Rodica Comendant


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    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.

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    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:

    • Cost  of the pills is prohibitive;
    • statistic is virtually inexistent;
    • low level of the awareness about the method in the population, low demand for comprehensive abortion care services, many existing myths;
    • lack of providers motivation to use a new method, the misuse, low efficacy;
    • unwillingness of the public health systems to take the necessary steps for the implementation of the medical abortion services, and unnecessary barriers imposed by their regulations.

    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.

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    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.

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    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.