Motivations and Obstacles to Use of Contraceptive and Abortion Services in Ukraine Rachel Criswell Fulbright Research Fellow, Ukraine 2007-2008 International Conference on Family Planning: Research and Best Practices Kampala, Uganda 17 November 2009 Background: Fertility in Ukraine • High abortion rate: 618/1,000 live births (DHS 2007) • Low modern contraceptive prevalence rate: 46.9% (DHS 2007) • Majority of abortions occur during marriage and after desired family size has been achieved Abortions per 1,000 live births in selected European countries (2000, 2004)* 1,800 2000 1,548 1,500 2004 1,200 1,100 1,068 1,062 900 883 767 618 600 581 358 343 341 282 279 300 279 Abortions per 1,000 live births 0 Britain Sweden Czech Baltic Ukraine Russia Romania Republic States *Source: USAID-funded Together for Health project from The Rationale for Family Planning in Ukraine, Kyiv, 2007. Modern Contraception Use in Ukraine and Europe* Modern Methods Traditional Methods All Methods Britain 81 3.0 84 Germany 71.8 2.9 74.7 Western Europe 70 4.0 74 Czech Republic 62.6 10.4 73 Russia+ 53 19.0 72 Ukraine 46.9 21.5 68.4 Poland 19 30.4 49.4 Georgia 20 21.0 41 0 20406080100 Contraceptive Prevalence *USAID-funded Together for Health project from The Rationale for Family Planning in Ukraine, Kyiv, 2007. Abortion Ratios in an International Context: Core EU countries, United States, Post-Soviet and Central/Eastern European Countries* Abortions per 1000 live births, 2004 Country <20 yrs old >35 yrs old All ages Britain 840.5 214.86 278.63 United States -- -- 238** Sweden 4165.21 362.51 341.37 Norway 1704.08 287.74 247.07 Germany 876.63 187.96 183.74 Ukraine 546.68 1860.53 618.07 Romania 687.08 2359.92 883.37 Czech 668.76 835.3 282.34 Republic Hungary 942.23 1104.64 552.25 Russia -- -- 1067.9 *Source: USAID-funded Together for Health project, The Rationale for Family Planning in Ukraine, Kyiv, 2007. **Source: http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5609a1.htm. However, there are persistent negative attitudes towards abortion in the medical, political, and social spheres… “He also has a right to life!” “What happiness it is to be a mother.” When there is a generally negative attitude towards abortion in Ukraine, why do women continue to use it as a form of fertility regulation at higher rates than women in the rest of Europe? What is standing in the way of preventative methods of fertility control such as modern contraception? Design • 113 women, men, and medical professionals interviewed with structured interviews (verbal informed consent) • Six oblasts (Kharkiv, Lviv, Poltava, Odessa, Vinnytsa, Dnipropetrovsk) • Interviewed at hospitals, polyclinics, factories, schools, government administration buildings, prisons • Partially in cooperation with the WHO Strategic Assessment of Abortion and Reproductive Health in Ukraine Characteristics of respondents • 69% between the ages Age of respondents 35 of 21 and 35 30 • 27% of participants 25 have had an abortion 20 15 • 45% of those who have of respondents Number had an abortion, have 10 had more than one 5 0 15-20 21-25 26-30 31-35 36-40 41-45 46-50 Over 50 • Condoms, COCs, and Age IUDs are the most ever- used methods Number of Abortions of Interviewees Who Have Had Abortions Proportion of Women Interviewed Who Have Had An Abortio one 6% 3% two three more than three 15% chooses not to say 27% 6% Yes No 52% No Answer 24% 67% 60 50 40 30 Contraceptive Method Mix of Interviewees 20 10 0 COCs IUD condoms natural methods spermicides hormonal patch hormonal ring female sterilization Method of Contraception male sterilization hormonal injections POPs LAM folk methods abstinence emergency contraception Results: Curative Health Care and Mentality • The Soviet system engendered a curative health care system, where public health prevention methods Curative health mentality are rare Economic Cognitive • This attitude manifests itself in Clinical Psychosocial psychosocial, Political economic, clinical, political, and cognitive barriers to contraceptive use Economic: Abortion is a one-time cost (and officially free), whereas contraception is a regular cost • “Contraception is expensive for the majority of the population.” --Midwife, city hospital • Many pharmacy kiosks or FAPs in rural areas do not stock contraception • “Abortion isn’t good, but it’s the most accessible of birth control. You pay once and you’re cleaned out. That’s all.” --Woman, middle- aged • Women cannot afford the methods they consider the best and do not trust the cheaper methods, so they end up using natural methods or nothing: “It’s a choice between buying contraceptive pills or sausage to feed my kids.” --Woman, rural area • Many women would not use free contraception because they are skeptical about the quality: “I would rather pay for contraception if I can than use free contraception. Free contraception may be of bad quality.” --Woman using contraception Clinical: Lack of provider-initiated counseling • 54% of women did not receive FP counseling after their abortion, and 56% did not receive FP counseling at their last gyn appointment • “I received practically no pre-abortion counseling. They told me that I might not be able to have children in the future. They didn’t say anything about the way the procedure would go, what would happen, possible side effects… I didn’t even see the doctor. In my memory, the glaring negative was that the doctor did not support me at all.” --Woman • “The doctor asked me if I was using condoms, and I told him I wasn’t. He gave me a brochure, but he didn’t say anything else.” --Woman not using contraception • Many women get pregnant during the unnecessary “period or rest” that doctors prescribe for the body after using contraception, having an abortion, or giving birth Did Your Gynecologist Talk to You About Contraception at Your Last Appointment? Did Your Doctor Tell You About Contraception After Your Abortion? Yes 4% Yes No No Don't remember 42% 44% 56% 54% Political: Lack of a connection between reproductive rights and reproductive health • The “choice” rhetoric of the US and Western Europe is not widely employed in Ukraine • Becomes problematic in light of the growing church-sponsored anti-abortion campaign and state-sponsored pro-natal campaigns • “There’s plenty of information about contraception out there. Now we need to work to change women’s opinions of ŅAbortion-- itÕs my right.Ó -- themselves. They don’t think Kyiv metro station about their health or their future.” --Woman, Eastern Ukraine “Life is beautiful, abortion is murder.” --Leaflet distributed in a women’s clinic to women considering abortion “Take my hand, not my life” -- Displayed in a women’s clinic outside the surgery Psychosocial: Abortion was a common form of fertility control during the USSR, and preventative birth control was considered dangerous • 51% of respondents were not using contraception when they got pregnant and then had an abortion • 74% of respondents had abortions after they were married • 55% of respondents had abortions after they had their desired family size • “We’ve been brought up to look on abortion as salubrious, almost ‘cleansing’… and on birth control devices as harmful and unreliable.” --Quoted in Francine du Plessix Gray’s Soviet Women: Walking the Tightrope • “People feel normally towards abortion. During the Soviet period it was the main method of contraception.” --Woman • “Why would I use contraception? Whatever happens, happens.” --Young woman • “I don’t think I’ll ever use contraception. What for?” --Young pregnant woman who had just remarked that she was unhappy that she was pregnant because she thought she was too young How Did You Get Pregnant Before Your Abortion? 8% Unsuccessful contraception Wasn't using contraception 3% "Period of rest" prescribed by the doctor 24% Other No answer 14% 51% When Did You Have Your Abortion in Relation to When You Had Children? What Was Your Marital Status at the Time of Your Abortion? Married 9% Before having kids 10% In between kids Dating 19% After having kids Civil Union No answer 3% Single 13% 16% 74% 56% Cognitive: Misperceptions about contraception • Many believe that committed, married couples should not use contraception: “If I use an IUD, my husband will think that I have a lover.” --Married woman, village • Folk methods are considered acceptable and safer than modern methods, even by medical professionals • Weak sexuality education system in the schools • “Parents don’t talk about sex—it’s a taboo. They think that if they tell their kids about contraception, that the kids will start having sex earlier.” --Midwife, city hospital • Aversion to hospitals: “Girls won’t go to the gynecologist because they’d have to wait too long.” -- Young woman, city • “There is a confidentiality issue in hospitals. People are embarrassed to go and ask about contraception because everyone will know and judge them.” --Married suburban woman, pregnant, no abortions, used condoms Implications • A reorientation of the health care mentality in Ukraine is necessary to shift focus from abortion to family planning • This shift in mentality needs to be accompanied by corresponding shifts in health care financing, political thought, and patient and provider behavior • Educating providers in preventative fertility control could serve as a useful starting point to build demand Recommendations • Initiate a targeted post-partum and post-abortion family planning program as part of the State Program for the Reproductive Health of the Nation (SPRHN) • Improve counseling skills of physicians and mid- level health providers • Promote family planning in spheres other than the medical sphere (schools, work place) • Connect feminism movement with family planning • Subsidize cost of contraception for the consumer Limitations • Small sample size • Language and translation barriers • No statistical analysis performed • Need to systematically analyze provider feedback and male feedback Acknowledgements Asta-Maria Kenney, JSI Dr.