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Family planning practices and attitudes among former Soviet new immigrant women in Israel
Sot'. Sci. Med. Vol. 41, No. 4, pp. 569-577, 1995
Pergamon
0277-9536(94)00382-3
Copyright © 1995ElsevierScienceLtd Printed in Great Britain.All rights reserved 0277-9536/95 $9.50+ 0.00
FAMILY P L A N N I N G PRACTICES A N D ATTITUDES A M O N G FORMER SOVIET NEW IMMIGRANT WOMEN IN ISRAEL LARISSA I. R E M E N N I C K , t D E L I L A A M I R , 2 Y U V A L E L I M E L E C H 2 and Y L I Y A N O V I K O W ~Graduate Program in Medical Sociology, Department of Sociology and Anthropology, Bar-Ilan University, Ramat Gan 52900, Israel, 2Department of Sociology and Anthropology, University of Tel Aviv, Tel Aviv, Israel and 3Department of Epidemiology, Tel Ha-Shomer Medical Center, Israel Abstract--One hundred young new immigrant women from the former U.S.S.R. now living in Israel answered a detailed semi-open questionnaire regarding their knowledge, attitudes and behaviors in fertility and birth control issues. A collective family planning profile of these women is largely in line with that of the urban population of Slavonic U.S.S.R., combining early marriage, early and low fertility, the latter achieved by both abortion and contraception. Most respondents and their partners tried to prevent unwanted pregnancies, usually starting from traditional methods and switching over time to modern ones. An IUD remained most popular contraceptive among parous women, while use of the pill, very rare in the U.S.S.R., has almost doubled upon migration, mostly among younger women. Still, they kept some misleading ideas on the pros and cons of traditional versus modern methods, suggesting lack of adequate information also upon migration. Like their ex-compatriots, our women preferred to solve their birth control problems without external professional involvement. Contrary to the expected, free abortion ideology was not universally advocated by our respondents, and most were fully aware of abortion limitations in Israel. While rationally condemning abortion in both moral and health terms, most respondents still use it, this gap between beliefs and practice being indicative of their readiness to adopt efficient contraception. This switch occurs faster in women actively involved with host society via work or studies. Younger women were found to be more flexible and advanced in their family planning practices than were older ones, while almost no differences were related to education and origin within the U.S.S.R. This exploratory study suggests that any investment into promotion of healthy fertility control practices among new immigrants will be cost-effective in the near future. Key words
family planning, health beliefs, Israel, abortion
INTRODUCTION The latest wave of immigration from the former U.S.S.R. that in four years (1989-92) has enlarged Israeli population by almost 10%, presents a special challenge for the host society because of its size and heterogeneity. A m o n g more than 400,000 of recent migrants, there are over 100,000 women of reproductive age [1]. Specific experiences and problems of these women facing a different gender system, new options and restrictions in their reproductive life need to be scrutinized specially as an important aspect of socio-cultural adaptation. Most international studies addressing the issue of change of fertility control patterns with advent of new contraceptive techniques were staged in developing countries implementing population programs aimed at fertility reduction [2-4]. What happens to immigrants who move from industrialized countries of the former Eastern Block to Western societies, sharing with them low fertility patterns but having very different birth control laws and practices, is much less understood--since the reality of mass emigration after the demise of the Eastern Block is a
new phenomenon [5]. We failed to find published studies concerning acculturation of migrants from former socialist countries to the Western patterns of family planning. Therefore our evaluation of this problem in Israeli context may also be of interest and relevance to other countries hosting former Soviet and other East European immigrants.
BACKGROUND The model of reproductive behavior prevalent in the Slavonic part of the ex-U.S.S.R., where the majority of Soviet Jews have lived, is characterized by low fertility (in 1990, for urban population 1.7-1.9 children per woman by the end of her reproductive lifespan [6]), prevalence of abortion as a birth control method (3-4 abortions per average sexually active woman), and underuse of modern contraceptive methods [7-9]. Age was shown to be most important determinant of patterns of contraceptive use, contraception as such and modern methods in particular being more used by younger women. Level of education and place of residence may also 569
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play a role: better educated women residing in big cities tend to be more active contraceptive users [6-8]. In spite of divergent socio-economic and cultural backgrounds, most former Soviet people share an inhibited and prejudiced attitudes towards sexuality, often combined with fatalistic and spontaneous approach to fecundity and its regulation [10]. Also common to all of them has been the lack of family planning options and services, since preventive maternity care has been one of the most neglected sectors of public health in the U.S.S.R. [11, 12]. As a result of long-term assimilative trends, Soviet Jews are fairly close in their life styles and mentality to the surrounding majority. What marks this part of the Soviet population, is its concentration in big cities and, generally, higher cultural and educational standards, with resulting better access to information and various services, including health and family planning, Total fertility rates of the European Soviet Jews, according to some studies [13-15], have been even lower than the national average: about 1.5-1.7 per woman during the last three decades. The same applies to the number of abortions, with anestimated mean of 2.0-2.5 [16, 17], which is indicative of more efficient contraceptive use. How readily may those general patterns be applied to the new immigrant population in Israel is still not clear, although we assume that, due to its mass character, this immigration wave was unselective. This is indirectly supported by comparison of available late Soviet and Israeli statistics, suggesting that in all major socio-economic aspects population of new immigrants presents Soviet Jewry as a whole [18]. Anyway, reproductive and birth control patterns of the new immigrants are markedly different from those common for most Israeli Jews. Due to a combination of reasons related to Jewish tradition and religion, political and demographic factors of the Middle East region, Israeli society is clearly pronatalistic, at both establishmental and individual levels. Total fertility level is among the highest in a developed world: around 3.0 per woman [1]. As may be inferred from low total abortion rate among Israeli Jewish women (about 0.6 throughout reproductive lifespan, estimated il!egai abortions included [I 6, 19]) efficient contraceptive use is common [20, 21]. Several alternative channels of family planning information and help, medical and other, are available in Israel; sex education ideology is shared at all levels of the estabishment, and sex-related issues are surrounded, overall, by open and tolerant public atmosphere, at least in the secular majority of the population. Abortion regulations are the subject of continuous debate between various political forces, mostly religious and secular [22]. The current law compromising between these ideologies defines a number of circumstances justifying pregnancy termination: woman's age ( < 17 and > 40); illegal nature of pregnancy (out-of-wedlock, rape, incest); threat to a
woman's physical or mental health, and suspected malformations of a fetus. Socio-economic indications for pregnancy termination were cancelled in the early 1980s under political pressure of religious circles. Each abortion application is considered by a hospital-based committee (two physicians and a social worker). Termination procedure costs to a woman around 300-500 USD (i.e. about half of an official minimal salary); only abortions for medical indications may be partly reimbursed from insurance or public funds. Altogether, this makes abortion procedure in Israel costly, bureaucratized and interfering with a woman's private life [23]--in contrast to unrestricted provision of abortion services in the former U.S.S.R. To evaluate continuity and initial change in fertility and birth control practices among new immigrant women, and to understand their specific needs in this area was an objective of the present study. Its limited size and exploratory nature may be justified by acute necessity to approach the newly appearing phenomenon of a former Soviet immigrant woman at the moment of her encounter with a different gender culture, medical and welfare establishments of a 'Western' type. STUDY G R O U P AND M E T H O D S
The study group included 100 former Soviet new immigrant women who arrived in Israel at least one year ago and lived in two major urban centers that host more than a half of all new immigrants (Greater TeI-Aviv and Jerusalem) [1]. Respondents, accrued to the study using snowballing method, were university students (28%) and other young women, usually unfamiliar one with the other. Three interviewers-female students of sociology and new immigrants themselves--were instructed to recruit women in accord with the pre-established proportions by age and place of residence in the U.S.S.R., so that the resulting group of respondents would roughly parallel composition of its source population. Some relevant socio-demographic characteristics of our study group are presented in Table 1. Although not claiming to be a representative sample, this group reflects fairly well the main features of younger part of immigrant women, of whom most are urban educated professionals, with high proportion of divorcees, with and without children. Singles are clearly overrepresented in this group (32%)---probably because of the fact that the starting point of the snowballing was a student population. We limited ourselves by 100 respondents considering qualitative, in-depth nature of the data being collected that is very problematic and costly to obtain in big samples. We considered it as an exploratory 'express-study', important to perform at the initial stage of immigrants integration, not waiting for the resources necessary for a survey in a large representative sample.
Family planning practices and attitudes Table 1. Socio-demographiccharacteristics of the study group (N = %) 28.5 + 7.4 years Usualoccupatimu: (38% < 25) Students 30 + 9 months Semi-qualifiedworkers in education, Mean time in Israel medicine, science;office workers 13.9 + 2.4 Qualifiedscienceand engineeringworkers Mean No. years of education % Marital status: Married 55 Teachers, physicians,economistsand 13 other professionals Divorced 32 Single Mean age
Place of residence in the f U.S.S.R.:
Moscow and Leningrad Other capitals and biggestcities Medium/smallcities
571
%
28 25 14 33
%
Current employment:
%
24 38 38
Studies (inc. retraining) Professional jobs Manual jobs (inc. part-time) Unemployed
49 23 22 6
Semi-close questionnaire in Russian contained 105 questions divided into four blocks: General; Childbearing and family planning; Gender relations and sexuality; and Adjustment to Israeli reality. Most questions provided sets of answers plus an open-ended one; about 20% of the questions were completely open. The optimal mode of administration was decided to be self-completion in presence and with help of interviewers. M a x i m u m possible anonimity was ensured by interview procedure. Only 9 of all women approached refused to participate (and were replaced by others), and in all but few questionnaires there were no blanks even at the most sensitive points. Returning a questionnaire, many women noted that it was interesting and awakening thought, that it made them see in a critical light things usually taken for granted. In this paper we present the part of the study data, concerning family planning practices, knowledge and underlying attitudes. More qualitative data from this study on gender roles, family relations and sexuality are discussed elsewhere (Remennick et al., forthcoming). Since we had 100 respondents, absolute numbers coincide with percentages in all the results below.
which is in agreement with demographic patterns in former Soviet population at large [6, 13, 14]. It is notable that more than one fifth of women have had their first intercourse yet at secondary school, but formation of stable relationship has occurred only in later life.
STUDY RESULTS
Prevalence and variability. Variance in n u m b e r of abortions by age, education and place of residence in the U.S.S.R. is shown in Table 3. Besides age, no significant variance is seen, since abortion is known to be a universal birth control method across the former U.S.S.R., common for all categories of women. A history of out-of-hospital abortion was reported by five women, of whom four had one such termination and one had two. All operations were performed by physicians, but in home conditions.
All respondents have filled into the table describing principal events of their feminine history in chronological order. Age at menarche was 10-12 years in 45% of women, and 13-15 in the rest 55%. Age at other events was distributed in the following way (Table 2). Most sex-related 'first events', including first marriage, were concentrated in age group 18-22,
Table 2. Distribution of respondents by age
Number o f children
Of respondents 41 were childless, and the mean n u m b e r of children for the rest of them was 1.56 _+ 0.62 (including 1.00 for women younger than 24, 1.45 for age group 25-34, and 1.77 for 35 and more, P = 0.026). Even given that one third were never married, the proportion of childlessless in our group is higher than might be expected, while fertility level is similar to the figures reported by other studies among Soviet Jews [ 13-15]. M e a n n u m b e r of children was significantly (P = 0.003) higher among women with least education (2.67), which may reflect their somewhat older age or be due to chance (they were only 11). Former residents of the capital cities had the lowest parity (1.31), while those of smaller urban centers in non-Slavonic republics had more children (2.0). Induced abortions
the principal feminineevents (N = %) Event Events Up to 17 18-22 23--27 28-32 missing Total First intercourse 22 64 8 0 6 100 First stable relationship l0 73 9 0 8 100 First marriage 4 51 13 0 32 100 First live-birth 2 28 27 2 41 100 Note: The age distribution in Table 2 is more detailed to account for fine variation in ages of sexual and reproductive initiation. at
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Table 3. Mean numbers of reported abortions by age, education and place,of residence in the U.S.S.R. Mean numbers of abortions calculated for: Independent variables
All women
Women who had abortions
0.21 1.03 1.69 0.89 P = 0.00
1.33 1.85 2.32 1.98 P = 0.21
0.64 0.81 1.05 0.89 P = 0.54
2.33 1.90 2.00 1.98 P = 0.86
0.71 0.94 1.20 0.89 P = 0.02
1.55 2.00 2.70 1.98 P = 0.44
Age <24 25-34 35 and more All ages
Education Up to 10yr 11-13 yr 14yr or more All levels
Place of residence (U.S.S.R.) Moscow and Leningrad Capitals and other biggest cities Medium/small cities All places
Nine women have had abortions already in Israel, all with official approval, and at least partial reimbursement from various public funds. Potential for illegal abortion. Given certain gap between expected demand for abortion procedures among new immigrants and actual numbers of legal abortions during their first two years in Israel [17], it may be suggested that some part of unwanted pregnancies are terminated illegally, probably with the involvement of new immigrant physicians. This speculation stems from obvious co-existence of demand (women can not switch overnight to new contraceptives) and potential supply: hundreds of experienced former Soviet gynecologists came to Israel as new immigrants, most of them still unemployed. Part of these doctors may be ready to perform abortions in their homes at a much lower fee than officially demanded. Beside lower cost, this would allow women to get the service in the familiar cultural and language setting, as well as to avoid unpleasant formalities. Out of five women who reported having had out-of-hospital abortions, some might have them already in Israel (the question did not specify it). Nine respondents stated they were familiar with other new immigrant women who used informal abortion services of a 'Russian' physician. When asked whether a respondent herself would be ready to use such services herself in case of a need, 61% declined this possibility completely, while 36% accepted it to a smaller or larger extent. This very limited and tentative data supports the view that illegal abortion may occur in a certain sector of a 'Russian' community. Health complications. Immediate and postponed complications of abortions are known to be the most common reason for gynecologic morbidity in the U.S.S.R. [9, 11]. In our study group, post-abortion complications (mostly, inflammatory conditions and menstrual disorders) were reported by 25 women, i.e. more than one half of the respondents who ever had an abortion (N = 45).
Normative and value aspects. The following group of questions attempted to evaluate normative and ethical aspects of abortion. About one fifth of respondents who had abortions said they suffered deep emotional trauma after termination, one half admitted having moments of depression and regrets, while the remaining third did not have post-abortion emotional disturbances. When asked about their general understanding of abortion, respondents chose the following answers: painful but brief medical procedure crude interference into physiological processes a murder of an unborn child never thought about it other and missing total
- - 38% ------
15% 23% 21% 3% 100%
Actual number of abortions did not vary significantly between these value groups; it was understandably lower only for women who said they never thought of abortion in ethical terms (lack of experience---lack of opinion). Only 14% of respondents believed that the aborted embryo may suffer of pain, while 32% answered " N o " and 54% had no opinion. A big number of indefinite answers to both these questions shows that many women tend not to reflect on the issue of abortion in ethical terms. When asked whether abortion could be used as a regular birth control method, 87% of women said "No, it should only be the last resort", while 13% revealed various extents of acceptance of this idea. Hence, majority of our respondents rationally condemn abortion, but nevertheless use it (or are ready to use). 72% of women also disapproved of abortion as an intervention more detrimental for health than chronic use of any contraceptive techniques. Notably enough, in spite of deliberate dichotomy of this question, several women, after choosing one of the answers, added by hand "Both are similarly detrimental".
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Table 4. Contraceptivemethods ever used by respondents(percentageof positiveanswers) Past use
Methods Rhythm (safe days) Withdrawal Douche Condom IUD Pill Barrier spermicides Caps/diaphragm
Current use
Regular
Sometimes
Regular
Sometimes
Ever user
21 I0 7 16 19 8 -I
35 50 31 49 6* 10" 13 4
11 7 3 17 21 15 -1
16 24 17 30 -5* 5 --
57 62 39 70 35 34 13 5
*By 'sometimes' usage of systemic methods (IUD and pill) respondents probably meant short-term episodes after which these methods were given up. t'Ever use' excludes double counting in various categories of use.
In other words, a woman is always punished for having sex, no safe escape is open for her. Awareness o f abortion situation in Israel Most women have shown at least partial awareness of the fact that pregnancy termination in their new home country is subject to many restrictions--legal, financial and other. Only 19% of women said they knew nothing about abortion regulations, while 71% knew that abortions were performed only under definite conditions specified by law. 59% of respondents could also name these conditions, in half of the cases all of them correctly. Most women were aware of monetary problems involved with abortion provision in Israel. 70% of respondents knew that a woman herself covers abortion costs, and 71% have also estimated correctly abortion costs to a client. On the whole, our respondents were better informed as to abortion situation in Israel than might be expected. Of respondents 41% agreed that abortion in Israel should be made as easily available as it was in the U.S.S.R., while 33% voted for certain restrictions in order to stimulate contraceptive use, and 9% thought that abortion performance should be made easier specifically for new immigrants. In the latter group, mean number of actual abortions was somewhat higher than in the rest of women (1.22 vs 0.73 in women who were against liberalization). Hence 'free abortion' ideology was not universally popular among our young respondents. Contraceptive use
A broad set of gender- and health-related attitudes and motives are involved in birth control decision making. The following section of the questionnaire addressed actual history of contraceptive use and some of the underlying psycho-social mechanisms. Firstly, women were asked to write a list of contraceptive methods they knew. Mean number of methods known to our respondents was 4 __+1.6, with no significant differences by age, education or origin. Most cited methods were condom, IUD and oral pill. Presumably, none the less popular 'natural' methods (withdrawal and safe days) and 'folc' methods (vaginal douche with various acid solutions) were cited less because respondents had trouble with
a 'nice' wording of these practices, being unaware of their 'scientific' names. Past and current patterns o f use. Individual history of contraceptive use was collected by means of the table listing eight common methods (see Table 4). Most women reported more than one method ever used, with the mean number of methods being 3.6 _+ 1.3. This number was somewhat lower in women coming from non-European part of the U.S.S.R. than in the rest of urban women (2.67 vs 3.6-4.0) but these differences were non-significant. Mean number of methods used increased somewhat with education (from 3.0 to 3.83) and with age (from 3.10 to 3.84), but in both cases differences lacked statistical significance. A clear reduction in use of all traditional methods, with an exception of condoms, is observed from past to present (i.e. already in Israel). Interestingly, this decline is not paralleled by substantial increase in other methods' use, with an exception of oral contraception--the number of pill users has almost doubled--suggesting overall diminishing of contraceptive (and sexual?) activity. This is especially true of the ad hoe methods (safe days, withdrawal, douche, to some extent condoms) used sometimes: their usage has dropped almost twice. Traditional methods tend to be used in combination: thus, out of 23 respondents who practiced in the past douching with spermicidic solutions 22 also used safe days and withdrawal methods, either regularly or sometimes. Ever-users of the pill, UIDs and condoms were evenly distributed by city size and place in the U.S.S.R., the only notable deviations being higher pill usage in women from Moscow and Leningrad (11% vs 2% in small non-Slavonic towns). Generally, very few users of all three methods come from Asian and Caucasian regions. There was no notable variance in the users' educational level, while their age composition was more conspicuous (Table 5) with Table
5. Distribution of ever-users of three contraceptive methods by age (N = %)
Age group <24 25-34 35 and more
IUD
Pill
Condom
2 19 14
18 11 5
25 27 18
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Table 6. Respondents' estimates of reliability, convenience and health safety of the main contraceptive methods. Percentage of those ascribing scores I - 4 ('1"),.5-7 ('2') and 8--10 ( ' 3 ' ) - - b y methods and qualities Reliability Methods Safe days Withdrawal Douche Condom IUD Pill Spermicides Cap/diaphragm
Convenience
Health safety
I
2
3
1
2
3
1
2
3
24 28 37 4 4 0 16 13
18 58 32 25 17 I1 28 24
48 0 4 55 61 68 10 16
30 68 52 39 9 7 35 36
29 II 16 26 15 17 17 14
29 6 4 19 55 55 3 3
17 22 22 1 20 21 17 10
14 21 18 12 31 33 27 22
57 43 32 7I 27 23 8 18
Note: Sums of I + 2 + 3 in each category are < 100% because of the missing answers.
pill use being more common in younger women, and IUD use--in older ones, Among students, there were more pill users than among other women (data not shown).
Attitudes towards specific contraceptive methods From several Soviet surveys, it is known that notions and beliefs of potential users about the 'pros' and 'contras' of contraception are strongly biased, which inevitably influences usage patterns [7-9]. In the following question, the women were asked to estimate within ten grades (the higher the better) the main qualities of each contraceptive method-reliability, convenience (including sexual aspect), and health safety (Table 6). The distribution of answers suggests that certain misjudgement of the advantages and shortcomings of various contraceptives is still rather common: more familiar traditional methods tend to be overestimated, while less common ones (like vaginal barriers, mechanical or chemical) are viewed more sceptically. But overall, our respondents perceive contraceptive methods more adequately than their counterparts in various Russian surveys of 8-10 year ago [7] and even in the early 1990s [8]. Particularly notable is that our respondents estimate the pill much more positively from either point of view (even health safety) than late Soviet respondents in the recent survey [8]. The remaining methods (chemical spermicides and cap/diaphragm) are virtually unused, and most respondents failed to ascribe them a score. Age was shown to be the strongest determinant in contraceptive decision-making among Soviet women [8]. In order to examine this in our study group, age
distribution of respondents who gave high estimates of basic properties of contraceptive methods was obtained (see Table 7). For most methods, younger respondents gave higher estimates than did older ones, the difference being especially clear for a condom, an IUD and the pill. No significant variance in attitudes towards specific contraceptive methods by education have emerged in this analysis, possibly because of lack of variance of this parameter in our study group. Most of our respondents saw the use of modern 'medical' contraceptives as a norm in the host society: 66% believed that the pill and an IUD were preference methods for most Israeli couples. Contraceptive failures. Thirty three respondents reported a history of contraceptive failures, usually no more than once or twice. This figure, juxtaposed with 45 women with a history of induced abortion, is in line with the Soviet data that most terminations result from contraceptive failure rather than non-use of contraception [6, 7]. Out of 14 first pregnancies terminated by our respondents, 11 cases occurred among women reporting contraceptive failures, indicating that at least one half of the first terminations occurred after attempted but failed contraceptive usage. Quite expectedly, safe days, withdrawal and douching were most cited methods that failed, but IUD was also reported as a failure method by as much as 21 women, suggesting both low quality of Soviet IUDs and women's unawareness of possible expulsions. Method change. Women in our group were fairly consistent in their contraceptive tactics. About 34% have been using their principal method for
Table 7. Age distribution of respondents who ascribed high scores (8-10) to the qualities of contraceptive methods (% ffi N)
Reliability Methods Safe days Withdrawal Douche Condom IUD Pill Spermicides Cap/diaphragm
Convenience
Health safety
<24
25-34
35+
<24
25-29
35+
<24
25-29
35+
16 0 I 23 21 29 6 5
18 0 2 22 25 28 3 9
14 0 I l0 15 11 I 2
I0 2 2 II 16 23 3 3
12 3 I 5 24 23 0 0
7 I 1 3 15 9 0 0
19 15 I0 26 9 l0 4 8
20 17 16 28 10 10 3 8
18 I1 6 17 8 3 1 2
Family planning practices and attitudes 4 years and more, while 44% have started it 3 years ago or less (the remaining 22% reported no main method). 35% reported ever changing their main method, mostly seeking higher reliability and/or convenience. These factors were clearly more important for younger women, while health risks and cost considerations were of more weight for older ones. Knowledge of oral contraceptives. This issue is of special relevance for the trends of contraceptive behavior in former Soviet women since the pill is the main natural replacement of abortion. For both Soviet physicians and potential users, hormonal contraception for decades has had a strong negative image because of anticipated health risks [8, 12]. In our study group, 18% of women have had some experience with the pill in the U.S.S.R. and 21% used it currently. So some understanding of how this method works might be expected. Judging by the answers about the content and mechanism of the pill's action, between one quarter to one third of the young women in our study understood the basics of this method. In this latter group, most were students and women in their 20s, suggesting their better access to information via contacts with Israeli mates, better language skills, etc. However, health risks of oral contraceptives still outweighed their health benefits in view of our respondents: most chose 3-4 types of potential complications (weight change, hormonal imbalance and tumors ranking first), while only 1-2 benefits were expected (mostly, safe sex life and regular periods), or none at all (30% of answers). About one quarter had no opinion in either case. This is indicative of the remaining ambivalence about this method, even among its current users. Interpartner communication. Efficiency of contraception is strongly modified by users' motivation and cooperation between the partners. Of 82 women who answered the respective questions, 71% said that they could discuss birth control issues with their partners without any problem, while 24% felt uncomfortable about it or avoided this at all. The women who had no communicative problems in contraception were younger than those who reported lack of communication (mean ages 28.9 and 32.8 years, P = 0.029), but were no different in terms of education or place of former residence. More than a half of women said that distribution of initiative in contraceptive matters was equal in their couple, while 29% said they took care (exclusively or mostly) of preventive measures and 11% said their male partner did it. In normative terms, 83% of respondents believed that both partners should be equally responsible for preventive measures. Utilization of the relevant services. Birth control in the former Soviet Union was viewed as a purely medical problem, hence the very concept of comprehensive family planning counselling, including psycho-social component, is unfamiliar to most
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people. Moreover, certain stigma is attached to seeking external (non-medical) aid for wider personal problems as a sign of weakness and dependence. Although in the last years of the Soviet Union marriage and family counselling centers started to appear, their clientelle was very limited and selective. Hence, in Israel new immigrants tend not to seek external aids to solving their intimate problems, often being unaware of existing possibilities or reluctant to use them. When given a list of eight available services, only 17 women said they would like to get contraceptive counselling, as compared to 26 for marriage and sex counselling and 42 for general or child/school psychologist (this also reflects relatively low priority of birth control problems in personal agenda of new immigrants). Every fourth woman in our group has ever used any kind of family planning services in Israel; this is not much given that most women were in their early or middle reproductive age. Available services seem to be underused by new immigrant women, in spite of the apparent need. DISCUSSION
Our study group, although small, is characteristic enough of the younger part of female ex-Soviet immigrants (educated urban professionals, coming mostly from Slavonic part of the U.S.S.R.; high percentage of divorcees, with and without children). Since our group was deliberately skewed towards young ages, about one third being students, we had disproportionate number of single women. They presumably represent the more advanced and responsive part of the immigrant population, and their behavioral patterns may therefore be indicative of the future general trends. The percentage of divorcees (13%) is in agreement with respective proportion in current immigration wave [1]. Most young women are sexually active, irrespective of their marital status, many cohabitate with their partners. Both desired and achieved fertility are low, so birth control is an important issue. Prevalence of induced abortion among our women is much lower than in their source population: 55% never had abortions, and among those who did their mean number was about two, with no much variation by background variables other than age. Women aged over 35 (i.e. given early Russian fertility, close to completion of their reproductive life [6]) reported on average 1.69 abortions overall, and 2.32 for those who ever had them. Out-of-hospital terminations were few, all of them performed by physicians and not causing complications. Only nine women have had an abortion in Israel. Given low fertility, lack of abortions may reflect lower sexual activity, or more effective contraceptive use, or their combination. Another explanation may be underreporting, which, judging by fairly good internal cohesion of the questionnaire data, seems implausible. This supports an assumption, put forward by other researchers [13]
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that Jewish women have less abortions than do other Soviet women (in 1992 total abortion rate in Russia was 3.5 per woman [6]). Our very modest data also suggests that illegal abortion services within Russian-speaking community are on demand and probably are provided on a limited scale. In order to understand how common it is, whether it causes any health problems and who are usual clients for this type of service, a special survey has to be performed. Abortion behaviors are largely shaped by availability of other family planning options, but may be strongly modified by personal values and social norms towards this practice. Popular medicotechnical attitude towards abortion as "just a special type of surgery" contributed a lot into its sustained dominance in birth control agenda of Soviet women. Abortion attitudes showed significant variance in our study group. The described 'technical' view of abortion was quite common, but not dominant (38%), while the rest of respondents attached to it more moral meaning, with over one fifth seeing abortion as a murder. Contrary to the expected, actual abortion history did not depend on a woman's perception of this procedure, pointing at objective restrictions (lack of acceptable contraceptives). It may be explained in terms of psychological ambivalence and a lag between what you believe and what you have to do, so common for the former Soviet people in many areas of life. Rational disapproval of abortion was reflected in 87% of respondents who rejected abortion as a routine birth control method, as well in 72% believing that abortions are more detrimental to health than chronic contraceptive use. Therefore, largely disapproving of abortion from any standpoint, most women still use it. This confirms an idea that contraceptive behavior is to a large extent irrational, being shaped, beside objective factors, by cultural inhibitions, attitudes toward risktaking and reluctance to introduce planning into sexual life. On the other hand, this gap between abortion beliefs and practices is indicative of readiness to adopt efficient contraception, at least among younger women. Most of them appreciate efficient contraceptive usage as a cultural norm of the Israeli society. As was mentioned above, one of the reasons for lower than expected abortion frequency in our study group might be efficient contraceptive use. This suggestion was largely confirmed: our women were reasonably well informed about both modern and traditional contraceptive methods, and most used contraception in a consistent way. 78% of respondents had some basic method they relied upon, and of those 34% used it for 4 years or more. Over one third reported ever change of their main method, usually for the reasons of efficiency in younger women and health problems in older ones. The usage of an IUD---most popular contraceptive among Soviet women [7, 8]--was not influenced by
migration: every fourth parous woman in our group had an IUD in situ. In contrast to that, pill usage has doubled, mostly on account of younger womenstudents. At the same time, dramatic decline in usage of traditional methods has occurred in the study group. Current pattern of contraceptive use in our immigrant women is a step forward compared to their source population: a little over one third of our women relied regularly on traditional methods (including condom), vs more than two thirds in the European part of the former U.S.S.R. [7, 8]. Since we did not ask women about exact timimg of the 'past' and 'present' contraceptive use, it is unclear whether this change in pattern has occurred after immigration or still at the place of origin. At least in case of the pill the former is more plausible. Most respondents revealed fairly balanced and realistic views as to the main properties of contraceptive methods. Still, the trend to overrating better familiar traditional methods and underestimating modern ones is also seen in our group, although to a much lesser extent than was shown in some Soviet studies [7, 8]. Younger women revealed more adequate, and overall more positive, opinion on the pros and cons of contraceptive methods than did older ones. They were more knowledgeable as to the pill's content and mechanism of action, and less apprehensive of its potential side-effects. Their contraceptive decision-making was mostly based on considerations of efficiency and convenience. Majority of our women can easily discuss contraception with their partners and also have a partner taking active part in practicing contraception. Still, more then one quarter of the women said that their partner was little or almost non-involved in birth control issues. At the same time, 83% of our respondents saw equal contraceptive responsibility of both partners as a norm. And finally, only minor actual and intended utilization of Israeli family planning services were found. This may be explained by a combination of reasons: language and cultural barriers in consulting local gynecologists, and lack of awareness of alternative voluntary services that are more flexible and responsive to women's needs. There are also some monetary barriers, since contraceptives are not covered by medical insurance. And, above all, health and family planning problems have low subjective priority in the immigrants' life full of more immediate problems like jobs and housing. Often both action and reflection start when an unwanted pregnancy is already there. CONCLUSION
This small exploratory study adressed the issue of fertility control among former Soviet women placed into the context of society with very different norms and practices in this area. We realize that, due to the small numbers involved and lack of formal representativity (that made us avoid the
Family planning practices and attitudes term 'sample' throughout the text) this study is not suited for any definitive inferences. However, we believe that the intense glance into reproductive lives o f this small group ('descriptive', in formal terms) may be insightful, not in the least because of its advanced, 'pioneering' profile (young, educated, in touch with the host society) that may be indicative of future trends in this migrant population. Our results, by and large, are in line with the view that as a group, Jewish migrants are more advanced in their birth control patterns than other urban dwellers of the former Soviet Union, having less abortions and using more efficient contraception. However, the gap between them and the host society in this area is still quite wide. The main signal of the new reality is initially related to legal and financial constraints in access to abortion, pressing women to seek birth control alternatives. In spite o f cultural barriers to utilization of local family planning services, many young women in this group started using oral contraceptives in their first post-immigrative years. Quite naturally, a faster switch to modern contraception is made by women having more contact with the host society via studies or work (most pill users in this study were students), while women closed within immigrant community tend to retain their old behavioral patterns. Overall, this study suggests that younger new immigrant women have made their first steps toward healthier fertility regulation pattern. The process in by no means smooth and further studies are important to monitor it. REFERENCES
1. Statistical Abstract of Israel, 1992 (No 43). Central Bureau of Statistics, Jerusalem, 1992. 2. Fertility Behavior in the Context of Development. Evidence from the World Fertility Survey. UN, New York, 1987. 3. Hernandez D. J. Success or failure? Family planning programs in the III world. Stud. pop. Urban Demography, No 4. Greenwood Press, 1984. 4. McFadyen I. R. Pregnancy. In Ethnic Factors in Health and Disease (Edited by Cruikshank J. and Beavers D.). Butterworth, 1989. 5. King R. (Ed.) Mass Migration in Europe: the Legacy and the Future. Belbaven, London, 1993. 6. Barkalov N. B. and Darsky L. E. Russia: Fertility, Contraception, Induced Abortion, Infant and Maternal Mortality. The Futures Group Int., Washington, 1994.
$SM 41/4--1
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7. Remennick L. I. Epidemiology and determinants of induced abortion in the U.S.S.R. Soc. Sci. Med. 33, 841, 1991. 8. Visser A. Ph., Pavlenko I., Remennick L., Bruyniks N. and Lehert P. Contraceptive practice and attitudes in former Soviet women. Adv. Contraception 9, 13, 1993. 9. Remennick L. I. Patterns of Birth Control. In Sex and Russian Society (Edited by Riordan J. and Kon I.), pp. 45-63. Pluto Press, London and Indiana University Press, U.S.A., 1993. 10. Kon I. Sexuality and Culture. In Sex and Russian Society (Edited by Riordan J. and Kon I.), pp. 15-44. Pluto Press, London, 1993. 11. The First Official Report on Pub lic Health m the Russian Federation, 1991. Moscow, Ministry of Health, 1992 (in Russian). 12. Visser A. Ph., Bruyniks N. and Remennick L. Family planning in Russia: experience and attitudes of gynecologists. Adv. Contraception 9, 93, 1993. 13. Darsky L. E. Fertility in the U.S.S.R.: Basic trends. In Population Reproduction and Family Dynamics (Edited by Andreev E., Bondarskaya G. and Darsky L.), pp. 47-62. Research Institute of Statistics, Department of Demography, Moscow, 1992. 14. Tolts M. Jewish Marriages in the U.S.S.R.: a Demographic Analysis. East European Jewish Affairs 22, 3, 1992. 15. Tolts M. The balance of births and deaths among Soviet Jewry. Jews and Jewish Topics in the Soviet Union and Eastern Europe. Hebrew Unit,. Jerusalem 2(18), 13, 1992. 16. Sabatello E. F. The impact of induced abortion on fertility in Israel. Soc. Sci. Med. 36, 703, 1993. 17. Sabatello E. F. Short-range changes in fertility and abortion patterns among female immigrants from the U.S,S.R. to Israel. Social Security (Bitachon Sotsiali) No 2, 1994 (in Hebrew). 18. Florsbeim Y. Soviet Jewish immigration to Israel in 1990---a demographic profile. Soviet Jewish Affairs 21, 1991. 19. Sabatello E. F. Estimates of illegal abortions in Israel, 1980-83. Isr. J, Med. Sci. 26, 204, 1990, 3, 1991. 20. Peritz E. and Baras M. (Eds) Studies of Fertility in Israel. The Institute of Contemporary Jewry, The Hebrew University of Jerusalem (Jewish Population Studies Ser.), 1992. 21. Salzberger L., Avgar A. et al. Patterns of contraceptive behavior among Jerusalem women seeking pregnancy counselling. P. Bauerwald School of Social Work, the Hebrew University of Jerusalem, 1991. 22. Amir D. and Navon D. Abortion policy in Israel. The P. Sapir Center for Development, Tel-Aviv University, Discussion paper Ser., 1989 (Hebrew). 23. Amir D. and Biniamin O. Abortion approval as a ritual of symbolic control. In Criminalizing Woman's Body (Edited by Fienewan C.), pp. 5-25. Haworth Press (U.S,A.) 1992.
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FAMILY P L A N N I N G PRACTICES A N D ATTITUDES A M O N G FORMER SOVIET NEW IMMIGRANT WOMEN IN ISRAEL LARISSA I. R E M E N N I C K , t D E L I L A A M I R , 2 Y U V A L E L I M E L E C H 2 and Y L I Y A N O V I K O W ~Graduate Program in Medical Sociology, Department of Sociology and Anthropology, Bar-Ilan University, Ramat Gan 52900, Israel, 2Department of Sociology and Anthropology, University of Tel Aviv, Tel Aviv, Israel and 3Department of Epidemiology, Tel Ha-Shomer Medical Center, Israel Abstract--One hundred young new immigrant women from the former U.S.S.R. now living in Israel answered a detailed semi-open questionnaire regarding their knowledge, attitudes and behaviors in fertility and birth control issues. A collective family planning profile of these women is largely in line with that of the urban population of Slavonic U.S.S.R., combining early marriage, early and low fertility, the latter achieved by both abortion and contraception. Most respondents and their partners tried to prevent unwanted pregnancies, usually starting from traditional methods and switching over time to modern ones. An IUD remained most popular contraceptive among parous women, while use of the pill, very rare in the U.S.S.R., has almost doubled upon migration, mostly among younger women. Still, they kept some misleading ideas on the pros and cons of traditional versus modern methods, suggesting lack of adequate information also upon migration. Like their ex-compatriots, our women preferred to solve their birth control problems without external professional involvement. Contrary to the expected, free abortion ideology was not universally advocated by our respondents, and most were fully aware of abortion limitations in Israel. While rationally condemning abortion in both moral and health terms, most respondents still use it, this gap between beliefs and practice being indicative of their readiness to adopt efficient contraception. This switch occurs faster in women actively involved with host society via work or studies. Younger women were found to be more flexible and advanced in their family planning practices than were older ones, while almost no differences were related to education and origin within the U.S.S.R. This exploratory study suggests that any investment into promotion of healthy fertility control practices among new immigrants will be cost-effective in the near future. Key words
family planning, health beliefs, Israel, abortion
INTRODUCTION The latest wave of immigration from the former U.S.S.R. that in four years (1989-92) has enlarged Israeli population by almost 10%, presents a special challenge for the host society because of its size and heterogeneity. A m o n g more than 400,000 of recent migrants, there are over 100,000 women of reproductive age [1]. Specific experiences and problems of these women facing a different gender system, new options and restrictions in their reproductive life need to be scrutinized specially as an important aspect of socio-cultural adaptation. Most international studies addressing the issue of change of fertility control patterns with advent of new contraceptive techniques were staged in developing countries implementing population programs aimed at fertility reduction [2-4]. What happens to immigrants who move from industrialized countries of the former Eastern Block to Western societies, sharing with them low fertility patterns but having very different birth control laws and practices, is much less understood--since the reality of mass emigration after the demise of the Eastern Block is a
new phenomenon [5]. We failed to find published studies concerning acculturation of migrants from former socialist countries to the Western patterns of family planning. Therefore our evaluation of this problem in Israeli context may also be of interest and relevance to other countries hosting former Soviet and other East European immigrants.
BACKGROUND The model of reproductive behavior prevalent in the Slavonic part of the ex-U.S.S.R., where the majority of Soviet Jews have lived, is characterized by low fertility (in 1990, for urban population 1.7-1.9 children per woman by the end of her reproductive lifespan [6]), prevalence of abortion as a birth control method (3-4 abortions per average sexually active woman), and underuse of modern contraceptive methods [7-9]. Age was shown to be most important determinant of patterns of contraceptive use, contraception as such and modern methods in particular being more used by younger women. Level of education and place of residence may also 569
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play a role: better educated women residing in big cities tend to be more active contraceptive users [6-8]. In spite of divergent socio-economic and cultural backgrounds, most former Soviet people share an inhibited and prejudiced attitudes towards sexuality, often combined with fatalistic and spontaneous approach to fecundity and its regulation [10]. Also common to all of them has been the lack of family planning options and services, since preventive maternity care has been one of the most neglected sectors of public health in the U.S.S.R. [11, 12]. As a result of long-term assimilative trends, Soviet Jews are fairly close in their life styles and mentality to the surrounding majority. What marks this part of the Soviet population, is its concentration in big cities and, generally, higher cultural and educational standards, with resulting better access to information and various services, including health and family planning, Total fertility rates of the European Soviet Jews, according to some studies [13-15], have been even lower than the national average: about 1.5-1.7 per woman during the last three decades. The same applies to the number of abortions, with anestimated mean of 2.0-2.5 [16, 17], which is indicative of more efficient contraceptive use. How readily may those general patterns be applied to the new immigrant population in Israel is still not clear, although we assume that, due to its mass character, this immigration wave was unselective. This is indirectly supported by comparison of available late Soviet and Israeli statistics, suggesting that in all major socio-economic aspects population of new immigrants presents Soviet Jewry as a whole [18]. Anyway, reproductive and birth control patterns of the new immigrants are markedly different from those common for most Israeli Jews. Due to a combination of reasons related to Jewish tradition and religion, political and demographic factors of the Middle East region, Israeli society is clearly pronatalistic, at both establishmental and individual levels. Total fertility level is among the highest in a developed world: around 3.0 per woman [1]. As may be inferred from low total abortion rate among Israeli Jewish women (about 0.6 throughout reproductive lifespan, estimated il!egai abortions included [I 6, 19]) efficient contraceptive use is common [20, 21]. Several alternative channels of family planning information and help, medical and other, are available in Israel; sex education ideology is shared at all levels of the estabishment, and sex-related issues are surrounded, overall, by open and tolerant public atmosphere, at least in the secular majority of the population. Abortion regulations are the subject of continuous debate between various political forces, mostly religious and secular [22]. The current law compromising between these ideologies defines a number of circumstances justifying pregnancy termination: woman's age ( < 17 and > 40); illegal nature of pregnancy (out-of-wedlock, rape, incest); threat to a
woman's physical or mental health, and suspected malformations of a fetus. Socio-economic indications for pregnancy termination were cancelled in the early 1980s under political pressure of religious circles. Each abortion application is considered by a hospital-based committee (two physicians and a social worker). Termination procedure costs to a woman around 300-500 USD (i.e. about half of an official minimal salary); only abortions for medical indications may be partly reimbursed from insurance or public funds. Altogether, this makes abortion procedure in Israel costly, bureaucratized and interfering with a woman's private life [23]--in contrast to unrestricted provision of abortion services in the former U.S.S.R. To evaluate continuity and initial change in fertility and birth control practices among new immigrant women, and to understand their specific needs in this area was an objective of the present study. Its limited size and exploratory nature may be justified by acute necessity to approach the newly appearing phenomenon of a former Soviet immigrant woman at the moment of her encounter with a different gender culture, medical and welfare establishments of a 'Western' type. STUDY G R O U P AND M E T H O D S
The study group included 100 former Soviet new immigrant women who arrived in Israel at least one year ago and lived in two major urban centers that host more than a half of all new immigrants (Greater TeI-Aviv and Jerusalem) [1]. Respondents, accrued to the study using snowballing method, were university students (28%) and other young women, usually unfamiliar one with the other. Three interviewers-female students of sociology and new immigrants themselves--were instructed to recruit women in accord with the pre-established proportions by age and place of residence in the U.S.S.R., so that the resulting group of respondents would roughly parallel composition of its source population. Some relevant socio-demographic characteristics of our study group are presented in Table 1. Although not claiming to be a representative sample, this group reflects fairly well the main features of younger part of immigrant women, of whom most are urban educated professionals, with high proportion of divorcees, with and without children. Singles are clearly overrepresented in this group (32%)---probably because of the fact that the starting point of the snowballing was a student population. We limited ourselves by 100 respondents considering qualitative, in-depth nature of the data being collected that is very problematic and costly to obtain in big samples. We considered it as an exploratory 'express-study', important to perform at the initial stage of immigrants integration, not waiting for the resources necessary for a survey in a large representative sample.
Family planning practices and attitudes Table 1. Socio-demographiccharacteristics of the study group (N = %) 28.5 + 7.4 years Usualoccupatimu: (38% < 25) Students 30 + 9 months Semi-qualifiedworkers in education, Mean time in Israel medicine, science;office workers 13.9 + 2.4 Qualifiedscienceand engineeringworkers Mean No. years of education % Marital status: Married 55 Teachers, physicians,economistsand 13 other professionals Divorced 32 Single Mean age
Place of residence in the f U.S.S.R.:
Moscow and Leningrad Other capitals and biggestcities Medium/smallcities
571
%
28 25 14 33
%
Current employment:
%
24 38 38
Studies (inc. retraining) Professional jobs Manual jobs (inc. part-time) Unemployed
49 23 22 6
Semi-close questionnaire in Russian contained 105 questions divided into four blocks: General; Childbearing and family planning; Gender relations and sexuality; and Adjustment to Israeli reality. Most questions provided sets of answers plus an open-ended one; about 20% of the questions were completely open. The optimal mode of administration was decided to be self-completion in presence and with help of interviewers. M a x i m u m possible anonimity was ensured by interview procedure. Only 9 of all women approached refused to participate (and were replaced by others), and in all but few questionnaires there were no blanks even at the most sensitive points. Returning a questionnaire, many women noted that it was interesting and awakening thought, that it made them see in a critical light things usually taken for granted. In this paper we present the part of the study data, concerning family planning practices, knowledge and underlying attitudes. More qualitative data from this study on gender roles, family relations and sexuality are discussed elsewhere (Remennick et al., forthcoming). Since we had 100 respondents, absolute numbers coincide with percentages in all the results below.
which is in agreement with demographic patterns in former Soviet population at large [6, 13, 14]. It is notable that more than one fifth of women have had their first intercourse yet at secondary school, but formation of stable relationship has occurred only in later life.
STUDY RESULTS
Prevalence and variability. Variance in n u m b e r of abortions by age, education and place of residence in the U.S.S.R. is shown in Table 3. Besides age, no significant variance is seen, since abortion is known to be a universal birth control method across the former U.S.S.R., common for all categories of women. A history of out-of-hospital abortion was reported by five women, of whom four had one such termination and one had two. All operations were performed by physicians, but in home conditions.
All respondents have filled into the table describing principal events of their feminine history in chronological order. Age at menarche was 10-12 years in 45% of women, and 13-15 in the rest 55%. Age at other events was distributed in the following way (Table 2). Most sex-related 'first events', including first marriage, were concentrated in age group 18-22,
Table 2. Distribution of respondents by age
Number o f children
Of respondents 41 were childless, and the mean n u m b e r of children for the rest of them was 1.56 _+ 0.62 (including 1.00 for women younger than 24, 1.45 for age group 25-34, and 1.77 for 35 and more, P = 0.026). Even given that one third were never married, the proportion of childlessless in our group is higher than might be expected, while fertility level is similar to the figures reported by other studies among Soviet Jews [ 13-15]. M e a n n u m b e r of children was significantly (P = 0.003) higher among women with least education (2.67), which may reflect their somewhat older age or be due to chance (they were only 11). Former residents of the capital cities had the lowest parity (1.31), while those of smaller urban centers in non-Slavonic republics had more children (2.0). Induced abortions
the principal feminineevents (N = %) Event Events Up to 17 18-22 23--27 28-32 missing Total First intercourse 22 64 8 0 6 100 First stable relationship l0 73 9 0 8 100 First marriage 4 51 13 0 32 100 First live-birth 2 28 27 2 41 100 Note: The age distribution in Table 2 is more detailed to account for fine variation in ages of sexual and reproductive initiation. at
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Table 3. Mean numbers of reported abortions by age, education and place,of residence in the U.S.S.R. Mean numbers of abortions calculated for: Independent variables
All women
Women who had abortions
0.21 1.03 1.69 0.89 P = 0.00
1.33 1.85 2.32 1.98 P = 0.21
0.64 0.81 1.05 0.89 P = 0.54
2.33 1.90 2.00 1.98 P = 0.86
0.71 0.94 1.20 0.89 P = 0.02
1.55 2.00 2.70 1.98 P = 0.44
Age <24 25-34 35 and more All ages
Education Up to 10yr 11-13 yr 14yr or more All levels
Place of residence (U.S.S.R.) Moscow and Leningrad Capitals and other biggest cities Medium/small cities All places
Nine women have had abortions already in Israel, all with official approval, and at least partial reimbursement from various public funds. Potential for illegal abortion. Given certain gap between expected demand for abortion procedures among new immigrants and actual numbers of legal abortions during their first two years in Israel [17], it may be suggested that some part of unwanted pregnancies are terminated illegally, probably with the involvement of new immigrant physicians. This speculation stems from obvious co-existence of demand (women can not switch overnight to new contraceptives) and potential supply: hundreds of experienced former Soviet gynecologists came to Israel as new immigrants, most of them still unemployed. Part of these doctors may be ready to perform abortions in their homes at a much lower fee than officially demanded. Beside lower cost, this would allow women to get the service in the familiar cultural and language setting, as well as to avoid unpleasant formalities. Out of five women who reported having had out-of-hospital abortions, some might have them already in Israel (the question did not specify it). Nine respondents stated they were familiar with other new immigrant women who used informal abortion services of a 'Russian' physician. When asked whether a respondent herself would be ready to use such services herself in case of a need, 61% declined this possibility completely, while 36% accepted it to a smaller or larger extent. This very limited and tentative data supports the view that illegal abortion may occur in a certain sector of a 'Russian' community. Health complications. Immediate and postponed complications of abortions are known to be the most common reason for gynecologic morbidity in the U.S.S.R. [9, 11]. In our study group, post-abortion complications (mostly, inflammatory conditions and menstrual disorders) were reported by 25 women, i.e. more than one half of the respondents who ever had an abortion (N = 45).
Normative and value aspects. The following group of questions attempted to evaluate normative and ethical aspects of abortion. About one fifth of respondents who had abortions said they suffered deep emotional trauma after termination, one half admitted having moments of depression and regrets, while the remaining third did not have post-abortion emotional disturbances. When asked about their general understanding of abortion, respondents chose the following answers: painful but brief medical procedure crude interference into physiological processes a murder of an unborn child never thought about it other and missing total
- - 38% ------
15% 23% 21% 3% 100%
Actual number of abortions did not vary significantly between these value groups; it was understandably lower only for women who said they never thought of abortion in ethical terms (lack of experience---lack of opinion). Only 14% of respondents believed that the aborted embryo may suffer of pain, while 32% answered " N o " and 54% had no opinion. A big number of indefinite answers to both these questions shows that many women tend not to reflect on the issue of abortion in ethical terms. When asked whether abortion could be used as a regular birth control method, 87% of women said "No, it should only be the last resort", while 13% revealed various extents of acceptance of this idea. Hence, majority of our respondents rationally condemn abortion, but nevertheless use it (or are ready to use). 72% of women also disapproved of abortion as an intervention more detrimental for health than chronic use of any contraceptive techniques. Notably enough, in spite of deliberate dichotomy of this question, several women, after choosing one of the answers, added by hand "Both are similarly detrimental".
Family planning practices and attitudes
573
Table 4. Contraceptivemethods ever used by respondents(percentageof positiveanswers) Past use
Methods Rhythm (safe days) Withdrawal Douche Condom IUD Pill Barrier spermicides Caps/diaphragm
Current use
Regular
Sometimes
Regular
Sometimes
Ever user
21 I0 7 16 19 8 -I
35 50 31 49 6* 10" 13 4
11 7 3 17 21 15 -1
16 24 17 30 -5* 5 --
57 62 39 70 35 34 13 5
*By 'sometimes' usage of systemic methods (IUD and pill) respondents probably meant short-term episodes after which these methods were given up. t'Ever use' excludes double counting in various categories of use.
In other words, a woman is always punished for having sex, no safe escape is open for her. Awareness o f abortion situation in Israel Most women have shown at least partial awareness of the fact that pregnancy termination in their new home country is subject to many restrictions--legal, financial and other. Only 19% of women said they knew nothing about abortion regulations, while 71% knew that abortions were performed only under definite conditions specified by law. 59% of respondents could also name these conditions, in half of the cases all of them correctly. Most women were aware of monetary problems involved with abortion provision in Israel. 70% of respondents knew that a woman herself covers abortion costs, and 71% have also estimated correctly abortion costs to a client. On the whole, our respondents were better informed as to abortion situation in Israel than might be expected. Of respondents 41% agreed that abortion in Israel should be made as easily available as it was in the U.S.S.R., while 33% voted for certain restrictions in order to stimulate contraceptive use, and 9% thought that abortion performance should be made easier specifically for new immigrants. In the latter group, mean number of actual abortions was somewhat higher than in the rest of women (1.22 vs 0.73 in women who were against liberalization). Hence 'free abortion' ideology was not universally popular among our young respondents. Contraceptive use
A broad set of gender- and health-related attitudes and motives are involved in birth control decision making. The following section of the questionnaire addressed actual history of contraceptive use and some of the underlying psycho-social mechanisms. Firstly, women were asked to write a list of contraceptive methods they knew. Mean number of methods known to our respondents was 4 __+1.6, with no significant differences by age, education or origin. Most cited methods were condom, IUD and oral pill. Presumably, none the less popular 'natural' methods (withdrawal and safe days) and 'folc' methods (vaginal douche with various acid solutions) were cited less because respondents had trouble with
a 'nice' wording of these practices, being unaware of their 'scientific' names. Past and current patterns o f use. Individual history of contraceptive use was collected by means of the table listing eight common methods (see Table 4). Most women reported more than one method ever used, with the mean number of methods being 3.6 _+ 1.3. This number was somewhat lower in women coming from non-European part of the U.S.S.R. than in the rest of urban women (2.67 vs 3.6-4.0) but these differences were non-significant. Mean number of methods used increased somewhat with education (from 3.0 to 3.83) and with age (from 3.10 to 3.84), but in both cases differences lacked statistical significance. A clear reduction in use of all traditional methods, with an exception of condoms, is observed from past to present (i.e. already in Israel). Interestingly, this decline is not paralleled by substantial increase in other methods' use, with an exception of oral contraception--the number of pill users has almost doubled--suggesting overall diminishing of contraceptive (and sexual?) activity. This is especially true of the ad hoe methods (safe days, withdrawal, douche, to some extent condoms) used sometimes: their usage has dropped almost twice. Traditional methods tend to be used in combination: thus, out of 23 respondents who practiced in the past douching with spermicidic solutions 22 also used safe days and withdrawal methods, either regularly or sometimes. Ever-users of the pill, UIDs and condoms were evenly distributed by city size and place in the U.S.S.R., the only notable deviations being higher pill usage in women from Moscow and Leningrad (11% vs 2% in small non-Slavonic towns). Generally, very few users of all three methods come from Asian and Caucasian regions. There was no notable variance in the users' educational level, while their age composition was more conspicuous (Table 5) with Table
5. Distribution of ever-users of three contraceptive methods by age (N = %)
Age group <24 25-34 35 and more
IUD
Pill
Condom
2 19 14
18 11 5
25 27 18
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Table 6. Respondents' estimates of reliability, convenience and health safety of the main contraceptive methods. Percentage of those ascribing scores I - 4 ('1"),.5-7 ('2') and 8--10 ( ' 3 ' ) - - b y methods and qualities Reliability Methods Safe days Withdrawal Douche Condom IUD Pill Spermicides Cap/diaphragm
Convenience
Health safety
I
2
3
1
2
3
1
2
3
24 28 37 4 4 0 16 13
18 58 32 25 17 I1 28 24
48 0 4 55 61 68 10 16
30 68 52 39 9 7 35 36
29 II 16 26 15 17 17 14
29 6 4 19 55 55 3 3
17 22 22 1 20 21 17 10
14 21 18 12 31 33 27 22
57 43 32 7I 27 23 8 18
Note: Sums of I + 2 + 3 in each category are < 100% because of the missing answers.
pill use being more common in younger women, and IUD use--in older ones, Among students, there were more pill users than among other women (data not shown).
Attitudes towards specific contraceptive methods From several Soviet surveys, it is known that notions and beliefs of potential users about the 'pros' and 'contras' of contraception are strongly biased, which inevitably influences usage patterns [7-9]. In the following question, the women were asked to estimate within ten grades (the higher the better) the main qualities of each contraceptive method-reliability, convenience (including sexual aspect), and health safety (Table 6). The distribution of answers suggests that certain misjudgement of the advantages and shortcomings of various contraceptives is still rather common: more familiar traditional methods tend to be overestimated, while less common ones (like vaginal barriers, mechanical or chemical) are viewed more sceptically. But overall, our respondents perceive contraceptive methods more adequately than their counterparts in various Russian surveys of 8-10 year ago [7] and even in the early 1990s [8]. Particularly notable is that our respondents estimate the pill much more positively from either point of view (even health safety) than late Soviet respondents in the recent survey [8]. The remaining methods (chemical spermicides and cap/diaphragm) are virtually unused, and most respondents failed to ascribe them a score. Age was shown to be the strongest determinant in contraceptive decision-making among Soviet women [8]. In order to examine this in our study group, age
distribution of respondents who gave high estimates of basic properties of contraceptive methods was obtained (see Table 7). For most methods, younger respondents gave higher estimates than did older ones, the difference being especially clear for a condom, an IUD and the pill. No significant variance in attitudes towards specific contraceptive methods by education have emerged in this analysis, possibly because of lack of variance of this parameter in our study group. Most of our respondents saw the use of modern 'medical' contraceptives as a norm in the host society: 66% believed that the pill and an IUD were preference methods for most Israeli couples. Contraceptive failures. Thirty three respondents reported a history of contraceptive failures, usually no more than once or twice. This figure, juxtaposed with 45 women with a history of induced abortion, is in line with the Soviet data that most terminations result from contraceptive failure rather than non-use of contraception [6, 7]. Out of 14 first pregnancies terminated by our respondents, 11 cases occurred among women reporting contraceptive failures, indicating that at least one half of the first terminations occurred after attempted but failed contraceptive usage. Quite expectedly, safe days, withdrawal and douching were most cited methods that failed, but IUD was also reported as a failure method by as much as 21 women, suggesting both low quality of Soviet IUDs and women's unawareness of possible expulsions. Method change. Women in our group were fairly consistent in their contraceptive tactics. About 34% have been using their principal method for
Table 7. Age distribution of respondents who ascribed high scores (8-10) to the qualities of contraceptive methods (% ffi N)
Reliability Methods Safe days Withdrawal Douche Condom IUD Pill Spermicides Cap/diaphragm
Convenience
Health safety
<24
25-34
35+
<24
25-29
35+
<24
25-29
35+
16 0 I 23 21 29 6 5
18 0 2 22 25 28 3 9
14 0 I l0 15 11 I 2
I0 2 2 II 16 23 3 3
12 3 I 5 24 23 0 0
7 I 1 3 15 9 0 0
19 15 I0 26 9 l0 4 8
20 17 16 28 10 10 3 8
18 I1 6 17 8 3 1 2
Family planning practices and attitudes 4 years and more, while 44% have started it 3 years ago or less (the remaining 22% reported no main method). 35% reported ever changing their main method, mostly seeking higher reliability and/or convenience. These factors were clearly more important for younger women, while health risks and cost considerations were of more weight for older ones. Knowledge of oral contraceptives. This issue is of special relevance for the trends of contraceptive behavior in former Soviet women since the pill is the main natural replacement of abortion. For both Soviet physicians and potential users, hormonal contraception for decades has had a strong negative image because of anticipated health risks [8, 12]. In our study group, 18% of women have had some experience with the pill in the U.S.S.R. and 21% used it currently. So some understanding of how this method works might be expected. Judging by the answers about the content and mechanism of the pill's action, between one quarter to one third of the young women in our study understood the basics of this method. In this latter group, most were students and women in their 20s, suggesting their better access to information via contacts with Israeli mates, better language skills, etc. However, health risks of oral contraceptives still outweighed their health benefits in view of our respondents: most chose 3-4 types of potential complications (weight change, hormonal imbalance and tumors ranking first), while only 1-2 benefits were expected (mostly, safe sex life and regular periods), or none at all (30% of answers). About one quarter had no opinion in either case. This is indicative of the remaining ambivalence about this method, even among its current users. Interpartner communication. Efficiency of contraception is strongly modified by users' motivation and cooperation between the partners. Of 82 women who answered the respective questions, 71% said that they could discuss birth control issues with their partners without any problem, while 24% felt uncomfortable about it or avoided this at all. The women who had no communicative problems in contraception were younger than those who reported lack of communication (mean ages 28.9 and 32.8 years, P = 0.029), but were no different in terms of education or place of former residence. More than a half of women said that distribution of initiative in contraceptive matters was equal in their couple, while 29% said they took care (exclusively or mostly) of preventive measures and 11% said their male partner did it. In normative terms, 83% of respondents believed that both partners should be equally responsible for preventive measures. Utilization of the relevant services. Birth control in the former Soviet Union was viewed as a purely medical problem, hence the very concept of comprehensive family planning counselling, including psycho-social component, is unfamiliar to most
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people. Moreover, certain stigma is attached to seeking external (non-medical) aid for wider personal problems as a sign of weakness and dependence. Although in the last years of the Soviet Union marriage and family counselling centers started to appear, their clientelle was very limited and selective. Hence, in Israel new immigrants tend not to seek external aids to solving their intimate problems, often being unaware of existing possibilities or reluctant to use them. When given a list of eight available services, only 17 women said they would like to get contraceptive counselling, as compared to 26 for marriage and sex counselling and 42 for general or child/school psychologist (this also reflects relatively low priority of birth control problems in personal agenda of new immigrants). Every fourth woman in our group has ever used any kind of family planning services in Israel; this is not much given that most women were in their early or middle reproductive age. Available services seem to be underused by new immigrant women, in spite of the apparent need. DISCUSSION
Our study group, although small, is characteristic enough of the younger part of female ex-Soviet immigrants (educated urban professionals, coming mostly from Slavonic part of the U.S.S.R.; high percentage of divorcees, with and without children). Since our group was deliberately skewed towards young ages, about one third being students, we had disproportionate number of single women. They presumably represent the more advanced and responsive part of the immigrant population, and their behavioral patterns may therefore be indicative of the future general trends. The percentage of divorcees (13%) is in agreement with respective proportion in current immigration wave [1]. Most young women are sexually active, irrespective of their marital status, many cohabitate with their partners. Both desired and achieved fertility are low, so birth control is an important issue. Prevalence of induced abortion among our women is much lower than in their source population: 55% never had abortions, and among those who did their mean number was about two, with no much variation by background variables other than age. Women aged over 35 (i.e. given early Russian fertility, close to completion of their reproductive life [6]) reported on average 1.69 abortions overall, and 2.32 for those who ever had them. Out-of-hospital terminations were few, all of them performed by physicians and not causing complications. Only nine women have had an abortion in Israel. Given low fertility, lack of abortions may reflect lower sexual activity, or more effective contraceptive use, or their combination. Another explanation may be underreporting, which, judging by fairly good internal cohesion of the questionnaire data, seems implausible. This supports an assumption, put forward by other researchers [13]
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that Jewish women have less abortions than do other Soviet women (in 1992 total abortion rate in Russia was 3.5 per woman [6]). Our very modest data also suggests that illegal abortion services within Russian-speaking community are on demand and probably are provided on a limited scale. In order to understand how common it is, whether it causes any health problems and who are usual clients for this type of service, a special survey has to be performed. Abortion behaviors are largely shaped by availability of other family planning options, but may be strongly modified by personal values and social norms towards this practice. Popular medicotechnical attitude towards abortion as "just a special type of surgery" contributed a lot into its sustained dominance in birth control agenda of Soviet women. Abortion attitudes showed significant variance in our study group. The described 'technical' view of abortion was quite common, but not dominant (38%), while the rest of respondents attached to it more moral meaning, with over one fifth seeing abortion as a murder. Contrary to the expected, actual abortion history did not depend on a woman's perception of this procedure, pointing at objective restrictions (lack of acceptable contraceptives). It may be explained in terms of psychological ambivalence and a lag between what you believe and what you have to do, so common for the former Soviet people in many areas of life. Rational disapproval of abortion was reflected in 87% of respondents who rejected abortion as a routine birth control method, as well in 72% believing that abortions are more detrimental to health than chronic contraceptive use. Therefore, largely disapproving of abortion from any standpoint, most women still use it. This confirms an idea that contraceptive behavior is to a large extent irrational, being shaped, beside objective factors, by cultural inhibitions, attitudes toward risktaking and reluctance to introduce planning into sexual life. On the other hand, this gap between abortion beliefs and practices is indicative of readiness to adopt efficient contraception, at least among younger women. Most of them appreciate efficient contraceptive usage as a cultural norm of the Israeli society. As was mentioned above, one of the reasons for lower than expected abortion frequency in our study group might be efficient contraceptive use. This suggestion was largely confirmed: our women were reasonably well informed about both modern and traditional contraceptive methods, and most used contraception in a consistent way. 78% of respondents had some basic method they relied upon, and of those 34% used it for 4 years or more. Over one third reported ever change of their main method, usually for the reasons of efficiency in younger women and health problems in older ones. The usage of an IUD---most popular contraceptive among Soviet women [7, 8]--was not influenced by
migration: every fourth parous woman in our group had an IUD in situ. In contrast to that, pill usage has doubled, mostly on account of younger womenstudents. At the same time, dramatic decline in usage of traditional methods has occurred in the study group. Current pattern of contraceptive use in our immigrant women is a step forward compared to their source population: a little over one third of our women relied regularly on traditional methods (including condom), vs more than two thirds in the European part of the former U.S.S.R. [7, 8]. Since we did not ask women about exact timimg of the 'past' and 'present' contraceptive use, it is unclear whether this change in pattern has occurred after immigration or still at the place of origin. At least in case of the pill the former is more plausible. Most respondents revealed fairly balanced and realistic views as to the main properties of contraceptive methods. Still, the trend to overrating better familiar traditional methods and underestimating modern ones is also seen in our group, although to a much lesser extent than was shown in some Soviet studies [7, 8]. Younger women revealed more adequate, and overall more positive, opinion on the pros and cons of contraceptive methods than did older ones. They were more knowledgeable as to the pill's content and mechanism of action, and less apprehensive of its potential side-effects. Their contraceptive decision-making was mostly based on considerations of efficiency and convenience. Majority of our women can easily discuss contraception with their partners and also have a partner taking active part in practicing contraception. Still, more then one quarter of the women said that their partner was little or almost non-involved in birth control issues. At the same time, 83% of our respondents saw equal contraceptive responsibility of both partners as a norm. And finally, only minor actual and intended utilization of Israeli family planning services were found. This may be explained by a combination of reasons: language and cultural barriers in consulting local gynecologists, and lack of awareness of alternative voluntary services that are more flexible and responsive to women's needs. There are also some monetary barriers, since contraceptives are not covered by medical insurance. And, above all, health and family planning problems have low subjective priority in the immigrants' life full of more immediate problems like jobs and housing. Often both action and reflection start when an unwanted pregnancy is already there. CONCLUSION
This small exploratory study adressed the issue of fertility control among former Soviet women placed into the context of society with very different norms and practices in this area. We realize that, due to the small numbers involved and lack of formal representativity (that made us avoid the
Family planning practices and attitudes term 'sample' throughout the text) this study is not suited for any definitive inferences. However, we believe that the intense glance into reproductive lives o f this small group ('descriptive', in formal terms) may be insightful, not in the least because of its advanced, 'pioneering' profile (young, educated, in touch with the host society) that may be indicative of future trends in this migrant population. Our results, by and large, are in line with the view that as a group, Jewish migrants are more advanced in their birth control patterns than other urban dwellers of the former Soviet Union, having less abortions and using more efficient contraception. However, the gap between them and the host society in this area is still quite wide. The main signal of the new reality is initially related to legal and financial constraints in access to abortion, pressing women to seek birth control alternatives. In spite o f cultural barriers to utilization of local family planning services, many young women in this group started using oral contraceptives in their first post-immigrative years. Quite naturally, a faster switch to modern contraception is made by women having more contact with the host society via studies or work (most pill users in this study were students), while women closed within immigrant community tend to retain their old behavioral patterns. Overall, this study suggests that younger new immigrant women have made their first steps toward healthier fertility regulation pattern. The process in by no means smooth and further studies are important to monitor it. REFERENCES
1. Statistical Abstract of Israel, 1992 (No 43). Central Bureau of Statistics, Jerusalem, 1992. 2. Fertility Behavior in the Context of Development. Evidence from the World Fertility Survey. UN, New York, 1987. 3. Hernandez D. J. Success or failure? Family planning programs in the III world. Stud. pop. Urban Demography, No 4. Greenwood Press, 1984. 4. McFadyen I. R. Pregnancy. In Ethnic Factors in Health and Disease (Edited by Cruikshank J. and Beavers D.). Butterworth, 1989. 5. King R. (Ed.) Mass Migration in Europe: the Legacy and the Future. Belbaven, London, 1993. 6. Barkalov N. B. and Darsky L. E. Russia: Fertility, Contraception, Induced Abortion, Infant and Maternal Mortality. The Futures Group Int., Washington, 1994.
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7. Remennick L. I. Epidemiology and determinants of induced abortion in the U.S.S.R. Soc. Sci. Med. 33, 841, 1991. 8. Visser A. Ph., Pavlenko I., Remennick L., Bruyniks N. and Lehert P. Contraceptive practice and attitudes in former Soviet women. Adv. Contraception 9, 13, 1993. 9. Remennick L. I. Patterns of Birth Control. In Sex and Russian Society (Edited by Riordan J. and Kon I.), pp. 45-63. Pluto Press, London and Indiana University Press, U.S.A., 1993. 10. Kon I. Sexuality and Culture. In Sex and Russian Society (Edited by Riordan J. and Kon I.), pp. 15-44. Pluto Press, London, 1993. 11. The First Official Report on Pub lic Health m the Russian Federation, 1991. Moscow, Ministry of Health, 1992 (in Russian). 12. Visser A. Ph., Bruyniks N. and Remennick L. Family planning in Russia: experience and attitudes of gynecologists. Adv. Contraception 9, 93, 1993. 13. Darsky L. E. Fertility in the U.S.S.R.: Basic trends. In Population Reproduction and Family Dynamics (Edited by Andreev E., Bondarskaya G. and Darsky L.), pp. 47-62. Research Institute of Statistics, Department of Demography, Moscow, 1992. 14. Tolts M. Jewish Marriages in the U.S.S.R.: a Demographic Analysis. East European Jewish Affairs 22, 3, 1992. 15. Tolts M. The balance of births and deaths among Soviet Jewry. Jews and Jewish Topics in the Soviet Union and Eastern Europe. Hebrew Unit,. Jerusalem 2(18), 13, 1992. 16. Sabatello E. F. The impact of induced abortion on fertility in Israel. Soc. Sci. Med. 36, 703, 1993. 17. Sabatello E. F. Short-range changes in fertility and abortion patterns among female immigrants from the U.S,S.R. to Israel. Social Security (Bitachon Sotsiali) No 2, 1994 (in Hebrew). 18. Florsbeim Y. Soviet Jewish immigration to Israel in 1990---a demographic profile. Soviet Jewish Affairs 21, 1991. 19. Sabatello E. F. Estimates of illegal abortions in Israel, 1980-83. Isr. J, Med. Sci. 26, 204, 1990, 3, 1991. 20. Peritz E. and Baras M. (Eds) Studies of Fertility in Israel. The Institute of Contemporary Jewry, The Hebrew University of Jerusalem (Jewish Population Studies Ser.), 1992. 21. Salzberger L., Avgar A. et al. Patterns of contraceptive behavior among Jerusalem women seeking pregnancy counselling. P. Bauerwald School of Social Work, the Hebrew University of Jerusalem, 1991. 22. Amir D. and Navon D. Abortion policy in Israel. The P. Sapir Center for Development, Tel-Aviv University, Discussion paper Ser., 1989 (Hebrew). 23. Amir D. and Biniamin O. Abortion approval as a ritual of symbolic control. In Criminalizing Woman's Body (Edited by Fienewan C.), pp. 5-25. Haworth Press (U.S,A.) 1992.