Women's Reproductive Health Needs in Russia: What Can We Learn from an Intervention to Improve Post-abortion Care?

Published in Health Policy and Planning (Volume 22, Number 2, Pages 83-94), this paper reports the results of an evaluation of interventions to improve post-abortion care in Russia. As detailed in the opening sections of the report, it has been well documented that abortion is a common means of controlling fertility in Russia; however, recent studies suggest that abortion rates are on the decline, use of modern contraceptives is increasing, and women dislike abortion as a method of fertility control.

In this context, the Women and Infant Health Project (WIN) launched an initiative in 1999 to improve the overall quality and effectiveness of maternal and infant health services, including post-abortion care. In cooperation with the Ministry of Health and the Health Care Departments of Perm and Novgorod Oblasts, this pilot project promoted evidence-based medical practices, quality assurance methods, and client-centred approaches in 3 cities (Perm and Berezniki in Perm Oblast and Veliky Novgorod, near St. Petersburg). Project interventions included training courses in family-centred maternity care, essential care of the newborn, exclusive breast-feeding, contraceptive technologies, and client-centred family planning counselling. Provider training began in September 2000, with Contraceptive Technology Update (CTU) seminars in each city for selected obstetrician-gynaecologists and midwives. Curricula were updated, training materials produced, and a cadre of local "master trainers" were trained. In addition, the project supplied informational brochures to participating facilities, and a national media campaign took place between December 2001 and February 2002 to inform women about contraceptive choices.

To assess the project's effectiveness and impact, pre- and post-intervention surveys of providers and clients were conducted in the 20 participating facilities. The anonymous surveys were designed to measure changes in key indicators of service quality, as reflected in reported provider practices and client experiences. Pre- and post-intervention household surveys were also conducted. This report focuses on data from abortion clients obtained in the 3 facility-based surveys conducted in 2000, 2002, and 2003.

In brief, "[t]he evidence presented here suggests that the project interventions were implemented effectively, but the training, increased post-abortion counselling, and other information provision did not diminish repeat abortion rates at the project sites, and the gap between knowledge and practice of effective contraception remains."

More specifically, on the positive side, the results show a significant increase in post-abortion contraceptive counselling. When interviewed at baseline, only 41% of abortion clients report being counselled about how to prevent another unplanned pregnancy. The proportion that report receiving counselling more than doubled by the time of the second round survey, and by the 2003 survey had increased to more than 90% of all abortion clients. Among those who chose a specific method prior to discharge, there was a significant increase in method-specific counselling by a health provider over the course of the project. Another significant change is the 10-fold increase in women who report receiving an informational brochure at the abortion facility. The data also show a significant increase in clients who could correctly report when return to the fertile state occurred: in both the second and third round surveys, three-quarters of clients said they could become pregnant again immediately, or within 2 weeks of the abortion, up from 62% at baseline. (This suggests that they retained some of the key information imparted during counselling and in brochures). "These data suggest that the training for providers resulted in increased, and possibly more effective, discussions about contraception with abortion clients. In all three surveys, more than 80% of post-abortion clients expressed not only an intention to use medical contraception but had identified their method of choice."

However, the evaluation found no reduction in the rate at which women present at clinics for repeat abortions. Thus, findings indicate a discrepancy between women's stated preferences for modern medical contraceptive methods and their abortion-seeking behaviour. Further exploration of these data suggests that certain women resort to abortion with greater frequency than others. Compared with other repeat abortion clients, they are likely to be younger, living in informal unions, report socio-economic reasons for the abortion, and have given little thought to future contraceptive needs. These women who repeat the procedure rapidly may need more support than others to safely achieve their reproductive intentions; this points to the need for a more focused investigation of these women. These results indicate the complexities associated with changing what has been a relatively common and long-standing practice, and have implications for improving reproductive health services. Meeting the reproductive health needs of Russian women requires not only improved provider and client knowledge but may also demand a more focused delivery of client-centred care than may be the case in other settings.

The authors conclude with several recommendations; among them:

• Expanding access to a wider range of long-term and permanent contraceptive methods needs consideration by the health system. Providing the option of intrauterine device (IUD) insertion at time of abortion may be a safer alternative than repeated abortion for many women. Causes of apparent IUD failures need to be investigated and addressed.
• In light of the apparent disparity between Russian women's dislike of abortion as a method of fertility control and their actual practice, an in-depth investigation of the motivations of women who rely on frequent abortion could be useful for designing more focused and more effective reproductive health programmes.
• Post-abortion counselling could focus not only on the range of pregnancy prevention measures that are available alternatives to abortion, but also refer to what is known about the relative health risks of these methods compared with the abortion procedure. At present, evaluators explain, this kind of information is not presented to women. They assert that a review of hospital records to document the extent of post-abortion complications, which are not currently tracked through the health information system, would be a useful first step in providing more information about these risks in the Russian context.
• The findings point to the need for a more focused investigation of the women most at risk of multiple repeat abortions, to identify their reasons for resorting to a procedure that most women do not like and that may put them at greater risk of subsequent morbidity.
• Russian medical practitioners are eager to learn from developments in medicine elsewhere, as evidenced by their "enthusiastic reception of the evidence-based approach to medical care introduced in WIN project training courses". According to evaluators, this indicates the potential for working with highly motivated physicians and with the health system to find ways to ensure that more contraceptive options are available, that providers are well equipped to offer the full array of contraceptive options in a high quality manner, and that they are compensated appropriately for doing so.
  

"The evidence presented in this paper suggests that women's fertility control needs and preferences are not being met by the existing system. Addressing women's reproductive health needs in Russia, and in other countries where similar conditions prevail, requires a more focused approach to delivering client-centred care than may be the case in other settings."