Figo Working Group on Prevention of Unsafe Abortion

FIGO WORKING GROUP ON PREVENTION OF UNSAFE ABORTION

TURKEY SITUATIONAL ANALYSIS

Dr Berna Bernar-Dilbaz

UNWANTED PREGNANCIES

· Incidence of unwanted pregnancies

According to 2003 Turkish Demographic Health Survey (TDHS-2003) results 1 780 556 pregnancies per year is expected and 201 203 of these pregnancies are terminated (voluntary termination of pregnancy). According to the same survey (2003) the percentage of married women who do not want to have any more children is 69.2%.

The percentage of voluntary termination of pregnancy is 11.3 per 100 pregnancies according to TDHS-2003, remarkably lower then the figure reported in TDHS-1998 which is 14.5 per 100 pregnancies .

· Vulnerable groups (refugees, internally displaced populations, youth, HIV positive women, rural population, etc)

· Rural population, internally displaced populations and youth

· Determinants of unwanted pregnancies (including access to contraceptive and contraceptive and user failure, violence against women, and lack of social support of pregnant women).

According to TDHS-2003; 24.4 % of the women who had voluntary termination of pregnancy used no contraceptive method one month prior to thie unwanted pregnancy whilst 46.1% used coitus interruptus. Only 23% of these unwanted pregnancies that ended up with termination of pregnancy occured while using a modern contraceptive method.

· Characteristics of women with unwanted pregnancies(health, poverty, etc)

· The risk factors for voluntary termination of pregnancy are using a traditional method, especially coitus interruptus and having a previous pregnancy just before having this unwanted pregnancy. Uneducated women, women living in rural areas, adolescents are at higher risk for unwanted pregnancies due to the difficulties in reaching family planning methods and FP services.

· Consequences of unwanted pregnancies

· The total fertility rate is 2.2 whereas the desired fertility rate is 1.6 This figures show that some of the unwanted pregnancies end up with abortion while some of the babies are delivered. The difference between the total fertility rate and desired fertility rate is higher among uneducated women and women living in rural areas.

· Barriers to certain methods (providers and health system barriers)

It is hard for women living in rural areas to reach the health services. For women who have immigrated to the cities reaching the health service delivery system is difficult.

INTERVENTIONS TO PREVENT UNWANTED PREGNANCIES AND INDUCED ABORTIONS

Contraceptive information and services including EC

· Overall and method specific prevalence rate

According to the Turkish Demographic Health Survey (2003) 71% of the married women are using a contraceptive method. Modern methods are used by 43% of the married women while 29% are using a traditional method such as withdrawal, vaginal douching etc..

The odds ratio of traditional method use vs modern methods is increased by:

1. increasing age of woman

2. decreasing educational status(man and woman)

3. husband’s disapproval of FP

4. having no child or only one child

Distribution of contraceptive methods among married women:

IUD 20.2%

Condom 10.8%

Female sterilization 5.7%

COC 4.7%

Diaphram 0.6%

Injectables 0.4%

Vasectomy 0.1%

Withdrawal (coitus interruptus) 26.4%

Calendar 1.1%

Lactational amenorrhea 0.6%

Other traditional methods 0.4%

Percentage of married women who are not using any contraceptive method: 29%

There is not a wide difference between the geographic regions in terms of the rate of the women who do not want to have any more children but there is a remarkable difference between the prevalance of modern method use from one region to another one and urban to rural areas

· Which methods are approved and sold in the country?

Modern family planning methods available in Turkey are:

1. Intrauterine device

2. Combined oral contraceptives

3. Injectables

4. Implant (Implanon- Organon)

5. Condom

6. Spermicides

7. Intrauterine system (LNG-IUS, Mirena)

8. Tubal ligation and vasectomy

9. Emergency contraception

· Which methods are distributed for free or at subsidized price through public or private health networks in the country?

· Intrauterine devices, combined oral contraceptives, condoms and injectables are available for the women either free or at a subsidized price through the public health networks. Tubal ligation and vasectomy is covered by the national social security system.

· Which is the real availability of methods in the public health services

· All the methods are available in the public health services but the social security system does not cover Implanon or Mirena, the clients have to pay for tem.

· What data are available on access to methods by young people, unmarried women and other marginalized groups (rural people, indigenous groups, refugees IDPs). [L]

· All of the Mother and Child Health Care Units (Ministry of Health) keep records about family planning method use and characteristics of the clients. There are “Youth Centers” (MOH) and “Medicosocial Departments” (Universities) that aim to serve young people. Unmarried women can apply for counseling and get family planning method, there is no legal or regulatory obstacle for this.

Comprehensive Sexuality Education

· What is the current situation of knowledge among women and men on sexuality education?

· Knowledge abou reproductive health is given in the 7th grade onwards.

· Are there governmental programs for comprehensive sex education?

· No

· How comprehensive is the coverage of sexuality education programs? Out of school youth?

· No, but the counseling sessions provide by Mother and Child Health Care Centers partially covers sexual health issues.

· How comprehensive and adequate is the training of teachers to provide sexuality education?

· No specific training

· Which is the technical orientation (scope and content) of the existing programs?

· There are some EU projects that aim to improve the sexual health issues on certain targeted populations.

Social protection of pregnant women and mothers of small children

· Is employment of pregnant women protected by law during pregnancy and after delivery and for how long?

· No.

· Is the law enforced?

· How long is the legal parental leave? Is it paid? Is it the same for all populations within the country?

· The legal maternal leave is 8 weeks before delivery and 8 weeks after delivery. The antenatal leave is 10 weeks for mothers with multiple pregnancies.

· Is maternal breast feeding effectively protected for working women?

· The postpartum patients can apply for payless maternity leave for 1 year after their maternal leave without losing their job. The women who return to work after their 8 weeks maternity leave are entitled to use one hour maternity brake per day for one year after delivery for breast feeding

· How is the compliance with the law on parental leave and maternal breast feeding?

· The compliance is high but there is no law to protect the employment of pregnant women during pregnancy in the private sector.

· Are there sufficient whole day nurseries, preschool and school for the children of working women?

· Yes, there are kindergardens, preschools in most parts of the country for working women but nurseries are not that widely available.

Adoption

· Is there support for women who wish to give baby to adoption?

· The babies who are not wanted by their families have to be accepted by the “Social Services” and then a family for adoption is arranged .

· Is there an effective procedure for adoption in the country?

· There is an effective procedure for adoption but the waiting list is very long. There are also some families who want to leave their children to “Social Services” and refuse adoption; these children are raised by the government orphanages. The children in the orphanages can have “protector families” who will partially take care of these children without actually adapting them.

ABORTION

· Incidence

· The percentage of voluntary termination of pregnancy is 11.3 per 100 pregnancies according to TDHS-2003

· Reliability of data

· TDHS is a reliable source and these figures about abortion are not official data ontained from the Ministry but actually from the women interviewed.

· Sources of data

· Ministry of Health General directorate of Mother and Child Health Care keeps records of all voluntary termination of pregnancies. The records of the procedures carried out at public sector can be missing.

UNSAFE ABORTION

· Incidence

· No national statistics are available

· What data are available on the magnitude and severity of the problem of unsafe abortion?

· The records of Ministry of health show 35 115 voluntary of terminations in 2007 but none of them were recorded as unsafe abortion. Tukish Society of Obstetrics and Gynecology will ask the reported casesof unsafe abortions from the maternity hospitals.

· Source of data

· Characteristics of women who come for abortion (age, place of residence, marital status, income)

· Characteristic of providers of unsafe abortion and method used

· Availability of misoprostol, is it registered/approved, what indications? Distribution channels, cost?

· Misoprostol is available in Turkey but it is registered for nonobstetrical indications.

Quality of the care of women consulting for complications of abortion

· Which methods are used in the country for incomplete abortion? Who can provide these methods?

· D&C, MVA are available but these services are not given at the primary health care facilities, so the patients need to apply to a hospital at the state sector. These services are also avaliabe at the private sector.

· Which is the real availability of those methods in the public health services, and how much they cost?

· For women under social security cover, these procedures are free of charge.

· How is the access to treatment of incomplete abortion services by young people, unmarried women and other marginalized groups (rural people, indigenous groups, refugees, IDPs)?

· There are no national statistics on this matter.

· Is physicians and other health professionals training following WHO recommended methods for treatment of incomplete abortion?

· The obstetrician are entitled to handle the incomplete abortion cases.

· Is the country implementing WHO guidance?

· Ministry of health is working on protocols for emergency obstetric care and these protocols are implementing WHO guidance.

Consequences of Unsafe Abortion

· The abortion related maternal mortality [C]

· All the cases of maternal mortality is evaluated by a committee under Ministry of Health’s Mother and Child Care Divison. The results will be obtained from them.

· Magnitude and severity of complications of unsafe abortion

· Is there an established national level mechanism for monitoring and evaluation of maternal mortality and morbidity resulting from unsafe abortion?

· All the maternal mortalities are recorded and analyzed by Ministry of Health .

· Cost of unsafe abortion to the health system, women and families

LEGAL SITUATION OF ABORTION AND REGULATORY FRAMEWORK

International standards

National Laws

· To save the women’s life

· To preserve women’s physical health

· To preserve women’s mental health

· To preserve women’s health (no specification)

· Pregnancy resulting from rape

· Severe fetal malformation

· Socioeconomic reasons

· Women’s choice

Regulatory framework-key elements

Provision of Legal Abortion Services

· Is the law being complied with for each legal indication?

· Yes, abortion on voulantary basis –up to 10 weeks of pregnancy has been legal in Turkey since 1983

· Which methods are used in the country for legal abortion?

· MVA and D&C

· Which is the real availability of those methods for legal abortion services in the public health services, and how much they cost?

· How is the access to legal abortion services by young people, unmarried women and other marginalized groups (rural people, indigenous groups, refugees).

· Is the physician and mid level provider training following the WHO recommended methods for legal abortion?

· Is the country implementing the WHO recommended list of essential medicines that includes mife/miso and essential commodities list of WHO and UNFPA that includes MVA? Are these being used?

· Are FIGO Ethics Committee Recommendations recognized and followed by the OBGYN society? Extend this point.

In situations of restrictive laws:

· Are women being prosecuted and jailed after induced abortion?

· No, induced abortion is legal up to 10 weeks of pregnancy. Induced abortion after 10 weeks can only be performed in the presence of a maternal disease worsened by pregnancy or a fetal abnormality incompatable with life.

· Are health providers/facilities following the ethical principle of confidentiality of health records in the care of women with induced abortion?

· Yes

· What are the consequences for physicians and other health professionals?

· Are professionals being prosecuted and jailed for providing induced abortion?

· No, if the abortions are carried out within legal limits and conditions.

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