Changes in women s health in the Baltic republics of Lithuania, Latvia and Estonia during

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1 Ž. International Journal of Gynecology & Obstetrics Changes in women s health in the Baltic republics of Lithuania, Latvia and Estonia during ˇ R.J. Nadisauskiene, Z. Padaiga a, ˇ b a Department of Obstetrics and Gynecology, Kaunas Uni ersity of Medicine, Kaunas, Lithuania b Department of Pre enti e Medicine, Kaunas Uni ersity of Medicine, Kaunas, Lithuania Abstract The rapid political, economic and social changes occurring in the Baltic republics of Estonia, Latvia and Lithuania fundamentally affect female health. Demographic trends, morbidity and mortality indicators point to a general decline in the status of women s health in the three Baltic republics since their independence from the Soviet Union. The transition period from socialist to market economy has clearly taken a toll in women s health. These have to be taken into consideration by health authorities in Lithuania, Latvia, Estonia as well as the European Union during the undergoing reforms being planned for healthcare systems in all EU countries in accession International Federation of Gynecology and Obstetrics. Keywords: Baltic republics; Females; Main health indicators 1. Introduction The rapid political, economic and social change occurring in the three Baltic countries Lithua- Corresponding author. Tel.: ; fax: address: lagd@lcn.lt Ž R.J. Nadisauskiene ˇ.. nia, Latvia and Estonia since reestablishment of their independence from the Soviet Union in 1990 has created new situations that fundamentally effect women s health. Together with other newly independent states of the former USSR in the beginning of the 1990s all three Baltic republics have experienced deep economic crisis. The encouraging signs of macroeconomic stabilization that appeared in 1994 have evolved $ International Federation of Gynecology and Obstetrics. Ž. PII: S

2 200 R.J. Nadisauskiene, ˇ Z. ˇ Padaiga International Journal of Gynecology and Obstetrics 70 ( 2000) Table 1 Change of gross domestic product, US$ per capita and unemployment rate during in Estonia, Latvia and Lithuania Year Estonia Latvia Lithuania GDP per Unemployment GDP per Unemployment GDP per Unemployment capita Ž US$. Ž %. capita Ž US$. Ž %. capita Ž US$. Ž % into a sustainable economic revival. The continued decrease in inflation, the growth of GDP, increased foreign investment, relatively low and stable unemployment, favorable changes in the balance of payments and privatization were all indicators of a transformation within the economical sector. Since 1992 the real GDP per capita was growing in all three countries, with the unemployment rate continuously increasing ŽTa- ble 1.. The transition from socialist to market economy has been marked by specific trends in healthcare development. The shifts in health indicators especially in women in the three republics have been rather similar and form the subject of this paper. 2. Demographic trends Since 1980, there has been a steady decline in the natural growth of population in all three Baltic republics. A simultaneous increase of all- Fig. 1. Trends, natural population growth rate.

3 R.J. Nadisauskiene, ˇ Z. ˇ Padaiga International Journal of Gynecology and Obstetrics 70 ( 2000) 201 cause mortality has resulted in negative population growth since The decline was especially great in Latvia Ž 6.9. and Estonia Ž 4.9. in In Lithuania natural growth is also below zero although most recent trends show some signs of recovery Ž Fig In general, population age structure and urban rural ratio in the Baltic republics is close to the EU average. Due to increased life expectancy the aging of the population has started with the proportion of population older than 65 years increasing Ž Fig. 2.. Due to higher male mortality a female predominance is observed. In 1997 the life expectancy at birth for females was 76 years in Lithuania and Estonia, 75 years in Latvia. The respective figures for males were 66, 65 and 64 years. A more than 10-year difference between female and male life expectancy was extremely large if compared to the 5-year difference within EU countries 1. Approximately one-third of women s life is spent postmenopause. This postmenopausal period is associated with high health risks. Osteoporosis-related morbidity is affecting increasing numbers of women. For many years the problems of menopause were underestimated in the Baltic Fig. 2. Trends, proportion of population aged 65 and more. Republics. However, in the last decade, great efforts have been made to raise awareness in society and to change the attitude of healthcare practitioners towards the management of the climacteric period of life. Elaboration of the consensus guidelines on diagnosis, treatment and follow-up of menopause patients is under way in all three Baltic Republics. Fig. 3. Mortality from cancer, females aged 0 64, latest available data.

4 202 R.J. Nadisauskiene, ˇ Z. ˇ Padaiga International Journal of Gynecology and Obstetrics 70 ( 2000) Fig. 4. Mortality trends, cancer of the cervix, age Main health indicators 3.1. Trends in main causes of mortality In most European countries the leading causes of death among women are diseases of the cardiovascular system Ž CVD., cancer and external causes. They account for approximately 52%, 18% and 15% of all deaths, respectively. Standardized death rate Ž SDR. per from cardiovascular diseases among women in the Baltic region was lowest in Lithuania being 22.1 in 1997, but it was almost three times the EU average of 7.7 Ž In Estonia the SDR was 26.7 Ž 1997., while in Latvia the rate was the highest being 32.8 in The most common cancer seen in women in Baltic Republics was breast cancer, followed by cancer of the ovaries and uterus, skin cancer and stomach cancer. Almost half of all cancers were diagnosed during the third or fourth stage ŽFig. 3.. In 1997, the SDR from breast cancer was highest in Estonia Ž 20.2 per , followed by Lithuania with 18.4, while in Latvia it was The EU average in 1996 was 19 Ž Mortality due to cervical cancer during 1997 in Lithuania was among the highest in Europe 8.1 per of population. In Estonia it was 6.5, while in Latvia it was 4.4. The EU average in 1996 was 2 per Ž Fig In all republics of the former Soviet Union a wide network of oncological services was created: cancer specialists present in almost every outpatient department of hospitals worked under supervision of highly specialized oncology centers. Gynecologists were not involved in prevention, diagnosis and treatment of breast cancer. They put greater emphasis on diagnosis and treatment of advanced cases than on early detection of cases Fig. 5. Mortality from external causes, females, latest available data.

5 R.J. Nadisauskiene, ˇ Z. ˇ Padaiga International Journal of Gynecology and Obstetrics 70 ( 2000) 203 victims indicated personal violence from the police Trends in morbidity of some infectious diseases Fig. 6. Mortality trends, suicide and self-inflicted injury. and high-risk groups. Screenings were occasional, and did not cover the entire population at risk. Although significance of preventive programs is currently recognized in all Baltic republics, the main obstacle for their implementation is lack of financial resources that are still mainly allocated for in-patient care. Death due to external causes has been falling within the EU since In Baltic countries, mortality from external causes among women exceeded the EU average in 1996 Ž Fig Standardized death rate from suicides and selfinflicted injury increased from 25.8 in Latvia, 27.3 in Estonia, 27 in Lithuania in 1990 to 34.9, 35.2 and 44.8 per in The EU average was 11.3 in According to the latest available data Lithuanian men and women were in the worst position among other Baltic republics ŽFig Violence against women as a public health issue has received limited attention. However, under financial support of United Nations UNIFEM foundation Lithuanian Women s Issue Information Center in carried out the project Stop violence against women. Data from the study indicated a worrying and underestimated situation: 42.2% of women had at least once suffered physical, sexual or psychological abuse from their current male partner; 63.3% of women over the age of 60 had at least one experience of physical or sexual violence; 10.6% of Decline in general living standards and reduction of quantity and quality of preventive programs has led to a rise in the incidence and prevalence of infectious diseases. According to the latest data available, incidence of tuberculosis per population in Lithuania reached 79, in Latvia it was 68.4, in Estonia it was 42.7, while the EU average was 13 per The rise in tuberculosis has been attributed to poverty, alcohol abuse, inadequate preventive activities, late diagnosis and ineffective treatment. Since 1990 a dramatic increase in reported cases of sexually transmitted diseases Ž STD. in the Baltic countries has been observed. The incidence of syphilis has reached epidemic levels, from 5 15 per population in 1990 to more than 100 per by 1997 Ž Fig. 7. 1,3. The incidence of congenital syphilis has doubled since 1996 in many countries, reflecting an increase in the prevalence of untreated syphilis among pregnant women. The incidence of syphilis has served as the most reliable indicator for trends of STD in the region. For other STDs, patients are more likely to seek treatment in the growing private sector, or to treat themselves. Based on the rate between reported cases of gonorrhea and Fig. 7. Incidence of syphilis per

6 204 R.J. Nadisauskiene, ˇ Z. ˇ Padaiga International Journal of Gynecology and Obstetrics 70 ( 2000) syphilis it is considered that only 1 in 20 cases of gonorrhea is currently reported. A high incidence of STD causes a high incidence of pelvic inflammatory disease Ž PID.. According to the survey carried out in Latvia in 1997, 27.5% of reproductive age women have had episodes of PID 4. Pelvic inflammatory disease and it s consequences ectopic pregnancy, infertility, chronic pelvic pain are common reasons for costly in-patient treatment. There is a great difference between the Eastern and Western schools in classification, diagnostic criteria and treatment of PID that led to great confusion among gynecologists and statisticians 5. Principles of evidence-based medicine in the management of PID are becoming more and more integrated in the national guidelines and reproductive health policy making in Baltic countries 6. Incidence of clinically diagnosed AIDS has increased during last few years in all Baltic countries, but it is significantly lower than the EU average Ž Fig. 8.. However, the recent outbreaks of HIV infection among intravenous drug users in the neighboring Belarus and Kaliningrad regions of the Russian Federation are extremely alarming. Considering the high incidence of STDs in the region it is easy to predict rapid spread of HIV infection in Baltic countries 1,3. 5. Maternal and child health In the Soviet Union, medical termination of pregnancy Ž MTP. on request up to the 12th week of gestation was legalized in Until recently, MTP was the most common method of birth control. According to latest data available, in 1997, the number of MTP per 1000 live births in Lithuania was , in Latvia and in Estonia. The EU average in 1995 was only According to the Lithuanian Family and Fertility Survey conducted in , the majority of the Lithuanian population starts its sexual life at the age of years. Today contraceptive usage among young people is slightly more popular than years ago. However, the use of contraceptives is far behind other European Fig. 8. Incidence of AIDS per countries. Oral contraceptive pills account for 4.1% of contraceptive-usage, intrauterine devices Ž IUD. account for 17%, condoms account for 19.2%, abstinence and rhythm method accounts for 17%, withdrawal method-for 19.4% while other methods account for 2.6% 8. The most popular methods of contraception in Lithuania are condoms, periodical abstinence, withdrawal and intrauterine devices. The low usage of effective contraceptives and widespread usage of unreliable contraceptive methods are responsible for a Fig. 9. Live births per 1000 women aged years.

7 R.J. Nadisauskiene, ˇ Z. ˇ Padaiga International Journal of Gynecology and Obstetrics 70 ( 2000) 205 great number of unplanned pregnancies, pregnancies among teenagers and abortions Ž Fig. 9.. The choice of contraceptive measures is less affected by religious beliefs, and more by education and place of residence. Rural inhabitants and poorly educated people resort to contraceptives less frequently 8. High abortion figures and low contraceptive prevalence in Baltic and neighboring countries can be explained by several reasons: Ž. 1 family planning was regarded as purely a medical issue; Ž. 2 women regarded medical termination of pregnancy as a method of contraception ; Ž. 3 lack of modern and effective methods of contraception until recent years Žthough available, they are relatively expensive and there is no system for reimbursing high risk groups.; Ž 4. negative public opinion and attitude of doctors towards hormonal contraception; Ž. 5 lack of counseling services in primary healthcare systems and sex education in schools. Gynecologists working in women s outpatient clinics mainly carry out the educational work on issues of family planning 3,7 9. Of late, some promising changes are being observed in the field of family planning: in most major outpatient women clinics family planning centers have been established, youth-friendly centers have been set up and since 1995 pharmaceutical companies have constantly reported a rise in sales of oral contraceptives. In the last decade non-governmental organizations, national societies of obstetricians and gynecologists and associations of sexual health and family planning are constantly promoting effective methods of contraception. Since 1980, the maternal mortality rate has declined in all Baltic countries. The highest maternal mortality rate per live births in 1997 was observed in Latvia Ž In Lithuania and Estonia these figures were considerably lower being and 15.84, respectively, while the EU average in 1996 was The main causes of maternal mortality were systemic diseases, septicemia, hemorrhage, and amniotic fluid embolism 1,9,10. Since 1991 the WHO recommended definition of perinatal mortality Žfrom a birth weight of 500 g and 22 weeks of gestation. were introduced in Fig. 10. Perinatal mortality rate per 1000 live births. Baltic countries. Since 1992 with the financial support of the Swiss government, the Program of Perinatology was implemented in all three Baltic republics. Due to reorganization of perinatal services, establishment of modern equipped neonatal intensive care units in Perinatal centers, organization of the neonatal transportation system. The main indicators of perinatal care decreased remarkably. Perinatal mortality rate in 1992 in Lithuania was 14.1, in Estonia 15.9, in Latvia 19.4 per 1000 births. In 1997, it was lowest in Lithuania Ž 7.7. and almost reached the EU average of 6.9 Ž while in Estonia it was 9.6 and in Latvia 14.8 Ž Fig The main causes of perinatal mortality were preterm birth, malformations, and Fig. 11. Infant mortality rate per 1000 live births.

8 206 R.J. Nadisauskiene, ˇ Z. ˇ Padaiga International Journal of Gynecology and Obstetrics 70 ( 2000) stillbirths 1,9,11. Infant mortality rate per 1000 live births in 1997 was 10.3 in Lithuania, 15.4, in Latvia, 10.1 in Estonia while the EU average Ž was 5.7 Ž Fig Approximately 10 years ago, antenatal wards, labor rooms and nurseries were under strict, closed hygiene regime. Routine enema and pubic shaving in preparation for delivery were used. Routine lithotomy position for the second stage of labor was practiced. Routine episiotomy for preterm birth was encouraged. Tracheal suctioning and medicated bathing of all newborns was required. After delivery routine nursery care for babies in hospital was performed. Mothers breastfed babies only 5 6 times per day. Test weighing of breastfed infants was used. Visits of family members after delivery were restricted. Mothers were able to visit their newborns in the intensive care units only a few times a day 12. Tremendous changes have happened in the reorganization of maternal and newborn healthcare in the last decade. Huge attempts have been made in order to change the attitude of the medical staff, to improve practices and routines, to maintain an atmosphere of normality, sensitivity to mother s and newborn s needs, ensuring quality of care according recommendations of evidence based medicine. The role of midwife was emphasized. Breast-feeding initiatives were highly encouraged. This large impact has had close collaboration with Scandinavian colleagues in various forms and levels of healthcare organization. A transition in many aspects of social live and in healthcare system tends to make women more vulnerable. Demographic trends, morbidity and mortality indicators point to a general decline in the status of women s health in the three Baltic republics since their independence from the Soviet Union. The transition period from socialist to market economy has clearly taken a toll in women s health. These have to be taken into consideration by health authorities in Lithuania, Latvia, Estonia as well as the European Union during the undergoing reforms being planned for healthcare systems in all EU countries in accession. References 1 Health for all data base. WHO EURO, Purvaneckiene G. Violence against women: survey of victimological study Ž WIIC UNIFEM. Vilnius Ž LTH. 1999: Task force for the urgent response to the epidemics of Sexually transmitted diseases in the Eastern Europe and Central Asia. Report of the first meeting of the task force Ž WHO EURO, UNAIDS.. Copenhagen, 1998:29. 4 Lazdane M, Bukovskis M. Epidemiology of sexually transmitted disease in the Baltic countries. Acta Obstet Gynecol Scand 1997;76: Lazdane G. Management of pelvic inflammatory diseases. The comparison of the Eastern and Western experience. Medicina 1997;33: Lazdane G. Pelvic inflammatory disease. Summary of the habilitation work: monography. Riga 1999:24. 7 Karro H. Abortion in the framework of family planning in Estonia. Acta Obstet Gynecol Scand 1997;76ŽSuppl 164.: Klimas V, Baublyte M. Fertility regulation in Lithuania: situation and attitudes. In: Stankuniene V, Mitrikas AA, editors. Lithuanian family and fertility. Vilnius: LTH, 1997: Sinimae H. Recent developments in perinatal problems in the Baltic countries. Acta Obstet Gynecol Scand 1997;76Ž Suppl 164.: Maciuliene K, Rudaitiene L. Maternal mortality in Lithuania during period Lithuanian General Practitioner Ž LTH. 1997;1: Basys B, Badikonyte MR, Vezbergiene N et al. Perinatal mortality trends in Lithuania. Lithuanian J Obstet Gynecol Ž LTH. 1999;2: Nadisauskiene R. A professional organization makes a difference in Lithuania. World Health 1998;51:26 27.