• This report also in Romanian and Russian.

(September 2003) In the past decade, countries in Eastern Europe and Eurasia have undergone economic and social transformations that have affected virtually every aspect of life, including health. By some measures, women’s reproductive health has improved, as women in the region today are more likely to use modern contraception and less likely to have an abortion to prevent an unplanned birth. But rates of maternal and infant death are still unacceptably high, the use of preventive health services is low, and there is little awareness about other issues, such as how to prevent HIV/AIDS.

This brief provides highlights of surveys taken in 11 countries since 1996, covering a wide range of women’s health topics and providing in-depth information on attitudes and behaviors related to reproductive health. The brief is based on a longer report that analyzes and compares survey results across countries (see For More Information below). The survey results give program officials, researchers, and policymakers an opportunity to learn about the characteristics of women who have the greatest health needs and the factors that lead to increased contraceptive use, reduced reliance on abortion, and other changes in women’s reproductive health behavior.

Purpose of the Surveys

Two U.S.-based agencies, the Centers for Disease Control and Prevention (CDC) and ORC Macro, helped national institutions conduct surveys in Eastern Europe and Eurasia from 1993 to 2001. The two types of surveys, Reproductive Health Surveys (RHS) and Demographic and Health Surveys (DHS), interviewed women from a representative sample of households in each country to gather extensive information on fertility, family planning, maternal and infant health, and other reproductive health topics. Major support came from the U.S. Agency for International Development, with funding in some countries from the United Nations Population Fund and UNICEF.

This brief highlights survey results in 11 countries: four in Eastern Europe (Moldova, Romania, Russia, and Ukraine), three in the Caucasus (Armenia, Azerbaijan, and Georgia), and four in Central Asia (Kazakhstan, the Kyrgyz Republic, Turkmenistan, and Uzbekistan).1 In Russia, the surveys were conducted in three urban areas only and do not reflect trends in the entire country.

These data provide a first look at women’s reproductive health knowledge, attitudes, and behaviors in the wake of the dramatic changes that took place in the region in the early 1990s. Recent family planning programs in the region have tried to increase the availability and use of modern contraceptives and reduce women’s reliance on abortion as a means of preventing unintended births. The RHS and DHS therefore looked at levels and trends in contraceptive use, how effectively contraception is being used, and women’s knowledge and attitudes about contraception and abortion. The surveys also provide up-to-date, nationally representative information on a range of reproductive and child health issues that can be addressed through new or improved programs.

The Context for Reproductive Health

The countries profiled here share a common history, having either been part of the former Soviet Union or within its sphere of influence. These countries had modeled their health care after Russia’s centralized, government-supported system, which provided universal health care to all citizens. The system promoted hospital-based care, creating a surplus of hospitals and specialists and a shortage of primary health care services.

Prior to and during the transition from centrally controlled to market-based economies, the hospital-based system became too costly for governments to maintain; consequently, most hospitals lack modern equipment, drugs, and supplies. Health care systems deteriorated rapidly in the 1990s, contributing to lower use of preventive health services, including reproductive health care. A combination of unhealthy behaviors (poor diets, smoking, and alcoholism) and low per capita spending on health contributes to the considerably lower life expectancy in the region compared with that of Western Europe.

Governments in all 11 countries are struggling with limited resources and emerging health problems. All of the governments continue to support health care, but many are turning parts of the system over to national insurance agencies or the private sector and may be leaving some population subgroups either uninsured or with minimum benefits.

Childbearing Trends

During the 1990s, countries in the region experienced dramatic declines in fertility — the average number of births per woman (see Figure 1). By 2000, fertility rates in most countries were below replacement level, or 2.1 children per woman on average, the number needed to replace parents. If fertility remains below this level, a country’s population will eventually decline (assuming there is no offsetting immigration).


Figure 1
Fertility Decline in Selected Countries of the Former Soviet Union

Note: The total fertility rate is the average number of children a woman would have in her lifetime given prevailing age-specific birth rates.
Source: C. Haub and D. Cornelius, World Population Data Sheet (1992 and 2001).


The surveys confirmed that fertility was at or below replacement level in all but three countries in the region: the Kyrgyz Republic, Turkmenistan, and Uzbekistan (see Table 1). Fertility has continued to decline in nearly all countries surveyed. Recent government estimates show fertility ranging from 1.2 children per woman in Ukraine to 2.9 births per woman in Turkmenistan.


Table 1
Selected Demographic and Social Indicators

  Population Mid–2002 (millions) Rate of Natural Increasea (%) Projected Pop. Change 2002–2050b (%) Total Fertility Ratec 1998–99
Eastern Europe
Moldova
4.3
-0.1
0
1.4
Romania
22.4
-0.2
-24
1.3
Russia
143.5
-0.7
-29
1.3
Ukraine
48.2
-0.8
-20
1.2
Caucasus
Armenia
3.8
0.2
-17
1.7
Azerbaijan
8.2
0.8
59
2
Georgia
4.4
0
-44
1.7
Central Asian Republics
Kazakhstan
14.8
0.5
-5
1.8
Kyrgyz Republic
5
1.3
51
2.7
Turkmenistan
5.6
1.3
42
2.9
Uzbekistan
25.4
1.7
52
2.8
Western Europe
Austria
8.1
0
1
1.3
France
59.5
0.4
9
1.9
  Life Expectancy in Years Per Capita Income (GNI PPP)d 2000 Health Expenditures per Capitae 1990-98 Percent of Women Enrolled in Secondary Schoolf 1993/97
Male Female
Eastern Europe
Moldova
64
71
$2,230
$30
82
Romania
67
74
6,360
65
78
Russia
59
72
8,010
130
91
Ukraine
62
74
3,700
54
94
Caucasus
Armenia
70
74
2,580
27
79
Azerbaijan
69
75
2,740
36
81
Georgia
69
77
2,680
46
76
Central Asian Republics
Kazakhstan
60
71
5,490
68
91
Kyrgyz Republic
65
72
2,540
11
83
Turkmenistan
63
70
3,800
Uzbekistan
68
73
2,360
88
Western Europe
Austria
75
81
24,600
2,108
102
France
76
83
23,020
2,287
111

a Rate of natural increase is the birth rate minus the death rate, implying the annual rate of population growth without regard to migration.
b Projected population growth (or decline) is based on current assumptions about the likely path of fertility.
c The average number of children that a woman would have during her reproductive lifetime, given present age-specific fertility rates. Fertility rates reflect the governments’ estimates for 1998-99, with the exception of Armenia and Georgia. These have been revised upward based on DHS and RHS survey findings, respectively.
d GNI PPP refers to gross national income converted to “international dollars” using a conversion factor for purchasing power parity. International dollars indicate the amount of goods and services one could buy in the United States with a given amount of money.
e The sum of public and private expenditures on health divided by the country’s population. Expressed in US dollars.
f The ratio of the number of students enrolled in secondary school to the population in the applicable age group. It can exceed 100 when the number of students exceeds the population of that age group.
Sources: C. Haub, 2002 World Population Data Sheet; World Bank, World Development Indicators 2000; and official government estimates for fertility.


Women throughout the region usually marry and begin having children earlier than women in Western Europe; childbearing peaks between ages 20 and 24 and drops off sharply after that. Little childbearing occurs after age 30 in these countries; women typically spend the rest of their reproductive years trying to avoid pregnancies.

Mainly because of low fertility, population growth rates in the region are around zero or even negative, except in the Central Asian countries (see Table 1). This situation has become a major social and economic concern in the region. With population size stalled or shrinking, some policymakers consider family planning programs unnecessary and counterproductive and instead advocate for measures to encourage women to have more children.

Contraception and Abortion: Trends and Relationships

For several decades, the reliance on abortion as a means of preventing births has been a prominent aspect of reproductive health in the former Soviet bloc. Modern contraceptives are often difficult to obtain, of poor quality, and not promoted by policymakers or the medical community. In contrast, abortion is generally legal, relatively unrestricted, and available at little or no cost. Governments, donor agencies, and nongovernmental organizations have helped increase the use of modern contraceptives, contributing to declines in abortion rates, but abortion still plays an important role in limiting the size of families in the region.

Abortion Rates and Trends

The average number of abortions that women have over their lifetimes (also known as the total abortion rate) ranges from 0.6 per woman in Uzbekistan to 3.7 per woman in Georgia (see Table 2) — some of the highest rates in the world. In most countries, the rates derived from the survey data were higher than the governments’ reported rates, reflecting some underreporting in the governments’ statistics.

In most countries, abortions are most common among women ages 20 to 34. Most women who reported having an abortion said that they did not want and could not afford another child. The vast majority of abortions follow unintended pregnancies, which mainly occur among women who do not use contraception or who use traditional methods that have relatively high failure rates. Between 71 percent and 90 percent of unintended pregnancies end in abortion, indicating that women are strongly motivated to avoid an unplanned birth.

In seven of 11 countries surveyed (Armenia, Georgia, Kazakhstan, Moldova, Romania, Russia, and Uzbekistan), abortion levels declined during the 1990s. The surveys asked women for a full pregnancy history, including their experiences with abortion. Trends in abortion were measured by looking at the abortion rate 6 to 8 years and 0 to 2 years before the survey. Abortion rates fell between 15 percent and 38 percent — a marked change in a relatively short period (see Figure 2). Most of the decline occurred among women under age 30 and was associated with increased use of modern contraceptives.


Figure 2
Trends in Abortion Rates in Selected Countries

Note: The total abortion rate is the number of abortions a woman would have in her lifetime if she experienced current age-specific abortion rates.


Still, most women continue to view abortion as an acceptable means of birth control, which may put their health at risk: Although abortion is legal, some abortions take place outside of medical facilities, leading to complications and even deaths. Vital statistics in Eastern Europe and Central Asia indicate that between 15 percent and 50 percent of maternal deaths are related to abortion.2 Moreover, women’s responses to survey questions about postabortion medical problems revealed more complications than had been reported elsewhere, suggesting that the quality of service is a problem.

Contraceptive Use

Married women’s use of contraception, whether modern or traditional methods, ranges from a low of 41 percent in Georgia to 74 percent in Moldova, with the highest rates found in Eastern European countries (see Table 2). Couples continue to rely heavily on traditional methods of birth control, particularly withdrawal and periodic abstinence. In several countries, such as Romania and the Caucasus countries, traditional methods account for more than half of all contraceptive use. Because these methods are less effective than modern methods, rates of failure and discontinuation are high, leading to large numbers of unintended pregnancies.


Table 2
Reproductive Health Indicators From the DHS and RHS

  Survey and Year Married Women Ages 15-44 Using Contraception (%) Most-Used Contra- ceptive Method Un- intended Pregnan- ciesb (%)
Anya Mod. Trad.
Eastern Europe
Moldova
RHS 1997
74
50
24
IUD
42
Romania
RHS 1999
64
30
34
Withdrawal
55
Russia
RHS 1999
73
53
20
IUD
66
Ukraine
RHS 1999
68
38
30
IUD
54
Caucasus
Armenia
DHS 2000
61
22
39
Withdrawal
62
Azerbaijan
RHS 2001
55
12
44
Withdrawal
57
Georgia
RHS 1999
41
20
21
Withdrawal
59
Central Asian Republics
Kazakhstan
DHS 1999
62
55
8
IUD
Kyrgyz Republic
DHS 1997
60
50
9
IUD
34
Turkmenistan
DHS 2000
55
47
8
IUD
Uzbekistan
DHS 1996
57
53
4
IUD
16
Western Europe
Austria
68
65
3
Pill
France
80
74
6
Pill
  Unmet Need for Contra- ceptionc (%) Women Ages 15-24 Reporting Premarital Sex (%) Lifetime Number of Abortions per Woman Mothers Receiving Prenatal Care, Begining in 1st Trimester (%) Births Outside Medical Facilities (%) Infant Deaths per 1,000 Live Births
Eastern Europe
Moldova
6
26
1.3
73
0.9
Romania
6
41
2.2
60
2
32
Russia
12
71
2.3
83
1.8
Ukraine
18
51
1.6
66
0.9
Caucasus