1. MVA in the context of Comprehensive Abortion Care (CAC) introduction in Eastern European countries Rodica Comendant, MD, PhD Reproductive Health Training Center, Medical University, Chisinau, Moldova ICMA Coordinator Moscow International Seminar: Abortion, Contraception and Women’s Health 27-28 October, 2005

2. Women Centered, Comprehensive Abortion Care – what is this?

3. Components of CAC Access Access Quality Quality Choice Choice Sustainability Sustainability

4. Need for CAC in Eastern Europe Unsafe abortions account for 24% of maternal deaths in region (WHO, 1998) Unsafe abortions account for 24% of maternal deaths in region (WHO, 1998) Abortion rates remain high Abortion rates remain high Percentage of women using modern contraception remains low (Population Reference Bureau, 2002) Percentage of women using modern contraception remains low (Population Reference Bureau, 2002) Abortion commonly used as a primary means to regulate fertility Abortion commonly used as a primary means to regulate fertility

5. Need for CAC in Eastern Europe Widespread availability of abortion on legal grounds for 50 years in many countries, but… Widespread availability of abortion on legal grounds for 50 years in many countries, but… Poor access for social-vulnerable groups Poor access for social-vulnerable groups Poor quality of services in public sector: main method D&C, no counseling, no choice of the methods, general anaesthezia for pain control, poor infection prevention, no contraception post- abortion, Poor quality of services in public sector: main method D&C, no counseling, no choice of the methods, general anaesthezia for pain control, poor infection prevention, no contraception post- abortion, No evidence-based guidelines, no trainings in CAC No evidence-based guidelines, no trainings in CAC

6. Need for CAC in Eastern Europe Access to abortion services has been challenged in recent years Access to abortion services has been challenged in recent years Concerns about declining birth rates, pressure from religious groups have reduced support for family planning and abortion Concerns about declining birth rates, pressure from religious groups have reduced support for family planning and abortion

7. MVA implementation project = a new approach to abortion care MVA not only an other abortion technique MVA not only an other abortion technique MVA as a possibility to improve abortion care, to implement patient care system, to change practice and policy… MVA as a possibility to improve abortion care, to implement patient care system, to change practice and policy… Partners: NAF, OSY-New York, Soros Ipas Partners: NAF, OSY-New York, Soros Ipas In the region: Ministries of Health, Medical Universities, Key-people,Hospitals, NGOs, abortion providers, distributors, women In the region: Ministries of Health, Medical Universities, Key-people,Hospitals, NGOs, abortion providers, distributors, women

8. Why MVA? It’s a safe, efficient, recommended by WHO method, that can be used in all the situations when uterine evacuation is needed. It’s a safe, efficient, recommended by WHO method, that can be used in all the situations when uterine evacuation is needed. No ‘checking curettage’ is needed (tissue exam)! No ‘checking curettage’ is needed (tissue exam)! It’s a cost-efficient method: Procedure costs, staff time and other resources are significantly reduced where MVA is used. It’s a cost-efficient method: Procedure costs, staff time and other resources are significantly reduced where MVA is used. Local anaesthezia, less risky than general can be used Local anaesthezia, less risky than general can be used MVA increases the patients’ satisfaction and patients’ flow MVA increases the patients’ satisfaction and patients’ flow MVA as educational tool for both – providers and patients! MVA as educational tool for both – providers and patients!

9. Tissue exam

11. MVA project in Central and EE region – training Training of Trainers in Comprehensive MVA abortion care, conducted by experts from NAF, with the support of Ipas and OSI (USA) Training of Trainers in Comprehensive MVA abortion care, conducted by experts from NAF, with the support of Ipas and OSI (USA) Training curricula is based on adult learning principles and includes: patient- centered elements of care, counseling, use of local anaesthezia, infection prevention, postabortion care and contraception following abortion. Training curricula is based on adult learning principles and includes: patient- centered elements of care, counseling, use of local anaesthezia, infection prevention, postabortion care and contraception following abortion. Lectures, case studies and practice with models and patients are used. Lectures, case studies and practice with models and patients are used. Countries: Moldova, Russia (Moscow and St. Petersburg)/ Ukraine, Georgia, Kyrgyzstan / Kazakhstan, Albania Countries: Moldova, Russia (Moscow and St. Petersburg)/ Ukraine, Georgia, Kyrgyzstan / Kazakhstan, Albania

13. Strategic importance of MVA trainings Trainings were done after an assessment of local situation Trainings were done after an assessment of local situation Trainings satisfied the real needs of national context (both providers and women) Trainings satisfied the real needs of national context (both providers and women) Offered a new for us approach - women centered and evidence-based approach, changed the mentality… Offered a new for us approach - women centered and evidence-based approach, changed the mentality… Built a team of local experts – the real “pioneers” and champions of the method and of CAC Built a team of local experts – the real “pioneers” and champions of the method and of CAC Pushed the things forward, initiated changes in abortion policy… Pushed the things forward, initiated changes in abortion policy…

14. MVA project in Central and EE region – a new abortion policy Trainings in cascade of national abortion providers, provided by local team of trainers Trainings in cascade of national abortion providers, provided by local team of trainers Publication of training materials, MVA is incorporated in University curricula Publication of training materials, MVA is incorporated in University curricula Official approval by MoHs of MVA equipment and method (<=12 weeks), Establishment of local distributor Official approval by MoHs of MVA equipment and method (<=12 weeks), Establishment of local distributor Guidelines, protocols on MVA with the elements of CAC were developed and approved Guidelines, protocols on MVA with the elements of CAC were developed and approved Education-information campaigns on safe abortion, raising community awareness and increasing the demand for better quality of services Education-information campaigns on safe abortion, raising community awareness and increasing the demand for better quality of services

17. MVA registration in Central and EE region by countries Russia Russia Georgia Georgia Moldova Moldova Ukraine Ukraine Lithuania Lithuania Uzbekistan Uzbekistan Kazakhstan Kazakhstan Tajikistan Tajikistan Turkmenistan Turkmenistan Kyrgyzstan Kyrgyzstan Armenia (?) Armenia (?) Romania Romania Turkey Turkey Albania Albania

18. Next steps toward really CAC: Moldova example Establishment of MVA National Centre, with the goal of Establishment of MVA National Centre, with the goal of MVA implementation as a routine method on the national level, and at primary level of care MVA implementation as a routine method on the national level, and at primary level of care Medical abortion implementation Medical abortion implementation Strategic assessment of abortion services: (with WHO, Ipas, EEIRH,UNFPA) was conducted in September 2005 Strategic assessment of abortion services: (with WHO, Ipas, EEIRH,UNFPA) was conducted in September 2005 New MoH order, abortion standards are developed and submitted New MoH order, abortion standards are developed and submitted National Strategy of RH for 2005-2015 developed, with WHO expertise (abortion quality is one of the priority) National Strategy of RH for 2005-2015 developed, with WHO expertise (abortion quality is one of the priority) System of continuing CAC education (MVA & Medical abortion) is developing now System of continuing CAC education (MVA & Medical abortion) is developing now

19. Trained in MVA providers, local anesthesia used and rate of MVA abortions in MVA Center in 2002-2004

20. Number of MVA abortions in MVA Centre, Chisinau, Moldova (2002- 2004)

21. WHO Strategic Approach/Assessment – an important tool to improve the situation in the region WHO meeting on Safe abortion and Strategic Approach in Riga, June 2004 (Russia, Ukraine, Moldova, Lithuania, Latvia) WHO meeting on Safe abortion and Strategic Approach in Riga, June 2004 (Russia, Ukraine, Moldova, Lithuania, Latvia) Strategic Assessment of Abortion services (WHO, MoH): Strategic Assessment of Abortion services (WHO, MoH): done in Romania, Moldova. Soon Russia, Ukraine (?) done in Romania, Moldova. Soon Russia, Ukraine (?)

22. Networking: sharing experience, learning CAC NAF: www.prochoice.org NAF: www.prochoice.orgwww.prochoice.org Astra www.astra.org.pl Astra www.astra.org.plwww.astra.org.pl Ipas: Training Forum www.ipas.org Ipas: Training Forum www.ipas.orgwww.ipas.org ICMA: International Consortium for medical Abortion www.medicalabortionconsortium.org ICMA: International Consortium for medical Abortion www.medicalabortionconsortium.org www.medicalabortionconsortium.org Gynuity Health Projects: Gynuity Health Projects: www.gynuity.org www.gynuity.orgwww.gynuity.org

24. СПАСИБО!

25. References: Safe Abortion: Technical and Policy Guidance for Health Systems, WHO, 2004 Safe Abortion: Technical and Policy Guidance for Health Systems, WHO, 2004 Traci Bird, Sarbaga Folk and Entela Shehu Shifting focus to the women: comprehensive abortion care in central and eastern. Europe. Entre-nous, No 59-2005.p. European Magazine for Sexual and Reproductive Health Traci Bird, Sarbaga Folk and Entela Shehu Shifting focus to the women: comprehensive abortion care in central and eastern. Europe. Entre-nous, No 59-2005.p. European Magazine for Sexual and Reproductive Health Bird, Harvey, et al. Similarities in women’s perceptions and acceptability of manual Bird, Harvey, et al. Similarities in women’s perceptions and acceptability of manual vacuum aspiration and electric vacuum aspiration for first trimester abortion. in 2003 Contraception 67 (2003) 207- 212. vacuum aspiration and electric vacuum aspiration for first trimester abortion. in 2003 Contraception 67 (2003) 207- 212. Greenslade, Forrest, Ann Leonard, Janie Benson and Judith Winkler. 1993. Manual vacuum aspiration: A summary of clinical and programmatic experience worldwide. Carrboro, NC: Ipas Greenslade, Forrest, Ann Leonard, Janie Benson and Judith Winkler. 1993. Manual vacuum aspiration: A summary of clinical and programmatic experience worldwide. Carrboro, NC: Ipas International Planned Parenthood Federation (IPPF). 2001. International Medical Advisory Panel (IMAP) statement on safe abortion. IPPF Medical Bulletin, 35(5). International Planned Parenthood Federation (IPPF). 2001. International Medical Advisory Panel (IMAP) statement on safe abortion. IPPF Medical Bulletin, 35(5).

26. References: Cates, Willard J. and David A. Grimes. 1981. Morbidity and mortality of abortion in the United States. In Hodgeson, J.E., ed. Abortion and sterilization: Medical and social aspects. London, Academic Press. Cates, Willard J. and David A. Grimes. 1981. Morbidity and mortality of abortion in the United States. In Hodgeson, J.E., ed. Abortion and sterilization: Medical and social aspects. London, Academic Press. Grimes, David A., Kenneth F. Schulz, Willard Cates, Jr. and Carl W. Tyler, Jr. 1977. The Joint Program for the Study of Abortion/CDC: A preliminary report. In Hern, Warren and B. Andrikopoulos. eds. Abortion in the Seventies. New York, National Abortion Federation. Grimes, David A., Kenneth F. Schulz, Willard Cates, Jr. and Carl W. Tyler, Jr. 1977. The Joint Program for the Study of Abortion/CDC: A preliminary report. In Hern, Warren and B. Andrikopoulos. eds. Abortion in the Seventies. New York, National Abortion Federation. Thonneau, Fougeyrollas, et al. Complications of abortion performed under local anesthesia. In European Journal of Obstetrics & Gynecology and Reproductive Biology 81 (1998) 59–63 Thonneau, Fougeyrollas, et al. Complications of abortion performed under local anesthesia. In European Journal of Obstetrics & Gynecology and Reproductive Biology 81 (1998) 59–63 G. Dean, L. Cardenas, et al. Acceptability of manual versus electric aspiration for first trimester abortion: a randomized trial. In Contraception 67 (2003), 202-2007 G. Dean, L. Cardenas, et al. Acceptability of manual versus electric aspiration for first trimester abortion: a randomized trial. In Contraception 67 (2003), 202-2007 Blumenthal PD and Remsburg RE. A time and cost analysis of the management of incomplete abortion with manual vacuum aspiration. International Journal of Gynecology and Obstetrics 1994; 45:261-267. Blumenthal PD and Remsburg RE. A time and cost analysis of the management of incomplete abortion with manual vacuum aspiration. International Journal of Gynecology and Obstetrics 1994; 45:261-267. Joffe, C. Abortion in historical perspective. In Paul, M, Lichtenberg, ES, Borgatta, L, Grimes, DA, & Stubblefield, PG (Eds.). A Clinician’s Guide to Medical and Surgical Abortion. Philadelphia: Churchill Livingstone, 1999. Joffe, C. Abortion in historical perspective. In Paul, M, Lichtenberg, ES, Borgatta, L, Grimes, DA, & Stubblefield, PG (Eds.). A Clinician’s Guide to Medical and Surgical Abortion. Philadelphia: Churchill Livingstone, 1999.