Postgraduate Training Course in Reproductive Health/Chronic Disease

Reproductive Health in Albania

Review prepared for the 12th Postgraduate Course in Reproductive Medicine and Biology, Geneva, Switzerland

Aulona Gaba MD
Tirana University Maternity Hospital
Tutors: Aldo Campana, Genc Kabili
2003

See alsopresentation

Introduction, background and demographic data

Albania is situated in the western part of the Balkan Peninsula. It shares borders with former Yugoslavia (Montenegro and Kosovo) in the North and Northeast, with Greece in the South and Southeast, and has an extensive coastline on the Adriatic and Ionian Sea. Significant social, economical and political changes have taken place in Albania since 1990 and the country is now set on a course of democracy, institutional reforms and a free market economy.
During the last 10 years e major changes took place. The transition years had an impact in every aspect of life: economical, political and social. The various Government programs during the transition period are supported by a number of international donors. Economic differences within the population have increased and about 30 % of the population is considered to be poor. Health and social services are particularly facing an increased demand for services, improved institutions and quality of care.
In addition, the Kosovo crisis in early 1999, with its massive influx of refugees into Albania, seriously strained the already overburdened economic situation especially within the health sector. Within a few weeks, the number of refugees reached over 14% of Albania’s total population.
Given the high prevalence of abortion, and in the light of the widespread unmet need for reproductive health information and services and the limited resources available, there is a need for a holistic approach to reproductive health (RH) care.

Objectives

• To assess the situation of reproductive health in Albania from 1990 on, and the factors that have contributed to these changes.

• To assess the impact of family planning in the reduction of abortion rate and/or maternal and child mortality.

• To assess the implementation of family planning methods in Albania.

• To identify the short and long term objectives in improving the current indicators of reproductive health.

Methods

There is a lack of Albanian publications in medical journals. This may be due to the difficult economical situation.
Most of the demographic information was considered a state secret until 1991 when a historical time series was published in the statistical yearbook (Albania, Institute of Statistics, 1991) and a Population Studies Unit was established in the Faculty of Economics of the University of Tirana.
We searched in Medline, using the term “Albania” which resulted in 347 matches. The majority of articles was not relevant; only 6 articles were included in this review.
The same search in Popline resulted in 256 matches; 13 articles were relevant to be assessed for this review.
The Ministry of Health in Albania was asked to provide data, and some relevant information has been received. Other sources were UNICEF, UNFPA, PHARE, AFPA, MSI, WHO, WHO region for Europe and pharmaceutical companies.
By personal communication, drafts, projects and data (some of them previously unpublished) were obtained from the Ministry of Health (MoH) and WHO.

Reproductive Health in Albania

1. Definitions of RH periods

1.1 Period of pre-reproductive health, which corresponds to adolescent age;

1.2 Period of reproductive health which includes:

1.2.1 Maternal period: prenatal, delivery, postnatal, postpartum and breast-feeding period

1.2.2 Interval between deliveries;

1.3 Period of post-reproductive health, which corresponds to menopause and andropause time

2. Structure of RH

2.1. RH as a concept does not necessarily need an independent structure (building, services, personnel). The concept should be integrated into different services by training the concerned medical personnel.

2.2. Vertical approaches to solve health care problems have been shown to be less cost-effective and less equitable than an integrated approach. Different elements of RH are closely linked and therefore elements like STD/AIDS prevention, FP, abortion, sterility, neonatal care, delivery and breastfeeding, cannot be considered separately. Integration and an overall understanding of RH are essential.

2.3. Central registration and orientation of clients towards different parts of the service.

2.3.1 First level care

2.3.1.1 Ambulances in rural zones

2.3.1.2 Public run health centers in rural zones

2.3.1.3 General Practitioner or Family Physician

2.3.1.4 Mother and Child consulting centers in districts.

2.3.2 Second level Care

2.3.2.1 District Maternities and Pediatric Hospitals

2.3.3 Third level Care

2.3.3.1 University Hospital of OB/GYN

2.3.3.2 University Level of Pediatrics

2.4. Who is concerned with RH elements?

2.4.1. Public Health Institutions

2.4.1.1. Primary Health Care directorate

2.4.1.2. Hospital Care directorate

2.4.1.3. Institute of Public Health (IPH)

2.4.2. Public Education Institutions

2.4.2.1. Ministry of Education

2.4.2.2. Medical Faculty of the University of Tirana, Department of OB/GYN.

2.4.3. Private Sector

2.4.3.1. Gynecologists

2.4.3.2. Pediatricians

2.4.3.3. Family physicians

2.4.3.4. Druggists

2.4.3.5. Different NGOs

3. Situation of RH components in Albania

3.1. Reproductive Health in Adolescents.

3.2. Mother health and Safe Pregnancy

3.3. Family planning

3.4. Newborn care.

3.5. Child health and development

3.6. Sexual health care.

3.7. Post-reproductive health.

3.8. Genital Cancer and Care.

3.1 Adolescent Care

This is a defined priority of RH in Albania, which needs to be properly addressed. Although sexual education has been introduced in the schools, its level remains quite low. The Ministry of Health and the Ministry of Education, in Collaboration with UNFPA, have organized a number of seminars and workshops in different cities.
After 1990 the overall number of pregnancies increased significantly. In 1994, 3.6% of the abortions were performed in girls 13-19 years old (2). Forty-five percent of the adolescents undergoing an abortion had an elementary school education, 48% had attended the high school. Only few of them, 2.9%, were undergraduate students.

Source: Health for All database

The information provided by mass media is often non professional and inadequate. Reproductive health information, education, and communication (IEC) materials have been produced; however the design of a National IEC strategy on RH, which has been identified as an important need, still remains incomplete.

3.2 Mother health and safe pregnancy.

There is inadequate data collection on reproductive health. A comprehensive study of current maternal and child health (MCH) conditions in Albania indicates there have been considerable improvements since democratization (12). Pre-1990 MCH statistics are considered unreliable due to pressures by the socialist government to falsify data (12).
The ongoing 2002-2003 Reproductive Health Survey (USAID/CDC Atlanta, UNFPA, UNICEF) implemented by the Institute of Public Health and INSTAT (National Institute of Statistics), should provide interesting new and additional information on these important issues.
It has been assumed that the decrease of maternal mortality was primarily due to the legalization and liberalization of abortion in 1991. For the period 1989-1992, unsafe abortions accounted for 36% of maternal deaths (25). Abortions became safer but there is no clear indication for a decrease in the abortion rate. Official data may not reflect the real figures, because of underreporting. Maternal deaths from abortions show a decrease and occur mainly with pregnancies terminated above 12 weeks.

Source: MoH/ Statistical Department; National Health Strategy Document

Maternal Mortality per 100 000 live births

Source: Ministry of Health, Albania

To reduce maternal and perinatal mortality, the Albanian MoH aims to improve reproductive health activities through national Safe Motherhood action plans. Considering cost effectiveness as the basic selection criteria, Reproductive Health is listed among the first priorities of primary health care services.
Antenatal care is provided in all Health Care Centres and in 67% of the Hospitals. In the facilities surveyed (3), the geographical access to neonatal care facilities is good; the travel time from home to the clinic is 18 minutes on average. This cannot be generalized to the whole country because the selected districts have a health care system that is better, in terms of access, than the national average. Also some remote districts were excluded a priori from the survey for security reasons. There is insufficient communication and transfer of information between hospitals and polyclinics. Antenatal cards are kept in the facilities, and the hospital delivery records carry no antenatal care information. The antenatal records used are not standardized. Guidelines are available only in a minority of facilities. During the past antenatal visit, iron supplementation was given to about 25% of the women, and a blood sample was drawn in 83%. Only 58% of women reported being told about warning signs during pregnancy. The average number of antenatal visits according to the MoH is 5.1. Ninety-two percent of the deliveries occur in health care facilities and 6.5% at home (data from 2000); 0.2% of all deliveries are not assisted by trained personnel (MoH, Department of Statistics).

Timing of the first antenatal visit as regarding the trimesters of pregnancy:

First trimester	18%
Second trimester	45%
Third trimester	37%

Source: KAPB Survey 1999 Multi agency survey, UNFPA, USAID, UNICEF etc.

Knowledge of antenatal clients of warning signs or problems during pregnancy.

Warning sign	Total
Previous bad obstetric history/abdominal scar, previous stillbirth	23%
Hypertension/headache/swelling/fits	68%
Anemia/pallor/fatigue/breathlessness	28%
Cessation of fetal movement/ baby does not move	30%
Abnormal lie/position of fetus	14%
Sepsis/foul smelling discharge/postpartum abdominal pain	35%
A=Light bleeding/spotting	32%
Hemorrhage/heavy bleeding	72%
Multiple pregnancy/large abdomen	5%
Obstructed /prolonged labor/ “sun set two times”	4%
Persistent headache, swelling, etc.	2%

Source: Safe Motherhood needs assessment in Albania, 1999, UNFPA, WHO

Source: Health for All Database

Percentage of women listed by the level of antenatal care they have received (data from 2000).

Source: Safe Motherhood needs assessment in Albania, 1999, UNFPA, WHO

Clean and safe delivery: In the health facilities surveyed (3), doctors attend deliveries in 78% and nurses in 22% of cases. Five indicators of performance and standard practices during delivery care are shown in the table below:

Source: Safe Motherhood needs Assessment in Albania, 1999, UNFPA, WHO

Some of these practices may have been carried out without being recorded. Midwives are not allowed to write in the clinical records, even if they clinically assess the patients. The WHO partogram is not used at all.

S/C per 1000 live births

Source: INSTAT

Timing of the first visit post delivery

During the first week	During the first 6 weeks	Only if the mother has problems	Never
59%	3%	16%	22%

Source: Safe Motherhood needs assessment, 1999, UNFPA, WHO.

3. Newborn care and 4. Child Health and Development

The perinatal mortality rate has increased significantly from 1991 to 1995, early postnatal mortality from 4.8% to 8.0% and late postnatal mortality from 8.6% to 11.3%. Neonatal mortality accounted for 27.6% of infant mortality in 1991, and this was increased in 1997 to 46.5%. The actual rate is still above the target set of 12 per 1000 live births. Data on perinatal mortality, especially for 1992/1993 may not be reliable. It is important to note the fact that early postnatal mortality (0-6 days) in 1997 accounts for 33.4% of infant mortality and late postnatal mortality (7-27 days) for 13.1% of it. The increased neonatal mortality may be due to the inadequate low technical level of medical personnel and their equipment in rural maternities and the lack of prenatal assessment.

Infant and perinatal mortality rates

Source: MoH

Infant mortality according to different causes:

Source :MoH and Environmental Protection

Breast-feeding.

The initiative of a baby-friendly hospital in Albania is progressing fast. UNICEF and different NGOs have collaborated in preparing these programs.

Year	1998	2001
Exclusive breastfeeding at 4 months	33%	52.4%
Exclusive breastfeeding at 6 months.	17.5%	43.6%

Source: MoH and Environmental Protection

Under 5 years old Children Mortality Rate

Source: MoH and Environmental protection

1-4 years old children mortality, according to different causes:

Source: MoH and Environmental Protection

Vaccination Coverage (DTP3) trends

1985	1990	1995	2000
96.0	94.0	97.0	97.0

Source: WHO/global summary

5. Family planning

Traditionally, there was a positive attitude towards childbearing during the communist regime (12). At the end of the Second World War Albania had the highest fertility rate in Europe with an average of more than 6 live births per woman (20). However, in 1990 fertility had fallen to three children per woman (20). Albania reported the youngest age-structure in Europe, with nearly 35% of the population below the age of 15.
After Family Planning services became available throughout Albania, a trend in decreasing fertility rate has been observed. IEC activities have included translating handbooks for health personnel and publishing an information leaflet on contraceptive methods. The primary aim of the National FP program is still in discovering ways to inform the population about birth control and contraceptive methods (5). National data on family planning for Albania were first reported in 1992. Many specialists and midwives participated in fellowship programs abroad and in training courses in Albania. But there was no assessment tool available to evaluate the knowledge, attitude and practice of the health care providers. Having adopted the Plan of Action of the International Conference on Population Development (Cairo 1994), the Albanian Government committed itself to a new population policy and the concept of reproductive and sexual health. New IEC initiatives and the family planning program approved by the Government in 1992, as well as the services established, have contributed to improve women’s health (27).
In 1995 the MoH, the Academy of Science and UNFPA as a follow-up of the Cairo Programme of Action organized the first National Conference of Population and Development. This was the first opportunity to discuss family planning issues within a wider auditorium and in public. The Conference documentation was published in August 1996. Now family planning services are available all over the country in all the hospitals and most of the health care centres.

5.1 Preconceptive counseling is at the very first steps in Albania. Most couples are not aware that such a possibility exists.

5.2 Safe Abortion

It is worth emphasizing that although the legalization of abortion had a positive impact on reducing the number of deaths, the conditions under which abortions are performed often do not reach minimum standards required. Although abortion was legalized in 1995, and has influenced maternal morbidity, abortion rates remain still high, representing one of the “classical” methods used for family planning purposes.
The number of sterilizations performed are insignificant (26).

Source:INSTAT (http://www.instat.gov.al/Tabelat/LDV/LDV07.html)

Recently safer abortion methods have been implemented, such as the manual vacuum aspiration (MVA) and electric vacuum aspiration (VA). VA has been available in Albania for the last 8 years, at the tertiary care hospitals, at some secondary maternities and at some private clinics. A number of different seminars have been held throughout Albania in order to train the clinicians and health care providers. Although there is no solid evidence of the superiority of VA over dilatation and curettage (D&C) (14), there is no evidence of inferiority of one of these techniques either.
Medical abortion methods such as mifepristone in combination with prostaglandins are currently not used in Albania. At Tirana University Hospital a premarketing acceptability trial for RU-486 is ongoing.
During the second trimester of pregnancy (14-21 weeks), the most widely used technique is the intrauterine installation of hypertonic solutions (NaCl 20%), uterotonics, dilapan and/or instrumental evacuation. (8)
In the second trimester of pregnancy the complications and the side effects are higher (heavy blood loss, uterine perforation, injury to organs, disseminated intravascular coagulation). These techniques are not available at all secondary level maternities of our country, so the patients are referred from districts to the tertiary level hospitals, or to 2-3 other secondary level maternities. (8)
Prostaglandins are being used since the last few years, and the results are promising. No available solid data at the moment for the prevalence of prostaglandins use in the second trimester of pregnancy.
It is important to note that about 68 % of second trimester abortions are performed for gender reasons. About 20% of women are not married, about 12 % are congenital malformations or missed abortion and 2-3% have other medical reasons for interrupting the pregnancy. (8)
The main modern FP-methods have been made available all over Albania. Until 1995, the contraceptives were distributed to and sold through the public pharmacies. When pharmacies became privatized in 1995, access to contraceptives decreased through higher retail prices. By order of the Ministry of Health, contraceptives were distributed free of charge through the FP facilities themselves, starting in January 1996. This had a positive influence on the utilization of the FP facilities and the access to modern contraceptives. On the other side, the distribution of contraceptives free of charge, would limit the sustainability of the FP services, especially when it comes to future finance of FP activities and contraceptives.
Data on the use of contraceptives are available since1996. The estimated contraceptive prevalence rate (CPR) of the first six months of 1996, (data from 28 of 36 districts), indicates that the use of contraceptives may not exceed 5 per cent. An additional difficulty in calculating the CPR was the unclear number of the target population per district or covered by FP facility. An increase in the use of oral contraceptives and injectable methods during 1995-1996 has been observed, while IUDs were no longer the most preferred method. The age group of 30-34 years accounts for 35% of total contraceptive users, followed by the age group of 25-29 with 24.9, while adolescents represent only 2% of the contraceptive users.
From mid 1992 to 1995 contraceptives (except condoms) were imported nearly exclusively through UNFPA and IPPF.
In the public FP-facilities contraceptives are given free of charge. There is no effective monitoring or control system for storage, consumption needs and demand of contraceptives, neither in the different districts, nor at the central level.
One study examined the knowledge, attitude and practices of family planning methods in Albania. Data were obtained from 8 focus groups discussions, which included married and postpartum women, unmarried university students, and women who had recent abortions. Some women knew about condoms, oral pills or injectables but did not know details about the different methods. The main constraint for using FP was lack of information, followed by mistrust about safety. Many women interviewed were unemployed and had cost concerns. Few were aware that raising a child or having an abortion were more expensive than FP cost. (23)
Most couples rely on natural methods (withdrawal or abstinence) (16)
The unmet needs in family planning were first estimated in 1996 on the basis of several hypotheses and demonstrated that the contraceptive needs of about 40% of women at reproductive age (WRA) are not met. Men were not sufficiently involved in RH and FP issues. (24) FP services, which are normally situated in maternity hospitals, and MCH services are not consulted by men. Unmet needs for family planning of WRA in Albania, 2000 were estimated to be around 52.84% (2).

Contraceptive methods in Albania.

Source: MoH http://www.instat.gov.al/TABELAT/SHN/SHN09.html

Family planning programs provide a wide range of contraceptive choices. Combined oral contraceptives, progestin-only pills, emergency contraception, depot medroxyprogesterone acetate, copper IUD, progestin IUD, condoms, female barrier methods, spermicids, vaginal rings. The wider selection of these methods is aiming to meet the needs of more women at reproductive age.

The trend of total fertility rate through the years

Source: Health for All Database. http://hfadb.who.dk/

There is no solid data about the contraceptive prevalence rate. The estimation of 1996 found that the contraceptive prevalence rate was 8%of the total population or 5%of the married WRA (24), while other data from MoH states that in 1996 the contraceptive prevalence was 8.27 in 1994, 10.9 in 1996 and 11.6 in 1998.

6.Care for sexual health

In Albania it was taboo to discuss sexual practices and behaviour for over 50 years during the communist regime and was absent from the medical literature (5). Until recently there was little sexual education. Discussing sex was traditionally considered immoral. There were no efforts to promote responsible reproductive behaviour. To strengthen resources for teenagers, students at Tirana University established a Student Organization for the Propagation of Sexual Education in 1993. (15). An increase in the occurrence of STDs emerged over the last years (22).
In Albania the first case of HIV infection was detected in 1993. The number of HIV cases is increasing slowly every year to 39 in 1997. The Epidemiological Sector, the Sector of Statistics in MoH and the Institute of Public Health (IPH), collects data on STDs/HIV.
Sexually transmitted infections have, during the last two decades shown a trend of change from traditional venereal diseases, like syphilis and gonorrhoea, to bacterial and viral infections including chlamydia and herpes. Morbidity resulting from STI’s continues to be a major problem including chronic and birth infections such as pelvic inflammatory diseases and congenital syphilis.
According to the Institute of Public Health recent data show that syphilis is increasing. Other non-traditional STIs have been found and the prevalence among the studied population seems to be high. Other surveys show that about 80% of women need more information about STIs (and may be assumed that the situation is similar among men.)
Of the reported STIs, syphilis and gonorrhoea remain the most common, although the exact magnitude of the problem remains unknown. Due to a non-functional reporting system, no reliable data exist on the country situation. Up to 1995 no syphilis cases had been reported in Albania during the last 40 years. Despite the positive aspect, this had a negative influence in keeping alive the surveillance system. As a result the specialized services and service providers gradually ceased to exist.
On the other sides the syphilis testing and syphilis test kits are not available in the health care services.
There are some attempts to include STIs within the primary health care services by introducing the syndromic or symptomatic approach in STI case management, but no guidelines or protocols on standard treatment procedures and counselling have been developed so far.
HIV/AIDS
Data collected by the Program against AIDS (Institute of Public Health-IPH) suggest that the first case appeared in Albania in 1993. At the end of July 2000, 49 cases had been reported in Albania, 11 went on to develop AIDS. At the end of 2001 the number of HIV positive cases reported was doubled, the total cases being 74, of which 26 have developed AIDS.
The predominant mode of transmission has been sexual (up to 90%-mainly heterosexual and homo/bisexual). The predominant age has been 20-35 (80%), the majority are men, who are a largely “mobile” population, travelling abroad for work and intermittently returning to Albania.
HIV positive women are mostly commercial sex workers. There is a wide geographical distribution of cases. This data has been collected through a passive surveillance mainly from blood banks, hospitals and a few numbers of volunteers. A sentinel surveillance site has been established in Tirana but supplies are lacking, and it is difficult to see trends.
Until November 2002 there were 89 detected HIV-positive cases in Albania, though it is estimated that the actual number is between several hundreds to one thousand people. During the last two years the number of HIV positive individuals is steadily increasing. In 2002, 60% of the new cases are women, compared to 15% the previous year. The number of voluntary testing has increased this year from 20%-40%.
Albania is still listed in the countries with the lowest prevalence of HIV/AIDS despite the tendency of growth in recent years. The transmission routes are mainly heterosexual. There are no cases of transmission via blood products or services recorded since 1996.
One of the most important strategies for reducing the rate of HIV/AIDS infection is the promotion of accurate knowledge of how AIDS is transmitted and how to prevent transmission.
Women in the MICS survey were given several statements about the means of HIV/AIDS transmission and asked to state whether they believed the statements were true. 55% believed that having only one uninfected partner sex partner can prevent HIV transmission. 42% believed that using a condom every time one has sex can prevent HIV transmission and 32% agreed that abstaining from sex prevents HIV transmission. Overall, 25% knew all three ways and 60 % were aware of at least one of the means of preventing transmission
A survey, jointly funded by various UN agencies in Albania, was finally completed at the end of 2000. The results show that the concept of safer sex behaviour remains far from reality in today’s Albania. Furthermore, according to some focus group studies conducted by NGOs only about 5% of the sexually active population uses condoms, and even then do so infrequently. The groups or communities exposed to a greater risk seem to be young people in general, particularly those involved in prostitution, drug use and illegal migration. (22,23)
The STI/HIV/AIDS behaviour patterns and trends in Albania appear to indicate a slow but steadily growing trend towards a future epidemic. The social and economic changes include economically forced migration, trafficking in women mainly for sexual exploitation, drug abuse and general social and family disruption. These, combined with the sudden liberalization of sexual behaviour and lack of sexual education, place new and difficult challenges on health in general and sexual/reproductive health in particular.
A study, conducted to assess the knowledge and attitude of undergraduate students in Tirana, Albania, towards STI showed that parental education and origin were strongly associated with knowledge, attitude towards STI and consistent condom use (9.11).

7. Post reproductive Health

So far the care for prevention and treatment of menopause disorders remains spontaneous and without national coordination. The number of women seeking treatment has increased but the actual number of woman receiving treatment remains very low.

8. Genital Cancer and Care

Early screening of breast and cervical cancer is performed in specialized polyclinics, in gynaecological hospitals and in services of gynaecological oncology. The service for prevention of genital cancer is not yet organized at first, second or third level services.

SDR, cancers all ages per 100 000

Source: INSTAT

Conclusions

Regarding adolescent health care it can be concluded that after an increase in the number of abortions occurring in the early ’90, probably due to a liberalization of sexual behaviour and legalization of abortion, there is a trend towards a later decrease. There is no satisfactory level of knowledge of risk behaviours and family planning methods among the adolescents.
It has been assumed that the decrease of maternal mortality was primarily due to the legalization and liberalization of abortion in 1991. Abortions became safer but there is no clear sign for a decrease in the abortion rate. The data showing a decrease in abortion rate are not reliable. Official data may not reflect the real figures, because of the number of abortions done privately and are not reported is increasing
There has been a reduction in maternal deaths but it still remains one of the highest in Europe. From 1991 to 1996 maternal mortality decreased by 25% and reached a level of under 30/ 100 000 live births. Most recent data show maternal mortality at 20/100 000 live births in 1999 (compared to 1997, when it was 27.5 per 100 000 live births. The major causes of maternal deaths are constituted by indirect obstetric death. Maternal and infant death, represent still an important proportion of the burden of mortality. The average figures in rural areas are higher. Poor access to emergency obstetric care, long distances and very poor condition of the roads, along with the poor quality of basic services and the unhygienic conditions contribute to the high figures of maternal mortality.
Infant mortality shows a decreasing trend but still remains the highest in Europe. There has been a noticeable increase in neonatal mortality in the mid 1990s.
The mortality from diarrhoea has decreased slightly but not significantly. The higher prevalence of breast-feeding may have contributed to this finding.
Almost every woman in Albania seems to receive antenatal care but there are big differences in the quality of care delivered among facilities. At present prenatal care is nearly universal, as women must see a physician to get the maternity leave (12).
Monitoring during labour is sub-standard (WHO partogram is not used, inadequate monitoring of vital signs). There is no reliable routine reporting system.
Haemorrhage related maternal death remains still high together with the cases of preeclampsia and eclampsia. Most of the causes are potentially preventable with simple and cost–effective interventions. Women living in rural areas have higher mortality rates than those living in urban areas.
The fertility rate in Albania has dropped consistently from 3.4 to 2.1 reaching the level of the replacement. One of the reasons that might have contributed to this decline is the slight increase of the average age of women at marriage.
Due to family planning programs the Contraceptive Use in Albania is increasing gradually. Contraceptive use still remains too low to have a significant impact on the reduction of the abortion ratio.
Abortion is still used as a method of family planning.
The prevalence of STIs is increasing rapidly.

Perspectives, inputs for the future

Prevention of unwanted pregnancy and prevention and management of unsafe abortion are key interventions for safe motherhood.
National policies need to address issues on unsafe abortion practices by promoting protection against unwanted pregnancy, how to obtain accessibility to good contraceptive care, to insure availability of services for management of abortion complications and abortion care by appropriate supplies and skilled staff.
The ministry of Health Reproductive Health Sector has focused on orienting programs and projects towards the improvement of mother and child health indicators. It is accepted that programs have constituted a useful tool that have influenced the Ministry of Health through identification of priorities. One example is the action plan developed by MoH (Directorate of Public Health and EU/ PHARE), which aims to ensure RH training of health care personnel of every Health Centre; that contraceptives are included in the “principal drug list”; that population information about the risks of abortion and promotion of contraceptive use is available; co-ordination of different donor activities and projects and inclusion of FP within all PHC program. The Albanian Family Planning Association (AFPA) has been very active in advocacy and lobbying activities in recent years. Recently, the AFPA, has been involved in the formulation of laws regulating NGOs and RH (21)
UNFPA, UNICEF, WHO, and other organizations such as USAID (19), have, supported programs in this field over the past ten years. Changes in indicators have started to show a positive trend, nevertheless the collection of such data is still inadequate, and much remains to be done.
The major overall need is a clear strategy development for RH, which should also permit periodical evaluation of achievements and to move forward with effective approaches in tackling priorities in Albania. The need for a national Logistics Management Information system is evident in order to ensure future sustainability of RH/contraceptive commodity needs. These would assist in preparing well-formulated programs, which could find necessary consensus amongst all interested parties, thus increasing the opportunity for these to be implemented.
A Reproductive Health Law was finalized and passed through the Parliament in the first half of 2002. The Reproductive Health Sector of the Albanian Ministry of Health plans to develop an operational plan to implement the law, and has requested assistance from UNFPA in this matter.

Areas for action and policy changes:

• Human resource development is a high priority at all levels.
• Strengthening the coordination between the Ministry of Health and Environmental Protection and NGOs especially women’s and donor NGOs through the appointment of a focal point within the Ministry itself.
• Mobilization of the mass media to inform couples about choice and right in practicing family planning.
• Need for urgent improvement in abortion equipment and training in new techniques in order to decrease maternal mortality.
• Lack of information on women’s health, makes a statistics index of accurate data a priority.
• Need for major changes and improvements in safe mother hood services, especially at community level
• Efforts should be made to boost couples knowledge of family planning methods, increase the demand for those services and ensure their availability
• Need to educate the public that abortion is not a contraceptive method and is always associated with risk.
• Assistance to adolescent health projects needed
• A new comprehensive multi-sector program on Reproductive Health has just been proposed.
• More control on the private clinics activity regarding the correct recording of the number of abortions, the condition under which the interventions are performed, and the top gestational age.

References

1. Definitions and Indicators in Family Planning, Maternal and Child Health and Reproductive Health. Used in the WHO Regional Office for Europe
2. Reproductive Health in Albania; Islami D, Kallajxhi F, Gliozheni O., in collaboration with the Geneva WHO Collaborating Center for Research in Human Reproduction.
3. Safe Motherhood Needs Assessment in Albania, 1999, final report. UNFPA, WHO.
4. Support to Reproductive Health in Albania, 2002. Project Document between the Ministry of Health of Albania and the United Nations Population Fund.
5. Geary J, Birth of a nation, FP in Albania, ORGYN.1994;(2): 2-8.
6. Multiple Indicator Cluster Survey Report (Albania), 2000, UNICEF.
7. Epidemiological Fact Sheet on HIV/AIDS and Sexually Transmitted Infections (Albania), UNICEF.
8. Situation Abortion in Albania; Gliozheni O, Kati K, Kallajxhi F, Beba D. Prague, Conference Material.
9. Sexual Practices of Undergraduate Students in Tirana, Albania; Burazeri G, Roshi E, Tavanxhi N, Orhani Z, Malo A; Croat Med Journal, 44(1): 80-85,2003.
10. World Health Organization, Regional Office for Europe, The European Commission. Health care systems in transition. Copenhagen: European Observatory on Health Care Systems, WHO Regional Office for Europe; 2001
11. Knowledge and attitude of Undergraduate students in Tirana, Albania, towards sexually transmitted infections; Burazeri G, Roshi E, Tavanxhi N, Rrumbullaku L, Dasho E. Croat Med J 2003; 44: 86-91.
12. Senturia KD, Maternal and Child Health in Albania, Social Science and Medicine.1996 Oct, 43(7): 1097-107
13. Kulier R, Fekih A, HofMeyr Gj, Campana A. Surgical methods for first trimester termination of pregnancy, (Cochrane Review). In: The Cochrane Review, issue 4, 2002. Oxford. Update software.
14. From abortion to contraception, Dymi A, Pine P, 1999, Albania; 51-67
15. Family planning and Reproductive Health in CCEE and CIS, UNFPA, from abortion to contraception.
16. Albania September 2002, Country Health Statistical Report, PNHI Country Health Statistical Report.
17. Kanani A, Albania: Breaking Cycle of Prostitution, London, England, Institute for War and Peace Reporting, 2002 Apr19.3p.BCR 332
18. Washington, D.C., AED, SARA, 2001 Aug. [2] p. Reproductive Health Brief; USAID contract No.AOT-C-00-99-00237-00
19. Falkingham J;Gjonca A, Fertility transition in Communist Albania; Population Studies. 2001 Nov; 55(3): 309-18.
20. Leskaj, V; Albanian Family Planning Association and Legislation. Choices. 2001 autumn; 11-3
21. Legins K; Saraci O: Albania: STD and youth culture; ENTRE NOUS, 1999 spring; (42): 9.
22. Gorishti E, Haffey J, Albanian women speak about family planning, Arlington, Virginia, John Snow [JSI], Family Planning Services Expansion and Technical Support [SEATS], [1998]n
23. National Report submitted by the Government of Albania, Reginal Population Meeting, Budapest, (Hungary), 7-9 December 1998.
24. Theodhosi G, Delia Z, Data about the reproductive health situation in Albania, New York, Parthenon Publishing Group, 1997. In: Assessment of research and service needs in RH in Eastern Europe-Concerns and Commitments. Proceedings of a workshop organized by ICCR and the WHO Collaborating Center on Research in Human Reproduction in Szeged, Hungary, 25-27 October 1993, edited by E.Johannisson, L.Kovacs, B.A.Resch, and N.P.Bruyniks.
25. Blayo C,ENTRE NOUS. 1993 Jun ;(22-23) :3
26. Dumani B, Fertility and FP in Albania, PLANNED PARENTHOOD IN EUROPE.1993 Jan; 22(1): 17-9.