Episode 60 - Iryna Mogilevkina

Reproductive Health Always Matters

Theme: Women and Medicine

Published: 3 September 2024

Summary
Iryna Mogilevkina is Professor of Obstetrics, Gynecology, and Perinatology at Bogolomets National Medical University in Kyiv and came to Sweden to be able to continue her research. In this podcast episode she discusses the profound impact of war and post-socialist legacies on sexual and reproductive health (SRH) in Ukraine. Iryna Mogilevkina details the pre-war SRH landscape, revealing persistent challenges despite ostensibly liberal abortion policies and the introduction of family planning initiatives. She also goes into the devastating consequences of the ongoing war in Ukraine, including disrupted access to maternal care, increased rates of violence against women, and the resulting mental health ramifications. This episode offers valuable insights into the intersection of conflict, healthcare systems, and gender equity within a post-Soviet context.

Keywords
Sexual health, reproductive rights, policy implementation, Ukraine

Suggested Link/s
Personal website: https://www.uu.se/en/contact-and-organisation/staff?query=N2-1233 External link, opens in new window.

Transcription of the Episode

Iryna Mogilevkina 00:09
War in Ukraine has resulted in crisis in access to safe childbirth and neonatal care, because very often women who was in delivery and birth needed to go in shelter or deliver outside of hospital. And of course, in this situation, fetal health monitoring can be disrupted, and it will be difficult to protect baby from freezing and emergency operative delivery can be postponed. Of course, it was some disruption in contraceptive services and safe abortion, comprehensive sexual education for youth, prevention and treatment for HIV and other sexual transmitted infection.

Natalie von der Lehr 00:53
Welcome to SCAS Talks, a podcast by the Swedish Collegium for Advanced Study. My name is Natalie von der Lehr, and in this episode, I talk to Iryna Mogilevkina, Professor of Obstetrics, Gynecology and Perinatology at Bogolomets National Medical University in Kyiv. She is an invited researcher at the Department of Women's and Children's Health at Uppsala University, and a SCAS-VUIAS fellow at SCAS during the academic year of 2023/2024. Iryna Mogilevkina's scholarly interests revolve around exploring various aspects of sexual and reproductive health in Ukraine. Her research includes the attitude of providers and patients towards care. While at SCAS, she explored sexual and reproductive health and right services, policies and status and humanity in maternal and child care in post-socialist Ukraine. And this is the third episode in our theme "Women and medicine". Very welcome to SCAS Talks and the studio.

Iryna Mogilevkina 01:59
Thank you.

Natalie von der Lehr 02:01
So very briefly then, what is your research about?

Iryna Mogilevkina 02:04
In my research in SCAS I focus on dynamics of sexual and reproductive health and rights, policies, services and status, with special emphasis on humanity in maternal care, in post-socialist Ukraine. Actually, this means looking at the women's first, their experience, the services provided. So exploring human side of sexual reproductive health. Medical humanity attempts to bridge the gap between medical science and patients' experience, but to do that, you have to understand what was around.

Natalie von der Lehr 02:40
As we all know, Ukraine was part of the Soviet Union until 1991 when it became an independent country. And then in 2014 Russia invaded and annexed the Crimea. You have looked at this different time periods in terms of women's sexual and reproductive health and rights dynamics. What was the situation like before? In 1991 when Ukraine was still part of the Soviet Union,

Iryna Mogilevkina 03:06
At that period of time, there was fertility rate around 1.9 but the total abortion rate - 2.7 per one woman. So there was no sexual education. Liberal abortion policy since 1955 on request up to 12 weeks and until 28 weeks on medical and social indications, and also the right to family planning was formally proclaimed to Europe in accordance with international conventions, it was never factualized. Contraception really plays role in control and fertility. And that was very, very low level of, let's say, oral contraceptive use, something like 6% that was huge amount of abortions. In 1990 in Ukraine that was more than 1 million abortions in the country. Abortion was main method of family planning. Actually, literature says that average Soviet woman undergoes eight abortions in her lifetime. Unfortunately, around even that was legally permitted, around 11% of abortions were illegal, and they contributed something like to 30% of maternal deaths, which actually stood to be much, much higher than in European countries, something around 38 per 100,000 live birthes. No evidence based obstretic care. Even this initiative started to develop in in the world since 1970s quite high perinatal mortality rate around 15 per 1000. Cesarean section rate around 6%, no informed consent, and I would like characterize this period like something like physician centered care for women and children.

Natalie von der Lehr 04:56
What happened then in post-socialist Ukraine, after 1991?

Iryna Mogilevkina 05:03
Unfortunately, many former Soviet Union orders still in place during 10 years, actually. It takes long, long period of time just to go through all of that. New policy has been developed, fortunately, because of democracy, non government organizations, patients organizations started to work. They started to struggle for patients' rights. During first something like 10 years, that was a lot of efforts to develop some policies and program related to HIV, because that was really big problem in Ukraine with that, and that was one of the highest speed of spreading HIV in Europe, in Ukraine. In five years after the solution of the Soviet Union, new order for neonatal care. And then something like in 10 years after the solution new orders in organizing obstetric and gynaecare come in. All policies which provided during this time, they actually been in line with international law, and that was really, really tremendous international support during this period of time. A lot of donors working, huge amount of project working, trying to help change situation, which was here.

Natalie von der Lehr 06:20
Can you tell us a little bit more about the changes? What changed there in post- socialist Ukraine?

Iryna Mogilevkina 06:26
Policies been developed, guidelines, national protocols, training arranged with international donors, within several program and afterwards they've been institutionalized. Infrastructure been developed. This three level perinatal can be developed during this period of time. Very important is that network of family planning centers, a network of youth friendly clinics, been developed during this period of time, and within that period of time, procurement contraceptive for certain disadvantaged population been actually implemented in the country.

Natalie von der Lehr 07:04
So did it change anything about the abortion rates then?

Iryna Mogilevkina 07:07
Yeah, actually that was, I believe, very important. With that was some policies, program policies, let's say that was national program of family planning, 1995 to 2000 after that, another nation program on the productive health 2001 - 2005 and safe motherhood conception developed within the country and actually productive health of nation program, 2006 - 2015. And abortion rate dropped 78%. During this period of time that was not only dropping abortion rate, that was dropping maternal mortality, maternal deaths, let's say something like around 49% drop, and perinatal death decreased something like three times. So if to look what's happened in the country, that was a lot of success in indices, improvement in care. Contraceptives, still something like sort of 8%. Still, I would like to say still low usage of overall contraceptive, even that was some increase, but still quite low. We have to understand that during this period of time that was according to data from Minister of Health and Center for AIDS statistics, number of individuals infected with HIV increase 16.5 times from 1995 to 1998. So that was period of time where a lot of policies been implemented and a lot of projects trying to stop all that.

Natalie von der Lehr 08:39
So things did improve, but a bit slow.

Iryna Mogilevkina 08:41
From my point of view, it's really slow. And actually, if to look what was done, and this is something what I'm working with my research here in SCAS, just to look why it's happened with so fantastic policies. Policies been absolutely clearly in line with international standards. Yes, it was improvement, but still, our indices - much, much worse than in European countries. So this is the way to find what's possible to do, where the gaps are.

Natalie von der Lehr 09:13
So you're looking at this in your research. What have you found so far there?

Iryna Mogilevkina 09:17
I have analyzed all these policies, and fortunately, that was possible to do. And there is success to these documents. And you can see that sometimes with very progressive policies, with a very progressive guidelines, on the way you can meet some very old fashioned instructions what to do with that. And of course, even you have some policies you actually do not know how they implemented in places. Unfortunately, in Ukraine during last two, three years, something like that, in obstetrecis and gynocology, since 2022, actually all cases personally implemented, all cases just collected in national system. Before that just was just aggregated data, and no one knows exactly what the result is. So just hospital present you something, and you do not know either to correspond to each case or not. So I believe that with this new system, we will find little bit, maybe something new with our figures, because now all cases linked to payment for these cases. That was one of the biggest problem in Ukraine, because systems still to be the same for long, long period of time when it was like semashka system, but was never a nice system, but payment was done for hospital, not for number of cases treated, for number of beds. So this means, doesn't matter how many patients you had, and now one change into the situation. Of course, it's different approach. Difficult, very difficult, especially because many things implemented during the war time. But I hope this is a way to do something, to make some change. Actually, this change better happen 20 years ago. It will be probably more quick progress in something you can look, you can find where you are and what's possible to do. And, of course, very interesting thing is that even we have so nice indices i have told you about, when coming to some discussion to professionals, and I've been involved in some research we have done, they have told about a lot of barriers to receive this care, and women were not so happy. And even in 2023 that was some information in mass media about some cases when women were treated incorrectly during delivery. So this means that even everything is doing here, we have to find where the gaps are to make improvement.

Natalie von der Lehr 10:21
Because one thing is the policy and the guidelines, and then the other one is how it translates into practice, right?

Iryna Mogilevkina 11:59
Yes, it's absolutely different things. And it can be amazing protocol provided in line with evidence based protocols. From my point of view, sometimes problem with new evidence based protocols is like, you know, there are two words in English, adaption and adoption. So when you adapt, you are trying to adjust or accommodate something for yourself. When you adopt, you just take it how it is and look for what needs to be advocated. Thus adaption can lead to the situation when very nice, evidence based protocols working well, let's say in Sweden, started to be not so evidence based in Ukraine. And now what we're trying to do, we're trying to some kind develop within some project in Ukraine, so called centers, advocations and implementation centers, where people will take, let's say, evidence based protocol. It can be from Sweden, it can be from Great Britain, because in these countries, all these protocols are really evidence based, and they really calculate money, trying to make it efficient with less amount of money. And after that, just to advocate, just to tell you see, we do not have this medicine and we need this medicine. We do not need other medicine because it was proven that only this one works. So this is something to do, and of course, it's a lot of things around here that was fantastic since in Ukraine when medical abortion been introduced, and that was many years ago. The only problem was pharmaceutical company, whose provided doses, insisted that some medicine, which has to be like one doses, should be three times higher. Even there was evidence from WHO and organizations that, what does it mean in Ukraine for this, this is the money which will be paid, not state - women have to pay by themselves, and not everybody can afford. So it's like sometimes attempt to adapt, not adopt.

Natalie von der Lehr 14:14
So how will your research contribute to the big picture here?

Iryna Mogilevkina 14:19
What I'm just planning to do this, I'm trying to answer several research questions in my research within this project, to look for dynamics of sexual reproductive health policies, programs, services, to find where the main challenges are, and I can talk about some of them and which factors affect provision of humanity in maternal care. And of course, to look for what key interventions really required to improve situation with sexual reproductive health and rights in Ukraine.

Natalie von der Lehr 14:49
In February 2022 Russia started a war against Ukraine, and it's still ongoing. What effect has this war had so far on women's sexual and reproductive health?

Iryna Mogilevkina 15:14
To talk about that we probably have first talk about some situation which was in Ukraine just before the war. Actually in the country, the old services and sexual reproductive health were very well arranged. At that point that was practically 100% birth been attended by the skilled professionals, and antenatal coverage was around 99.2% and practically there was no deliveries outside of medical facility, just around 0.1. At that point, something like 27 per 1000 women of the reproductive age deliveries and six abortion per 1000 women. And at that time, prevalence of HIV in population was around 0.9. In Ukraine, perinatal service has been arranged in three levels, and that was more than 1500 facilities, 68 hospital maternities and 14 regional perinatal centers taking care of mothers and babies. And that was huge amount of outpatient department. We actually had more than 100 family planning centers where you can get services. At the beginning of the war, there were 9.5 million women in reproductive age, and around 260,000 of them were pregnant. During the first year of war, 8 million of Ukrainians started to be refugee and around 5.4 million internally displaced people. During that period of time that was more than 1300 attacks on doctors, hospital and infrastructure in Ukraine and around 200 doctors been killed. During these attacks, around 700 hospitals been either damaged or completely destroyed. Of course, it was some change in medical staff, and during the first year, it was declared that around 40% were declined, that mean doctors, nurses and junior medical personnel. Talking about staff for prenatal maternal care, it was declined like 7% obstetrician gynecologists and neonatologists and around 12% of midwives. It was difficult to find some place of employment for those internally displaced people, and we actually missed a lot of staff. Study conducted in Ukraine shown that there was some decline in access to primary care. Let's say 20% of internally displaced people could not access to family doctors, and face certain problems when receiving pregnancy healthcare services. Actually, war in Ukraine has resulted in crisis in access to safe childbirth and neonatal care, because very often women was in delivery and birth needed to go in shelter or deliver outside of hospital. And of course, in this situation, fetal health monitoring can be disrupted, and it will be difficult to protect baby from freezing and emergency operative delivery can be postponed. Of course, it was some disruption in contraceptive services and safe abortion, comprehensive sexual education for youth, prevention and treatment of HIV and other sexual transmitted infection. And just one example to show how it was important, because during that period of time, significantly increased interest in keywords: condom, rape, HIV, syphilis. So this mean people tried to find information in internet. That was some problems with protecting people in different sexual orientation and gender identity, and of course, medical social support to victims of domestic and other type of violence. National policy has received more than 93,000 phone calls declaring that they were sexually assaulted by members or members of the Russian militaries and all these cases were verified and transmitted directly to emergency assistance centers. Actually, prosecutors in Ukraine opened and handed over to court 225 cases. But you have to know that, unfortunately, not every one report and study conducted in 2023 has shown that around 41% of people who personally encountered sexual violence will never tell about that to anyone. So problem can be even bigger. During this period of time that was dramatic drop in number of births, around 23%. It's very difficult to say what happened totally from year 2021, decrease was like 32% in delivery rate. When coming to some complications during delivery, cesarean section was increased little bit and still around 28% in the country, and that was some increase in vacuum assisted delivery and drop in forcep assisted delivery, maybe because you need to have more experience, and maybe we have missed some very professional people who has left country. Maternal deaths was lower, fortunately, than it was in year 2021, when country been affected, and all world been affected by covid pandemic. It was around 19.3 but really do not know exactly all these cases, because probably it was difficult to follow all cases. Prenatal morbidity increased, and one of the reasons for that was especially among those baby more than one kilo, asphyxia, this was four times more often. So this probably means some disruption in monitoring these babies. Prenatal mortality, fortunately, was not changed. But in structures, prenatal mortality among very little baby, before one kilo, asphyxia was a more often reason for that, and survivors during the first six days and 27 days really decreased among these very little babies.

Natalie von der Lehr 21:28
And asphyxia means lack of oxygen and blood flow to the brain, and is of course, a very serious condition. We have all seen the pictures in the news of hospitals and maternity wards that have been bombed and where pregnant women and children had to go into shelter to get care. So what about giving birth and postnatal care in shelter? What is done there to make it work, and what can be done?

Iryna Mogilevkina 21:58
To make it possible to work in shelters, that was decision taken in Ukraine and each hospital has shelter, and in each hospital and shelter that was arranged some places, not only for delivery, but for even emergency operation. So they have everything prepared here. There is generators here, in case it will be no possibility to have access to electricity. Of course, it's not so comfortable, and of course it will be a lot of women around. But hospitals really can do that. And you can imagine how difficult it can be just when there is delivery and active phase, just to move in shelter. So within that year, so I have personally been involved in some project where we have provided hospitals, 61 maternities in Ukraine with some equipment which they can use when there is restricted access to electricity. And within that project, women been involved in monitoring, because if you need to go just from hospital ward into shelter, it's very difficult to continue monitoring of the baby. So mothers been invited to do this by themselves, using ultrasound equipment, and they've been actually happy. And they really help to find cases when that was needs to help to improve situation.

Natalie von der Lehr 23:21
And this self monitoring and that sort of, in a sense, also empowers the women.

Iryna Mogilevkina 23:27
You're absolutely right, because they can do this by themselves, or their partners can do that, and they're really happy, because they can really control what is going with their babies. And actually, that was continuous monitoring provided by medical professional. What the women or their partners has done, they have monitored their baby after each contraction. So that means not like it's in protocol every 30 minutes, but each contraction. So it makes it easy to define some change with status of baby earlier, and now it started to analyze this data collected around 30,000 cases in all hospitals. And we'll see how it works. What we have found interesting, even from the beginning, all of that, that cases which has been recognized in the group where mothers has been involved in monitoring, as to compare what only physicians had done the monitoring. Actually, in these cases, there was more simple things just to improve situation was done, and situation with baby was better, less need to go for resuscitation, and there was less need for admission to intensive care for neonatals.

Natalie von der Lehr 24:44
Looking ahead, how can the health system meet the challenges of the war?

Iryna Mogilevkina 24:49
I would like to say that, that was really internal resources mobilization to do that. And from my point of view, that was the system actually been very well arranged from the beginning. From national health services that was support provided to staff even on occupied territories, just to keep help to pregnant women ongoing, not only pregnant women, to all Ukrainians living on occupied territories. That was change in rules and interns, because it was sometimes not a examined physician. Those in training for doctors, they were allowed to work officially at hospitals, and ministry of health they tried to provide equipment and supplies needed. During the whole period of war, universities provided continuous professional development trainings and medical students who teach online and continue to teach online and on on site and PhD programs running in medicine. So of course, at this point was very important international support, and I would like to say that a lot of agencies open access to international resources for Ukrainians that was training medical students and professionals abroad. And a lot of collaborative projects for development and implementation, they have been simply started during this period. But when coming to international support, I would like to underline that that was really, really important support from United Nation Population Fund. More than 200 metric tons of sexual reproductive health medical kits for obstetric and gynae care been delivered for more than 70 hospitals in Ukraine. And all this equipment designed to ensure health and well being of the mothers and children during pregnancy, childbirth and postpartum period and medical assistance in case of rape, unprotected sex, and of course, providing contraception. During this period of time, 25 sexual reproductive health mobile clinic being open and started to work in Ukraine with support of UNFPA. They provide free contraception, they provide counseling for HIV, sexual transmitted infections, Women's Health Counseling during pregnancy. Of course, they provide medical and social psychological support to victims of domestic and other kind of violence, including those related to war. Another very important initiative is sexual reproductive health barriers, free surgeries. So that was 86 gynae offices with barrier free access in Ukraine will open for local residents or internally displaced women, victims of gender based violence and people with disabilities, to receive quality medical and psychological assistance. During this time, that was a lot of project related to different types of violence, mental health, and I have told about that project for support for prenatal care in our hospitals. What's possible to do but first we need to stop war. And of course, we need support from international institutions, donors to support our hospitals. And of course, we need support in future, when war will we stop. For our development, staff training, continous support it's crucial, important, yes.

Natalie von der Lehr 28:19
But I'm very fascinated about the resilience and also the level of preparedness.

Iryna Mogilevkina 28:24
You see, situations can be different. First of all, Ukraine been quite well developed. System was quite well developed. There is national health services provide packages for different areas, for different services provided in Ukraine. And international organization, international donors, done amazing, and we're really grateful to everybody who support us. Protect our land, protect our sky, protect our people. Thank you for all of that.

Natalie von der Lehr 29:03
You're as SCAS-VUIAS fellow. You are in residence at SCAS during this academic year, 2023/2024. We can start at SCAS. What is your experience of the multi- and interdisciplinary research environment here at the collegium?

Iryna Mogilevkina 29:18
The Swedish Collegium of Advanced Study is renowned for its commitment to fostering interdisciplinary research and providing a conducive environment for scholars to engage in cutting edge research. The opportunity to collaborate with researchers from various fields significantly enhanced my project scope and its potential impact. In SCAS I have decided to look for several new aspects. For humanity and mental care, let's say role of pushing of non evidence based medicine in sexual reproductive health services by pharmaceutical companies in the country of transition, and role of lack of English knowledge among health providers in promoting non evidence based approaches and maternal care published in Russian journals, as a result of being able to read publications only in that language. Several ideas for new research came here, let's say, semi structured interview on birth experience with women delivering their first baby during that period of time, and qualitative analysis of complaints on sexual reproductive health services by clients and their families to understand more in deep gaps in humanity of service providers. So actually, in SCAS there is amazing opportunity to work in multi- and interdisciplinary environment. And honestly, unbelievable chance to look for your research from absolutely unpredictable site. For example, here with astrobiologist Natushka Lee, we have participated in grant application for the project to aim to study rule on science fiction in education and attracting news to research. So this is something which can never come to my mind before.

Natalie von der Lehr 31:16
But you're also a fellow of VUIAS, and VUIAS stands short for Virtual Ukrainian Institute of Advanced Study. You're in the first cohort of fellows. So what is this like to be a fellow at this virtual Institute?

Iryna Mogilevkina 31:32
It's unique project, because for the first time, with help of international reviewers and under a international umbrella that was selected cohort of Ukrainian scientists in different research areas, fields, different ages, different academic positions, who are involved in absolutely not typical for Ukrainian science, multidisciplinary discussion. This as a step to create new approach in science development in Ukraine. I would like to say some kind of scientific freedom, where researchers can openly planning and sharing their studies with colleagues, trying to find solutions, in collaborations with researchers from other fields of knowledge and sharing their findings with colleagues from different fields. This is unique opportunity for Ukrainian researchers to find simple words to present their research to those who are not professional in your field. Open opportunity for collaboration, developing network for scientists with Ukraine and with an international scientific community, which is really crucial for future of Ukrainian science.

Natalie von der Lehr 32:51
Your cohort, some of you are at other Institutes of Advanced Studies, like you, you're here at SCAS, and some are actually in Ukraine.

Iryna Mogilevkina 32:59
You're absolutely right. Some people still in Ukraine, and something like half of people working in different institutions, like Advanced of Studies abroad in Netherlands, in Romania and in Bulgaria and Germany, majority in Germany. It's really a fantastic opportunity for people to communicate. And we have, every two weeks, we have meetings, we have our seminars, and like here in SCAS, we discuss a project related to different topics. They're not only social science, there are people from natural science, and I believe that this is something like basic maybe for future development of new researchers in Ukraine, open minded. And I realize it, because it works like trying to keep Ukrainians with Ukraine, not something like brainwashing, just to let people to go out. And this is very important, being on top of that idea. That was really great idea to join researchers and to let them to go ahead, just to develop new cohort of people looking around, trying to find a way for their own country to be developed and grow.

Natalie von der Lehr 34:21
Thank you for coming here to the studio and talking to me and to our listeners, of course.

Iryna Mogilevkina 34:26
Thank you very much.

Natalie von der Lehr 34:30
And thank you for listening to SCAS Talks, a podcast by the Swedish Collegium for Advanced Study. In this episode, I've talked to Iryna Mogilevkina, Professor of Obstetrics, Gynecology and Perinatology at Bogolomets National Medical University in Kyiv. She's an invited researcher at the Department of Women's and Children's Health at Uppsala University, and a SCAS-VUIAS fellow in residence at SCAS during the academic year of 2023/2024. We have talked about women's reproductive health in Ukraine, both during the current war and in post socialist times. And this was the third episode in our theme "Women and medicine". Why do women go to the doctor twice as often as men? That was the title of the first episode within this theme. There Anat Biegon told us more about bias and education about women's health and Stefan Enroth has told us more about self sampling for better screening and diagnosis of gynecological cancers. And these are episodes 57 and 59 respectively. SCAS Talks features a broad variety of topics, which is a reflection of the multi- and interdisciplinary research environment at the collegium. We're sure that there's something of interest for everyone. Tune in, find your favorite topic or surprise yourself with something new. And as always, we're very happy if you can recommend SCAS Talks to your colleagues and friends. Subscribe to us and you won't miss any new content. SCAS Talks is available on podbean, Apple podcast, Spotify and most podcast apps. I would like to thank Iryna Mogilevkina once again for talking to me, and of course, thanks to you for listening. Bye for now.

Transcribed by https://otter.ai