1. Brankica Mladenovik, MD, MPH, PhD Daniela Panova, Ob&Gyn specialist
Report on action plan implementation: REDUCING THE NUMBER OF induced ABORTIONS IN MACEDONIA, 2010 – Chisinau, Moldova, June 2011
Brankica Mladenovik, MD, MPH, PhD
Daniela Panova, Ob&Gyn specialist

2. Demographic and socio-economic indicators
Total population of ;
Life expectancy at birth: 74.2 years  (2010);  male: 72.4 years, female: 77.6 years;
Human Development Index: 0,701;
Gini index: 42,8 (2006); 28,21 (1998);
GDP per capita: 4,515 USD (2009);
Unemployment rate /ILO definiton: 31.7% (2010);
Average net paid wage per emloyee: ; denars (=350 EUR) (2010).

3. SRH indicators: IMR: 11.7/1000 births (2009);
MMR: 8/ live births;
7% of births were delivered by juvenile mothers (under the age of 19);
5.5% of sexually active teenage girls use oral contraception (HBSC Study, 2006);
No case of maternal mortality related to abortion, morbidity data related to abortion is NA;
CPR – 13.5% (any contraceptive method);
CPR – 9.8% (modern contraceptives);
33.6% of married women with unmeet need for contraception.
Source: State Statistical Office of R.M, Multiple Indicator Cluster Survey (MICS), 2007

4. Abortion rate per 100 life births in Macedonia
? ( sub registration)
Source: Institute for Mother and Child Health, 2010.

5. The current situation of abortion services in Macedonia
Abortion must be carried out only by gynecologist-obstetric specialist, in gynecological hospitals or another authorized health-care facility that has a gynecological-obstetrical unit;
Abortion in private gynecological cabinets is illegal;
Abortion costs are not covered with National Health Insurance;
Macedonia has still not registered and included the medical abortion in the essential drug list;
Sharp curettage is the only method performed at the gynecological hospitals;
None of the available contraceptive methods in Macedonia (including condoms, IUD’s, pills...) are on the EDL and reimbursed from the National health insurance Fund.

6. Policy environment
Macedonia is one of most liberal country regarding abortion.
There is a formal population policy addressing decreasing fertility trend in the past several years.
In 2008 "National Strategy for Demographic Development of Republic of Macedonia " was adopted.
Following it’s adoption, a number of legal and policy changes were introduced aimed at achieving one of it’s key strategic objectives – an increase in the natural population growth (campaign for a third child).
There were no significant anti-choice activities on abortion rights compared to the situation in the last year. No activities from the Religious leaders, individuals and/or anti-choice NGOs can be
reported in 2010.

7. Policy environment
Strategic assessment of policy, quality and access to contraception and abortion in the Republic of Macedonia, 2008
In December 2010 new Safe abortion protocols officially presented and adopted by the Professional Ob&Gyn Association.
National Sexual and Reproductive Health Strategy , developed in 2010 and adopted in 2011 by the Government of Macedonia, (without Action Plan).
Health Information System improved (new reporting forms prepared - disaggregation of data by age and ethnicity)
NGO accreditation at the MoH - NGOs can apply for activities, allocating funds from the Budget to citizens associations and foundations. 
During the past 2 years there were a lot of activities aimed to improve the safe abortion services in the country with the support of international organizations. In this regard in 2008 the Institute for Public Health with the support of UNFPA did a Strategic assessment of policy, quality and access to contraception and abortion in the Republic of Macedonia (available on request) in which introducing medical abortion as alternative to surgical abortion techniques was one of the main conclusions in the report.

8. Action Plan –
Goal: To reduce the induced abortion rate by increasing contraceptive prevalence rate.

9. Specific objective 1. – Raising community awareness about the reliable methods of contraception and SA, including medical abortion
Activities:
Responsible agents/partners
Process indicators.
1.1 Preparing, printing and distribution of health promotional leaflets for different target groups;
1.2. Organizing training courses for NGO working on SRH;
1.3. Organizing sensitization workshop for local community authorities;
1.4. Organization of informational campaigns for media representatives on SRH issues (2 days training)
NIPH
UNFPA
- Institute for mother and child health (IMCH)
- Macedonian association of G&O
- NGO-HERA
- MoH
- SA WG
- IEC materials for contraception developed and distributed, with focus on rural and Roma women;
- Number of workshops and training courses ( 2);
Number of NGO members trained and knowledgeable in SRHR of youth(in effective contraceptive use) (10);
Number of community members trained in social and health aspects of family planning and SRHR of youth (35).
Number of media representatives (15) attended the training

10. Specific objective 2. Improve accessibility for contraception by integrating contraception in PHC services
Activities:
Responsible agents/partners
Process indicators.
2.1. Developing, printing and distributing contraceptive guideline for health providers in PHC (community nurses);
2.1 Delivering workshop for health care providers in PHC (community nurses):
modern contraceptive methods
communication and counselling skills
- NIPH
Institute for mother and child health
UNFPA
- Macedonian association of G&O
- HERA –NGO
- SA WG
- Guideline developed and approved;
Number of workshops for community nurses (3x25 nurses);
- 87 community nurses trained and enhanced their contraceptive counselling skills

11. Specific objective 3. Improving the legal and regulatory framework regarding contraception and medical abortion
Activities:
Responsible agents/partners
Process indicators
3.1. Registration of Medabon;
3.2. Inclusion of contraception on essential drug list
3.3. Pilot study for medical abortion at G&O Clinic;
3.4. Inclusion of mifepriston and misoprostol in list of essential drugs;
MoH
Macedonian association of G&O
SA WG
Concept Foundation
NGO HERA
- Medabon registered
- Draft protocol for pilot study prepared;
- Article on pilot study published
- 2 contraceptives included on EDL

12. Specific objective 4. Strengthening the capacities of gynecologists on SA practices including medical abortion
Activities
Responsible agents/partners
Process indicators
4.1. Establish relation with EEARC;
4.2. Printing, distribution of SA Protocols;
4.23 Awareness rising workshop with three international speakers;
4.4. ToT of gynecologists;
4.5. Trainings of gynecologists on SA including medical abortion;
4.6. Obtaining and distributing Informational package on SA
EEARC
Concept Foundation
NGO HERA
- Country abortion profile prepared and posted
- National guidelines on safe abortion printed and distributed;
- Advocacy meeting on medical abortion- organized and results from KAP survey presented (November 2010);
- Number of training courses organized (1);
- Number of participants attended (12)
- Number of informational packages on FAQ on MA distributed (150)

13. Awareness rising meeting, Skopje, November 2010

14. Awareness rising meeting, Skopje, November 2010

15. Main results from KAP survey, 2010
Despite the fact that the medical abortion is still not registered and available in Macedonia, 29,5% gynaecologists reported having experience in its use to terminate pregnancies, due to ″its non-invasiveness“ (46,1%) and ″on women’s demand“ (23,0%).
Doctors not providing medical abortion cited several reasons: “it is not registered yet″ (67,7%), “feel not trained enough″ (19,3%) and “fear of adverse effects″ (9,7%).
Almost two-third of doctors (65,9%) were very interested in receiving training on medical abortion methods; 93,2% of gynaecologists think that it should be registered because of the “right of women to choose″ (63,3%) and “positive medical aspects″ (43,2%).

16. Training on Medical Abortion regime, 20 – 22 June 2011
The training was designed to improve knowledge of the abortion care providers (gynaecologists) on medical abortion regime, to allow them to shared and reviewed positive and negative values and experience in medical abortion and to plan for further activities need to be undertaken to introduce this method in practice.
It focused specifically on the mechanisms of action of the medical abortion drugs and clinical care, in particularly to complications and side effects.
The training was co-organized with the Association of Gynaecologists and Obstetricians and facilitated by d-r Annette Aronsson from the Karolinska University of Stockholm, Sweden.
The NGO Concept Foundation provided the facilitator.

17. Obstacles for realization of AP
Family planning and RH commodities are not on the Government agenda
Pro-natalist policy
No budget line for contraception
Ongoing reforms in health system- other priorities are in play
Economic crisis (budget restriction)
Parlaimentarian elections
Long procedure for registration - introducing of new drugs;

18. Obstacles for realization of AP
Reforms in PHC – commercialization –contraception counseling (and medical abortion) is not seen as profitable, while surgical abortion is.
Resistance/inertia/lack of motivation of the gynecologists (low incentive from the HIF);
Lack of coordination between different PH institutions (MOH, NIPH, IMCH);
Inadequate PH workforce - there is no Department for SRH within the MoH.

19. What was done to overcome the obstacles?
Collaboration with NGO sector (NGO H.E.R.A)
Collaboration with international organizations (UNFPA)
Collaboration with Women Parliamentarian Group
Collaboration with media

20. Future activities

21. Responsible agents/partners Process indicators. Timeframe
Objective 1: To facilitate the availability and accessibility of the medical abortion drugs in the country
Activities:
Expected outcomes
Responsible agents/partners
Process indicators.
Timeframe
Activity 1. Preparing country-specific introductory strategy;
Activity 2. Stimulate local pharmaceutical companies or branch offices of the international pharmaceutical companies to register medical abortion drugs;
Activity 3. Pilot project on combination package of Mifepristone and Misoprostol at the Ob&Gyn teaching hospital in Skopje;
Expert group created which fasciliate the registartion of MA drugs
Medical abortion drugs are registered and consistent supply at national level and within the hospitals is ensured,
Initiated development of a service delivery model for medical abortion, beginning with Ob&Gyn hospital in Skopje
MoH
Macedonian association of G&O
SA WG
Concept Foundation
NGO HERA
Combination of Misoprostol + Mifepristone is part of the National Essential Drug list for induced abortion
2012
Number of drugs containing combination of Misoprostol + Mifepristone who are registered at the National Bureau for Drugs
An effective procurement mechanisms for medical abortion drugs is in place at the hospitals

22. Objective 2. Increase access and quality of medical abortion services in the hospitals
Activities:
Expected outcomes
Responsible agents/partners
Process indicators
Timeframe
Activity 1. Training of service providers on medical abortion;
Activity 2. Distribution of the service protocol on medical abortion among abortion providers.
Abortion providers equiped with with knowledge and skills how to perform medical abortion in their clinics;
MoH
Macedonian association of G&O
SA WG
Concept Foundation
NGO HERA
Number of gynaecologists and nurses trained in medical abortion regime and follow up care;
% of the trained gynaecologists who actually are using and practising their skills for medical abortion

23. Objective 3: to raise awareness among women on medical abortion and its availability as alternative to surgical abortion
Activities:
Expected outcomes
Responsible agents/partners
Process indicators
Timeframe
Activity 1. Building partnership with women organizations and NGOs;
Activity 2.Conducting outreach and IEC activities on medical abortion and post-abortion contraception among women, particularly those who are most vulnerable and marginalized;
Activity 3.Development of IEC materials for women;
Activity 4. Working with media
Women organizations and NGOs as providers actively involved awareness raising activities on medical abortion;
Women, particularly those who are most vulnerable and marginalized, informed on medical abortion and post-abortion contraception;
More visibility is given to the medical abortion procedure, and to the right to choose between differrent abortion methods
Macedonian association of G&O
SA WG
NGO HERA
Women NGOs
RHMs
Media representatives
% of women provided with medical abortion compared to total number of abortions registered ;
% of the women and girls reached through outreach and IEC activities who are well-informed about medical abortion and could consider it as alternative to surgical;
Number of journalists informed about MA;
Media coverage: Number of articles and interviews on medical abortion;

24. Never give up