Voices from the Partnership

Twenty years on: looking back at MSI’s impact on safe abortion in Romania By Erica Nelson

Executive summary

In December 1989, Nicolae Ceausescu’s dictatorship came to a violent end. Overnight, life changed dramatically for ordinary men and women living in Romania. For decades, women had endured rigidly enforced anti-abortion and anti-family planning legislation. Many had been forced to resort to risky illegal abortion procedures, one in five of which resulted in serious complications or death. Now the newly democratic government made first-term abortion on request and modern contraceptives legal for the first time. This proved to be pivotal moment for both Romanian public health services and for international family planning organisations: Romania’s doctors faced the unprecedented challenge of providing modern safe abortion services and family planning counselling after 24 years of total isolation from developments in sexual and reproductive health.
Weeks after the collapse of Ceausescu’s regime, the London-based reproductive health agency Marie Stopes International (MSI) flew to Bucharest to provide support in the form of safe abortion training and medical supplies. This timely and targeted response provided the impetus for the proliferation of women-friendly abortion and family planning services in Bucharest and helped to reverse the damage done to women’s bodies and lives under Ceausescu.

Introduction

For 24 years, Romanians endured rigidly enforced anti-abortion and anti-family planning legislation under the dictatorial rule of Nicolae Ceausescu.1 His government, with the support of the Orthodox authorities, criminalised abortion in all cases except for these: women with a minimum of four children; women over 45 years of age; women pregnant as a result of rape or incest; and women whose lives were endangered by the pregnancy.1-3 At the same time, Ceausescu banned the importation of modern contraceptives, making the practice of family planning all but impossible. As a consequence of these policies, illegal and unsafe abortions became common practice. Some two-thirds of all abortions were illegally induced; one in five of these resulted in serious complications or death.4 Between 1981 and 1989 the maternal mortality rate nearly doubled, rising from 86 deaths per 100,000 births to 159 deaths per 100,000 births.1 Of those women who survived the complications of unsafe abortion, many suffered severe physical and psychological damage including permanent. sterility3 5

In December 1989, the newly democratic Romanian government legalised first-term abortions and modern contraceptive methods for the first time. Overnight, tens of thousands of women sought treatment for serious complications associated with unsafe abortion. Equal numbers sought safe abortion services for the first time. Lacking adequate medical supplies and with woefully out-of-date training, the country’s public health services struggled to keep up with this huge increase in demand. Within weeks of Ceausescu’s demise, Marie Stopes International (MSI), alongside other international organisations, rushed to fill the gaping holes in Romania’s sexual and reproductive health (SRH) knowledge and services. Beginning in January 1990, MSI and others began to direct much-needed family planning supplies, from condoms to medical equipment, towards Romania’s public health services. 1 The Ministry of Health set up a “Family Planning and Sex Education” division with World Bank funding. This included 11 family planning referral centres and 230 family planning offices.3 The impact on women’s lives was immediate: within two years, the maternal mortality rate dropped two-thirds from 1989 levels, due almost entirely to the 60% drop in abortion-related death.4 After decades of punitive anti-abortion law, one doctor described this transformation as “... like escaping from prison”.

In spite of these immediate improvements to Romanian sexual and reproductive health services, however, the public’s demand for safe abortion far outstripped existing capacity.3 Obstetricians and gynaecologists had little experience of modern safe abortion techniques prior to the change in legalisation. They lacked the training and equipment necessary to provide women-friendly services. As a result, throughout the 1990s, many doctors continued to use unnecessarily traumatic abortion methods and many women continued to rely on abortion as their primary family planning method.

This article illustrates how MSI’s timely response created a ripple effect on safe abortion and family planning practices in Romania’s capital city.

Ceausescu’s anti-abortion legacy: damaged bodies and damaged lives

In order to capture this pivotal moment in history, MSI travelled to Bucharest in January 2009 – 20 years after the fall of Ceausescu – to interview key staff members and doctors involved in the early days of MSI’s Bucharest clinic.

Many of the doctors who work today at the MSI clinic in central Bucharest began their professional careers during the communist period. Dr. Silvia Niculescu and Dr. Virginia Ionescu, for example, spent their first decade as obstetrician/gynaecologists under the close watch of the state police. In Dr. Ionescu’s case, she worked within the confines of Ceausescu’s rigid policies for 18 years, providing abortions only in cases of extreme medical emergency. Speaking of her experience, she emphasised the incredible stress and pressure that she and her patients suffered:

“Women would find methods to self-abort and then we would have to finish what they started and report them to the hospital police. Many women came to the hospitals too late, with advanced complications. A lot of them were forced to have hysterectomies and in many cases they died. Those who had hysterectomies were often very young women…their reproductive lives were over.”

Like her colleague, Dr. Silvia Niculescu recalled with horror the many emergency hysterectomies she performed on women who were dangerously ill following unsafe abortions. Worse still than those patients left sterile were the women who arrived at the hospital too late to be saved. As Dr. Niculescu explained:

“They were terrified of being punished, of their families finding out what they had done. Some women were able to get abortions from ‘back alley’ providers, but these people didn’t have the right tools, they weren’t working in sterile environments. Sometimes even the nurses at the state hospitals would do abortions on the side, but most doctors would not take the risk because you could easily lose your practice. So women would try to self-abort using vinegars, or taking medical ‘cocktails’, or by puncturing themselves with knitting needles, jumping belly-first into cold water, all sorts of things…I don’t want to remember those days, or those mutilated women.”

Dr. Ionescu and Dr. Niculescu were just two of many Romanian doctors put in the difficult position of providing emergency-only care to the victims of unsafe abortion. The total crackdown on modern contraceptive methods and legal abortion pushed women to take extreme health risks in order to terminate unwanted pregnancies. The extent to which the state achieved control over women’s reproductive lives made post-abortion emergency hospital visits the norm rather than the exception. Though the full impact of Ceausescu’s rigidly enforced anti-abortion and anti-contraceptive policies was not revealed until after 1989, the collateral damage became apparent as early as 1970 with the discovery of a substantial increase in Romania’s abortion-related maternal mortality rates.6 Of the 315 abortion-related deaths recorded that year, only one could be attributed to a legally provided service.6 According to anecdotal evidence, Romanian women had accessed illegal and unsafe abortions on a massive scale throughout the 1966 to 1989 period, in large part provided by ill-equipped and untrained non-medical providers.7 On behalf of a documentary project, MSI Romania clients testified to the horrors of unsafe abortion during this period. They shared stories of procedures carried out on their family kitchen tables; procedures performed by the local village mechanic; and procedures resulting in the deaths of loved ones.

As a representative of MSI, (and current Chairman of the Board), Dr. Tim Rutter first visited Bucharest in January 1990. There he came face to face with the huge amount of damage inflicted on women under Ceausescu’s rule. His field notes reveal a state of shock at discovering the backlog of patients at Bucharest’s public maternity hospitals. At one hospital, he reported, “fifty patients a week are still being admitted with complications from self-induced abortions. A mother of two, waiting for an operation, was asked why she had not come to the hospital first. ‘I didn’t want to believe it was true,’ she said. Thirty minutes later, her damaged uterus was removed.”

During Dr. Rutter’s visit, an official from the Ministry of Health estimated that one in four women between the ages of 15–49 in Bucharest suffered some form of injury following an illegal abortion. Both public hospitals he visited reported waiting lists of up to 10,000 patients for treatment of sterility caused by unsafe abortions.

Faced with two generations of physically and psychologically scarred women, Romanian public health services confronted an enormous challenge: where to begin the rehabilitation of sexual and reproductive health services?

Dr. Rutter’s reconnaissance revealed a medical community eager to address the significant gaps in safe abortion and family planning knowledge and training. In his trip field notes he wrote, “the doctors know their [abortion] methods are out-dated, more expensive and more risky than necessary.” MSI decided to provide basic training and supplies with the aim of encouraging affordable and comprehensive sexual and reproductive health services. Within weeks, MSI returned to Romania with funding from the Wellcome Trust to recruit participants for an innovative safe abortion training-exchange programme.

Safe abortion and family planning: sharing best practice

In February 1990, MSI first contacted Dr. Niculescu, head of the Bucur public hospital’s maternity division in central Bucharest. She explained her facility’s lack of up-to-date safe abortion equipment to the visiting representative. Dr. Niculescu was shocked when MSI returned the very next day with the necessary supplies in hand.

This same scenario played out at all of the major public maternity hospitals in Bucharest, Iasi-Moldova and Transilvania as MSI sought out leading public health physicians to participate in safe abortion training. Throughout the course of this initial recruitment period, MSI representatives delivered safe abortion supplies to the hospitals they visited, generating interest in MSI’s family planning expertise and giving on-site demonstrations of the latest techniques. By April, Dr. Rutter and his colleagues had signed up 16 doctors for a one-month theoretical family planning and safe-abortion course in London.

This initial training project proved to be the impetus for a formal and informal expansion of safe abortion and family planning best practice in Romania. Dr. Niculescu said, “the idea was to disseminate the information and the new techniques as widely as possible in Romania”. After completing the course, these doctors returned to their public maternity posts where they shared their safe abortion training and quickly multiplied the impact of MSI’s intervention. They invited colleagues to take part in on-site demonstrations, thus bringing greater numbers of practitioners up-to-date on modern safe abortion practices. According to Dr. Ionescu, who was working at the Bucur maternity hospital at the time, MSI’s provision of safe abortion equipment helped expand technical expertise beyond the highest level doctors who previously monopolised access to limited supplies.

Unfortunately, it was at precisely this early moment in MSI’s efforts that the project ran out of money. While the trainees continued to provide informal training to colleagues at public maternity hospitals like Bucur, MSI could no longer support the large-scale safe abortion workshops necessary to reach a national audience of obstetricians and gynaecologists.

At the same time, the British embassy in Romania received a donation of one million condoms. MSI was given permission to sell them, having arranged contracts with local retail outlets throughout the country. MSI used the profits as capital for the foundation of the first MSI clinic in Romania , which opened in 1991. As the inaugural private provider of safe abortion services and modern contraceptives in Bucharest, the MSI clinic gave many Romanian women the opportunity to experience comprehensive family planning services for the first time.

Opening the door to client-friendly services

The foundation of an MSI clinic in Bucharest served an immediate demand for safe abortion services. In the first five years, on average 900 women came through the clinic doors every month. According to Dr. Niculescu this was a “staggering number”. In 1996, Dr. Beatrice Dinulescu joined the MSI team as a dedicated family planning counsellor. Dr. Dinulescu’s comprehensive contraceptive counselling stood in direct contrast to the limited family planning services offered by the public maternity hospitals.8

MSI was the first private clinic in Bucharest to use vacuum aspiration abortion techniques, a significantly less traumatic method in comparison with traditional dilatation & curettage (the so-called “scraping method”). When Dr. Monica Dunarintu joined MSI later that year, she was astounded by client demand: “Everyone wanted to come and see what it was like to get an abortion at a nice, private clinic, at a reasonable price, with excellent conditions, and where you would be treated as a person.” Client numbers rose dramatically due to the reputation of MSI’s quality and client-centred services in the first five years of services. These numbers later declined with the increase in private safe abortion clinics and the improvement in public health abortion services (see Graph 1).

Graph 1 



Initially, there were queues stretching onto the pavement and non-stop phone enquiries. According to lead receptionist Laura Bobaru:

“Most women came on recommendation from their friends. They knew they could get anaesthesia and that they would not feel anything when getting the abortion, which is what they wanted. Hospitals at the time were still using the curette – the scraping method, and women were terrified of the horrible metallic sound. So women came from all over the area to MSRF for services, including from the countryside.”

Similarly, Dr. Dunarintu reported that:

“There was a tremendous difference between the doctors who worked at MSRF and those that worked in the public hospitals in that we were, and are, much more client-focused. Here at MSRF all of our supplies are fresh for each client, but in hospitals this is not always the case. They don’t always have the syringes on hand in hospitals to do abortions and they have to use older equipment.”

What Ms. Bobaru witnessed from the receptionist’s desk, and Dr. Dunarintu from the operating table, tallies with the findings from studies on post-Ceausescu abortion service provision. In 1996, one study confirmed that many Romanian women had no experience of legal abortion beyond the overburdened public health facilities, which in most cases meant non-anaesthetic “scraping method” abortions and open-plan recovery areas.2 Similarly, a 2004 report found that the majority of abortion providers continued to rely on unnecessarily traumatic and out-of-date abortion techniques.8 Yet, when surveyed, Romanian women stated clear preferences for “quick but gentle” abortions provided with minimal invasiveness and maximum pain relief.2

The impact of MSI’s pioneering use of up-to-date safe abortion techniques reverberated throughout the public health community. Throughout the 1990s Dr. Niculescu regularly invited her colleagues from Bucharest’s public maternity hospitals to come to the clinic for technical training. In the afternoons, a rotation of visiting doctors brought clients to the clinic to practice their technique under the supervision of MSI’s experts. In this way, MSI functioned as a training site for obstetricians and gynaecologists eager to perfect their modern safe abortion techniques.

MSI continued to serve as a technical training site well into the mid-nineties, providing on-site demonstrations with the arrival of new safe abortion equipment. Without expanding services beyond the Bucharest clinic, MSI was able to achieve a ripple effect in terms of safe abortion expertise and practice.

Conclusion

Twenty years ago, the legalisation of abortion provided MSI with an opportunity to play a catalytic role in the dramatic improvement of safe abortion and family planning practices. MSI’s arrival in Bucharest came at a pivotal moment when doctors faced the challenge of providing modern safe abortion services for the first time. As a doctor under communist rule Dr. Niculescu explained that she had to “contend with so much fear on both sides – the client’s fears and your fears. Now suddenly people could speak freely about issues that they couldn’t even talk about before. MSI used this openness to create momentum within Romania’s medical community for the adoption of modern safe abortion and family planning practices, and helped to reverse the damage caused by 24 years of Ceausescu’s restrictive policies.

Since 1991, MSI has continued to make a positive impact on tens of thousands of Romanian women’s lives. To this day, the MSI clinic in Bucharest provides comprehensive sexual and reproductive health services, including some 3,600 safe abortions in 2008 alone. Between 1990 and 2002, thanks to the work of organisations like MSI, the number of maternal deaths in Romania attributed to unsafe abortion has dropped significantly. The stories of those who lived within the prison of Ceausescu’s regime remind us of the importance of reproductive choice and the challenges that remain when freedom of choice is first established. It is one thing to make it legally possible for women to exercise control over their bodies, but quite another to provide the necessary technical and logistical support to countries to make this a reality. Twenty years on, safe abortion remains out of reach for many of the world’s women. Let us hope that in twenty more, through the work of MSI and the global sexual and reproductive health community, this is no longer the case.


Key Contact

Cornelia Francisc

Programme Director
Marie Stopes Foundation Romania
3A Bucur Street
Bucharest
Romania

Tel: +40 21 330 15 36
Fax: +40 21 330 23 30
Email: pd@stopes.ro  
Website: www.mariestopes.ro  



References

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3. Johnson BR, Horga M, Fajans P. A strategic assessment of abortion and contraception in Romania. Reprod Health Matters 2004;12(24 Suppl):184-94.
4. Remez L. Romanian Maternal Death Rate Fell by Two-Thirds After the 1989 Revolution. Family Planning Perspectives 1995;27(6):263-65.
5. Baban A, David HP. Voices of Romanian Women: Perceptions of Sexuality, Reproductive Behavior, and Partner Relations During the Ceausescu Era: Transnational Family Research Institute and the Center for Development and Population Activities, 1994.
6. International Family Planning Digest. Delegalization of Abortion in Romania Led to Increased Rates of Infant, Maternal Mortality. International Family Planning Digest 1975;1(2):12 - 13.
7. Lambert A. The misery of women denied a basic choice; Abortion was a crime in Romania for 20 years: Dr. Tim Rutter tells Angela Lambert of the suffering it caused. The Independent 1990.
8. World Health Organization. Abortion and Contraception in Romania: A Strategic Assessment of Policy, Programme and Research Issues. 2004.