The article discusses results of an expert survey conducted in February-May 2021 in ten constituent entities of the Russian Federation in order to analyze trends in abortion-related behaviour of Russians, as well as to develop recommendations for a comprehensive special program to prevent and reduce abortion rates in the Russian Federation. The conducted expert interviews (n=15) with representatives of socially oriented non-profit organizations (SO NPO) and specialists of health care facilities (gynecologists, psychologists) made it possible to structure the areas of activity in the field of pre-abortion counseling in the constituent entities under study and identify effective institutional resources. The regions under study significantly differed in both socio-cultural characteristics and technologies for organizing pre-abortion counseling. The article doesn’t distinguish between the concepts of “pre-abortion” and “prior to abortion” counseling using them synonymously. The study showed that some experts (with a personal position that abortions are unacceptable without medical indications) are reluctant to use the concepts of “pre-abortion” and “prior to abortion” counseling and prefer to use the concept of “anti-abortion” counselling instead, which, according to hermeneutics, fills this concept with a different meaning, highlighting the purpose of the technologies used. The following problems have been identified: difficulties in collecting statistical data in private health care facilities, insufficient number of qualified specialists, and lack of a unified methodology for conducting pre-abortion counselling. According to the data obtained, the abortion-related behaviour of Russians is being transformed under the influence of new medical technologies. Measures of state support for families with children hardly change the abortion-related behaviour of Russians.

termination of pregnancy, woman, abortion, demographic policy, pre-abortion counseling, Russia

According to Decree of the President of the Russian Federation No. 400 dated July 2, 2021 “On National Security Strategy of the Russian Federation”, one of the key goals of the state policy in regard to preserving the Russian population is a steady natural growth and improved quality of life of the population (Decree of the President… 2021). Increased fertility is a key indicator of the National Project “Demography”. By 2030, Russia plans to increase the total fertility rate up to 1.7 and life expectancy - to 78 years (Natsional’nyi proekt... 2023). Discussions about conditions for increasing fertility are increasingly focusing on issues of reproductive choice and abortion-related behaviour. These are serious issues, as the right to abortion is defended by the World Health Organization (WHO) in the context of women’s reproductive health. Abortion-related behaviour is understood as procedures aimed at preventing unwanted birth. According to statistics, more than 20 million abortions in the world are unsafe, and almost 15% of pregnancy-related deaths are due to complications associated with unsafe abortion (WHO 2022).

Data on the prevalence of abortion-related behaviour are monitored by the World Health Organization (WHO), however, abortion statistics are not accurate in any country of the world, since spontaneous termination of pregnancy in the early stages is attributed to natural physiological processes, while the termination itself often occurs before pregnancy registration. In Russia, statistical data are accumulated by the Russian Federal State Statistics Service (Rosstat) (Demographic Yearbook... 2023; Healthcare in Russia 2023; Chislennost’ naseleniya... 2023; Chislennost’ postoyannogo... 2023) and Ministry of Health of the Russian Federation. To assess dynamics in abortions in Russia, the total number of abortions is recorded: both as requested by the woman, for medical or social reasons, and due to miscarriage when pregnancy could be wanted. Thereafter, it is necessary to distinguish between abortions that are requested by women and spontaneous abortions – miscarriages caused by inability to carry a fetus associated with biological termination of pregnancy.

Since 2007, the total number of registered abortions has decreased, and the number of births has exceeded the number of abortions. According to the Federal State Statistics Service, as well as Federal Research Institute for Health Organization and Informatics of the Ministry of Health of the Russian Federation since 2015 the absolute number of abortions has dropped below 1 million with the trend continued to date. That is, the total number of abortions has fallen three-fold in 15 years, or by 66%. The number of abortions per 1,000 women of childbearing age decreased 2.5 times – from 38.2 in 2005 to 15.1 in 2019. In 2019, there were 35.9 abortions per 100 births (live and stillbirths), which is almost three times lower than in 2005 (Rostovskaya et al. 2022). The assessment of abortion rates by 5-year age group, used by Rosstat in the period from 2008 to 2015 also suggests a faster decrease in the number of abortions among the youngest Russian women: 2.7 times in the group aged15-19 and 1.6 times in all age groups. Nevertheless, the problem remains relevant: Russia develops programs to work with women in the context of reproductive choice (Obuchenie ginekologov... 2023).

The state policy related to the implementation of the decrees of the President of Russia “On measures to implement demographic policy of the Russian Federation” (2012): “On national goals and strategic objectives of the development of the Russian Federation until 2024” (2018, National Project “Demography”), as well as executive orders of the Government of the Russian Federation “On approval of the Concept of state family policy in the Russian Federation until 2025” (2014), “On the basics of state youth policy of the Russian Federation until 2025” (2014), etc. has raised the profile of family, its higher prestige, and conditions for reproductive choice among both society and the state.

At all levels of political management, it is important to implement the objective of forming and further developing safe reproductive behaviour among the population based on the value of the first birth and subsequent children in a prosperous full family. At the same time, making managerial decisions in the area of abortion prevention is impossible without analyzing trends in abortion-related behaviour of Russians. Due to a high relevance and significance of the problem of abortion, a female social profile before pregnancy termination in the early stages of pregnancy is of scientific interest. The main purpose of the study is to analyze trends in female abortion-related behaviour, as well as to develop recommendations for a comprehensive special program to prevent and reduce the number of abortions in the Russian Federation.

Abortion, as an artificial termination of pregnancy, is practiced in many countries with some regulatory restrictions on gestational age and reasons for pregnancy termination, since the reproductive choice of a pregnant woman is associated with many medical, ethical, moral, religious, social, economic and legal aspects. In general, it is necessary to divide the concepts explaining abortion-related behaviour into the following two groups: the first group deals with the right of females to control their bodies; and the second group of concepts proves that the fetus (an unborn child) has the right to life from the moment of conception. Both theoretical postulates serve basis of different legal practices to allow and restrict the use of abortions for family planning (Plotnikova 2022).

The consolidation of women’s right to control their bodies is associated with the discussion on the scale and consequences of abortion at the institutional level, as well as the idea of overcoming social inequality, related to the availability or inaccessibility of abortions to women (Singh et al. 2014; Becker et al. 2011). The main declared goal is to ensure access to medical care, which meets restrictions due to women’s age, marital status, ethnicity, region of residence, lack of financial resources, etc. (Coast et al. 2018). The unavailability of abortions results in insecure medical procedure for pregnancy termination with a subsequent loss of reproductive health. The main reasons for the risk are delayed care seeking, unavailability of services in countries where abortion practices are stigmatized (Hanschmidt et al. 2016). These studies serve basis for stating WHO goals and objectives – to develop an effective policy to increase access to abortions as a method of safe pregnancy termination to minimize post-abortion complications to reduce mortality associated with abortion complications (WHO 2022; WHO 2023). This problem statement makes it possible to rationalize the expansion of the practice of artificial pregnancy termination to overcome stigma, ensure a freely construction of a woman’s trajectory of life, implement principles of self–preservation behaviour, etc.

The second theoretical direction is justification of the fetus’s right to life from the moment of conception. If we are to take the position that a person is formed from the moment of conception, then abortion is equated to murder, which means there must be a legal framework for protecting the fetus (Niţă & Ilie Goga 2020). From a religious point of view, abortion is unacceptable in all religions, and the least number of abortions are registered in deeply religious societies and families. Religion considers the beginning of human life from the moment of conception, and abortion is considered as a form of homicide (Cherry 2009).

Thus, from an ethical point of view, termination of pregnancy can be considered as a choice between the woman’s right to her own body and child’s (fetus) right to life. Depending on the values of the man and woman who have conceived a child, potential parents face or do not face an ethical choice regarding voluntary termination of pregnancy. Often, the decision to have a pregnancy terminated is made only by a woman if she has been abused or has not informed her partner about the pregnancy, or a woman’s decision to keep pregnancy is disputed by relatives who do not support the idea of having a child.

In Russian science, the discussion about pregnancy termination has developed according to a different scenario than in foreign countries (Petrov & Baikulova 2016), because the USSR was one of the first countries to officially allow abortions. Religious barriers to terminate a pregnancy have been hardly discussed in Russia for a long time, the problem began to take shape in the 1990s only, due to the gradual articulation of different points of view on the value of a woman’s or child’s life. It was also influenced by the fact that abortion has been legalized in our country since the 1920s, and the struggle against religious worldview made irrelevant arguments about the value of human life before birth, because they were associated with the idea of the soul existence. In 1936, the USSR banned abortions (except for medical reasons) resulting in the increased female mortality from complications associated with illegal procedures, therefore, in 1955 the ban on abortions was lifted (Shaderkina 2016). The institutionalization of abortion in Russia, which has a long history, has made Russia a long-time leader in the number of abortions per 1,000 women (Apolikhin et al. 2015; Vishnevsky et al. 2017). In comparison, as of early 2023, not all US states quieted down the discussion about legislation on voluntary abortion at the request of the woman, facilitating access to abortion (What the data says... 2023).

Abortion-related behaviour in Russia is not stigmatized; on the contrary, the practice of abortion is widespread (Denisov & Sakevich 2014; Sakevich & Denisov 2019), as evidenced by the analysis of Internet keyword queries “abortion” (Kalabikhina et al. 2020). As a result, in Russia there is no problem of inequality of access to medical services for pregnancy termination, such services are included in the compulsory health insurance policy. The problem is different: to identify whether the actors understand that abortion is a big responsibility for everyone involved in the decision–making? In this regard, a sociological survey conducted by O. N. Bezrukova and V.A. Samoilova is interesting. According to the survey results, the question “Which judgments about the rights of the father do you agree with and which do not?” with the judgment “A woman can have her pregnancy terminated only with the consent of the father of the child” was evaluated by the respondents as follows: “agree” - 63.5% of men and 36.6% of women; “disagree” – 29.5% of men and 55.4% of women; the rest of the respondents were hesitant to answer (Bezrukova & Samoilova 2023).

In addition to a wide pool of theoretical studies, there are well-known empirical studies aimed at identifying the reasons for terminating an unintended pregnancy. The main ones include socio-economic, medical, and psychological problems (Marinescu et al. 2014; Turner et al. 2018), which often lead to the decision to terminate a pregnancy, regardless of legal restrictions existing in some countries. As a result, the practice of illegal abortions is formed, resulting in the increased risk to the health and life of a woman, given that in most cases inappropriate methods are used, hygienic conditions are not met, and medical examination is not carried out. WHO claims that abortions performed in line with medical recommendations are associated with a very low risk of complications; at the same time, abortions make a significant contribution to maternal morbidity and mortality worldwide (Sedgh et al. 2012).

The factors affecting the decision to terminate a pregnancy can be divided into social (marital status, education level, income level, the fact of violence), psychological (presence or absence of support from parents and partners) (Gbagbo et al. 2015) and institutional ones, developing or complicating the conditions for implementing abortion-related behaviour. Institutional factors include religious taboo and related social stigmatization, as well as legal restrictions (Alhassan et al. 2016), infrastructural limitations, including availability of institutions providing abortion services (Frederico et al. 2018).

Religious taboo is not relevant to all regions of Russia, but it is important, for example, in the Chechen Republic, where the abortion rate is the lowest one (Ryazantsev et al. 2019). According to data of the All-Russia Public Opinion Center (VTSIOM), published on June 7, 2022, the share of Russians who consider abortions unacceptable under any circumstances has increased over 6 years. In 2016 this view was shared by 4%, while in 2022 - already by 13%. Health care workers are much more likely to talk about the need for state regulation of contraceptive methods that prevent abortions (53%), and about the responsibility of both partners for the decision to have a pregnancy terminated (85%). Interestingly, in the North Caucasus, 41% of the respondents support state measures to prevent abortion, while in the Northwestern district, on the contrary, 61% are against the state involvement in birth issues (VTSIOM 2022). In general, the analysis of abortion-related behaviour requires a study on all processes in aggregate, circumstances of pregnancy, that develop over several weeks and can be extremely unpredictable, as they are influenced by both physiological processes and psychological, socio-economic, etc. conditions of a woman’s life. Termination of pregnancy cannot be understood linearly; it is a process that is driven by changing personal circumstances and individual characteristics of the actor.

In the context of population decline in Russia, some institutional barriers are being introduced to prevent impulsive termination of pregnancy (impossibility to have an abortion on the day of care seeking, referral to pre-abortion counseling, etc.) (Obuchenie ginekologov... 2023). Taking into account the specifics of theoretical research on abortion in Russia and other countries, let’s try, based on expert assessments, to answer the following questions: what are the motives of abortion-related behaviour of women coming to pre-abortion counseling, and how do modern measures of the state demographic policy affect trends in abortion-related behaviour, do they contribute to keeping a pregnancy among women making a reproductive choice?

The conclusions are based on data refinement of the mass survey obtained as part of the first stage of the All–Russian monitoring “Demographic well-being of the population of the Russian regions” (late 2019 - early 2020), by the method of expert survey (February-May 2021) conducted as part of the second stage of the All-Russian monitoring. Both stages of the empirical data collection were carried out in 10 regions of Russia (Moscow and the Moscow Region, Republic of Bashkortostan, Republic of Tatarstan, Volgograd, Vologda, Ivanovo, Nizhny Novgorod, Sverdlovsk regions and Stavropol Territory. The regions were selected according to the following criteria: first, the regions of the European part of Russia included in the Central, Volga, Southern, North Caucasian, Northwestern and Ural Federal districts were selected. Second, rating of the region socio-economic situation according to the 2019 results was taken into account: Moscow (1st place), the Ivanovo region(61st place), Volgograd region (29th place), Vologda region (28th place), Moscow region (4th place), Nizhny Novgorod region (14th place), Sverdlovsk region (7th place), Republic of Bashkortostan (13th place), Republic of Tatarstan (5th place), Stavropol Territory (30th place), which made it possible to include in the sample regions with different levels of economic development. Third, the regions forming the ethnic and religious diversity of the European part of the Russian Federation were deliberately included in the sample. More information on the selection criteria justification of the mass survey see the work of T.K. Rostovskaya et al. (2021). Fourth, dynamics in the decrease in the number of abortions in a region was considered. There is a general decrease in the number of abortions, but the indicators significantly vary across regions (Table 1). The results of the author’s questionnaire survey conducted within the framework of the project “Demographic Well-being of Russia” in 2019-2020 in ten constituent entities of the Russian Federation with a sample of 5,616 people also indicate that abortion remains an important method of birth control (Rostovskaya et al. 2022).

The survey results show that, on average, 16% of women had an abortion before marriage (the question: “Have you had abortions before entering into your current marriage?” (Table 2). In the Ivanovo region, one third had an abortion before marriage registration, in the Volgograd region – 25%, in the Nizhny Novgorod region – 20%, in the Sverdlovsk region – 19%. 9% of women had an abortion before the birth of their first child (the question “Have you had abortions after entering into your current marriage before the birth of the first child in the current marriage?”), while 25% of women had an abortion between the birth of the first and second child and 27% of women - between the birth of the second and third (in the last two cases, it was not specified which marriage it was) (Rostovskaya et al. 2022).

Low public awareness of reproductive problems is typical of many Russians. For example, a study conducted in the city of Vologda shows that about 50% of people of reproductive age lack information about reproductive behaviour, 13% have sexual relations outside marriage, and 12% do not use any contraceptives. This situation increases the risk of unintended pregnancy and the risk of sexually transmitted diseases.

Official statistics of the Russian Federation estimate the use of female contraceptives, such as intrauterine devices (IUD) and hormonal contraceptives, as methods of pregnancy prevention. However, official statistics show that in Russia neither hormonal contraception, nor IUD became widespread (for the analysis of dynamics in statistical indicators, please, refer to (Rostovskaya et al., 2022)). On the other hand, hormonal contraception and IUD methods to prevent unintended pregnancies are often used in the Siberian, Ural, Far Eastern and Volga Federal Districts, and these districts are also characterized by a high rate of abortions. However, a high prevalence of contraceptive use by women in these federal districts fails to contribute to the decrease in the number of abortions. On the contrary, these federal districts are anti-leaders in the number of abortions in Russia (see Rostovskaya et al. 2022).

Higher rates may be associated with a low culture of contraception, insufficient awareness of family planning and the role of contraception in it, high cost of modern contraceptives, lack of confidence in contraceptives (due to insufficient knowledge how to use them and health effects), as well as husband reluctance to use contraceptives. The discussed results indicate that it is necessary to conduct a federal survey of the socio-economic status of the Russian families and effects of regional programs aimed at supporting the family, motherhood and childhood.

Thus, the data obtained show that termination of pregnancy has become a common practice among the Russian population. In the current situation, it is important to obtain as much data as possible on how to preserve women’s reproductive health and how specialized programs aimed at pre-abortion counseling operate. Let’s highlight technologies that are currently used in Russia.

To clarify data of the mass survey, an expert survey (n=15) of representatives of SO NPOs and specialists of health care facilities (gynecologists, psychologists) was conducted. The survey used a semi-formalized guide, which made it possible to process results of the expert assessments based on the “grounded theory” method.

The texts of the expert interview can help us to identify motives of female abortion-related behaviour, systematize data through describing socio-psychological profiles of women coming to pre-abortion counseling. First, it is important to determine age categories of the applicants. According to experts (the expert interview was conducted using sound recording equipment with a subsequent data transcription), women aged 24-40 decide to have an abortion most often, as a rule, there are married with at least one child (experts in pre-abortion counseling from the Republic of Bashkortostan, Volgograd and Yekaterinburg). In the Ivanovo region, experts noted a different age category – the average age varied from 32 to 40, also mainly married women. As a positive fact, the experts noted that in their practice of pre-abortion counseling, cases of working with minors are rare.

“It’s rare <...> minors have never been in this office. One client was 18 years old, the other one - 20 years old. One kept her pregnancy, the other did not” (expert in pre-abortion counseling, Yekaterinburg).

Second, experts-psychologists master competence to define the psychological profile of women who came to pre-abortion counseling:

“women who accept the possibility of having a child agree to pre-abortion counseling. Such women are in great need of psychological assistance, an outside point of view of the difficult life situation. I think we can say that such women expect to be dissuaded from having an abortion, and they could partially shift the responsibility for their decision to a specialist” (expert in pre-abortion counseling, the Moscow region).

This category of women is defined as “women who doubt the need to have an abortion and find themselves in conditions of reproductive choice”. In this case, more often a woman wants to continue her pregnancy, but finds herself under pressure from relatives who are against keeping a pregnancy, i.e. the main reason is disrupted family ties, emotional and psychological difficulties in family relations, lack of support from the immediate environment (a husband, parents), unwillingness of the partner to have a child, pressure from parents of both or one of the spouses.

Categories of women can be distinguished, taking into account the objective and subjective motives of abortion: medical indications; socio-economic and psychological reasons. Medical indications for pregnancy termination are stipulated by the Order of the Ministry of Health and Social Development of the Russian Federation dated 03.12.2007 No. 736 (edited on 27.12.2011) “On approval of the list of medical indications for artificial termination of pregnancy”, the indications include infectious diseases and cancer, systemic and mental disorders. In this context, cases of fetal malformation are not taken into account, we are talking about maternal medical indications. Fetal development is also an important factor in decision-making about terminating vs keeping a pregnancy. Experts note that there are cases when medical indications are unreasonably used by incompetent specialists:

“And in one health care facility there were 80% of abortions for medical reasons. What does this mean? This means that this is our abnormal mini-city, in which just all pregnant are ill. It’s absurd. The actual share of deformities in Russia is about 4-5%, while in one of our health care facilities this share skyrockets up to 80% ... It turned out that there are only two gynecologists in that women’s clinic and there are no narrow specialists. That is, when a woman has varicose veins or some minimal risks related to age or her health, gynecologists simply play safe and prescribe a medical termination of pregnancy not to take on risks” (expert, Nizhny Novgorod).

In the described case, “women who doubt the need to have an abortion and find themselves in conditions of reproductive choice”, women with a planned pregnancy can keep it, seek a second opinion in other health care facility. While women who did not plan a pregnancy, on the contrary, will undoubtedly terminate it, because the responsibility for this decision is on medical staff.

Increased anxiety of a woman who has got the experience of giving birth to an unhealthy child is a totally different situation.

“More recently, there have been a couple of women with children with pathologies... Let’s say, a woman was raising, a special child. There is a great fear of giving birth at all... And it is precisely those women whose children are differently abled who do not want to give birth. Because there is a great risk - she has two children, the second one with a pathology, she says: I don’t need the third, I need to raise these two somehow” (expert in pre-abortion counseling, Yekaterinburg).

The next type of women is “financially insecure women who find themselves in conditions of reproductive choice”. For this category of women, the main motive for terminating a pregnancy is their financial status. But this can be both a subjective perception of the situation as insecure, and objective circumstances – poverty and misery. Subjective perception and objective circumstances are determined by housing/substandard living conditions, lack of a permanent employment, lack of funds, etc. In this case, family support measures (within the framework of the state demographic policy or activities of SO NPOs specializing in family assistance) can contribute to keeping a pregnancy. But at the same time, there is a distrust in family support programs: “I tell them (my clients) that they can get support from the state, there is a maternity capital, and other programs for young families. They are still afraid that they will not be able to raise, afford education, and provide housing” (expert in pre-abortion counseling, the Republic of Bashkortostan). An expert from the Ivanovo region noted that keeping a pregnancy leads to a decreased financial well-being of families in the region. In order to keep incomes at the same level in case of a baby birth, “men are forced to go to other regions to earn money” (expert in pre-abortion counseling, Ivanovo). Thus, financial distress results in a significant transformation of the family, a possible rupture of family ties due to the relocation of the spouse, which may later lead to a divorce.

The next type of women is “women with marginal social status who find themselves in conditions of reproductive choice”. Marginal status (in this case, it is interpreted as indefinite) is always a difficult life situation: lack of citizenship (migrant women); pregnancy out of wedlock, including by a married man; low level of education of young women, etc. Often, such a situation is formed in the absence of a supportive social environment, violation of social ties. Experts, representatives of SO NPOs note that in such cases, the practice of follow-up and constant support for a woman is important –meeting at the maternity hospital after delivery, friendly participation, etc. With professional support, in the case of a decision to give birth, a woman forms new social ties, restores the value of her own personality.

We will separately distinguish a type of “successful career-minded women who find themselves in conditions of reproductive choice”; in this case, women do not want to change their established lifestyle, they are afraid of reducing their social status, and the choice is made in favor of a career or education.

“Successful women are reluctant to give birth to the third and fourth children in our region. And this is just one of the reasons of our high rates of abortion. That is, a woman who has given birth to two children or one says: “I need to work, develop further, I don’t need to give birth anymore”. This is the main share of women with whom we can do nothing, only psychological counseling” (expert in pre-abortion counseling, Nizhny Novgorod).

We should also distinguish a category of “sexually liberated women who find themselves in conditions of reproductive choice”; women from this category often change partners, do not plan either pregnancy, nor marriage in the near future, these are young women who come for an abortion in the early stages of pregnancy.

Another category is “women focused on self–preservation behaviour who find themselves in conditions of reproductive choice”. This category of women has got cognitive attitudes of an exculpatory nature: “I do not want to spoil my health and figure”.

For each category of women, pre-abortion counseling exerts develop their work plan with due regard to the identified motivations. Only experts with a long-term experience working with women in conditions of reproductive choice master technologies that allow them to influence a woman’s decision within a short period of time. However, there are few specialists working since 2015, when institutionalization of the pre-abortion counseling technologies was initiated, therefore regions have introduced a system of professional development. It was in 2015 when the Ministry of Health made a proposal to organize pre-abortion counseling, and the Russian movement “Save the Life” was established. During the development of the pre–abortion counseling technologies, referral of women considering to have an abortion to a psychologist was of a recommendatory nature, and women who decided to terminate a pregnancy did not trust psychologists: “... many women believed: well, if it is a recommendation, it means it is not necessary, that is, someone did come, while others did not even remember about it at all...” (expert in pre-abortion counseling, Yekaterinburg).

An expert from Nizhny Novgorod noted that a geneticist was in the team, his consultation was important if women who were worried about their health or the health of an unborn child showed up for a pre-abortion counseling. Experts working together with a geneticist note that some pregnancy screenings are inadequate: the probability of having an unhealthy child is lower than the screenings show, and screening results increase a woman’s anxiety many times. Thus, high anxiety among pregnant women has resulted in more abortions during the pandemic: “The pandemic - people were afraid to go on maternity leave. There are many cases when someone in the family was ill, someone was admitted to the hospital. Then there was such situation when they got vaccinated and suddenly found out that they were pregnant” (an expert from Yekaterinburg), i.e. the reasons for having an abortion included illness or pregnancy after vaccination against COVID-19. Actually, geneticists still lack accurate data on how coronavirus infection or vaccination against it would affect the health of an unborn child.

Consultations are both mandatory and recommendatory, since a woman has the right to choose whether to visit a psychologist or not; in this case, she writes a refusal from consultation.

“...we refer all, but a woman has the right to refuse an appointment with the psychologist. She simply writes an informed refusal to the doctor reading “I do not need to consult a psychologist”” (expert in pre-abortion counseling, the Republic of Tatarstan).

A different nature of the organization of counseling (mandatory or recommendatory) affects the share of refusals from pre-abortion counseling.

“For 8 years now, I have been conducting consultations in the women’s clinic and women know when they come for an abortion that they will have to undergo a pre-abortion counseling and meet with me and the senior midwife for a conversation” (expert in pre-abortion counseling, Ivanovo).

“Since 2016, one woman has refused pre-abortion counseling” (expert in pre-abortion counseling, Volgograd).

“Yes, there are refusals from pre-abortion counseling, of course. About less than half of the women who are thinking about having an abortion agree to pre-abortion counseling” (expert in pre-abortion counseling, the Moscow region).

The psychologist’s reputation is formed depending on his work experience, that can also affect refusals or consents of women if the consultations are of a recommendatory nature.

When working with women who find themselves in conditions of reproductive choice without social support, group consultations are effective, but individual consultations are more often conducted, since the type of consultation is much affected by both the needs of women, and institutional capacities and infrastructure (offices allocated to psychologists are not always equipped for group work).

“When there is a group, they look at each other and draw conclusions. Of course, it’s easier with a group. Group activity heals by itself” (expert in pre-abortion counseling, the Republic of Bashkortostan).

A specific type of group counseling can be a consultation of a woman and her partner (spouse): “Very rarely do women come to pre-abortion counseling with a partner. According to experts, 2-3% of women” (expert in pre-abortion counseling, Volgograd) or when “migrant families join the consultation if the woman does not speak Russian” (expert in pre-abortion counseling, Moscow).

Although women are aware that the consultation is conducted for both partners: “When they come to see a gynecologist, they got a referral to a psychologist, and it says that the consultation is for both partners. But the consultation is by agreement with the patient. A woman decides whether to come with the potential father of the child” (expert in pre-abortion counseling, the Republic of Bashkortostan).

Also, women come with partners in case of abortion for medical reasons, when a man provides support:

“A woman wanted to give birth, but for medical reasons she can’t...Such couple come. It is very heartening to see when a man supports a woman and does not leave her in such a situation” (expert in pre-abortion counseling, Yekaterinburg).

Experts believe that it is the partners who support the woman in the decision to have a pregnancy terminated (according to women, both those who come to the consultation and those who don’t), therefore it is necessary to develop separate measures aimed at working with the motivation of men towards abortion-related behaviour. Only “in 15-17% of cases, the partner is not aware of the pregnancy, the woman decides to terminate her pregnancy on her own” (expert in pre-abortion counseling, Volgograd).

If the decision on abortion is a joint family decision, then coming to pre-abortion counseling with a partner increases the chances of keeping a pregnancy:

“Look, if a partner came, 80% guarantee that she will keep the baby. As a rule, it’s faster to win over a man if they came to a joint consultation, the men are all sane, and they don’t really want to kill anyone. All consultations with a man present ended positively” (expert in pre-abortion counseling, Nizhny Novgorod).

“The man who came to the women’s clinic is already more loyal to keeping a pregnancy than the one who refused” to come (expert in pre-abortion counseling, the Moscow region).

For women who doubt their decision to terminate a pregnancy, but do not have social ties and are afraid that they will not cope with the birth of a child without support, it is important not only to consult a psychologist, but also receive social support. State support systems are less accessible than SO NPOs working with family and pregnant women in a crisis situation; it is most effective if the psychologist conducting a pre-abortion counseling is on staff at SO NPOs:

“... our specialists have corporate cellular phones, and are to answer calls until 8 pm. They give their business cards to the women they’ve counselled. Accordingly, any woman can contact them again. For example, she came home and her mother-in-law went hard on her, and she’s crying, she needs to talk. Plus, when our specialists work in different women’s clinics, a woman can come to the one most convenient for her” (expert in pre-abortion counseling, Nizhny Novgorod).

Experts, specialists of SO NPOs working with crisis pregnancies, compare the motivation and their availability and availability of psychologists working on a part-time basis in a health care facility:

“What is the difference between a psychologist at a women’s clinic and ours? A woman who goes for an abortion is an unmotivated client. And a psychologist of the women’s clinic, who receives a low wage, does not want to waste his or her time on this woman and even get some benefits for work. And only convinced people who are well-payed can calmly cope with this and perceive it as their job” (expert in pre-abortion counseling, Nizhny Novgorod).

The time spent on the consultation is an important factor in making a decision: an unmotivated client (women who have decided on abortion) comes to the consultation, and the specialist “needs to communicate with her for 30-40 minutes so that she at least started to doubt ...” (expert in pre-abortion counseling, Yekaterinburg). “Unfortunately, one-time pre-abortion counseling shows low effectiveness if it is not supported by actual assistance to a pregnant woman in crisis situation” (pre-abortion counseling expert, the Moscow region).

In general, specialists of SO NPOs who counsel by agreement with women’s clinics, have vast experience in counseling, and leave their contact details to women, effectively use the allotted time: “a psychologist from an NPO can receive clients in one facility twice a week and this is quite enough to talk to all women about this problem” (expert in pre-abortion counseling, Nizhny Novgorod).

Private health care facilities do not build a system of cooperation on pre-abortion counseling, which is confirmed by expert assessments received from both specialists of private health care facilities and NPOs:

“We have tried to work in private companies, but private companies do not refer woman to us. We had two private centers that seemed to agree to accommodate our specialists, but we served only two people there in six months. And for us, it is completely unprofitable” (expert in pre–abortion counseling, Nizhny Novgorod).

The position of doctors who believe that pre-abortion counseling puts pressure on a woman who has already made her reproductive choice complicates work with women: “hypothetically, there are five gynecologists in each women’s clinic, and now we have one ally, maximum two out of them. The rest of the doctors are either not interested in us, or they cannot calmly share their opinion. We teach doctors not to give their opinion regarding “to give birth or not”. And the doctor is often used to the phrase “well, why do you need this third one, why are you giving birth to it?”. And we are trying to convince doctors to be unbiased, not to express their personal opinion” (expert in pre-abortion counseling, Nizhny Novgorod).

In the Volgograd region, the effectiveness of pre-abortion counseling specialists is calculated as 30% of refusals to terminate a pregnancy out of 100% of those who applied. Perhaps the optimization of technologies to work jointly with gynecologists can increase the figure up to 50% in the Russian Federation.

At the same time, gynecologists in women’s clinics do not have time for a detailed conversation with women who have come for an abortion: “the doctor within 12 minutes allocated for the appointment with a client and sometimes less, collects all the paperwork from the women, does not tell the woman about all possible consequences of abortion. The doctor just gives the woman a piece of paper, reading that all consequences of abortion has been explained to the patient and the women simply signs this piece of paper, but in fact, the women has not been informed about possible infertility, cancer, and so on” (expert in pre-abortion counseling, Nizhny Novgorod).

Thus, demographic policy, focused on supporting pregnant women in difficult life situations, forms the standards of quality of the services. Taking into account a full range of motivation of both women and men, the following appropriate family support tools can be offered (Table 3).

The experts believe that in order to increase work effectiveness when talking with a woman, it is necessary to establish trust, find out reasons for the reproductive choice made and jointly try to find ways to solve the problem situation. In further work, the methods of art therapy (expert in pre-abortion counseling, the Republic of Bashkortostan), group psychological trainings for women and family counseling (expert in pre-abortion counseling, the Moscow region) proved useful. Psychologists influence the decision of women, demonstrating how a child looks at the moment, so that women do not perceive the conceived life as “something virtual”, as “kind of a cell”: “And many women do not comprehend that there is a baby inside. All our psychologists are equipped with different models, for example, babies (shows a small baby doll on the palm of her hand), this is 12 weeks. And they think that there is some kind of a cell, that there is like no child in there” (expert in pre-abortion counseling, Nizhny Novgorod).

In case of a difficult life situation, an analysis of all resources available to a woman can help her make a decision about keeping a pregnancy: “When a woman is in a crisis situation, she sees everything like in a tunnel, in a negative way, and you start to switch her a little bit, what if you think about how to keep a pregnancy. There are reserves anyway, the main thing is that she understands this, wanted to understand” (expert in pre-abortion counseling, Yekaterinburg).

In general, some experts note that there is a lack of consistency in the work of specialists in pre-abortion counseling: “In this regard, we would like to have common channels (both federal and regional ones) to consolidate efforts of specialists to contribute to keeping a crisis pregnancy and the birth of healthy children. Currently, a lot of things what we are implementing in this area are carried out based on personal professional relationships between management and specialists” (expert in pre-abortion counseling, the Moscow region).

In the Volgograd region, Nizhny Novgorod region, on the contrary, the system of work has been developed. The responsibility of specialists increases when a psychologist, after consultation, provides an opinion to a woman who has decided to have an abortion. But this is not a document regulated at the federal or regional level, it is a local internal report to track how the system works: “And sometimes we make reconciliations at the end of the year when we have official statistics. For example, we see that 300 abortions have been performed, and we have, for example, only 150. We see, yeah, 150 have gone somewhere. That is, those women were not referred to us. And when I ask the doctors where the other 150 are, no one can give me a clear answer” (expert in pre-abortion counseling, Nizhny Novgorod).

Such local documents can be useful if women who, after the counseling, did terminate their pregnancy, require a long-term assistance by a psychologist or a curator: “I always leave my contacts, phone number. If she has a need, she is welcome. If I see that she has a high level of anxiety, if it suddenly becomes obvious that there once was a traumatic experience of abortion and the woman suffers mental consequences – it is called post-abortion syndrome, you know, many such things emerge during a conversation, and she herself asks: can I come again? Of course, you are always welcome. I tell they can come again and again – we will talk if there are questions” (expert in pre-abortion counseling, Yekaterinburg).

We have systematized motives of women who are going to have an abortion (worries that a sick baby will be born, lack of support from loved ones, not ready to spoil the relations or afraid of health deterioration, getting out of share or losing good looks, not willing to interrupt career, worries about the family financial well-being, not ready to separate with the spouse when he is forced to look for a job in another region to maintain the regular income level in the family, fears that the spouse can cut loose from family if he is reluctant about the birth of another child, etc.), as well as provided information on the forms of pre-abortion counseling of women in different regions that have been developed within the framework of the demographic policy and civil initiatives, and suggested major directions for developing demographic policy in order to support women who find themselves in conditions of reproductive choice.

Women who are going to have an abortion can be divided into the following categories:

1. young girls in early fertility who have reached the age of “sexual debut” (15-16 years) and women before getting married aged 22-24;
2. young women aged 25-35, in middle fertility, who are not married;
3. women of reproductive age, married, with a child/children;
4. women in late (aged 36-42) and fading fertility (42-49 years) with adult children;
5. women of any age who have medical indications for abortion.

The main focus of work with different categories of women is the provision of targeted assistance to pregnant women in difficult life situations by socially-oriented nonprofit organizations such as the All-Russian Public Movement Autonomous Nonprofit Organization “For Life!”, charity program for crisis pregnant women “Save the Life”, Foundation for Family, Motherhood and Childhood “Women for Life”, Charitable Foundation “Family and Childhood”, etc., including provision of accommodation, clothing, household, food assistance, as well as career guidance and retraining of pregnant women. In private health care facilities, one-time individual consultations by a gynecologist are carried out, and women can retain services of a psychologist on a paid basis.

As part of pre-abortion counseling, regional and municipal institutions of health and social welfare (for example, the state institution of social services “Volgograd regional center for psychological and pedagogical assistance to the population”, the state institution Republican resource center “Family”, etc.), conduct individual and family consultations for a woman and her immediate environment, which can be both on an one-time and regular basis, depending on the needs and situation of the woman.

Over the past years, a system of pre-abortion counseling has been developed in state health care facilities and related family assistance centers. Pregnant women visit a gynecologist, undergo a fetal ultrasound, have their gestational age determined and the doctor gives an opinion on the possibility of an abortion. Then women get an appointment with the head of the women’s clinic or a senior nurse-midwife (for a conversation about possible health consequences of abortion), a psychologist (individual counseling) and a lawyer (to sign documents on abortion).

Cooperation between NPOs and specialists in pre-abortion counseling who themselves work in non-profit organizations, is better developed. This cooperation is realized in the following areas:

• development, publication and dissemination of information and educational materials,
• implementation of activities aimed at preventing termination of unintended pregnancy and promoting family values;
• information about assistance and support available at social service institutions,
• joint training of specialists working with women in difficult life situations (expert in pre-abortion counseling, Volgograd).

When a woman decides to keep pregnancy, work with her is continued until 30 weeks of gestation and, if necessary, after delivery. The follow-up duration is determined by a specialist-curator together with a woman, depending on her life situation, and can be extended if needed. The curator engages specialists necessary to solve different problems (a psychologist, legal adviser, etc., including specialists from other departments – health, education, etc.). In private health care facilities, a long-term follow-up is available on a paid basis only.

Different specialists are involved in pre-abortion counseling: gynecologists, senior nurse-midwives, medical psychologists, social psychologists, family work specialists, social work specialists. In women’s clinics, there are specially equipped medical and social care offices (expert in pre-abortion counseling, the Moscow region), which are a structural unit of the women’s clinic, and their activities are regulated by the Order No. 389 of the Ministry of Health and Social Development of the Russian Federation dated 01.06.2007 (Ministry of Health... 2007).

Most often, the pre-abortion counseling system includes women’s clinics and NPOs working in the field of family preservation. For example, in the Republic of Bashkortostan there is a network of resource centers “Family”, in which pregnant women in difficult life situations can stay from two months to two years. In the Ivanovo region, in such cases women are referred by a women’s clinic psychologist to the public organization for motherhood protection “Cradle”, where they receive support in the form of food packages and things for the baby.

In case of cooperation, employees of state health care facilities route pregnant women to receive targeted material and psychological assistance, temporary residence in a difficult life situation due to a crisis pregnancy.

Lack of an established system of cooperation remains the main problem, and cooperation is mostly implemented on a personal initiative of the interested actors. For example, an expert from Kazan noted that she knew about NPOs dealing with crisis pregnancy, but cooperation between state health care facilities and NPOs were yet to be established.

According to the Ministry of Health of the Russian Federation, in Russia only 20% of abortions are for medical reasons (Rostovskaya et al. 2022). In general, 6-7% of women in Russia agree to keep pregnant. In regional services, these figures vary; about 7% in the Republic of Bashkortostan, Ufa; 9% in Yekaterinburg; up to 30% in Volgograd. The experts themselves assess the performance effectiveness as insufficient, however, they emphasize that even 5% of the continued pregnancies is an important result.

A high effectiveness of pre-abortion counseling in some regions, for example in the Volgograd region, is due to the fact that the region has developed a methodology that includes the following three stages:

1. establishment of contact (it is necessary to take into account characteristics of a pregnant woman, her lifestyle and thoughts),
2. main conceptual stage (it is necessary to keep contact, encourage pregnancy keeping, and develop skills of an expecting mother),
3. completion stage (collecting “feedback”, discussing issues of further assistance, etc.) (expert in pre-abortion counseling, Volgograd).

During pre-abortion counseling, a woman cannot always determine the prime reason, the argument “in favour of” terminating a pregnancy, therefore it is necessary to assess her psychological status, presence or absence of medical indications, analyze living conditions, specifics of her life situation and family relations, determine prior reproductive experience, awareness and skills of successful problem solving. The experts agree that in order to improve effectiveness of pre-abortion counseling, it is necessary to identify the main reasons for an abortion. Thus, in Nizhny Novgorod, they have been identifying all needs of women within a year, since assistance in meeting these needs is a factor of keeping a pregnancy in conditions of reproductive choice. And then, to accommodate the identified needs, a special technology for meeting each need has been developed. “It turns out that we have classified our clients by need. And depending on the percentage ratio, we have worked out some actions that can be offered to these women so that they do not have an abortion” (expert in pre-abortion counseling, Nizhny Novgorod). The need assessment result is an individual follow-up plan.

Regarding the format, both offline and online consultations are effective (expert in pre-abortion counseling, the Moscow region). According to experts, to make pre-abortion counseling more effective, it is necessary to conduct an in-depth analysis of the reasons of women’s reproductive choice. Measures to improve effectiveness of pre-abortion counseling include a closer cooperation between psychologists and specialists of women’s clinics, working meetings, informal communication and joint preventive activities, involvement of partners in pre-abortion counseling, involvement of representatives of the clergy (if desired by a woman). A specialist from a private clinic noted the need for tougher control over the enforcement of prohibition on having an abortion on the day of care seeking (especially in private clinics), since any abortion should be preceded by a pre-abortion counseling, including with the participation of a qualified psychologist.

To date, the practice of receiving an abortion on the day of care seeking in private medical clinics is rare, yet does happen, although it is not reflected in the facility reporting forms. Therefore, a comprehensive state program for pre-abortion counseling is needed, with the participation of all health care facilities regardless of the forms and types of ownership.

A number of measures will contribute to reducing the number of abortions:

1. state and regional programs and projects to prevent abortions, providing for a set of mechanisms such as raising awareness about contraception, harmful consequences of abortion, widespread of medical, social and psychological assistance points in women’s clinics, as well as private medical clinics, education of population (social advertising, lectures), availability of psychological assistance to the population, including online and by telephone hotline. Development of a negative image of having an unintended pregnancy terminated in society through dissemination of information materials (in public places –transport, shops, etc.), preventive measures aimed at preserving the lives of children, as well as measures to form a responsible attitude towards family, children, and family values. More family-oriented commercials, advertisements, etc. in all media.
2. measures of state support for families with new addition:

• provision of social housing for up to 5 years (from the moment a woman is registered for prenatal care; and if necessary, no matter whether the young parents possess own property or not): family-type dormitories; apartment-type family dormitories, small apartments;
• performance of infant-feeding centers, free public transport for all schoolchildren students, higher number of free hobby groups at all state educational institutions (kindergartens and schools).
• introduction of a flexible system of academic leave for student parents with a possibility to continue studies in a distance format according to an individual learning trajectory.
• development of charitable shelters for women exposed to violence, including forced abortion, including at large medical centers.
• introduction of a shortened working day (up to six hours instead of eight) for one of the parents raising children under the age of 10 to engage in family parenting and ensure safety of children outside of school hours.
• higher number of vouchers for summer holidays and recreation for children (partial payment) and expansion of categories entitled to subsidized vouchers.

Thus, the experts in pre-abortion counseling have identified the following reasons for having a pregnancy terminated: termination for medical reasons; socio-economic reasons; psychological reasons; low literacy in contraception among both of men and women. A correct identification of the reason for decision to have a pregnancy discontinued helps to develop a follow-up program until birth and beyond. However, this requires effort coordination of specialists in various fields, cooperation between state or private health care facilities with NPOs. Yet, such cooperation is currently implemented through personal contacts.

To reduce the number of abortions, it is necessary to develop state and regional programs, projects on abortion prevention and further develop measures of state support for families. The genesis of state approaches in Russia is the development of institutional capacities that will facilitate informed decision–making on pregnancy termination. The decisions taken are reflected in Rosstat Order No. 76 dated 22.02.2023 “On approval of the federal statistical observation form with instructions on filling out to organize federal statistical observation in health”, which has introduced a new statistical form “Results of pre-abortion counseling, human”; this form makes it possible to monitor effectiveness of counseling pregnant women in conditions of reproductive choice in modern Russia. It should be noted that women in Russia are free to make reproductive decisions.

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Rostovskaya Tamara K. – Doctor of Sciences (Sociology), Professor, Deputy Director for Research of Institute for Demographic Research of the Federal Center of Theoretical and Applied Sociology of the Russian Academy of Sciences, Moscow, 117218, Russia; Director, Institute of Modern Languages, Intercultural Communication and Migration, RUDN University, Moscow, 117198, Russia. Email: rostovskaya.tamara@mail.ru

Vasilieva Ekaterina N. – Doctor of Sciences (Sociology), Associate Professor, Chief Scientific Officer of Institute for Demographic Research of the Federal Center of Theoretical and Applied Sociology of the Russian Academy of Sciences, Moscow, 117218, Russia. Email: vasilevaen@yandex.ru

Knyazkova Ekaterina A. – candidate of Political Sciences, Leading Researcher of Institute for Demographic Research of the Federal Center of Theoretical and Applied Sociology of the Russian Academy of Sciences, Moscow, 117218, Russia. Email: eapavlova@bk.ru