Jan 1, 2001
Like many Communist or post-Communist nations, Russia has one of the highest abortion rates in the world. These rates have created a legacy of significant medical problems. Complications from abortion are the cause of more than one in four maternal deaths in Russia. Overall, two in three Russian women aborting their pregnancies suffer health complications as a result of the procedure, further stressing the overburdened Russian health care system. Abortion has also led to high rates of secondary sterility in Russia; an estimated one in ten women is left sterile by the procedure. The picture has improved considerably, however, since the late 1980s, as contraception has become more available. Although the abortion rate remains more than three times the U.S. rate (Figure 1), it has declined substantially in the past decade. Continued improvement in contraceptive availability and quality could cut the abortion rate even further.
These are the conclusions reached by RAND analysts Julie DaVanzo and Clifford Grammich in Dire Demographics: Population Trends in the Russian Federation. The report examines the historical causes underlying traditionally high abortion rates in Russia, the contribution of family planning programs in recent years to reducing abortion rates, and prospects for continued improvement.
Two influences have worked to keep Russian abortion rates high. First, Soviet ideology hindered the development and spread of effective contraception. Soviet ideology held that declining fertility rates were not typical of socialism and that socialist economic improvement would yield higher birth rates and lower abortion rates. Such views resulted in little effort to develop or distribute modern contraceptives. They also led the Stalin government, which equated power with population size, to prohibit abortion and to restrict contraception for nearly 20 years in an effort to fuel population growth.
When abortion was re-legalized in the 1950s, an increasing desire for smaller families, due in part to growing urbanization, resulted in very high abortion rates. By 1965, the Russian abortion rate had risen to more than 16 abortions per 100 women (or 1 in 6) of childbearing age. By contrast, fewer than 1 in 30 women of childbearing age in the United States has had an abortion in any single year since the Roe vs. Wade decision. Confronted with such high abortion rates, Soviet health planners began to make contraceptives more available. In doing so, however, they paid little attention to contraceptive quality or distribution. Erratic supplies in rural areas, the poor quality of Russian-made contraceptives, as well as popular fears of deleterious health effects resulting from use of hormonal contraceptives reinforced preferences for abortion over contraception into the 1990s.
Second, both Soviet and Russian medical professionals have faced incentives that kept abortion rates high. Until the late 1980s, obtaining a legal abortion required a subsequent three-day hospital stay, a boon to Soviet hospitals financed by their number of occupied beds. Even today, profits from the procedure are an incentive for low-paid physicians in post-Soviet Russia to perform abortions rather than to encourage contraception.
By the late 1980s, the number of women using modern contraceptive methods to prevent births exceeded the number who used abortion to do so. Available annual data on Russian contraceptive use are limited to the number of women using intrauterine devices (IUDs), hormonal contraceptives, and permanent contraception, but these indicate that since the late 1980s the use of IUDs or hormonal contraceptives (e.g., birth control pills) has roughly doubled (Figure 2). In this same time, the abortion rate declined by half. About eight million women in Russia use IUDs to regulate their fertility. Use of hormonal contraceptives is growing rapidly, with about two million women using this method. As a consequence of increased contraceptive use, the health problems resulting from frequent recourse to abortion have declined in recent years.
Russian contraceptive access has increased in part through efforts by the Russian government and the United States Agency for International Development (USAID) to expand the use of effective contraception and to reduce abortion and maternal mortality at selected sites. Russians also made significant strides in increasing contraception and reducing abortion through their Federal Family Planning Program, which increased threefold the number of family planning clinics between 1991 and 1997. These efforts have helped Russia nearly achieve a freely operating market for contraceptives.
Yet use of contraception, particularly of permanent methods, remains lower in Russia than in many other nations. Voluntary sterilization, for example, is relatively rare in Russia, where, between 1991 and 1998, about 90,000 women obtained it. By contrast, voluntary sterilization is the main method of fertility regulation in the United States, where one in four women of childbearing age, and nearly half of all women between 35 and 44, opt for it. In the 1930s, the Stalin government, in an effort to increase fertility, prohibited voluntary surgical contraceptive sterilization. Re-legalization of the procedure in 1990 included restrictions on its availability until 1993.
There is growing resistance to both abortion and family planning programs in Russia. Both to mitigate health problems resulting from abortion and to boost the Russian fertility rate (which, at less than 1.2 lifetime births per woman, is one of the lowest in the world), some Russian officials are seeking curbs on both abortion and contraception. Some Russian nationalists, seeing in declining birth rates "a plot to smother Russia in its cradle," have, with the backing of the Russian Orthodox Church, campaigned successfully for reductions in funds for family planning programs. The chief obstetrician of the Russian Ministry of Health succinctly summarized the Russian political problems confronting family planning programs when he quoted lawmakers telling him "few enough of us were being born as it is, and then you come along with your [family planning] program." Complicating these matters is strong resistance, dating from Communist days, to formal education on sexuality. Education on sexuality issues was absent from Soviet medical schools. Even today, few Russian schools are willing to go against public opinion opposing sex education.
Nevertheless, as DaVanzo and Grammich observe, the Russian record indicates that improved contraceptive access can help reduce high abortion rates. Continuing improvements in contraceptive knowledge and access can help Russian women lead more stable reproductive lives and avoid problems of maternal morbidity, mortality, and secondary sterility resulting from abortion in Russia.