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Family Planning in Romania: An update after 6 years of

donors’ withdrawal

Merce M. Gasco, MD

ICFP Bali, 2016

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Romania Statistics 1999

Population: 20 M, 2 M Roma

CPR 1999 Total: 29.5%. Rural:20.9%

Abortions WRA 1999 rural:2.4

MMR 52/1000 half due to abortion

TFR 1.9

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OBJECTIVES OF THE PRESENTATION 1. Analyze maternal mortality, contraceptive

use, induced abortion and fertility rate in Romania from 2000-2008

2. Examine whether changes achieved during the program persisted beyond donors’ withdrawal in 2008

3. Identify the factors that lead to resilience of key elements of the program

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Strong political commitment and ownership, including financial:

National FP program with national coverage

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FP coverage of the smallest administrative units in Romania: 2,686 rural communes

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Include FP at every interaction; client provider, integration

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RURAL PHC rural clinics Family doctors &

nurses Community

Nurses Roma Health

Mediator

WRA

HOSPITALS Post Partum FP Post Abort FP

ObGyn

URBAN FP clinics

PHC clinics ObGyn Nurses

Social Workers Youth Centers

Police

FP information/ counseling

Free contraceptives

FP information/ counseling

Free contraceptives

FP information/ counseling

Free/subsidized contraceptives

FAMILY PLANNING AND CONTRACEPTIVES AVAILABLE AT ALL ENTRY POINTS OF THE HEALTH SYSTEM: AN FP SAFETY NET

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Enabling policies: FP as part of the essential package of

PHC services, PPFP and PAC, task shifting and training

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POST-PARTUM FAMILY PLANNING: INTRODUCTION OF IUD INSERTION AFTER DELIVERY

YOU CAN BE A MOM WITHOUT WORRIES Are you breastfeeding only? Is your baby less than 6 months old? Have your menses returned yet? Did you answer YES to these three questions? In this case…you should not get pregnant! For more information ask…. Attention!!! This method does not protect against sexual transmited infections (STI)

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, / You can get pregnant again as

early as 7 days after an

abortion.

If you want to have a child after

having an abortion, it is best to

wait 6 months.

For more information on this and

on family planning methods, ask

the… or go directly to a clinic

showing this sign (The NFPP logo

is posted in all FP clinics).

POST ABORTION FAMILY PLANNING

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Community involvement: Pro-poor policies, addressing

inequalities

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TACKLING INEQUALITIES: ROMA AND URBAN POOR COMMUNITIES

-Roma cultural mediators

-Roma population: 2 million

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Access to contraceptives: free and private sector

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Relationship between health providers trained, abortion rate and FP active users

Source: MOH and project records

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Access to contraceptives: free and private sector

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TRENDS IN THE USE OF CONTRACEPTIVES FREE/ PRIVATE SECTOR ROMANIA, 2002-2006

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MATERNAL MORTALITY AND MATERNAL MORTALITY DUE TO ABORTION

Source: MOH and project

records

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KEY ACHIEVEMENTS MONITORED 2008-2014

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RELATION MODERN CONTRACEPTION/ABORTION RATE

Source: MOH, DHS and WV

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CONTRACEPTIVE USE IN ROMANIA 2004-2010

Recent national RH surveys have not been conducted, but a sub-national World Vision survey of new mothers indicated sustainable propensity to use modern contraception among Romanian WRA in rural areas.

Source:2004 RHS, 2010 World Vision

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RELATION MODERN CONTRACEPTION/ABORTION RATE

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SHIFT FROM ABORTION TO CONTRACEPTION

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MATERNAL MORTALITY RATIO, ROMANIA 2001-2012 (MATERNAL DEATHS/100.000 LIVE BIRTHS)

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MATERNAL DEATHS AVERTED BY INCREASING CONTRACEPTIVE USE

Source: Dr. Saifuddin Ahmed, et al. Lancet 2012

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KEY ACHIEVEMENTS MONITORED

• Favorable evolution of key health indicators: maternal mortality, abortion rates, CPR and FR

• Provision of FP at PHC level is maintained and incentivized

• Maternal health remains a priority in the political agenda

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SEVEN YEARS AFTER DONORS’ WITHDRAWAL: A sustainable decline of maternal mortality ratio from 52 per 100,000 death/live births in 2000 to 21.1 per 100,000 in 2008-2012 A continuous decline of abortion ratio from 1.11 abortions/live births (1999), 0.88 abortions/live births (2004), and eventually to 0.44 abortions/live births in 2013, while fertility rate remained constant since 1999 (1.3-1.4 children/woman). Recent evidence suggests modern contraception use continues to increase among rural women 54.6%.

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FACTORS THAT LEAD TO RESILIENCE OF KEY ELEMENTS OF THE PROGRAM

Strong political commitment and ownership, including financial

All interventions within the system

Enabling policies: FP as part of the essential package of PHC services, PPFP and PAC, task shifting and training

Include FP at every interaction; client provider, integration

Community involvement: Pro-poor policies, addressing inequalities

Access to contraceptives: free and private sector involvement

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FACTORS THAT LEAD TO RESILIENCE OF KEY ELEMENTS OF THE PROGRAM (CONT.)

National coverage and monitoring systems

Solid partnership with local organizations

Pilot and scale-up only affordable interventions

Church involvement

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CONCLUSIONS

• Sustained, favorable evolution for key epidemiological indicators could be observed

• PHC providers contracted by the National Health Insurance House and reimbursed for FP services

• FP “culture is prevalent across all communities • Maternal health remains a priority under the

National Health Strategy 2014-2020 • The shift from abortion to contraception resulted

in increased use of subsidized contraceptives along with growth of the free market

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Thank you