Abortion and Contraceptive Use in

the Russian Federation

by Molly Strachan, Ruth Berg, and Victoria Sakevich

August 2000

ABORTION AND CONTRACEPTIVE USE IN THE RUSSIAN FEDERATION

Prepared by Molly Strachan, Ruth Berg, and Vika Sakevich

INTRODUCTION In 1994, endorsed the principles and objectives set forth in the International Conference on Population and Development’s (ICPD) Programme of Action. The Programme of Action recognizes reproductive health as a fundamental human right, and it encourages countries to work toward an environment in which women and men are able to make informed choices about fertility regulation, and have access to affordable, safe and effective methods of family planning. Although Russia has taken legislative steps in support of the ICPD Programme of Action, current funding limitations may hinder its ability to achieve ICPD objectives, thereby limiting access to safe and effective family planning methods. Contraceptive access is also threatened by mounting concerns among certain groups of the society that contraceptive use is at least partly to blame for the decline of Russia’s population over recent years.

As policymakers make decisions about family planning services, it is important that they understand the relationship between contraception and abortion. Russia has one of the highest rates of abortion in the developed world. Worldwide experience suggests that as contraception becomes more widely available in countries where are common, a “replacement effect” often occurs (i.e., women choose contraception over abortion to prevent unwanted fertility). Moreover, in many settings this leads to an overall improvement in women’s health status, a reduction in maternal mortality and morbidity, and a reduction in secondary infertility. The purpose of this paper is to review these global experiences.

BACKGROUND OF DEMOGRAPHIC AND FAMILY PLANNING SITUATION IN RUSSIA The size of the population in the Russian Federation has been declining since 1992. Sub- replacement fertility, high levels of mortality and morbidity in comparison with other developed countries, and migration patterns have contributed to Russia’s demographic trends. Currently, the annual number of deaths exceeds the annual number of births (Goskomstat, 1999b), although the recent situation is a result of the demographic trends in previous decades.

Fertility: Low fertility is the main cause of the recent population decrease in Russia. Estimated at 7.5 births per woman on average in 1896, the reached 2.1 births per woman (the number of children needed for the population to replace itself) in the mid-1960s, and since then Russia has experienced sub-replacement fertility. During the 1990s the fertility rate began to decline rapidly and was most recently calculated at 1.24 births per woman (Goskomstat, 1999a). Russia is not alone in experiencing such trends. To date, 44 percent of the world’s population live in countries with below-replacement fertility, including almost all of Europe, East Asia, Thailand, and Cuba (Ross and Frejka, 1998).

Russia is undergoing a fertility transition, associated with an increase in the mean age of childbearing, which is called a “second demographic transition” (Population of Russia, 2000). The mean age of childbearing decreased steadily up to the mid-1990s and in 1995 more than 60

2 percent of the total fertility rate was attributable to women under the age of 25 (Population of Russia, 2000). Fertility rates are highest among women aged 20–24. However, in the last few years fertility has tended to decline in women under 20 and increase among women 30 years and older (Goskomstat, 1999a).

The two-child family has been the ideal for Russians for more than 25 years and remains so today. The 1996 Russia Women’s Reproductive Health Survey (VCIOM et al., 1998) finds that 65 percent of newly married couples want two children while 24 percent want only one child. Yet, many women are postponing births.

Mortality: Trends in mortality have been so alarming that some call the situation a “demographic crisis” (Becker and Bloom, 1998). Worldwide, life expectancy increased by 13 years for males and 14.1 years for females between the 1960s and 1980s (Bennett, Bloom, and Ivanov, 1998). In Russia, however, life expectancy only increased by 1.8 years for males and by 2.9 years for females between 1958–1959 and 1988 (Goskomstat, 1994). The gap in life expectancy between Russia and , North America, and Japan has been increasing since at least the mid-1960s. By 1994, life expectancy fell to a new low for males in a setting absent of war and famine – 58 years of age, well below comparable data from other industrialized countries. Recent progress can be noted in the 1998 figures for life expectancy at birth for males (61.3) and for females (72.9) (Goskomstat, 1999a). A large portion of mortality is due to cardiovascular disease, alcoholism, violence (suicide, homicide, and other), poisoning, and other non-natural reasons for death (Shkolnikov and Meslé, 1996). An anti-alcohol campaign implemented between 1985 and 1987 led to a dramatic decrease in alcohol-related deaths, but this trend quickly reversed when the campaign ended (Shkolnikov and Meslé, 1996).

Migration: Immigration patterns, once contributing to population growth, have shifted. Since 1992, net migration is the only positive factor in the population equation (Goskomstat, 1999a). However, migration patterns are no longer high enough to sustain population growth by compensating for high mortality and low fertility (Vishnevsky, 1996).

FERTILITY REGULATION Russian women, like women throughout the world, regulate the timing and number of their children. Findings of a survey conducted in three regions of Russia indicate that 76 percent of all births are wanted (VCIOM et al., 1998). Of unwanted , 95 percent are aborted, as are 83 percent of mistimed pregnancies (VCIOM et al., 1998). This high percentage of wanted births highlights the fact that women are using the methods available to them to regulate fertility. A survey in Kazakhstan, in which 47 percent of the respondents were ethnic Russians or Ukrainians, indicates that of their most recent pregnancies, virtually all women who had method failures (12 percent) used abortion to terminate the (Foreit and McCombie, 1995). Both examples suggest that Russian women are for the most part already having the number of children they want when they want them.

Contraception: Statistics on contraceptive practice were not routinely collected at the national level until 1988, and data remain scarce. In fact, until recently there has been no national data on contraceptive

3 prevalence and method mix in Russia. According to sample surveys it appears that use of modern methods of contraceptives was very low until recent years (Popov, 1996; Hollander, 1997; Borisov et al., 1997; Darsky and Dworak, 1992; Ross and Frejka, 1998). In the 1990s the situation began to change. The Russia Longitudinal Monitoring Survey indicated that the contraceptive prevalence rate among married women 20–49 years old was about 50 percent for modern methods and 65 percent for all methods in 1996 (Entwisle, 1997). According to the 1996 Russia Women’s Reproductive Health Survey, 51–59 percent of women 15–44 years old in union used modern methods of contraception, and 69–77 percent used any method (VCIOM et al., 1998).

Knowledge of modern methods including oral contraceptives (OCs), intrauterine devices (IUDs), and condoms is almost universal in Russia (VCIOM et al., 1998). However, there is a significant gap between knowledge and use. Data vary widely but suggest that by the mid-1990s between 20 and 35 percent of sexually active women were using the IUD; about 12 percent were using condoms; 3 to 11 percent were using OCs, and about 2 percent were using sterilization (Entwisle, 1997; VCIOM et al., 1998; Kingkade, 1997).

The Ministry of Health (MOH) reported 17.3 percent of women 15–49 years old using the IUD and 7.2 percent of women using OCs in 1998 (The State of Health of the Population, 1999). This is an increase in use of oral contraceptives compared to 1990, when the MOH reported 1.7 percent of women used this method. However, it is important to note that the MOH collects data on OCs and IUDs, but only for those women who are under the supervision of a physician. Additionally, female and male sterilization were not legalized in Russia until the early 1990s (Popov, 1996), and trends suggest use of this method is increasing.

Abortion: Historically, Russian women have relied heavily on abortion to regulate their fertility. Statistics reported by the Russian Federation State Committee on Statistics show that as of 1998 the national abortion rate was 61 abortions per 1,000 women aged 15–49, a decrease of almost 50 percent since the 1970s. However, this rate is still seven times greater than the abortion rate in the United Kingdom and 12 times higher than in the Netherlands. While these rates may be underestimated due to incomplete data collection in the private sector, they indicate that in Russia today, a woman will have an average of 2.1 abortions in her lifetime (Population of Russia, 2000). Ministry of Health statistics indicate that approximately 68 percent of reported abortions are performed within 12 weeks gestation. Some 24 percent of reported abortions are mini-abortions occurring before seven weeks gestation (Popov, 1996). The majority of women having abortions are between the ages of 20 and 34; almost 10 percent of abortions occur among women under 20 years of age, and about 20 percent occur among women 35 years and older (Popov, 1996).

REPLACING ABORTION USE WITH CONTRACEPTION The declining rate of induced abortion and the recent increase in contraceptive prevalence suggests that women are starting to replace abortion with contraception (Zakharov and Ivanova, 1996; Ross and Frejka, 1998). Figure 1 shows data indicating that in the 1990s the replacement effect is well underway.

4 Figure 1: Abortion and Contraceptive Prevalence Rates (IUDs and OCs) among Women (15–49) f h R i F d i 1990 19986

300

250

200 CPR 150 Abortion 100

Rate per 1,000 Women 50

0 1990 1991 1992 1993 1994 1995 1996 1997 1998

Sources: Goskomstat, 1999; Ministry of Health, 1999.

Qualitative data from Russia and various countries in the former and Eastern Europe affirm that women are eager to adopt modern methods of contraception: • Interviews of women in Moscow and surrounding areas reveal that women would prefer to use modern contraceptives rather than abortion (WHO, 1998). • Respondents of a knowledge, attitude and practice (KAP) survey conducted in Kazakhstan strongly agree that using modern contraceptives, such as pills, condoms, IUDs, and injectables, is better than having an abortion (Foreit and McCombie, 1995). • Interviews conducted among postabortion patients in revealed a high level of interest in modern contraceptives (Bolton et al., 1997). • 95.4 percent of women interviewed in hospitals in Bucharest, Transylvania, and Moldova preferred modern contraception to abortion (Johnson et al., 1996).

ABORTION AND MATERNAL MORTALITY AND MORBIDITY Maternal mortality is currently 44 deaths per 100,000 live births in Russia (Goskomstat, 1999b). This figure is several times higher than rates in Western Europe (Kingkade, 1997). Approximately one-quarter of all maternal mortality is attributable to induced abortion (Popov, 1996; Kingkade, 1997). However, levels of maternal mortality due to abortion vary throughout the country. For example, in St. Petersburg between 1990 and 1992, abortion accounted for 40.6 percent of maternal mortality (Stephenson et al., 1997).

About 90 percent of abortion-related maternal deaths result from non-hospital based and unsafe abortions (Kingkade, 1997). Research conducted in 1990 found that the majority of maternal deaths related to induced abortion occurred among women who had the procedure during their second trimester; these terminations were often performed outside of hospitals (Volgina and Gurtovoi, 1990). Sepsis and hemorrhage were the leading causes of death for these cases (Volgina and Gurtovoi, 1990). Some women turn to abortion outside of hospital settings for

5 reasons of privacy. Abortions performed in hospitals require a two- or three-night stay in some instances and medical excuses for employers note the reason for hospital stay. Younger women, pregnant for the first time, are also more likely to have out-of-hospital procedures (Remennick, 1991).

Many abortions may result in complications that can cause serious harm to women’s health. For example, regional data show that one in six women who undergo an abortion require medical treatment soon after for such complications as hemorrhage and pelvic pain. Up to half of those women receiving treatment are hospitalized (VCIOM et al., 1998).

Evidence suggests that an increase in the use of modern contraceptives could help reduce maternal mortality and morbidity. Women can effectively avoid the consequences of abortion by using modern contraceptives. Utilization of modern contraceptives could also reduce the spread of STDs often harmful to fertility if untreated. Furthermore, unsafe motherhood can be prevented by making use of family planning methods (Shane, 1997). In Romania, for example, policies restricted access to abortion and modern contraception between 1966 and 1989. Despite these restrictions, women controlled their fertility through the use of illegal abortion. During this time, maternal mortality doubled due to the unsafe conditions associated with illegal abortion; almost 86 percent of maternal deaths were due to illegal abortion. When abortion and contraception were legalized, the rate of legal induced abortion almost reached 315.2 abortions per 100 live births in 1990, an increase from 52.5 abortions per 100 live births in 1989 (Ghetau, 1996). At the same time the maternal mortality ratio dropped significantly from 170 to 60 deaths per 100,000 live births largely due to the provision of safer abortions (Kulczycki et al., 1996; Serbanescu et al., 1995).

Another example highlighting the relationship between abortion and maternal mortality is the case of Chile. Chile has one of the most restrictive abortion policies worldwide. Between 1950 and 1965, hospitalizations from abortion-related morbidity rose from around 30,000 per year to 55,000 per year. In 1965, to address morbidity and mortality, Chile implemented a national family planning program. The result of this program was to drastically reduce the abortion- related mortality (Viel, 1993). Contraceptive prevalence in Chile in the early 1960s was less than 5 percent, and the abortion rate was 77 per 1,000 women aged 15–44. By 1990, the contraceptive prevalence rate had increased to 56 percent, and the abortion rate had dropped to 45 per 1,000 (Shane, 1997). Despite these advances, experts advocate for the continued emphasis on the national family planning program and liberalization of the restrictive .

The examples and data reviewed above suggest that maternal mortality can be reduced in Russia through continued emphasis on family planning.

HIGH CONTRACEPTIVE USE IS ASSOCIATED WITH DECLINING ABORTION AROUND THE WORLD Understanding historical trends provides a broader framework in which to understand fertility regulation patterns in the Russian context. The movement away from abortion toward contraception has occurred in countries around the world. The following section draws on quantitative data from Russia, former Soviet Union countries, Eastern and Western Europe, Japan, and the United States to illustrate patterns of contraceptive and abortion use. Figure 2 highlights the inverse relationship between the use of abortion and modern contraception (IUD, OCs, sterilization, and condoms) in Eastern and Western European countries and Japan.

6 Figure 2: Abortion Rates (1996) and Contraceptive Prevalence Rates (1993–95) in Europe and Japan

90 90

80 80

70 70

60 60

50 50 Abortion Rate CPR 40 40

30 30

20 20 Sterilization, and Condoms) Abortion Rate per 1,000 women 10 10

0 0 Contraceptive Prevalence Rate (%) (OCs, IUDs, Romania Latvia Czech Japan Netherlands Republic

Sources: Abortion Data: Henshaw et al., 1999; CPR Data: UN, 1999

TRENDS OVER TIME AMONG COUNTRIES IN WESTERN AND EASTERN EUROPE AND FORMER SOVIET UNION Central Asian Republics (CARs): Surveys in the CARs show that women in both Kazakhstan and Uzbekistan are currently moving from reliance on abortion to use of modern contraceptives (Westoff et al., 1998). In Kazakhstan between 1988–89 and 1993–95, the abortion rate dropped 15 percent as use of OCs and the IUD rose 32 percent (KDHS, 1995). Findings from the Kyrgyz Republic do not suggest a similar trend due to small declines in abortion incidence (Westoff et al., 1998).

Hungary: In Hungary from the late 1950s to present, there is a clear pattern of replacement of abortion by contraception. Modern contraceptives became widely available during the 1960s, and women adopted this method of controlling their fertility instead of abortion. Figure 3 illustrates the pattern of abortion replacement in Hungary over a 30-year period.

7

Figure 3: Abortion and Contraceptive Use in Hungary 1958– 1993

80 80

70 70

60 60

50 50

Abortion 40 40 CPR

30 30 Abortion Rate per 1,000 Women 20 20

10 10

and OCs Condoms) (IUDs, (%) Rate Prevalence Contraceptive

0 0 1955 1960 1965 1970 1975 1980 1985 1990 1995

Sources: Abortion Data: Balogh, A. and Lazlo Lampe, 1994; CPR Data: Bureau of Census, International Data Base, 1999.

Western Europe and North America: In Western Europe and North America, both abortion and modern contraception have played key roles as determinants of fertility. One cross-national study (Jones et al., 1989) of the relationship among contraceptive services, method use, and level of unintended pregnancy in Belgium, Canada, Denmark, Finland, , Great Britain, Greece, Italy, Netherlands, Norway, Sweden, and the United States finds a negative association between induced abortion and contraceptive prevalence rates. The review of survey data from 1975 to 1984 found that countries where the majority of women—an average of 57 percent—use the most effective methods of contraception, unintended pregnancies and therefore, total abortion rates are low.

Conversely, when modern contraceptive use is reduced, abortion rates increase. For example, in England, Wales, and Norway in 1995 negative publicity concerning oral contraceptives led to its decreased use. Consequently, induced abortion rates increased suggesting that less effective methods lead to higher failure rates and therefore abortion (Henshaw et al., 1999). Even in settings with few unintended pregnancies, abortion is still important for women with mistimed or unwanted pregnancies (Jones et al., 1989).

SUMMARY The size of the population in Russia is declining. Low levels of fertility, high levels of mortality in comparison with other developed countries, and changing migration patterns are all contributing to this decline. Some groups are concerned that expanded access to contraception

8 will contribute to further declines in fertility levels and population size.

This paper has provided an overview of fertility regulation in Russia and has compared the current trends in Russia with international trends. Similar to several countries, Russia is moving from reliance on abortion to control fertility to that of increasing modern contraceptive use. The data reviewed suggest that Russian women are already having the number of children they want, using either abortion or contraception to regulate their family size. Thus, greater access to contraception is likely to replace reliance on abortion rather than lead to further declines in fertility. Further, the international data suggest that strengthening family planning programs would lead to improvements in women’s reproductive health and reductions in maternal mortality.

REFERENCES

Becker C. and D.E. Bloom. 1998. “The Demographic Crisis in the Former Soviet Union: Introduction.” World Development 26(11): 1913–1919.

Bennet, N.G., D.E. Bloom, and S. F. Ivanov. 1998. “Demographic Implications of the Russian Mortality Crisis.” World Development 26(11): 1921–1937.

Balogh, A. and Lazlo Lampe. 1994. “Hungary.” Pp. 139–156 in Abortion in the New Europe: A Comparative Handbook, edited by Bill Rolston and Anna Eggert. Westport, CT: Greenwood Press.

Barkalov, N.B. and L. Darsky. 1994. Russia: Fertility, Contraception, Induced Abortion, Infant and Maternal Mortality. Washington DC: The Futures Group International.

Bolton, P., M. Corciova, and B. Koo. 1997. Experience with Family Planning and Perceptions about Voluntary Sterilization among Women Seeking Reproductive Health Services at Four Romanian Hospitals. New York: AVSC.

Borisov, V., A. Sinelnikov, and V. Arkhangelsky. 1997. “Expert Opinion on .” Choices 26(2): 23–26.

Bureau of Census. International Programs Center: International Database. 1999. Washington DC: Bureau of Census.

Darsky, L. and N.B. Dworak. 1992. “Fertility, Contraception, and Induced Abortion in Russia: Some Recent Measures.” Paper presented at the Meeting on Population Activities in the NIS conducted by the Office of Population, USAID, March 19, 1992, and for the working seminar at the Office of Population, USAID, April 24, 1992.

David, Henry, (ed.). 1999. From Abortion to Contraception: A Resource to Public Policies and Reproductive Behavior in Central and Eastern Europe from 1917 to the Present. Westport, CT: Greenwood Press.

DaVanzo, Julie and David Adamson. 1997. Russia’s Demographic “Crisis”: How Real is it? RAND Issue Paper. Santa Monica: RAND Center for Russian and Eurasian Studies.

9 Entwisle, B., and L. Watterson. 1997. "Family Planning and Abortion in the Russian Federation: The Russia Longitudinal Monitoring Survey 1992–96." Report submitted to the U.S. Agency for International Development. Carolina Population Center, University of North Carolina at Chapel Hill, North Carolina.

Foreit, K., and S. McCombie. 1995. Family Planning Knowledge, Attitudes and Practices Among Urban Women in Kazakhstan. Washington DC: The Futures Group International, SOMARC Project.

Ghetau, Vasile. 1996. Maternal Mortality in Romania: Trends from 1989 to 1995 and Territorial Differentials. UNFPA Romania.

Goskomstat of Russia. 1999a. The Demographic Yearbook of the Russian Federation. Moscow: Goskomstat.

Goskomstat of Russia. 1999b. Russian Statistical Yearbook. Moscow: Goskomstat. (In Russian)

Henshaw, S., S. Singh, and T. Haas. 1999. “The Incidence of Abortion Worldwide.” International Family Planning Perspectives 25 (Supplement): 30–38.

Hollander, D. 1997. “Post-Soviet Russia, Fertility Is on the Decline; Marriage and Childbearing Are Occurring Earlier.” Family Planning Perspectives 29(2): 92–94.

Johnson, B.R., M. Horga, and L. Andronache. 1996. “Women’s Perspectives On .” Social Science and Medicine. 42(2): 521–530.

Jones, E., J.D. Forrest, S. Henshaw, J. Silverman, and A. Torres. 1989. Pregnancy, Contraception, and Family Planning Services in Industrialized Countries. New Haven: Yale University Press.

Kazakhstan Demographic and Health Survey. 1995. Calverton, MD: Macro International, Inc.

Kingkade, W. 1997. “Population Trends: Russia.” Washington, DC: Bureau of the Census.

Kulczycki, A., M. Potts, and A. Rosenfield. 1996. “Abortion and Fertility Regulation.” The Lancet 347(9016): 1663–1668.

Popov, A. 1996. “Family Planning and Induced Abortion in Post-Soviet Russia of the Early 1990s: Unmet Needs in Information Supply.” Pp. 84–112 in RAND conference proceedings, Russia’s Demographic “Crisis”, edited by Julie DaVanzo with the assistance of Gwendolyn Farnsworth. Santa Monica: RAND Center for Russian and Eurasian Studies.

Population of Russia. Annual Demographic Report. 2000. Moscow: Center for Demography and Human Ecology Institute for Economic Forecasting, Russian Academy of Sciences.

Remennick, Larissa. 1991. Epidemiology and Determinants of Induced Abortion in the USSR. Social Science Medicine 33(7): 841–848.

Ross, J. and T. Frejka. 1998. “Paths to Subreplacement Fertility: Overview and Ten Country Cases.” Background Paper prepared for the Conference on the Global Fertility Transition. Bellagio, May 8–12.

Serbanescu, F., L. Morris, P. Stupp, and A. Stanescu. 1995. “The Impact of Recent Policy Changes on Fertility, Abortion, and Contraceptive Use in Romania.” Studies in Family Planning 26(2): 76–87.

10 Shane B. 1997. Family Planning Saves Lives. Washington, DC: Population Reference Bureau.

Shkolvikov, V.M. and F. Meslé. 1996. “The Russian Epidemiological Crisis as Mirrored by Mortality Trends.” Pp. 113–162 in RAND conference proceedings, Russia’s Demographic “Crisis”, edited by Julie DaVanzo with the assistance of Gwendolyn Farnsworth. Santa Monica: RAND Center for Russian and Eurasian Studies.

The State of health of the population of Russia and the activities of health care establishments in 1998 (Statistical materials). 1999. Moscow: Ministry of Health, medical statistics and informatics department. (In Russian)

Stephenson, C., B. Chalmers, V.F. Kirichenko, M.A. Repina, and M. Wagner. 1997. “Reducing Maternal Mortality in St. Petersburg.” World Health Forum 18(2): 189–193.

United Nations. 1999. World Contraceptive Use 1998. New York: United Nations.

Viel, Benjamin. 1993. “The Need for Reform.” Planned Parenthood Challenges 1993/1.

Vishnevsky, A. 1996. “Family, Fertility, and Demographic Dynamics in Russia: Analysis and Forecast.” Pp. 1–35 in RAND conference proceedings, Russia’s Demographic “Crisis”, edited by Julie DaVanzo with the assistance of Gwendolyn Farnsworth. Santa Monica: RAND Center for Russian and Eurasian Studies.

Volgina V. and B. Gurtovoi. 1990. “Abortion as a Cause of Maternal Mortality.” Akusherstvo I Ginekologiia 10: 11–15.

Westoff C., A. Sharmanov, J. Sullivan, and T. Croft. 1998. Replacement of Abortion By Contraception in Three Central Asian Republics. Calverton, MD: Macro International, Inc.

World Health Organization. 1998. “Russia: Why Do So Many Women Choose Abortion?” Safe Motherhood: A Newsletter of Worldwide Activity 26(2). Geneva: World Health Organization.

Zakharov, S and E. Ivanova. 1996. “Fertility Decline and Recent Changes in Russia: On the Threshold of the Second Demographic Transition.” Pp. 36–83 in RAND conference proceedings, Russia’s Demographic “Crisis”, edited by Julie DaVanzo with the assistance of Gwendolyn Farnsworth. Santa Monica: RAND Center for Russian and Eurasian Studies.

Zakharov, S. 1997. “Fertility, Nuptiality, and Family Planning in Russia: Problems and Prospects.” Pp. 41–58 in Population Under Duress: The Geodemography of Post-Soviet Russia, edited by D. Demko, G. Ioffe, and Z. Zayonchkovskaya. Boulder: Westview Press.

1996 Russia Women’s Reproductive Health Survey: A Study of Three Sites. Final Report: May 1998. All- Russian Center for Public Opinion and Market Research (VCIOM), CDC, USAID.

11