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The Gynaecologist’s Gaze: The Inconsistent Medicalisation of Contraception in Contemporary Russia

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This essay discusses the medicalisation of contraception by gynaecologists in present-day Russia. I explore the disciplining discourse and tactics of gynaecologists as experts who aim to orient women towards properly planned and prepared pregnancy. Gynaecologists are important agents of reproductive control because they instruct women in detail about reproductive health and contraception. However, these disciplining medical discourses and professional practices are characterised by inconsistency. In accordance with the demographic priorities of the state, doctors are more oriented towards pregnancy treatment than consultation on contraception, and they are inconsistent in their regulation of contraceptive use. This biopolitical regime reflects the demographic priorities of the Russian state—to increase the population of Russia—and the role of women as the primary objects of this policy.
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Europe-Asia Studies
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The Gynaecologist’s Gaze: The Inconsistent
Medicalisation of Contraception in Contemporary
Russia
Anna Temkina
To cite this article: Anna Temkina (2015) The Gynaecologist’s Gaze: The Inconsistent
Medicalisation of Contraception in Contemporary Russia, Europe-Asia Studies, 67:10,
1527-1546
To link to this article: http://dx.doi.org/10.1080/09668136.2015.1100371
Published online: 22 Dec 2015.
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EUROPE-ASIA STUDIES
Vo l . 67, No. 10, December 2015, 1527–1546
The Gynaecologist’s Gaze: The Inconsistent
Medicalisation of Contraception in
Contemporary Russia
ANNA TEMKINA
Abstract
This essay discusses the medicalisation of contraception by gynaecologists in present-day Russia.
I explore the disciplining discourse and tactics of gynaecologists as experts who aim to orient women
towards properly planned and prepared pregnancy. Gynaecologists are important agents of reproductive
control because they instruct women in detail about reproductive health and contraception. However,
these disciplining medical discourses and professional practices are characterised by inconsistency.
In accordance with the demographic priorities of the state, doctors are more oriented towards
pregnancy treatment than consultation on contraception, and they are inconsistent in their regulation of
contraceptive use. This biopolitical regime reflects the demographic priorities of the Russian state—
to increase the population of Russia—and the role of women as the primary objects of this policy.
IN HER NOVEL AKUSHER-KHA! (OBSTETRICIAN-HA!) THE popular author and former
obstetrician- gynaecologist Tatyana Solomatina writes:
So, you’ve found out that you’re pregnant. And now you have one way forward—go to a women’s
clinic [Zhenskaya Konsul'tatsiya].1 As soon as possible. If you want an abortion, you should go there.
If you want to give birth, you should go there. If you haven’t yet decided what to do, you should go
there. All roads lead to the women’s clinic. (Solomatina 2011, p. 265)
In spite of her irony, Solomatina insists, as do many doctors in Russia, on the exclusive
authority of professionals and medical knowledge over reproduction. This institutional control
over reproduction is established in the name of the health and wellbeing of women. Solomatina
1
The Zhenskaya Konsul'tatsiya (Zh.K.) or Women’s Consultation Office (referred to in the text as ‘women’s
clinic’) is an outpatient health centre providing gynaecological and obstetric care, including early registration of
pregnant women, detection of pathologies in pregnancy, social care before and after delivery, and management
of patients in the postpartum period.
ISSN 0966-8136 print; ISSN 1465-3427 online/15/1001527-20 © 2015 University of Glasgow
http://dx.doi.org/10.1080/09668136.2015.1100371
The author wishes to thank Johnny Rodin, Michele Rivkin-Fish, Meri Larivaara, Elena Zdravomyslola, Victoria
Sakevich and two anonymous reviewers for their helpful comments. My special thanks to Tristam Barrett for
language editing and very useful comments.
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ANNA TEMKINA
1528
is quite serious when she writes ‘All roads lead to the women’s clinic’. Planned and unplanned
pregnancy is entirely medicalised in Russia with few exceptions, however, contraception is
a much more ambivalent object of professional regulation.
This essay focuses on the medicalisation of reproduction, and in particular the role of
medical professionals and institutions in regulating contraception in contemporary Russia.
Considering how entangled reproductive medicine is with issues of gender identity, intimate
life, bodily integrity and morality (Borozdina 2012; Krasylnikova 2012; Zdravomyslova &
Temkina 2012a), I intend to discuss here how control over contraceptive practices is exercised
in medical discourse and encounters. Discipline and power are both produced and contested
in interactions between gynaecologists and women—through the expectations of ‘proper’
behaviour and the tactics of power employed by doctors—but as I show in this essay when it
comes to contraception, these medicalised practices encounter constraints.
In this essay, I address the following questions: how do gynaecologists relate to
contraception and what kind of contraceptive and reproductive behaviour is expected of
women in their care? What instructions do gynaecologists give to female patients with regard
to contraception? And what are the limitations of medical control and medical power in
relation to contraception?
The material for this essay has been drawn from in-depth thematic interviews with
obstetricians and gynaecologists, analysis of textbooks and observation in women’s
clinics. The essay is organised as follows. I first outline the theoretical approach that I
adopt in the essay and give an account of my data and the methodology used to obtain it. I
then provide brief empirical background on how reproductive medicine is administered in
today’s Russia. In the subsequent empirical parts of the essay I analyse in turn the attitudes
of gynaecologists to family and pregnancy planning; doctors’ attitudes to contraception
and their construction of women’s ‘proper’ behaviour in relation to reproduction; and the
contraceptive attitudes and practices of women as understood by doctors. I am especially
interested here in the tactics of persuasion and control used by doctors to construct an
ideal of ‘proper’ behaviour as well as the barriers to these persuasive tactics and the ways
in which medical authority is challenged. I then discuss the institutional constraints to
contraception advocacy and, finally, the inconsistency between declared professional
advocacy of contraception and the limited actual promotion of it in the context of state
biopolitical priorities and institutional constraints.
Biopolitics and the medicalisation of contraception
Contraception is here analysed as an instance of medicalisation. Numerous scholars have
demonstrated how the female body is medicalised and controlled both in reproduction and
the whole lifecycle (Martin 1987; Conrad 1992; Davis-Floyd 1992; Lock 2001; Rapp 2001).
As Kevin White puts it, ‘In feminist analyses, medicine is shown to define women by their
biology and their reproductive capacity. … When defined as medical problems, which can
only be resolved with medical solutions, women lose control of fundamental aspects of their
experience—fertility, sexuality, menopause and ageing’ (White 2009, p. 133).2 Motherhood,
reproductive health, abortions and contraception are thus medicalised in so far as they become
part of public discourse and medical regulation.
2 See also Oakley (1984).
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THE GYNAECOLOGIST'S GAZE 1529
Medical institutions and scientific knowledge orient women towards healthy, deliberate,
prepared and planned pregnancy and maternity. Within this context, contraception can be
seen as a technique whereby one is subjected to specific rules of reproductive regulation:
Contraception and abortions are the focal points of societal ambivalence about the feminine
role. … Controversies over the provision of contraception and safe methods of contraception
for women have revolved around notions of ideal motherhood for all women and the
desire of the medical profession to maintain control over women’s reproduction. (Lupton 1994, p. 138)
Drawing on Foucault’s work on medical surveillance as social control, Peter Conrad argues
that ‘certain conditions or behaviours become perceived through a “medical gaze” and that
physicians may legitimately lay claim to all activities concerning the condition’ (Conrad
1992, p. 216). One example of this is childbirth and the medical control of obstetricians over
prenatal lifestyles, pregnancy, delivery, infertility and new reproductive technology, abortion
and contraception:
Women are expected to be responsible for reproduction yet they must interact with the medical
establishment in order to use common forms of controlled contraceptives. The mediation of a
healthcare provider (i.e. doctors and pharmacists) in women’s obtaining [of] contraceptives
means that the power to prevent pregnancy does not lie with women. (Medley-Rath & Simonds
2010, p. 784)
As this medicalisation becomes a site of contest between the state sector, markets, pharmaceutical
companies and consumers (Conrad 2007, 2009), power is redistributed between experts and
women. Women adopt medical discourse but they do not necessarily submit themselves to the
rules of medical control (Jordan 1978; Martin 1987; Lock 2001).
The historical lack of contraception and the widespread use of abortion in Russia have
impacted on the specific ways in which reproduction has been medicalised. Michele Rivkin-
Fish argues that theories of medicalisation which were developed in Western contexts cannot
be applied to the Russian context without taking into account the internal struggles among
professionals who devise different approaches to medicalisation (Rivkin-Fish 2005). I agree,
though I do not focus here on differences in the approach of Russian medical professionals
but rather on the inconsistency of the demands and practices of Russian medical professionals
in regard to contraception.
Gynaecologists in Russia who have begun to promote contraception in the post-socialist
period explicitly do this for the sake of women’s health and wellbeing, and they promote it on
the basis of objective scientific criteria of public health. Medical professionals expand their
power through medicalisation: by overseeing and controlling contraception and intervening
into reproductive choices.
The concept of biopower provides insight into the specific approaches and techniques
whereby the population is reproduced and bodies disciplined. Paul Rabinow and Nikolas Rose
argue that ‘from about the 1970s … reproduction [has become] a problem space, in which
an array of connections appears between the individual and the collective, the technological
and the political, the legal and the ethical. … And, in the West at least, a related issue of
“reproductive choice” begins to take shape’ (Rabinow & Rose 2006, p. 208). Working within
the framework of biopower, I posit that the disciplining tactics of gynaecologists as experts
who aim to orient women towards properly planned and prepared pregnancy reflects the
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ANNA TEMKINA
1530
biopolitical regime and demographic priorities of the Russian state—to increase the population
of Russia. Medicine, and gynaecologists in particular, are important agents of biopolitical
reproductive control.
To analyse the ways in which contraception is medicalised and the limitations of this
medicalisation, one must first understand the particular context of family planning, sex
education (including education in effective use of contraceptives) and the politics of abortion
in Russia in a more general biopolitical context.
Family planning and the promotion of contraception in Russia in a pronatalist context
There are two important factors which help explain the medicalisation of contraception
in Russia. The first is the Soviet legacy. In the Soviet period there was no systematic sex
education and family planning. Furthermore, people had limited access to contraception
and there was widespread use of abortion and ineffective techniques of ‘traditional’
contraception (withdrawal or the rhythm method). From 1955 onwards abortion became
the main method to control childbirth. According to Amy Rankin-Williams, ‘oral
contraceptives were not only of poor quality and availability, they were also prohibited
by the Ministry of Public Health except when needed for medical reasons … physicians
and their clients regarded them as an undesirable and unsafe form of birth control’
(Rankin-Williams 2001, p. 700).3
In spite of the widespread availability of contraception following the political and economic
reforms of the 1990s and 2000s, various survey data show that around between 20% and
25% of Russian women nonetheless use only traditional methods of pregnancy prevention,
and about 25% of sexually active women have not used any contraceptive method (Rankin-
Williams 2001; Vishnevskii 2006; Zakharov 2008; Zakharov & Sakevich 2008; Meilakhs
2009; Perelman & McKee 2009; Regushevskaya et al. 2009; Kon 2010).
The consequences are a relatively high level of unplanned and unwanted pregnancies and
a spread of sexually transmitted infections (STIs). Russia still has among the highest abortion
rates in the world. Researchers have also found that women frequently change their method
of contraception, which leads to a decline in its effectiveness (Denisov & Sakevich 2012).
The second factor of importance concerns the pronatalism of contemporary Russian
politics, which has featured critiques of sex education and family planning in the 1990s and
restricted access to abortion from the 2000s (Sakevich 2011a). As an important instrument of
biopower, reproduction in contemporary Russia—and in other post-communist countries—
constitutes a topic of struggle and negotiation within and between the state, political parties and
NGOs, the church and the medical professions, as well as within and between demographic,
religious, moral, medical, scientific and other discourses.
Russian policies regulating abortion during the 1990s were quite liberal, with free access
up to 12 weeks.4 However, starting in 2003 various amendments have been approved to limit
access to abortion. Numerous politicians, church officials and religious NGOs encouraged the
Federal Duma and the regional parliaments to restrict or prohibit access to abortion. Public
reaction and several protests followed, although this did not lead to mass mobilisations. In
3 See also Popov et al. (1993), Kon (2010).
4 Article 36 of Osnovy zakonodatel'stva Rossiiskoi Federatsii ob okhrane zdorov'ya grazhdan (FZ #
5487-1 ot 22 07 1993 goda), available at: http://www.rg.ru/1993/08/19/osnovy-zdorovya-dok.html, accessed
8 September 2015; see also Sakevich (2011a).
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THE GYNAECOLOGIST'S GAZE 1531
2011 politicians suggested amendments to the Law on Public Health that would further
restrict access to abortion. The majority of amendments were dismissed, with the exception
of the special period of waiting before going through with an abortion (the week of silence)
(Sakevich 2011b).5 This practice already exists for abortion services that are free-of-charge,
where women are also required to undergo several days of medical tests.
Since 2006, Russia’s demographic policy has been oriented towards increasing the
population—especially by supporting the birth of second children (Rotkirch et al. 2007)—and
employs the rhetoric of a ‘demographic crisis’ and the ‘dying out of the nation’. Under this
policy, ideological and institutional measures have been introduced to encourage women to
give birth to more children. Birth rate stimulation is a core element of the new demographic
politics. The key instrument of this policy is the awarding of maternity payments [materinskii
kapital] by the state. The state thus attempts to instrumentalise women ‘as useful biological-
demographic tools for state needs. They envision an activist state deploying its technological
resources, surveillance power, and tactics of persuasion to prevent abortion—after a pregnancy
has been established’ (Rivkin-Fish 2010, p. 722).
Contraception is medicalised and politicised to a lesser extent than abortion and pregnancy
treatment in contemporary Russia, but institutional control has increased in recent decades, as
several contraceptive methods have become more diffused and accessible.6 In the late 2000s
pregnancy treatment was defined as one of the state’s healthcare priorities and is supported
by special economic measures. In 2006, a programme of maternity certification [rodovye
sertifikaty] that follows women throughout their pregnancy up to birth was inaugurated to
encourage a better health service for pregnant women in women’s clinics and maternity
hospitals. This programme was launched within the framework of Russia’s National Health
Policy [natsional’nyi proekt Zdorov’e] and in addition to providing some payment to pregnant
women who register their pregnancy with a women’s clinic within the first 12 weeks, it also
offers a small financial and material incentive to participating doctors and clinics by giving
bonuses to doctors for each woman who receives ‘successful’ treatment, and by funding
equipment in women’s clinics and maternity hospitals (Borozdina 2012). In contrast to
pregnancy treatment, the issue of contraception receives neither special state support nor
attention from politicians or the public. Yet the role of medicine in its regulation has grown.
In comparison with abortion, there is little public discussion on the topic of contraception
outside the professional sphere. However, critics of sex education and family planning interpret
the giving of information about contraception as an attempt to sexually corrupt children.7
Furthermore, according to Rivkin-Fish,
Conservatives persistently reminded policymakers to see reproductive trends as a measure of national
vitality. They portrayed new, globally inspired sex education and family planning programmes as
deliberate tactics by a hostile West to weaken Russia by reducing its population. (Rivkin-Fish 2010,
p. 711)
5
Resolution of the State Duma Committee on Health during the fifth convocation of the State Duma of the Russian
Federation, 24 November 2011, available at: http://komitet2-2.km.duma.gov.ru/site.xp/052057124049048048053.
html, accessed 1 December 2012. Proceedings of the State Duma, 21 October 2011, available at:
http://transcript.duma.gov.ru/node/3525/, accessed 1 December 2012.
6 During the 2000s and 2010s the hormonal pill was available over the counter, although it was assumed
that everybody had received medical advice.
7 ‘Zashchitim detei ot rastleniya’, Orthodox Medical Server, available at: http://www.orthomed.ru/pms.
php?id=library.decay.index, accessed 1 December 2012.
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ANNA TEMKINA
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Conservatives argue that such programmes ‘teach our children how to use condoms and
our girls how to have abortions in order to reduce the rate of childbirth’ (Snarskaya 2009,
pp. 65–6). Attempts in the mid-1990s to foster systematic family planning have failed.
Although some family planning centres and other such institutions were created and have
been working continuously many have since been closed, officially due to lack of resources.
Since the 2000s public discussion of abortion has been tied up with the issue of demographic
crisis and the dying nation (Rivkin-Fish 1999, 2010). The Russian Orthodox Church condemns
contraception, although it is much more active in its condemnation of abortion. According
to the social conception of the Russian Orthodox Church, intrauterine devices (IUDs) and
hormonal contraceptives (the pill) are not acceptable because they are defined as abortive
contraceptives.8 The use of IUDs and hormones is equated to abortion, which is supposed to
lead to a decline in fertility and morality.
Contraception is not discussed widely as a mechanism for reducing the number of abortions
in Russia; nor is it promoted through comprehensive sex education in schools. Viktoriya
Sakevich, a Russian demographer, explains:
The myth that it is possible to regulate the birth rate by limiting the number of abortions and the
myth that the decline of childbirth is a consequence of contraception are widespread both among
decision-makers and laymen. … Political decisions [about demographic issues] are oriented towards
limiting access to abortion. Alternative measures for regulating fertility are not discussed. The issues
of preventing unwanted pregnancies and providing wider access to contraception disappear from
the documents of the Ministry of Health. They are replaced by ‘pre-abortion consultations’, that is,
pressure on women who are already pregnant. (Sakevich 2011a)
In summary, the issues of abortion, sex education and family planning are broadly negatively
articulated within the present-day politics of population management in Russia, and this
has ramifications for both professionals and medical institutions. Childbirth and pregnancy
treatment are high priorities for the state and medical institutions. On the other hand, a position
on contraception has scarcely been articulated at the political level, and medical professionals
have become important actors in its regulation.
Contraception in Russia and medical care
Given the absence of sex education, lack of family planning and the promotion of a restricted
right to abortion, contraception remains either a private or medical (gynaecological) issue.
Although the views of gynaecologists have not been extensively investigated in Russia, it is
evident that the position of professionals has changed during the last decades in comparison
with the Soviet period, when, with the exception of the IUD, contraception was mostly not
a topic of discussion or medical intervention.
In the Soviet period, gynaecologists, like their patients, were suspicious of hormonal
contraceptives. Nowadays, regarding contraception, as Meri Larivaara has shown, gynaecologists
generally have a positive relation to modern methods of contraception as opposed to traditional
ones. They consider users of modern contraception to be knowledgeable and progressive, and
8 See for example the comments of Archpriest Maksim Obukhov, director of the ‘Life’ Medical and
Educational Centre, Soyuz Orthodox TV channel, 26 October 2011, available at: http://tv-soyuz.ru/programms/
tv/religious/besedy-s-batyushkoy/at19494, accessed 1 December 2012.
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THE GYNAECOLOGIST'S GAZE 1533
they insist on maintaining medical control over contraception (Larivaara 2009, pp. 318–26).
She also observes that fertility and motherhood are the central foci of care (Larivaara 2010).
Larivaara argues that the position of gynaecologists is predominantly paternalistic and oriented
towards persuading women to use contraception ‘as a means of fostering future fertility and
avoiding harmful health consequences of induced abortions’ (Larivaara 2010, p. 357). Further
research shows that gynaecologists generally expect cooperation from women and that they
expect woman to have basic medical knowledge about reproduction and reproductive health, to
be trustful of medicine and responsible for their own health (Odintsova 2009; Zdravomyslova
& Temkina 2012a).
In Russia gynaecological medical care (pregnancy treatment, prophylactic consultations—
including contraception—treatment for gynaecological diseases) is provided in women’s
clinics at the district level of the public health system. Gynaecological departments in medical
centres and some family planning clinics are also administered at the district level. Obstetric
care is provided in maternity hospitals. Since the beginning of the 1990s commercial medical
services have become legally available. In principle, women’s clinics are free of charge for the
population of the district, though informal payments are widespread in all medical institutions
and official payment may be required for certain tests or procedures. A district doctor attends to
women in the district in which they are registered. Pregnant women should register themselves
in women’s clinics and regularly visit the gynaecologist until delivery in a maternity hospital.
Midwives mostly work with gynaecologist-obstetricians as assistants without professional
autonomy and legal responsibilities, both in women’s clinics and maternity hospitals.
Methods and data: interviews with gynaecologists and professional discourse
The following analysis is based on in-depth thematic interviews with obstetrician-
gynaecologists conducted in 2009 in three Russian cities, Arkhangel’sk, Kazan and Samara.
With a population of approximately one million, Kazan (the capital of the Republic of
Tatarstan) and Samara are amongst the largest cities in Russia, whereas Arkhangel’sk is
somewhat smaller with a population of around 350,000. Although we may expect some
difference in access to medical services, we did not find any significant regional differences
in doctors’ attitudes to contraception and relations with their patients.
We interviewed 15 obstetrician-gynaecologists (four in Samara, seven in Kazan and four in
Arkhangel’sk; a total of 13 women and two men). During these interviews we discussed work
practices (treatment of pregnant women, advice given on contraception, abortion, delivery,
diseases, ways of exerting influence), attitudes towards their patients (expectations in terms
of knowledge and behaviour, attitudes towards health and young women’s practices) and
working conditions.
Interviewees were selected according to the professional position of the expert; no other
criteria were significant. Ages ranged between 33 and 74 years old. Most were doctors working
at municipal gynaecological polyclinics (the aforementioned Zhenskie Konsul’tatsii, or
women’s clinics), and their length of work experience ranged from six to 46 years. Their status
position was on average high, and we could suppose that their influence within the clinics
was commensurately high. The gender structure corresponds to professional segregation in
Russia whereby the majority of gynaecologists are women, especially in the primary health
care sector.
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ANNA TEMKINA
1534
An additional source of data on gynaecologists’ perspectives was around 90 hours of
observation of medical encounters in women’s clinics conducted between April and July
2009, by a member of our research team, Dariya Krasil’nikova. The research also draws on
professional textbooks on gynaecology published since 2000.9
In analysing these data, I examine different attitudes and approaches to control by experts
in contraception. The thematic coding used to analyse interviews (Miles & Huberman 1994)
was developed on the basis of the theoretical foundations of this research. The analysis
contains two steps. First, the codes were created a priori, referring to contraception use and
interactions with the doctor. In the second phase, sub-codes were developed inductively
on a more detailed level. These codes refer to types of contraception and women’s relation
towards contraception, doctors’ different modes of instruction and tactics of persuasion, and
the limitation of medical control in interactions and organisations.
Our analysis is based on a small number of interviews that are not representative of the
whole field of Russian encounters between gynaecologists and patients. Nevertheless, we
propose that our findings about contraception can to some extent be applied to urban women
in Russia more generally. The disciplinary tactics used by physicians towards educated women
reveal pervasive efforts to control women’s behaviour. We suspect that these efforts may be
even more widespread among women with fewer social, material and cultural resources than
the group we studied, but the responses of women in other social strata may well differ from
those described here.
Gynaecologists’ views on family and pregnancy planning
According to our data, the main purpose of promoting contraception is found in the necessity
for women to plan pregnancy and avoid undergoing an abortion. In contrast to the pervading
public discourse that is hostile towards family planning, gynaecologists appear in interviews
as supporters of contraceptive use and pregnancy planning. They emphasise that their relation
to contraception has changed in comparison with the Soviet period. This is also confirmed by
Larivaara, who finds that ‘methods [of family planning] were often contrasted with Soviet birth
control practices and perceived as a token of a new kind of reproductive culture’ (Larivaara
2010, p. 369). Gynaecologists argue that ensuring a healthy maternity and birth is necessary
under the present conditions of the new reproductive culture and sexual liberalisation in
Russia.10 Physicians recognise an intergenerational shift in the lifecycle and the inclination
of young women to postpone childbirth: ‘Formerly women first became pregnant and gave
9 All interviews were collected as part of a research project ‘The Gender Arrangement of Private Life in
Russia’ led by me and Elena Zdravomyslova and supported by the Ford Foundation and Novartis Corporation.
Interviews were conducted by a team of researchers and Ph.D. and M.A. students in sociology and gender
studies, trained by the principal investigators. We triangulated our data and assessed its reliability and validity
with the additional sources of data discussed above (participant observation and gynaecological textbooks)
and cross-checked our findings with previous research on reproductive health in Russia (Zdravomyslova &
Temkina 2012a). See also Ailamazyan (2003, 2008), Gritsuk and Gurkin (2003), Savel’eva and Breusenko
(2004, 2011), Golota and Benuk (2005), Susloparov (2007).
10 In common with Igor Kon (2010), I identify sexual liberalisation in Russia in the following trends:
detraditionalisation of sexual mores, weakened familial control of sexuality, increased prevalence of reproduction
outside marriage, and increased frequency of premarital and extra-marital sexual relations amongst both men
and women.
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THE GYNAECOLOGIST'S GAZE 1535
birth, and only became interested in contraception afterwards. Nowadays they begin with an
active sexual life, and only after many years do they plan pregnancy’.11 Doctors recognise the
necessity to use contraception from the very beginning of sexual life, which no longer leads
‘automatically’ to pregnancy and childbirth as was typical for Soviet generations. Nowadays
doctors argue that pregnancy should be planned and prepared and contraception should be
used for this purpose.
In textbooks contraception is also defined predominantly as a ‘means to prevent pregnancy’
(Savel’eva & Breusenko 2004, p. 367; 2011, p. 375; Ailamazyan 2008, p. 271). Gynaecologists
argue that contraception should be used if one is not planning pregnancy. If pregnancy is
planned, it should be prepared under medical supervision. The interpretation of ‘pregnancy
planning’ (a term widely used by gynaecologists and women) is mostly connected to healthy
medicalised preparation for pregnancy and childbirth,
12
and differs from the broader concepts
of ‘family planning’ and ‘sex education’ that were introduced to Russia in the 1990s and remain
unpopular today. In common with many others, one doctor explains: ‘Pregnancy should be
planned. … Diseases should be tested. You should visit a general practitioner in advance, a
dentist, an otolaryngologist. You might have other problems, in which case you should visit
other doctors. … Infections should be checked …’.13
Failure to use contraception is observed by gynaecologists in the dilemma of abortion or
unwanted childbirth. In such cases the attitudes and instructions of doctors vary significantly.
In interviews, some gynaecologists say that they will dissuade pregnant woman from abortion
or at least will tell them about the attendant health risks: ‘As a rule, I insist that she gives
birth, especially those who are pregnant for the first time. We do not know whether they
can become pregnant next time or not’.14 Risks to health and future fertility are the focus
of medical arguments, as well as presuppositions about the unquestionable importance of
maternity in a woman’s life.
In the case of abortions the moral and sometimes religious values of doctors otherwise not
articulated in interviews are made manifest: ‘My own stance [towards abortion] is negative,
… from moral, ethical and medical standpoints’.15 The dependence of professionals on
state regulation of abortion is also reported: ‘A doctor doesn’t want to break the law and
go to prison’.16 Legal regulation is changing nowadays and the possibility of professionals
refusing to perform an abortion on religious grounds is recognised by the law. However, some
professionals say that reproductive choice is ‘a woman’s personal business’,
17
and ‘we should
not interfere in her private life’.18
Our data show that in order to plan pregnancy and avoid abortions gynaecologists tend to
advocate modern contraception and pregnancy planning.19 Doctors demonstrated a general
11 NO, female, aged 38; obstetrician-gynaecologist; 12 years’ work experience in Zh.K.
12 See also Larivaara (2011).
13 OL, female, aged 48; obstetrician-gynaecologist; 24 years’ work experience in Zh.K. and hospital, held
position as Head of Department in Zh.K.
14
VG, male, aged 70; obstetrician-gynaecologist; Head of Department at Zh.K., 42 years’ work experience.
15 MN, female, aged 36; obstetrician-gynaecologist; 12 years’ work experience, seven years in Zh.K.
16 VG, male, aged 70; obstetrician-gynaecologist; Head of Department at Zh.K., 42 years’ work experience.
17 DE, male, aged 50; obstetrician-gynaecologist, held position as Head of Zh.K.; 25 years’ work experience
in Zh.K.
18
EZ, female, aged 52; obstetrician-gynaecologist, held position as Head of Zh.K.; 26 years’ work experience.
19 The position of Orthodox physicians on contraception has become more visible in recent years, but lies
out of the scope of this essay.
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ANNA TEMKINA
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consensus in their opinion of the necessity of using modern contraceptive techniques.
Although the sample was small, we did not find any significant differences in their discourse
about contraception. The only exception to this trend of non-religious advocacy of modern
contraception was found by one of the MA students on the project, Anastasiya Novkunskaya,
in her ongoing research on responsibility in reproductive health in a provincial Russian
city. A gynaecologist, aged 48, argued that free access to and the effectiveness of modern
contraceptives has led to a decline of risk, facilitates promiscuity and resulted in a reduction in
the rate of childbirth. I also found small differences in attitudes towards modern contraception
in so far as personal preferences and experiences informed the choice of one form over
another. Gynaecologists argue: ‘I personally do not like IUDs’;20 ‘To tell the truth, a doctor
recommends the contraception she uses herself’;21 ‘I myself never use female condoms and
I couldn’t recommend them’.22
Gynaecologists appear as strong supporters of pregnancy planning and avoiding abortions.
As medical experts, doctors advocate modern contraceptive use for the sake of health, prepared
pregnancy and childbirth.
Gynaecologists’ views on contraception
Gynaecologists construct norms of ‘proper’ behaviour while educating patients about health
issues, including the issue of contraception. This new reproductive culture presupposes
systematic medical control over contraceptive behaviour. Gynaecologists promote modern
contraceptives (hormonal pills and IUDs) and condemn both non-use of contraception and
traditional methods of preventing pregnancy. A boundary is constructed between proper
behaviour (using modern means of contraception) and improper behaviour (disregarding or
using traditional contraceptive methods). However, the boundary is porous, and traditional
methods are not disparaged unequivocally. While doctors evaluate these methods as old-
fashioned, numerous women continue to use them and gynaecologists sometimes accept this
as a ‘lesser evil’ (Larivaara 2009, pp. 319–20).
Gynaecologists report that they ask questions about contraception during routine check-
ups. Their professional task is to recommend the most appropriate method and to monitor its
use. In order to implement this task they should understand the woman’s preferences, assess
her state of health and propose different options. Gynaecologists say that they take account
of the patient’s state of health, age, reproductive plans, type of partnership (stable or not),
number of partners, lifestyle and frequency of sexual intercourse. Based on these criteria
and on medical examination, the doctors we interviewed distinguished three main groups of
women and appropriate forms of contraception. Such prescriptions coincide with medical
instructions given in contemporary textbooks on gynaecology; however the textbooks give
much more detailed recommendations (Ailamazyan 2003, pp. 507–21; 2008, pp. 271–83;
Savel’va & Breusenko 2004, pp. 367–96).
20 NB, female, aged 42; obstetrician-gynaecologist at Zh.K.; 17 years’ work experience.
21 DV, female, aged 31; obstetrician-gynaecologist; six years’ work experience.
22 OL, female, aged 48; obstetrician-gynaecologist; 24 years’ work experience in Zh.K. and hospital, held
position as Head of Department in Zh.K.
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THE GYNAECOLOGIST'S GAZE 1537
The prescription of contraception is based on health criteria. However, it conforms with
ideas of proper reproductive behaviour. Hormonal pills or other types of hormones are
predominantly recommended to young women in a stable partnership (or marriage) without
children; they are described as the most reliable contraceptives (Ailamazyan 2003, p. 507;
Savel’va & Breusenko 2004, p. 373). It is expected that such women have only one partner and
that they are going to give birth in the future. An IUD is typically recommended to women in
a stable partnership with children (normally one or two). An IUD is installed after a medical
test and subsequently monitored by a doctor. It is expected that such women do not plan a
birth (at least in the near future), and neither do they have parallel relationships. Otherwise
use of an IUD can lead to infections (Gritsuk & Gurkin 2003, p. 91).
Condoms demarcate the border between ‘proper’ and ‘improper’ lifestyles. When
recommending pills and IUDs, monogamy and an unproblematic orientation towards
childbirth are presupposed. Condoms are recommended for young women with numerous
partners and ‘peculiar’ lifestyles, whose reproductive plans are unclear. According to doctors
who were interviewed: ‘Condoms are recommended in cases where she hasn’t got a single
partner, and she has a “peculiar” way of life’;23 ‘Different partners, different infections …’.24
Use of condoms is explicitly linked to one’s sexual lifestyle, however, doctors have some
trouble defining this lifestyle. They do not directly condemn women, but try to describe this
‘peculiar’ way of life as risky for health: ‘you know, this way of life is not … it will cause
infections’.25 Doctors indicate that condoms are widely used by young women,26 and although
they recommend them in some cases they criticise condoms as not being sufficiently reliable
and impossible to monitor: ‘The reliability of condoms is low, unwanted pregnancy could
occur. It is better to turn to more reliable forms of contraception’.27 Contraception should
guarantee that pregnancy will happen when planned and prepared and condoms are considered
to be too difficult to control. Gynaecologists recommend other methods as more controllable
in comparison with condoms. Several of the doctors agree with this perspective: ‘I recommend
pills as a more controlled form of contraception’;28 ‘Men are not so interested in safety’.29
Some professionals argue that men prefer unprotected sex. One doctor tells the story of a man
who lied to his wife about using a condom and insists that it is difficult to trust men to use
condoms.30 According to the textbooks condoms are prescribed to female patients who have
casual sexual intercourse with a high risk of STIs, and those with an irregular and infrequent
sexual life (Savel’eva & Breusenko 2004, p. 390; 2011, p. 391). While doctors disparage
condoms because they prefer control over contraception to lie with women, it is equally
23 OL, female, aged 48; obstetrician-gynaecologist; 24 years’ work experience in Zh.K. and hospital, held
position as Head of Department in Zh.K.
24 VG, male, aged 70; obstetrician-gynaecologist, Head of Department at Zh.K.; 42 years’ work experience.
25 DV, female, aged 31; obstetrician-gynaecologist; six years’ work experience.
26 This is confirmed by survey data. See Gerber and Bernam (2008).
27 MN, female, aged 36; obstetrician-gynaecologist; 12 years’ work experience, seven years in Zh.K.
28 MN, female, aged 36; obstetrician-gynaecologist; 12 years’ work experience, seven years in Zh.K.
29 AB, female, aged 74; obstetrician-gynaecologist; 46 years’ work experience.
30 In gynaecological textbooks condoms are also considered to be an insufficient method of pregnancy
prevention. In one textbook there is no separate section on condoms, as opposed to the IUD and hormonal
pill. Condoms are instead discussed under the rubric ‘traditional methods’, as distinct from cervical caps and
diaphragms which are discussed as mechanical methods (Savel’eva & Breusenko 2004, p. 389). In the 2011
edition, condoms were transferred to the section ‘Barrier methods’ (Savel’eva & Breusenko 2011, p. 390). In
another book condoms are also included in the section ‘Barrier methods’ as linked mostly to the prevention of
STIs (Ailamazyan 2003, p. 516; 2008, p. 280).
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ANNA TEMKINA
1538
true that condoms do not entail a medicalisation of reproductive behaviour or guarantee the
physician’s authority. In other words, because condoms are not subject to medical oversight,
the explicit preference of doctors that women choose methods that allow them to retain medical
control over contraception—such as the pill or the IUD—also implies that doctors retain a
degree of authority that they would not otherwise have.
Different methods of contraception produce different demands on professional expertise:
systematic medical control in the case of IUDs, systematic self-control and self-discipline as
well as medical check-ups in the case of pills. The use of condoms and prevention of STIs
is not a primary concern for gynaecologists; they consistently recommend the use of more
reliable and more controllable methods than condoms.
For gynaecologists, contraception is predominantly a question of providing for a ‘proper’
medicalised pregnancy and managed childbirth. Gynaecologists connect the ‘proper’
behaviour of women to this norm. The ideal of women in a stable relationship, oriented
towards childbirth (or having already given birth) under medical supervision is embodied in
the practices of gynaecologists and in professional discourse. The proper use of contraception
should guarantee safe pregnancy and maternity, which is assumed to apply to every woman
of reproductive age, and it is the role of gynaecologists to instruct women in order to ensure
this ‘proper’ behaviour. Gynaecologists recommend the type of contraception based on health
criteria but this entails an implicit moral evaluation of non-procreative sexual behaviour.
Disciplining women in interactions: the gynaecologist’s gaze
As institutional agents of control over reproduction, gynaecologists disseminate authoritative
knowledge about health that embraces ideas of proper reproductively healthy women oriented
towards childbirth. In this section I analyse how gynaecologists instruct women, and control
‘proper’ contraceptive and reproductive behaviour and the limits to this control. ‘Proper’
behaviour is expected from responsible women under medical supervision, while irresponsible
women are held accountable and chastened by physicians. The behaviour of women who
question medical authority confuses gynaecologists.
The liberal construction of self implicit in gynaecological practice presupposes discipline;
a systematic effective medical and personal control over pregnancy and contraception. This
mode is preferable to gynaecologists. It differs from the Soviet one, in which women did not
plan pregnancy and perceived it as spontaneous, natural and taken-for-granted. In the liberal
mode, women are described by the gynaecologists we interviewed as systematically supervised
by medical professionals, as well as responsible for their own choices and behaviour. Doctors
emphasise that many young women systematically visit gynaecologists, undergo tests, receive
advice on contraception and follow it. Gynaecologists instruct and supervise women on how
to use contraception in a safe way. With many contraceptive options, they attempt to give as
detailed instructions as possible: ‘I try to inform women about different methods’;31 ‘There
are a lot of hormonal methods, the [contraceptive] patch, the vaginal ring, these are good. If
she is observed by a doctor, if she’s tested, has her breasts checked, she will be safe’;32 with
31 KL, female, aged 33; obstetrician-gynaecologist; six years’ work experience, three years in Zh.K.
32 IK, female, aged 42; obstetrician-gynaecologist; 17 years’ work experience.
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THE GYNAECOLOGIST'S GAZE 1539
choice, ‘women are at an advantage nowadays’;33 it is a doctor’s task to ‘choose the proper
… means of contraception’. In so far as modern contraception may be harmful to health,
medical control is necessary. For example ‘the IUD could cause inflammation and bleeding’.34
However, ‘they may use hormones for years under supervision without any problems’.35
Doctors stress the significance of women taking personal decisions: they ‘can make their
own choice’.36 According to a medical textbook ‘the patient herself makes a decision about
contraception after prior consultation. … The personal choice of a patient increases the
effectiveness of the method, so far as it motivates her to implement the regime and consistently
use her capacity of choice’ (Ailamazyan 2003, p. 507).
In professional discourse hormonal pills are a marker of women’s responsible behaviour
and discipline. The hormonal pill should be recommended by the doctor (although it is sold
in pharmacies in Russia without prescription) and should be taken systematically every day. A
woman who uses the pill is evaluated by doctors as displaying the proper mode of behaviour:
she ‘cares about herself, she is honest, she will take the pill each day’.37 The pill, according
to the textbook, demands that a woman develop a ‘sense of duty’ (Gritsuk & Gurkin 2003,
p. 83). For doctors it symbolises discipline as internalised by responsible patients. The pill
thus implies that a woman takes control of her life while at the same time relying on medical
expertise. This mode of behaviour also presupposes that women do not have constraints in
access to medical services and financial resources.
Doctors do not consider all women to be responsible. Others are identified as ignorant,
irresponsible or undisciplined. Although technical and economic conditions have changed,
this kind of behaviour has Soviet precedents. Religious revival has also had an impact, with its
discouragement of ‘rational’ reproductive planning. Gynaecologists tend to describe women
negatively who do not regularly visit doctors, or who reject modern contraceptives and medical
prescriptions, and they accuse such women of ignorance and carelessness. Doctors argue:
‘Our women are still ignorant’; they still use traditional ineffective methods: ‘there are women
who prevent pregnancy using the calendar method, or coitus interruptus’.38
According to professionals, the group of women classed as ‘irresponsible’ is not
homogenous. Included in this category are ignorant women who rely on lay knowledge, have
prejudices similar to the Soviet generation and follow ‘fate’: ‘I ask what kind of contraception
do you use? I don’t use any, they answer. I ask do you want to get pregnant? No. Maybe
you do something [to avoid pregnancy]? Maybe condoms? Withdrawal? They do not know
anything’;39 ‘It is very difficult to convince them about pills … they are afraid to grow fat,
they are afraid of getting tumours’.40 Some women take advantage of new technological and
market possibilities and regularly use emergency hormonal contraception that is harmful to
their health. Others are characterised by doctors as ‘deviant’ and ‘careless’ because they have
33
NA, female, aged 49; obstetrician-gynaecologist at Zh.K. and in private clinic; 26 years’ work experience.
34 NB, female, aged 42; obstetrician-gynaecologist at Zh.K.; 17 years’ work experience.
35 KL, female, aged 33; obstetrician-gynaecologist; six years’ work experience, three years in Zh.K.
36 LM, female, aged 33; obstetrician-gynaecologist; 6.5 years’ work experience, 3.5 years in Zh.K.
37 VG, male, aged 70; obstetrician-gynaecologist, Head of Department at Zh.K.; 42 years’ work experience.
38 IK, female, aged 42; obstetrician-gynaecologist; 17 years’ work experience.
39 LM, female, aged 33; obstetrician-gynaecologist; 6.5 years’ work experience, 3.5 years in Zh.K.
40 IK, female, aged 42; obstetrician-gynaecologist; 17 years’ work experience.
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ANNA TEMKINA
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a ‘peculiar’ lifestyle: ‘If a woman is not careful, or a tramp … or if she drinks alcohol, she
will not follow the instructions’.41
Social inequality also impacts on such modes of behaviour. Some women, mentioned by
the gynaecologists, cannot afford or do not want to pay for contraception and thus refuse it.
Doctors then propose free-of-charge or inexpensive methods: ‘I suggest the IUD; you pay
only once; or I advise cheap pills and see how it works. If it is okay, we can continue’.42
According to doctors, such women do not have the discipline to systematically use the
pill: ‘If I see that a young woman is an airhead, why should I recommend the pill? She
will take one today and stop tomorrow’;43 ‘She has sex and forgets about the pill and then
she ends up with a child’.44 IUDs are also dangerous for those with a ‘peculiar’ way of life
(multiple partners are interpreted as a cause of infections). The options are to use condoms
or traditional methods which are beyond medical control and are not strongly advocated by
professionals. The absence of systematic, modern and effective contraception characterises this
group as a whole. Due to the existence of different contraceptive possibilities, doctors do not
consider a woman’s economic circumstances to be an excuse. Their reproductive behaviour
is problematic because such behaviour leads to irresponsible pregnancy and childbirth, or to
the regulation of reproductive life through abortion and the morning-after pill.
Another type of behaviour that doctors consider to be problematic is the questioning
of medical authority evinced by a new breed of demanding patients. Such patients act as
responsible individuals, but they do not take the authority and authoritative knowledge of
doctors as granted. According to doctors, such women are too demanding and quarrel with
them on every occasion: ‘She visits the doctor, asks for advice about contraception and begins
to argue: I won’t, I don’t want, this is nonsense. … They refer to the experience of their mother
or friend or to the internet’.45 Women refer to their own negative experiences, to the contrary
opinions of different experts and to information they obtain on the internet. They consciously
refuse medical prescriptions and interventions (Zdravomyslova & Temkina 2012b). Doctors
describe such attitudes as pedantic: ‘I will not go on the pill, I do not want to interfere with
my IUD!’.46 The behaviour of such ‘sceptical consumers’ challenges medical institutional
expertise (Mechanic 1996, p. 172). Doctors are uncomfortable in such interactions. They
comment, ‘it does not matter what you prescribe, nothing will work’.47 Women’s voices
confuse physicians. One gynaecologist describes such a conflict and her response to the
woman in question: ‘Why do you come then if you will not follow [my advice] … if you
will only decide by yourself’.48
Gynaecologists say that they try to change the behaviour of women (Larivaara 2010). In
textbooks, gynaecologists argue that doctors should ‘inspire women to think about their sense
of duty when using hormonal pills’ (Gritsuk & Gurkin 2003, p. 83). It is their professional
entitlement to advocate and discipline women to change their mode of behaviour: ‘We speak
41 VG, male, aged 70; obstetrician-gynaecologist, Head of Department at Zh.K.; 42 years’ work experience.
42 AB, female, aged 74; obstetrician-gynaecologist; 46 years’ work experience.
43 GD, female, aged 46; obstetrician-gynaecologist; 19 years’ work experience.
44 VG, male, aged 70; obstetrician-gynaecologist, Head of Department at Zh.K.; 42 years’ work experience.
45 AB, female, aged 74; obstetrician-gynaecologist; 46 years’ work experience.
46 DV, female, aged 31; obstetrician-gynaecologist; six years’ work experience.
47 DE, male, aged 50; obstetrician-gynaecologist, held position as Head of Zh.K.; 25 years’ work experience
in Zh.K.
48 DE, male, aged 50; obstetrician-gynaecologist, held position as Head of Zh.K.; 25 years’ work experience
in Zh.K.
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THE GYNAECOLOGIST'S GAZE 1541
a lot, let them know about … we need to encourage women so that they are not afraid of the
pill’.49 Rather paternalistically, one doctor argued, ‘We should lead them in the necessary
direction’.50 Doctors try to find a way of dealing with demanding patients, though sometimes
they ask, ‘What reason is there to come to a doctor if they have no intention of listening to
him?’51
Doctors, though morally neutral by their own estimation, stigmatise women who do not
follow this discipline, and they persuade and threaten them. One gynaecologist criticised a
patient for her ignorance: ‘Do you use the calendar method? What is it? Don’t you read the
medical literature? We haven’t used the calendar method since perestroika … you will get
into problems. … You should love yourself’.52
Physicians moralise about contraceptive culture, while increasingly recognising that
judging women for their behaviour is unacceptable. The explicit basis for making moral
judgements is the health risk related to behaviour that is negatively evaluated by medical
professionals.
According to gynaecologists, the regulation of pregnancy and childbirth demands medical as
well as personal control over reproduction. Practices differ from the Soviet generation’s putting
themselves into the hands of fate or regulating reproductive life with the help of abortion and
unreliable contraception. The doctor’s task is to advocate the proper form of contraceptive use.
This is possible if a woman accepts professional authority, follows professional advice, cares for
herself, is responsible and shows self-discipline. Some demanding women refuse to take medical
and institutional authority for granted, while some ‘ignorant’ women avoid modern methods. Such
behaviour challenges medical control over contraception and the authority of doctors.
Problematic advocacy of contraception: institutional constraints and the priorities of
gynaecologists
In practice, despite what doctors say, they do not always instruct women about the use
of contraception. According to our data, neither doctors nor women often follow rules of
systematic medical management of contraceptive use. As participant observation and other
research shows (Larivaara 2009, 2010), in practice, gynaecologists do not systematically
advocate that women use modern contraception. To a certain extent they accept ‘traditional’
forms of contraception, even if they consider them to be less effective. They accept unplanned
pregnancy and mostly attempt to persuade women to continue with the pregnancy, rather than
terminate it. Sometimes contraception is actively addressed in interactions and sometimes
it is ignored.
Gynaecologists recognise that lack of knowledge, discipline and responsibility may lead
to unplanned and undesired pregnancy. Doctors admit the necessity of educating women by
explaining risks and advocating contraception. However, participant observation shows that,
contrary to what they say in interviews, doctors mostly do not ask patients about contraception
and do not speak about it in detail, nor do they discuss pregnancy planning.53
49 IK, female, aged 42; obstetrician-gynaecologist; 17 years’ work experience.
50 DV, female, aged 31; obstetrician-gynaecologist; six years’ work experience.
51 VG, male, aged 70; obstetrician-gynaecologist, Head of Department at Zh.K.; 42 years’ work experience.
52 Observation of medical encounter, 22 April 2009.
53 Krasilnikova, research diary. See also Larivaara (2009).
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ANNA TEMKINA
1542
Due to institutional constraints physicians have limited opportunity to comprehensively
expand the use of contraception and pregnancy planning and advocate the ethic of discipline
which they consider necessary. Expert medical power in Russia has many limitations. As in
Soviet times, gynaecologists do not act as autonomous professional agents. Physicians are not
visible in political and public health decision-making in Russia. As state employees they are
restricted by numerous bureaucratic regulations and inefficiencies, including a high volume
of paperwork, and shortages in equipment and medication. They also depend on opportunities
presented by the market. In contrast to the Soviet era, gynaecologists as well as other
physicians may attempt to increase their income by commercial means, including asking for
informal payments or increasing their working hours with overtime or by working for several
organisations including private clinics and the commercial segment of state women's clinics
(Kolosnitsyna et al. 2009). The time schedule for appointments in the state sector is rigid,
and doctors complain in interviews about the lack of time, over-exigent insurance companies
and governing bodies, and the low quality of their working conditions (Zdravomyslova &
Temkina 2012a). They often do not have sufficient incentives or resources for prophylactic
work (including consultation on contraception).
As a poorly salaried and economically vulnerable professional group, gynaecologist-
obstetricians in women's clinics mostly depend on the state and are subject to its legal and
financial priorities. The special maternity certification programme creates economic and
ideological priorities in provision for pregnant women and encourages doctors to single out
pregnant women for better service. Pregnant women regularly visit gynaecologists, they are
encouraged to consult different doctors, their cases are well documented, and they receive
certain medicines free of charge. In interviews doctors say that they prefer to care for pregnant
women, and they receive additional payment, if only a small amount, for every patient.
Pregnant women are mostly not required to wait in line, but can immediately see the doctor,
while other women are still waiting.
Gynaecologists said in interviews that the care of pregnant women brings them positive
emotions; in these cases especially patients often show gratitude to the doctor: ‘Of course,
it’s nice for the doctor, definitely nice … it is an assessment of your work, it is feedback. If
there is a good result, when you monitor the pregnancy and it ends with a healthy baby, a
normal delivery, the doctor clearly sees these results’.54 It is important for the doctor to have
good results in the management of such rigorously monitored pregnancies. By caring for
pregnant women gynaecologists as a professional group are able to manifest their authority
(Borozdina 2010, 2012).
The medicalisation of reproduction is therefore an important means by which they can exert
influence but, given the state’s biopolitical priorities of population growth, this medicalisation
only partially extends to contraception. Advocacy of contraception does not increase the
professional power and influence of gynaecologists under present-day conditions of the
decline of family planning, pronatalist politics, political concerns about birth control, and
the over-the-counter availability of contraception. Institutional priorities are given for the care
of pregnant women, while doctors do not have enough resources and incentives to educate
women on contraception.
54
NA, female, aged 49; obstetrician-gynaecologist at Zh.K. and in private clinic; 26 years’ work experience.
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THE GYNAECOLOGIST'S GAZE 1543
Discussion: tensions between the promotion of contraception by professionals and
biopolitical priorities and institutional constraints
In the last decade new medical possibilities have emerged, allowing Russian women to
regulate their reproductive life and avoid undergoing abortion. Gynaecologists advocate
contemporary knowledge and practices that were denied to Soviet society and are nowadays
condemned by conservatives in the interests of national security and population growth.
Modern contraception is recognised by doctors as a very important medical priority and an
important dimension of healthy women’s behaviour. They claim that detailed instructions and
education on contraception in patient consultations is required.
As medical professionals, doctors consider themselves to be morally neutral. Nevertheless,
they frequently flag issues such as having multiple partners, apparent lack of knowledge
and discipline, irresponsible behaviour, leading a ‘peculiar’ lifestyle, rejection of medical
advice as being risky to women’s health and not connected to the ‘proper’ behaviour of
planned reproduction. The possibility of prescribing and monitoring the use of contraceptives
is an important component of professional authority. Gynaecologists responded negatively
to women who reject their recommendations. Labelling women as ‘irresponsible’ or ‘too
demanding’ helps physicians to feel that they are experts in what constitutes the ‘proper’
lifestyle and thus authorises them to judge others and pronounce on their moral status.
‘Inappropriate’ women’s behaviour reduces medical authority, which can be restored
by paternalistic control and disciplining for the sake of women’s health and regulation
of reproduction. I agree with Michele Rivkin-Fish (2005) who argues that doctors use
medicalisation to restore their power and compensate for the political and economic
marginalisation that resulted from the erosion of the esteem in which the profession was
held during the Soviet era, and which has continued in the post-Soviet period.
What constitutes the ‘proper’ behaviour that doctors expect of women? Gynaecologists
mostly connect responsible use of contraception to the issue of fertility and maternity. In
contrast with Soviet discourse, contemporary medical discourse identifies the ‘proper’
behaviour of women as first and foremost a woman’s taking responsibility for a considered,
healthy pregnancy and childbirth. By focusing on maternity, gynaecologists tend to support
pronatalist state policies and their own authority rather than the autonomy of women and the
possibility of them gaining control over their own lives.
The institutional organisation of women’s clinics does not help doctors to promote
contraception. At the institutional level priority is not given to prophylactics and prevention.
There is only a marginal space allotted to prophylactic services, including consultation on
contraception. Gynaecologists report that caring for pregnant women and treating illness and
infertility are their priorities. As a professional group, gynaecologists are not empowered
by advocating contraception, and they receive neither political nor economic capital by
doing so. Nor do midwives have possibilities to promote contraception due to their lack of
professional autonomy within women’s clinics (or maternity hospitals). On the other hand,
if gynaecologists provide pregnancy treatment in line with the state policies on population
growth, they stand to slightly increase their power and resources.
Contemporary Russian biopolitics upholds the vital importance of reproduction to the
nation. This process was reinforced in the 2000s under national demographic and health
programmes to improve conditions and privileges for pregnant women. Resources are limited
and economic and political priority is given to population growth and pregnancy treatment and
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ANNA TEMKINA
1544
delivery. Gynaecologists as professionals are aligned to state pronatalist goals by prioritising
services for pregnant women. Whereas gynaecologists recognise contraception as an important
dimension of health, in practice it still remains a marginal issue in doctor–patient consultations
and medical care more generally.
Physicians are inconsistent in their messages and tactics. Doctors declare the importance
of instructing women on contraception, of advocating modern forms of contraceptives, and
of planning pregnancy. But the medical control of contraception is problematic under the
institutional constraints of the Russian health service and the pronatalist biopolitical priorities
of the state. There is a discrepancy between, on the one hand, contraception for professionals
as both a health issue and one of medical control and authority, and the priority given by
the state on the other hand to maternity with a consequent lack of institutional incentives to
promote contraception.
Reproductive control is strictly gendered. Gynaecologists mostly assume that contraception
is a female practice and responsibility, which is ultimately oriented towards reproduction.
Contraception is seen as a matter exclusively for women and their doctors or gynaecologists.
Similarly, obstetric services are oriented towards women. Nevertheless, some professionals
report that men became more visible in obstetric care, in cases of infertility and sometimes
when planning a partner’s pregnancy and when in maternity. Gynaecologists hardly promote
the inclusion of men in family planning: not one of the physicians we interviewed and observed
suggested that a couple might discuss contraception together with their doctor, though this
is theoretically possible. In her research on medical consultations, Larivaara found a few
exceptions to this trend, where gynaecologists expressed the view that it is important to discuss
contraception with couples, or at least within the couple (Larivaara 2009, p. 324). Just as
‘medicalising women’s bodies … is nothing new and the way all contraceptives are advertised
further medicalises women’s bodies in ways men’s bodies are not’, the same is true for the
promotion of contraception in medical appointments (Medley-Rath & Simonds 2010, p. 784).
Conclusion
Gynaecologists are important agents of reproductive control, pregnancy planning and the
promotion of contraception in Russia. They see the main purpose of advocacy as to assist
women to plan their pregnancy and avoid undergoing an abortion. When educating women
about contraception, doctors construct the norms of their proper behaviour, namely, a stable
relationship and orientation towards childbirth under medical supervision. Women are
presented unambiguously as mothers who should regulate their life and take responsibility
for their fertility with the help of contraception. Doctors expect ‘proper’ behaviour from
responsible women under their supervision, and many women regularly visit gynaecologists
and follow their advice. Those women who do not systematically follow the prescriptions
of doctors and do not accept medical authority are frequently considered to be either
‘irresponsible’ or ‘demanding’.
Contraception is not a priority in the organisation of medical care or in consultations with
women. On the other hand, pregnant women are the main priority for gynaecologists, and this
is in accordance with the contemporary demographic politics in Russia. The discourse and
practice of medical professionals in relation to contraception is characterised by inconsistency.
Whereas gynaecologists advocate all-encompassing and comprehensive oversight over
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THE GYNAECOLOGIST'S GAZE 1545
contraception, the biopolitical priorities of the state healthcare system are pregnancy treatment
and not contraception advocacy. Thus while professionals and service-users tend towards the
use of contraception and planned pregnancy, institutional barriers and state priorities facilitate
services for pregnant women and not for pregnancy prevention.
European University at St Petersburg
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Chapter
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Chapter
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This article examines the gendered consequences of linking family support to state pronatalist goals in contemporary Russia. By analyzing the policies, proposals, and critiques circulating on the maternity capital program, Michele Rivkin-Fish demonstrates how state power and citizenship are being constructed through struggles over the meanings of gender and family. She further argues that studies of Russian demographic politics must bring attention to both institutional transformations and the symbolic levels of discourse. This holistic approach, rooted in feminist anthropology, illuminates the particular, cultural logics informing demographic debates as well as the apparent contradictions between ideologies, policies, and practices. Pronatalist discourses engage Russian politicians, experts, and laypersons in efforts to undo the troubling legacy of Soviet gender relations and the 1990s fertility crisis; in the process, these policies define and deploy state power in ways that sustain and normalize gender inequalities.
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Full-text available
This article analyses the new demographic programme that was announced by the Russian president, Vladimir Putin, in 2006. The main goal of this programme is to encourage fertility, especially the birth of a second child. New benefits should elevate the status of women taking maternity leave, who might otherwise suffer from discrimination in the family. The housewife is considered to be dependent and `degraded'. We argue that this demographic politics recalls continuity with soviet gender politics centred on the support of wage-earning working mothers. The programme provokes different critiques. Liberal critics argue that the programme is a populist one and it may have undesired economic and social consequences. Conservative critics want to encourage more traditional `woman' and `family' roles in society. Feminist critics argue that this politics would reinforce both the inferior position of women on the labour market and gender imbalances on the symbolic level.
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An unparalleled study of a transforming and privatizing Russian health care system, of the promises and perils of prescriptive programs for change, that points to the areas that need change in the change-makers themselves.... part of a larger story about the inherent dangers of current neoliberal economic transformations of fragile post-socialist social welfare arrangements.... "Rivkin-Fish takes the reader into a new understanding of the fragile and tense relations between state and market transitions, and into the deep and largely silent struggle for gender and health equity in Russia. - Adriana Petryna, author of Life Exposed: Biological Citizens after Chernobyl In the first decade after the collapse of the Soviet Union, deteriorating public health indicators such as below-replacement fertility and high rates of sexually transmitted diseases, abortions, birth traumas, and maternal mortality raised acute anxieties about Russia's future. This study documents the efforts of global and local experts, and ordinary Russian women in St. Petersburg, to explain Russia's maternal health problems and devise reforms to solve them. Examining both official health projects and informal daily practices, Michele Rivkin-Fish draws ethnographic and theoretical insights about the contested processes of interpreting and managing neo-liberal transitions in Russia and explores the challenges of bringing anthropological insights to public health interventions for women's empowerment.
Article
This article examines the gendered consequences of linking family support to state pronatalist goals in contemporary Russia. By analyzing the policies, proposals, and critiques circulating on the maternity capital program, Michele Rivkin-Fish demonstrates how state power and citizenship are being constructed through struggles over the meanings of gender and family. She further argues that studies of Russian demographic politics must bring attention to both institutional transformations and the symbolic levels of discourse. This holistic approach, rooted in feminist anthropology, illuminates the particular, cultural logics informing demographic debates as well as the apparent contradictions between ideologies, policies, and practices. Pronatalist discourses engage Russian politicians, experts, and laypersons in efforts to undo the troubling legacy of Soviet gender relations and the 1990s fertility crisis; in the process, these policies define and deploy state power in ways that sustain and normalize gender inequalities.
Article
Despite access to high-quality family planning services and contraceptive devices, women in St. Petersburg, Russia, continue to rely on ineffective contraception and abortion to limit fertility. These are the findings of a 1995 study I conducted in which 163 adult and teen women were interviewed at two of St. Petersburg's foremost women's health clinics. The study, a cross-sectional, nonrandomized, descriptive design, employs a four-page questionnaire to collect data on socioeconomic background, marriage and parity, and contraception and abortion use. The legacy of family planning in the Soviet era, bias against hormonal contraceptives, and low satisfaction with contraceptive devices indicate that both adult and teen women will continue to rely on abortion as a means of limiting fertility.
Book
Medicine as Culture is unlike any other sociological text on health and medicine. It combines perspectives drawn from a wide variety of disciplines including sociology, anthropology, social history, cultural geography, and media and cultural studies. The book explores the ways in which medicine and health care are sociocultural constructions, ranging from popular media and elite cultural representations of illness to the power dynamics of the doctor-patient relationship. The Third Edition has been updated to cover new areas of interest, including: studies of space and place in relation to the body; actor-network theory as it is applied in research related to medicine; the internet and social media and how they contribute to lay health knowledge and patient support; complementary and alternative medicine; obesity and fat politics. Contextualising introductions and discussion points in every chapter makes Medicine as Culture, Third Edition a rigorous yet accessible text for students.