Implementation of national action plan to prevent unsafe abortions in Republic of Moldova FIGO initiative on unsafe abortion, Third Central and Eastern Europe Regional Workshop, Chisinau, Moldova, rd June 2011 Rodica Comendant Stelian Hodorogea Dorina Darii

Abortion situation, overview Legal since 1955: up to 12 weeks on the request, weeks on a list of social, juridical and medical indication, no limit to save women’s lifeLegal since 1955: up to 12 weeks on the request, weeks on a list of social, juridical and medical indication, no limit to save women’s life Provided in a large network of public health facilities, only by ob/gynsProvided in a large network of public health facilities, only by ob/gyns Free of charge before, paid service since 90thiesFree of charge before, paid service since 90thies Quality not a priorityQuality not a priority

Current challenges Is no more free of charge, except second trimester abortion In 2007 legal limit for second trimester abortion was reduced to 22 weeks 2 nd trim abortion indications: –To save the women’s heath or life – no limitations. –Severe foetal malformation –up to 22 weeks. –Pregnancy resulting from rape or incest –up to 22 weeks. –Husband’s death or divorce – up to 22 weeks –Imprisoned women or privation of maternal rights Socio-economic reasons – no.

Strategic solutions Abortion and pregnancy termination services is one of the components of NATIONAL STRATEGY ON REPRODUCTIVE HEALTH (2006 – 2015) Expected outcomes: –Abortion rate – less than 15 on 1000 –Decreased number of abortion complications –Avoid maternal deaths due to abortion –More that 70% will accept a method of contraception after abortion Implementation instrument – WHO’s Strategic Approach to Strengthening RH Policies and Programmes

Quality of abortion care D&C still often used, general anesthesia Manual or electrical vacuum aspiration, with checking curettage MA – rarely, mostly in urban areas Very few providers offer good counseling, including on family planning Practices differs very much and are not standardized WHO recommendations are poorly known, they are not incorporated in the actual training Curricula

Access to abortion Limited for poor, women from rural area and adolescents The decision of MoH to cover abortion on medical or social ground by insurance doesn’t work well Access is limited by the price, by the lack of trained providers and lack of equipment, the low level of knowledge among women

Absolute number of deliveries and abortions

Abortion rate in Republic of Moldova

Abortion related maternal mortality

According to the confidential inquiry, in the years among 28 cases of MM there have been 4 abortion-related =14%

2nd trim legal abortions (official MoH data) implementatio n of new viability criteria since 22 weeks ,1 % ,8 % ,7 % ,0 % 782 5,3 %

Criminal abortion According to the MoH data one in 100 women is undertaking illegal abortion each yearAccording to the MoH data one in 100 women is undertaking illegal abortion each year The exact number is unknown, but the estimated rate is 2-50%. In 2010 they were 4, according to MoH dataThe exact number is unknown, but the estimated rate is 2-50%. In 2010 they were 4, according to MoH data Most of them are in de second trimester, some times after being denied by the “commission”Most of them are in de second trimester, some times after being denied by the “commission” Last women died is a yang, 22 year old women, who left orphans three children…Last women died is a yang, 22 year old women, who left orphans three children… In 2005 a 25 year woman was sentenced to 20 years for homicide, after self induced 2nd trimester abortion. She is still in jail.In 2005 a 25 year woman was sentenced to 20 years for homicide, after self induced 2nd trimester abortion. She is still in jail.

Growing stigmatization of women requesting abortion

Growing anti-choice movement: 4 September 2010 conference „Stop Abortion!” conference „Stop Abortionconference „Stop Abortion

MOLDOVA: national action plan Specific Objective 1: To improve the legal and regulatory framework, including the functioning of monitoring and evaluation system. ActivitiesGoalsTime frame Progress Achieved 1.Development and approval of national standards and protocols on Comprehensive Abortion Care (CAC) 2. incorporation into the national accreditation system of the institutions, providing abortion care National standards and protocols on CAC based on WHO recommendati ons Achievement 98%, but only in June 2011 the Standards have been approved. New abortion regulation of thye MoH passed in September Not incorporated yet into accreditation system, but the process has started

Development and approval of national standards and protocols on Comprehensive Abortion Care (CAC) Barriers –MoH does not trust the expertise of members of working group –There are no MoH mechanisms in place to monitor how standards and protocols, as well as other legislative documents are implemented Facilitating factors - Collaboration with WHO in implementing CAC in the context of the Strategic Approach project –Draft guideline was presented, discussed and approved at the Ob- Gyn Association meeting –Standards and protocols on CAC have been implemented and tested in two model sites –Existence of a national strong NGO (RHTC) working in improving quality of abortion services –After approval of national protocols on CAC, National Accreditation Agency is obliged to develop criteria for accreditation of facilities offering abortion services

MOLDOVA Specific Objective 1: To improve the legal and regulatory framework, including the functioning of monitoring and evaluation system. ActivitiesGoals Time frame Progress Achieved 3. The modification and elaboration of indicators of the monitoring and evaluation of the quality of abortion services Efficient function of the monitoring and evaluation system of the quality of abortion care Modern indicators (including quality) elaborated and incorporated into the monitoring and evaluation system Achievement 100% - indicators are approved by MoH and incorporated into monitoring and evaluation system.

MOLDOVA Specific Objective 2: To improve the access to quality abortion services ActivitiesGoals Time fram e Progress Achieved 1. Development and testing the model of Comprehensive Abortion Care (CAC) 2.Implementation of CAC, based on the developed Model and National standards in 10 perinatal centers, at the ambulatory level: 1 ) Training of the staff of perinatal centers on CAC 2) Equipping the perinatal centrers 3) Implementation of auto- monitoring and evaluation system 4) Modest renovation of the space CAC implemented and developed in ten perinatal centers 60 providers trained in CAC 10 centers equipped with MVA and necessary supplies, Self-monitoring system is on place CAC offered to 90% of clients Overall achievement 80% The model developed, tested, results presented at national meeting in November 2009 Establishment of three Model-Centers of CAC (Chisinau, Drochia and Beltsi) Training curricula on CAC developed, tested Medical staff of the three Centers trained Centers equipped M&E indicators for self-monitoring developed and used Two more centers have been established during in Cantemir and Orhei and the youth clinic staff have been ytrtained on CAC in the context of WHO Strategic Approach, Scaling-up phase Remaining 4 centers will be established by 2015

2.Implementation of CAC, based on the developed Model and National standards in 10 perinatal centers, at the ambulatory level: Barriers –The former legislation didn’t allow abortions in ambulatory and in private institutions. The ambulatory level institutions are not familiar with service delivery –Medical abortion has been officially permitted; but there are no mechanisms of drug supply and service delivery –High cost of MA drugs –Absence of interest from the administration of the institutions Facilitating factors –Many abortion providers already trained in MVA, MA and CAC –Drugs for MA registered for long time in the country –Existence of a national NGO, with high expertise on the field of safe abortion – Inclusion of mifepristone and misoprostol into the National list of essential drugs in June 2011 Proposal for ensuring/accelerating implementation –Implementation of a mechanism of accreditation of facilities offering abortion services based on national standards and protocols

MOLDOVA Specific Objective 3: To improve the level of knowledge and the skills of abortion providers on CAC ActivitiesGoalsTime frameProgress Achieved 1.Development and implementation of the curricula of CAC into study programs of the providers of all levels of abortion care (residents and post-graduation training of obstetricians- gynecologists) Improvement of provider’s level of knowledge on CAC Achievement 70% - curricula of CAC developed and tested during training of staff from CAC models. Curricula was approved, incorporation into study programs discussed with the chair of the departments

Specific Objective 3: To improve the level of knowledge and the skills of abortion providers on CAC Barriers –There is no mechanism of monitoring of staff knowledge and quality of training in offering abortion services. –Abortion providers can offer abortion services without special training in CAC. Facilitating factors –Staff of ObGyn Departments have been trained in CAC –There is new facility, RHTC, for training in CAC –During years more than 200 abortion providers have been trained with support of Gynuity Health Projects –A number of studies on feasibility and acceptability of MVA and evidence-based regimens of MA have been conducted and results presented to MoH and Obstetricians and Gynecologists

MOLDOVA Specific Objective 4. To improve the level of community awareness on the prevention of unwanted pregnancy and unsafe abortion ActivitiesGoals Time frame Progress Achieved 1.Development of the Information – Education- Communication (IEC) system on prevention of unwanted pregnancy and unsafe abortion and women’s sexual and reproductive health and rights (development, printing and dissemination of educational materials, radio and TV broadcast programs etc...). Development of a website for the population Improvement of community awareness IEC system is in place: 5 models of educational leaflets and posters materials elaborated, printed and disseminated in the ten perinatal centers, in all family doctor’s and RH centers, 12 radio programs conducted during the year Interactive and user friendly website created % achievement 5 models of educational materials (posters and leaflets) elaborated, in process of printing and dissemination. 2 radio and broadcast programs presented Website developed and launched for the population (in Romanian and Russian)

Lessons learnt during the past years Change of abortion legislation and sophisticated procedures for obtaining second trimester abortion may increase number abortion related Maternal deaths. Most important prerequisites for offering CAC are: existence of EBM national guidelines and protocols approved by MoH, incorporation of CAC in training curricula (pre-service and CME), accreditation of facilities offering abortion services according to criteria stipulated in national protocol. ObGyn professional association may play a more important role in promoting CAC and preserving access to safe and qualitative abortion.

New partnerships Concept Foundation : the process of registration of “Medabon” has started in 2009, but pending… Gynuity Health Project – study on alternative follow up protocol after medical abortion and 2 nd trimester abortion UNFPA, CRR – a round table were the barriers toward access to CAC services, including to the second trimester abortion have been discussed was held in September An advocacy campaign on releasing Z. from the jail was started.

The remaining objectives and activities proposed to MoH ( National Workshop for evaluation of implementation of National Strategy on Reproductive Health (23-24 March) To improve access to second trimester abortion (decision to be taken by 3 specialists of the facility, to abandon requirement to have decision of a commission). To develop a mechanism for obtaining legal abortion for adolescents <16 years without parental consent To facilitate the mechanism for covering costs of pregnancy terminations on medical and social indications, of abortion complications and of postabortion contraception by National Health Insurance Fund. To develop a mechanism of monitoring of implementation of this decision.