Institutionalizing Manual Vacuum Aspiration Abortion in Central and Eastern Europe and the Former Soviet Union 2 The National Abortion Federation’s mission is to ensure safe, legal, and accessible abortion care to promote health and justice for women. Authors Anita Kuennen, RN, NAF Clinical Curriculum Development St Petersburg, Russia Services Director D. Ott Scientific Research Institute of Sally Girvin, RNC-NP Rodica Comendant, MD, PhD Obstetrics and Gynecology Ann Gerhardt, MPH Patricia Smith, MD Dariko Niaury, MD Tengiz Asatiani, MD Edward Popov, MD Participating Family Women’s Antenatal Clinic #22 Planning Fellows Flora Koutueva, MD Editors Guzel, Mamleeva, MD Michelle Fox, MD Vicki Saporta, NAF President & CEO Nicola Moore, MD Beth Kruse, CNM, NAF Associate Tirana, Albania Director, Clinical Services Katherine O’Connell, MD Tirana University Hospital, Max Yurowsky, MD Jenny Blasdell, JD, NAF Public Department of Gynecology Policy Director & Albanian Association of Perinatology In-Country Coordinators Contributors Orion Glozheni, MD and Contributors Rubena Moisiu, MD Laura Castleman, MPH, MD Aisuluu Bolotbaeva & Elvira Elizaveta Kan, MD Muratlieva, Soros Foundation Skopje, Macedonia Eric Schaff, MD of Kyrgyzstan Skopje University Hospital, Clinic of Ledia Curri, Open Society Foundation Obstetrics and Gynecology of Albania Katerina Stankova, MD Vera Dimitrievska, Soros Foundation Jovan T Project of Macedonia ofoski, MD Acknowledgements Tatjana Evtihieva, Ipas, Russia Bishkek, Kyrgyzstan Open Society Institute Viorel Soltan, Soros Foundation of Moldova Kyrgyz Research Institute of Karen Plafker, MPH Obstetrics and Pediatrics Lasha Zaalishvili, Soros Foundation Nina Schwalbe of Georgia Nataliya Ravilievna Kerimova, MD Danielle Tuller Marat Anatolievich Jajiev, MD Training Sites and NAF Training Faculty Kyrgyz Russian Slovenian University Susan Cahill, PA-C Project Coordinators Gulnara Asymbekova, MD Laura Castleman, MPH, MD Chisinau, Moldova Elizaveta Kan, MD Rodica Comendant, MD, PhD Clinical Municipal Hospital N 1 Stelian Hodorogea, MD Rodica Comendant, MD, PhD Tbilisi, Georgia Johanna Hauser, PA-C Iurie Dondiuc, MD Center for Clinical Effectiveness in Reproductive Health Anita Kuennen, RN Valentin Friptu, MD Tengiz Asatiani, MD Eric Schaff, MD Stelian Hodorogea, MD Zaza Bokhua, MD Patricia Smith, MD Jini Tanenhaus, PA-C Moscow, Russia Research Centre for Obstetrics, Gynecology and Perinatology of Project Partners at Ipas the Russian Academy of Medical Traci Baird, MPH Science Lisa Clemens Olga Frolova, MD Irina Ilitcheva, MD 1660 L Street, NW, Suite 450 ■ Washington, DC 20036 ■ p: 202.667.5881 ■ f: 202.667.5890 ■ www.prochoice.org 3 PREFACE Advantages of MVA: • equal or slightly decreased risk of This report documents the results of the Manual Vacuum complications in comparison with EVA; Aspiration (MVA) project in building support to improve the quality of abortion care within medical, governmen- • ability to be provided under local rather tal, and non-governmental organization (NGO) sectors; than general anesthesia and pain may be in strengthening the institutional capacity of service and more easily managed; training programs; and in identifying strategies for future • equipment is portable, not electric; work in abortion quality in the regions of Central and Eastern Europe and the former Soviet Union. • equipment is easy to maintain, reusable, and much less expensive than surgical or Although there is a significant body of evidence demonstrat- electric equipment; ing the greater safety of aspiration abortion in comparison to sharp curettage, without a decrease in effectiveness (at gesta- • abortions may be provided outside of an tional ages suitable for comparison), the latter has remained operating room, decreasing the cost and the primary method of abortion care in these regions, as in use of expensive medical personnel and many other countries. Manual vacuum aspiration (MVA) facilities; entails the use of a hand-operated syringe and flexible can- • allows for easy examination of the products nula to aspirate the uterus, thus offering a gentle, effective of conception to confirm completion; technology ideal for use in low-resource settings. Studies comparing electric vacuum aspiration (EVA) and manual • operative technique is not complicated to vacuum aspiration (MVA) have found equivalent levels of teach to qualified providers; and effectiveness between the two techniques. 1 • excellent tool for management of early In June 1999, participants at a Special Session of the United pregnancy failure and endometrial biopsy. Nations General Assembly agreed, “in circumstances where abortion is not against the law, health systems should train Introduction and equip health-service providers and should take other measures to ensure that such abortion is safe and accessible.” This project was implemented over a two-and-a-half-year In keeping with this international goal of ensuring safety and period and included seven training sites: one site each in access for abortion care, the National Abortion Federation Moldova, Macedonia, Kyrgyzstan, Georgia, and Albania; (NAF), in collaboration with Ipas2 and funded by the Open and two sites in Russia: St. Petersburg and Moscow. The Society Institute (OSI), developed a plan to extend abortion- goal of the project was to improve the quality of abortion related quality assurance concepts to interested health care care and promote patient-centered care concepts within the providers in nations of Central and Eastern Europe and the framework of clinical safety and reproductive rights through former Soviet Union. NAF’s North American experience in the following measurable objectives: developing and setting evidence-based guidelines, measur- 1. to introduce MVA instruments and ing quality, promoting quality improvement, and developing techniques to practitioners and accredited continuing medical education programs created organizations; the basis for the international training model. 2. to build awareness and acceptance of a model of evidence-based care utilizing a woman-centered approach; and 3. to provide assistance to participants in planning the institutionalization of MVA and patient-centered care. 1 Greenslade, FC, Benson J, Winkler J, Henderson V, Wolf M, Leonard A. “Manual vacuum aspiration: a summary of clinical and programmatic experience worldwide,” Advances in Abortion Care, 1993:3(2):1-4. 2 Ipas is a global leader in MVA technology. Their instruments are used in more than 100 countries worldwide and Ipas provided the MVA devices used in this project. 4 Project developers and managers found it critical to develop Training covered all aspects of patient care, and incorporate common clinical concepts and values into including: the assessment and planning phase in order to determine • counseling and informed consent; feasible goals and strategies for measuring achievements. As • patient screening; part of this process, economic, political, and bureaucratic fluc- • method selection; tuations within national, regional, and international policies • pain management; influencing reproductive health care issues were considered. • clinical techniques for surgical abortion; In order for economic decision makers as well as individuals • tissue examination; providing direct care to agree on proposed changes to service • complication management; delivery, rationales for change also needed to be relevant to • quality improvement techniques and the setting. For instance, process-assessment demonstrated measurement; and that public facilities required more time and commitment • instrument processing and infection to make a successful impact by implementing crucial health prevention. system improvements. Ultimately, training participants and organizers were able to identify primary strategies to guide future work in quality abortion care, and agreed that Fifteen physicians from the training sites attended the building on the acceptance and integration of new abortion Networking Resource Meeting held in Budapest, Hungary care models within public and private health systems would on June 30 and July 1, 2004. All participants were asked to strengthen future efforts. present on their progress in institutionalizing MVA since the NAF/OSI trainings. The key objectives for this meet- ing were to provide participants with a forum for sharing Overview of MVA Project experiences, identifying common obstacles, and developing Each site in the program was visited three times. First, strategies for overcoming those obstacles. Activities included a needs assessment was performed; then the training a discussion of best practices in training for quality abortion program was conducted; and an evaluation followed. care and key learning points for the different sites. A final These visits were conducted at each site by the NAF objective was to address the concerns and questions of the program coordinator, training faculty, and in a few representatives about the future of the project and further sites with post-doctorate family planning fellows and efforts. NAF, Ipas, and OSI identified available opportuni- OSI representatives. Trainings were carried out using a ties and resources, and helped to clarify the components sites comprehensive patient-centered curriculum developed would need to accomplish individually in order to sustain by NAF specifically for the project. Initial trainings were and advance their work. Before adjourning, each country undertaken in three countries in 2002 by one physician representative was charged