Playing grown-ups... or adolescent reproductive health: From free services to lack of information and funding[:]
Too few times is the silence an indicator that things are going well in one area or another. That’s what it looks like when it comes to adolescent reproductive health. As well as having services, we also have taboos and high-level visions that are not always oriented in the same direction. In this material we explain how well the necessary and the useful are combined, what adolescents have and what they lose, and how much more needs to be changed in terms of raising awareness of the importance of reproductive health among minors. Author: Olga Scripnic. 11 July 2023.
Silence with shocking data
In 2022 alone, 1,505 births were registered among girls aged 15 to 19, and 455 girls in the same age group had their pregnancies aborted.
However, the situation does not seem to be that disastrous – although the fertility and abortion rates among minors in Moldova remain higher than the European average, the numbers still show a decrease in recent years, says the head of the youth-friendly health centre “Neovita”, Galina Leșco.
“From 2015 to 2022, the number of births to teenagers aged up to 19 has almost doubled. In 2015, there were 34 births for every 1,000 girls aged 15 to 19. In 2022 – 26 births per 1,000 girls. The abortion rate has fallen by 30% during this period.” We welcome this positive trend, but we still have a lot of work to do. The average number of teenage births in Europe is 15 per 1,000 girls, but in our country it is 26 per 1,000 girls.” – Galina Leșco, head of the “Neovita” Youth Friendly Health Centre.
Another cause for concern is the increasing number of cases of sexually transmitted diseases among adolescent girls.
”Between 2015 and 2020 there was a clear downward trend. In 2021, we saw more cases of syphilis in teenagers and gonorrhoea increased after the pandemic period.” – Galina Leșco, head of the “Neovita” Youth Friendly Health Centre
Translated into numbers, in 2021, 253 young people aged 15 to 34 were infected with human immunodeficiency virus (HIV), which was 18.8% more than in 2020.
At the same time, by age 15, one in four boys (24%) and one in seven girls (14%) report having had sex. And, according to the World Health Organization (WHO) Regional Office for Europe, Moldova falls into the category of countries with the lowest rate of consistent condom use among sexually active 15-year-olds.
But these indicators, even if they leave our country at the bottom, are more encouraging compared to the internal situation in previous years.
”Behavioural studies indicate that from 2014 to 2022 the number of 15-year-old girls using contraceptive pills during last sexual intercourse has almost doubled.”- Galina Leșco, head of the “Neovita” Youth Friendly Health Centre
A study by the Centre for Demographic Research using 2018 data shows that 34% of sexually active girls aged 15-19 use contraception.
Benefits for young people that few know about
There is a national network of Youth Friendly Health Centres in Moldova. Among the services they offer are: confidential sexual health counselling, contraception, testing and treatment of sexually transmitted diseases, family planning and counselling in case of unwanted pregnancy.
“Any girl or boy can come to us who wants to know more about their own development, about their health, including their sexual and reproductive health. We not only provide information, but also offer products such as contraceptives. If a girl does happen to get pregnant, we can help her make a decision, either to have a safe abortion or to keep the pregnancy safe,” explains Galina Leșco.
Any help offered by these youth centres is free for young people up to the age of 24, including contraception and testing.
”Young people can come alone, with their friends, with their parents or even with a referral from their family doctor. All services however are absolutely free for those up to 24 years old, whether medically insured or not. Including for refugees.”- Galina Leșco, head of the “Neovita” Youth Friendly Health Centre
In addition, the centres are committed to maintaining the confidentiality of the people who use their services.
”Even if they are minors, they do not need parental consent. It’s only more complicated when it comes to surgery, such as abortion. In this area, in 2012, when the law on reproductive health was revised, we succeeded in lowering the age limit at which a girl can terminate a pregnancy to 16.” – says the director of the Reproductive Health Training Centre, Rodica Comendant.
In 2022, 168,254 adolescents up to the age of 24 benefited from the services of the Youth Klinik or Youth Friendly Health Centres.
”In 2022 the centers distributed about 300,000 condoms. They provided 12,776 cycles of contraceptive pills. There are also reports of about 1,052 other types of contraceptives, which include emergency contraception, meaning injectables.” – Galina Leșco, head of the Youth Friendly Health Centre “Neovita”
In Moldova there are 41 such centres in each region of the country. Specialists include psychologists, social workers, gynaecologists, urologists-andrologists, dermato-venerologists, HIV/AIDS counsellors.
According to data obtained by the Demographic Research Center, for young people using the services of the Youth Klinik (YK) or Youth Friendly Health Centres, access to condoms is not a problem, but the difficulty is related to socio-cultural perceptions and constraints, fear that they will be condemned by those in their close circle, even parents.
From policies to (non-)implementation
Moldova is a signatory to all international conventions and strategies relevant to sexual and reproductive health. In 2022, the National Programme on Sexual and Reproductive Health and Rights for 2018-2022 was finalised and a new strategy is to be approved.
One of the priorities included in the text of the programme is information about sexual and reproductive health, access to services a person can benefit from and knowledge of their rights. More specifically, it is about:
“the right to sexual and reproductive health education is recognised by law for minors”;
“access to information on family planning and contraceptives, risks of pregnancy at a young age, prevention of HIV/AIDS and other sexually transmitted infections”;
“legislative measures encouraging the mass-media to promote sexual health”.
Even though Moldova is among the first countries in Europe to adopt a new programme on sexual and reproductive health and rights, in 2018, things are a bit different on the other side of the page.
On the one hand, the law on the protection of reproductive health and family planning says that “sex education is compulsory and training for family life is carried out in educational institutions and other institutions where adolescents or young people are present”.
On the other hand, the subject “Health Education and Life Habits”, which promotes healthy lifestyles in compulsory public education, was not adopted by the Government. Since 2012, there are only optional subjects, such as “Health Education” in secondary school and “Family Life Education” – in high school. And since 2012 the subject “Decisions for a healthy way of life” has been introduced into the compulsory curriculum for the first year of studies, the first semester, at vocational schools in the country.
”The introduction into the curriculum has to be quiet and careful, because it is a taboo subject, and against this background smear campaigns and scepticism have a greater impact than the effort to achieve something. It’s an easy thing to discredit the ideea”. – Rodica Comendant, Director of the Reproductive Health Training Centre.
Beyond education, information would not give this topic much success either. The law requires the opinion of the State Public Health Surveillance Service for any mass information campaign and action, education and communication for health promotion and the obligation for advertisers to devote at least 5% of daily advertising time or space to health promotion.
According to the analysis of the implemented programme, we find that these regulations would not be respected. Information and education campaigns through the mass-media to promote a healthy lifestyle and sexual and reproductive health are sporadic. And the budget allocated to health programmes would be almost non-existent.
”I don’t think we have had a strong and serious national information campaign because we don’t get support. And the last experience has shown us that there is no support for promoting these initiatives. There were no budgets allocated for sexual and reproductive health information-education programmes. ”- Rodica Comendant, Director of the Reproductive Health Training Centre
Bottlenecks in the activity of Centres
All these issues, which take shape only at the written level, would in fact be constant impediments to the work of the centres and hamper their efforts.
Due to lack of financial support, it becomes more difficult to facilitate access to the services they offer for more people, it becomes more difficult to reach vulnerable categories of beneficiaries. At the same time, it is more complicated to gain visibility and increase the impact of the actions they are planning.
At the same time, it would also be about funding for the studies and research that are done to monitor behaviours and indicators.
”At the moment, we could perhaps do more, but the money for information and education activities is practically non-existent in the budget. We are looking for help from external partners, we are trying to ensure some outreach, especially in rural areas. A lot of work is still needed there.” – Galina Leșco, Head of the Youth Friendly Health Centre “Neovita”
Another element influencing the quality of reproductive health services is the training of sexual and reproductive health providers (such as family doctors and nurses) in this area, according to the National Programme on Health and sexual and reproductive rights for 2018-2022.
“In order to train and strengthen the capacities of medical staff involved in the provision of sexual and reproductive health services, including family planning, the process of adapting the university and postgraduate curricula, especially the training components for family doctors, and the training curriculum for mid-level medical staff began in 2014,” the document states.
In this context, we note that the development of a standard of conduct for specialists in Youth Friendly Health Centres is in the final stages of implementation.
”Together with the State University of Medicine, we have developed an operational standard of conduct in the case of teenage pregnancy for everyone, starting with the family doctors and ending with specialists in maternity units.” – Galina Leșco, head of the Youth Friendly Health Centre “Neovita”
But the list of priorities would not end there, in order to make these activities more visible. Thus, according to experts, there is a need to implement measures aimed at increasing the level of information and education of the population, including the younger generation, to have safe sexual behaviour. At the same time, there is also a need for a precise strategy of action to guide and clearly regulate the interventions offered by health services.
”We would like to have a strategic plan, specifically dedicated to the health and development of the rising generation, because it would keep all interventions under control and help develop youth-friendly health services, schools promoting sexual health and health services in schools.” – Galina Leșco, Head of the Youth Friendly Health Centre “Neovita”
For young people, but without them
The geographical location of the centers and the activity program of the institutions influence the access of young people to the services they provide. Thus, for the rural population, often with limited financial resources, accessing these “benefits” means travelling to the regional towns or to the capital and incurring additional costs.
”The centers are usually located in the regional center. To get there, teenagers need money, which they don’t ask for from their parents, because sometimes there are confidential aspects they don’t want their parents to know about. ”- Rodica Comendant, Director of the Reproductive Health Training Centre
In this sense, a new model of Youth Klinik (YK) service delivery, called mobile YK, is currently being piloted. It is taking place in Chisinau municipality and Cimislia region and consists of a team of specialists travelling to beneficiaries in areas with a higher degree of vulnerability.
“The medical teams and those providing medical-psychological care, offer rapid HIV, syphilis, and hemoglobin testing. They offer contraceptives, condoms, syndromic treatment, pills, iron supplements. Almost the whole set of services that young people usually benefit from at our centers.” – Galina Leșco, Head of the Youth Friendly Health Centre “Neovita”
However, the problem takes a different level and a reticence is identified, in terms of acceptability of services and their utilisation.
”Sexual and reproductive health topics remain ‘taboo’. It is time for Moldovan society to become aware of the importance of measures to inform and educate the population on sexual and reproductive health, which will prevent risky sexual behaviour, especially among adolescents and young people, which would ultimately contribute to reducing the incidence of infertility in Moldova” – Tatiana Zatîc, Head of Section for Primary and Community Healthcare Policy, said in an interview.
Local communities are not supportive and often “judgmental” about young people seeking sexual and reproductive health services, according to a study by the Demographic Research Centre. In addition to this, fear of lack of confidentiality is one of the factors causing young people’s reluctance to access services offered for their reproductive health.
”Medicine has also been discredited. It affects confidentiality, peer-to-peer attitudes. The doctor is more tempted to moralize than to help, and may pass on the information to parents later. Even if we have a law that says that adolescents have the same sexual and reproductive rights as adults and are free to decide for themselves when to plan their family or their sexual and reproductive lives.” – Rodica Comendant, Director of the Reproductive Health Training Centre
One good, two bad and still an important taboo subject
All along this text, I have mentioned the importance of education and information. To a significant extent, programmes and strategies emphasise the value that education plays in this equation. However, while attempts are made to take action in this direction, they are not explicitly stated and are addressed in a roundabout way.
”One of the most important and primary interventions is ensuring access to education. We would like to see comprehensive or complex health education that includes sexual and reproductive health.” – Galina Leșco, head of the Youth Friendly Health Centre “Neovita”
However, the objectives of specialists concerned with adolescent reproductive health and the objectives of the Ministry of Education and Research seem to construct two different worlds. In May this year, Minister Anatolie Topala, when asked at a press conference whether sex education would be introduced in schools, said that the subject of biology would already contain all the necessary information that children should know, and that there was no need for a separate subject:
“For this we have different subjects in schools that provide both education for society and health education. Including the subject of biology contains information and everything necessary for all children to know and to develop harmoniously.”
”The introduction to the curriculum must be quiet and careful, because in our country it is still a taboo subject. Thus, it’s very hard to get some results in this area and at any small mistake or misunderstanding the decline and regression is super fast. It doesn’t matter what you’ve achieved before.” – Rodica Comendant, Director of the Reproductive Health Training Centre
Progress in this area would not be the responsibility of one single side, but requires the involvement of many factors. Education, access to services and information are equally important. At the moment, in Moldova, these spheres would have opted for paths with too little common ground.
”To make visible changes, interventions are needed in several key areas – comprehensive sexuality education, access to youth-friendly health services and effective communication in the community to raise health awareness and general knowledge about sexual and reproductive health and gender stereotypes.” – Rodica Comendant, Director of the Reproductive Health Training Centre
Moreover, the importance and outcome of these interventions would be reflected in lower fertility rates among underage girls, STD infection and subsequent infertility. All would mean a transcription into practice of the tidy way in which the goals lie on the page.
Contact dates Youth Klinik
Youth Friendly Health Centres are open from Monday to Saturday, 9:00 – 17:00, in all regions of the country.
Phone number, for confidential information or details about the activity – 022-40-66-34.
You can also call the Support Line – “the teenager and youth helpline”, which operates 24 hours a day: 0 800 800 22.
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