Pregnancy prevention, reproductive health risk, and morality: a perspective from public sector women's clinics in St. Petersburg, Russia
Health and Social Welfare Services National Institute for Health and Welfare (THL) Helsinki, Finland
Use of reliable contraception remains lower and rates of induced abortion higher in Russia, when compared to Western Europe, even though reliable contraception has been better accessible for nearly two decades. Due to the organisation of women's health services in Russian cities, gynaecologists could have a major influence on women's contraceptive choices, but little is known about their attitudes and practices that are related to contraception promotion. This study draws on qualitative observation and interview data of gynaecologists (all women) in public sector women's clinics in St. Petersburg, Russia's second largest city, in order to investigate their perceptions of various birth control methods and contraception counselling. Clinical counselling practices are also examined. The results reveal that gynaecologists had up-to-date knowledge of the most recent contraception methods and they were willing to promote their use. Gynaecologists' ideal of counselling and doctor-patient interaction can be best described as maternalistic. This is very close to what is traditionally termed paternalistic interaction pattern, but gynaecologists emphasised their role as caring, warm, well-meaning maternal figures, who are willing to accept full responsibility of the clinical decision-making and focus on patients' individual interests. In practice, gynaecologists took active role in counselling, although the coverage was not wall-to-wall. The depth of counselling varied considerably and counselling practices were mainly paternalistic. Maternal warmth could be seldom observed. Yet in about one-third of observed cases, interaction pattern differed clearly from paternalism and patient preferences were incorporated into clinical decision-making. Gynaecologists perceived reliable contraception essentially as a means of avoiding harmful health consequences of induced abortions and fostering future fertility. Using reliable contraception was equated with being a responsible and morally respectable woman. The results suggest that links between health, risk, and morality are vividly present in contraception counselling in St. Petersburg, and reliable contraception has become a powerful source of new moral demands for individual women to foster their reproductive function.