Following its independence from China in 1921 and then 70 years of socialist rule, Mongolia transformed into a democratic republic in 1990. The country's rapid change to a market economy caused financial chaos, from which it is only now recovering.

One consequence of the economic crisis was the decline of health care services. To help address this problem, the Mongolian Ministry of Health and Social Welfare and AVSC worked together to send teams of experts into four parts of the country in March to assess the quality and availability of reproductive health services. The United Nations Population Fund (UNFPA) will use the assessment findings to design and fund a program to improve services in Mongolia that will be implemented by the government and executed by AVSC.

As part of this assessment, three Mongolian doctors and I visited Uvs aimag (province), the westernmost region of the country, near Russia. One of our main tasks was to interview men, women, and adolescents as we visited gers (the traditional tented houses of the nomadic people), maternity facilities, a large public health complex, and clinics run by family doctors, obstetrician-gynecologists, and other specialists to find out what clients needed and wanted from the health care system.

Accessing Services

Health care services in Mongolia are provided through several channels. In recent years, some private clinics and small private hospitals have been established, principally in Ulan Bator, the capital. Family planning and adolescent clinics operate within a network of health centers throughout the country. Baghs, or villages, are served by a single feldsher, a primary-level health provider who visits each of the 50 to 200 resident families once a month.

Uvs is an area of almost 102,000 people that has the country's coldest temperatures and its largest lake, as well as snow-capped mountains, steppes, and deserts. Poor roads, the need to travel on horseback, and the long distances between ger settlements and health care facilities affect the quality of service delivery.

One woman reported that it takes her five to six hours to travel the 50 kilometers to the nearest health care provider. "It's a big loss of time," she said. "She will look at me and tell me I need some medicine, but she doesn't have any, and I'll have to go somewhere else and again spend time. It's very complicated." Women are often sent to maternity hospitals weeks before delivery because of transportation difficulties.

Contraception and Abortion

Until recently, the government pursued a pronatalist policy through a series of awards and incentives. Contraception was banned until 1970, and its use was restricted until 1989.

Since then, the range of available contraceptives has rapidly increased, and 42% of women now regularly use family planning methods. Most women use IUDs--partly because the method does not necessitate frequent visits to a health care facility--though the popularity of oral contraceptives is increasing.

Other contraceptive methods are used less frequently or not at all. Some women do not like the side effects caused by Depo-Provera, and trials to study the effects of Norplant implants have met with mixed results. Tubal ligation is only performed when medically necessary, and vasectomy is illegal.

Barriers to Contraceptive Use

Though Mongolia has had a family planning program for several years, myths about contraceptives continue to be widespread. For instance, one woman we spoke with attributed her baby's cleft lip to an IUD that she had used for five years.

Traditional attitudes also help limit contraceptive use. For example, it is common for husbands to agree to contraception only after their wives have borne sons. Buying condoms can be a source of embarrassment. One man remarked, "Everyone knows everyone's business. You can cause a big sensation by buying condoms. So people travel a distance to buy them."

On the other hand, despite the need for more information, most women understand that contraception can help them. Many men feel that they have been left out of reproductive health services and are more than ready to play their part.

"Doctors discourage men from being included in discussions. Husbands don't know what's going on," said one man. "I want to know so I'll know what I'm supposed to do. My wife gets pregnant, and that's all I know."

Painful Abortions

Abortion is legal in Mongolia, but anesthetics are scarce. A 27-year-old woman who was having her first abortion told us, "They don't give you any anesthesia, and it's very painful. Can't anesthesia be used? Can't the husband watch so he'll understand what's happening and be more likely to agree to use contraception?"

Although the abortion rate in Mongolia has steadily declined since its peak in 1992, it is still very high at 262 abortions for every 1,000 live births--indicating a large, unmet demand for family planning services and postabortion family planning counseling, which is also very limited.

Sexually Transmitted Infections

Mongolians are fearful of sexually transmitted infections (STIs), which are considered a source of shame. Health administrators have undertaken an aggressive campaign of compulsory screening aimed primarily at schoolgirls, women, and soldiers--a poorly targeted campaign that reflects a lack of understanding of transmission and at-risk behaviors. Frequently, treatment is available only on an inpatient basis in hospitals, and voluntary anonymous screening is available only for a fee. STI transmission and management are areas that require further education for both clients and providers.

Youth Services

Although many Mongolian health care workers recognize the need to serve adolescents, the system as a whole appears to be ambivalent. Health care workers regularly go into schools to lecture young peo-ple about family planning and STIs, yet medical facilities offer limited counseling and services, and many doctors are reluctant to provide contraception to adolescents under the age of 19.

One adolescent girl told us, "It's hard for girls to get treated by gynecologists. If I go to the gynecologist, everyone will know and think I'm pregnant or have an STI." Another commented, "It's difficult for adolescents to get contraceptives and abortions in the government hospitals, so they go to private practices, and there are no questions asked." A mother observed, "Mothers often don't have the answers, and not all girls will talk to their mothers."

Future Efforts

The assessment team interviewed not only clients but obstetrician-gynecologists, family doctors, midwives, and health care managers. All of their opinions and observations will help shape AVSC's future efforts to improve reproductive health care services in Mongolia, which include assisting the Mongolian Ministry of Health and Social Welfare in training service providers, improving STI services, and developing and distributing client-education materials.

Libby Antarsh is the senior director for AVSC programs in Eastern Europe, the Central Asian Republics, and Russia.