‘We already learned this lesson’

A regional health minister in Russia is asking clinics to cancel their abortion licenses voluntarily. Here’s what local doctors have to say about it.

On November 20, Samara Regional Health Minister Mikhail Ratmanov announced that his agency had asked all private clinics in the region to refuse to provide abortions. Ratmanov said that out of the 31 clinics in his region that are licensed to perform abortions, 10 responded to his recommendation: By the time the health minister made his announcement, all ten had “voluntarily given up” their licenses. Beginning in 2020, private clinics in the Samara region will stop performing abortions entirely, according to Ratmanov. Regional officials have assured their constituents that state-owned medical facilities will continue to provide those services on the condition that staff at public facilities will try to persuade patients to continue their pregnancies. Anti-abortion protests, sometimes lasting several days, preceded the announcement both in the Samara region and elsewhere.

Health Ministry employees in the region said that the decision to change their abortion policies was driven by the argument that commercial interests push private clinics to offer abortions without having the means to conduct the procedure safely. An online petition has been initiated against the new recommendations, and the regional prosecutor’s office has already begun investigating whether the clinics’ refusal to provide abortions is legal. Alexey Yurtayev spoke with gynecologists and obstetricians from the Samara region’s private clinics to hear their opinions about the new recommendations.

Vladimir Durasov

OB-GYN, 31 years of service

I’m not an abortion specialist, though I led the gynecological division for 25 years and conducted operations every day. A doctor should provide help to women who are ill and give them life, but they must not take life away. According to my own moral code, I believe that doctors should not perform abortions. I could decline to be in that position because there were [other] doctors who conducted those operations, thank God.

I believe this [regional Health Ministry] recommendation is correct. Operations should not be conducted on every corner. Private clinics, as a rule, keep an incomplete record of abortions, and they may not comply with the period of “silence,” when women are given time to think about this serious decision and discuss it with a psychologist. I don’t think that all private clinics, especially small ones, have a psychologist on their staff who could conduct those conversations. In many cases, it’s a formality, and many women decide not to have abortions if a well-trained specialist talks to them about it.

All abortions have complications, and I have seen the formidable consequences myself. More than 30 years ago, when I was a student, I also observed a fatal outcome where an individual died following an abortion. Maybe that shocked me for the rest of my life. Terminated pregnancies mutilate the psyches of doctors and patients alike, so the fewer of them there are, the better.

There should be abortion clinics — three or so per city, not more. If there are doctors whose moral beliefs dictate that performing abortions is acceptable, then for God’s sake, let them do it, but that’s the only thing those doctors should work on. [Abortions] should be done in large health centers where it is possible to correct the complications that can come up in the process.

Women in our city haven’t been negatively affected [by the 10 clinics’ refusal to perform abortions] because nobody’s banning abortions in public medical facilities. They have the necessary infrastructure and conditions. Plus, in the past 10 years, the number of abortions in Samara has significantly decreased. As department chair, I’ve seen that happen because women have become better-informed when it comes to contraception.

I support the new health minister, who’s a trained surgeon. I don’t think this is a populist decision or an attempt to score points. It’s a stance that’s based on principle, and he’s bringing it one step further into life. Now, even in public clinics, they aren’t allowed to do abortions every day, only on certain days. There’s strict regulation for the performance of these procedures.

The recommendations given by the health ministry should be followed because nobody’s going to oppose them. Nobody’s going to want to fight them.

Anastasia Sinitsyna

Reproductive doctor at a private clinic, nine years of service

As a doctor and a woman, I’m against abortions. But they shouldn’t be banned. The entire world, us included, has been through that already. When terminations were banned in the [United] States and the Soviet Union, that had criminal consequences with a high fatality rate for women. Operations were done without anesthetics or painkillers in random apartments. The world has gotten past that stage. That’s not the path we should follow.

For me, the fight against abortions is about increasing sexual literacy in the population: It’s about working with teenagers and young adults to increase their education on contraception. Those tactics work, and that’s been proven in European countries. You can get results using sex education, but you need people to get away from making sex a taboo. I’m not sure that schools are prepared to do that. But for our children to have accessible information and not just watch porn, you have to have those conversations in families, too.

Some women see medical abortions as a pill against pregnancy. They don’t understand the harm, though if you have to choose between a typical surgical abortion and a medical one, the latter is better, of course — it has fewer side effects. But banning abortions is a bad way to fight them. It causes an increase in complications and criminal abortions. I specialize in tubal factor infertility. Abortion is one of the leading causes of that condition.

This will make life harder for women who decide to have abortions. Any good doctor, whether they’re in a public clinic or a private one, will talk to the patient and warn them about the risks, give them time to think. But the decision remains the woman’s, just like the place where she chooses to get help.

At first, [the government] introduced stricter rules for receiving licenses. On one hand, that’s safer for clients, but on the other, clinics are facing higher demands in terms of equipment. Nowadays, for the most part, termination is conducted through a pill. In most cases, you don’t need an operation room for that. For that reason, complicating the licensing process can decrease the number of clinics that can conduct more than medical terminations.

All of this is hidden behind a good cause, and it sounds good. But the health ministry’s actual position that private clinics don’t follow the law isn’t true, and it will decrease the quality of private medicine. If women start to go to hospitals [instead], the level of service will probably suffer.

If OB-GYNs say that abortion is evil and they won’t do it, then all the “good” doctors who are “right” will start doing operations underground. That’s unequivocally bad, but what you have to fight isn’t the number of abortions; you have to fight so that there won’t be unintended pregnancies.

Marat Tugushev

Gynecological surgeon, head doctor at a private clinic, 27 years of service

At first, we developed as clinic for reproductive medicine — that is, enabling the creation of new life. So conducting medical abortions would be unethical toward the women who come to us for a baby, for help. But we still need a license because the license is a general one, and we need it in case we have to terminate a pregnancy for medical reasons or because of developmental defects — for example, if the offspring has no head. Then, you have to evacuate the contents of the uterine cavity.

Legally, it’s impossible to just take away or ban a license. That’s why the minister is working to get clinics to do it voluntarily. We all understand perfectly that medical abortions have a massive number of complications that don’t appear immediately after the procedure. Gross interference into a woman’s body can cause infertility.

What should be the top priority isn’t banning abortions; it should be working with women who have decided to have abortions. That’s what’s in all our standards when you have to hold a pre-abortion consultation. During that consultation, the doctor must talk to the woman and speak to the negative consequences of abortions. That’s the right thing to do. And the minister has ideas about how to limit the time a woman takes to decide whether to have an abortion. When women have a “day of silence,” they can think through everything and reverse any hasty decisions to save their fetus.

Women’s rights aren’t being violated. After all, abortions aren’t being banned completely. Women still have the right to choose, and they can go to a public clinic that still conducts this procedure. In my view, it’s wrong to ban abortions. Otherwise, the pendulum will swing in the other direction, where criminal abortions start happening, and that’s much worse than conducting the procedure in standard medical conditions. We already learned that lesson in 1936 [when abortion was banned in the USSR]. Back then, criminal abortions done outside of medical institutions took off, and women’s death rates took off with them. It doesn’t matter who does it — a doctor, someone who’s not a doctor, or an obstetrician. If it’s not within the walls of a medical facility, it’s a criminal abortion. As a rule, those end in disaster.

Svetlana Beglova

OB-GYN in a private clinic and a public hospital, 24 years of service (name changed at source’s request)

We learned about this [the new recommendations against providing abortions] a long time ago, as soon as the new minister started. Letters with the Health Ministry’s recommendations were sent out as early as the summer of 2019. They suggested that public hospitals only conduct terminations on Tuesdays and Thursdays so that women getting abortions and women just going to the operating room wouldn’t intersect.

That’s typical in the United Arab Emirates or in other Oriental countries where abortions are prohibited. In Russia, you can’t do that because there’s nothing like it in civilized countries. People should make decisions themselves, and nobody should force them to do it.

A lot of clinics [in Samara] really have already decided to stop doing abortions. Maybe all of them will, but the thing is, that won’t decrease the number of abortions. If somebody has to have an abortion, then that person will do it anyway. There are a lot of regions around us — the Ulyanovsk region, the Saratov and Orenburg regions — where women can travel easily, and they can have an operation there.

If the government doesn’t want there to be abortions, you have to do something to make that happen. Not just calling for spirituality and increasing the number of psychologists employed here. You have to prevent unwanted pregnancies. You have to explain, beginning in school, what it all is and how it’s structured so that people understand at a young age what they might be walking into. The first priority should be sex education. We go from public hospitals to schools and lyceums and give lectures on morals and protection. In 2017, we went to a marriage registry office and told everybody who registered about safe sex and about how to avoid unwanted pregnancies, how to prepare for that.

In the late 1990s and the early 2000s, we were given free IUDs, contraception pills for women, and condoms for men. Because there’s a class of the population that just can’t buy an IUD even if it costs 1,000 rubles ($15.70). Back then, we would write in the patient’s card that they should be given condoms or pills. I had five women’s dormitories in my division, and I implanted IUDs for the girls. A lot of people were given the pill, and they would take it, bring in their empty packs, and take new ones. It worked. Now, none of that support exists anymore.

I understand that it [terminating a pregnancy] is bad, and I explain to every woman that, from a moral perspective, she’s committing murder. All the chit-chat about how fertilized eggs have no heart is just chit-chat. They’ve got everything — it’s just very small. But there are various situations that come up when I want to say, “No, you know what, better if you do it.” Because the destitute conditions in which some women live and where they would raise their child are awful. She would do better to kill the baby in utero than torture him for half his life. Nonetheless, you always have to talk about two people. So I explain to the men who come with the women to get an abortion that it’s their murder too. Don’t think that she’s killing the baby alone.

Only 30 or 40 percent of women regret what they’ve done. I think only people who have a low IQ don’t have regrets about it. But abortion is every woman’s personal decision because I’m not the one who would be raising the baby, and neither is the government or the psychologist or the church — it’s her. She has to be with the child her whole life.

I think not a single doctor believes 100 percent that abortions are bad. Unless, of course, they’re some kind of radical religious believer. We always talk about this with doctors a lot. In my circles, 80 percent of women gynecologists have had a pregnancy terminated. And guess what, we’re people just like you with families just like yours. For example, I have a girlfriend who’s a doctor and was always categorically against abortions, but when the question of whether to have a fourth, unwanted child came up, she did go that far.

Transcription by Alexey Yurtayev

With reporting from Daniil Brezhnev

Translation by Hilah Kohen