1. Strategic assessment of policy, quality and access to contraception and abortion services in Macedonia Main findings 2007/08

2. Family planning and contraception in the context of reproductive behavior in Macedonia

3. POPULATION INDICATORS IN MACEDONIA Decreasing birth rate Increasing total mortality rate Decreasing infant mortality rate Reduced rate of demographic growth ( natural increase) Regional disparities in population indicators

4. POPULATION INDICATORS IN MACEDONIA

5. Reproductive behavior Age structure of pregnant women ( 2006) »64,5% - 20-29 years »7,2% - 15-19 years ( fertility rate – 20,1 per 1000) Average age of mother for the first newborn »1996 – 23,7 year »2000- 24,1 year »2004 24,8 year Total fertility rate »1996 – 1,9 »2000- 1,7 »2004 – 1,5 Regional disparities

6. Family planning counseling services ( no of visits)

7. Utilization of family planning services in public health sector- Some indicators 9,9% ( 12,6% in private HC) of recorded first visits ( 2006) are among female adolescents ( age 15-19) 1,6% contraceptive coverage rate among female adolescents ( 2006) Total coverage with FPS »2003- 3% with average 1,5 visits per woman »2004- 2,7% with average 1,4 visits per woman »2005 – 2,6% (1,5 visits per woman ) »2006 – 2,9% ( 1,4 visits per women)

8. Abortion rate per 100 life births in Macedonia 13.6 per 1000 women ( 15-44 ) for 2006 ??????? ( sub registration)

9. women in reproductive age, community members, local government authorities, adolescents (focus group discussion, in depth interview, questionnaire survey ) Knowledge, perception and attitudes regardingcontraception

10. Women’s perception »Unmotivated health care providers to discuss with clients about family planning issues »Lack of access to information for contraceptive option »Fear of adverse effects due to contraceptive use ( hormonal contraceptive, IUD…) »Financial barriers –contraceptive pills, IUD… are not in essential drug list

11. Adolescent perception »Misinformation about adverse effect of using oral contraception ( obesities, masculinization, vaginal bleeding …) »Insufficient knowledge about urgent contraception »Inappropriate interaction with health care providers ( privacy, confidentiality, sense of safety in discussing contraceptive and sexual issues )

12. Health care provider perception ( gynecologist) »Expensive contraception drugs »No policy for free of charge contraception for socially vulnerable groups »Overburden with routine health practice ( lack of time for family planning counseling) »Family planning counseling should be part of PHC basic benefit package

13. women in reproductive age, community members, local government authorities, adolescents (focus group discussion, in depth interview, questionnaire survey ) Knowledge, perception and attitudes abortion services regarding abortion services

14. Summary –Liberal attitudes towards abortion –Lack of knowledge about abortion legislation framework –Inadequate post abortion counseling in health care facilities –Gander role in decision making for abortion ( the influence of male partner in some population groups) –Inadequate respect of rights of privacy and confidentiality in public hospitals

15. Quality Quality of abortion services –Discrepancy in perception of abortion services quality among health care providers and WHO guidelines for safe abortion –Quality matters as: right to information, right to choose abortion technique and type of anesthesia, pre and post abortion counseling are not considered as strong quality issue.

16. –Use of abortion method – is not comply with WHO recommendation »First trimester – dilatation, vacuum aspiration and curettage »Second trimester –(intra- amniotic installation of 20% NaCl, ) »Medical abortion is not available –Pain management is not comply on WHO recommendation (general anesthesia or no anesthesia) –No existence of up to date safe abortion medical protocols

17. monitoring and evaluation Data collection, monitoring and evaluation of abortion and contraceptive services Insufficient data managements ( sub- registration in private health facilities, ) No available national abortion data disaggregate by age, location, method of use, early and late post abortion complication No appropriate and standard follow-up post abortion procedure

18. General competence of doctors and medical assistants is quite good. Residents learn to perform the abortion within the first surgical procedures. Obstetrician-gynaecologists consider abortion to be simple and routine. The most important criterion of a doctor competence, according to their own opinion, is lack of abortion-related complications cases.

19. No recorded any case of abortion-induced maternal mortality over the past 10-15 years