Family Planning and Induced Abortion in Post-Soviet Russia of the Early 1990s: Unmet Needs in Information Supply

by Andrej A. Popov  [1]

Introduction

Induced abortion remains possibly the most common and effective means of family planning in Russia. Russian society and the public health system have adapted to the provision of induced abortion as the primary method of family planning. Therefore, Russia can be defined as having a stable abortion culture. Induced abortion is still the primary and often the only method of reducing fertility in many regions. At the same time, there is a high degree of regional differentiation in family planning behavior related to ethnic, social, and demographic variations across Russia.

Since 1991, new "post-Soviet" features have emerged in family planning in Russia. This has been due to the following societal trends and organizational innovations introduced by the Ministry of Health of Russia:

  • Societal reflection on the high rate of induced abortion and its predominance as a method of family planning has increased considerably. This is most clearly illustrated by the official adoption of a conceptual review of family planning by the Ministry of Health. Different issues such as the high rate of induced abortion, family planning services, and even personal reproductive rights are being actively discussed now.[2]
  • An entirely new phenomenon is the use of the induced abortion issue for a wide variety of political purposes.

  • There has been a demonopolization of the position of the Ministry of Health as the only agency endowed with powers to formulate social policy in the field of family planning. Traditionally, the Ministry of Health has been involved in the fight against abortion, mostly through the ineffective publication of new orders and leaflets. Many newly established organizations are now involved in this area. Among them are the Russian Orthodox Church, the Russian Association of Family Planning, various women's political organizations, and nationalist political movements. There is also active participation by various religious groups and religion-related public movements, such as the Roman Catholic Church and, associated with it, the "Pro-Life Movement" and "Right-to-Life International."

    The Russian Orthodox Church became very active in the field of anti-abortion propaganda by publishing miscellaneous pamphlets, leaflets, and articles in early 1990s. Even the Orthodox Church in America has been involved in such anti-abortion activities.
  • Beginning in 1988, the state monopoly in medical family planning services was progressively destroyed, and legal commercialization of induced abortion and contraceptive services ensued. This decentralization and legal commercialization has occurred mostly in the larger cities and economically advanced regions of Russia. In most cases this process was merely the legalization of pre-existing illegal and quasi-legal commercial enterprises, which functioned in the "gray" field of gynecological and abortion services before 1991. Now a real abortion industry exists in Russia and this branch of the market for family planning services is totally oriented to the provision of induced abortion.

    This abortion industry has developed new, advanced techniques for performing induced abortion, including magnetic cervical cups, manual massage, and different reflectorial techniques. One of the most advanced technologies is the magnetic cervical cup ("Magnetic Cup" or "Magnitoforny' Kolpachok"), which induces abortion by weak, localized magnetic fields within the first trimester of pregnancy in out-patient conditions. This method was approved and licensed by the Ministry of Health, and there is currently a flood of advertisements in Moscow newspapers for this new Russian abortion technology.
  • Abortion and family planning statistics by the Ministry of Health of Russia were revised in 1991 and further defined in a Health Ministry directive issued March 1992.[3] The new State Statistical Registration Form titled "The Abortion Report" (No. 13) was also introduced in 1991. In this way, a new system of statistical registration of induced abortion and contraceptive usage was introduced to replace the old one, which had remained practically unchanged since 1956. This change brought very serious consequences. The new statistical system is an incomplete reflection of actual trends and is not comparable with the previous one.
  • The number of officially registered induced abortions reveals an apparently decreasing trend. However, it is not possible to accurately estimate the real size of this decline because the official statistics do not capture the dynamics of commercial medical services and are reported as improperly calculated aggregate indices. Additional difficulties were created by changing the official system of conducting and registering induced abortions.
  • In comparison with European and Western countries, Russia allows the broadest legal provision of induced abortions. Only the Netherlands, the United States, and, perhaps, Sweden, which allow abortion on request up to about 26 weeks, can be compared with the USSR and contemporary Russia (Table 3.1). Additionally, on December 28, 1993, the Ministry of Health of the Russian Federation significantly extended the approved list of medical indications for artificial interruption of pregnancy.[4] The historically most significant changes in legislation concerning induced abortion in the USSR and Russian Federation in 1920-1990s are briefly presented in Table 3.2.
Table 3.1
Grounds for Legal Abortion in the USSR and Selected Countries
(approx. 1986-1987)

MedicalSocial
Country Narrow (life) Broad (health) Eugenic (fetal) Juridical (rape, incest) Social & Medical On Demand
Austria x x x x x x
Bulgaria x x x x x -
Czechoslovakia x x x x x -
Finland x x x x x -
France x x x x x x
Germany (FRG) x x x x x -
Germany (GDR) x x x x x x
Hungary x x x x x -
Italy x x x x x x
Netherlands x x x x x x
Norway x x x x x x
Poland x x x x x -
Romania x x x x x -
Spain x x x x - -
Sweden x x x x x x
United Kingdom x x x x x -
Yugoslavia x x x x x x
Ireland, Northern x x - - - -
Ireland, Rep. of x - - - - -
United States x x x x x x
USSR, 1987 x x x x x x
Russia, 1993 x x x x x x

SOURCE: See references 3-11.

Table 3.2
Conditions for Legal Abortions in the USSR and Russian Federation,
1920-1993

MedicalSocial
Year, Document, Reference No. Narrow (life) Broad (health) Eugenic (fetal) Juridical (rape, incest) Social & Medical On Demand Final Gest Age Place of Service Cost
1920,L[14] x x x x x x - C Free
1924,I[12;13] x x x x x - - C Free
1924,L,a[12;13] x x x x x x - PC Fees
1924,I,a[12;13] x x x x x - - C Fees
1926,I,a[12;13] x x x x x - 12 wk C Fees
1936,L,[15] x x x x - - - C Free
1955,L,[16] x x x x - - 12-28 wk C Free
1955,L,[12] x x x x x x 12 wk C Fees
1962,I,a[12;19] x x x x x x 12 wk C Fr+Com*
1976,I,a[17] x x x x x x 12 wk C Fr+Com**
1982,I,a[11] x x x x x x 12 wk C* Fr+Com**
1982,I,a[11] x x x x - - 12-28 wk C* Fr+Com**
1987,I,a[8] x x x x x x 20 days Amb Fr+Com**
1988,L [18] x x x x x x 20 days CC Fees
1993,I,a[3] x x x x x x 12-28 wk C* Fr+Com **
KEY:
L State laws of the USSR
I Instructions of the Ministry of Health of the USSR
Ia Amendment to a previous Law or Instruction
C Only in special clinics or hospitals
C* Changing of local abortion clinic or hospital is permitted
PC Abortions made available in private clinics
CC Abortions made available in commercial clinics
Amb Abortions made available in hospitals on an outpatient basis
12 wk Abortion is available up to 12 weeks gestation only
12-28 wk Abortion is available up to 28 weeks gestation only
20 days Abortion is available up to 20 days gestation only
Fees Abortions made available only for a fee
Free Abortions made available only free of charge
Fr+Com* Abortions free of charge and monetary compensation is available for employed women only
Fr+Com** Abortions free of charge for all women, monetary compensation available for all women in case of complications

SOURCES: See references 3, 7-19.

Family Planning Statistics in Post-Soviet Russia

The statistical registration of induced abortion in the USSR was virtually unchanged between 1956 to 1991. During this period, abortion was differentiated into the following categories: spontaneous abortion, induced therapeutic abortion, induced abortion on demand, out-of-clinic (clandestine) abortion and, since 1988, early abortion (by vacuum aspiration). The officially published family planning statistics consisted of the absolute number of induced abortions on demand, the abortion rate per 1,000 women aged 15-49, the induced abortion rate per 100 births (born alive or dead), the number of abortions to primigravidae (first-time pregnant) women, the number of abortions to women under 14 and under 17, and the number of mortality cases resulting from induced abortion.

The object of analysis here is officially registered induced abortion performed on demand and on all non-medical grounds. The indices were calculated separately for legal induced abortions and clandestine induced abortions. There are no data prior to 1991 for by age, except for age groups under 14 and under 17.

In the 1980s to 1990s, the statistical registration of abortions was revised twice: first slightly, in 1988, and then fundamentally, in 1991 and 1992. In 1988, the registration of early abortions and of intrauterine and oral contraception use was introduced. In 1991 and 1992, the Ministry of Health of Russia disseminated new statistical registration forms.[5] In the new forms, abortions were differentiated into the following categories: legal induced abortion on demand, spontaneous abortion, therapeutic induced abortion, clandestine induced abortion, and abortion without clear grounds. The last were not considered to be induced abortion because of the vagueness of the cause. Early abortions are still registered separately from induced abortions because they are not officially considered abortions at all, but only a method of menstrual cycle regulation.

To summarize, family planning information available since 1991 is limited to the following:

  • induced abortion rate per 1,000 women at ages 15-49;
  • abortion rate per 100 children born alive and dead;
  • number of induced abortions within the first 22-28 weeks of pregnancy;
  • number of induced abortions for women at ages under 15, 15-19, 20-34, 35 and over;
  • number of vacuum-aspirated abortions within the first two weeks of pregnancy;
  • number of women who died as a result of a legal induced abortion;
  • number of women who died as a result of clandestine and illegal induced abortion;
  • number of registered users of intrauterine devices;
  • number of registered users of hormonal contraceptives; and
  • rate of women using contraceptives per 100 fertile-age women.
Clandestine Abortion

At present, the authorities consider only registered induced abortion performed in a clinic by a professional doctor to be a legal one. Theoretically, all possible kinds of clandestine abortions would include:

  1. Those performed by a woman herself (self-induced abortion);
  2. Those performed by a professional doctor in a clinic, but not registered (an unregistered induced abortion); and
  3. Those performed unprofessionally, out-of-clinic, and not registered (a criminally induced abortion).
Before 1991, all of these types of clandestine abortions were included by the Ministry of Health in one category--"out-of-clinic" abortion. The official statistics defined out-of-clinic abortions to be those officially registered but performed outside of an official clinic. Therefore, this is not a valid statistic of clandestine abortion, but merely an indicator of complications and side-effects following clandestine abortions which ultimately required professional medical treatment and hospitalization.

Only serious complications resulted in the official registration of clandestine abortions. Probably only half of the clandestine abortions have been officially registered. Nevertheless, the rate of officially registered clandestine abortions was very high. This statistic may also indicate in part the decline in registration of all induced abortions. Until 1991, the authorities considered all abortions which were performed out-of-clinic and which caused the death or serious bodily injury of a woman as criminal ones.

In the USSR in 1989, only 15 doctors were sentenced for performing criminal abortion, though in that year 1,500,000 clandestine abortions were officially registered. The number of registered criminal abortions was low because confirmation of its criminal nature was needed in each case. The main criterion for classifying this kind of abortion as criminal was direct evidence of interference (i.e., uterus perforation or sepsis). However, confirmation by the woman herself regarding the criminal nature of the clandestine abortion was also required, and a criminal investigation would subsequently be initiated.

The main problem of the statistics system introduced in 1991 is its total incomparability with the previous one. Under the new classification most clandestine abortions are now registered as abortions for unknown reasons. Only a small portion of registered clandestine abortions are now registered as criminally induced abortions. As a result, the number of registered criminal abortions remains low, because the criminal nature of interference still must be proved and confirmed by the woman herself, which is very rare. When clandestine abortion is not detected or proved, the abortion is registered as one with an unestablished cause, or "spontaneous," and is excluded from the total number of induced abortions. As a result, the 1991 decline in the number of induced abortions was a statistical artifact--the result of transferring clandestine induced abortions into the category "spontaneous abortion."

Understanding the importance of these changes in the induced abortion registration system enables us to comprehend the dramatic decrease in the number of abortions in Russia from 3.9 million in 1990 to 3.5 million in 1992, and to 2.9 million in 1993. That is a more than 25 percent decline in only two years.

Early Safe Induced Abortion (Mini-Abortion)

In the early 1980s, large-scale provision of early, safe abortion began in the USSR outside the government health system, though it was not legal or officially recognized until 1988. Despite the common name "mini-abortion," this type of induced abortion has been officially considered "regulation of a menstrual cycle by vacuum-aspiration," and not as an induced abortion. In 1992, 26 percent of all registered induced abortions were "mini-abortions" (Table 3.3). Moreover, professionals generally recognize that registration of early abortions is incomplete.

Table 3.3
Officially Registered Induced Abortion on Demand in the Russian Federation, by Types of Abortion, 1970-1992*

1970 1980 1985 1990 1991 1992
Total abortions (thousands) 4,670 4,506 4,415 3,920 3,442 3,531**
Early (mini) abortions (thousands) n.a. n.a n.a. 952 829 914
Abortions per 1,000 women aged 15-49 134.9 127.8 115.7 108.8 100.3 98.1
Abortions per 1,000 women aged 15-49 (early) n.a n.a. n.a 26.5 23.6 25.4
Abortions per 100 births 200.5 192.9 184.2 195.3 199.4 224.62

SOURCE: Ministry of Health of the Russian Federation (MZRF), 1993
NOTES: * Departmental statistics not included.
** Some departmental statistics included.
n.a. = No data available.

Since 1988, early abortions have been substituted for full induced abortion within the first 12 weeks of pregnancy. It is widely believed that relatively poor registration of early abortions could result in an increase in the number of unregistered induced abortions in Russia.

Commercial Induced Abortion

In 1988 the Ministry of Health of Russia introduced a revolutionary innovation which had long-term consequences for family planning and abortion statistics--legalization of commercial induced abortions.[6] Since 1988, induced abortion can be legally performed in private clinics or in the commercial sections of state hospitals and, since 1991, by doctors with a private practice at their residences. This legal commercialization is more typical in big cities and the more economically advanced regions of Russia.

As noted above, in most cases this process only legalized preexisting illegal and quasi-legal commercial abortion services already in existence before 1991. However, a system of statistical registration of such abortions was not created in 1991, perhaps due to a desire to maintain a degree of secrecy surrounding abortions.

The lack of a system for registering commercially induced abortions resulted in a considerable gap in induced-abortion statistics in Russia. The abundance of commercial advertisements for induced abortions in private clinics and the miscellaneous ads placed by privately practicing doctors provide some indication of the scope of the gap in the registration of induced abortions.

Similarly, there is no procedure to register hormonal and intrauterine contraceptives users in the commercial health care sector. It is also likely that other cases of medical assistance in commercial clinics are also not registered, including services for venereal diseases, infertility, sexual disorders, and even contraceptive sterilization.

Family Health and Inducted Abortion Statistics of Independent Departmental Government Health Services

It is still commonly assumed that the number of induced abortions registered by the Ministry of Health of Russia represent the total for the nation. This is not correct. The Ministry of Health medical statistics are not the same as national medical statistics, but are only a part of it. The health ministry is only the largest of several health care systems in contemporary Russia, with additional health care services provided by independent departmental health care services.

Each government department with its own health care service also has its own medical statistics system, independent of the Ministry of Health. The largest known institutions which had their own systems of independent public health in 1992 were the Ministry of Defense, the Ministry of Railroad Transportation, the Ministry of Domestic Affairs, the Committee of State Security (former KGB), the Ministry of the Defense Industry, the Ministry of River Transportation, the Academy of Sciences, and the Aeroflot Air Company. In 1992, practically every other large ministry had its own independent health system. In fact, the complete list of such independent health systems is still classified as top secret and is, therefore, not publicly known.

Most of such departmental health services are quite significant and include their own network of hospitals, ambulatory clinics, sanitariums, pharmacies, and staff of physicians. For an illustration of the size of such departmental systems, the role of the Ministry of Railroad Transportation provides an example. The total number of induced abortions provided in this departmental health system alone represents up to 5 percent of the total number of induced abortions in the USSR in 1989.

Induced abortions performed by these institutions are not included in the total number of national abortion statistics, the Ministry of Railroad Transportation being the only exception. We don't know how the reorganization of these institutions after 1991 affected their public health systems. Therefore, complete national family planning and induced abortion statistics are still not available in Russia.

Induced Abortion Age Distribution

The development and publication of data concerning the age distribution of abortion constituted another of the innovations in induced abortion statistics introduced by the Ministry of Health in 1991. The only official data by age collected before 1992 concerned abortions by women under the ages of 14 and 17. The data concerning women under 14 was collected but was available only theoretically because it was never published.

In 1991, the Ministry of Health began collecting and publishing data on induced abortion for women at ages under 15, 15-19, 20-34, and above 34 (as seen ahead in Table 3.13). Unfortunately, these groups are not comparable with those in data from previous years. This circumstance lowered the scientific and practical value of published data on the age distribution of abortions.

Monthly Registration of Induced Abortions

Introduction of monthly registration of the number of induced abortions performed has been another recent statistical innovation.[7] The statistical quality of this information is poor, however. For example, we still do not know whether early abortion (vacuum-aspiration) is included in the monthly data on induced abortion. We can only hope that such vagaries are clarified in the future.

Contraceptive Use

Since 1988, the Ministry of Health has maintained a statistical registry of women who were officially implanted with intrauterine devices (IUDs) and women officially known to be using hormonal oral contraceptives ("the pill"). In both cases, the statistics include only patients who are using official prescriptions and were officially under the extended supervision of a physician. More recently, the Ministry of Health began to report the number of registered patients using intrauterine and hormonal contraceptives relative to the number of fertile-age female residents by region of residence.

The comprehensiveness and validity of these data are very problematic, however. First, they may be incomplete because women using these contraceptives without official medical supervision are not registered. Second, women who were treated in an independent departmental health facility, by a private doctor, or in any commercial facility were never registered in the Ministry of Health statistics. Advertisements, again, are perhaps the only indicator of the private market for contraceptives. As a result, comparing the entire fertile age female population in a region to the number receiving contraceptive services from the Ministry of Health facilities is deceptive. Simply stated, this is a problem of using the wrong denominator. Thus, the validity of the official Ministry of Health data, as far as contraceptives usage is concerned, is questionable. The official data describe the registration of patients in the Ministry of Health system only, and should not be considered true and complete data on intrauterine and hormonal contraceptive usage by local female populations.

Induced Abortion in Post-Soviet Russia of the Early 1990s

Since 1966, there has been a continuously decreasing trend in the number of officially registered abortions on-demand per woman in Russia (Table 3.4). It is still impossible to estimate the real scope of this decreasing trend, due to the successive changes in the registration of abortion procedures as discussed above.

Data imperfections aside, even the official abortion rate (which underestimates abortion in the Russian Federation) demonstrates the possibility that Russia has the highest abortion rate in the world. In 1992, 3.5 million induced abortions were officially registered in the Russian Federation. The abortion rate per 1,000 women aged 15-49 years was 98.1 and the rate per 100 births was 224.6; i.e., for every live birth in the country, there were over 2.2 officially registered abortions. This figure is two to three times higher than those for most Western and Eastern Europe countries (Table 3.5).

Table 3.4
Officially Registered Abortions in the USSR, 1957-1990*

Year Number of Abortions, Thousands Abortions Per 1,000 Women Aged 15-49 Abortions Per 100 Deliveries
Source 1; 2 1 2 1 2
1957 5,109 84.7 66.3 98.9 76.8
1958 5,927 98.6 80.6 113.1 92.2
1959 6,014 101.1 85.8 114.2 96.2
1960 6,623 112.0 96.1 124.0 107.1
1961 7,109 119.6 103.6 136.9 118.4
1962 7,361 123.1 110.2 148.4 132.1
1963 7,617 126.7 114.7 161.1 144.8
1964 7,251 120.1 120.2 n.a. 161.3
1965 7,260 119.6 122.5 170.6 169.3
1966 7,904 129.4 118.2 186.3 168.5
1967 7,878 127.7 109.7 192.5 161.9
1968 7,611 122.3 105.2 186.2 158.3
1969 7,256 120.9 101.8 171.5 152.3
1970 6,970 110.7 101.4 165.0 149.0
1971 7,262 112.S 101.1 166.1 147.9
1972 7,160 109.4 98.3 162.6 144 5
1973 7,160 108.2 97.5 162.2 145.5
1974 7,114 106.6 95.9 156.5 139.7
1975 7,135 105.7 95.7 154.7 137.7
1976 7,293 107.4 97.2 155.0 140.1
1977 7,238 106.1 96.2 154.0 138.7
1978 7,160 104.7 95.0 150.0 136.1
1979 7,009 102.4 93.2 146.0 131.6
1980 7,003 102.3 93.2 143.0 130.5
1981 6,834 99.6 91.1 137.0 124.6
1982 6,912 100.3 92.1 135.0 120.3
1983 6,765 97.7 90.1 124.0 115.1
1984 6,780 97.2 90.0 125.0 115.7
1985 7,034 100.3 92.8 127.0 118.6
1986 7,116 101.2 89.5 126.0 110.6
1987 6,818 97.0 85.7 121.0 109.3
1988ab 7,228 103.2 92.4 112.0 124.1
1989a 6,974 99.8 90.0 136.0 126.9
1990 6,194 89.8 84.8 132.0 123.5

SOURCES: 1= data from references [12, 20, 22-25, 31]; 2 = data from reference [26].
NOTES: a = Including some departmental health services; b = Including early abortions by vacuum aspiration within the first 20 days of pregnancy.
* = Departmental statistics are not included.

Table 3.5
Officially Registered Induced Abortion Rates in Russia (1992) and Several European Countries (Circa Late 1980s-Early 1990s)

R>
Moscow city 109.3 112.6 102.6 97.7 91.6 78.7
Volga-Vyatsk n.a. n.a. n.a. 120.4 n.a. 99.1
Central "Chernozem." n.a. n.a. n.a. 101.6 n.a. 123.1
Volga n.a. n.a. n.a. 112.0 n.a. 99.4
North Caucasus n.a. n.a. n.a. 107.8 n.a. 74.7
Urals n.a. n.a. n.a. 132.6 n.a. 103.7
West Siberian n.a. n.a. n.a. 140.8 n.a. 95.7
East Siberian n.a. n.a. n.a. 122.5 n.a. 105.7
Far East n.a. n.a. n.a. 125.7 n.a. 94.5
Baltic n.a. n.a. n.a. 118.4 119.4 104.4
Russian Republic within USSR 134.9 127.8 118.0 115.7 n.a. n.a.
Russian Federation n.a. n.a. n.a. n.a. 108.8 98.1
USSR 114.2 105.7 102.3 100.3 n.a. n.a.

SOURCES: For RSFSR, 1970-official data of the Ministry of Health of the RSFSR (departmental statistics not included);
For USSR, 1970-1985, official data of the Ministry of Health of the USSR (departmental statistics from MPS included).
For Russian Federation, 1992, official data of the Ministry of Health of Russia (departmental statistics from MPS included)
NOTE: n.a.: data not available

Early Abortion in Post-Soviet Russia of the Early 1990s

The statistics on early abortion appear to be the least influenced by regional registration variations. This statistic is also an important indicator for evaluating the Ministry of Health's declared policy of transitioning to "safe abortion," which in Russia means early abortion. Nevertheless, it is difficult to estimate the real trend in early abortion dynamics because of the successive changes in abortion legislation and registration of induced abortion. However, the total number of early abortions in Russia in 1990-1992 was relatively stable--952,000 cases in 1990 and 914,000 in 1992.

Table 3.7
Officially Registered Early Abortion Rates Per 1,000 Women Aged 15-49 in the Russian Federation, by Economic Region, 1990-1992

Region 1990 1992
North n.a. 31.8
Northwest n.a. 18.7
St. Petersburg city 17.9 18.3
Central n.a. 19.0
Moscow city 17.7 21.5
Volga-Vyatsk n.a. 22.4
Central, "Chernozem." n.a. 24.3
Volga n.a. 25.0
North Caucasus n.a. 14.5
Urals n.a. n.a.
West Siberian n.a. 27.1
East Siberian n.a. 27.1
Far East n.a. 22.8
Baltic n.a. 40.4
Russian Federation 26.5 25.4

SOURCE: Official data of the Ministry of Health of Russia
NOTE: Departmental statistics from the Ministry of Railroad Transportation are included.

In some territories, such as the Orel province and the Rostov region, the number of registered early abortions decreased between 1990 and 1992. Abortion dynamics in Russia appear to correspond to regional economic development. For example, the rate of early abortion in 1992 in Moscow city was 21.5 while the less developed Republic of Maryi El recorded 58.4 early abortions per 1,000 women aged 15 to 49. It is likely that this is a result of the interaction between regional differences in the diffusion of early induced-abortion technology, abortion migration,[9] and the peculiarities of statistical registration.

Induced abortions in Russia are registered at the place of service. Because of better availability and service quality, abortion registration is statistically concentrated in the largest cities. However, it is well known that the level of commercialization of health care in Moscow is the highest in Russia, and that most early abortions are performed at commercial facilities. Women who are residents of the Moscow region in most cases have early abortions in commercial facilities in the city of Moscow. Therefore, we should expect the largest gap in registration of early abortion in Moscow, as no statistics are collected on commercially performed abortions. This may help to explain the wide variation between rates of early abortion in the city of Moscow, in the Moscow region, and in the Maryi El republic (the ratio is 1:5:14, respectively).

Contraception in Post-Soviet Russia of Early 1992

In 1988, the Ministry of Health introduced annual statistical reporting of women using intrauterine and hormonal contraceptives. In both cases, only patients using government health care facilities were included. Later, the Ministry of Health began to report the number of officially registered users of intrauterine and hormonal contraception relative to the number of fertile-age women residing in a given region. These data are officially presented as describing the regional prevalence of intrauterine and hormonal contraceptive usage (Table 3.8).

When analyzing these data, it should be taken into account that the official registration system for hormonal and intrauterine contraceptives users is imperfect and may underestimate true usage rates. Only peculiarities of the registration process could explain the low rate of female contraceptive users in Moscow city and the Moscow region, which has always been one of the most advanced regions in Russia.

Table 3.8
Officially Registered Users of Intrauterine Devices and Hormonal Oral Contraception, Per 1,000 Women Aged 15-49, by Provinces of the Russian Federation, 1992

Region Intrauterine Devices Pills
Northern 269.4 31.8
Northwest 100.0 31.4
St. Petersburg city 66.7 13.0
Central 116.2 26.2
Moscow city 77.0 18.4
Volga-Vyatsk 225.4 22.4
Central, "Chernozem" 147.7 23.1
Volga 232.0 46.2
North Caucasus 142.5 24.6
Urals n.a. n.a.
West Siberian 278.3 42.1
East Siberian 170.4 19.1
Far East 217.8 27.6
Baltic 167.2 25.3
Russia181.930.6

SOURCE: Official data of the Ministry of Health of Russia.
NOTE: Departmental statistics from the Ministry of Railroad Transportation are included.

Voluntary Surgical Sterilization in Post-Soviet Russia of the Early 1990s

Voluntary surgical contraceptive sterilization was legalized in the USSR in the early 1990s. Earlier such sterilization was strictly prohibited in the USSR pursuant to Stalin's prohibition of abortion.[10] During that time, numerous policies were introduced to curtail individual reproductive freedom and increase fertility. During the 60 years between the end of the 1930s and the early 1990s, this method of sterilization was not officially recognized and, as a result, was considered to be clandestine. Contraceptive sterilization could be obtained by payment ("under the table") or through an "acquaintance" only.

The prohibition of voluntary surgical contraceptive sterilization extended until 1990, when the Order of the Ministry of Health of the USSR No. 484, "On permission for surgical sterilization of women," was published.[11] However, judging by personal communications with practicing physicians in the larger cities of the former USSR, this method was very rarely used for contraception in the early 1990s.

Until 1990, a woman theoretically had the opportunity of obtaining medical sterilization at the local hospital closest to her place of residence, but only after a complex series of medical investigations. It was only in 1990, on the basis of Order No. 484, that women were allowed to have sterilization performed at a facility outside her region of permanent residence. Order No. 484 included official permission for surgical contraceptive sterilization on demand for some limited cases only. Those special cases include women having:

  • three or more children;
  • over 30 years of age, and with at least two children;
  • had repeated cesarean sections, and with children;
  • sustained injury of the uterus after myomectomy;[12]
  • particular cancers and any blood diseases;
  • any mental disorders.
The full list of such indicators consists of 18 groups of different pathological disorders and diseases. It should be noted that the possibility of male voluntary surgical contraceptive sterilization was not mentioned at all in that order. Moreover, Order No. 484 included very detailed instructions for performing the sterilization operation.

One constraint in providing medical sterilization was that the required laparoscopic equipment and instruments were imported and available only in large hospitals and medical-scientific research institutes. Smaller hospitals did not have access to this technology. The collection of statistical data on contraceptive sterilization in the USSR began only in 1991 and was first published in the 1991 statistics on family planning in Russia.

A new government order, No. 303, concerning voluntary surgical contraceptive sterilization was published in 1993, replacing Order No. 484.[13] The primary goals of this order were officially declared as the "protection of public health; realization of rights [of access] to specialized medical treatment; reducing the number of abortions and post-abortion mortality." The main action of this order was that ". . . Medical sterilization, as a special procedure with the goal of limiting personal reproductive potential or as a method of contraception, may be provided...with the agreement of the citizen . . . without limitation by age and number of children." Additionally, Order No. 303 included:

  • instructions concerning the rules permitting the provision of medical sterilization;
  • a list of medical indications for providing medical sterilization;
  • instructions concerning medical technology for sterilization of women;
  • instructions concerning medical technology for sterilization of men.
Some very important innovations in family planning and in contraceptive sterilization were introduced by Order No. 303. Most significantly, for the first time, medical sterilization was considered a method of family planning and sterilization of males was permitted. In addition, the list of medical indicators for sterilization was broadened, consisting of more than 50 diseases and pathological disorders. Finally, this order also made it possible to obtain contraceptive sterilization outside of one's region of residence.

In sum, voluntary surgical contraceptive sterilization in the USSR and Russia has progressed through four periods of legalization: before 1939 it was legal; from 1939 to 1990 it was de jure prohibited and de facto barely provided; from 1990 to 1993 there was de jure legalization of female contraceptive sterilization on medical (and some social) grounds; and in 1993 there was de jure legalization of the provision of male and female contraceptive sterilization on medical and social grounds and on request.

Commercial Sterilization

In 1993 in Moscow and St. Petersburg, some private commercial clinics began providing voluntary surgical contraceptive sterilization for a fee. Advertisements concerning provision of such contraceptive sterilization are regularly published in newspapers in the larger cities.

Legalization of sterilization and the subsequent publication of official information in 1989 raised certain important problems. Even in 1994, contraceptive sterilization of women did not constitute a statistically significant phenomenon, averaging in 1991 barely 0.3 percent of the total number of fertile age women in all of Russia (Table 3.9). Nevertheless, it is more important to pay attention to the annual growth in the number of contraceptive sterilizations performed in Russia, which rose from 7,255 in 1991 to 9,660 in 1992 (Table 3.9).

Table 3.9
Officially Registered Voluntary Contraceptive Sterilizations, by Province in the Russian Federation, 1991-1992

Number of Sterilizations As Percentage of Women of Fertile Age
Region 1991 1992 1991 1992
Northern 468 840 0.32 0.57
Northwest 149 205 0.07 0.10
St. Petersburg city 60 57 0.05 0.04
Central 1,272 1,834 0.16 0.24
Moscow city 483 488 0.21 0.21
Volga-Vyatsk 724 458 0.34 0.21
Central "Chernozem." 103 441 0.5 0.22
Volga 720 1,164 0.17 0.28
North Caucasus 932 716 0.22 0.17
Urals 1,393 1,874 0.27 0.37
West Siberian 701 1,040 0.19 0.28
East Siberian 402 643 0.18 0.29
Far East 289 417 0.15 0.22
Baltic 102 28 0.47 0.13
Russia 7,255 9,660 0.20 0.26

SOURCE: Official data of the Ministry of Health of Russia.
NOTE: Departmental statistics from the Ministry of Railroad Transportation are not included.

It is important to note that the real increase in the number of voluntary contraceptive sterilizations may be higher, because of the concentration of such operations in commercial health facilities in the larger cities of Russia. Also, rural residents are likely to be undercounted because they tend to travel to big cities to take advantage of the greater availability and higher quality medical care. Such "provincial" cases are not registered in provincial medical statistics, nor in the medical statistics of big cities. Moreover, the statistics do not differentiate the proportion of sterilizations which were provided voluntarily as a method of contraception. Because of this approach to statistical reporting, we lose the most interesting and essential information about such operations performed as a method of family planning.

Other Characteristics of the Distribution of Induced Abortion in Post-Soviet Russia of the Early 1990s

Data in Tables 3.10-3.13 show some additional characteristics of abortion in Russia and the former Soviet Union. Among the former Soviet republics, abortion rates per 1,000 women range from a low of 14.2 in Azerbaijan to a high of 108.8 in Russia. The statistics suggest that nearly two-thirds of all abortions are legal, induced abortions, and another 24 percent are early induced abortions (Table 3.11). Just over two-thirds of all reported abortions in the Russian Federation in 1991 occurred in the first 12 weeks of pregnancy (Table 3.12). Ten percent of all abortions are to women under age 20, and nearly 20 percent are to women aged 35 or older (Table 3.13).

Table 3.10

Abortion Rates in the Soviet Republics, 1990

Soviet Republics Total Abortions Per 1,000 women age 15-49
USSR 6,193,561 89.8
RSFSR (Russia)3,920,287 108.8
Ukraine 1,019,038 82.7
Byelorus 254,726 103.5
Uzbekistan214,137 44.7
Kazakhstan 354,430 85.0
Georgia 61,127 45.9
Azerbaijan 25,536 14.2
Lithuania n.a. n.a.
Kirgizstan 78,105 76.1
Tajikistan52,658 44.3
Armenia 25,282 29.6
Moldavia81,931 74.6
Latvia 45,360 70.4
Turkmenistan 35,698 40.4
Estonia 25,246 66.3

SOURCE: Official data of the Ministry of Health of USSR and Russia.
NOTES: Departmental statistics are not included.
na = No data available.
Table 3.11
Main Characteristics of Abortions in the Russian Federation, 1991

Type of Abortion Total Number of Abortions Percentage of All Abortions
All abortions 3,442,395 100.00
Spontaneous abortions229,230 6.70
Induced abortions for medical reasons57,787 1.70
Legal induced abortions2,203,536 64.00
Criminal induced abortions 13,493 0.39
Abortions of unknown causes 114,348 3.32
Early induced abortions 827,001 24.02

SOURCE: Official statistical data issued from Central Data Processing Center of the Ministry of Health of Russian Federation, 1993.
NOTE: Departmental statistics are not included.

Table 3.12
Abortions in the Russian Federation, by Gestational Age, 1991

Gestation Age Total Percentage of All Abortions
Up to 12 weeks 2,338,311 67.9
22-27 weeks 61,965 1.8

SOURCE: Official statistical data issued from Central Data Processing Center of the Ministry of Health of Russian Federation, 1993.
NOTE: Departmental statistics are not included.

Table 3.13
Abortions in the Russian Federation, by Age of Women, 1991

Age of Women Total Percentage of All Abortions
Under 15 6,015 0.2
15-19 38,848 9.8
20-34 2,458,948 71.4
35 and over 638,584 18.5

SOURCE: Official statistical data issued from Central Data Processing Center of the Ministry of Health of Russian Federation, 1993.
NOTE: Departmental statistics are not included.

Conclusion

This investigation was undertaken in order to present and discuss the principal officially issued statistics concerning family planning in Russia. The core of this work was focused on evaluating issues of macro-level statistics on family planning, and particularly induced abortion, in Russia.

The social and demographic aspects of induced abortion in family planning in contemporary post-Soviet Russia reflect the unique experience in the social and demographic development of the country.

The right for family planning, or "free and responsible parenthood," as defined by the United Nations/World Health Organization (UN/WHO), is an internationally acknowledged and inherent right of each person.[14] Family planning is referred to in a number of UN documents which were ratified by the USSR and recognized and supported by the Russian Federation at the 1994 Cairo International Conference on Population and Development. However, in Russia the right to family planning, despite being de jure legalized in domestic law and confirmed by international commitments, remains restricted due to the lack of information, lack of specialized and qualified medical care personnel and assistance in family planning, and of modern contraceptives. In practice, only the right to induced abortion on request has been realized de facto in Russia.

Since the 1970s, Russia's decline in fertility was primarily accomplished by a very high abortion rate. Moreover, induced abortion in Russia has been used not only for birth limitation, but also for birth spacing. The substitution of abortion with effective methods of contraception has yet to take place on a large scale, and induced abortion is still the primary method of family planning in Russia. In addition, because abortion services remain inadequate, clandestine abortions are performed at a very high rate.

The issue of induced abortion in Russia may be viewed not only as a national problem, but also as an extreme case relevant to world-wide population policy discourse. Russia can be used as a model of what happens when information, services, and contraception are unavailable or inadequate. A system of family planning services has yet to be created in Russia. It is one of the few economically developed countries where abortion still prevails over the use of contraceptives in family planning. The difference between Russia and all Western countries lies not only in this temporal lag, but also in the continuing and widespread underestimation of this as a social problem for Russia.

Nevertheless, we expect a deterioration in the situation[15] as a result of the problem of AIDS and great changes in sexual behavior (especially among the young), changing demographics, and increasing democratization in Russian society.

References

1. Russian Federation. Ministerstvo Zdravookhraneniya Rossiiskoi' Federatcii, 1992 (Ministry of Health of the Russian Federation, 1992). Directive of the Minister of Health of the Russian Federation, Moscow, August 30, 1992, No. 06-15/7-15: On the Abortion Situation and Organizing of Family Planning Services. Moscow: MZ RF. 7 pp.

2. Russian Federation. Ministerstvo Zdravookhraneniya Rossiiskoi' Federatcii, 1992 (Ministry of Health of the Russian Federation, 1992). Directive of the Minister of Health of the Russian Federation, Moscow, March 3, 1992, No. 171-y: On the Collection and Presentation of Monthly Medical Records. Moscow: MZ RF. 1 p.

3. Russian Federation. Ministerstvo Zdravookhraneniya Rossiiskoi' Federatcii, 1993 (Ministry of Health of the Russian Federation, 1993). Order of the Minister of Health of the Russian Federation, Moscow, December 28, 1993, No. 302: On Confirmation of the List of Medical Indications for Artificial Interruption of Pregnancy. Moscow: MZ RF. 16 pp.

4. Henshaw, S.K., "Induced Abortion: A World Review, 1990," International Family Planning Perspectives, Vol. 12, No. 2, 1990, pp. 59-65.

5. Henshaw, Stanley K., Morrow, E., Induced Abortion: A World Review 1990 Supplement, New York: The Alan Guttmacher Institute, 1990, 120 pp.

6. Tietze, Christopher, Henshaw, Stanley K., Induced Abortion: A World Review 1986, 6th Edition, New York: The Alan Guttmacher Institute, 1986, 144 pp.

7. Popov, A., "Sky-high Abortion Rates Reflect Dire Lack of Choice," Entre Nous (The European Family Planning Magazine), No 16, September 1990, pp. 5-7.

8. USSR. Ministerstvo Zdravookhraneniya SSSR, 1987 (Ministry of Health of the USSR, 1987). Order of the Minister of Health of the USSR, Moscow, June 05, 1987, No. 757, On Confirmation of the Instruction on Artificial Interruption of Early Pregnancy by Vacuum Aspiration. Moscow: MZ SSSR. 6 pp.

9. USSR. Ministerstvo Zdravookhraneniya SSSR, 1987 (Ministry of Health of the USSR, 1976). Order of Minister of Health of the USSR. Moscow, December 31, 1987. No 1342: On the Confirmation for the Developing of Operation for Artificial Interruption of Pregnancy for Non-medical Reasons. Moscow: MZ SSSR, 3 pp.

10. SSSR. Ministerstvo Zdravookhraneniya SSSR, 1982 (Ministry of Health of the USSR, 1982). Order of the Minister of Health of the USSR. Moscow, April 22, 1982, No 430: On Confirmation of the Instruction on the Organization of a Women's Clinic. Moscow: MZ SSSR, 99 pp.

11. USSR. Ministerstvo Zdravookhraneniya SSSR, 1982 (Ministry of Health of the USSR, 1982). Order of the Minister of Health of the USSR, Moscow, March 16, 1982, No 234: On Confirmation of the Instruction on Providing Surgical Artificial Interruption of Pregnancy. Moscow: MZ SSSR, 18 pp.

12. Sadvokasova, E.A., Social and Hygienic Aspects of Birth Control, Moscow: Meditsina, 1969, 192 pp.

13. Vasilevskii L.A., Vasilevskii L.M., 1924. Abortion as a social phenomena. Social and hygienic essay. Moscow-Leningrad: Izdatel'stvo Frenkelia. 128 pp.

14. RSFSR. Narkomzdrav, Narkomiust, 1920 (RSFSR. People's Comissariat of Health. People's Comissariat of Justice, 1920). Order of the People's Commissariat of Health and the People's Commissariat of Justice of the Russian Federation. Moscow, November 16, 1920: On the Artificial Interruption of Pregnancy, in Orders of the CPSU and the Soviet Government on public health protection. Moscow: Medgiz, 1958. p. 63.

15. USSR. TSIK i SNK Soyuza SSSR, 1936 (Central Executive Committee and Council of the People's Commissars of the Soviet Union, 1936). Decree of the TSIK and SNK of the USSR. Moscow, June 27, 1936: On the prohibition of abortion, the increase of financial help to mothers, the establishment of State help for large families, the broadening of the network of maternity hospitals and daycare centers, the amplification of judicial penalty for deviation from prescribed child support and about certain changes in legislation of divorce. In: Orders of the CPSU and the Soviet Government on public health protection. Moscow: Medgiz. 1958. p. 264. GCNMB:[Ksp 667/s-p].

16. USSR. Prezidium Verkhovnogo Sovieta SSSR, 1955 (Presidium of the Supreme Council of the USSR, 1955). Decree of the Presidium of the Supreme Council of the USSR. Moscow, November 23, 1955: On the Elimination of Abortion Prohibition, in Orders of the CPSU and the Soviet Government on Public Health Protection. Moscow: Medgiz, 1958, p. 333.

17. USSR. Ministerstvo Zdravookhraneniya SSSR, 1976 (Ministry of Health of the USSR, 1976). Order of the Minister of Health of the USSR. Moscow, July 8, 1976. No. 08-23/11: On the Permission for the Operation of Artificial Interruption of Pregnancy. Moscow: MZ USSR, 10 pp.

18. USSR. Soviet Ministrov SSSR, 1988 (Council of Ministers of the USSR). Directive of the Council of Ministers of the USSR. Moscow: December 29, 1988: Instruction for Realization of the Decree of the Soviet of Ministers of the USSR. Moscow: Mir., 12 pp.

19. USSR. Ministerstvo Zdravookhraneniya SSSR, 1962 (Ministry of Health of the USSR). Order of the Minister of Health of the USSR. Moscow, August 2, 1962. No. 377: On the Measures of Adjusting the Fight Against Abortion. Moscow: MZ SSSR. 5 p.

20. Goskomstat, USSR, "Demographic Yearbook of the USSR 1990," in Finance and Statistics, Moscow: 1990, p.640.

21. Ministry of Health of the USSR, 1990. Public Health in the USSR in 1989, in Statistical Materials, Moscow: MZ SSSR, 110 pp.

22. Goskomstat, USSR, 1988. Population of the USSR in 1987: Statistical Yearbook, in: Finance and statistics. Moscow. p. 440.

23. Ministry of Health of the USSR, 1989. Population Health in the USSR and Activities of Public Health Services in 1988. Moscow: Ministry of Health of the USSR. 220 pp.

24. Reayennik L.I., "The Role of Abortion in the Structure of Methods of Birth Control in the USSR and Abroad," in Problems of Demographic Development of the USSR. Moscow: ISI AN USSR, 1988, pp. 86-99.

25. Aborty v 1926 g.(Abortion in 1926). 1929. Moscow: Statizdat. 150 pp.

26. Avdeev Alexandre, Alain Blum, Irina Troitskaja, 1993. L'avortement et la contraception en Russie et dans l'ex- USSR: historie et present. Paris: Institut National d'Etudes Demograhiques, 1993. 74 pp.

27. WHO, 1994. Women's Health Profile. Conference on the Health of Women in Central and Eastern Europe, February 16-18, 1994. UNO, Vienna.

28. USSR. Ministerstvo Zdravookhraneniya SSSR, 1990 (Ministry of Health of the USSR, 1990). Order of the Minister of Health of the USSR. Moscow, December 14, 1993. No. 484: On Legalizing Surgical Sterilization of Women. Moscow: MZ SSSR, 23 pp.

29. Russian Federation. Ministerstvo Zdravookhraneniya Rossiiskoi' Federatcii, 1993 (Ministry of Health of the Russian Federation, 1993). Order of the Minister of Health of the Russian Federation. Moscow, December 28, 1993. No. 303: On Providing Medical Sterilization of Citizens. Moscow: MZ RF. 28 pp.

30. Russian Federation. Ministerstvo Zdravookhraneniya Rossiiskoi' Federatcii, 1992 (Ministry of Health of the Russian Federation, 1992). Directive of the Minister of Health of the Russian Federation. Moscow, March 3, 1992. No. 171-y: On the Collection and Presentation of Monthly Medical Records. Moscow: MZ RF. 1 p.

31. Russian Federation. Ministerstvo Zdravookhraneniya Rossiiskoi' Federatcii, 1988 (Ministry of Health of the Russian Federation, 1988). Order of the Minister of Health of the Russian Federation. Moscow, March 29, 1988. No 250: On Organizing Commercial Clinics (departments, rooms) and Free-of-Charge Clinics (departments, rooms) with State Financing for Patients Who Require Permanent Care and Commercial Gynecologic Clinics (departments, rooms) for Providing Operations of Artificial Interruption of Pregnancy (abortion). Moscow: MZ RF. 10 pp.

Discussants' Comments

Discussants: Catherine Jackson, RAND; and Jack Molyneaux, RAND

The discussants of Dr. Popov's paper noted that the lessons of birth control in the United States could be used in designing the family planning strategy in Russia. Perhaps the most important of these lessons is that a wide availability and accessibility of effective pre-conception birth control methods can substantially diminish the incidence of abortions, since abortion in Russia is often the result of the failure of ineffective contraception.


[1] Andrej A. Popov was a director of the Transnational Family Research Institute in Moscow and a research associate of the Center for Demography and Human Ecology, Institute for Economic Forecasting, Russia Academy of Sciences. He died tragically on April 23, 1995, immediately prior to the conference for which this paper was prepared. This paper was completed with the financial support of the Russian Foundation for Basic Research and by the John D. and Catherine T. MacArthur Foundation. The paper owes a great deal to Dr. Henry P. David (Transnational Family Research Institute, USA), Michele Rivkin-Fish (Princeton University, USA), Anna Lukina, Nadegda G. Baclaenco, Dr. Sergei V. Zakharov, Anna Vorobyova, Nadezda Azhgikhina, and Alexandra Sokolova.

[2] Ministry of Health of the Russian Federation, 1992, Directive of the Minister of Health, August 30, 1992, No. 6-15/7-15: "On the Abortion Situation and Organizing Family Planning Services," Moscow: MZRF, 7 pp.

[3] Directive of Minister of Health of the Russian Federation, No. 171-y, "On the Collection and Presentation of Monthly Medical Records," Moscow: MZRF, 1 p., March 03, 1992.

[4] Order of Minister of Health of Russian Federation, No. 302, "On the Confirmation of the List of Medical Indications for Artificial Interruption of Pregnancy," Moscow: MZRF, December 28, 1993, 16 pp.

[5] Directive of the Minister of Health of the Russian Federation. No. 171-y, "On the Collection and Presentation of Monthly Medical Records," Moscow: MZ RF, March 3, 1992, 1 p.

[6] Order of the Minister of Health of the Russian Federation. No. 250, "On Organizing of Commercial Clinics (departments, rooms) and Free-of-Charge Clinics (departments, rooms) With State Financing for Patients Who Require Permanent Care and Commercial Gynecologic Clinics for Provision of Operations for Artificial Interruption of Pregnancy (abortion)," Moscow: MZ RF, March 29, 1988, 10 pp.

[7] Directive of the Minister of Health of the Russian Federation, No. 171-y, "On the Collection and Presentation of Monthly Medical Records," Moscow: MZ RF, March 3, 1992, 1 p.

[8] Editor's Note: The statistics in the tables included in the present article are not disaggregated enough to support this argument. Due to the author's death prior to preparation of the present volume for publication, further elaboration is not possible here.

[9] Editor's Note: By "abortion migration," the author may mean migration from regional periphery to center, across regions, or from public to private facilities in order to obtain the highest quality services.

[10] Prohibition of contraceptive sterilization was officially established by the Order of Narkomzdrav of the USSR, "On the Prohibition of the Operation of Cutting or Ablation of Healthy Fallopian Tubes of the Uterus," No. 303, August 7, 1939. Narcomzdrav is the abbreviation for the Narodnyi' Comissariat Zdravookhranieniya, or the Peoples' Comissariat of Public Health Services.

[11] Ministry of Health of the USSR, Order No. 484, "On permission for surgical sterilization of women," December 14, 1990, Moscow: MZSSSR, 23 pp.

[12] Myomectomy is the surgical removal of a myoma (a tumor composed of muscle tissue), specifically of a uterine myoma.

[13] Order of the Minister of Health of the Russian Federation. No. 303, "On Providing Medical Sterilization of Citizens," Moscow: MZ RF, December 28, 1993, 28 pp.

[14] Moreover, the right of each person to conduct family planning serves as the legal and organizational basis for guaranteeing many other fundamental human rights--women's rights in general, the woman's right to -43choose, children's rights, the right of a person to health, etc., UN/WHO.

[15] Editor's Note: The author may have meant that an improvement, in the form of a reduction in the abortion rate and increase in contraceptive use, is expected.


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