Irina Savelieva, MD, Russia
The growing economic difficulties have made it hard to implement universal access to health in Russia. Significant cuts in the public health care budget have resulted in a decrease of state-guaranteed health services for women and children. Due to the lack of appropriate contraceptives and counseling services, abortion was and still remains the principal means of fertility regulation in Russia, sometimes exceeding the number of live births by two or three times. Though the number of abortions performed annually has declined drastically over the past decade (the abortion rate was 100.3 per 1,000 in 1991 compared with 47.7 per 1.000 women of reproductive age in 2001) abortion remains to be an important cause of preventable morbidity and mortality among women of reproductive age. In 2001, abortion accounted for 27,7% of maternal deaths in Russia, as compared with an estimated 13% of maternal deaths attributable to abortion globally. At the same time the number of post-abortion complications remains high, and according to some research can reach 40-60% with high level of incomplete medical abortions, of which nearly half (46.2%) required hospitalization. There are also several safety issues (abortion in nulliparous women, multiple pregnancy terminations, second trimester abortion) which have not be addressed adequately and need special attention, not to mention the psycho-social effects of multiple abortions and possible secondary infertility, and the growing interest and practice of assisted reproduction techniques, such as in vitro fertilization (IVF). These data demonstrated that quality abortion care in Russia does not satisfy world standards and WHO recommendations.
Abortions are more common among women ages 20 to 34 (approximately 70%), with 15.3% women who were pregnant for the first time; the mean number of abortions is 2.8-3.07. Almost 40% of abortion clients had already terminated a pregnancy by abortion during the previous 12 month. About half (43%) were using contraception at the time of their last pregnancy (39% were using condoms, 20% - natural family planning, 12% - spermicides and 11% - pills). The principal reasons for abortions (62,3%) were indicated as socioeconomic reasons; and 20,0% did not want more children. Only 36,9% of abortion clients, including young adults and primigravidae, what is of a crucial importance, received family planning counseling prior to the discharge and only 22,0% left medical facility with a contraceptive method of their choice. Since many women who are terminating an unwanted pregnancy intend to have a child later, it is extremely important to identify high level of post-abortion complications on subsequent reproductive function. The entire population is covered by a national health insurance, but abortion as a procedure has not been included. The country has adopted the Essential Drug Policy but has not included contraceptives in the Essential Drug List.
Clinical abortions are performed in medical facilities. The services are provided in maternity hospitals, consultancies of obstetrics and gynecology, private practices and Family Planning Centers. According to state regulations and laws all state institutions provide family planning counseling and abortions free of charge, but the present socio-economic situation has triggered a growing habit of charges made for clinical abortions.
Increasing and more human counseling, improved and good quality of services, good technology (including new medications), good facilities, better information through well-trained providers, careful follow-up, offer choices of contraceptive methods to women and help them to avoid unwanted pregnancies and consequent maternal health risks.