Quality of Services Pre-abortion counseling Informed agreement * There is almost no discussion or contact prior to the intervention * Most often the patient does not know which gynecologist is going to perform the intervention * Their first meeting is after the patient is already lying down * There is no offer for a choice between various techniques * Short-lasting i.v. anesthesia or without anesthesia

Pre-abortion Counseling * Convincing to keep the pregnancy *Possible complications from the intervention are pointed out *In some places a general agreement is signed for an intervention and anesthesia *Most often check ups after the intervention are not defined *Nowhere is a document issued that lists the symptoms of the possible complications

Abortion Performance Procedure Method of conducted interventions up to week 12 of the pregnancy Dilatation, Vacuum aspiration, and curettage (independent of the performer or place) Manual vacuum aspiration (Gynecology and Obstetrics Clinic (GAK), private hospitals)

Abortion Performance Procedure Conditions *Premises and equipment most often satisfy basic standards *Electrical vacuum aspirators, sterilizers *Instruments (most often metal) over 20 years old (but with satisfactory quality). *Plastic cannulae. *Supporting rooms in some of the public health facilities are not at a satisfactory level

Abortion Performance Procedure Privacy * Insufficient care is taken to protect privacy (waiting room, changing room, night gowns, slippers, movement to intervention room, attitude inside the theatre, reanimation room) * Abortion is considered a routine intervention where the technique is most important ?!

Personnel Competence - Those performing the method do it as routine, performance technique is good, principles on protection from infection are followed, antibiotic prophylaxis is widespread. -Very little attention is paid to the approach and attitude toward the patient. -Additional training for young doctors. -Over 85% of gynecologists agree on the need to introduce standards and directions which should include WHO recommendations.

Patient – Doctor Communication Respecting Confidentiality and Privacy * No need of a family gynecologist *Prices vary (with or without anesthesia) *No written explanation is given of the intervention itself and symptoms in case of complications * Communication with the patient and respecting of privacy is not at a satisfactory level. The situation is somewhat better in private clinics, but not enough.

Pre-intervention Investigations - Most often blood type, Rh factor, Hepatitis B, C, and HIV are checked. -There is no PAP test screening. -In specific cases the anesthesiologist determines the tests -A previous ultrasound examination is requested - There is no unified protocol for investigations before and after the intervention.

Procedures and Instruments Standard technique in the first trimester: *Dilatation *Vacuum aspiration with metal cannulae *Sharp curettage *Short-lasting anesthesia *Transportation on a hospital bed to the room until fully awake, leaving

Second Trimester Abortion Intra-amnial application of hyper-tonic solution NaCl 33% Recommendation from WHO: *Dilatation, forceps, vacuum aspiration *Mifepristone/misoprostol

Infection Prevention (sanitary and hygiene norms ) * Intervention rooms respect sanitary and hygiene norms *Instruments are sterilized according to institution’s protocol *Some private institutions perform compulsory screening for hepatitis B,C and HIV *Personnel uses sterile working gloves, caps and masks occasionally, hands are not washed, protective goggles are not used *Pre-abortion sanitary treatment is most often with iodine solution (allergy) *Antibiotic prophylaxis is always given

Pain Control * Short-lasting i.v. anesthesia or analgesia *There is emphasized skepticism among service providers and patients regarding performance of abortion under local analgesia (Paracervical block – WHO recommendation)

Complications Mortality There is inappropriate registration of all direct and indirect reasons for maternal mortality.

Post-abortion Contraception Post-intervention counseling primarily means prevention from another unwanted pregnancy and provision of contraceptives Only 14% of those surveyed (all from private clinics) replied that post-abortion counseling is an important factor that contributes toward quality of abortion

Connection to Other Services WHO recommends that maximum information be gained from women who come for abortions regarding all of their reproductive health problems, including social problems, family or work place abuse, human trafficking, narcotics, etc. In Macedonia, abortion services are not related to other services as mentioned above.

Manual Vacuum Aspiration * Several gynecologists from GAK have been trained to use this method, but they are not applying it. *Only one gynecologist at only one private clinic in Skopje uses this method.

Patients’ Satisfaction with Services Medical workers say that patients are happy with services received as they usually come back to see the same doctor or recommend him/her to others. There is no established mechanism for monitoring patient satisfaction that would contribute toward improving the quality of services.

Service Management. Quality Control. Monitoring, Assessment and Reporting of Services * Generally, there is no known quality control concept – it all comes down to following the rate of number of abortions related to abortions with complications. *In Macedonia, no clear records of abortions are kept (form no ) – disrespect of the legal obligation to register and report abortions performed. *All doctors who perform abortions are obligated to fill out this form.

Service Management. Quality Control. Monitoring, Assessment and Reporting of Services Inappropriate keeping of medical records prevents deeper analysis of disaggregated data on abortions performed in Macedonia, abortions by age, place of residence, ethnicity, vocation, employment and other variables.

Abortions at GAK Abortion up to 12 g.w. Abortion induction using NaCl 33%

Post-abortion Complications Number of incomplete abortions with hysto- pathological verification: 2005 – – – 19

Abortions up to week 12 at GAK Patients up to age 18: Adult patients: Total:

Abortions at GAK by induction Patients up to age Adult patients Total: