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Article Excerpt
Over the last several years, Russia has had one of the highest rates of induced abortions in the Baltic region, in addition to a comparatively low use of reliable contraceptives. (1) Although medical personnel generally discuss the use of modern contraceptives with their female patients, and contraceptives are widely available, induced abortion remains one of the main methods of family planning in Russia. While the abortion rate in Russia has declined in the last decade, it is still twice the rate in Estonia and five times the rate in Finland. (1)
In most countries that have low abortion rates, contraceptive use has been encouraged. (2) In the 1990s, an estimated 75% of western European women who were in a steady sexual relationship used reliable contraceptive methods, while in the former Soviet countries the proportion among women of reproductive age was much lower; in Russia, it was estimated to be 25%). (3,4) The impact of recent changes in reproductive health policy in Russia--including restriction of the conditions under which abortion is permissible--can only be assessed at some point in the future. (3)
Historically, induced abortions were very common in Russia, and contraceptive methods were rarely or half-heartedly introduced into practice. Negative attitudes of health care providers were often supported by government policy. For example, in 1974, the USSR Ministry of Health forbade the use of oral contraceptives for contraceptive purposes, though it was prescribed to treat some medical conditions. (5) A ministry document from 1974 listed about 30 contraindications for oral contraceptive use, (6) including cancer risk; most of these contraindications were not cited in other countries' medical recommendations, and current understanding shows them to be inaccurate. Moreover, the ministry monopolized the importation and distribution of medicines. (5) Hence, oral contraceptives and other modern methods were not generally available until the latter half of the 1980s, in part because of providers' negative attitudes. (7,8) As modern contraceptives became increasingly available, use of the pill and the IUD in urban Russia rose at the end of that decade. (5)
Following the collapse of the Soviet Union in 1991, new actors--such as private health care providers, Western pharmaceutical companies, commercial mass media, international foundations and agencies, new nongovernmental organizations and the Russian Orthodox Church--began to play a role in family planning. The church has opposed sex education in schools, (9) while mass media, influenced by pharmaceutical companies, have promoted oral contraceptives and IUDs. But providers of obstetric and gynecologic services had a financial interest in the provision of abortions, and this may have slowed the growing use of contraceptives. Conflicting messages about and approaches to preventing unintended childbearing may have led to misperceptions and confusion among potential contraceptive users regarding the safety and effectiveness of different contraceptives, further impeding the shift away from reliance on abortion.
The factors associated with contraceptive use have been extensively studied in many European countries. (4,10) At the individual level, use of reliable contraceptives has been associated with being single, high education level and high income, as well as other social, demographic and behavioral characteristics. (4,10,11) For example, older women have an increased likelihood of using the IUD, and younger women have an increased likelihood of using the pill. (4) No current data are available from representative Russian surveys on women's knowledge of, attitudes toward and practice of contraception. A study in the mid-1990s among health service users showed high awareness of contraceptive methods, but not accurate, comprehensive knowledge or widespread use, (12) and a study among adolescents in the early 1990s found that they had poor knowledge about and negative attitudes toward condoms. (13) Because of the limited research and the dramatic changes in Russia's socioeconomic situation, we set out to study characteristics associated with using different contraceptive methods and abortion, among women of reproductive age living in St. Petersburg.
St. Petersburg is the second largest city in Russia, with a population of 4.7 million. Women's clinics are part of the city's public health care system, and they provide a wide range of reproductive health services, mainly through gynecologists and other specialists, such as therapists and psychologists. This study was conducted as part of the REFER Project, (14) whose aim is to assess reproductive health and health services in Russia and St. Petersburg since the collapse of the Soviet Union. The bordering nations of Estonia, another former Soviet state, and Finland are used as comparison countries in the larger project. Estonia was part of the Soviet health care system, but is culturally closer to Finland; the latter is a Nordic welfare country with a low abortion rate. Because data in countries of the former Soviet Union are scarce and often unreliable, REFER's comparative approach helps put new information on reproductive health and associated services in perspective.
METHODS
Procedures
Data were collected between November 2003 and October 2004 in a survey that was conducted by the REFER research group and that has been described elsewhere. (14) For the sake of feasibility, we restricted our study to two districts out of 20: Krasnogvardeyskiy is a residential suburb consisting of areas with populations of diverse socioeconomic status, and district residents are mostly employed in light industry and construction; Primorsky has recently experienced an increase in home-building, and has attracted an influx of businesspeople.
The sample was drawn from databases maintained by the district authority police departments. In these two districts, there were 90,532 women of reproductive age, who were served by three women's clinics; 2,501 women born between 1959 and 1985 were randomly chosen for the study. We sent each woman an invitation letter that described the study and gave contact information for the researchers and for the participating clinics. The letter informed recipients that they would be contacted by telephone to arrange a visit to one of the clinics, where they could complete the confidential survey questionnaire; the questionnaire included 109 closed-ended questions and took about a half hour. Completed questionnaires were placed in an unmarked envelope by the respondent, and so all surveys were anonymous. After completing...
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