MVA in the context of MVA in the context of Comprehensive Abortion Comprehensive Abortion

Care (CAC) introduction in Care (CAC) introduction in Eastern European Eastern European

countriescountries

Rodica Comendant,Rodica Comendant,MD, PhDMD, PhD

Reproductive Health Training Center, Medical Reproductive Health Training Center, Medical University, Chisinau, MoldovaUniversity, Chisinau, Moldova

ICMA CoordinatorICMA Coordinator

MoscowMoscowInternational Seminar: International Seminar:

Abortion, Contraception and Women’s HealthAbortion, Contraception and Women’s Health2727--28 October, 200528 October, 2005

Women Centered, Comprehensive Women Centered, Comprehensive Abortion Care – Abortion Care –

what is this?what is this?

Components of CACComponents of CAC

AccessAccess QualityQuality ChoiceChoice SustainabilitySustainability

Need for CAC in Eastern Need for CAC in Eastern EuropeEurope

Unsafe abortions account for 24% of Unsafe abortions account for 24% of maternal deaths in region (WHO, 1998)maternal deaths in region (WHO, 1998)

Abortion rates remain highAbortion rates remain high Percentage of women using modern Percentage of women using modern

contraception remains low (Population contraception remains low (Population Reference Bureau, 2002)Reference Bureau, 2002)

Abortion commonly used as a primary Abortion commonly used as a primary means to regulate fertilitymeans to regulate fertility

Need for CAC in Eastern Need for CAC in Eastern EuropeEurope

Widespread availability of abortion on legal Widespread availability of abortion on legal groundsgrounds for 50 years in many countries, for 50 years in many countries, but… but…

Poor access for social-vulnerable groupsPoor access for social-vulnerable groups Poor quality of services in public sector: Poor quality of services in public sector:

main method D&C, no counseling, no main method D&C, no counseling, no choice of the methods, general choice of the methods, general anaesthezia for pain control, poor infection anaesthezia for pain control, poor infection prevention, no contraception post-abortion,prevention, no contraception post-abortion,

No evidence-based guidelines, no trainings No evidence-based guidelines, no trainings in CACin CAC

Need for CAC in Eastern Need for CAC in Eastern EuropeEurope

Access to abortion services has been Access to abortion services has been challenged in recent yearschallenged in recent years

Concerns about declining birth rates, Concerns about declining birth rates, pressure from religious groups have pressure from religious groups have reduced support for family planning reduced support for family planning and abortionand abortion

MVA implementation project = a MVA implementation project = a new approach to abortion carenew approach to abortion care

MVA not only an other abortion techniqueMVA not only an other abortion technique MVA as a possibility to improve abortion MVA as a possibility to improve abortion

care, to implement patient care system, to care, to implement patient care system, to change practice and policy… change practice and policy…

Partners: NAF, OSY-New York, Soros IpasPartners: NAF, OSY-New York, Soros Ipas In the region: Ministries of Health, Medical In the region: Ministries of Health, Medical

Universities, Key-people,Hospitals, NGOs, Universities, Key-people,Hospitals, NGOs, abortion providers, distributors, women abortion providers, distributors, women

Why MVA?Why MVA? It’s a safe, efficient, recommended by WHO It’s a safe, efficient, recommended by WHO

method, that can be used in all the situations method, that can be used in all the situations when uterine evacuation is needed.when uterine evacuation is needed.

No ‘checking curettage’ is needed (tissue No ‘checking curettage’ is needed (tissue exam)!exam)!

It’s a cost-efficient method: Procedure costs, It’s a cost-efficient method: Procedure costs, staff time and other resources are staff time and other resources are significantly reduced where MVA is used.significantly reduced where MVA is used.

Local anaesthezia, less risky than general Local anaesthezia, less risky than general can be used can be used

MVA increases the patients’ satisfaction and MVA increases the patients’ satisfaction and patients’ flowpatients’ flow

MVA as educational tool for both – providers MVA as educational tool for both – providers and patientsand patients! !

Tissue examTissue exam

MVA project in Central and EE MVA project in Central and EE region – trainingregion – training

Training of Trainers in Comprehensive MVA Training of Trainers in Comprehensive MVA abortion care, conducted by experts from NAF, abortion care, conducted by experts from NAF, with the support of Ipas and OSI (USA)with the support of Ipas and OSI (USA)

Training curricula is based on adult learning Training curricula is based on adult learning principles and includes: patient-centered principles and includes: patient-centered elements of care, counseling, use of local elements of care, counseling, use of local anaesthezia, infection prevention, postabortion anaesthezia, infection prevention, postabortion care and contraception following abortion. care and contraception following abortion.

Lectures, case studies and practice with models Lectures, case studies and practice with models and patients are used.and patients are used.

Countries: Moldova, Russia (Moscow and St. Countries: Moldova, Russia (Moscow and St. Petersburg)/ Ukraine, Georgia, Kyrgyzstan / Petersburg)/ Ukraine, Georgia, Kyrgyzstan / Kazakhstan, AlbaniaKazakhstan, Albania

Strategic importance of MVA Strategic importance of MVA trainingstrainings

Trainings were done after an assessment of Trainings were done after an assessment of local situationlocal situation

Trainings satisfied the real needs of national Trainings satisfied the real needs of national context (both providers and women)context (both providers and women)

Offered a new for us approach - women Offered a new for us approach - women centered and evidence-based approach, centered and evidence-based approach, changed the mentality…changed the mentality…

Built a team of local experts – the real Built a team of local experts – the real “pioneers” and champions of the method “pioneers” and champions of the method and of CACand of CAC

Pushed the things forward, initiated Pushed the things forward, initiated changes in abortion policy… changes in abortion policy…

MVA project in Central and EE MVA project in Central and EE region – a new abortion policyregion – a new abortion policy

Trainings in cascade of national abortion Trainings in cascade of national abortion providers, provided by local team of trainersproviders, provided by local team of trainers

Publication of training materials, MVA is Publication of training materials, MVA is incorporated in University curricula incorporated in University curricula

Official approval by MoHs of MVA equipment Official approval by MoHs of MVA equipment and method (<=12 weeks), Establishment of and method (<=12 weeks), Establishment of local distributor local distributor

Guidelines, protocols on MVA with the Guidelines, protocols on MVA with the elements of CAC were developed and approved elements of CAC were developed and approved

Education-information campaigns on safe Education-information campaigns on safe abortion, raising community awareness and abortion, raising community awareness and increasing the demand for better quality of increasing the demand for better quality of servicesservices

MVA registration in Central and EE MVA registration in Central and EE region by countriesregion by countries

RussiaRussia GeorgiaGeorgia MoldovaMoldova UkraineUkraine LithuaniaLithuania UzbekistanUzbekistan KazakhstanKazakhstan TajikistanTajikistan TurkmenistanTurkmenistan KyrgyzstanKyrgyzstan Armenia (?)Armenia (?) RomaniaRomania TurkeyTurkey AlbaniaAlbania

Next steps toward really CAC: Next steps toward really CAC: Moldova exampleMoldova 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 MVA implementation as a routine method on the

national level, and at primary level of care national level, and at primary level of care Medical abortion implementationMedical abortion implementation Strategic assessment of abortion services: (with WHO, Strategic assessment of abortion services: (with WHO,

Ipas, EEIRH,UNFPA) was conducted in September 2005Ipas, EEIRH,UNFPA) was conducted in September 2005 New MoH order, abortion standards are developed and New MoH order, abortion standards are developed and

submitted submitted National Strategy of RH for 2005-2015 developed, with National Strategy of RH for 2005-2015 developed, with

WHO expertise (abortion quality is one of the priority)WHO expertise (abortion quality is one of the priority) System of continuing CAC education (MVA & Medical System of continuing CAC education (MVA & Medical

abortion) is developing now abortion) is developing now

Trained in MVA providers, local anesthesia Trained in MVA providers, local anesthesia used and rate of MVA abortions in MVA used and rate of MVA abortions in MVA

Center in 2002-2004Center in 2002-2004

7

70

30

92

0

96

0102030405060708090

100

Trained inMVA

providers

Localanesthesia

MVA

2002

2004

Number of MVA abortions in MVA Number of MVA abortions in MVA Centre, Chisinau, Moldova (2002-Centre, Chisinau, Moldova (2002-

2004)2004)

300

1200

0

200

400

600

800

1000

1200

Number ofpatients

2002

2004

WHO Strategic Approach/Assessment – an WHO Strategic Approach/Assessment – an important tool to improve the situation in the important tool to improve the situation in the

regionregion WHO meeting on Safe abortion and WHO meeting on Safe abortion and

Strategic Approach in Riga, June Strategic Approach in Riga, June 2004 (Russia, Ukraine, Moldova, 2004 (Russia, Ukraine, Moldova, Lithuania, Latvia)Lithuania, Latvia)

Strategic Assessment of Abortion Strategic Assessment of Abortion services (WHO, MoH):services (WHO, MoH):

done in Romania, Moldova. Soon done in Romania, Moldova. Soon Russia, Ukraine (?)Russia, Ukraine (?)

Networking: sharing experience, Networking: sharing experience, learning CAClearning CAC

NAF: NAF: www.prochoice.org Astra Astra www.astra.org.pl Ipas: Training Forum Ipas: Training Forum www.ipas.org ICMA: International Consortium for ICMA: International Consortium for

medical Abortion medical Abortion www.medicalabortionconsortium.org

Gynuity Health Projects: Gynuity Health Projects:

www.gynuity.org

СПАСИБО!СПАСИБО!

References:References: Safe Abortion: Technical and Policy Guidance for Health Systems, WHO, Safe Abortion: Technical and Policy Guidance for Health Systems, WHO,

2004 2004 Traci Bird, Sarbaga Folk and Entela Shehu Shifting focus to the women: Traci Bird, Sarbaga Folk and Entela Shehu Shifting focus to the women:

comprehensive abortion care in central and eastern. Europe. Entre-nous, comprehensive abortion care in central and eastern. Europe. Entre-nous, No 59-2005.p. European Magazine for Sexual and Reproductive HealthNo 59-2005.p. European Magazine for Sexual and Reproductive Health

Bird, Harvey, et al. Similarities in women’s perceptions and acceptability Bird, Harvey, et al. Similarities in women’s perceptions and acceptability of manualof manual

vacuum aspiration and electric vacuum aspiration for first trimester vacuum aspiration and electric vacuum aspiration for first trimester abortion. in 2003 Contraception 67  (2003) 207-212. abortion. in 2003 Contraception 67  (2003) 207-212.

Greenslade, Forrest, Ann Leonard, Janie Benson and Judith Winkler. Greenslade, Forrest, Ann Leonard, Janie Benson and Judith Winkler. 1993. 1993. Manual vacuum aspiration: A summary of clinical and Manual vacuum aspiration: A summary of clinical and programmatic experience worldwide.programmatic experience worldwide. Carrboro, NC: Ipas Carrboro, NC: Ipas

International Planned Parenthood Federation (IPPF). 2001. International International Planned Parenthood Federation (IPPF). 2001. International Medical Advisory Panel (IMAP) statement on safe abortion. Medical Advisory Panel (IMAP) statement on safe abortion. IPPF Medical IPPF Medical BulletinBulletin, 35(5)., 35(5).

International Planned Parenthood Federation (IPPF). 2001. International International Planned Parenthood Federation (IPPF). 2001. International Medical Advisory Panel (IMAP) statement on safe abortion. Medical Advisory Panel (IMAP) statement on safe abortion. IPPF Medical IPPF Medical BulletinBulletin, 35(5)., 35(5).

References:References: Cates, Willard J. and David A. Grimes. 1981. Morbidity and mortality Cates, Willard J. and David A. Grimes. 1981. Morbidity and mortality

of abortion in the United States. In Hodgeson, J.E., ed. of abortion in the United States. In Hodgeson, J.E., ed. Abortion and Abortion and sterilization: Medical and social aspectssterilization: Medical and social aspects. London, Academic Press.. London, Academic Press.

Grimes, David A., Kenneth F. Schulz, Willard Cates, Jr. and Carl W. 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 Tyler, Jr. 1977. The Joint Program for the Study of Abortion/CDC: A preliminary report. In Hern, Warren and B. Andrikopoulos. eds. preliminary report. In Hern, Warren and B. Andrikopoulos. eds. Abortion in the SeventiesAbortion in the Seventies. New York, National Abortion Federation. . New York, National Abortion Federation.

Thonneau, Fougeyrollas, et al. Complications of abortion performed Thonneau, Fougeyrollas, et al. Complications of abortion performed under local anesthesia. In European Journal of Obstetrics & under local anesthesia. In European Journal of Obstetrics & Gynecology and Reproductive Biology 81 (1998) 59–63Gynecology and Reproductive Biology 81 (1998) 59–63

G. Dean, L. Cardenas, et al. Acceptability of manual versus electric G. Dean, L. Cardenas, et al. Acceptability of manual versus electric aspiration for first trimester abortion: a randomized trial. In aspiration for first trimester abortion: a randomized trial. In Contraception 67 (2003), 202-2007Contraception 67 (2003), 202-2007

Blumenthal PD and Remsburg RE. A time and cost analysis of the Blumenthal PD and Remsburg RE. A time and cost analysis of the management of incomplete abortion with manual vacuum management of incomplete abortion with manual vacuum aspiration. International Journal of Gynecology and Obstetrics aspiration. International Journal of Gynecology and Obstetrics 1994; 45:261-267. 1994; 45:261-267.

Joffe, C. Abortion in historical perspective. Joffe, C. Abortion in historical perspective. In Paul, M, Lichtenberg, In Paul, M, Lichtenberg, ES, Borgatta, L, Grimes, DA, & Stubblefield, PG (Eds.). ES, Borgatta, L, Grimes, DA, & Stubblefield, PG (Eds.). A Clinician’s A Clinician’s Guide to Medical and Surgical AbortionGuide to Medical and Surgical Abortion. Philadelphia: Churchill . Philadelphia: Churchill Livingstone, 1999.Livingstone, 1999.