A Contraceptive Revolution

Russia has just had a great contraceptive revolution, and it is not over: unwanted pregnancies are more often prevented than terminated. Russians now engage in family planning with more confidence: the number of births is almost equal to the number of pregnancies. On the basis of studies completed by HSE demographers, IQ.HSE examines the Soviet and Russian culture of birth control.

The Pill Revolution

Relying on abortion as one’s method of family planning is now a thing of the past. Russians more often use a range of contraceptives, ranging from condoms to hormone drugs and intrauterine devices (IUDs). Incidentally, this year marks the 110^th anniversary of the IUD. The prototype of the modern spiral was created in 1909. Hormonal contraception, on the other hand, is much newer: ideas about its potential first arose in the early 1930s.

The West had its contraceptive revolution in the 1960s and 70s. Modern contraceptive methods came to be used more widely than traditional, less successful ones (such as the pull out method and douching) and abortion. In Russia, this change began at the beginning of the 1990s.

As a famous Soviet song goes: ‘Revolution has a beginning, but revolution has no end’. We can’t talk about the Russian contraceptive revolution in the present perfect yet.

The ratio of modern contraceptives (such as hormonal drugs) to old-fashioned ones (such as the pull out method) still reveals a certain conservatism in family planning in Russia. Nonetheless, the contraceptive revolution cannot be stopped.

According to data of the most extensive survey study to date of Russian women’s reproductive health (VORZ, 2011), 72.3% of women aged 15 to 44 years old, married or partnered, had used some form of contraception recently (within a month before the survey). A recent survey, ‘Reproductive Health of the Russian Population: Prevention, Diagnosis, Therapy’ (RZNR-2018) yielded almost the same result: 74% of married women aged 20 to 39 years old used contraception in 2018.

In terms of the extent to which contraceptives are used, Russia is approaching the rates of Australia, Belgium, Germany, Austria, and Spain. However, Russia still lags far behind the world’s leaders in contraception use: according to UN data, the countries with the highest rates of contraceptive use are Norway (88.4%), Czech Republic (86.3%), Canada and China (85%, respectively).

The fact that the fight against unwanted pregnancy has been replaced by prevention is reflected in abortion statistics.

In the post-Soviet period — that is, for almost 30 years — the number of abortions in Russia has been steadily declining, Viktoria Sakevich, Senior Research Fellow at HSE’s Institute of Demography, noted in a paper presented at the conference, Demographic Trends in Russia: Legacy of Soviet Era or a New Tendency?

From 1992 to 2018, the abortion rate per 1000 women of child-bearing age (15-49 years old) dropped fivefold, from 94.7 to 19. And if we exclude involuntary or spontaneous abortions, such as miscarriages, the number is 7.4 times lower, with a decrease from 89 to 12.

A Soviet Vestige

There are both traditional and modern methods of contraception. The most widely used methods in the Soviet Union are of the former group. These included the pull out method, douching, and the calendar method, whereby a woman calculates her ‘safe’ days. The latter group includes condoms (the most traditional of all modern methods, well known before the contraceptive revolution), hormonal agents (the pill, injections, implants), IUDs, spermicides, and sterilization.

According to the VORZ study, 80% of Russians who generally use contraception prefer modern methods. Herein lies the main difference between the present-day Russia and the USSR.

Soviet advertisement, 1938 / Wikimedia Commons. ‘Contraceptives sold in pharmacies. Condoms and diaphragms. (Krasnyi Rezinshchik Factory) Rubber and metal diaphragms. Before choosing a contraceptive, consult your gynecologist’.

So far, the contraceptive practices of Russians are clearly different from those in the West, which changed half a century ago. In Russia, the three most effective forms of contraceptives— hormonal drugs, intrauterine devices, and sterilization—are not widely used. The percentage of women using these three forms among all married or partnered women is only 41%. In Canada and the USA, on the other hand, this number is 75%, and in the Netherlands, Germany, Great Britain, France, and Belgium, it is over 80%. In other words, in these countries, the revolution is complete. Unreliable and ineffective means of contraception are almost never used. In Russia, however, the most commonly used form of contraception is the condom.

Almost 27% of couples (or 37% of all contraceptive users) use a condom. The second most used contraceptive is the IUD (14.2% of couples), followed by hormone drugs (13.2%).

However, according to experts, the condom is not a very effective tool for family planning. If used over the course of one year, the condom still gives couples a 14% chance of pregnancy. This is the lower limit of accidental pregnancy rates (the upper limit is 26%). With more modern contraceptive methods, such as the pill, for example, the risk of unwanted pregnancy is reduced to less than 1%.

Why is the condom still the most popular form of contraception? The question lies not only in its relative low price. Researchers attribute its popularity among Russians to their reluctance to turn to the state medical system unless it is absolutely necessary. While many other means of contraception require a trip to the doctor, condoms can be purchased in any supermarket. In addition, Russians prefer to avoid ‘medical supervision’ of their personal lives.

It is possible that fear of HIV and other sexually transmitted diseases also plays a role. Condoms are most likely considered to be the best contraceptive method in a country where HIV is widespread but little is done to prevent it.

Contraception in Russia

The current generation of Russians, of course, are much more aware of contraceptive forms than their parents are. In the mid-1980s, the demographers note, Soviet citizens’ views on birth control methods ‘were formed in conditions of very limited information, and even misinformation’ about contraception. Even Muscovites in those years considered the pull out method to be the most effective method of pregnancy prevention. In 1983-1985, up to a third of young city dwellers did not know about the existence of hormonal contraception. Now, of course, almost everyone is aware of this method. But this awareness does not necessary translate into use.

This is partly due to a lack of confidence in the safety of contraception for one’s health and a lack of regular family planning counseling. It is also partly due to the relatively high cost of contraceptives, insofar as they are not covered by medical insurance. In this regard, Russia differs significantly from France, for example, where the cost of contraceptives is partially covered by the state (65% of hormone medications, implants, and IUDs are covered by basic insurance). And in the Netherlands, which sought to reduce its national abortion rate, hormonal contraceptives, IUDs, diaphragms, and sterilization were covered completely by basic insurance until 2004. After 2004, these forms continued to be covered for women younger than 21 years of age.

Russia, on the other hand, presents a contrary situation: abortions performed in institutions of the state’s Ministry of Health are covered by basic medical insurance. As a result, it is cheaper to have an abortion than to purchase a contraceptive.

However, in terms of health, the opposite is true: abortion, rather than contraception, can be damaging to a woman’s health.

But not everyone takes these risks into account. Moreover, people are still inclined to demonize modern means of protection due to prevailing old Soviet ideology (about it below).

Among the reasons cited for not using modern methods of contraception are, first of all, ‘fear of side effects’ (cited by 77% of users of traditional methods), ‘husband/partner’s choice’ (77%) and limited accessibility to modern contraceptives (65%).

14.8% of married women rely solely on traditional methods. In Western Europe, less than 5% of couples use these methods.

Nevertheless, shifts in contraceptive thinking are evident: the popularity of old forms of contraception has fallen since the 1980s. Modern Russians consider female sterilization to be a ‘very effective’ contraceptive method (53%) (rather than the pull out method, which was considered to be so at the end of the Soviet period), followed by the IUD (26%) and oral contraceptives (20%). But hormonal injections (3%), evidently, are still not very familiar to Russians.

The Beginning of New Attitudes Towards Birth Control

The most important evidence of the contraceptive revolution is the rapidly decreasing number of abortions and the convergence of the number of births with the number of pregnancies. ‘People are more confidently and skillfully engaging in family planning,’ the researchers explain. This process was clearly manifested in the 1990s, with the advent of the market for modern contraceptives, information transparency, and the official recognition of the need for family planning.

In the early 1990s, a nationwide Family Planning Programme was created, and in 1994 it received presidential status. The President’s Decree provided shocking statistics on abortion: 4 million procedures performed a year, as well as high rates of maternal mortality (one out of every three operations ended in death). The goal therefore was to reduce the number of abortions. A state family planning service was then created with modern equipment, forms of contraception, and the task of educating people about means of prevention.

Almost half of the funds of the Family Planning Programme went to the purchase of hormonal contraceptives, which were distributed free of charge to socially disadvantaged groups: youth, low-income women, etc.

1994 ushered in a period of abortion decline and an increase in contraception.

The number of births and abortions in the country and the proportion of pregnancies ending in abortion (1960–2015)

Source: Calculations by A. Vishnevsky, B. Denisov, and V. Sakevich based on Rosstat data.

Interruptions in the Downturn

Abortions in Russia are classified as ‘legal medical’ (or ‘legal instillation’; i.e., elective abortions performed in medical institutions within the first trimester); those which are performed ‘for medical reasons’ (when the mother’s health is under threat); those which are performed ‘for social reasons’ (for pregnancies resulting from rape), ‘criminal’ (operations that are not performed in a medical institution); and ‘unspecified’ (other; those which are not performed in a hospital). There are also ‘spontaneous’ abortions (i.e., miscarriages). This latter classification represents a special case: it essentially refers to a miscarriage that might have been intentional. Legal medical abortions constitute the largest share of abortions in Russia, followed by miscarriages.

Breakdown of registered abortions in Russia, 2018, (according to Rosstat)

Source: Viktoria Sakevich, ‘State Statistics on Abortion in Russia: Changes in the Registration System, Opportunities for Demographic Analysis’. (Conference paper presented at Demographic Trends in Russia: Legacy of Soviet Era or a New Tendency?).

According to Viktoria Sakevich, the rate of legal medical and instillation abortions is especially significant. This rate particularly points to an increase in the effectiveness of family planning in Russia: the number of such abortions, according to the Ministry of Health, decreased most significantly from 1992 to 2018 — by 9.3 times.

After 2007, there was a slight increase in spontaneous abortions, and after 2012, it increased significantly. This is primarily due to changes in the system of abortion classification, when ‘other abnormal products of conception’ – another category of the International Classification of Diseases of the 10^th Revision – was added to the classification. (This additional category includes, for example, non-developing pregnancy.)

On the other hand, the increase in the number of spontaneous abortions is to some extent explained by the general rise in the birth rate in the country, which has been stimulated in part by the introduction of ‘maternal capital’ and other incentives to increase birth rates in the Russia. As the number of pregnancies has grown, so, too, has the number of miscarriages. After 2016, miscarriage rates fell along with rates of births.

Fortunately, No Longer a Leader

The ratio of terminated pregnancies to births also informs the situation with abortions. It reveals the proportion of pregnancies that are terminated. Until 2007, for several decades, the annual number of abortions in Russia exceeded the number of births, and sometimes the ratio was more than two abortions for every one birth.

In 2018, the situation was already completely different: for every 100 births in Russia, there were 41 abortions.

A few years ago, Russia was one of the world’s leading countries in abortion rates. Now, however, the gap between Russia and developed countries has been largely bridged, Viktoria Sakevich notes. In terms of fertility and abortion, Russia now ranks in the middle range among developed countries and ‘certainly no longer deserves the title of “abortion champion”’, says the researcher.

The number of instillation abortions in developed countries, per 1000 women aged 15–44

If we rely only on official statistics, then the socio-demographic characteristics of women who elect to have an abortion remain unknown to us. This includes marriage status (official union or unregistered), level of education, number of children, and geographical location. It is even problematic to determine age, since the Ministry of Health in recent years has decided to single out only five age groups instead of nine. Moreover, one group includes women aged 18 to 44. We can only assume that women of the most active reproductive age — 25-29 years old, as before — resort to abortion more often.

The Demonization of Contraception

In the 1960s, when the contraceptive revolution spread in the West, Russia knew little about new means of protection. There were no family planning services. According to a survey of married women of reproductive age at Moscow enterprises (1966, a sample of 1,351 people), only a quarter of the respondents had never had an abortion.

For a long time, Soviet women did not know about hormone pills and IUDs, which were the main ‘weapons’ of the contraceptive revolution in the West.

And if they did, they were suspicious of them – thanks to the Ministry of Health, which emphasized the possible side effects of oral contraceptives. The main weapons in the USSR’s fight against abortion were fearmongering and propaganda promoting motherhood. In fact, the authorities feared that any family planning at all would lead to a decrease in the birth rate.

Rubber condoms, made in the USSR, 1955 / Wikimedia Commons

One way or another, the collapse of the USSR was marked by the final triumph of abortion culture, a shortage of contraception, and a low level of sex culture amongst the population. Only in post-Soviet Russia did things start to change.

Soviet Abortion Culture: When the Woman Was in Parentheses

The now antiquated use of abortion as one’s primary method of family planning deserves separate consideration. In 1920, Soviet Russia was the first in the world to legalize elective abortion. This was considered a temporary measure, which they tried to justify with the country’s transitional state. In a resolution of the People’s Commissariat of Health and the People’s Commissariat of Justice of the Russian Soviet Federative Socialist Republic (RSFSR), abortion was linked to ‘moral relics of the past’ and economic difficulties. It was assumed that the ‘strengthening of the socialist system’ and the protection of ‘motherhood and infancy’ would lead to the eradication of abortion. And families, of course, would again be large.

Needless to say, women’s opinions on how many children they wanted to have (and at that time, the country was already transitioning to a lower birth rate - on average, two children per family), went largely unconsidered.

Thus, the USSR legalized the rapidly spreading, but previously considered criminal, practice. Abortion was at that time the most obvious and affordable method of birth control.

Abortions quickly went ‘to the people’; hospitals could barely keep up with the demand, often running out of beds. So, due to mass practice, an abortion culture took form.

At the same time, the authorities encouraged the population to plan their families in other ways: for example, contraceptives were legalized by the People’s Commissar in 1923. A Central Scientific Commission on the study of contraceptives was even created: scientists suggested preventing pregnancy, by a variety of means including… X-rays! But the project did not take off. Soon authorities even outlawed abortion.

This happened in 1936, against a background of rhetoric about the importance of the developing contraceptive production.

In a decision of the Council of People's Commissars of July 31, 1936, an initiative was enacted to expand the production of ‘rubber products’ (condoms) and other prophylactic agents (uterine caps, spermicidal pastes, etc.). However, all these solutions were obscured by the state’s overriding call to increase birthrates.

Abortions, of course, did not disappear; they were simply went underground, and maternal mortality increased.

The next lifting of the ban in 1955 was, in fact, a recognition of the triumph of abortion culture. The authors of the law, as before, believed that abortion could be combated with the help of ‘state measures to encourage motherhood’. But the opinions of women themselves regarding childbearing were never taken into account.

A Coda to the Revolution

The contraceptive revolution in Russia is not over. Many Russians still use methods that are by no means the most effective. Distrust of hormonal contraception persists. Few people are aware of long-term contraceptives, such as hormonal implants and injections.

But most importantly, old prejudices endure. ‘In Russian public opinion, and in the minds of many Russian politicians, the myth that family planning and affordable contraception lead to lower fertility persists’, the researchers suggest.

However, this myth is easily refuted by the example of many European countries. In France, where contraception is widespread and partially covered by medical insurance, the birth rate is at a record high for a developed country (the total birth rate [TFR], the number of births per woman, is 1.9). In the Netherlands, which has similar conditions and practices, the TFR is only slightly higher than Russia’s, which is approximately 1.6. In these countries, as well as in Germany, where today there is a very low abortion rate, there is compulsory sexual education for adolescents.

Subsidies for the purchase of contraceptives are provided by the state in Spain as well. And this is simply the response of the state to the needs of many of its constituents.

In Russia, family planning does indeed exist. But the advancement of modern methods of contraception is almost imperceptible. Moreover, according to the Levada Center, Russians learn about contraception methods not from specialists, but mainly from friends and acquaintances.

According to the RZNR-2018 survey, more than half (58%) of married women using contraception did not consult a doctor when choosing their preferred method. This included, among other things, hormonal pills. One third of women who chose them as a contraceptive did so without consulting a gynecologist. It is not surprising that even with the use of modern methods, Russian couples often experience malfunctions or ‘contraceptive failures’ — that is, unwanted pregnancies.

Research Authors:

Viktoria Sakevich, Senior Research Fellow, Institute of Demography, HSE

Boris Denisov, Center for the Study of Population Problems, Faculty of Economics, Moscow State University M.V. Lomonosova

Anatoly Vishnevsky, Director, Institute of Demography, HSE

Author: Olga Sobolevskaya, December 20, 2019

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