PART 1

CHAPTER VII

FAMILY PLANNING AND ABORTION PRACTICE 

1.6.1. Main Sources of Information

In general, people in Armenia have the right to decide freely and responsibly the number and spacing of their children. The Government officially has recognized these Reproductive Rights in 1996 in its law on Medical Service and Care. The concept of pregnancy prevention is based on the rights of both partners to regulate their fertility. However, in spite of the increasing use of modern methods of contraception, thousands of women face unwanted pregnancies each year as a result of failure to use family planning methods. In this chapter we focus on the male involvement in family planning and abortion practice to find out background factors to the high abortion rates.

This survey shows that among the sample of 1400 men of reproductive age, the majority (79%) have ever used at least one method of contraception. At the time of survey-interview 68% of men were currently using family planning methods, but 11% stopped, and 21% never used contraception (Figure 1.7.1).

Table 1.7.1 describes the reasons for never using contraception, explained by 288 respondents. The most important reason was desired or current pregnancy, or postpartum. About 6% of men never used contraception supposing that it might decrease sexual pleasure. For 4.5 % of men the contraceptives either were unknown, unavailable, inaccessible, or were expensive.

The most frequently mentioned reasons for stopping contraception were either desired or current pregnancy, or postpartum period of the spouses  (75%). However, a significant proportion of couples stopped contraception use because of subsequent sub-fertility (19%). 

1.7.2. The Most Popular Methods Ever Used

In Tables 1.7.2 and 1.7.3 specific methods of contraception that were ever or currently used either by men or any of their sexual partners are given. The most popular methods were withdrawal, IUDs and condoms.

The coitus interrupts or the withdrawal method was the most popular method ever (61%) and currently (51%) used. The second most popular method was the condom, which had been ever used by about 52% of respondents and currently by 40%. The IUD was the third most popular method ever used by more than 25% and currently by 23% of the sexual partners of the survey respondents. The use of pills has been reported only by 1% of respondents, sterilization and other modern methods were also occasionally used. In comparison with data from the previous nation-wide Reproductive Health survey among married women of reproductive age, which was carried out in 1997 by the Armenian Research Center on Maternal and Child Health Protection and National Health Information and Analytic Center of the Ministry of Health of Armenia with support of the WHO/UNFPA/UNICEF, women reported 53% of the current use of withdrawal method, 17% of condom, 17% of the IUDs, and 1% of pills.

1.7.3. Unwanted Pregnancy and Frequency of Abortion Use

In Armenia, abortion laws and policies are not restrictive: through 12 weeks of gestation it is legally permitted and widely available on request of women in maternity or hospital-based gynecological departments and in specialized health centers. The assessment of RH indicators in two randomly selected regions of Armenia carried out by the Armenian Family Health Association showed that the vast majority of induced abortions were never reported and official data on abortion rates are grossly underestimated.                              

Results of this first countrywide survey on reproductive health of Armenian men in support to the previous nation-wide Reproductive Health survey among married women of reproductive age, indicate that induced abortion is widely used all over the country as a method of birth control. According to the obtained information, 731 out of 1400 respondents of this survey (52%) reported that their sexual partners had at least one induced abortion during their lifetime. The partners of about 47% of respondents never had an abortion. There were 15 men (1%), who did not remember the exact number of abortions or did not want to reply to the question.  

The number of reported abortions varied widely from 1 up to 42 abortions during the life span.  An average number of abortions for total survey sample was 2.1 (SD=4.06), and for the sample of 731 men whose partners had an abortion, was 4.0 (SD=4.86). The percentage distribution of men according to the total number of abortions of their sexual partners is given in Table 1.7.4. 

The calculated total number of conceptions was 6309, and most of them (46.5%) had an outcome of induced abortion. Below is a summary of the main statistics surrounding abortion use:

1.7.4. Background Factors and Common Reasons

In total, 225 men (about 31%) did not want to reply or did not remember how old they were when their sexual partner had their first abortion. The age of the remaining men varied from 17 up to 47, with an average 28.9 years (SD=6.26). The great majority of all men (82%) already had at least one child before their partners had their first abortion (Mean±SD=1.9±0.75). However more than 15% did not have children at that time and 2% did not want to reply. At the time of the last abortion the majority of men had at least 2 children (Mean±SD=2.3±0.88).

Results of this survey show that the lack of Family Planning in Armenia is one of the most important background factors of the abortion use. Before the first abortion, more than 49% of couples did not use any methods of contraception, however 47% tried to prevent unwanted pregnancy, but it failed. Before the last unwanted pregnancy and abortion, the number of non-contraceptive users decreased to 40% and the majority (56%) used some method of birth control (Figure 1.7.2).

Failure of the contraceptive method of choice, as well as incorrect use of the method are the main background factors of unwanted pregnancy and induced abortion in Armenia. Figure 1.7.3 demonstrates contraceptive methods that failed prior to the first and the last abortions. In most of the cases, the unreliable withdrawal method was used prior to the first (68%) and the last (73%) abortion. However, there were also cases of unwanted pregnancy and induced abortion among the condom, pills and IUD users, which suggests that these methods may not have been properly used.

According to the obtained information, the most common reason for the first abortion was a willingness to postpone the birth of the next child (37%), while the most common reason for the last abortion was completed family formation (41%). The lack of income and inappropriate housing were also stated to be important reasons for abortion. The partners of about 13% of respondents performed their first abortion because the pregnancy was outside the marriage (Table 1.7.5).

1.7.5. Safety, Complications and Consequences

In Armenia, according to governmental regulations, abortion should be performed by a licensed obstetrician-gynecologist and only in hospital conditions (maternity/hospital, specialized center). According to the best knowledge of survey respondents, in most of the cases both the first and the last abortions were performed in the maternity/hospitals/specialized health centers (Table 1.7.6). However, in about 13% of cases of the first abortion and 11% of the last one, it was performed out of the hospital, in a facility where the abortion procedure is not permitted.

In most of the cases a obstetrician-gynecologist performed the abortion procedure (93% of the first abortion and 95% of the last one). About 6% of men, however, did not know who performed the first abortion and 3.5% had no idea who performed the last one.

The majority of men (about 70%) did remember the gestational age of the first and the last terminated pregnancy of their partner. For both first and last abortion it varied from 5 up to 20 weeks of gestation, with an average of 7 weeks (Mean±SD=7.2±2.3).  However, in about 8% of cases of the first abortion and 7% of the last one, the procedures were performed at 12 or more weeks of gestation, which increases the health-related risk of the procedure. Subsequently, the frequency of immediate post-abortion complications and late consequences, as reported by the survey respondents, were quite high (Table 1.7.7).

1.7.6.  Self-induced Abortion

To overcome financial difficulties and because of the fear of abortion, many women in Armenia try to induce spontaneous abortion themselves through unsafe, unhygienic, and often-dangerous interventions, facing the high risk of complications and even death. Most women, who have experienced self-induced abortion are never referred to a health facility for medical care, therefore these kinds of unsafe abortions are not officially registered.

To find out background factors of self-induced abortions we investigated the history of attempts to induce miscarriage by sexual partners of the survey respondents (Table 1.7.8). Almost 4% of men were aware that their wives/partners did try to interrupt unwanted pregnancy by mean of self-induction of the miscarriage.

The outcomes of self-induced abortions are demonstrated in Table 1.7.9. About 41% out of 53 of these attempts were successful without medical intervention.

Those women who had “successful” self-induced abortion never applied to the health facility for medical care; therefore these kinds of abortions most probably are not officially registered. Respondents of this survey reported successful self-induced abortion as a spontaneous abortion. The frequency of spontaneous abortion was quite high (Table 1.7.10.). More than 19% of men mentioned the history of at least one spontaneous abortion that their partners had.

More than 11% of women among those who tried to induce miscarriage, had heavy vaginal bleeding due to incomplete abortion and were hospitalized for medical curettage and further health care. The rates of the immediate complications and the late consequences were quite high (Table 1.7.11).

The high number of couples who resort to unsafe abortion is a powerful reminder about unmet family planning needs.

1.7.7. Post-abortion Family Planning Services

Women who have undergone abortion are at risk of another unwanted pregnancy and unsafe abortion. However, a significant number of couples did not receive adequate post-abortion family planning counseling or care (Table 1.7.12).