Reproductive Health in Georgia
in collaboration with the
Geneva WHO Collaborating Centre for Research in Human Reproduction
Georgia is situated between Eastern Europe, Asia, the Black Sea and the Caspian Sea. The territory of the Republic of Georgia is spread from West to East-from the Black Sea to the Mingachauri water storage and covers 69.492 sq. km. Tbilisi is the capital of Georgia. The population is close to 5.5 million and the official language is Georgian. From the point of nationality the majority of the population are Georgians and they form about one third of the entire population. Some other nationalities reside in Georgia as well: Russians, Armenians, Azerbaijanians, Greeks and Jewish. Looking at the demographic characteristics, Georgia is similar to countries of European type, where low birth rate and a tendency towards increase of population ageing is typical. Orthodox Christianity is the main religion in Georgia. Other religions, amongst others, are Islam and Judaism.
During more than 70 years Georgia was one of the 15 Soviet Republics. In a national referendum in 1991, the people of Georgia voted overwhelmingly in favour for an independent country. During two years, 1992-1993, a civil war took place between Abkhasia and Osetia in the territory of Georgia. Only in 1994, the political situation was more or less stabilised. But Georgia had lost some territory and the economic situation was poor. There were major infrastructure problems giving rise to serious difficulties such as water and electricity supplies.
Roads in Georgia are still in bad conditions making transport very difficult even in urban areas, but especially the more remote mountain regions are almost impossible to access in winter. Since late 1996 the economic situation has improved but it is yet still far from the normal position. After the end of the communist regime, a huge wave of emigrants left for mainly the neighbouring Russia, Europe and the United States.
Nowadays, the health system of the Republic of Georgia undergoes a fundamental reorganisation from a general state system to a system shared between state, private and public. Currently, at the beginning of this process, it is rather difficult to determine their share and structure. But it seems that all of them are necessary like in the developed world, when their positions are defined by the principles of reasonable competition of market economy.
It is very difficult to draw a clear picture of the health status of Georgian population. Data collection is difficult because of various factors including the demographic movement and communication problems. In addition, the use of different definitions and methods of data collection and recording added to staffing problems and a lack of co-ordination results in inaccuracy in the field of reproductive health statistics.
Due to the present economic situation in Georgia, the data obtained is not sufficient, maybe due to underreporting. For example, the drastic increase in maternal mortality ratio to 128% over 5 years and the high abortion rate despite an apparent decrease over three years are not reflected in the data on maternal mortality from abortion.
There is minimal information about sexual, physical and psychological violence against children and women. In general, tradition and culture prevent women and children from violence reporting.
Georgia has one of the highest rates of doctors and nurses in the world. Midwives still play a central role in providing health care for pregnant women.
The government tries to reform the health care system but the economic situation and the threat of unemployment for medical staff makes it very difficult. Although maternity hospitals are relatively easy to access, many of them are under-equipped. Sanitary conditions in hospitals are poor and health risks resulting from abortion are high, especially in rural areas.
Maternal mortality is expected to further increase as a result of the rise of unprepared home deliveries (estimated to be approximately 10% of all deliveries), non-functional referral systems and a diminishing capacity of health services being able to deal with obstetric complication.
Annually, the world population increases by 1.73%, i.e. 87 million. This fact causes the intensive increase of resource consumption (water, food, power and even, fresh air); thus mankind will face a catastrophe at the beginning of the 21th century. Therefore, voluntary family planning directed to the zero increase of the population (0-1%) is common to all populations and embraces the majority of population at fertile age.
According to data of WHO, about 525.000 women die because of pregnancy complications every year, 99% are from developing countries. Approximately 20 million illegal abortions cause thousands of women's deaths, about 120 million women wish to avoid unwanted pregnancy, but have no possibilities and 15 million girls at the age of 15-19 years have one delivery every year, which presents the main reason of mortality in this group.
Annually, 300 million people suffer from STDs, and 1 out of 20 being an adolescent.
HIV in Africa and Asia will infect about 40 million people by the year 2000.
It has also been estimated to save about 20 million women by increasing the interval between pregnancies to 2-3 years.
Infertility affects about 10% of all marriages. Except for medical problems, low fertility rate is associated with higher personal welfare, while on the other hand, it negatively influences the demographic situation in Georgia.
In summary, the necessity of an established state policy in the field of voluntary family planning and infertility therapy is apparent and should be part of a general National Reproductive Health Programme.
Previously, Georgia had the second lowest ratio in maternal mortality in the present CCEE and CIS states. The number of registered cases for complications in pregnancy in general health care institutions was lower than in any other of the CCEE and CIS countries. The main causes of maternal mortality were haemorrhage (over 25%), sepsis, emboli, abortion and toxemia. Action is now being taken to analyse the causes of maternal death and what will be the implications for health services.
Until 1992, Georgia underwent a steady decrease in infant mortality close to the European average (15.8 per 1.000). The major causes of infant death were diseases of the respiratory system (38%) followed by perinatal and diarrhoeic conditions. But recent data from 1995 show an increase in infant mortality (21.4 per 1000) indicating a risk of two thirds caused by perinatal abnormalities. There is a significant difference in infant mortality between urban and rural areas. The mortality rate is higher in rural areas, reflecting the more difficult conditions there.
The available statistics on mortality do not classify the number of deaths according to initial causes of death (cold, malnutrition, and stress). Furthermore, some causes of death may be related to the already existing poor socio-economic situation in the country. In fact, according to some estimation, at least 1/3 of the increasing number of deaths may be attributed to this situation.
In Georgia, fertility rates in rural areas are still higher than in urban areas. Although there is a tendency for the two rates to become similar. This is probably due to the migration of couples at reproductive age to cities. The crude birth rate declined in the nineties, probably because of the civil war. Different ethnic groups present different demographic behaviours. In 1995, only 53.587 deliveries were reported. It is estimated that 10-12% of married couples are infertile.
The incidence of STDs consistently increased as a consequence of low socio-economic conditions, poor state maintenance and sanitation infrastructure, malnutrition, the unavailability of medicines and frequent migration of the population to different countries for temporary employment.
A large part of the population suffering from STD does not seek specialised medical care mostly because of financial problems and the fear of social consequences. There are different, well-practised treatments without having to attend the specialised clinics.
Georgia has a 'Republican Centre for Combating and the Prevention of AIDS'. According to its reports, 11 AIDS cases were detected in the whole country till the end of September 1996. This number is steadily increasing.
Several programs for the training and education on breast-feeding are already in place and mainly UNICEF sponsors them. The World Bank sponsors safe motherhood programmes.
According to data of one study on the abortion situation, around 4,5% of abortions are performed in girls 13-19 years old. 70% of 13-19 years old adolescents had sexual experience.
Sexual education in school has only started and is still very limited. Even teachers are not yet liberated from the ancient mentality and hardly speak freely or naturally about sexual problems.
Issues regarding birth control and infertility have been neglected during the last 20-30 years. Because of their global social importance they have become a problem for the state. Therefore, the World Health Organisation (WHO) considers birth control as one of the main problems in a number of developed and developing countries. Besides being a medical problem it also includes other aspects such as sociology, demography, economics and physiology which need to be addressed.
Reproduction and human fertility regulation is of particular importance for Georgia, as the birth rate in a number of regions is very low and the present economic and political situation alongside with migration negatively influences the demographic situation of the Republic. On the other hand, it should be noted that modern contraceptives are the only way to fight the demand for abortions (both medical and illegal).
Despite the difficult political and economic situation created in the Republic, all the current situation requires the establishment of a national reproductive health service lead by the Zhordania Institute of Human Reproduction (ZIHR) with Reproductive health consultations (RC) for the regions. It is desirable to establish Departments in reproductive health (RD) in large cities, such as Kutaisi, Batumi and Rustavi. This kind of service should represent a general system with unified organisational and methodological management.
Investigation and treatment of a considerable part of diseases affecting reproductive health can be carried out in an outpatient way. The inpatient medical service is necessary for those patients, who need invasive methods of investigation and treatment (diagnostic and operative laparoscopy, surgery). In total, the rate of these patients does not exceed 20-25% of the total number of patients. Hence, in case of normal working conditions a great number of patients will be able to get the qualified service in RC according to their residence, which will significantly reduce the treatment costs. Those patients, who can not be treated in regional consultations due to the therapy difficulties and lack of appropriate personnel skills will be sent to the National Centre of Human Reproduction (NRC) where exist up- to date facilities exist. Results of the treatment and investigations obtained in the National Centre, with all necessary recommendations on further rehabilitation treatment and prophylactic medical examination will be forwarded to the regional consultation centre and so establishing a highly qualified reproductive health service system with affordable economic expenditures.
The consultation centres (RC) should introduce record cards and prophylactic medical examination, carrying out the primary investigation and treatment and sending patients for highly qualified investigations, treatment and follow-up if necessary to the NRC. Another important task will be to emphasise on the education on family planning issues and modern contraceptive methods.
It is desirable, that one RC serves for 1-3 regions (according to the size of the population) and is with a large medical institution. This will be important to carry out different investigations on the patients avoiding extra organisational expenses (including ultrasound and X-ray). The RC staff should consist of 1 gynaecologist, specially qualified in human reproduction, a part time urologist, qualified as andrologist, 1 nurse and 1 laboratory assistant (cytologist). In such case, the clinic will become the regional centre of birth control and infertility treatment. A good example of the importance of such a centre is the one in Batumi, where 528 primary patients were treated during the first year of its existence. The total number of visits was 4900, and 50% of the patients became pregnant. Highly specialised investigations and treatments, like echo-monitoring, hormonal, bacteriologic and immunologic investigations, diagnostic and operative laparoscopy, hysteroscopy, microsurgery, "in-vitro" fertilisation and determination of treatment tactics by skilled specialists should be carried out in every NRC.
Selection and training of personnel in reproductive health, development and introduction of methodological recommendations in the Republic, processing and generalisation of statistic data, working on a reproductive health strategy and its realisation are carried out in the National Centre. NRC should have a single leadership and act within the general medical principles.The Zhordania Institute of Human Reproduction has elaborated the main directions for its activity, which will be in force in case of establishing the general national reproductive health service:
- Birth control (aspects of abortion and contraception)
- Social aspects of birth and demographic situation in Georgia
- Establishment of general reproductive health service in the Republic
- Clinical and experimental andrology
- Diagnosis and treatment of woman infertility due to endocrine and inflammatory causes
- STD and AIDS centres.
Besides the above mentioned issues, this service, as it is in the Institute, can solve the problems connected with adolescent gynaecology, gynaecological endocrinology and problems concerning the climacteric period (menopause) in the whole country.
Therefore, the number and qualification of staff engaged in practical medicine should be determined according to the number of patients using the service of the centre. Namely, if about 50 beds of the inpatient clinic are occupied, no more than 5 doctors and one senior specialist should be the staff of the department. Similar, for the outpatient service, 1 doctor for 15-20 outpatients will be required (with corresponding quantity of nursing staff).
Hence, the structure of the National Reproductive health Service cannot be determined once and forever. It should undergo annual assessment and correspond to the needs existing in the Republic based on the principles of market economy. As for medical and other personnel, an agreement (contract) should be made for a definite period (0,5-1-3-5 years), which will contribute to the flexibility of the reproductive health service structure and maintenance of a high level medical service.
To provide financial support for the reproductive health service is a rather difficult problem and of course, it can not come from only one source. Particularly, the directions we mentioned above: creation of general reproductive health service in the Republic, social aspects of birth rate and demographic situation in Georgia can be financed only in the framework of a national programme and the participation of central and local medical organisations. The only real source of financial support for these programmes is the government. The realisation of the programme - birth control by using modern methods of contraception should be implemented in cooperation with International programmes, especially with ZIHR being is a Collaborating Centre of WHO.Another possibility to realise the programme would be based on financial support from the state and market economy principles. The increase of the latter depends on the establishment and development of medical insurances and the general economic situation of the Republic. The scientific work should also be developed in the framework of the national reproductive health service, which will be focused on:
- International cooperation
- Research priority
- Solving national (specific) issues
Financial support for research should be done on the basis of contracts for different projects, both, on the expenses of state (budget) and contract orders. The number of people engaged in research should not be permanent and should be defined by the need of current, financed subjects.
On the background of many years of experience in Western countries, in order to make medicine serving a greater number of people, it is important for the coexistence and cooperation state, insurance and private medicine. Therefore, it is absolutely important, that the state contributes to introduce and develop the insurance and, particularly private medicine in Georgia. As mentioned above, birth control is among high priority issues discussed even on political levels in developed and developing countries and besides being a medical problem, it is associated with sociology, demography, economics and psychology. This fact has been proven once more in September 1994, at the United Nations International Conference of Population and Development (ICPD).
The regulation of human reproduction has a particular importance for Georgia as in some regions of the Republic the birth rate is very low. The present political and economic situation, alongside with migration seems to negatively affect the demographic situation of the country. At the same time, modern methods of contraception are an important step to decrease abortion rates.
The realisation of a National Family Planning Programme should be carried out through the National Reproductive Service. The organisation and the principal of the programme should be the RNC and its branches in the region should be the RCs . As for the big cities, such as Kutaisi, Batumi, Telavi, RDs are to be established. This service should represent the joint system with common organisational and methodological management.
Primary consultations on family planning issues can be performed on an outpatient basis in the regional RCs. Only those patients, who need more complicated methods of contraception will be especially supervised. The total number of these patients should not exceed 20-25%. Hence, a great number of patients will be able to have qualified service in regional RCs according to their residence and this will considerably reduce the treatment costs. These patients who cannot be treated in a regional RC because they require more complicated treatment or investigations or the RC lacks highly skilled personnel will be immediately sent to the National Centre, where modern facilities exist. The results obtained from the referral centre with further recommendations on rehabilitation treatment will be sent back to the regional consultation centres and the joint, highly qualified reproductive service system will therefore be economically affordable.
The National Centre should select and carry out the training of gynaecologists, develop and introduce methodological recommendations in the Republic and process statistical data. The National Reproductive Service should have a single authority and act within the general medical principles.
As it is well known, family planning represents a global social, ecologic, demographic, medical and even political problem, considering of course the regional peculiarities. This was one of the aspects the participants of a conference in Cairo focused on and is the basic principle of the Programme of Action. Accordingly, the Family Planning Programme of Georgia should be founded on medical background, in the framework of reproductive health service development and reform.
The modern principles of family planning have been pursued in Georgia since 1987, when the number of abortions significantly reduced (from 100.000 to 41.000 by 1992). Though, the birth rate in the same period considerably reduced by 15%, but the decrease of abortions for more than 100% indicated the efficacy of the existing family planning programme. Taking into account that the above mentioned programme has been worked out in accordance with the main principles of WHO for years, when Georgia was still in the process of developing medical reforms.
As it is known, financial and economic support from international societies to reform Georgian medicine is based on the high efficiency of its results. Thus, the ignorance of achieved results, even if it embraces only the starting stage cannot be justified and state, church and our society should attract great importance to the support of working programs.
After the efforts of UNFPA and its executive Director Dr. Nafis Sadik, the Programme GEO/96/P01 "Strengthening of Reproductive Health Service" was approved for the Republic of Georgia on May 21, 1995. This programme includes a number of significant activities, such as education of doctors and medical personnel, contraceptive distribution, local and abroad training, visits of foreign experts, working with mass media (population education) etc. The final result of the programme implementation should be the creation of so called "National Programme on Reproductive Health". Because of different reasons, the programme started its activities only in February 1996, but it is already implemented, and the whole project is scheduled to finalise in December 1999.
According to the decision of APR last April, the start of the National Programme implementation was recommended and its executors were also determined. The above mentioned activity has already started, though, at this stage the creation of the National Programme is not yet possible, because of the absence of epidemiological data on Reproductive Health in the Republic. For this reason, this Programme is preliminary and should be used only for orientation until the above mentioned international standards of epidemiological data will be available for Georgia.
|Project title||Strengthening of reproductive health services in Georgia|
|Execution||WHO-EURO / ZIHR|
|Actual start date||01.01.1997|
a) Development objectives
Contribute to the reduction of maternal mortality by 50% by year 2000 with government assistance in the implementation of a National Reproductive Health Programme, which aims to reduce the high abortion rate.
b) Immediate objectives
- To improve access to RH/FP services available at 55 service delivery sites through training of service providers, supply of modern contraceptives medical equipment.
- To develop capability of Ministry of Health to evaluate trends in RH/FP care through development and implementation of the management information system (MIS).
- To provide information of knowledge, attitudes, beliefs and practices of Georgian population towards RH/FP and to assess the impact of the project through design and administration of KAP survey.
c) Expected output
55 centres fully equipped and working.
d) Programme budget
Financial security of the national reproductive health and family planning programmes is a rather complicated issue and, of course, cannot be provided by only one source. Creation of a joint reproductive health service in the Republic may be financed only in the framework of the National Programme with the participation of central and local medical organisation. Correspondingly, governmental financing is the only source for the program’s financial security.
Realisation of voluntary family planning and contraception should be implemented by participating in international programmes and with the assistance of these programmes, mainly with that of the Institute as a WHO Collaborating Centre.
Realisation of other directions is also possible through combined ways, based on the financial support of the state and economic principles. Increase of the latter totally depends on the development of medical insurances and on the general economic situation of the Republic.
e) Main tasks
- Creation of a joint national service in reproductive health and infertility treatment
- Training of highly skilled personnel in RH/FP
- Establishment of health and education organisation service
f) Main strategy
- Foundation of a National Centre
- Creation of RDs in big cities
- Establishment of regional RCs
- To meet needs of the population by free or acceptable priced modern contraceptives
- Establishment of training centres in RH/FP
- Programme elaboration to up-to-date level
- Development of methodological recommendations
- Health and educational work among population
g) Material and technical basis
NRC will be located at ZIHR in Tbilisi, which is situated 43, Kostava str. The Institute has an in-patient clinic with a surgical department (80 beds), policlinic and clinical and experimental departments: clinical-diagnostic, biochemistry laboratories, laboratory of physiology and pathology of reproductive organs, experimental andrology, contraception, bacteriology and immunology, medical information and patent service, hormonal diagnostics and organisational sector.
The Institute is equipped with all modern techniques, such as: diagnostic and surgical laparoscopes, ultrasound machines, thermography, X-ray, sperm counter, radio-immunological and biochemical equipment and clinical laboratories.
All these services are more or less supplied with reagent and laboratory equipment, but the main equipment exploitation period is not longer than 6-8 years.
The Institute employees 392 people, including 12 head of the departments, 1 leading scientist, 10 senior scientific workers, 8 scientific workers, 40 junior scientists, 8 scientific workers, 1 academician, 8 scientific doctors, 29 scientific candidates, 3 professors.
h) Working Plan
- 1998-2003: organisational activities of the Ministry of Health and ZIHR for the establishment of a general reproductive health service
- 1998-2003: Ministry of Health and ZIHR organise training centres for preparinghigh skilled personnel in reproductive health
- 1996: Start to prepare personnel in RH/FP ZIHR
- 2000: Start to apply general National Reproductive Health System Programme, monitor and assess its progress,
- Further evaluation of the actual situation is needed to identity specific action.
- Technical assistance in human reproduction is needed through the continuous support, supply of contraceptives by means of raising funds and thus strengthening FP promotion.
- Strengthening MCH services and training health care staff, thus strengthening FP promotion.
- Future projects should include medical equipment and supplies for primary health care services, training in public health issues on healthy infants and mothers and issues on AIDS.
- Antenatal and perinatal care and the management of respiratory diseases should be examined in order to reduce the avoidable deaths in infants.
- Assistance to adolescent health projects is needed.
- United Nations Population Fund (UNFPA): Family Planning and Reproductive Health in CCEE and CIS -working document-Updated edition December 1997
- World Health Organisation, Regional Office for Europe Copenhagen: Highlights on Health in Georgia Dec. 1992
- World Health Organisation, Regional Office for Europe, Sexuality and Family Planning Unit: Background Document (Table, Paper) on International Activities in CCEE/NIS Prepared for working meeting /interagency; Copenhagen March 1993
- WHO-EURO Copenhagen, September 1996 AIDS cases reported to Global Program on AIDS by countries in Europe.
- Country profile: Georgia, Armenia, Azerbaijan 1996-97.The economist Intelligence Unit, UK.
- Family Planning and Reproductive Health in CCEE/NIS. WHO-EURO and UNFPA Division of Arab States and Europe.
- Health in Europe; WHO- EURO 1997
- Department of Statistics, Tbilisi Georgia
- Abortion in Europe, 1920-91: a public health perspective. David HP; Transnational Family Research Inst. Bethesda, MD20817. Stud Fam Plan1992 Jan.23 (1): 1-22