Transcript Russia - International Consortium for Medical Abortion

3rd ICMA International Conference: Expanding Access to
Medical Abortion: Building on Two Decades of Experience
Russia: Challenges faced and lessons learned in
trying to expand access for medical abortion
Irina Saveleva, MD, PhD, professor
Lisbon, Portugal, March, 2-4, 2010
Russian Federation: country specific
 Biggest state in the world

territories of 17 075 400 km² or 1/9 all land, or 1/8 landed people, twice more than Canada (2nd place)
 Population





141.9 mln (01.01.09, Rosstat) – 9th place in the world
~ 80% population lives in European part and 20.7 % – in Asia part
73.1% population - urban; 26.9% population - rural
Migration – increase on the 64.2%
Proportion between death and birth is 1.2 (in whole country), and
2.0-2.2 times in 4 subjects’ Federation
 Nationality


180 nationalities
About 80% of populations are Russians

Less 5% Russians in some territories
Russian Federation: country specific


Political System

Federation consist of 83 equal subjects, inc. 21 Republics, 9
Krays, 46 oblasts, 2 Federal Cities (Moscow and SPb), 1
autonomy oblast and 4 autonomy okrugs

There are Parliament, Government and President (in case of
Republic) or Governor (region) in each region/ city
Religion

About 50% - believers, inc. 10 % who are visits church
regularly and 43% - visits church only in special Days

Russian Orthodox Organization - 66-67% believers

Islam - 5-6%

Others - not more 1-2% respondents
Specific challenges in Russia





High prevalence of abortion
Abortions account for close to one fourth of all
maternal deaths
Abortion are widely used as a means to control
fertility; high level of repeat abortions
Widely held misconception that abortion is safer
than contraception
Lack of integrated family planning services for
abortion clients
Russian Federation: Law and Policy

Legislation

RF Constitution (1993)

Civil Laws concerning Health (1993) – Articles 32, 35,
36,37

Family Code (1995)

Criminal Code (1996)

Other laws in according ratified international
documents in the RH and RR fields

Women’s Rights

International agreements (ICPD, ICPD +5)
Law and Policy: Barriers to access
Government’ Demography policy: support motherhood and
childbearing
Government officials demonstrate strict negative attitude towards
abortion






Limits access to abortion to claim to moral legitimacy
Liberal abortion legislation is increasingly criticized and
restricted
Absence of financing “Safe abortion” Program, inc. MA
Growing influence by the members of the Russian Orthodox
Organization on the Parliament policy in the field of RH, inc.
abortion

The draft of the project law “Protection of the human being
before birth” is under consideration

Limitation of the indications for 2nd trimester abortion (social from 13 to 4 and further limitation of medical indications)
President’ Guarantee to safe abortion

Safe abortion and abortion prevention/ contraception are
included in the President Program of social guarantee

Settings depends on the terms of pregnancy: out-patient
clinic and hospital

Safe abortion is covered by obligate medical insurance
(federal level) in case of public medical facility
BUT for all needs

Budget’ Norm for out-patient clinic – 8.7 visits/year and for
hospital – 1.89 bed-day/year

Cost for out-patient clinic - 168.4 rubles/ visit (US$ 5.6) and
for hospital – 1167 rubles (US$ 38.9)

Budget’ for 1 person/ year – 4059.6 rubles (US$ 135.3)
Note The cost of medical abortion ~ US$ 160.0 - ….
surgical abortion (early terms) ~ US$ 100.0 – 2 000.00
Russia: Health Care System





According International agreements HCS have a responsibility to
provide services “Safe abortion”
Health Care System, 2008

Maternity House and women’s consultation – 232

FP Centers - 34

“Abortion bed” ~ 3.6 thousands (0.92 : 10 000 women’s population),
12% of them – in rural area

Private clinic – not more than 5-10% from all MF; in some regions ~
25%

39.4 thousands Ob & Gyns (5.7 : 10 000 women’s population)
Abortion Legislation

facilities: governmental, private

practitioner: Ob/Gyn staff
Medical Facilities are presented at all levels: federal, regional, municipal
Data on the number of abortions are limited and vary widely by source
of information
Abortion in Russian Federation
250
204,0 209,2
214,0
201,0
200
191,4 191,9 186,0
173,7 170,6
156,2
142,2
150
100,3
100
50
90,3
81,9
75,1
128,3
115,9
106,6 102,4
96,0
81,9
68,1 64,5
60,3 57,3
53,1 50,5 47,7
45,8 42,9 40,6
37,8 35,6 33,3
1000 WFA
100 births
0
1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
Health Care System: Barriers to access
to medical abortion





Limitations of accessibility to the services in public medical facilities

unavailability of mifepristone and misoprostol

the choice of abortion method absence

insufficient counseling before and after of abortion

consent parental – teens till 15 years

working hours limited
The National Reproductive Health Standards and Guidelines

gestational age limitation for MA ≤ 43 days of LMP

overprotective service delivery protocols

dose of mifepristone and regimes

follow-up and scheduled visits
Provision MA mainly in the private facilities
Absence of private facilities/ drugs in small and rural regions
Cost of the services, inc. pre- and post-abortion care
Health Care System: Barriers to access


Protocols vs. practice

dose approved: 600mg Mifepriston versus 200 mg

women go home within half an hour

the upper limit with medical abortion - 8-9 weeks and up to…

additional doses of misoprostol

home use of misoprostol

ultrasound examination/ surgical intervention
Providers

knowledge/ attitudes (“There is no Safe abortion”, religious,
motivation to use a new method, “Not for me”, etc)

educational/ training programs

shift between WHO standards and National Guidelines

lack of technical support from professional groups

providers in small towns and rural area are afraid of MA’
complications
Convenient: Information before
abortion
How we can influence on the situation
for expanding access to safe abortion
Legislation
Social and
economic factors
Medical and
Health care system
ABORTION
“National character”
Culture,
Education
Religion
Expanding access to safe abortion:
legislation and advocacy

Collaboration with Parliament Representatives in legislation
issues and laws

Advocacy work for developing and supporting of regional
medical-social FP& Safe abortion Programs

Establishment positive attitude toward FP& Safe in the civil
society

Creation an information system to provide population with
the state-of the-art knowledge on reproductive and sexual
behavior, and contraceptive use
Expanding access to safe abortion:
Health care system
To establish of abortion service, incl. post-abortion care, at all
service delivery levels


To make RH/FP services available and acceptable to women

To create and implement National Safe Abortion Guideline

Training of FP providers (medical and social staff)
Improving the quality of care; procedural issues; choice of
abortion method


Implementing of counseling in post-abortion practice
Provision of free abortion drug for special group (adolescents,
first pregnancy)

Expanding access to safe abortion:
“National character”, Culture, Education





Activity's integration of different professionals and nonprofessionals in the RH programs
Creating an information system to provide population with the
state-of the-art knowledge on reproductive and sexual
behavior, safe abortion and contraceptive use
Production and distribution of educational materials (cue
cards, population reports, booklets, brochures, posters) for
general population and health care professionals
Involving mass media in the coverage of family planning, safe
abortion and sexual culture of the matrimonial relations’
issues
Improving system for adolescents’ education in the area of
family planning, sex education, HIV/AIDS and STI prevention