Current problems and solutions on abortion in Eastern Europe (EE)
Rodica Comendant MD,
Reproductive Health Training Center, Director, ICMA Coordinator, Chisinau, Moldova
Description of the problem: Despite the widespread availability of abortion on legal
grounds for 50 years in most of the EE countries, the quality of services remain poor: the
main method is D&C, no patient centered care concept. Unsafe abortions account for 24%
of maternal deaths in region. Abortion rates remain high, and is commonly used as a
primary means to regulate fertility. 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 in the region.
MVA project: The goal of the project was to improve the quality of abortion care with of
institutionalization of Manual Vacuum Aspiration (MVA), and promote patient centered
care concepts within the framework of clinical safety and reproductive rights. This project
was initiated by NAF, funded by the Open Society Institute, and in collaboration with Ipas.
The seven selected countries included Moldova, Macedonia, Kyrgyzstan, Georgia,
Albania, and Russia. The training project was successful in the goals of introducing MVA
in the countries and presenting a model of comprehensive evidence-based abortion care
with a woman-centered approach.
Medical abortion implementation: Mifepristone is currently registered in 10 EE
countries, Misoprostol is used off-label in ob/gyn practice in whole region. But still the MA
method is expensive and unavailable for general population. Introductory studies, with
seminars and trainings for policymakers and health providers have been conducted by
Gynuity Health Project in the region, with the aim to offer practical clinical experience with
evidence-based protocols and provide useful data to revise existing guidelines and
protocols or to establish new one.
A need for creative, individual, country-level, sustainable strategies: Strategic
assessment of the contraception and abortion, currently taking place in some countries in
the region will assist in improving the quality of services. Trainings of providers;
development of standards and guidelines; IEC, targeting potential users, to increase the
demand for better and affordable services among women, advocacy campaigns for
women right to the access to the fruits of modern science, could be listed.
Eastern Europe: Turning back the wheel?
Rodica Comendant, Galina Maistruk, Irina Savelyeva (Moldavia)
Reproductive Health Training Center, Moldavia
Despite the widespread availability of abortion on legal grounds for more than 50 years, unsafe abortions account for 24% of maternal deaths in Eastern European (EE) region (WHO, 1998). Abortion rates remain high. Abortion is commonly used as a primary means to regulate fertility; the use of modern contraception methods remains low. Access to abortion services in EE has been challenged in recent years. Concerns about declining birth rates, pressure from religious groups have reduced support for family planning and abortion. The low quality of services is influenced by the lack of quality of care standards and quality control.
In this context, the recent registration of Mifepristone in many of EE countries, hasn’t much contributed to the improvement of the quality of abortion care. Medical abortion is still inaccessible for general population and remains an “elite” method for most of the women. The analysis of the access to medical abortion in several EE countries has showed the following common trends:
Recently launched by the leading abortion professionals and women advocates from 10 EE countries network „European Alliance for Reproductive Choice“ , supported by ICMA, among other objectives, has decided to focus on developing strategies, to make MA technology accessible in practice in EE countries. Experience-sharing, information, education, communication (IEC) activities, targeting potential users, to increase the demand for better and affordable services among women, advocacy for women rights to the access to the fruits of modern science, the improvement of providers knowledge among providers, transforming them in women advocates, advocacy events to register and utilize medical abortion are some of the listed strategies to consider.
Dr. Comendant holds a PhD as an obstetrician
gynaecologist. She is the Director of the
Reproductive Health Training Center (RHTC)
of Republic of Moldova, and since 2005 has
served as the Coordinator of the International
Consortium for Medical Abortion. In this capacity,
she successfully supported the development of
the ICMA regional networks in Latin America,
Asia, and Eastern Europe. Additionally, Dr.
Comendant is the National Coordinator of Safe
Abortion Programme of the Reproductive Health
Strategy of Republic of Moldova, an attendant
Professor of the Department of Obstetrics and
Gynecology of State University of Medicine
and Pharmacy of Moldova, a regional and
international trainer in safe abortion methods,
a senior consultant for Gynuity Health Project,
USA, and a consultant for the WHO Strategic
Assessment of Abortion in several countries.
ICMA: global, regional and national networking to
reduce the burden of unsafe abortion
In spite of increased attention to sexual and
reproductive health and rights, and particularly
to maternal mortality, in spite of the development
of effective technologies to make abortion very
safe, pregnancy-related deaths and unsafe
abortion remain a major public health problem in
largeparts of the world.
There are many organisations working worldwide
to improve women’s access to safe abortion
services – through advocacy, law and policy
reform, capacity building, service delivery, training,
information sharing and networking. Everyone
feels there is a growing need to link together and
combine the efforts towards ensuring the right to
safe abortion in all the countries. It was agreed an
international movement is needed to challenge the
growing threat posed by conservative political and
religious forces who are seeking to turn the clock
back, block efforts to improve laws and provide
services, and exclude abortion from maternal
mortality reduction and family planning initiatives.
This is why representatives of several dozen
NGOs from all world regions, consulted and
called together by the ICMA and it’s four afﬁliated
regional networks (ASAP, EEARC, CLACAI and
ANMA), in 2011-12, decided to launch the
International Campaign for Women’s Right to
Safe Abortion in April 2012, which after only a few
months has been endorsed by more than 620
groups and individuals all over the world.
Simplified medical abortion screening
Rodica Comendant1, Mark Hathaway2, Ginger Gillespie3, Elizabeth Raymond4
1Reproductive Health Training Centre, Clinical Hospital #1, Chisinau, Moldova, Republic of Moldova, 2carafem, Washington, DC, USA, 3Institute for Family Health, New York, NY, USA, 4Gynuity Health Projects, New York, NY, USA
Introduction: Currently, most providers perform an ultrasound or pelvic examination before medical abortion to assess the duration and location of the pregnancy. These evaluations are expensive, time-consuming and uncomfortable and they must be done by a skilled clinician in a medical setting. Our pilot study is designed to assess the safety and acceptability of offering medical abortion to selected women without either procedure.
Methods: We will recruit women requesting medical abortion in Moldova, the United States, and Mexico. To be eligible, a woman must be certain that her last menstrual period started within the prior 56 days, not have recently been using hormonal contraceptives, have no risk factors for or symptoms of ectopic pregnancy and not have had an ultrasound or examination in this pregnancy. Some sites exclude women with evidence of uterine enlargement on abdominal palpation. Each subject is treated with a standard regimen of mifepristone and misoprostol and followed until the abortion is complete.
Results: Up until May 2016 182 women had been enrolled at three sites. In Moldova 76% of all women having medical abortion at the study site have joined the study. In the United States the proportion is much lower; many abortion clients were ineligible because of irregular menses or contraceptive history and some prefer to have an ultrasound. Of the 175 subjects, with complete follow-up to date, 94% had complete pregnancy termination without additional treatment, 2% had surgical aspiration and 3% had extra misoprostol. No serious complications have occurred related to the absence of initial ultrasound and examination. Most subjects (89%) were pleased with omitting the screening ultrasound and pelvic examination. We will present updated data at the meeting.
Conclusion: Simplifying the screening procedures for medical abortion appears safe and could substantially increase access to this service.