For decades, abortion has been the principal birth control method for Soviet ... better educated urban residents, mostly from Russia and the Ukraine. Some.
Advancesin Contraception. 1993;9:13-23. 9 1993KluwerAcademicPublishers. Printed in the Netherlands
Contraceptive practice and attitudes in former Soviet women A.Ph. VISSER (1), I. PAVLENKO (2), L. REMMENICK (3), N. BRUYNIKS (4) and P. LEHERT (5)
(1) International Health Foundation, Avenue Don Bosco 8, 1150Brussels, Belgium (2) Magazine 'Health' (Zdorovje), Moscow, Russia (3) Department of Clinical Epidemiology, Tel-Hashomer, Israel (4) Rosmalen, The Netherlands (5) Universityof Mons, Belgium Abstract For decades, abortion has been the principal birth control method for Soviet women. As indicated by some earlier local surveys, most couples use unreliable methods. Little is known about the latest trends in contraceptive use affected by the recent general liberalization of Soviet society, including more open attitudes about sex. A survey was conducted in 1991 via a questionnaire in the popular 'Health' magazine with national circulation. A total of 8059 women returned the questionnaire. The sample is selective with an overrepresentation of young and better educated urban residents, mostly from Russia and the Ukraine. Some 81% reported use of a contraceptive method during the last 5 years. Traditional methods still prevail (41% used withdrawal, rhythm and douche). Among women younger than 25 years there is a clear trend toward use of modern methods (IUD 35% and the pill 10%), although their notion of the 'pros' and 'cons' is biased. Of the respondents, 20% used a barrier method, mainly condom. The preferred method is the IUD (51%) and the pill (18%). Abortions resulting from contraceptive failure were reported by 60% of women. Eighty-nine percent considered pregnancy termination more dangerous than its prevention. For only 12% of respondents, a physician was the main source of contraceptive information, although 49% addressed him for advice. The results indicate a gap between conservative birth control practice and preferences of Russian women, with a positive general trend in the near future.
Visser et al.
14
Introduction
During the last forty years, induced abortion has been the main method of birth control in the former USSR. The introduction of the pill on a mass-scale never happened. Due to the traditional orientation of the health care system, negative opinions on modern contraceptives, material and financial conditions, and the perception of induced abortion as a routine procedure, the abortion practice continued [1]. Abortion never became the important political topic it has become in some Western countries [2]. Figures presented by Remennick [1] show that more than 9 million terminations are performed annually in the former USSR. Other sources mention more than 12 million induced abortions annually [3,4]. This means 112 abortions per 1000 women of fertile age. The few reliable surveys performed in the 1980s show that most couples use traditional contraceptive methods, which have high failure rates [5]. Table 1 indicates that rhythm and the condom are the most frequently used contraceptive methods. Less reliable methods like vaginal douches and coitus interruptus are used by 31% of the women. The IUD and the pill are used by only 13% of women.
Table 1. Practice and attitude towards contraception by Soviet women during the 1980s*
Positive estimation of." Using contraceptive methods (%)
Reliability (%)
Convenience (%)
Safety for health (%)
Rhythm (calendar)
40
28
45
64
Condoms
22
36
21
56
Vaginal douche
13
5
9
22
Coitus interruptus
18
24
9
10
IUD
10
19
22
19
Oral pill
3
6
25
6
Spermicides
3
3
10
8
Diaphragms
1
5
3
20
*Mean percentages from five samples of women living in Moscow, Saratov and Tartu; adopted from Popov et al. [4]
Family planning inadequacies cannot be explained by the unavailability of modern contraceptives alone. Lack of knowledge, fear of health consequences, and negative attitudes toward these methods are also of influence. Table 1 indicates that traditional
Contraceptive Practice and Attitude in Former Soviet Women
15
methods are perceived as more reliable, more convenient, and more safe for health than the IUD and the pill. The figures presented are based on studies performed approximately 10 years ago, before the social and political changes took place in the USSR. The development of the so-called 'open society' led to discussions of the reduction of the number of abortions. More information on sexuality was published and the national family planning organizations became accepted members of international organizations in this field [6]. The study reported here was the response to the question of how contraceptive practice and attitudes of former USSR women are changing. The study was conducted among readers of a family journal in the former USSR.
Methods
The survey was performed by means of the monthly journal 'Health' (Zdorovje), a popular magazine read by millions of women living in various republics of the former USSR. The questionnaire was published in April 1991, containing questions on sociodemographic factors, use of contraception, attitudes towards it and the information sources used. Table 2 contains a description of several sample characteristics. Table 2. Sociodemographic characteristics
f%) Marital status (n = 8042) Single Married Living with friend
5 87 8
No. of children (n = 8059) No children 1 child 2 children 3+ children
12 49 32 7
Age (years) (n = 8044) 15-19 20-24 25-29 30-34 35-39 40-44 45-50*
7 38 31 14 7 3 1
*Women older than 50 years have not been included
**Mainly Kazakhstan (n = 62) and White Russia (n = 18)
(%) Level of education (n = 8043) Primary (.< 8 years) Secondary (10 years) Higher (;~ 15 years)
52 13 35
Urbanization (n = 8059) Big city Small city Village
35 39 24
Republics (n = 7452) Western Russia Ukraine Middle Siberia Western Siberia Eastern Siberia Elsewhere**
35 22 21 13 8 1
16
Visser et al.
Most of the women are married (87%) with one child (49%). The mean age is 26.3 years (SD-5.9); 45% are younger than 25 years; 52% are between 25 and 39 years old, and 4% are 40 years and older. The level of education is rather high. The women are from areas with various levels of urbanization, but mainly live in big cities in Western Russia (e.g. Moscow, St. Petersgrad), and in several parts of Siberia and the Ukraine.
Results
Failing contraception Forty-one percent of the women questioned have experienced one or two abortions and 19% three or more (Figure 1). Number
of
abortions
Number
of unwanted
pregnancies
80 7o
.................................................................................................................
80
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6o
........................................................................................................................ 40
-
4t
'
30
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2O
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
No
lor2
3or4
6)
0
1
2
Figure 1. Abortions and unwanted pregnancies due to failing contraception (%) 100 so
~,
60 I
~ .....
:}~ ........... i ............
i .......... ili:!}}~ I ifilili
inter.
IUD Regular
Rhythm Douche ~
i .................
i!~itiii ~ . ili;i
0-
Condom Coitus
!:Ii
i
.................................................
Pill
Sometimes
Figure 2. Contraceptive methods used in the last 5 years (%)
Chem. Chem. ยง Never
Cap
Contraceptive Practice and Attitude in Former SovietWomen
17
The frequency of abortions is dependent on the number of unwanted pregnancies due to failed contraception. It is striking that only 3% of the women did not experience an unwanted pregnancy; about two thirds had one unwanted pregnancy and 30% had experienced this more than twice. The first unwanted pregnancy was carried to term by 42% of the women. In half of the cases (52%) an abortion was performed; 6% experienced a spontaneous abortion. However, in almost three-quarters of the women the second unwanted pregnancy ended in an induced abortion (73%) or a spontaneous abortion (24%); only a few women (2%) carried the second pregnancy to term.
Use of contraception Eighteen percent of the women indicated that they used no contraception. Use of the main method of contraception is fairly consistent: 39% of the women had used the main method longer than three years, 28% for 1-2 years, and one-third had chosen their contraception method less than one year ago. The women were also asked to indicate whether contraceptive use was regular, sometimes, or never. Figure 2 shows that the condom and the IUD are the most steadily-used contraceptive methods; also the natural methods (coitus interruptus and rhythm) are rather frequently used (31% answered regularly). Ten percent of the women use vaginal douches as their contraceptive method. Only 10% of the women regularly use the pill. The vaginal cap is a rather unpopular contraception method in former Soviet women. 40 35
3=
No
Figure 3. Contraceptiveuse (%)
Natural
Barrier
IUD
Pill
Visser e t aL
18
To determine the main contraceptive methods, the following classification was used in the further statistical analysis: (0) no method used at all and no answer; (1) natural method: regular and/or sometimes rhythm or coitus interruptus; (2) barrier: regular and/or sometimes condom, spermicide, vaginal cap and vaginal douche; (3) IUD: regular use; (4) pill: regular use. If more than one method has been indicated, the method with the highest code (see above) is retained. The results of this analysis are presented in Figure 3. It is clear that the IUD is the most frequently-used contraceptive method, while the pill is the least used. Supposing that most women prefer to postpone or prevent pregnancy, about 36% are at risk: 16% use natural methods and 20% use rather unreliable barrier methods. The reasons for 'no use' are not available. Several sociodemographic factors may influence the choice of the main contraceptive methods (Table 3). Table 3. Use of contraceptives by demographic groups (%) No
Natural
Barrier
32 18 26
20 16 19
19 20 23
17 37 19
11 9 14
23 16 15 25
17 16 15 21
22 18 18 33
27 41 46 17
11 9 6 4
22 18 16
16 15 17
18 20 23
35 36 34
9 10 11
Urbanization* Big city Small city Rural area
18 19 22
t6 16 18
24 19 14
32 36 37
10 10 8
Republics* Western Russia Ukraine Western Siberia Middle Siberia Eastern Siberia
20 19 17 18 18
22 18 11 13 16
19 23 18 19 16
30 30 42 38 42
8 10 11 12 8
Total
19
16
20
35
10
Marital status* Single Married Living together
IUD
Pill
Age groups (years)* 15-24 25-34 35-44 45-50
Educationallevels* Low
Medium High
*X2 tests on demographic factors by method of contraception: p
