“They Left Us Dead in the Water”: Romania’s Crisis in Family Planning

In the 1990s, Romania built a wide network of doctors specialized in providing contraceptive services. Today, most doctors in this field are poised to retire, the number of family planning offices has plummeted, finances available to them have evaporated, and Romania is at the bottom of EU rankings regarding the use of modern contraceptives. | Foto: Octavian Coman

The Family Planning Centre at Panait Sîrbu Hospital in Bucharest was established in 1990, in the year after the Revolution that ousted the Communist dictator Nicolae Ceasescu. “It is the first of its kind in the country,” says the website of the medical institution.

We tried to schedule a consultation at this centre. On the phone, the receptionist told us that the family planning doctor is elderly and, due tof the pandemic, only offers online consultations and she redirected us to an electronic application of the Hospitals and Medical Services Administration in Bucharest, where we should have been able to make the request.

But the online application process was suspended by default starting mid June 2021.

We called the  hospital again to ask for a consultation with another family planning doctor, who we could meet face to face. The receptionist told us there was no one else except the elderly doctor, who could only be contacted online. But this application didn’t work.

This is how the oldest family planning office in Romania functions.

Several other calls we made to family planning centres in Bucharest ended with no one answering, or  when we  asked the operators to transfer the call to the family planning centre, they answered with a confused silence. A woman from the University Emergency Hospital Bucharest seemed surprised and we heard her ask  her colleague: “Is there a family planning office?” She was told yes. However, after she transferred our call, no one picked up. In theory, the office exists. In practice, it’s a telephone extension which no one answers. 

This Decree Chronicles investigation shows how the family planning network created thirty years ago by the Romanian state is in crisis. Consequently, the provision of accessible contraceptive services remains only on paper. Meanwhile, the COVID-19 pandemic has closed more of the few remaining doors. In some cases, medical staff in family planning offices have now been reassigned to the COVID vaccination program or epidemiological investigations.

The disinterest of authorities is so great that the Ministry of Health could not, at first, provide us with the number of family planning offices still in operation. Our request was redirected to the National Health Insurance House (CNAS). They sent us the situation of the offices under contract with CNAS: only nine at national level in 2021. Moreover, in the entire country there are only 15 doctors with a family planning certificate who provide these services based on a contract with CNAS.

However, the number of family planning offices indicated by CNAS is smaller than the number of family planning centres in operation, as some  do not have a contractual relationship with CNAS. From the answers received from each county’s public health directorates (DSPs) and discussions with doctors, it appears that most of these offices are financed through salary transfers from the Ministry of Health or directly from the budgets of the hospitals where they function. 

After we made another request to the Ministry of Health, they told us that 117 family planning offices were still operational in 2020. 

To understand a clearer image of the systemic neglect of family planning offices, it is worth knowing that, according to the National Institute of Public Health, there were 122 family planning offices across the country in 2020, while in the 1990s, their numbers ranged from 210 to 240, according to specialists who contributed to launching the family planning program in Romania.

In thirty years the number of centres specialized in providing contraceptive services has halved, even though the need for contraception has increased.

An inventory of family planning offices was also carried out by the NGO Sex vs. Barza (Sex Versus The Stork) which advocates for the provision of reproductive and sexual health services. The research carried out by the organization’s volunteers found 119 operational offices in Romania in 2020. Here are the lists per county.

After the fall of the communist regime and the legalization of on-demand abortions, the number of pregancy terminations in Romanias exploded. In 1990, almost one million abortions were performed.

In the period immediately after the Revolution, contraceptive methods were still unknown or inaccessible to many Romanians. At the dawn of rediscovering democracy, family planning in Romania was undertaken by doctors using the surgical abortive procedure of curettage.

Even the training of doctors was precarious when it came to contraceptive services. Doctor Iuliana Balteș, who finished her medical studies in the ’80s, remembers that “we talked a lot in college about conception, but never about contraception. (…) It was an underground thing.”

Photo: Octavian Coman

In those years, the Romanian Government applied for a loan from the World Bank for a modernization plan in the field of health. According to Dr Balteș, who later became a trainer, the money was also offered for the initiation of a national family planning program.

At the time, Romania ranked first when it came to the number of on-demand abortions in Europe, says Carmen Suraianu, director of the Society for Contraceptive and Sexual Education (SECS), which appeared in 1990 with the help of the International Federation of Family Planning.

Starting in 1993, doctors were trained to develop family planning skills, and SECS was involved in this program. Those who attended the sessions were usually general practitioners.

Among the objectives of this new specialization was to reduce the number of abortions, maternal mortality and the incidence of sexually transmitted diseases.

With financial support from the United States Agency for International Development (USAID), more than 5,000 general practitioners and nurses (considered to be closer to rural communities) were trained in family planning.

According to Dr Balteș, and SECS’s Carmen Suraianu, before Romania’s EU accession in 2007, between 200 and 240 family planning offices had been created, most of them in cities.

After 2007, USAID withdrew support for family planning projects in Romania. “The Ministry of Health should have continued,” says Balteș. “Unfortunately, the program started going downhill, instead of going up.”

All the doctors I spoke with during this investigation argued that the main way to attract Romanians to family planning offices is to offer contraceptives either free of charge or at a very low price.

Over the years, condoms, birth control pills and other contraceptives have reached these offices through donations from associations, purchases made by hospitals or local authorities, and from the stocks of the Ministry of Health.

One way contraceptives could be provided by the Ministry of Health is through the Women’s Health Subprogram.

On paper, the subprogram allows gynaecologists, general practitioners and family planning specialists to offer contraceptives free of charge to a wide range of people: the unemployed, pupils and students, people benefitting from social assistance, women in rural areas or who have had an on-demand abortion, as well as those without an income. 

We requested data from the Ministry of Health regarding the functioning of this public contraceptive service. The response we received shows that from 2013 to 2021, the only budget allocations for “preventing unwanted pregnancies by increasing access to family planning services” were in 2016 and 2017. It was 650,000 lei (approximately 130,000 euros) for 2016 and 144,000 lei (less than 30,000 euros) in 2017.

In both cases, the money was assigned for “conducting a nationally representative population study on the reproductive behaviour of the population of childbearing age”.

In the other years between 2013 and 2021, the governments did not allocate any money for this program. For each year, the Ministry of Health reported drily: zero lei.

Between 2013 and 2017, the Ministry of Health benefitted from stocks of contraceptives, but these came from purchases made in previous years.

Photo: The answer provided to us by the Health Ministry clearly illustrates the lack of interest of the Romanian State in providing family planning services. 

The family planning doctors we talked to for this investigation say that the effects of the decisions in Bucharest were immediately felt at grass-root level.

Irina Frunză is among the pioneers of family planning in Romania. She is part of the generation of doctors formed in the early ’90s and currently has an office in Bacău, in the maternity clinic.

Frunză says that those who come to her for counselling “want something tangible besides explaining to them what is what, what is right and what is wrong”. She thinks that in 2016 she received the last batch of free contraceptives.

“From the moment we had nothing to give them [for free],” she says, “there was a dramatic decline [in the number of patients].”

As proof, Frunză reads to us from her registers. At the end of 2009, she had 14,000 consultations per year. In 2019, she had registered approximately 7,000 consultations, and the pandemic has further halved that number.

The doctor also says that she had a working capital which she could use to buy contraceptives. To those she counselled, she sold them at lower prices than in pharmacies. She then used the money to purchase new batches of contraceptives.

In the absence of free contraceptives, Dr. Camelia Petre, who coordinates the Reproductive Health Centre at Sibiu County Hospital, also uses the institution’s working capital to buy further stocks. Despite the very low prices, many of those who use family planning services still can’t afford them. For a contraceptive pack, the price in Dr. Petre’s office is between five and seven lei.

The doctor from Sibiu says that she has days when she has a maximum of two consultations. If she sells a pack every three months, she considers that “a lot”.

Dr Iuliana Balteș, who now works at a family planning centre in Bucharest’s northern Sector 1, but who started her career in the small town of Urziceni, says that she used to give, free of charge, 3,000 packs of contraceptive pills per month and several dozen injectable contraceptives. In Urziceni, she was sought by women from rural areas who wanted to obtain “control over their fertility”.

“We had patients who we saw through from the beginning of their sexual life until menopause without any abortions,” says Balteș. She remembers that when she gave out free contraceptives, there were more patients at her door than at the gynaecologist, where they would have gone for an abortion.

At the family planning centre in Sector 1, where she has been working since 2008, she offers free contraceptives, but they were bought by the local administration and can only be given to residents in the sector. Iuliana Balteș doesn’t have much time to spend at the centre, because she also holds a management position in the unit. In addition, she is also dealing with the COVID vaccination program.

The Ministry of Health told us that in 2020 there were only two offices nationwide where free contraceptives were offered.

Tulit-Incze Agnes, from a family planning office in Miercurea Ciuc, Harghita County, is a psychologist. The last year when she was able to offer free contraceptives was 2014. Ever since, the number of people using her services has decreased. She thinks that gratuities are very important, because they give her a chance to offer informed advice, which “matters a lot to patients”.

During this investigation, we tried to find out from the Ministry of Health why no money was allocated for the purchase of contraceptives through the Women’s Health Subprogram. We have not yet received a clear answer.

From the correspondence with the representatives of the institution regarding the situation of family planning offices, it appears that one reason would be that there were no more tenders organized for contraceptives. Why? Apparently, contraceptives lack a technical standard, namely the HTA evaluation, which is a process of “Health Technology Assessment”, a cost-benefit analysis and cost-effectiveness for devices or drugs.

Irina Mateescu has recently held the position of Counsellor at the Ministry of Health. She was one of former Health Minister Vlad Voiculescu’s honorary advisers, then she worked under Secretary of State Andra Migiu during the time Ioana Mihăilă was Health Minister, in 2021.

Photo: Bogdan Dincă

According to her explanations, HTA is a complex process, and only HTA-approved drugs can be included in the national programs developed by the Ministry.

However, she points out, there are drugs on the market that are considered urgent and have been included in national programs without this technological assessment. When Mateescu brought up family planning at the Ministry, she says that she encountered opposition from people who invoked the HTA evaluation. If the process has a role in the case of curative drugs, Mateescu no longer sees its use in the case of contraceptives: “[condom brand] Durex and other contraceptives prevent pregnancy, they do not cure. prevention methods should not be treated in the same way [as curative drugs].”

According to her, there is only one person at the Ministry of Health who deals with the chapter on reproductive health. “A lady who is just a bureaucrat who moves papers around,” as Mateescu describes. Her conclusion is that, at the ministry level, it’s not possible to create policies and strategies regarding family planning in Romania.

“There is no one, we can forget [about it]. There is no one, that is the reality,” adds Mateescu.

The former counsellor from the Ministry of Health remembers that she also had difficulties in finding out how many active family planning offices exist in Romania. She needed the figure because she was working on introducing them into the EU-funded National Recovery and Resilience Plan (PNRR), requesting funding for renovation and equipment.

In order to reach a conclusion, she created a WhatsApp group with doctors in this field. The number that came out of the group discussion was different from the one she received from the public health directorates (county structures subordinated to the Ministry of Health). On the discussion group, people pointed out that there were cases where doctors had retired, or the office was no longer active.

In video calls, Irina Mateescu also noticed that the specialists were of advanced age, and she frequently heard mention of “retirement plans”.

Two of the doctors I spoke to for this investigation were already of retirement age. The third, Dr Irina Frunză from the only family planning office in Bacău, had applied for an extension of activity beyond retirement age on the very day I called her, because there was no one to take her place.

Irina Mateescu, the former counsellor at the Ministry of Health, explained that in recent years there have been no training programs/sessions in family planning at all.

Camelia Petre, the coordinating doctor of the Sibiu Reproductive Health Centre, is even more categorical:

“There is a complete lack of interest [in the topic],” she says. “No new doctors have been trained, many have retired, others have gone to other fields. Recently, my colleague retired, and she was not allowed to stay after she turned 62 because the program and activity here did not justify the presence of two doctors. I am 57 years old, and I’ll be glad if I can last here until I’m 62.”

In order to justify her employment, the doctor from Sibiu offered to be detached to anti-COVID vaccination. She also volunteered to help DSP with epidemiological investigations. The pandemic emptied Camelia Petre’s family planning office, but this exceptional situation has overlapped with the existing indifference on the part of authorities.

“They left us dead in the water”

, Camelia Petre sums up the situation.

Irina Mateescu is also under the impression that the doctors from family planning offices have been left to fend for themselves. She is not convinced that the objectives included in PNRR regarding the modernization of family planning offices will materialize, because the PNRR can be blocked at any moment if the government in Bucharest doesn’t carry out the plans set on paper.

The situation is further complicated by the fact that some doctors from family planning centres have been professionally marginalized even by colleagues from other specializations or by the managers of the hospitals where they work. For example, in some cases, their offices have been moved to inappropriate or inaccessible places.

Most of the time, these specialists are paid salaries that come through transfer from the ministry, through DSPs. The salaries are fixed, regardless of the number of consultations. Exceptions are the very few who have a contract with CNAS: only nine family planning offices in Romania.

The consultations that the family planning centres provide are free and accessible to the uninsured. This makes them financially unprofitable, and in the eyes of some hospital managers they are burdens, according to doctors we have spoken with

Family planning consultations can also be carried out by general practitioners or gynaecologists. In fact, some of them have this competence. Most of the time, however, they lack the time.

Photo: Octavian Coman

Irina Frunză explains: “They come in because they bought [contraceptive pills] from the pharmacy and they don’t feel well, they have bleeding or other symptoms. Others, such as students, take what their girlfriends currently take or have taken in the past, but what might work for your friend, might not work for you”.

A 2020 report by the European Bureau of the World Health Organization mentions that the fertility rate for adolescents in Romania (15-19 years) is 36 per thousand, which is high compared to the average of ten per thousand in the European Union. The document also points out that there are no reproductive health services adapted to communicating with adolescents.

Counsellors in a family planning centre also encounter young women who are pressured by their boyfriends into starting their sex life.The doctor can advise her not to do it.

“It also means the prevention of abuse, the prevention of human trafficking,” says Mateescu. “It means they start their sex life later. It means less pregnancies in minors, less sexually transmitted infections,”The former counsellor at the Ministry of Health thinks that in Romania there is a fear among decision makers about  public opinion.

“In their minds, public opinion means the religious factor, the conservative factor,” says Mateescu.

Iuliana Balteș, a family planning doctor, also says that a political decision is needed to fix the current situation. “[Politicians need] to look at the numbers and see what such programs can bring: a decrease in hospital costs, a decrease in maternal mortality, a decrease in infant mortality. If you want a task done, you pursue it. If you don’t want it done, you neglect it.”

Family planning does not mean not having children, concludes Iuliana Balteș. “Family planning means having as many children as you want, when you want them, and knowing that you have all the conditions to raise them. It means a better quality of life.”