Feature

Dying for effective contraception

Maternal mortality rates in Russia are comparable to those in Britain half a century ago. One in five of these deaths is due to abortion. Denise Kendrick reports

Health care in Russia is based almost entirely on a system of specialisation and super-specialisation. Primary care on the UK model does not yet exist, although groups of enthusiastic doctors are currently trying to establish primary care based on vocational training. ‘District therapists’ are the generalists of the Russian system. They are based in walk-in polyclinics, which also house a wide variety of specialists and professionals from fields such as physiotherapy and dentistry. District therapists care for a caseload of approximately 1,600 patients, providing care in the polyclinics and also at home. They do not provide 24 hour cover - all out-of-hours emergency care is undertaken by ambulances staffed by medics. They do not provide the breadth of care provided by general practitioners in the UK, dealing mainly with cardiac and respiratory diseases in adults.

All paediatrics, obstetrics and gynaecology, surgery including the minor surgical specialties and general medicine other than cardiac or respiratory disease is dealt with by specialists. Patients can self refer to these specialists by writing their name in the appointment book in the polyclinic, or can be referred by a district therapist.

Maternity care is undertaken at special maternity hospitals which also hold antenatal clinics. Family planning is provided by gynaecologists, termination hospitals and paediatric gynaecologists for teenagers. Preventive medicine, in the form of screening for previously unrecognised disease, is carried out on a large scale by doctors in schools and the workplace.

Medicine is a profession afforded only mediocre status, staffed predominately by women and relatively low paid. Perestroika has made Russian doctors aware of the difference between their status and that of colleagues in other countries, their poor pay and their lack of access to scientific literature, drugs and medical equipment. As a result morale in the Russian medical profession is low.

I recently visited St Petersburg to find out about Russian family planning services and to offer advice and information on the organisation of family planning services from the British perspective. Statistics on women’s health in St Petersburg revealed a maternal mortality rate of 70 deaths each year per 100,000 pregnant women, approximately 10 times the rate in England. Twenty per cent of the maternal deaths are attributable to termination of pregnancy, with most of the deaths occurring in women who have had terminations outside the medical system. On average a Russian woman will have 5 or 6 terminations during her reproductive lifetime.

Termination hospitals have both fee paying and free wards. In the hospital I visited, the only differences between them were that the fee paying ward had curtains at the windows and was full, whilst the free ward was empty. The cost of a termination is approximately 500 roubles (average monthly wage at the time of my visit being 1,000-2,000 roubles). The clinic staff explained that people prefer to pay rather than accept free services because of personal pride and a belief that paid-for services are likely to be better. This may be true, but fails to explain why women choose terminations outside the medical system when free terminations are apparently provided.

The majority of terminations are undertaken early - at around 6 weeks gestation. Complications are less common with early terminations than later ones, and indeed the complication rates quoted by the termination hospital were very low. It seemed paradoxical that the state system was sufficiently accessible to allow an early termination for the majority of women, yet women were still resorting to essentially ‘back street’ abortions with all the ensuing risks.

The coil is the second most common method of contraception in Russia, used by up to 20 per cent of women. Hormonal contraception was infrequently used, for a variety of reasons. While talking to Russian gynaecologists, it became clear that many believed hormonal contraception to be unsafe for most Russian women. This may be due to the gynaecologists’ ‘medical model’ approach to family planning - they saw their role as finding and treating disease, and would instigate extensive screening tests on women to search for previously unrecognised disease. Russian women I spoke to found this very off-putting and would only see a gynaecologist if they considered themselves unwell. As a result, the gynaecologists probably saw those women who had worse than average health.

The availability of contraceptive pills is an additional problem; pills could be purchased at the local pharmacy for about 10 roubles a packet, but many that I saw were the old high dose type, and women told me the supply was very variable - one month they could get pills, but not the next.

Teenage conceptions are an important problem. Many occur in single women on low incomes, often unsupported by their families because they have moved to the city to find employment. I visited a teenage clinic, but this dealt mainly with paediatric gynaecology, again centred on the medical model and concentrating on the diagnosis and treatment of disease, rather than providing accessible family planning for teenagers.

Condoms were available, but extremely expensive at 30-50 roubles each, not trusted by Russian women and disliked by Russian men. Caps were unpopular because they are difficult to use in overcrowded apartments with shared bathrooms and little privacy. Laparoscopes, used in ‘keyhole’ surgery in the UK, were scarce so female sterilisation was rare. Vasectomy was extremely unpopular among Russian men. The reliance on contraceptive methods dependent on medical input was not surprising in view of the power of the medical model in the Russian health care system.

It is sobering to remember that maternal mortality in Russia today is similar to that in Britain 40 to 50 years ago. We achieved our current level of health in a stable political climate over a 50 year period. In a country in the midst of great political and economic turmoil any improvements in health are likely to take very many years.