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National Strategy on Reproduction Health

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National Strategy on Reproduction Health Powered By Docstoc
					   National Strategy
on Reproduction Health

      for the years
       2005 – 2015
Contents


1. Foreword.……………………………………………………….page 1

2. Introduction.…………………………………………………….page 3

3. International and European Context…………………………….page 4

4. Priority Concepts and Areas.……………..……………………...page 5

5. Present   situation in reproduction health.………………..…..page 6

6. Basic Principles……..………………………………………...…page 25

7. Aims and Objectives ……………………………………………page 25

8. Expected Results………………………………………………..page 29

9. Implementation Aspects…………………………………………page 31

10. Necessities ……………………………………………………...page 39

11. Responsibilities ………………………………………………...page 40

12. International Collaboration.…………………………………..…page 40

13. Monitoring and Evaluation ……………………………………..page 41




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2.    Introduction
The Reproduction Health, on the international level, is recognized as one of the fundamental
components necessary for the human development. The general health of the population, the thriving
and the development of all the countries depend on it. The healthy reproductive behavior ensures a
positive impact on the following generations.

The efficacious implementation of the family planning reduces the number of undesired pregnancies
and of unsafe abortions, it prevents the mortality and the morbidity induced by pregnancy, diminishes
the incidence of the sexually transmitted diseases, including the infection HIV/AIDS, it protects the
adolescents health and is one of the most real and cost-effective possibilities that can improve the
health and the welfare of women, men, young generation and community.

In the last years, in the Republic of Moldova there has been undertaken a set of measures towards the
reproduction health improvement. There has been elaborated a legislative basis in the reproduction
health and have been launched several national programs. Thanks to the international assistance,
collaboration and partnership with the civil society and public organizations, the providers of
reproduction health services have been trained, and there have been realized different educational and
informative programs aimed to ensure a safer and more responsible sexual-reproductive behavior.

Nevertheless the reproduction health in the Republic of Moldova is still a lot below the level of the
present day possibilities and requirements. The maternal, perinatal, and infantile mortality overcome the
level of the developed countries. The access of population to the family planning services is limited.
The incidence of the sexually transmitted infections has reached an alarming quota. On the background
of the emigration growth and of the infertility increase, the birth rate has drastically diminished. The
right of adolescents to education and reproduction health services is ensured not everywhere. Abortion
still continues to be used very often for a family planning purpose, and it often is accompanied with
real risks that affect the reproduction health even more. The consequences of the domestic violence,
the sexual abuse and human beings trafficking are not yet fully estimated. The genital and breast cancer
is taking a large scope, turning into an ample medico-social problem. The sexual problems of the
elderly aged people are disregarded.

For the first time the present day strategy initiates a set of long-term measures, aimed to improve
considerably the reproduction health in the country. It reflects the vision of the government and of
many representatives of the civil society from the Republic of Moldova, regarding the reproduction
health policies and programs.

Once with the strategy elaboration and approval, the Republic of Moldova lines up to the World Health
Organization recommendations in the sphere of reproduction health.

Strategy elaboration and approval was performed in the following stages:
    • I. Elaboration. Ten work groups were created with a view of it, they have their staff experts in
       the given fields that have elaborated the chapters of the given strategy on the basis of the
       national legal normative documents and international recommendations concerning this
       problem, after analyzing minutely the present day situation of each component of the
       reproduction health.
    • II. Discussion. The Strategy Project has been discussed in the frame of the work-groups
       sittings, of the scientific council sittings of the CNSPSRGMP, of the national conference
       “Strategy in the reproduction health in the Republic of Moldova”, of the meetings with the
       representatives of the international and public organizations of the republic.
    • III. National Endorsement. The Strategy Project was endorsed by national independent
       experts with the following handing for notification to the governmental institutions, to the civil
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       association that concerns the stipulated fields in the strategy, as well as to the international
       funds and organizations accredited in the Republic of Moldova.
   •   IV. International Endorsement. The Strategy Project was endorsed by independent experts
       of the international organizations: WHO, UNFPA, UNICEF, East-European Institute of
       Reproduction Health.
   •   V. Approval. The Strategy has been approved by the Experts Council, by the Ministry of
       Public Healthcare College and the Government of the Republic of Moldova.
   •   VI. Implementation. The strategy was promoted in the frame of the Society of obstetrician-
       gynecologist, perinatalogist, pediatrician, oncologist, dermatologist-venerologist, family doctors
       and through mass-media with its text distribution in every medical institution, education
       institution and civil organization rallied round this activity.

The strategy was elaborated in full accordance with existing national Concepts, Strategies, Programs
and Projects in the public health fields, social assistance, education, young people, human rights, and
the combating with the domestic violence, sexual abuse and human trafficking etc.

3. International and European Context

Reproduction and Sexuality Health presents a special interest for the European Countries, especially for
the Countries of Eastern Europe. In the process of the social-economic transition the countries of the
Eastern Europe, including the Republic of Moldova, confront with unemployment and poverty growth,
the disintegration of the social protection systems, the significant decrease of the state budget provided
for health care and social spheres. The reproduction health field is characterized by increased indicators
of maternal and neonatal mortality. The infections of the reproductive tract are very spread and their
level grows further on. The abortion practice continues with a view to the birth control on the
background of the insufficient use of the modern contraception methods. Adolescent pregnancy,
domestic violence and sexual abuse affect more and more the countries with a transition economy. The
increased emigration on the background of a decreased birth rate and infertility increase constitutes the
present day problems that require a pan-European and national approach.

The reproduction health is the foreground field of the World Health Organization that in 2001 has
launched the European Strategy in Sexual and Reproduction Health and has called all the 51 state-
members of the Council of Europe to elaborate similar strategic documents resulting from the national
specific character. This priority is also mentioned both in the UN recommendations and in the
stipulations of the international forums and conferences that took place in the last years: the
International Conference for Population and Development (Cairo, 1994); the XXI-st session of the UN
General Assembly (New York, 1999); the Population Forum (Geneva, 2004).

The Strategy of the Republic of Moldova in the reproduction health has been elaborated in strict
correspondence with the European Strategy of WHO provisions in Sexual and Reproduction Health
and the adopted document through international consensus:
    • the Chapter of the elimination of all the women discrimination forms;
    • the Program of the International Conference for Population and Development and the Actions
        Program Cairo-5;
    • UN Declaration concerning the infection with HIV/AIDS;
    • the Platform of Actions Beijing-5;
    • UN Convention of the Children Rights.
4. Priority concepts and areas
During the last years through international consensus there have been adopted the definitions of the
reproduction health, of the sexual health and of safe motherhood (see it below). There have been
formulated a set of recommendations for the improvement of the reproduction health.
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In the frame of the strategic planning and of consulting with different national experts, there have been
identified the relevant reproduction health fields for the Republic of Moldova:
    • Family planning. The rights in the realization of the reproduction function. Contraceptive
         options.
    • Safe motherhood. The preconception care. Diagnosis and prenatal care. Birth preventing of
         the children with congenital malformations.
    • Adolescents and young people. Reproduction and sexuality health with adolescents and
         young people. Youth friendly services. Sexual education at school.
    • Infections of the Reproductive Tract. Prevention and management of the sexually
         transmitted infections and of the infections HIV/AIDS. Diagnostics and treatment services for
         STI.
    • Abortion. Safe abortion. Post abortion counseling.
    • Infertility. Infertility prevention. Infertility diagnostics and treatment.
    • Domestic violence and sexual abuse. Prevention and management of domestic violence and
         sexual abuse.
    • Human beings trafficking. Prevention from human beings trafficking. Emigration.
    • Genital-mammary cancer. Precocious diagnostics and the management of the genital-
         mammary cancer.
    • Elderly aged people. Sexual health of elderly aged people. Counseling services.
    • Men's participation. Men and reproductive health.

 Reproduction health
 Within the framework of WHO’s definition of health as a state of complete physical, mental and social
 wellbeing, and not merely the absence of disease or infirmity, reproductive health addresses the reproductive
 processes, functions and systems at all stages of life. Reproductive Health implies that people are able to have a
 responsible, satisfying and safe sex life and that they have the capability to reproduce and the freedom to decide
 if, when and how often to do so. Implicit in this are the right of men and women to be informed of and to
 have access to safe, effective, affordable and acceptable methods of fertility regulation of their choice, and to
 appropriate health care services that will enable women to go safely through pregnancy and childbirth and
 provide couples with the best chance of having a healthy infant (WHO 1994).
 In this internationally accepted definition (ICPD, Cairo 1994) of reproductive health, the areas of sexual health
 (responsible, satisfying and safe sex life), reproductive freedom (access to information, methods and services)
 and safe motherhood (safe pregnancy, childbirth and healthy children) are included.

 Sexual health

 The sexual health represents a physical, emotional, mental and social well-being in the domain of sexuality, and
 it does not consist only of disease absence, dysfunctions or infirmity. The sexual health allows the realization of
 a pleasant sexual life, in conditions of safety. It is based upon a positive and respectful approach of sexuality
 and sexual relations, without coercion, discrimination of sexuality or violence (WHO/EUR, WHO/HQ
 Geneva and World Association of Sexology, November 2002).


  Safe motherhood
 Safe motherhood aims at attaining optimal maternal and newborn health. It implies reduction of maternal
 mortality and morbidity and enhancement of the health of newborn infants through equitable access to primary
 health care, including family planning, prenatal, delivery and postnatal care for mother and infant, and access to
 essential obstetric and neonatal care (WHO 1994).




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    5. Present day situation in reproduction health in the Republic of Moldova

    Below there are presented the main relevant indicators of the reproduction health in the Republic of
    Moldova. The main data sources used are the statistical reports of the statistics Department of the
    Republic of Moldova; Ministry of Public Healthcare; Scientific Research Institute of Mother and Child
    Healthcare; National Scientific-practical Center of Reproduction Health, Medical Genetics and Family
    Planning; the Study of the Reproduction Health in the Republic of Moldova (1997).


    Indicators of reproductive health of the Republic of Moldova population
                                                                                                  Table 1.
The studied            1994    1995    1996    1997    1998     1999     2000     2001    2002      2003
indicators
Birth-rate             14.3    13.0    12.0    11.9     10.9    10.1      9.8     10.0     9.9      10.1
(per 1,000)
General                11.8    12.4    11.6    11.5     10.9    11.4     11.5     11.0    11.6      11.8
Mortality
(per 1,000
inhabitants)
Maternal               25.8    40.8    40.2    48.3     36.3    28.6     27.1     43.9    28.0      21.9
Mortality
(per 100,000 live-
born children)
Perinatal              14.8    15.2    15.3    15.2     14.8    13.9     15.2     14.7    13.1      11.4
Mortality
(per 1,000 still- or
live-born children)
Infantile              22.6    21.2    20.2    19.8     17.8    19.1     18.4     16.3    14.7      14.3
Mortality
(per 1,000 live-
born children)
Abortions (total)      58106   57181   46005   37137   31293   26240    24647    16038    15739    15713
Abortions               53.5    52.7    42.6    34.4    27.3    23.0     21.6     16.0     15.6     15.5
(per 1,000 women
of fertile age)
Abortions with                                  6.6     8.5      9.6      9.5     11.9    12.8      13.9
primigravida (%)
Abortions with                                  9.8     8.9     10.4     10.6     10.6    11.1      11.0
adolescents % (15-19
years old)
Mini-abortions %       26.6    22.6    21.3    25.4     27.0    30.5     37.2     30.2    32.2      32.1
Spontaneous %          13.9    14.3    13.5    15.5     19.9    21.3     20.3     27.0    26.9      28.1
Contraception          21.3    22.3    22.6    25.2     23.7    22.8     22.4     20.4    20.1      19.7
(IUD) %
Hormonal                1.2     1.2     2.0     3.9     5.1      5.4      5.2     4.3      5.4       5.5
contraception
(%)
Surgical                 1      1       1       1        1        1       1        1        1         1
sterilization (%)



                                                                                                           6
Syphilis              118.0    174.4     200.6    188.0     155.5    109.0     91.4      96.5     90.4      74.4
(per 100,000
inhabitants)
Gonorrhea (per        115.4     99.8     80.2      70.5     64.9      59.0     49.1      39.8     39.6      45.2
100,000
inhabitants)
HIV-carriers                     7        47       404       408      155       174      199       155      134


    5.1. Family planning
    Health System and Legal Reform
    For the first time in our country, the family planning was granted the statute of specialized medical
    service through the Ministry of Public Healthcare Order of May 17, 1994, no.89 “About organization
    of the republican service of reproduction health and family planning”. This order has especially
    disposed the organization in the frame of the Scientific Research Institute of Mother and Child
    Healthcare of the “Republican Center of Reproduction Health and Family Planning” and in the
    composition of each consultation for women from districts and cities, of family planning rooms with
    the rules and lists of the given states.
    During the next years the Family Planning Concept has been developed and consolidated in a series of
    normative and legal acts of the Republic of Moldova as it is:
         • Order of the Ministry of Public Healthcare of August 03, 1994, no.152 “About the citizens
             Healthcare”;
         • Healthcare law of March 28, 1995, no. 411-XIII:
                 - Art.31. Voluntary Surgical Sterilization;
                 - Art.32. Voluntary pregnancy interruption;
                 - Art.33. Artificial Fecundation and Embryo Implantation.
         • Order of the Ministry of Public Healthcare of January 10, 2001, no.232 “About the regulations
             approval concerning the minimal requirements of a consultation visit in the family planning
             room”.
         • The law concerning reproduction health care and family planning of May 24, 2001, no.185-XV.
         • Criminal code
             Chapter II:
                 - Art.159. Illegal abortion provocation;
                 - Art.160. Illegal Performing of surgical sterilization;
                 - Art.161.The performing of an artificial fecundation or au Embryo Implantation without patient’s
                     consent.
             Chapter IV:
                 - Art.171. Rape;
                 - Art.172. Violent actions with a sexual character;
                 - Art.173. Compulsion to actions that have a sexual character.
         • Family code, Title I, Chap.2
                 - Art.5. Equality in family relationships;
                 - Art.6. Realization of family obligations rights and the discharge;
                 - Art.7. Protection of family rights.
         • National Program of assistance in family planning and reproduction healthcare in the Republic
             of Moldova for the years 1999-2003.
    The Ministry of Public Healthcare has elaborated and approved the medical assistance structure and the
    list of the medical documentation forms of primary evidence of the family planning service.
    Accessibility and services quality


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One of the essential conditions of the medical assistance efficacy and efficiency in the family planning
fields is the unlimited access of the population to this specialized health service.
In this regard there are:
     • the Republican service of family planning with vast network of family planning rooms (the total
         number 47) and the National Scientific Practical Center of Reproduction Health, Medical
         Genetics and Family Planning. The medical assistance in these rooms is offered by the
         obstetrician-gynecologist doctors with a special training.
     • Full geographical access, ensured by the emplacement of the family planning offices in all the
         districts and city sectors of the republic.
     • Partial Financial Access, where counseling is granted for free, contraceptives are issued only
         partially free and abortion at request is performed for money.
     • Address to the services below the level of the service possibilities and population needs,
         conditioned by the low level of sanitary information of the society.
 Information, education and communication.
As it is concerned, in the Republic of Moldova there already exists a rich experience that could be
successfully developed and promoted in the future.
Among the realized measures in the years in this regard during the last years there must be mentioned:
     • Preparation with the support of the international organizations of the national trainers in the
         family planning;
     • Carrying out of the periodical campaigns of information, education and communication with
         the help of media (radio and TV programs “Family Planning” Week, Municipal Monthly
         Newspaper “Pro-health”.
     • Organization and carrying out on a republican level with the participation of the local and
         international experts of numerous seminars on the topic “Family Planning and Contraception”
         for obstetrician-gynecologist doctors, physicians, midwifes and nurses;
     • Training in the family planning field of the psychologists and of the teaching staff of Higher
         Education Institutions;
     • Elaboration and publication of the informative materials for Health care workers with the
         support of the international organizations: “Guide of the family planning services”; “Family
         planning and reproduction health”; “Handbook of Family Planning”; “Family Planning”;
     • Publication and distribution of booklets and posters on the given topic to the population.
Research
There have been performed only two studies on the national scale that reflect the situation in the field
of reproduction health and family planning.
     • The study of reproduction health in the Republic of Moldova, 1997 (MPH of the Republic of
         Moldova, ICSOSMC, DSSM, Association of Family Planning of Republic of Moldova, CCD
         Atlanta, UNICEF);
     • Study of multiple factors (MICS), 2000 (UNICEF, Government of the Republic of Moldova,
         CNSPMP).
Monitoring and evaluation
In the republic there does not exist a whole integral system of monitoring and evaluation of process,
impact and result indicators in the field of family planning. Nowadays, there can be mentioned some
impact indicators that can allow only partially the evaluation of the situation in the family planning line:
     • Fertility Rate;
     • Birth Rate;
     • Birth;
     • the Rate of a contraception method application;
     • Abortion rate (per 1,000 live-born children);
     • Syphilis Incidence;
     • HIV/AIDS incidence
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Statistical data
In the statistical report about contraception it is included the information only about the use of intra-
uterine devices, of combined hormonal contraceptives and of voluntary surgical sterilization. There are
no official statistical data about the use of other methods, like condoms, spermicidal method, calendar,
coitus interruptus, etc.

The analysis of the contraception methods application during 1990-2003 reveals a slow improvement
of the access to contraception (for intra-uterine devices, combined oral contraceptives and surgical
sterilization): from 18.8% in 1990 to 31.8% in 2003. The application rate of the combined oral
contraceptives has increased from 1.4 in 1990 to 5.4% in 2003. The Contraceptive Prevalence in the
Republic of Moldova is of 73.5%, including the use of modern contraception methods - 41.8%.

In accordance with the data of the Reproduction Health Study in the Republic of Moldova performed
in 1997, of 4023 women with reproductive age, the use of contraception methods constituted 73.7%,
including the application of modern methods – 50.0%.

The unsatisfied necessities of the modern contraception have been estimated at 29.0%. From the total
number of fertile age women – 38.4% used intra-uterine devices, 5.9% - preservatives, 3.4% -Fallopian
tubes binding, 2.1%-combined oral contraceptives, 21.6% - coitus interruptus, 2.0% - the calendar
method. On the whole the rate of the efficient contraception constituted only 46.4%. At the same time
26.3 of women did not use any contraception method.

Thus, among the specific peculiarities of the family planning in the Republic of Moldova there can be
mentioned the insufficient use of modern contraception methods, like for example oral combined
contraceptives or surgical sterilization, in the same time with the exaggerate use the intra-uterine
devices if we take into account the present day high incidence through the infections of sexual
transmission, anemia with red cells deficit and hypermenorrhea with women of the Republic of
Moldova.

Achievements
The reorganization and the reforms of the healthcare system promoted and achieved by the Ministry of
Public Healthcare in the last years, contributed decisively to:
   • Organization and the family planning rooms (total number 47) in 1997 in every district and
       municipal sector of the republic;
   • Teaching of the whole staff of the family planning offices in the frame of numerous seminars
       and trainings;
   • Opening of 3 health centers for women:
           - in Chisinau city “Dalila”;
           - in the North of the republic, in Drochia district, ”Ana”;
           - in the South of the republic, in Cahul district, “Virginia”;
   • The phasing of medical assistance in family planning in 3 levels in 1998:
           - I level – family doctor;
           - II level –family planning rooms in districts and cities;
           - III level –National Scientific-Practical Center of Reproduction Health, Medical Genetics
               and Family Planning.
   • Creation in 2003 of the National Scientific-Practical Center of Reproduction Health, Medical
       Genetics and Family Planning.

In the last years there has been organized and accomplished an entire row of training seminars of the
medical staff with the international support. There have been prepared the national family planning for
matures for the medical staff.
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Problems remaining unsolved
   • The normative frame concerning the reproduction health and the family planning is limited.
   • The lack of an integral undergraduate and postgraduate teaching program for reproduction
      health and family planning of the family doctors, obstetrician-gynecologists, mid wives and
      nurses.
   • The insufficient endowment of more than 40,0% of the district family planning rooms.
   • The low level of population’s knowledge and information concerning the contraception and the
      prevention of the sexual transmissible infections.
   • The low level of oral combined contraceptives use, especially in villages.
   • Frequent non-motivated and unjustified use of infra-uterine devices on the background of a
      high spreading level of the urogenital apparatus infections.
   • The absence of male surgical sterilization and the performing of the female one in an extremely
      small number.
   • The insufficient rallying of the family doctors in the population counselling concerning the
      choice of the most propitious contraception methods, as well as the non-utilization of murices
      potential in the granting of family planning services.
   • High level of abortions at request – 361.2 per 1000 live new born children.
   • High rate of undesired pregnancies – 60.0%.
   • Lack of obvious tendency of sexually transmissible infections decrease (HIV/AIDS, syphilis,
      gonorrhea, etc.).

5.2. Safe motherhood
Health System and Legal Reform
The fundamental principles of risk-free maternity are guaranteed by:
    • Healthcare Law of March 28, 1995, no. 411 – XII;
    • National program of the improvement of the prenatal medical assistance for the years 1997 –
        2002, approved through the Decision of the Republic of Moldova Government of December
        18, 1997, no. 1171;
    • Promotion program of the prenatal quality services for the years 2003 – 2007, approved
        through the Order of the Ministry of Public Healthcare of June 18, 2003, No. 185, and the
        decision of the Ministry of Public Healthcare College of April 15, 2003, report no. 4.
    • The unique program of compulsory medical assistance insurance for the year 2004, approved
        through the Decision of the Government of the Republic of Moldova of December 15, 2003,
        no. 1515;
    • The statute of the perinatologist.
Accessibility and services quality
The implementation of the national program of the prenatal medical assistance improvement for the
years 1997 – 2002, ensures totally the medical and geographical access of the population to perinatal
medical assistance phased in three levels: I level – 25 district maternity hospitals; II level – regional
perinatal centers, and III level – the Institute of Scientific Research of Mother and Child Healthcare.
The unique program of compulsory medical assistance insurance for the year 2004 guarantees the
financial access of the population to prenatal medical services.
Research
The real situation of the prenatal medical assistance was established on the basis of the Evaluation
Studies of the National Program of the Improvement of the Prenatal Medical Assistance performed in
the years 2000, 2001 and 2002. In 2003 there has been performed an Evaluation Study of 10 maternity
hospitals.
Monitoring and evaluation
In order to ensure an objective monitoring and evaluation of prenatal medical assistance during the last
three years, the forms of primary health evidence and the statistical reports have been considerably
                                                                                                      10
revised and modified with the creation in the year 2003 of the informational managerial system of
prenatology.
Statistical data
According to the WHO criteria, the Republic of Moldova is placed among a low rate at the maternal
mortality compartment, under 30.0 cases per 100 newborn children in the last five years. Thus, the
maternal mortality has registered an evolution from 51.3 in the year 1992 to 21.9 cases per 100
thousand live-born children in the year 2003. In the last 10 years the main causes of maternal death are:
abortion complications – 30.3 %; hemorrhages – 19.7 %; septic complications – 18.1 % and
preeclampsia-eclampsia – 11.2 %. The majority of maternal deaths (58.3 %) happened to women from
villages, every fourth woman (25.7%) died at home.
During the last 10 years the prenatal mortality rate also decreased from 15.2 in the year 1992 to 11.4 at
1000 still- and live-born children in the year 2003. The main causes of perinatal mortality in ranged
order are: intrauterine hypoxia, obstetric asphyxia; congenital abnormalities, chromosomal
abnormalities and deformations; specific infections for the prenatal period; respiratory sufferings of the
new-born children and other respiratory states, and thews breaks, and intracranial hemorrhages, caused
by obstetric traumatism.
The main achievements
     • The approval of the national Program of the improvement of the prenatal medical assistance
         improvement for the years 1997 – 2002, through the Decision of the Republic of Moldova
         Government of December 18, 1997, No. 1171, and of the Promotion Program of the quality
         prenatal services for the years 2003 – 2007, through the Order of the Ministry of Public
         Healthcare of June 18, 2003, No. 185, and the Decision of the ministry of Public Healthcare
         College of April 15, 2003, report no. 4, has defined the prenatology policy of the Ministry of
         Public Healthcare, plenary reflected in the Unique Program of compulsory medical assistance
         insurance for the 2004.
     • Elaboration and distribution of the National Guides of perinatology:
     A. “Organization and Granting Principles of Prenatal Assistance”;
     B. “Regionalized Prenatal Service: levels and contents “ and
     C. “Care and Treatment Protocols in Obstetrics and Neonatology”
     • The initiation of a lasting partnership with all the programmes that refer to mother and child
         health;
     • The equipping of all prenatal centres of II and III level with modern medical apparatus and
         instrumentarium;
     • Human potential fortification of the prenatology service.
The problems remaining unsolved
     • High rate of maternal mortality caused by complications after abortion;
     • High rate of prenatal mortality among the children with a body weight higher than 2500g;
     • High rate of maternal mortality caused by congenital malformations and chronicle
         abnormalities;
     • The contradiction between the standards of prenatal medical assistance approved in the frame
         of the compulsory medical assistance insurance, and the provisions of the National Prenatology
         Guide;
     • The inadequacy of the accreditation principles of the prenatal service of the health institutions
         to the WHO requirements and to the quality criteria promoted through the Risk-free Pregnancy
         Initiative;
     • The lack of the population’s behavior habits at the chapter “Risk-free maternity”;
     • The inefficiency of the national policy of the health service interaction with the family and
         community in the field of prenatology;
     • Insufficient information and participation of the community in the solving of the problems that
         deal with mother and child health;

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    •    The weak involvement of the family in preconceptional, pre-, intra- and postnatal care.

5.3 Reproduction and sexuality health of adolescents and young people
Health System and Legal Reform
Reproduction and Sexuality healthcare of adolescents and young people is regulated by:
     • The law concerning the child rights of December 15, 1994, No. 338-XIII - Chapter II Art. 4.
         The right to life.
     • The law of healthcare of March 28, 1995, No. 411-XIII. Art. 50. Health assistance for
         adolescents and children.
     • The law concerning the youth, of February 11, 1999, No. 279-XV. Art. 10. Healthcare and
         physical development, Art. 12. Supporting of the young family.
     • The law regarding the reproduction healthcare and family planning of May 24, 2001, No. 185-
         XV-Art.8. Minors right to reproduction healthcare and sexual education.
     • Criminal code:
         Chap. II. Offences against one’s person life or health, Art. 159. Illegal causing of abortion.
         Chap. IV Offences regarding the sexual life, Art. 171 Rape, Art. 17 Sexual contact with a person that has
not reached the age of 14 years;
         Chap. VII. Offences against family and minors;
         Chap. VIII. Offences against public health and social life. Art.211. The transmission of a venereal disease,
Art. 212. Contamination with AIDS, art. 220.Procuring
     • Family code
         Title II. Marriage:
         Chap. III the conditions and the modality of concluding a marriage. Art. 14. Matrimonial age.
         Chap. X. The rights of minor children
         Chap. XI The rights of minor parents
     • National Program of family planning assistance and reproduction health protection in the
         Republic of Moldova for the years 1999-2003.
     • The strategy for youth, 2004-2005 of the Republic of Moldova’s Government – Priority A.
         Young people access to services and information. “Objective: Facilitation of the access to information and friendly
         services for young people, as well as the qualitative free time.”
     • The Order of the Ministry of Public Healthcare of April 26, 2004, no. 123. “About the creation of
         the work group for the coordination of the extension of the friendly health services to young people.”
Accessibility and services quality
The essential condition in the medical assistance of young people is the access to qualitative health
services.
     • The specialized medical services of health for young people do not have definite article.
     • The medical services of reproduction and sexuality health granted by family planning rooms
         that exist in the republic have a formal character.
     • The geographical access is ensured through the emplacement of family planning rooms in all
         the districts and city sectors of the republic.
     • The financial access to is partial: free counseling, partial free contraceptives and paid abortions
         at request;
     • The services quality – low.
Information, education and communication
At this chapter there is a solid experience, that can be developed and promoted further on, and it
includes:
     • The teaching of the optional course in the preparation for family life;
     • The implementation of curriculum “ The development of life habits”;
     • The carrying out of periodical campaigns of information, education and communication in
         mass-media.
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     • The organization of out of school sporadic campaigns by civil organizations.
     • The carrying out of lessons and seminars by the medical workers of the family planning service.
Research
The reproduction and sexuality health of adolescents and young people is reflected only fragmentary in:
     • The reproduction health study in the Republic of Moldova, 1997 (MPH of RM, ICSOSMC,
         DSSM, the Association of family planning of the Republic of Moldova, CCD Atlanta,
         UNICEF);
     • The multiple indicators study (MICS), 2000 (UNICEF, Government of the Republic of
         Moldova);
     • The study of young people knowledge, attitudes and practices (KAP) as far as their own
         development and health are concerned, Republic of Moldova, 2003 (MPH of RM, CNSPMP,
         the Association Health for young people, UNICEF);
     • The scientific work “Medical-social aspects of the pregnancy and birth at adolescents in the
         Republic of Moldova” (Public Healthcare Department, FPM, SUMF “N. Testemitanu”);
Monitoring and evaluation
Nowadays there are monitored and evaluated only several impact indicators:
     • Birth rate at adolescents (the number of births per 1000 women 15-19 years old);
     • Abortion rate at adolescents (the number of abortions per 1000 women 15-19 years old);
     • The abortion balance (the number of abortions with adolescents reported to the total number
         of abortions);
     • Syphilis and gonorrhea with adolescents.
Statistical data
The adolescents and the young people constitute a fourth of the republic’s population. The existing
statistical data concerning the reproduction and sexuality health of adolescents and young people reveal
a set of serious problems that are expecting their solving.
The problems remaining unsolved
     • High abortion rate at adolescents;
     • High rate of undesired pregnancies at adolescents;
     • High incidence of sexually transmissible infections (HIV/AIDS, syphilis, gonorrhea);
     • The low level of young people knowledge concerning the contraception and the prevention of
         the sexually transmissible infections;
     • The extremely reduced access of adolescents and young people to specialized medical services
         promoted by in accordance with the principles of friendly services to young people;
     • The lack of national concept about friendly clinic services to young people;
     • The lack of quality standards and care protocols in the reproduction and sexuality health of
         young people;
     • The imperfection of the normative frame concerning the reproduction and sexuality health of
         adolescents and young people;

5.4 The infections of the reproductive tract
Health System and Legal Reform
Through the decision of the Republic of Moldova’s Government of June 18, 2001, No. 482, the
national Program of prophylaxis and combating with HIV/AIDS infection and sexually transmissible
infections for the years 2001-2005 has been approved; one of the essential provisions is the elaboration
of the national prevention principles of the transmission of HIV/AIDS infection from the mother to
the fetus, including the access of HIV positive pregnant women and the new born children of the
mothers that are infected with HIV/AIDS to the antiretroviral therapy.
There has been elaborated and approved through the Order of the ministry of Public Healthcare the
Guide “HIV and AIDS infection with maternal-fetal transmission”, concerning the territorial-

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administrative units connection to the regional centers of birth receiving of HIV positive pregnant
women.
Accessibility and services quality
The adolescents and young people of the republic have unlimited access to the consulting room of
examination, testing and treatment of the sexually transmissible infections that work in all the districts
and cities of the republic.
In order to ensure optimal conditions of free diagnosis, supervision and treatment with antiretroviral
preparations, in accordance with the WHO protocols, there has been created the specialized section for
the persons with HIV/AIDS infection, with a capacity of 35 beds, including 5 for children, in the frame
of the Republican Dermatological-Venerologic Health Unit.
Information, Education and communication
Through the realized measures in this field there can be mentioned:
    • The publication and distribution to the population of the materials that concern the prevention
        of the sexually transmissible infections spread with the support of the international
        organizations;
    • The broadcasting of radio and TV programs
    • The organization of seminars with the family doctors, obstetrician-gynecologist, midwives,
        nurses and youth organizations.
Research
The problem of knowledge, attitudes and behavior of 15-49 years old women as concerns sexually
transmitted infections, has been partially tackled in the Reproduction Health Study in the Republic of
Moldova, 1997.
Monitoring and evaluation
In accordance with the reports of approved by the Ministry of Public Healthcare in the republic, it is
monitored the incidence with syphilis, gonorrhea, HIV/AIDS at men, women, pregnant women and
young people.
Statistical data
In the period of the years 1987-2003, there have been traced 1945 persons infected with HIV, 1982 of
them are citizens of the Republic of Moldova, inclusively: men - 1355 (71.6%), and women - 537
(28.4%). From the number of those infected, 103 persons have developed the disease AIDS, form
which 70 persons died. In 2003, the incidence and prevalence with HIV/AIDS infection has
constituted 6.0 and 44.7 cases per 100 thousand inhabitants.
The HIV/AIDS infection affects especially young persons, prevalently those that use intravenous
drugs. Concomitantly, there can be noticed a growth of the risk of the HIV/AIDS infection spread on
sexual way, conditioned by the high level sexually transmissible infections among young people.
The frequency of the syphilis cases at hem in the period of the years 1990-2001 increased 5 times.
Therefore, the risk of the HIV infection transmission from mother to fetus has increased a lot. In this
way, during these years there have been traced 78 HIV positive pregnant women, inclusively 12
infected women in 2003. With 10 new-born children having HIV-positive mothers, including 4 children
born in 2003, there has been traced the HIV-infection with the confirmation of the prenatal infecting.
The main achievements
The policy adoption by the Government of the Republic of Moldova concerning the prevention of the
sexually transmissible infections. The elaboration and the approval of the guide “HIV and AIDS
infection with maternal-fetal transmission.”
The access of HIV-positive pregnant women and of their new-born children to free antiretroviral
treatment.
The problems remaining unsolved
The imperfection of the normative frame concerning the supervision way of the HIV infected pregnant
women in cities.
The tergiversation of the WHO syndrome approach of the diagnosis and treatment of sexually
transmissible infections.

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The fragmental character and the insufficient involvement of mass-media in the information, education
and communication activity of thee reproductive active population in the problem of sexually
transmissible disease.
The insufficient involvement of family planning rooms in the granting of medical counseling and
treatment services of the sexually transmissible infections.
The lack of some present day studies in the field of the sexually transmissible infections at thee persons
of active reproductive age.

5.5 Abortion
Health System and Legal Reform
In the Republic of Moldova the abortion is proclaimed and regulated by:
     • The order of the Ministry of Public Healthcare of 03.08.1994, No. 152. “About some measures
         of women healthcare, decrease of the abortion number in the republic”;
     • Healthcare Law of 28.03.1995, No. 411-XIII:
     - Art. 32. Voluntary interruption of the pregnancy course;
     • Criminal Code
         Chap. II:
     - Art. 159. Illegal causing of abortion;
     The order of the Ministry of Public Healthcare of April 07, 2004, no. 103 “ About application and
     the implementation of the manual vacuum aspiration method in the Republic of Moldova.”
Accessibility and quality services
In accordance with the regulations of the Ministry of Public Healthcare, the performing of an abortion
is allowed only to obstetrician-gynecologist doctors in the conditions of the obstetrical-gynecological
sections of the district, municipal and republican medical institutions, that fully ensure both the medical
and geographical access of women to abortion.
The performing of the big majority (65.0%) of abortions through curettage is one of the main causes of
the low quality of pregnancy interruption services, and respectively the high risk of complications after
abortion.
Information, education, communication
Among the realized measures in this field in the last years, there must be mentioned:
     • The training of national formatives with the support of the international organizations in the
         problem of ensuring an abortion without risk;
     • The carrying out through mass-media of periodical campaigns of information, education and
         communication about the risk of abortion;
     • The organization and carrying out on republican level with the participation of local and
         international experts in the seminars on the topic “Abortion without risk” for the obstetrician-
         gynecologist doctors;
     • Elaboration and publication of the clinical guide “Abortion in the first quarter through manual
         vacuum aspiration”
     • Publication and distribution to population of booklets and posters on the given topic;
Research
On the research scale, the abortion has found its reflection only partially in the reproduction health
study in the Republic of Moldova, 1997 (MPH RM, ICSOSOSMC, DSSM, Association of Family
Planning in the Republic of Moldova, CCD Atlanta, UNICEF)
Monitoring and evaluation
It is performed only on the basis of the quarterly and yearly statistical report no.13.
Statistical data
The statistical data denote an obvious decrease (4 times) of the abortions number and rate in the year
2003 compared to the year 1992. The abortions rate is of 19.2% per 1000 women 15-49 years old or
441.0 per 1000 live-born children. In accordance with the data of the republican health study in the

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Republic of Moldova, in 1997 the frequency of complications after abortion constituted 16.0%,
including 11.0% - immediately and 5.0% - subsequently.
The rate of the complications after abortion in the maternal mortality structure constitutes 30.3%
during the years 1992-2003. Of 8 cases of maternal mortality (21.8 per 100 thousand live-born children)
registered in the year 2003 – 3 (37.5%) occurred because of complications after abortion.
Main achievements
     • The endorsement of the legal frame concerning abortion;
     • The constant decrease of the abortion number and rate during the last decade;
     • The training of the specialists in the use of the manual vacuum aspiration;
     • The elaboration and publication of the clinical guide “The pregnancy interruption in the first
         quarter through manual vacuum aspiration (MVA)”;
The problems that remained unsolved
    • The lack of the national standards and protocols of abortion care;
    • The existence of the practice of illegal pregnancy interruption, in risky conditions, without a
        statistical evidence;
    • Insufficient integration of pregnancy interruption service with the family planning service;
    • Insufficient practice of contraceptive counseling after abortion;
    • High rate (10.6%) of abortions with teenagers in the total number of abortions
    • High maternal mortality (82 per 100 thousand alive new born children) because of post-
        abortion complications;
    • Poor development of the monitoring, evaluation and audit system of the pregnancy
        interruption service.

5.6 Infertility prevention and management
Health System and Legal Reform
The legal and normative acts that confirm the right to reproduction are:
    • Healthcare Law of April 28, 1995, no. 411-XIII, Art.33. Artificial fecundation and embryo
        implantation;
    • The law concerning the reproduction healthcare and family planning of August 24, 2001, no.
        185-XV;
        Chap. II
    - Art. 10. The right to artificial insemination and in vitro fecundation;
    • Criminal Code
        Chap. II
    - Art. 160. Illegal performing of surgical sterilization;
    - Art. 161. Performing of artificial fecundation and embryo implantation without patient’s consent;
    • Family Code, Title I, Chap. II:
    - Art. 5. Equality in family relationships;
    - Art. 6. Realization of rights and the accomplishment of family obligations;
    - Art. 7. Protection of family rights;
    • National program of assistance in family planning and reproduction healthcare in the Republic
        of Moldova for the years 1999-2003.
The order of the Ministry of Public Healthcare of July 05, 2004, no. 2002 “About medical services of
assisted human reproduction”.
Accessibility and quality services
The provisions of the normative acts of the Ministry of Public Healthcare ensure:
    • Geographical access to modern services of infertility diagnosis and treatment;
    • Medical access in counseling, investigation and treatment of the infertile couple on level:


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     I-family doctors, II-family planning rooms, III-National Scientific Practical Center of Reproduction
     Health, Medical Genetics and Family Planning;
The absolute majority of medical services in the infertility field are paid.
Information, education, communication
In this respect there have been:
     • Published informative materials for obstetrician – gynecologist and family doctors;
     • Organized republican and local seminars with training in this field of the medical staff of the
         family planning and family doctors rooms;
Research
On national plan there have been performed only scientific studies tangent to the problem;
     • Gynecological morbidity in the Republic of Moldova and the measures of its improvement;
     • Patient’s rehabilitation after endoscope correction of tube-peritoneal sterility;
     • Contributions to the therapy of chronicle relapsing salpingophoritis through local application of
         autolymphocites;
     • Immunobiological aspects of the peritoneum liquid at women with a tube-peritoneal sterility.
Monitoring and evaluation
There no statistical indicators of the infertility monitoring and evaluation on the population scale.
Main achievements
Among the most important achievements in the field there can be enumerated:
     • Elaboration and approval of the legal frame that regulates the medical assistance in the case of
         infertility;
     • Publication of informative materials for medical staff rallied round the carrying out of these
         medical services.
     • The training of specialist doctors in the field.
The problems remaining unsolved
It is necessary to notice that:
     • The existing normative frame does not correspond to the real necessities and possibilities:
     • There are no national standards in the conduct of the couples suffering form infertility and
         prematurity;
     • The institutional capacities do not correspond to the existing methodological possibilities;
     • There is no informational managerial system of health in the field;
     • The level of information, education and motivation of the population in the infertility problems
         is low.

5.7 Domestic violence and sexual abuse
Health System and Legal Reform
Among the legal and normative acts that confirm the human rights and liberties (including in the frame
of family) and foresee the mechanisms of their defense, there can be mentioned:
    • Constitution of the Republic of Moldova;
    • Family Code;
    • Civil Code;
    • Criminal Code;
    • Code of Administrative Minor Offences;
    • National plan of equality promotion between human genders in the Republic of Moldova for
        the years 2003-2005, approved by the Government of the Republic of Moldova;
    • National plan of actions in the field of human rights for the years 2004-2008, approved by the
        Parliament of the Republic of Moldova.
Accessibility and services quality


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    •   The medical necessities of the domestic violence victims are covered for free, by the medical
        institutions of profile of the republic in the amount foreseen by the Unique Program of
        compulsory medical assistance insurance for the year 200 4, approved through the Decision of
        the Republic of Moldova’s Government of 15.12.2003, No. 1515.
    • As well as the necessities of the domestic violence victims and their family members, are
        covered for free also by two centers of crisis for ill-treated women in Chisinau and in Balti City;
    • Free services of multidisciplinary assistance (social, psychological, medical and juridical) to the
        abused and neglected children, are offered by the National Center of Children Abuse
        Prevention, that activates in the frame of the project the Center of psycho-social assistance of
        child and family-AMICUL, organized by the city Department for child rights protection in
        partnership with UNICEF”;
    • Activities of counseling, education and information of children and parents are realized by the
        Children Rehabilitation Center of the Education, Youth and Sport Department of Chisinau
        City;
    • Family counseling services are also offered by the Psychological Counseling Clinics of the
        FIUM.
Information, education, communication
In the last years, the state organizations and institutions in collaboration with the civil associations and
international organizations have organized different actions of population information and education in
the domestic violence:
    • The yearly informational campaign “16 days of combating with the women violence”;
    • The informational campaign (2001-2002) “Life without violence”;
    • The Prevention Program of Children Abuse;
    • The Educational Program of Children Abuse prevention;
    • The quarterly publication of the informative gazette IMPACT;
    • The communication campaign “Do animals also beat their cubs?”;
    • The regional campaign of communication “Let’s not exclude any child”;
    • The educational program of violence prevention between genders through gender education;
    • Teaching of optional courses in schools: “Education for health”, “Education for family life”,
        “Education for life-habits formation”.
Research
In the problem of the domestic violence there have been realized the following researches:
    • UNIFEM study (UN fund for women), 2001-2002 “Women and men attitude towards the
        domestic violence and sexual harassment at the place of work”;
    • Micro study concerning the children abuse in Moldova 1999-2000.
Monitoring and evaluation
On the national level, the domestic violence monitoring and evaluation is performed by the
Governmental Commission for women problems and by civil organizations.
Statistical data
The official statistics is kept by the Ministry of Internal Affairs, and it includes only murders and cases
of serious lesions of the body integrity. While the majority of domestic violence cases (psychological,
economic and sexual) usually remain unregistered.
Victims of the family violence are women of all ages, representatives of all social layers and study levels.
The traditional moral principles and the limited protection of aggressed women, make a big part of
them suffer in loneliness and tolerate violence. In consequence, in 2001 because of aggressive family
relationships died 28 women and 6 men. From the total number of the committed murders in the year
2002, 19.6% constituted murders in family. During the year 2003 on the territory of the republic have
been committed 61 crimes in the family relationships sphere, inclusively 28 murders and 33 cases of
serious deliberate harm of the body integrity.


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Thus, the statistics towards domestic violence phenomenon remains to be a problem and there are no
relevant indicators of it.
In the Republic of Moldova there is no official statistics, adequate to the cases of children abused and
neglected.
Main achievements
    • Identification of the problem on governmental level;
    • Society consciousness of the sexual violence problem and of its consequences;
    • The creation of an information and education basis of the population in the domestic violence
         prevention;
    • Initiation of counseling services of domestic violence victims;
Problems that remained unsolved
    • Incomplete normative frame in the domestic violence program;
    • Weak assurance of juridical and social protection of domestic violence victims;
    • Insufficient information, education and communication of population in the domestic violence
         problem;
    • Neglect of the abusers’ counseling necessity;
    • Social tolerance of different forms of child ill-treatment;
    • Imperfection of reporting mechanism by some professional categories (teachers, doctors, social
         assistants) of children ill-treatment cases;
    • The absence in the code of civil Procedure of the regulation provisions of the addressing and
         examination modality in the courts of the children aggressing cases and the protection measures
         of them;
    • The limited competence of local public authorities in counteracting, tracing out, examination
         and punishing of the child abuse and neglect cases;
    • The lack of specialized courts and prosecutor’s offices in the supervision of the legal rights
         defense of minors;
    • The absence of a strict record of the abuse and neglect cases of minors in the frame of the
         national statistics system;
5.8. Human beings trafficking
Health System and Legal Reform
To be mentioned:
    • Criminal code
    • The law as concerns the state protection of the harmed part, of the witness and of other
         persons that grant help in the criminal trial, of January 28, 1998, no. 1458-XIII
    • The law concerning the combating with human beings trafficking approved by the
         Governmental Decision of October 15, 2001, no. 1219.
Prevention and rehabilitation services
International bodies actively support the activity of the state campaign against human beings
trafficking, among which are:
    • Campaigns of population informing about the danger of human beings trafficking;
    • Programs of social assistance and reintegration of the human beings trafficking victims;
    • Provision of a safe place of living and rehabilitation of the minors, the victims of the human
         beings trafficking;
    • Program of preparation for life aimed at institutionalized children;
    • Organization of the “hot line” for informing and counseling;
    • Program “Migrant” for financial support of the potential victims of trafficking.




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Monitoring and evaluation
At the national level monitoring and evaluation of the human beings trafficking are realized by the
National Committee for Combating with human beings trafficking and by the respective public
organizations (funds).
Statistical data
We can learn about the proportions of human beings trafficking from the data of the Regional
Information Center of the Stability Pact for South-East Europe Report, in conformity with which of all
female trafficking victims identified and present in Bosnia-Herzegovina and Macedonia – 48.0% and
44.0% respectively are the citizens of the Republic of Moldova.
It is important to mention that the statistics concerning human beings trafficking remains a problem
and there are no relevant indicators of this.
Principal realizations
In this chapter there will be shown the following:
     • Revision and improvement of the legislation aspect;
     • Bringing into the evidence of the population the danger and consequences of the human beings
         trafficking;
     • Organization of assistance and consulting services for the victims of human being trafficking;
Problems remaining unresolved
The most pressing being:
     • reduced possibilities of realization of legal and normative acts under the discussion provision;
     • absence of the National Program of medical and social assistance of the human beings
         trafficking victims;
     • low scale of living (poverty) of the persons under the risk of trafficking;
     • absence of the national system of references for the human beings trafficking victims.

5.9. Genital-mammary cancer
Health System and Legal Reform
The female reproductive organs cancer combating is regulated by:
    • National program for cancer combating for 1998-2003, adopted by the Decision of the
         Government of the Republic of Moldova of December 25, 1998, under no. 1269;
    • Subprogram for the female reproductive organs cancer combating, the componential part of
         the National Program for cancer combating for 2002-2005;
Accessibility and quality of services
There is provided a complete access of women to the following services:
    • primary examination of a woman by a family doctor;
    • examination of a woman by an oncologist at a regional central hospital or territorial medical
         association;
    • examination by an oncology gynecologists specialist or oncology-mammologist at the Oncology
         Institution.
Service quality of female reproductive organs cancer combating at the primary and secondary level of
medical assistance is much below expectations.
Informing, educating, and communicating
In this chapter there will be mentioned the following:
    • Annual organization and performing of a week “Anticancer” by the Oncology Institution;
    • Organization and carrying out once in three years a televised-marathon “Anticancer”;
    • Holding discussions by means of mass-media concerning the cancer of the reproductive organs
         of women real situation;
    • Editing and distribution of information materials for women.
Research activity
Here we can mention the following scientific works:
                                                                                                    20
   •     Structure of susceptibility to illness with oncological diseases of the reproductive organs of
         women in the Republic of Moldova;
     • Strategies of susceptibility to illness, mortality and invalidism through mammary cancer in the
         Republic of Moldova;
     • Role of the clinical cytology in mammary diagnostics in the conditions of a polyclinics;
     • Mammary gland cancer in the Republic of Moldova: Realizations and perspectives.
Monitoring and evaluation
It is carried out in conformity with the medical evidence record cards and annual statistic reports in
oncology adopted by the Ministry of Health.
Statistical data
During the period of the last ten years there can be noticed a reduction by 5-6 years of age of the
patients’ primarily diagnosed with genital-mammary cancer. In the period 1990-2003 there increased as
mammary gland affection from 33.5 up to 40.8 cases per 100 thousand of population, so mortality
because of it from 16.1 up to 24.0 respectively. Likewise, the prevalence has registered an increase from
223.4 up to 331.1 cases per 100 thousand of population.
Along with the establishment of neck of uterus cancer incidence during these years (15.0 cases per 100
thousand of population), the mortality caused by it has increased approximately 1.5 times, from 7.0 up
to 10.2 cases per 100 thousand of population.
Principal realizations
     • Adopting of a subprogram of female reproductive organs cancer combating, a componential
         part of the National Program of Cancer combating for 2002-2005;
     • Arrangement of the oncological medical assistance in three levels: I – family doctor, II –
         oncologist doctor at the district central hospital, II – Oncology Institution specialists.
     • Carrying out a prophylactic examination and cytological screening of the neck of uterus and
         mammary gland.
Problems remaining unresolved
     • Absence of a complex national epidemiological study in the field of female reproductive organs
         cancer.
     • Poor organization of the cytological screening of the neck of uterus and mammary gland.
     • Reduced capacities and possibilities of the cytological service in the territory of the republic.
     • Absence of the dispensary evidence of neck of uterus and mammary gland pathology diagnosed
         previously.
     • Insufficient preparation of the medical personnel in the sphere of primary medical assistance in
         diagnosing of precancerous stages and neck of uterus and mammary gland cancer.

5.10. Sexual health of elderly aged people
Health System and Legal Reform
Here we can mention only the following:
    • Health protection Law of March 28, 1995, no. 411-XIII.
Accessibility and quality of services
Elderly aged people have a free of charge access to the consultations of the family doctors, specialists at
the central district, municipal, and republican hospitals. The quality of consultations leaves much to be
desired due to the inadequate preparation of these specialists.
Informing, education, and communication
Within the latest 5 years there was elaborated a recommended methodology “Medical aspects of
menopause” and respectively the instructions of obstetrician-gynecologists and family doctors through
regional seminars. There was edited and distributed among elderly aged women a brochure “Youth,
happiness, health after 45”.
Research
During the last 10 years there were carried out no researches concerning sexual health of elderly aged
people in the Republic of Moldova.
                                                                                                        21
Monitoring and evaluation
In the country the sexual health of the elderly aged people is not monitored.
Statistical data
Statistical reports concerning the sexual health of elderly aged people are not made up.
Principal realizations
Here the following can be mentioned:
    • Elaboration of methodical recommendation “Medical aspects of menopause”;
    • Training of the obstetrician-gynecologists and family doctors in the sphere of sexual health of
         elderly aged people through regional seminars;
    • Editing and distribution of the brochure “Youth, happiness, health after 45” among the elderly
         aged women.
Problems remaining unresolved
The most actual are:
    • Low level of preparation of the specialists in the sphere of elderly aged people sexual health.
    • Low level of informing, instruction, and communication of the elderly aged population in what
         concerns sexual health;
    • Low level of address and access of elderly aged people to the sexual health services.

5.11. Men’s participation
Health System and Legal Reform
The right of man to protection of sexual-reproductive health is partially reflected on the Law
concerning reproduction health care and family planning of May 24, 2001, no.185-XV. Normative acts
concerning involvement of male in family planning are not developed yet.
Accessibility and quality services
According the actual structure of health assistance men’s can address for solving sexual-reproductive
needs to family doctors, gynecologists, urologists, family planning specialists. A special services for
men’s not existing. The address of males to family planning cabinets is insufficient. The main cause for
addressing to family planning services is sexual-transmitted disease and infertility.
Information, education and communication
The informational and educational materials developed during past years are mainly addressed to
women. The sexual and reproductive problems of men’s in educational activities are also negligee.
Research
During the past there were carried out only few researches concerning sexual health of men’s. The 1997
Reproductive Health Survey are evaluated only the prevalence of male contraception (condom).
Monitoring and evaluation
In the country the sexual health of men’s is not monitored.
Statistical data
Statistical reports concerning the sexual health of men’s are not made up. According the Reproductive
Health Survey (1997) the level of condoms usage is 6%, male sterilization is not performed.
Principal realizations
Here the following can be mentioned:
    • Men’s have access to reproductive health services through family planning cabinets.
    • Youth friendly clinics in Chisinau provide information and education in SR/RH also for male.
Problems remaining unresolved
The most actual are:
    • Low level of preparation of the specialists in the sphere male sexual health.
    • Low level of informing, instruction, and communication of the male in what concerns sexual
         health;
    • Low level of address and access of male to the sexual health services.


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6. Basic principles

The elaboration of the National Strategy in Reproduction health sphere was carried out in conformity
with the documents WHO and UNO, with recommendations and provisions of the international
reunions and conferences. The basis for their elaboration served the European Regional Strategy in
Sexual and Reproduction Health. Also there was taken into consideration the experience of the similar
neighboring countries: the Ukraine, Russia, and Romania.
The basic principles of the strategy elaboration are:
    • Health is the fundamental human right. Everyone has the right to the highest attainable
        standard of physical and mental health, including sexual and reproduction health.
    • Provision of the equal possibilities for men and women in sexual and reproduction health
        services.
    • Legal and normative aspects regulation in sexual and reproduction health strategies standards
        and recommendations of the international bodies and organizations.
    • Integration of the reproduction health services in primary medical assistance to increase their
        accessibility for the population.
    • Development of the quality medical services in reproduction health of the population in
        conformity with the modern science demands.
    • Respect for the ethic values and cultural traditions of the population in conformity with the
        universal human rights.
    • Promotion and seconding of the initiatives of individuals, communities, governmental and
        public organizations in what concerns making projects and support of the highest sexual and
        reproduction health standards.
    • Coordination and integration of the Reproduction Health Strategy with all other national
        strategies and programs development.

   Strategy directions:
   • Creation of an adequate medium in this sphere through advocacy, and social mobilization
       involving the community, decisive factors, and service providers.
   • Encouragement of healthy sexual behavior;
   • Amelioration of relations between the service provider and client applying the best practices;
   • Access promoting to the quality medical services in reproduction health;
   • Guarantee of the possibilities of instruction through seminars and other activities for capacities
       extension;
   • Collaboration with similar organizations and institutions from home and abroad;
   • Application of the practices based on the certificates with the development of investigations
       and spreading of information.

7. Aims and objectives

The principal aim:
Provision of the rights of the citizens of the Republic of Moldova in realization of sexual and
reproduction function for:
    • To reach healthy sexual development and maturing, to be able to hold hazard-free sexual
        relations;
    • To have a desired number of children in secure and healthy conditions;
    • To avoid maladies caused by the reproduction and sexuality;
    • To enjoy quality medical services in case of reproduction and sexual functions derangement;

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   •  Not to suffer or undergo violence and other abusive practices connected with sexuality and
      reproduction.
General objectives:
   • Support of couples and individuals in realization of reproduction purposes;
   • Prevention from undesirable pregnancy or that of a high risk;
   • Provision of legal security and in safe conditions of an abortion;
   • Reduction of maternal and prenatal morbidity and mortality;
   • Prevention from infections transmitted through sexual act and of the HIV/AIDS virus;
   • Amelioration of sexual and reproductive health of adolescents and youth;
   • Prevention and effective management of infertility;
   • Protection against violence and other abusive practices connected with sexuality and
      reproduction;
   • Rendering quality, accessible, acceptable and convenient medical services in the sphere of
      reproduction health of all who desire it;
   • Amelioration of consulting, informing and communicating quality in sexuality and reproduction
      problems.

7.1. Family planning
Aim:
Formation of the attitude of responsibility and security of the population in what concerns sexual
behavior, prevention from the undesirable consequences or those of high risk.
Objective:
    • Provision for the optimal conditions for reproductive function realization of couples and
       individuals;
    • Achievement of the ideal – “Every pregnancy must be desired and planned”;
    • Reduction of the abortion role as a means of birth rate regulation by provision with the modern
       contraceptives options;
    • To increase the knowledge level of the population about advantages and beneficial effects of
       family planning; on their right to make free and informed choices on the number and timing of
       children,
    • To improve the accessibility of the population for quality services concerning family planning
       and reproduction health;
    • To increase the active participation and responsibility of men in informed decision-making on
       SRH issues and to promote use of male contraceptive methods.
    • Optimization of the monitoring system, evaluation and relations in family planning.

   7.2. Safe motherhood
   Aim: Reduction of maternal, prenatal and new-born morbidity and mortality in the Republic of
   Moldova though amelioration of quality and increasing of accessibility to he medical services.
   Objectives:
   • To reduce the levels of maternal mortality and morbidity.
   • To reduce the levels of perinatal and neonatal mortality and morbidity.
   • Provision of a complete access and social equality in prenatal nursing.
   • To substantially increase the level of knowledge in the general population on issues related to
       pregnancy and childbirth.

7.3. Reproduction and sexuality health of adolescents and youth
Aim: Improvement of sexual and reproductive health of adolescents and youth.
Objectives:

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   •   To inform and educate adolescents on all aspects of sexuality and reproduction and assist them
       in developing the life skills needed to deal with these issues in a satisfactory and responsible
       manner.
   •   Ensure easy access of adolescents to appropriate specific user-friendly and accessible services
       without discrimination, to address effectively their reproductive and sexual health needs, taking
       into account their right to privacy, confidentiality, respect and informed consent.
   •   To reduce the levels of unwanted pregnancy, induced abortions and STIs among young people.

7.4. Reproduction tracts infections
Aim: Prevention from spread of infection by sexual transmission and of HIV/AIDS infection among
sexually active population.
Objectives:
    • Improvement of diagnosing of infections transmitted sexually and of infections HIV/AIDS at
        reproduction health clinics;
    • Amelioration of consultations and managing of the patients suffering from infections
        transmitted sexually and HIV/AIDS infections;
    • Extension of accessibility of the population to the services of prophylaxis, diagnosing and
        treatment of infections transmitted sexually and of HIV/AIDS infection;
    • Rising of informing and education level of the population concerning possibilities and ways of
        diagnosing of infections transmitted sexually and of HIV/AIDS infection.

7.5. Abortion and abortion services
Aim: Reduction of abortion method as a means of birth rate regulation and provision of its
effectuation in case of necessity, in secure conditions.
Objectives:
    • Reduction of morbidity and mortality as a consequence of complications after abortion;
    • Reduction of total rate of abortions and of repeated abortion rate;
    • Amelioration of quality of services in abortion by means of implementation of cost-efficient
        technologies, recommended by WHO and their integration with the other health reproduction
        services;
    • Increasing of accessibility of population to secure abortion services;
    • Strategic approach to the problem of abortion system functioning, offered by WHO;
    • Strategic evaluation of the abortion service in the republic.

7.6. Prevention and management of infertility
Aim: Provision of complete access of the population to quality medical serviced in infertility.
Objective:
    • Revision of the normative aspect concerning infertility management;
    • Elaboration of national regulations and standards in concerning infertile couples;
    • Fortification of institutional capacities of modern diagnosing and treatment of infertile couples;
    • Extension of accessibility to specialized medical services of infertility diagnosing and treatment;
    • Effectuation of scientific and practical profound study in evaluation of multiple aspects of
        infertility in the republic;
    • Rising of the informing and educational level of the population concerning infertility
        prevention.

7.7. Prevention and management of domestic violence and sexual abuse
Aim: Reduction of domestic violence and sexual abuse
Objective:

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   •   Provision of adequate legal and normative aspect in domestic violence and sexual abuse in the
       republic;
   •   Organization of specialized services aimed at domestic violence and sexual abuse victims;
   •   Increasing of the informing and educational level of the population in the domestic violence
       and sexual abuse aspect;
   •   Organization of social assistance services for the families that do not fulfill adequately their
       responsibilities towards their children;
   •   Application of psychological rehabilitation programs for children, victims and witnesses of
       violence.
   •   Organization of consulting services for abusers.

7.8. Prevention of human beings trafficking
Aim: Prevention and decreasing of human beings trafficking
Objective:
    • Provision of the normative aspect adequate to the combating against human beings trafficking
        and medical and social assistance to its victims;
    • Organization of specialized services for the victims of human beings trafficking;
    • Raising of the informing and educational level of the population concerning combating with the
        human beings trafficking.

7.9. Early detection and management of the genital and mammary gland cancer
Aim: Amelioration of early diagnostics and management of genital and mammary gland cancer
Objective:
    • Perfection of the normative aspect concerning early diagnostics of neck of uterus and
       mammary gland cancer;
    • Elaboration finishing and approbation of the National Program of fight against cancer for the
       years 2004-2008;
    • Extension of access of the population to the diagnostics and prophylaxis of genital and
       mammary cancer;
    • Effectuation of cytological screening for diagnosing of the early precancerous processes and
       neck of uterus cancer;
    • Training of medical service providers in early diagnostics of neck of uterus and mammary
       cancer;
    • Training of obstetrician-gynecologists and midwives from rural localities in correct collection of
       cervical smear and smear from the cervical canal for cytological analysis;
    • Elaboration of the modern concept of informing and education of the population in the sphere
       of genital-mammary cancer;
    • Popularization of primary and secondary prophylaxis measures of female reproductive organs
       cancer through mass-media;
    • Publishing of brochures concerning neck of uterus and mammary gland cancer early diagnostics
       measures;
    • Involving of the broad masses of population in active combating against neck of uterus and
       mammary cancer;

7.10. Sexual health of elderly aged people
Aim: To improve the sexual health of aging people. Amelioration of sexual health of elderly aged
women and men.
Objective:
    • Expansion of access and address of elderly aged people to the sexual health services;

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   •   Raising of the level of informing and education of elderly aged people in the sphere of sexual
       health.

7.11. Men’s involvement
Aim: To improve sexual and reproductive health of men’s and to involve their in family planning.
Objective:
    - Encourage men to take more responsibility for their sexual behavior;
    - Increase men's access to reproductive health information and services;
   -   Help men to communicate with their partners and make contraceptive choices together;


8. Expected results

In general:
    • There will be defined perfection of the normative aspect concerning functioning reproduction
         health service;
    • The subject-matter of family planning will be included in the programs of the university and
         post-graduate studies;
    • In every region and municipality of the republic there will be organized reproduction health
         qualified services;
    • The regulations concerning medical assistance rendering in family planning will be adapted to
         the international requirements;
    • There will be elaborated a managerial informational system of family planning;
    • Sexual education will be included into the system of education;
    • There will be developed an indigenous informing, educational and communicational system.
8.1. In family planning
    • The prevalence of modern methods of contraception application will increase;
    • Contraceptive services are provided as part of primary health care.
    • The level of informing and education of population in the sphere of family planning will raise;
    • The address and access of the population to he family planning services will rise.

8.2. In safe motherhood
    • There will be reduced the rate of:
            • maternal mortality below 20.0 per 100 thousand live-born;
            • prenatal mortality below 10.0 per 1 000 live-born and still-born;
            • neonatal premature birth mortality below 5.0 per 1 000 live-born;
            • neonatal premature birth morbidity below 200.0 per 1 000 live-born.
    • There will be provided the equitable access of women to the prenatal services regardless their
        residence and social status.
    • In the sphere of antenatal medical assistance for pregnant women there will be provided at least
        six visits, including one in the first trimester of pregnancy;
    • The marked population will have wholesome attitudes and habits towards prenatal care.
8.3. In reproduction and sexuality health of adolescents and youth
    • The level of informing and education of adolescents and youth in the sphere of sexuality and
        reproduction health will raise;
    • Adolescents and youth in their majority will be provided with the amicable health services;
    • There will be reduced:
            • pregnancy rate with the adolescents by 30.0%;
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             • syphilis incidence with the adolescents by 20.0%.
8.4. In prevention and management of reproduction tract infections
    • The level of informing and education of childbearing age people concerning infections
        transmitted sexually and HIV/AIDS infection will rise.
    • The degree of participation of childbearing age population in taking decisions concerning risk
        behavior will increase.
    • The frequency of HIV-infection transmission from mother to fetus will reduce below 1.0%.
8.5. In abortion and abortion services
    • The level of informing and education of population concerning abortion problem will rise.
    • The rate of abortions will not exceed 15.0 per 1 000 women of childbearing age.
    • The degree of complications after abortion will be reduced.
    • Maternal death as a result of complications after the abortion will be avoided.
    • More than 70.0% of patients will leave medical institutions after the abortion by selected
        contraception method.
8.6. In prevention and management of infertility
    • The address and access of infertile couples to the qualified medical services will increase.
    • The level of informing and education of childbearing age people concerning infertility
        prophylaxis will rise.
8.7. In prevention and management of domestic violence and sexual abuse
    • The level of informing and education of population concerning prevention of domestic
        violence and sexual abuse will rise.
    • The number of cases of domestic violence and sexual abuse will reduce.
8.8. In prevention of human beings trafficking
    • The level of informing and education of population concerning human beings trafficking and
        its consequences will rise.
    • The number of trafficked people will reduce.
8.9. In early diagnostics and management of genital-mammary cancer
    • The level of informing and education of population concerning combating with genital-
        mammary cancer will achieve the European standards.
    • The percentage of neck of uterus diagnosing at the stage 0 will exceed 25.0% and at the stage I-
        II – 45.0%.
8.10. In sexual health of elderly aged people
    • The level of informing and education of elderly aged people concerning sexual health will rise.
8.11. Men’s involvement
   • Legal and other barriers to male sterilization are lifted.
   • The level of knowledge of male on reproductive health issues will increase.
   • SRH services for men are made available.

9. Implementation aspect

Health System and Legal Reform
   • Development of reproduction health services in every region and municipality of the republic.
   • Integration of reproduction health services in the system of primary medical assistance.
   • Establishing of a mechanism and criteria of reference of patients with reproduction
      dysfunctions.
Accessibility and quality of services
   • Rendering of reproduction health services and primary medical assistance services in the frame
      of the assistance system.

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   •   Increasing of capacities of the cabinets of family planning and of the Scientific Practical
       National Center of Reproduction Health, Medical Genetics and Family Planning in consulting,
       prophylaxis, diagnostics and management of the patients with sexual and reproduction
       problems.
    • Elaboration and implementation of the instructive methodical guides and standards in
       reproduction health assistance.
Training of the medical services providers
    • Elaboration of the university and post-graduate studies curriculum in reproduction health for
       family doctors and obstetrician-gynecologists.
    • Inclusion of the subject-matter of reproduction in university and post-graduate studies
       curriculum.
    • Elaboration of the instructive methodical guides and practical knowledge and attitudes
       standards for medical services providers in reproduction health.
    • Organization of continuing education seminars for the family doctors, obstetrician-
       gynecologists, dermatologist-venereologists and medical assistants in reproduction health.
Informing, education, and communication
    • Creation of the system of education for family health and life within educational institutions.
    • Creation of system of informing, education, and communication in reproduction health for
       population of childbearing age.
Gender equality
    • Provision of information and access to the reproduction health services in equal proportions
       for men and women.
Research, monitoring, and evaluation
    • Adopting and promotion of acceptable definitions and classifications in reproduction health on
       the international level.
    • Creation of the managerial informational system of reproduction health.
    • Management promotion of services quality in reproduction health.
    • Effectuation of a complex study of medical assistance evaluation in reproduction health.
    • Effectuation of population periodical studies in reproduction health.

9.1. Family planning
Health System and Legal Reform
    • Development of family planning services in every region and municipality of the republic.
    • Integration of family planning in primary medical assistance service.
Quality of Service
    • Improvement access of the population from rural area to the family planning services through
       integration family planning counseling in the activity of family doctors.
    • Elaboration the standards for knowledge and skills for reproductive health care providers.
    • Integration of services of family planning with other reproduction health services as adolescent
       services, STI/HIV prevention and diagnostics, preconceptions services.
    • Improvement of post abortion contraceptive counseling.
    • Creation of regional centers for women voluntary surgical sterilization.
    • Creation of the mechanism for affordable contraceptive provision of vulnerable groups of the
       society.
Training of the medical services providers
    • Inclusion of the family planning and reproductive health in the curricula of undergraduate and
       postgraduate studies.
    • Elaboration of the guidelines for knowledge and practical skills in family planning for medical
       services providers.
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   •  Organization of continuing education seminars in family planning, including on-the job learning
      principles for the family doctors, obstetrician-gynecologists and nurses.
Information, education, and communication
    • Promotion of sexual and contraceptive education at school, universities and other educational
      institutions.
    • Development the didactic material for teachers, psychologists, medical personal from school in
      family life and sexual education.
    • Elaboration, publication and distribution of informative materials in the sphere of family
      planning for population.
    • Involvement of nongovernmental associations and civil societies in the educational-informative
      and communication work.
    • Holding mass-media informative-educational campaigns in sexual education and family
      planning.
    • Involvement of family doctors in contraceptive education of the population.
    • Development of the mechanisms for male involvement in family planning.

Gender equality
   • Informing of women and men about right of choice in what concerns family planning.
   • Orientating of school and out-of-school education in the frame of family planning toward
      equality between girls and boys.
   • Promotion of public education in reproduction health both for women and men.
   • Provision of contraception methods accessibility for women and men.
   • Provision of relevance and access to the family planning services equally for women and men.
Research, monitoring, and evaluation
   • Creation of the managerial informational system on family planning.
   • To develop a system for evaluation of the quality of care provided by health care providers in
      the field of family planning.
   • Effectuation of a periodical survey and research on contraceptive prevalence and family
      planning.

9.2. Safe motherhood
Health System and Legal Reform
    • Conformity of the standards of perinatal medical assistance adopted in the frame of obligatory
        medical assistance insurance with the certified medicine principles and with the active clinical
        guides.
    • Perfection of the criteria of medical institutions accreditation specialized in rendering perinatal
        medical assistance in conformity with the principles of the initiative “Pregnancy risk-free”.
    • Identification of the mechanisms of protections of vulnerable groups of society
Quality of Service
    • Promotion of the concept: “Perinatal services friendly to the families” – a quality guarantee
        instrument.
    • Continuation of perfection of prenatal medical assistance definitions and indicators system and
        continuing preparation of the personnel involved in data gathering and processing.
Training of the medical services providers
    • Continuation of post-graduate training of the prenatal service medical personnel in priority
        spheres: prenatal services planning principles; management of total quality; evidence-based
        medicine; essential care in obstetrics and neonatology; infection HIV/AIDS transmission from
        mother to fetus prevention.
    • Reestablishment of midwives institution in primary medical assistance.

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    • Identification of necessities of prenatal service medical personnel training.
Capacities of women, families and communities
    • Evaluation of the level of knowledge, behavioral habits and consumers’ satisfaction concerning
       prenatal services.
    • Elaboration of national policy of family and community interaction in the field of prenatal
       development.
    • Development of partnership between prenatal services and society.
    • Establishment of mechanisms of encouragement of active participation of mothers and
       community representatives in amelioration of prenatal services quality.
    • Fortification of capacities and habits of interpersonal and intercultural communication of the
       medical personnel of the mother and child protection system.
Gender Equality
    • Preparation of both future parents in preconception, antenatal, natal, and postnatal care.
    • Planning and implementation of interventions for identification and solution of problems
       connected with violence in pregnancy.
Research, monitoring, and evaluation
    • Completion of elaboration, adopting and implementing of the Prenatal assistance indicators
       Guide.
    • Perfection and completion of the existing instruments for prenatal services evaluation.
    • Effectuation of operational studies with a direct impact upon maternal and prenatal mortality
       and morbidity.
    • Establishment of risk factors in reproductive function realization.
Interaction with other reproduction health programs
    • Provision of transparent mechanisms of coordination and efforts reporting.
    • Provision of the adequate funds for realization of programs connected with the health of
       mother and child through priority mentioning on the national health level.
    • Coordination of perfection activities with their integration in the university and post-graduate
       training programs.
    • Provision of correlation of educational messages promoted in the frame of different programs
       messaging the initiative “Pregnancy risk-free”.

9.3. Reproduction and sexuality health of adolescents and youth
Health System and Legal Reform
   • Elaboration of a national concept of youth friendly clinics.
   • Organization of youth friendly health services in every district and municipality.
   • Implementation of sexual and reproductive education in the school studies program.
Quality of Service
    • To provide appropriate, specific, user-friendly and accessible services to address effectively
       their reproductive and sexual health needs, including reproductive health information and
       education, counseling of adolescents in the areas of gender relations and equality,
       responsible sexual behavior, violence against adolescents, family life, responsible family
       planning practices, preventing unwanted pregnancy, sexually transmitted diseases and HIV
       infection. These services should safeguard the rights of adolescents to privacy,
       confidentiality and informed consent
   •   Sexually active adolescents will require special family planning information, counseling and
       health services as well as sexually transmitted diseases and HIV/AIDS prevention and
       treatment, and those adolescents who become pregnant will require special support from their
       families, health-care providers and the community during pregnancy, delivery and early
       childcare. Special attention should be devoted to vulnerable and disadvantaged youth.
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Training
   • Elaboration of the educational materials and clinical guidelines for youth friendly services.
   • Organization of training courses for the family doctors, obstetrician-gynecologists and nurses in
      the field of adolescent health care.
   • To involve and train all who are in a position to provide guidance to adolescents concerning
      responsible sexual and reproductive behaviour, particularly parents and families, and also
      communities, religious institutions, schools, the mass media and peer groups.
Information, education, and communication
   • School education. Promotion of sexual education at school, universities and other educational
      institutions. Include at all levels of schooling, education about population and health issues,
      sexual and reproductive health issues, responsible sexual behaviour, gender relations and
      equality, violence against adolescents, responsible family planning practices, family life, sexually
      transmitted diseases, HIV infection and AIDS prevention.
   • Parents involvement. Promoting programmes directed to the education of parents, in providing sexual
      and reproductive health information to their children.
   • Peer education. Promoting peer education through workshops and seminars, group
      discussions, organizational training, artistic activities, newspaper and radio programmes.
   • Youth involvement. To involve youth in the planning, implementation and evaluation of
      information, education and communication activities. Adolescents and youth themselves should
      be involved in the design and implementation youth friendly services.
   •   Health care provider involvement. Involvement of family doctors, medical staff of the
       family planning cabinets in sexual and reproductive education of adolescents and youth.
   •   Mass media involvement. Prepare and disseminate accessible information, through public
       health campaigns, the media and the education system, designed to ensure young people, can
       acquire information on sexuality and reproduction.
   •   Education materials. Publication and distribution of educational and informative materials
       for adolescents and youth.
   •  Community involvement. To involve of nongovernmental associations and civil societies in
      the educational-informative and communication work with adolescents and youth.
Gender equality
   • Develop school information and educational program in the area of sexual and reproductive
       health both for girl and boys.
   • Support mechanisms for the education and counselling of adolescents for mutually respectful
       and equitable gender relations and gender equality.
Research, monitoring, and evaluation
  • Integration of data concerning reproduction and sexuality health of adolescents and youth in the
      national managerial informational system of reproduction health.
  • Evaluations of the youth needs in RH/FP at the national level.
  • Realization of survey and research in adolescent reproduction and sexuality.

9.4. Prevention and management of reproduction tracts infections
Health System and Legal Reform
    • Implementation of diagnostics and treatment of infections transmitted sexually and of
        HIV/AIDS infection in the frame of family planning service.
    • Making efforts at family planning service and primary medical assistance in prevention and
        timely diagnostics of infections transmitted sexually and of HIV/AIDS infection.
    • Perfection of normative acts concerning prevention and management of infections transmitted
        sexually and of HIV/AIDS infection in accordance with the WHO recommendations.

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Quality of Service
    • Amelioration of childbearing age population access to the services of prophylaxis, diagnostics
       and treatment of infections transmitted sexually and of HIV/AIDS infection.
    • Elaboration of medical assistance standards of the patients infected sexually, HIV/AIDS
       infected.
    • Amelioration of consulting services of the patients infected sexually, HIV/AIDS-infected.
Training of the medical services providers
    • Elaboration of the instructive methodical guides of medical assistance of the patients infected
       sexually, HIV/AIDS-infected.
    • Organization of training seminars for the personnel that renders services of prophylaxis,
       diagnostics and treatment of infections transmitted sexually and of HIV/AIDS infection.
Informing, education, and communication
    • Publication and distribution of informative materials for childbearing age population
       concerning protection from infections transmitted sexually and HIV/AIDS infection.
    • Involvement of family doctors in consulting patients infected sexually, HIV/AIDS-infected.
Research, monitoring, and evaluation
    • Adopting and implementation of international classifications and definitions in diagnostics and
       treatment of infections transmitted sexually and HIV/AIDS infections.
    • Realization of periodical studies concerning dissemination among the population of
       childbearing age of infections transmitted sexually and HIV/AIDS infections.
    • Effectuation of a complex study of prophylaxis, diagnostics and treatment of infections
       transmitted sexually and of HIV/AIDS infection services.

9.5. Abortion and Abortion services
Health System and Legal Reform
    • Renovation of medical regulations concerning induced abortion.
    • Elaboration of clinical guides, standards and protocols of post abortion care.
    • Implementation of abortion methods through vacuum aspiration and medication abortion.
Quality of service
Extension of accessibility for the secure and quality services of abortion through:
    • Elaboration of quality standards, active, corresponding to the medical assistance level, for
       medical institutions rendering abortion services;
    • Implementation in all institution of the country of manual and electrical vacuum aspiration
       method for abortion during the first trimester of pregnancy;
    • Implementation of medical abortion in abortion services;
    • Application of modern methods of abortion in the second trimester, recommended by WHO;
    • Implementation in the abortion services of the concept “system centralized on the patient”;
    • Application of the pain control methods, recommended by WHO: psychological and verbal
       support before and during the procedure; para-cervical Lidocainum blockade in abortion during
       the first trimester of pregnancy;
    • Elaboration of standards of prophylaxis, diagnostics, treatment and reference of the patients
       with complication after the abortion;
    • Instruction and training of family doctors in pre- and post-abortion consulting.
Training of the medical services providers
    • Creation and implementation of the continuing education system of abortion services
       providers.
    • Training of medical personnel of family planning system and primary medical assistance in pre-
       and post-abortion consulting services.


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Informing, education, and communication
    • Organisation of periodical campaigns of continuing education of the population in the problem
      of abortion and questionable abortion risks.
    • Publication and distribution of informative materials about abortion for the population of
      childbearing age.
Research, monitoring, and evaluation
    • Effectuation of strategic evaluation of abortion services.
    • Creation of the system of monitoring and evaluation of abortion service.
    • Realization of periodical studies in abortion and its consequences.
    • Elaboration and implementation of the system of monitoring and evaluation of the patients’
      opinion concerning abortion services.

    9.6. Prevention and management of infertility
Health System and Legal Reform
    • Perfection of the normative acts concerning infertility.
    • Elaboration of behavioral standards of an infertile couple.
    • Extension of the capacity of the National Scientific Practical Center of Health and
        Reproduction, Medical Genetics and Family Planning in diagnostics and treatment of an
        infertile couple.
Quality of service
    • Increasing of accessibility of infertile couples to the services of family planning.
    • Implementation of modern technologies in diagnostics and treatment of infertile couples.
Training of the medical services providers
    • Elaboration of the instructive methodical guides for infertility services providers.
    • Organization of training seminars in the field of infertility for medical services providers.
Informing, education, and communication
    • Publication and distribution of informative materials about infertility problems for the
        population.
    • Organization of periodical campaigns of information and education of the population
        concerning infertility.
Research, monitoring, and evaluation
    • Realization of periodical studies in infertility.
    • Evaluation and monitoring of the infertility phenomenon on the population level.
    • Creation of a database in the field of infertility.

9.7. Prevention and management of domestic violence and sexual abuse
Health System and Legal Reform
    • Perfection of the normative acts concerning domestic violence and sexual abuse prevention and
        protection of this phenomenon victims’ interests.
    • Development of partnership between state structures and civil society.
Quality of service
    • Creation of specialized consulting centers for the victims of domestic violence and sexual
        abuse.
    • Involvement of the family planning service in consulting victims of domestic violence and
        sexual abuse.
Training of the medical services providers
    • Elaboration of the instructive methodical guides concerning family planning service in
        consulting.


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   •   Organization of seminars with the participation of family planning doctors and family doctors
       on consulting victims of domestic violence and sexual abuse.
    • Elaboration of university and post-graduate training curriculum in consulting and assistance of
       victims of domestic violence and sexual abuse.
Informing, education, and communication
    • Publication and distribution of informative materials for the population concerning prevention
       of domestic violence and sexual abuse.
    • Organization of informative campaigns for the population concerning the phenomenon of
       domestic violence and sexual abuse.
Equality of sexes
    • Provision of equal conditions and chances for women and men in the campaigns of education
       and information.
    • Provision of equal accessibility for women and men to the consulting and assistance services of
       domestic violence and sexual abuse victims.
Research, monitoring, and evaluation
    • Realization of studies concerning problems of domestic violence and sexual abuse.
    • Monitoring and evaluation of the phenomenon of domestic violence and sexual abuse.
    • Creation of a database and elaboration of he relevant indicators in this sphere.

9.8. Prevention of human beings trafficking
Health System and Legal Reform
    • Perfection of the normative acts concerning combating against human beings trafficking and
        assistance to its victims.
    • Development of partnership between the state structures and civil society in combating against
        human beings trafficking.
Quality of Service
    • Development of specialized centers in assistance to the human being trafficking victims.
    • Involvement of family planning doctors, family doctors and social assistants in consulting and
        assistance of the human being trafficking victims.
Training of the medical services providers
    • Elaboration of the instructive methodical guides in consulting and assistance of the human
        being trafficking victims.
    • Organization of training seminars for the family planning doctors, family doctors and social
        assistants in consulting and assistance of the human being trafficking victims.
Informing, education, and communication
    • Publication and distribution of informative materials for different levels of society concerning
        human being trafficking prevention.
    • Organization of periodical information campaigns for the population concerning the
        phenomenon of human beings trafficking.
Gender equality
    • Provision of equal accessibility for women and men to the process of and information and
        education aimed at combating with the human beings trafficking.
    • Provision of equal accessibility for women and men victims of human beings trafficking to
        respective services and assistance.
Research, monitoring, and evaluation
    • Realization of periodical studies in the field of human beings trafficking.
    • Evaluation and monitoring of the phenomenon on the national scale.
    • Creation of a database and elaboration of the relevant indicators of human beings trafficking.


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9.9. Early diagnostics of genital-mammary cancer
Health System and Legal Reform
    • Elaboration of a national concept in early diagnostics of genital-mammary cancer.
    • Organization of neck of uterus cancer screening of women.
Quality of service
    • Effectuation of genital-mammary cancer screening of women in the frame of primary medical
       assistance system.
    • Involvement of the family planning doctors in early diagnostics of genital-mammary cancer.
Training of the medical services providers
    • Elaboration of the instructive methodical guides in genital-mammary cancer diagnostics.
    • Organization of seminars for the family planning doctors and family doctors on consulting,
       early diagnostics and treatment of patients with genital-mammary cancer.
Informing, education, and communication
    • Publication and distribution of informative materials for the population concerning prevention
       of genital-mammary cancer.
Research, monitoring, and evaluation
    • Perfection of national register of genital-mammary cancer.
    • Realization of periodical research studies concerning problems of genital-mammary cancer.

9.10. Sexual health of elderly aged persons
Health System and Legal Reform
    • Elaboration and approbation of normative acts concerning sexual health of elderly aged
        persons.
    • Involvement of elderly aged persons’ sexual health medical assistance in reproduction health
        service.
Quality of service
    • Amelioration of elderly aged persons’ access to the sexual health services.
    • Elaboration of medical assistance standards in endocrine and sexual derangement of the elderly
        aged people.
Training of the medical services providers
    • Elaboration of the instructive methodical guides in treatment of elderly aged persons with
        endocrine and sexual derangements.
    • Organization of training seminars for the medical personnel rendering services to the people
        with sexual health problems.
Informing, education, and communication
    • Publication and distribution of informative materials in sexual health for the elderly aged
        persons.
    • Involvement of family doctors in consulting of elderly aged persons with sexual health
        problems.
Research, monitoring, and evaluation
    • Realization of periodical studies in sexual health of elderly aged people.

9.11. Men’s involvement
Health System and Legal Reform
    • Elaboration and approbation of standards for counseling of men’s in family planning clinics.
   • Implementation of counseling for men’s in the activity of reproduction health service.
Quality of services
   • Making services for men’s to be accessible and friendly.
   • Men’s services will include:

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           • Counseling on how to prevent STDs. Screening and treatment for STDs,
             including HIV/AIDS,
           • Giving correct information about family planning,
           • Providing contraceptive methods,
           • Counseling and treatment for infertility,
           • Counseling and treatment for sexual dysfunction,
           • Screening and treatment for penile, testicular, and prostate cancers
    • To facilitate couple counseling for contraceptive choice
    • To implement vasectomy as a method of contraception
    • To promote education and counseling of men’s in youth friendly clinics
Training of the medical services providers
    • Elaboration of the instructive methodical guides on counseling and communication with men’s.
    • Organization of training seminars for the medical staff of family planning cabinets in counseling
       of men’s.
    • Organization of training courses for family doctors, gynecologists, nurses in counseling of
       men’s.
Informing, education, and communication
    • Publication and distribution of informative materials in sexual and reproductive health for
       men’s.
    • Involvement NGO organization and mass-media in sexual education of men’s.
    • Holding IEC campaigns to help men:
           • to communicate with their partners and make contraceptive choices together
           • to slow the spread of human immunodefiency virus/acquired immune deficiency
               syndrome (HIV/AIDS ) and other sexually transmitted diseases (STDs);
           • to prevent unintended pregnancies and reduce unmet need for family planning;
           • to foster safe motherhood and practice responsible fatherhood;
           • to stop abusing women.
Research, monitoring, and evaluation
    • Realization of periodical studies on knowledge, attitude and practice of men’s in FP/RH in
       sexual health of elderly aged people.
    • Elaboration the system for monitoring and evaluation male contraception and sexual-
       reproductive health.

10. Necessities

For successful implementation of the Strategy human, financial and technical resources are necessary.
Human resources will be constituted of medical personnel, pedagogical staff, persons who activate in
public organizations and international funds.
Financial resources will be received from budget allocations, fund of the National Medicine Insurance
Company, contribution of public associations, private sector and international charity organizations
donations.
Technical resources embraces the totality of necessities for sexual and reproduction health programs
and projects management.

11. Responsibilities

Governmental sector
Ministry of Health will coordinate the course of Strategy implementation, elaboration and realization
in the frame of reproduction health assistance Programs.
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Ministry of Education will coordinate implementation of the educational programs in the following
spheres: preparation for the family life; equality of sexes; sexuality and reproduction health at general
education schools, lyceums, colleges, and universities. It will participate in elaboration of informative-
educational and communicational materials and will provide pedagogical personnel training.
National Medicine Insurance Company of in will contribute to implementation of the Strategy
through payment of expenses for reproduction health medical services by obligatory system of medical
insurance, on the basis of contracts between the Company and services providers.
National Scientific Practical Center of Reproduction Health, Medical Genetics and Family
Planning will coordinate the integral process of the Strategy implementation.
Scientific Research Institute in the field of Mother and Child Healthcare will participate in the
process of implementation of the Strategy through coordination of maternity risk-free sector
realization.
Center AIDS will participate in elaboration and implementation of the programs in the sphere of
infections transmitted sexually and HIV/AIDS infection prevention.
Oncology Institution will participate in implementation of the Strategy provisions concerning genital-
mammary cancer.
State University of Medicine “N. Testemitanu” will participate in realization of the section of the
Strategy referring to the training of students and doctors in reproduction health.
Academy of Science of the Republic of Moldova will contribute to the realization of the Strategy
through effectuation of scientific researches and studies in reproduction health.
Family doctors centers and territorial medical institutions will provide primary and consulting
medical assistance to the patients regarding provisions of the Strategy at the community level.
Public sector
Public organizations represent a key element in provision of the logistic sector of the Strategy advanced
measures promotion. They, together with the governmental organizations, will realize the informative,
educational and communicative programs and projects in the ranks of population in conformity with
the Strategy objectives.
Private Sector
Private sector will be an important reproduction health service provider, especially in the sectors non-
covered by the obligatory medical assistance insurance.

12. International Collaboration

International bodies are the most important partners in realization of the programs and projects
promoted in the Strategy frame. The Government of the Republic of Moldova strives for support on
the part of the international bodies in the following measures determined by the Strategy:
    • Optimization of the assistance service in family planning and reproduction health
        projection, that presupposes:
             • Restructuring and adapting of the existing family planning service to the conditions of
                 obligatory medical assistance insurance in view of priority satisfaction of the
                 adolescents, youth and persons from the rural area necessities;
             • Regulation of the family planning cabinets and of the women health centers activity in
                 the frame of reproduction health system;
             • Integral involvement of the family planning doctor and medical assistance in family
                 planning;
             • Institution of the managerial information system in family planning and reproduction
                 health.
    • Provision of contraception oriented at:
             • Provision of the vulnerable groups of population with modern contraceptives free of
                 charge or at a reduced price;
             • Creation of regional of voluntary surgeon sterilization;
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          • Organization of the system of distribution and evidence of contraceptives use.
   •   Fortification of capacities of assistance, training and management of the family
       planning service:
          • Amplification of organizational-methodical, assistance and training capacities of the
               National Scientific Practical Center of Reproduction Health, Medical Genetics and
               Family Planning;
          • Amelioration of the quality of accorded assistance and optimization of the
               informational-educative work of the family planning cabinets.
   •   Training of the medical personnel in reproduction health, that will consist in:
          • Evaluation of national necessities of family planning training;
          • Elaboration of university and post-graduate training curriculum in family planning;
          • Preparation of the departmental lecturers of university and post-graduate training in
               reproduction health;
          • Perfection of the doctors in problems of reproduction health at international clinics of
               reference;
          • Preparation of the molders in family planning foe every level of medical assistance;
          • Organization of training courses and seminars for all categories of family planning
               services providers.
   •   Elaboration, publishing and distribution of national standards and guides in family
       planning assistance.
   •   Effectuation of informing, educational and communicating activities among the
       population.

13. Monitoring and evaluation

In the purpose of surveillance mode, the Strategy objectives to be achieved, there will be elaborated:
    • Annual reports about the course of strategy realization, with monitoring and evaluation of
        efficiency of human, financial, and technological resources use;
    • Trimester and annual reports concerning family planning service, that will present the data
        about: number and characteristics of the consulted patients, including men and youth;
        application of modern and traditional methods of contraception; cases of infections transmitted
        sexually; degree of provision with contraceptives and consumables;
    • Questionnaires and forms on the basis of which will be evaluated services accessibility,
        availability and quality, level of knowledge and of practical habits of the providers of
        reproduction health medical services.
    Will be effectuated:
    • Strategic evaluation of reproduction health services;
    • Audit of maternity hospitals and clinics of reproduction health;
    • The studies on the basis of which will be determined the Strategy impact upon the population
        health.




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