family doctor centres in Chisinau and three in Level 3 national institutions (Personal communication, the responsible specialist obstetrician-gynaecologist, Ministry of Health, 15 June 2005).

There are no official statistics on the number of private clinics where abortion services are provided, the number of abortions they do or the quality of care in them.

Cost of services

From 1955 to 1998 abortions were performed free of charge. However, most women (67%) according to a survey in 1997, had to make unofficial payments (in money or gifts) to medical personnel.⁵ Regulations passed in 1998 stipulated that payment for abortion services in the public sector was required, about 37-65 lei (about US$5). Today, as abortion is not covered by health insurance, the public sector price has officially been raised to 170-250 lei (about US$20), while the average income is 250 lei per month. In the private sector the price for an abortion ranges between 300 lei and 900 lei (US$25-US$70).

There are no officially approved categories of women for whom abortion fees are waived.

Patterns of fertility regulation: national statistics

Moldova's patterns of fertility regulation share many features with Russia and other countries of the former Soviet Union. Fertility has decreased sharply to below replacement levels, with induced abortion the main method of fertility control. Modern contraceptives have been under-utilised. The relative isolation of the former Soviet Union from the contraceptive advances in western countries limited both knowledge and availability of modern methods. Compounded by fatalistic attitudes towards health issues, and the availability and high tolerance of pregnancy termination, there has been extensive reliance on induced abortion.⁸ This pattern is further affected by a climate of strong condemnation of premarital and extra-marital pregnancy, disapproval of sex education in schools, discouragement of open discussion about sex-related issues and prejudicial attitudes toward sexuality.

However, during the last decade, due to implementation of a national family planning programme, there has been a steady and relatively strong rise in contraceptive prevalence from 45% in 1992 to 73.3% in 2003.⁷

For many decades, the levels of induced abortion in the former Soviet Union were among the highest in the world. Moldova had the sixth highest abortion rate of the 15 Soviet Republics, about 75 abortions per 1,000 women of reproductive age around 1990.⁸ Since then, abortion rates have gradually declined to 17.3 per 1,000 women in 2003, with the abortion-to-live-birth ratio at about one abortion per two live births.⁶ For the past three years the official number of abortions recorded in the public sector has been stable at 16,000-17,000 per year, though, as elsewhere, there is under-reporting in the system. Regardless of the decline in the overall number and rate of abortions, there is still a high level of maternal mortality from abortion complications, 37.3% of all maternal deaths were due to abortion in 2003.⁶

In addition to the high cost of services and the need for permission from a special commission for a second-trimester abortion, there are other barriers to accessing legal abortion, such as long waiting times between the first appointment and the abortion. These potentially contribute to women seeking illegal abortions from unskilled providers in clinics with a lack of sanitary conditions. There is no information about where illegal abortions take place, however, or who performs them. The proportion of abortions that are illegal is also unknown, but estimates range widely, from 2% to 50%.⁷

Quality of abortion services

There is no system in place in Moldova for monitoring quality of care, but many aspects of abortion services do not meet the clinical practice recommendations established by the World Health Organization.⁹ Abortion services should be an essential component of comprehensive reproductive health care, but in Moldova, being concentrated in the hospitals, they are often separate from family planning services and other reproductive health services, which are found at primary care level.

All obstetrician-gynaecologists are taught to perform curettage at post-graduate level, but other elements of comprehensive abortion care are not included in the university or post-graduate curricula. Formal training on new abortion technology did not exist before 2002, and no local training materials were available.

According to Ministry of Health statistics,⁶ dilatation and curettage remains the most common method of abortion (70% of all abortions). Most clinicians in the regions continue to use sharp curettage rather than vacuum aspiration,⁷ and so-called curette “checks” of the uterus are always performed following electric vacuum aspiration. Lack of instruments and their cost are cited as barriers to the use of manual vacuum aspiration (directors of the regional hospitals, personal communication, 22 August 2005). The most common form of pain management offered is general anaesthesia.

There is compulsory testing for tuberculosis, HIV and syphilis, with no pre-test counselling. Screening for gonorrhoea and other reproductive tract infections is by swab smear. Generally, the termination of pregnancy is performed one to five days after the woman's first visit to request an abortion, or later if she needs treatment for an infection.

There is no concept of “patient-centred care” , that would include confidentiality, informed consent, or choice of abortion method, type of anaesthesia or pain medication. Pre-abortion counselling and post-abortion family planning counselling and provision of contraceptive methods are not routinely offered in abortion clinics, leading to continuing high rates of unwanted pregnancy. In some cases, the information given to women is biased, with the aim of convincing them to continue the pregnancy.

Confidentiality is often abused; the fact that a woman has had an abortion rarely remains unknown to other people in the community where she lives. Because abortions are provided in general gynaecological or obstetric units, many people can see who is there. Everybody can access the files, and in the units, everybody knows that the women are there for abortions.

Women have their abortions the same day they come to the hospital, usually 4-5 hours after they arrive, after the doctors have finished their work with other patients on the wards. There are many women in the same room, waiting for the procedure, or recovering afterwards. Women can be examined on the gynaecological chair while there is more than one person in the room, or can have the abortion procedure with the door open, with other people entering and leaving the room.

Morbidity from abortion is common in Moldova. The 1997 Reproductive Health Survey found that 11% of women had complications associated with abortion within six weeks of the procedure. At six months after the procedure, 5% of these women had reported complications. Most early complications involved severe or prolonged bleeding or pelvic infection, with or without fever.⁵

As shown in the survey, 44% of immediate complications required one or more nights hospital stay and a fourth of all abortions were associated with late complications. Most of the effects at six months or later were associated with menstrual changes. All of the conditions reported were consistent with pelvic infection and intra-uterine adhesions, and in fact 15% of women with late complications were diagnosed with pelvic infection. Chronic pelvic pain was reported in 33% of abortions with late complications, of which 3% were followed by secondary infertility.⁵

Current projects to improve quality of care

Introduction of manual vacuum aspiration

The transformation of abortion services in Moldova started in 2002 when the National Abortion Federation in the United States, with support from the Open Society Institute in New York, provided training of trainers in the use of manual vacuum aspiration (MVA) and comprehensive care for early abortion for seven providers at the Clinical Municipal Hospital No.1 in Chisinau. I was one of the providers who received this training, along with colleagues from the hospital gynaecology unit. By 2003, the abortion caseload had more than tripled in the new MVA Centre created by the team of the Reproductive Health Training Centre,^* an NGO based in the same hospital.

We attribute the caseload increase to the high quality of care offered, which drew women away from other facilities, and to the fact that most of the procedures began to be done with local, rather than general, anaesthesia. As providers made the shift to local anaesthesia, they learned to talk with and support their patients, treating them as partners in their care. In 2004, MVA training and the elements of the National Abortion Federation's Comprehensive Abortion Care package were incorporated into the university curriculum. With support from Ipas and the National Abortion Federation, a total of 120 Moldovan gynaecologists have since received MVA training. In addition, the MVA Centre holds one-day training sessions for the gynaecologists from the outlying regions. One of the trainers from the MVA Centre and I have conducted MVA training in other countries, including Georgia, Russia, Albania, Kyrgyzstan and Mongolia.

Providers are pleased with the MVA services which, they say, are not only safe and effective but also save time and costs. Women who have MVA are also pleased: ongoing monitoring during 2003-04 at the MVA Centre found that more than 90% were very satisfied with their care and would recommend it to others needing an abortion.⁹

Other steps that have been important in transforming and sustaining improvements in the quality of abortion care in Moldova include registration of MVA for commercial distribution, dissemination of technical materials on MVA and abortion care in Moldova, and the Ministry of Health's 2004 recommendation of MVA for first-trimester abortion, accompanied by approved clinical guidelines.

Introduction of medical abortion

Moldovan doctors and women have been aware of medical abortion since 2000, when the National Pharmaceutics Institution registered Cytotec (misoprostol), a Searle product, for gastro-intestinal diseases. Without any official permission, on the basis of international information on the use of misoprostol, obstetrician-gynaecologists started using it to prepare the cervix to induce delivery,¹⁰¹² and to induce first trimester abortions.¹¹

Since then, almost all specialists have had misoprostol tablets in their drugs cupboards, usually bought secretly on the black market at a much higher price than the official one, about US$2 per 200mcg pill. The discussions with doctors invited by the MVA Centre team to training sessions on medical abortion have revealed that all of them have been providing misoprostol alone for first and second trimester abortions to about 2-3 women per week, with good effectiveness, and with very varied regimens. Many are determining the regimen for first trimester abortion empirically, usually 400mcg twice or 200mcg four times orally or vaginally. The effectiveness of the regimen 200 mcg four times orally, as shown in a case study in the Clinical Municipal Hospital No.1 in Chisinau, was approximately 82-84%.¹¹ As misoprostol is not officially registered, there are no national statistics of the numbers of medical abortions. As most of the women have been satisfied with the method, they have kept asking for it. Today, misoprostol (Cytotec) is available in drugstores and can be bought with or without prescription.

In 2002 the Ministry of Health raised the issue of unapproved use of misoprostol by obstetrician-gynaecologists, especially in obstetrics, which had resulted, in their opinion, in several uterine ruptures. At a meeting between the responsible officials from the Ministry of Health and the medical staff at the biggest maternity hospital in Chisinau, the Ministry proposed banning the drug. But because the specialists expressed strong opposition, misoprostol was not banned. Instead, agreed regimens for its use in obstetrics were established through protocols. Its use for induced abortion was not discussed at that point.

In 2003 the Reproductive Health Training Centre launched a project to institutionalise medical abortion services on a national scale, to provide Moldovan women with this important alternative for pregnancy termination. Under this project three team members, including myself, the professor and head of the Department of Obstetrics and Gynaecology of the State Medical and Pharmacy University, and the responsible specialist in obstetrics and gynaecology of the Ministry of Health and lecturer in the same Department, were trained at the Centre for Training in Reproductive Health Technologies in Paris. It was a training of trainers in comprehensive medical abortion care, including in the methodology for clinical study and in the training process itself.

After that first training of trainers, the same three specialists carried out a clinical study in the Central Municipal Hospital No.1 in Chisinau. It looked at the acceptability of medical abortion and the feasibility of providing 200mg mifepristone followed by 400mcg misoprostol orally up to 56 days LMP, with misoprostol administration either at home or at the clinic, according to the woman's preference. This study was completed earlier in 2005; the results are not yet published. A preliminary analysis of the data shows a complete abortion rate of approximately 96%, and the interviews with 150 women found a high level of satisfaction with the method, especially given the possibility of home use of misoprostol (Srelian Hodorogea, personal communication, 20 February 2005). The study also demonstrated that there was no need for routine use of ultrasound to determine the length of pregnancy or whether the abortion was complete at the follow-up visit.

The same team, with the involvement of other doctors from Hospital No.1 in Chisinau, are now carrying out clinical studies on the use of misoprostol for incomplete abortion and a randomised study comparing different means of misoprostol administration for medical abortion.

An education and informational campaign for the Moldovan population was conducted in 2003-05 by the Reproductive Health Training Centre on the subjects of medical abortion, reproductive rights, a woman's right to choose the abortion method she uses and receive information about abortion, and to have counselling if requested. Booklets with the most common questions and answers regarding medical abortion were also developed by the Centre and sent to other NGOs active in women's issues. Information in Russian and Romanian on medical abortion was placed on the Centre's website (<www.avort.md>), along with information about surgical abortion. These as well as radio and TV programmes have raised public awareness of women's reproductive rights and thus prepared the country for the official introduction of medical abortion.

In September 2004 Shell Pharma managed to register mifepristone in Moldova. This is the Indian drug MtPill, produced by Cipla Ltd. Its label was translated into Romanian, with indications for pregnancy termination up to 49 days LMP, with the (now outdated) regimen of 600mg mifepristone followed by 400mcg oral misoprostol. After multiple negotiations with the importing company the price of one 200mg pill was set at (150 lei) US$12. However, in a few months it was raised by the company to 220 lei (US$20). The official fee for medical abortion, since then, was established at 360 lei (US$30).

In January and July 2005 the Reproductive Health Training Centre, sponsored by Shell Pharma, organised its first two training days on medical abortion. The curriculum was based on interactive work and principles of adult learning, with many case studies, and modules on regimens for first and second trimester abortion, pre- and post-abortion counselling, supervision and management of side effects, and complications. It was attended by 25 abortion services managers and gynaecologists from five clinics in Chisinau and 40 gynaecologists from clinics in the countryside. (Only gynaecologists were trained because only gynaecologists may perform abortions.) Training materials were prepared by the Reproductive Health Training Centre team and printed with the help of Shell Pharma.

Still the implementation of medical abortion in Moldova faces problems. There are difficulties in the organisation of service delivery as most abortions are currently being provided on an inpatient basis, and the fees include payment for a hospital stay. The cost of a medical abortion, including the cost of the pills, is much higher than for vacuum aspiration. Thus, many women will not have access to this method, preferring the cheaper option.

The fact that the drugs are currently delivered directly from the pharmaceutical company is also a problem. The managers of the hospitals refuse to buy the drugs from the company to make them available in the hospital pharmacies.

Doctors' reluctance to use what for them is a new method, the misuse of the drugs, the continued use of misoprostol alone for abortion because of the price of mifepristone, the lack of counselling skills as well as a lack of understanding of the necessity of making counselling available are all problems that need to be overcome. Specialists need more training and it is important to introduce this method into the undergraduate and post-graduate medical curricula. This needs additional efforts and financial support.

Monitoring and evaluation of the quality of services and of the effectiveness of medical abortion are issues too, since statistical packages for collecting data on medical abortion have not yet been developed. As a result, all the abortions using a medical method, outside of the Reproductive Health Training Centre, are not recorded, making it difficult to evaluate medical abortion provision in Moldova or to determine the challenges and obstacles in this process.

Next steps

The Moldovan National Reproductive Health Strategy for the years 2005-2015, elaborated by a national team of experts from Moldova and WHO, including Reproductive Health Training Centre team members, was approved by the Government in 2005. It states that abortion and fertility regulation services are one of the priority areas for the country. The goals are to reduce unwanted pregnancies and therefore the need for abortion, reduce abortion-related morbidity and mortality, improve access to abortion and quality of care, and provide the abortion methods recommended by WHO,¹³ including medical abortion.

To this end, at the request of the Ministry of Health, a new Ministry of Health Order on abortion was developed in January 2005 by the Reproductive Health Training Centre team and submitted for approval. This new Order approves medical abortion and the regimen of 200mg mifepristone and 400mcg misoprostol orally for abortions up to 49 days LMP and 800mcg misoprostol vaginally for abortions up to 63 days LMP. Clinical guidelines and protocols for medical abortion are being developing at this writing (July 2005).

In 2005 the World Health Organization Department of Reproductive Health and Research has been working with a Moldovan team to conduct a strategic assessment of abortion services in Moldova. The assessment focuses on understanding how to improve the safety and quality of services and access to services as well as how to reduce unwanted pregnancy. The assessment will produce recommendations for new or revised policies and interventions to improve fertility regulation within existing resource constraints, including proposals to resolve the difficulties related to the provision of medical abortion in Moldova.¹⁴

Moldova, 2000

Acknowledgements

The project for implementation of MVA and medical abortion in Moldova was supported through grants from the Open Society Institute, New York, the Soros Foundation-Moldova, and the National Abortion Federation and Ipas in the US. The medical abortion implementation project was supported by Gynuity Health Projects. The following people all provided invaluable support throughout these activities: Beverly Winikoff, President, Gynuity Health Projects; Stelian Hodorogea, MD, Lecturer, Ob/Gyn Department, State Medical and Pharmacy University of Moldova; Valentin Friptu, MD, Professor, Head of Ob/Gyn Department, State Medical and Pharmacy University; Dr Iurie Dondiuc, Director, Hospital No.1, Chisinau; and Danielle Hassoun, MD, Director, Centre for Training in Reproductive Health Technologies, Paris.

Notes

* The name of this NGO was Society against Infectious Diseases in Obstetrics and Gynaecolology at the time, and was changed in 2005.