In a time of sweeping political and social change in Russia, AVSC International has worked with reproductive health care providers to improve the quality of services and to expand access to an array of contraceptive methods.

Nina Schwalbe, country advisor in AVSC's office in Ekaterinburg, Russia, is enthusiastic about the program and praises the Russian government for its commitment to increasing access to contraception and helping women avoid unwanted pregnancies.

A Change in Attitude
According to Schwalbe, the most exciting thing to come out of AVSC's work in Russia is the change brought about by counseling training.

"There has been a change in people's attitudes," she explains. Doctors who never spent any time developing interpersonal skills before training have changed their beliefs after training from "the doctor should choose for the patient" to "the client should choose for herself."

Participants have also reported a change in client satisfaction, even during the training sessions themselves. Even though they received the service in a training setting with three or four people watching, women who participated in IUD training came out smiling and saying "I've never had such good care in my life...thank you."

Expanding Access to Methods
The goals of increasing access to and use of a broader array of contraceptive methods is being gradually realized as well.

The most dramatic increase in use has been with the pill. In Russia, there has been a bias against the pill for years. The biggest challenge for reproductive health care providers was to dispel the myths surrounding it.

To counter these biases, AVSC's Russia program conducted seminars to educate providers about the pill. Lower-dose pills are now available, and according to Schwalbe, "People like them."

Sterilization in Russia
Female sterilization is also becoming more accepted now. Although doctors once only considered sterilization as a way to prevent high-risk pregnancies, there are fewer restrictions today.

According to Schwalbe, in the programs that AVSC supports, doctors who had never done minilaparotomy procedures postpartum are "doing them every week now."

Vasectomy, on the other hand, is a method about which attitudes and acceptance do not appear to be changing quickly. It is still virtually unavailable in Russia.

Educational Activities
In addition to its work with contraceptive acceptance and quality of care, AVSC's Russia program has undertaken a number of educational activities.

The program has held reproductive health seminars for more than 1,500 health professionals and has trained 196 providers in counseling and clinical skills. Activities have included contraceptive updates, IUD insertion training, and surgical training for female sterilization.

In addition to conducting seminars and training, AVSC's Russia program has adapted a number of materials that are distributed throughout Russia, including a cost-assessment manual, a terms glossary, posters, and a family planning flip chart that has been produced and distributed for use in counseling.

These educational activities and materials are key to increasing use of different contraceptive methods. According to Schwalbe, family planning programs are often initially met with skepticism in Russia, and many think the purpose of the programs is to decrease the Russian birth rate. Once they understand that the purpose is to improve women's health and reduce abortions, they become more receptive to family planning.

A Confusing Time
Substantial progress has been made in increasing access to, and the quality of, reproductive health care in Russia. However, the same political and social changes that have made many of these exciting changes possible have created a level of instability and disorder that seriously undermines efforts to effect systematic change.

Right now everyone in Russia can still get health care of some kind, but the quality varies. Doctors' salaries are low, and doctors are undervalued. The profit to be made performing abortions still acts as a strong disincentive to providing family planning services. The regions have little money for health; supplies are few and equipment is deteriorating. Clinics run out of drugs, sutures, and antiseptics. Clients may start on one type of pill only to return to the pharmacy and find that it is out of stock.

"It's a confusing time," Schwalbe concedes, but she remains optimistic. The national and local governments have made a strong commitment to family planning. They recognize that abortion is "an enormous drain on the system," both financially and in terms of women's health. She is "very impressed" with their commitment and confident that it will outlast the difficult times.

AVSC's work in Russia is primarily funded by the U.S. Agency for International Development.

Margaret Schehl is a freelance editor/writer for AVSC International.