NONE OF YOUR BUSINESS: How Private Clinics Have Become the Leading Providers of Abortion Services in Romania

Many Romanian doctors who refuse to terminate pregnancies in the low-cost state sector are offering this service privately. The public-private symbiosis has become so strong in recent years that, in 2020, almost one in two abortions performed in the country was done in a private practice.

“Terminations [of pregnancy] are not performed here,” explains an employee of the Obstetrics-Gynecology Department of Fălticeni Municipal Hospital in Romania’s Suceava County. “Try a private clinic.”

Since 2018, the hospital, which serves about 25,000 people, has not officialy conducted any abortions on demand.

“You can also try the doctors who work at this hospital,” adds the employee. “Ask at their private practices. You can go somewhere they do it.”

In recent years, the share of abortions on demand performed in private clinics and practices has increased nationwide from 33.1% of the total in 2017, to over 47% in 2020, according to the National Institute of Public Health (INSP).

In the first four months of 2021, for the first time since 2017, there were more abortions on demand performed in private medical units than in the public system: 2,056 compared to 1,598.

However, this investigation by the journalistic team of The Decree Chronicles reveals a strong link between the private and public systems in Romania.

Our research demonstrates a parallel reality in which the same medical staff who refuses to perform abortions in the public system are willing to offer this service in their private practices or in private institutions. In addition, our investigation uncovers a lack of transparency in the private sector, which could mean the numbers of abortions taking place in Romania are grossly under-reported.

“The private sector does not want to report. They report zero abortions, although it can’t be zero,” the spokesperson of one local public health structure told us.

So we followed the facts.

In the private sector, abortions are mainly performed on demand, either surgical (curettage) or with medication. For example, in 2020, out of a total of 8,655 abortions reported (nationwide) by private clinics and practices, 7,339 were on demand, i.e. almost 85% of the total.

At the same time, in the public sector, on-demand abortions have accounted for about half of the total number of abortions in recent years. The share of on-demand abortions decreased even further in 2020, when they accounted for about a third of the total number of abortions performed in the public system.

The evolution of the two sectors is inversely proportional, as the collected data shows. As more public hospitals refuse to provide this service on demand, the share of the private sector increases. However, as abortion is more expensive in the private sector, this course of events mainly impacts low-income women, as well as public access to these health services in small communities.

According to the rates on the websites of several private clinics, the price for a surgical on-demand abortion in the private sector starts at 600 – 700 lei (120 – 140 Euro) and can go up all the way to 1,200 lei (242 Euro)

By comparison, prices in state hospitals are much lower. At Alexandria County Hospital in Teleorman county, a curettage on demand, with local anesthesia, costs 150 lei (30 Euro). At Târgu Mureș County Hospital, the price is 100 lei (20 Euro). At Zalău County Hospital, the price for an abortion is set at 500 lei (100 Euro), including the cost for a one-day hospitalization.

There are four obstetricians-gynecologists listed on the website of Fălticeni Municipal Hospital who do not perform abortions. Two of them are currently offering, or offered until last year, abortion services in private practices.

One of these doctors, Dr. Bogdan Grămadă, reported to the DSP (Department of Public Health) Suceava abortions on demand performed at his private practice every year between 2017 and 2020. Last year, he reported 31 abortions on demand. A relatively small figure – but still higher than the total number of abortions on demand registered at the level of all the state hospitals in Suceava County. The last statistic shows 25 abortions on demand.

The Private Clinic Dr. Lungu, where  Dr. Usruf Wajdy, the Head of the Obstetrics-Gynecology Department at Fălticeni Municipal Hospital, also works reported abortions on demand to DSP Suceava only in 2018. But when our team call the Dr. Lungu Clinic in mid-September, we can make an appointment with Dr. Usruf Wajdy for an abortion on demand.

However, the receptionist tells us that on-demand abortions are not legal in Romania.

This is the dialogue:

To understand why this happens, we attempt to call Dr. Vlad Morariu, the Manager of Fălticeni Municipal Hospital, but he refuses to talk to us. A gynecologist at the hospital also tells us, erroneously, that abortions are illegal in state hospitals in Romania.

The Head of the Obstetrics-Gynecology Department, Dr. Usruf Wajdy, confirms, in a telephone conversation, that there are no abortions on demand performed in the hospital. “For what reason? Religious reasons. Nobody does it!” he says.

“Only for therapeutic reasons, if there are problems concerning malformations, but otherwise, if the lady just doesn’t want that pregnancy, no, we can’t. We don’t do it,” adds the doctor.

Dr. Usruf adds that he only performs abortions at the private clinic if they are therapeutic. “And I do it with pills. I don’t do curettage.” However, the receptionist at the private clinic where he works has told us curettage is possible.

“You are asking me about the private sector. Why is my private activity any of your business?”

, asks the Head of Department at Fălticeni Municipal Hospital.

The private medical sector in Suceava County has a much higher share of on-demand abortions than its public counterpart, according to the INSP.

For example, in 2019, 11 times more abortions were reported in the county’s private clinics and practices than in local public hospitals: 77 abortions on demand in state units and 847 abortions on demand in private centers.

A doctor who works at Suceava County Emergency Hospital (a medical unit where abortions are performed) reported to DSP Suceava more on-demand abortions at his private practice than at the county health unit in 2017, 2018 and 2019: 251 compared to 178.

Câmpulung Moldovenesc Municipal Hospital in Suceava County has not reported any abortions (on demand or medically) since 2017.

However, Dr. Mioara Piticar, the only gynecologist at the hospital, reported on-demand abortions at her private practice between 2017 and 2019, according to data from DSP Suceava.

“I am left with just one gynecologist and that’s what we have to work with,” explains Adrian Cosinschi, Interim Manager of Câmpulung Moldovenesc Municipal Hospital. “[Dr. Mioara Piticar] has a private practice. We have no requests at the hospital [for abortions], and that’s why [we do not perform them].” 

He says he is trying to find other specialized doctors to provide emergency services within the hospital, but that there is “a severe shortage of doctors”.

“[Dr. Mioara Piticar] has a private practice and she goes there when she can. The rest of the time she is mostly with us. We need her. She also goes on home calls, for all sorts of obstetric emergencies. We have a plan for such things [requests for on-demand abortions], we even have set rates. But we really haven’t had any requests,” adds the manager.

Suceava is not the only county where private medical units exceed the public health sector in terms of the number of on-demand abortions reported to county public health departments.

For example, in Bistrița-Năsăud, in 2019, ten times more on-demand abortions were reported in private units than in the public sector: 388 compared to 38. In 2020, the year of the pandemic, all on-demand abortions in the county were moved to private clinics and practices. State hospitals reported zero such procedures (compared to 362 performed privately).

In Brașov County, only 15 abortions were registered in public hospitals in 2018. During the same period, the statistics show 420 abortions performed in private units, i.e. 28 times more on-demand abortions performed in the private sector.

In Constanța, the gap between the public and private sectors is even bigger. In 2017, there were 38 on-demand abortions performed in public health facilities and 1,447 in private centers. This is 38 times more. The actual numbers might be higher, given that out of the 50 private obstetrics-gynecology practices in the county and 52 medical companies specializing in obstetrics-gynecology, only one private institution in Constanța reports on on-demand abortions: Euromaterna private network.

In Sălaj district all abortions on demand were performed in the private sector beginning with 2017. | Source: DSP Sălaj

Other counties where the private sector surpassed the public sector in terms of on-demand abortions in the researched period include Ilfov, Maramureș, Mehedinți, Sibiu, Teleorman, Tulcea, Vrancea, Neamț, Sălaj, Bistrița-Năsăud, Bihor and Olt.

In Neamț, between 2017 and 2021, no on-demand abortion was reported in the public system, according to DSP Neamț. This means that the only place where one can get an on-demand abortion in the county is in the private sector.

The largest hospital in the county, the County Hospital in Piatra Neamț, has not performed abortions on request for many years. The decision was officially established by a decision adopted in the summer of 2015.

What options do women in Neamț have if they want to have an abortion?

We call Roman Municipal Hospital in Neamț County, requesting an appointment for an abortion on demand. The hospital, which serves a city of about 50,000 residents, has reported zero abortions since 2017, as have all other hospitals in the county.

“There are no more terminations of pregnancy in our hospital. You need to go to a private practice, to Dr. Trica, or wherever else you want. You can also go to Bacău or Piatra. In Roman she is the only one doing it. She has a practice next to the hospital.”

, a medical employee tells us on the phone,

Dr. Lenuța Trica, also an employee of Roman Hospital, did not report to DSP Neamț any on-demand abortions performed at her private practice from 2019 to 2021.

The City Hospital “St. Dimitrie” in Târgu Neamț hasn’t reported any on-demand abortion to DSP Suceava since 2017.

“Maybe no one requested it,” explains Dr. Larisa Cristina Udrea, the hospital’s Medical Director and spokesperson. “On-demand abortion is a service that was available throughout the year, during our working hours, in an outpatient setting. There were no doctors who refused to perform the abortion, at least not in the past year.”

She says that 13 abortions were performed at the hospital, but all were by medication. “The medication is purchased by the patient, and the price of the ultrasound is 30 lei [6 Euro]”.

However, this data does not reflect the official statistics. The Medical Director doesn’t know why.

Unofficially, when I call the hospital, I am given two options regarding abortion on demand.

“Either you come to see Dr. Iovoaia on Thursday, in the outpatient clinic, in the polyclinic, or you can go to her private practice. Another option is Dr. Dumitrescu, at the private practice. He can help you too,” explains a doctor on the phone.

Dr. Gheorghe Tudose, now retired, has one of the few private practices in Piatra Neamț that offer on-demand abortion services and that rigorously report the figures to DSP Neamț: 346 in 2019, 201 in 2020, 68 in the first four months of this year.

There are 29 private obstetrics-gynecology practices registered in the county, according to DSP Neamț. Only three reported on-demand abortions between 2017 and 2019.

“The hospitals have the obligation, at least towards women with many children, to provide them with this medical service. And it’s not available to them anywhere,” says Dr. Tudose, who has also worked in the county hospital.

“I think it depends on the head of the department. In our hospital, you had to give a reason why you wouldn’t do them [abortions on demand], and if it was plausible, a pertinent excuse, they would call someone else. I think public hospitals have certain responsibilities,” adds the doctor.

“They [the other doctors] criticize me, but ultimately, when there is a woman with five children and she is pregnant, they send her to me to take care of it. But these days I see that things are starting to settle down. I am only still working because patients force me to.”

, says the 77-year-old doctor.

Although the county hospital doesn’t offer this service, some doctors in the hospital still offer it in a private setting. For example, one of the gynecologists in the hospital performs abortions in his private practice. The condition is for the abortion not to be surgical, only through medication, which means the age of the pregnancy should be fewer than eight weeks.

Satu Mare County Hospital is in a similar situation. Although the Obstetrics-Gynecology Department of the unit has 12 specialists, none of them perform abortions on demand, according to an official response from the hospital.

When we call the public hospital unofficially, to ask if an appointment can be made for an on-demand abortion, a private practice is the main solution given to us.

“Do you want an abortion? Then only Dr. Pop can do it at his practice. On-demand abortions are not performed at the hospital,” a member of the medical staff says on the phone.

Why? “That I don’t know. Because doctors don’t want to perform abortions. Nobody performs abortions. Only in the private sector.”

In 2013, when she became pregnant, Bianca (a pseudonym chosen to protect her identity) was 27 years old, still living in a dorm room and barely employed. She decided to have an abortion.

She went to her gynecologist at Cuza Vodă Maternity Hospital in Iași, an institution that has not performed abortions on demand for many years.

“He told me he can’t do a termination because he just can’t. It would weigh on his conscience if he did it and he doesn’t feel ok with it. No one in the hospital did it. And he recommended a doctor who did it at his private practice. And I went to him”

, says Bianca.

But the doctor who performed the abortion in his private practice was also an employee of Cuza Vodă Maternity. He did not perform abortions at the public hospital, but he did at his private practice.

“When I got there, there were another five or six women. None of them were with the partner,” she remembers. The experience left a mark on her: “I did not feel that he [the doctor] was judging me, I felt that he was judging the situation: here is another person in this situation”.

There is an intersection between the public and private sectors in pre-abortion medical services, such as consultation, ultrasound and psychological counseling.

In some state hospitals in Romania, these services are offered outside the medical units and only the surgical act itself – the curettage – is performed in the hospital.

At Alexandria County Emergency Hospital, for example, women who want to have an abortion on demand “need to show up with a referral from outside the hospital, from private medical offices,” says an official response from the health unit.

Dr. Dumitru Mandoiu, who works in the Obstetrics-Gynecology Department, explains that it is possible to have an ultrasound in the hospital only if the patient has a referral from the family doctor and is given a day’s hospitalization. Another option is for the patient to have an ultrasound in a private center. “More patients do it in private clinics,” says the doctor.

“Some doctors, such as myself, we no longer perform abortions in our private practices. Or if it is a problematic pregnancy, or a difficult curettage, the patient is diagnosed in the private practice and then referred to the hospital for curettage”

, adds Dr. Dumitru Mandoiu.

At Târgu Mureș County Emergency Clinical Hospital, “the patient must have a document from a gynecologist, certifying the age of the pregnancy,” reads an official response from the hospital submitted at the request of our journalistic team.

“Patients come to us with that document, no matter where it’s from, a private clinic, another state hospital, they can even be scheduled, prior to the intervention, in our integrated outpatient clinic, if they have a referral,” explains Ana Voichița Pantea, the spokesperson of the hospital.

“There are many medical practices in the county. The practice issues the document. There is even an obstetrician-gynecologist private practice in this hospital, but they are only using the space, the practice operates separately from the hospital. Many bring a referral from that doctor”

, she adds.

The spokesperson goes on to say that the county emergency hospital is the only public medical unit in Mureș that performs abortions on demand. Apart from it, only private practices offer this service.

At Bega Maternity Hospital, part of “Pius Brînzeu” County Emergency Clinical Hospital in Timișoara, pre-abortion counseling services are offered by a private association, based on a partnership agreement with the hospital.

The official partnership is dated 2017, but the association has been providing its services since 2005.

The association is called Pro Vita Medica and was founded by Doctor Cristina Valea. In an article in the local press, she is presented as “the doctor who convinced over 700 women to give up abortion.”

According to the partnership agreement, the counseling services take place in the “premises of the telephone exchange, in the morning, between 8 and 12”.

The counseling is an attempt to persuade women who have come to get an abortion to not go ahead with the procedure. This is openly admitted by Dr. Marius Craina, Head of Department at Bega Maternity Hospital and the former Manager of the hospital.

“Every patient who comes in for an on-demand abortion is advised by a specialist who has a special training for this,” he says. “We have been using this method for many years, with many, many benefits. Many women have given up on-demand abortion, uterine curettage, after discussions with our counselors.”

No document stipulates that such counseling is mandatory. But, in practice, women who want to have an abortion do go through this counseling.

“Before the curettage, in addition to the information we provide from a medical point of view, the patient must immediately make a mandatory visit to the counseling office, where she talks to the counselor,” explains the Head of Department.

This investigation by The Decree Chronicles shows a lack of transparency and a problem reporting on-demand abortions performed in the private sector, at which the county public health departments (DSPs) shrug helplessly.

When it comes to the number of voluntary abortions carried out in private clinics and practices, the actual figures are most likely higher than those reported to DSPs.

Data collected from INSP shows that there are counties where zero on-demand abortions have been reported in the private sector since 2017. Examples include the counties of Botoșani, Hunedoara and Galați. There are also counties where very small numbers have been reported in the private sector: 28 abortions on demand in Vâlcea, in total, since 2017.

Representatives of DSPs acknowledge that these figures do not correspond to reality, and are the result of underreporting or no reporting. However, local health institutions that should monitor these aspects of public health (and formulate realistic and efficient public policies) declare themselves powerless.

“The private sector does not want to report,” says Delia Băda, spokesperson at DSP Hunedoara. “We can’t force them to report. They report zero cases, although it can’t be zero.” 

In Arad County, for example, out of a total of 42 obstetrics-gynecology practices, only one practice reports having performed abortions, according to data from DSP Arad. This is the Genesys MedLife Hyperclinic, part of the Medlife network.

“When it comes to abortion, there is a suspicion of underreporting,” explains Horea Timiș, Director of DSP Arad. “Basically, the number is much higher. You can only get a partial image from official statistics, it is not the reality. But there’s no way to check.”

The answer from DSP Timiș states that only one clinic in the district reports the numbers of abortions performed. 

Liliana Iordăchescu, spokesperson at DSP Galați, tells us that “there is no legal framework to force private institutions to report the data requested by you to public health departments.”

Hospitals and other health facilities with beds, whether public or private, are required to report every four months on the number of abortions on demand, by age group, according to a 2006 Ministerial Order.

We have also requested data from the largest private medical networks in Romania – Regina Maria, Medlife, Sanador and Medicover. I have asked if and how many abortions they have had in recent years, how many doctors perform the procedure, how many abortions have been reported to DSPs.

Medlife and Medicover had not responded by the time this article was published.

Sanador’s representatives reply dryly: “We don’t have an answer to your request.”

The representatives of Regina Maria give a general answer, from which we extract some fragments:

“In our network, most requests in the obstetric field are for monitoring normal pregnancies, those at risk, and saving problematic pregnancies. Requests for termination of pregnancy for non-medical reasons form a marginal proportion.

In the maternity hospitals of Regina Maria Health Network there are gynecological obstetricians who also offer on-demand abortion services.”

Dr. Marius Craina, the Head of the Obstetrics-Gynecology Department at Bega Maternity Hospital, believes that health authorities have never been interested in a real, national statistic of abortions performed in private units.

“Statistics concerning the private sector have never been made. There were a lot [of abortions] performed illegally,” argues the doctor. “When we come up with a statistic, we can never be sure that the statistic is true, that it reflects reality. And then we only deceive ourselves. There is no point in me coming out and saying that Timisoara has reported 100 abortions. Wow, only 100 abortions on demand – when in fact, the real number is much, much higher.”