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Article Excerpt
Internationally, high abortion rates often are considered an indication that women's access to effective contraceptives is inadequate. (1) In Russia, rates of induced abortion have long been high, (2-4) and abortion-related complications are common; (5-7) the limited information available suggests that use of modern family planning methods vanes widely by region but is generally low. (8) Recent political concern about declining fertility, and consequently population size, (9) has resulted in government pressure on family planning organizations to limit the provision of family planning (5,8,10) and in legislation to restrict abortion. (8) Although these policy proposals are founded on reasonable knowledge of the number of abortions, relatively little is known about contraceptive use in Russia. In this study, we seek to understand how patterns of contraceptive use have changed on a national level and how these changes relate to national trends in abortion and fertility.
FAMILY PLANNING IN THE SOVIET ERA
Historically, induced abortion was the most commonly used method of preventing unwanted childbirth in the Soviet Union. Abortion was legalized by the Bolshevik regime in 1920; this legislation was revoked during the 1930s, (11) and then reinstated in the 1950s. By the 1960s, the abortion rate was 160 per 1,000 women aged 15-49; (5) this high rate continued until the 1980s, when abortion levels began to decline, (5) particularly in Estonia and Latvia. (12) Nonetheless, in 1988 the Soviet Union accounted for 10-20% of the world's abortions. (2) Official data indicate that women aged 15-49 had 1.2 abortions for every live birth; in some regions, they had seven abortions for every live birth, the highest ratio ever recorded. (2) Moreover, these figures may be underestimates: The true ratios may have been twice as high if illegal abortions are taken into account. (2) In a survey conducted in St. Petersburg shortly after the collapse of the Soviet Union, only 14% of women aged 15-65 reported that they had never had an abortion. On average, respondents had had three abortions by age 25, and a small proportion had had more than 20 in their lifetime. (13)
Lack of access to a wide range of contraceptives, coupled with limited knowledge and information, was thought to underlie these high abortion rates. (2) The state had a monopoly on medical supplies, modern contraceptives were in short supply> and the quality of Soviet condoms was notoriously poor. (15) Misinformation may have influenced attitudes toward contraception: The introduction of oral contraceptives in the 1970s was accompanied by government propaganda warning women and doctors of many unsubstantiated risks, and the officially published contraindications applied to 80-90% of potential users. (14) The government's stance may have reflected its concerns about ensuring regular supplies to a widely dispersed population. (16)
Nevertheless, use of modern contraceptives increased gradually during the 1980s, (5) although use remained much less frequent than it was in the West. In each of five studies conducted during that period (three in Moscow, one in Saratov and Moscow, and one in Tartu and Moscow), just 2-3% of women were using oral contraceptives, and approximately 10% were using IUDs, (14) which were often inserted following abortion. * (3) However, more than half of women in these studies were using traditional methods, such as douching or withdrawal, which are unreliable, (17) and many sexually active women were taking no precautions to avoid unwanted pregnancy. (14)
RECENT TRENDS
Access to contraceptives appears to have improved in Rassia following the disintegration of the Soviet Union. Between 1989 and 1993, the proportion of St. Petersburg women who believed that access was "adequate" rose from 12% to 38%; nonetheless, even in 1991, 41% of women reported using traditional methods. (13) Women younger than 25 were more likely than older women to be using a modern method; 35% were using an IUD, and 10% oral contraceptives. (13) A 1996 survey in two cities (Perm and Yekaterinberg) and one rural area (Ivanovo Province) showed that one-third of women aged 15-44 were using an IUD; however, only one in 10 were using condoms, and fewer still oral contraceptives. (18) Another option became available when sterilization was legalized in 1993, overturning a ban that had been in effect since the 1930s. (5)
Despite these advances, the availability of family planning was limited during the early 1990s; only 1% of 15-67-year-old women in St. Petersburg believed that services were satisfactory, and most resented paying the necessary bribes. (13) The low level of clinician knowledge was a further obstacle. In one study, just half of gynecologists reported having received training in family planning, and fewer than two-thirds knew how oral contraceptives worked. (19) However, women's awareness of modern contraceptive methods was improving, and was almost universal in Yekaterinberg and Perm by 1996. (18)
Between 1990 and 2000, the number of abortions in Russia declined by half. (3) Although this decrease coincided with a major reduction in fertility, the ratio of abortions to live births declined only slightly in the early and mid-1990s, from 2.04 abortions per live birth in 1990 to 1.92 in 1996; this was followed by a steeper decline, to 1.56 abortions per live birth in 2000. (6) While changes in the recording of abortions occurred after the breakup of the Soviet Union, the decline in the abortion rate is thought to be genuine, since it was documented in both survey and official data. (3) The reliability of the survey data is further supported by evidence that women almost always report a "miniabortion" (vacuum aspiration during the first seven weeks of pregnancy) as an abortion, (20) although they do so less often if they have had multiple abortions. (21)
Nonetheless, abortion remains much more common in Russia than in western Europe. (8) Moreover, Russia's total fertility rate has fallen sharply, from 2.0 births per woman in 1989 to 1.2 in 1999; despite a subsequent rise, it was still only 1.3 in 2004. (22) The combination of low fertility and high premature adult mortality has led to a shrinking population. (9) However, it is uncertain whether improved access to contraceptives accounts for the declines in abortion and fertility Some researchers have argued that fertility has declined because the pronatalist policies of the 1980s led women to reduce the intervals between births, so that by the 1990s many women had achieved their desired family size; (23) however, this theory does not explain why the fertility rate remains low today
At least two structural and political factors in Russia may be promoting abortion and limiting access to effective contraceptives. First, health care providers may have little financial incentive to provide family planning services. During the Soviet era, a three-day hospital stay was mandatory for an abortion, and even now the procedure (excluding miniabortions) must take place in a hospital; as a result, abortions represent an important source of income for providers and help justify the retention of otherwise underutilized hospital facilities. (5) Second, national concern about declining fertility has led to policies that may have detrimental effects on family planning. For example, government financial incentives encourage women to have more children, (9) legislation...
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