Implementation of national action plan to prevent unsafe abortions in Republic of Moldova

1. 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, 22-23rd June 2011 Rodica Comendant Stelian Hodorogea Dorina Darii

2. Abortion situation, overview Legal since 1955: up to 12 weeks on the request, 22-28 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/gyns Free of charge before, paid service since 90thies Quality not a priority

3. 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 • 2nd 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.

4. 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

5. 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

6. 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

7. Absolute number of deliveries and abortions 2005-2009

8. Abortion rate in Republic of Moldova

9. Abortion related maternal mortality

10. According to the confidential inquiry, in the years 2006-2008 among 28 cases of MM there have been 4 abortion-related =14%

11. 2nd trim legal abortions2005-2009(official MoH data)

12. Criminal abortion According 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 data 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… In 2005 a 25 year woman was sentenced to 20 years for homicide, after self induced 2nd trimester abortion. She is still in jail.

13. Growing stigmatization of women requesting abortion

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

15. MOLDOVA: national action plan

16. 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

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19. 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 expertiseon 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

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21. 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 2006-2011 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

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23. 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.

24. 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 2nd 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 2010. • An advocacy campaign on releasing Z. from the jail was started.

25. 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 • Tofacilitatethe 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.