Johnson's Russia List
#6596
11 December 2002
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A CDI Project
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#19
From: "Stephen Massey" <[log in to unmask]>
Subject: Russia's Maternal & Child Health Crisis: Socio-Economic Implications
and the Path Forward - EWI Policy Brief by Stephen M. Massey
Date: Tue, 10 Dec 2002
EastWest Institute Policy Brief, Vol. 1 No. 9
Russia's Maternal & Child Health Crisis: Socio-Economic Implications and the
Path Forward
by Stephen M. Massey ([log in to unmask])
Full text available at http://psp.iews.org
Executive Summary
Today, fewer than one in three Russian newborns is healthy, disease rates
among Russian children are surging, and shrinking access to quality family
planning and prenatal care has worsened the state of women's reproductive
health across Russia. The health of Russia's infants and children is
especially significant given the country's shrinking population and the
mounting problems of infectious disease, rural poverty, illegal narcotics,
and alcohol abuse - all contributing factors to poor birth outcomes. The
long-term economic impact of unhealthy children born in the past decade is
already a serious limiting factor to Russia's emergence as a strong economic
partner and international actor. Many infant deaths and childhood illnesses
could be prevented with expanded investments in infrastructure and
education, improved access to quality care, and reform of Russia's
healthcare sector - each of which is too costly for Russia to finance on its
own. Untapped opportunities also exist for collaboration between Russian,
European, and American civic groups, healthcare experts, scientists, and
policy leaders that would have a positive impact on maternal and child
health in Russia and beyond.
Key Recommendations
- Focus on prevention and quality of care. Russia's national healthcare
system is designed to provide treatment rather than deliver quality
preventive care. The Russian government should shift resources towards
prevention programs aimed at improving maternal and child health, expand
access to prenatal and postnatal care, and implement a national system of
birth defects surveillance.
- Support family planning and public education initiatives. A 1999 State
Duma moratorium on federal funding for family planning programs has
dramatically reduced access to preventive care and reproductive counseling.
The international community should work with Russian partners to improve
access to and quality of family planning and contraception programs; support
physician training initiatives in modern neonatology and reproductive
counseling; and, expand public education campaigns aimed at reducing
smoking, drinking, and drug use among pregnant women.
- Harness the promise of scientific breakthroughs in genetics.
Underemployed Russian scientists represent significant, untapped resources
in the effort to improve maternal and child health in Russia and beyond.
International scientific partnerships in genetics should be expanded to
better integrate the expertise of Russian scientists in the process of
identifying disease-causing genes and developing specific treatments.
THE POLICY CONTEXT
The Russian government's conservative projections warn that by 2050, the
country's population will shrink by 30 percent from 143.6 million to 101.3
million; its worst case scenario predicts that the population could drop to
77.2 million, a reduction of nearly 50 percent. For a country facing a
dramatic demographic decline and an increasingly unhealthy adult population,
Russia can ill afford to under-invest in its human capital, especially in
the treatment and care of its infants and children. An increasingly
unhealthy and constantly shrinking population in Russia represents a
formidable economic and security challenge deserving of decisive action
backed by substantial resources, including from the international community.
Russia's Infant Health Crisis
Babies in Russia are born smaller and sicker today than in the past. Key
statistics provide an alarming snapshot of Russia's looming infant health
crisis:
- Nearly two-thirds of all Russian babies are born unhealthy, and at least
75 percent require an extended hospital stay or intensive medical treatment;
- Russia's official infant mortality rate remains 3-4 times higher than in
Western Europe and North America, and Russia reports the second highest rate
(behind Romania) of under age-5 child mortality in Europe;
- The percentage of Russian babies born with a dangerously low body mass
(less than 2.5 kg, or 4.4 lbs.) jumped nearly 6 percent from 77,500 in 1996
to 82,000 in 2000, due in large part to rising rates of tobacco and alcohol
consumption among Russian women;
- Ten percent of pregnant women in Russia lose their unborn children as a
result of health problems, and nearly half of Russia's expectant mothers are
malnourished.
National statistics mask the worsening conditions in Russia's poorest
regions - including the North Caucasus, eastern Siberia, and the Far East -
where infant mortality rates are on par with Third World countries in South
Asia and Latin America. The Chukotskiy region in Russia's Far East, for
example, reports an infant mortality rate (42.1 deaths per 1,000 live
births) higher than those of Guatemala and Indonesia. And, as a result of
discrepancies between the Russian and international definitions of 'live
birth', Russia's real infant mortality rate is likely to be at least 25
percent higher than the official rate.
Meanwhile, recent demographic data points to the deteriorating state of
women's reproductive health in Russia, with devastating effects on the
health of infants and children. A growing number of Russian infants face
lifelong disease and disability as a result of unhealthy pregnancies or
disease transmission from their mothers. Mother-to-child transmission (MTCT)
of HIV, which is generally prevented in developed countries with proper
antiretroviral treatment and regular care, has expanded rapidly as the
incidence of HIV infection among Russian women increased from less than
1,000 cases in 1997 to an estimated 180,000 in 2001.
Reproductive health among Russian women is also negatively affected by a
lack of reliable contraception and inadequate access to family planning.
Abortion rates in Russia are among the highest in the world, and
three-quarters of all Russian abortions take place after the first trimester
of pregnancy, dramatically increasing the long-term heath risks to the
mother. In 2000, Russia reported nearly 170 abortions per 100 live births,
a rate that remains over six times greater than that of the United States.
Failure of Prevention
Even more tragic than the great numbers of Russian infants who die or suffer
from lifelong disability and disease is the reality that so many poor birth
outcomes are preventable. Compared to its G-8 partners, Russia's rates for
certain causes of infant death, including congenital malformation,
infection, respiratory disease, and pneumonia, point to the large number of
potentially preventable deaths in Russia with improved access to quality
prenatal care and education. Effective public policy action, coupled with
additional resources, can decisively improve maternal and child health in
Russia by expanding access to quality care, improving education and family
planning programs, and shifting resources towards other prevention
initiatives.
Access to Quality Care
Public health programs for health promotion, disease prevention, and family
planning remain low priorities in Russia, and little effort has been made to
improve prenatal care programs for expectant mothers. Low wages and poor
training for primary-care physicians, coupled with limited access to the
latest medical information and technology, results in a dangerously
inadequate and demoralized national healthcare infrastructure. General
physicians, who are not properly trained in neonatology or pediatrics, often
treat newborns that require extended hospital stays, and many Russian
hospitals lack even basic equipment to effectively treat premature or
unhealthy newborns. The Russian Ministry of Health recently admitted that
25 percent of the municipal and regional hospitals rendering healthcare to
infants and children are in need of a "radical overhaul."
Access to quality care also varies considerably by region. In urban areas,
for example, expectant mothers are routinely subjected to complete
screenings for infection and often undergo genetics counseling. In rural
areas, testing depends on the equipment available and the local healthcare
provider's level of training. Dispersed rural populations in Russia often
have access to a local feldsher (similar to a physician assistant) or
midwife who can provide basic treatment and first aid, administer
immunizations, and offer limited family planning services. Local healthcare
workers, however, often do not receive regular medical training and are not
subject to strict regulation.
Education and Contraception
Limited access to quality contraception and inadequate sex education are
additional factors that warrant attention. Although there has been a steady
increase in the percentage of Russian women using contraception since 1990,
the use of contraception remains lower in Russia than in any other G-8
country. During the 1990s, the Russian government's Federal Family Planning
Program significantly expanded the availability of contraception and access
to family planning counseling across the country. However, concerns about
Russia's low fertility rate and population decline prompted the State Duma
to discontinue federal funding for family planning services in 1999, which
significantly reduced access to contraception and reproductive counseling.
Meanwhile, public education programs about the risks of smoking and alcohol
consumption during pregnancy are sporadic at best.
Treatment versus Prevention
Russia's inability to adequately respond to its many simultaneous healthcare
crises - HIV/AIDS, TB, infant mortality, maternal morbidity, malnutrition,
chronic substance abuse - is also a function of a national healthcare system
designed to provide treatment rather than prevention. Russia's high rate of
hospitalization (206 discharges per 1000 population in 1996) and long
average length of stay (16.9 days in 1996) reflect a hospital-centered
healthcare system. The dependence on hospital-based care in Russia not
only makes its healthcare system extremely expensive and inefficient, but
also precludes much-needed investments in primary care, local polyclinics,
and facilities that provide obstetric care, maternity care, and preventative
care more generally.
Notably, President Vladimir Putin's new "Children of Russia" initiative,
designed to improve the maternal and child health situation in Russia, has
begun to shift federal resources towards prevention by creating a network of
prenatal diagnosis centers and establishing a national child health
surveillance system. However, significant investments in family planning
services and public health education initiatives remain noticeably absent
from the program, which can only be interpreted as a serious failure by the
Russian government to understand fully and address its infant and child
health crisis.
Economic & Security Implications
The dramatic rise in disease and disability among Russian infants and
children is both unprecedented in an industrial nation and exceptionally
costly for Russia's already resource-scarce healthcare system. Poor birth
outcomes often require lifelong treatment, which is many times more costly
than prenatal care and other preventative measures. In addition to the
long-term fiscal consequences of unhealthy infants and children (i.e. the
rising costs of treatment, the adverse effect on budgetary expenditures for
other social programs, etc.), these conditions also reduce economic
productivity and extract socio-psychological costs over the long-term.
Meanwhile, the worsening condition of women's reproductive health in Russia
presents an immediate challenge to the country's economic viability,
precisely because women of reproductive age are also at the prime of their
labor productivity. And, since the population with the highest reproductive
capacity is also the group at highest risk of infectious disease and
substance abuse, ignoring maternal and child health could magnify the
connection between poor birth outcomes and other conditions, including
HIV/AIDS, TB, and alcoholism.
Russia's response to its multiple health crises and related demographic
decline will factor significantly in its ability to integrate economically
and socially with the West. Many of Russia's European neighbors already
harbor reservations about enhanced integration with Russia that would allow
freer movement of goods and people across Europe's borders. An unhealthy and
shrinking Russian population will only reinforce the EU's negative
perceptions and stymie efforts to incorporate Russia as a full partner with
the West. Russia's national healthcare indicators - from HIV to infant
mortality - already position the country at the bottom of the G-8 in terms
of the general health and life expectancy of its population. Despite their
own formidable healthcare problems, no other country in Russia's
neighborhood - including key regional powers like India, China and Iran -
faces such a daunting array of interrelated healthcare crises. Clearly, the
stakes for Moscow are extremely high.
International Engagement
During the past decade, international assistance programs have provided
limited family planning and prenatal care services in key Russian regions
where abortion rates are particularly high and where maternal and child
healthcare services are especially weak. Partnerships between Russian and
international doctors and healthcare facilities have also made important
progress towards improving access to quality services for expectant mothers
and infants in poor regions. International support for Russian civic
organizations has expanded training programs for doctors, midwives, and
social workers.
However, there remains significant untapped potential for cooperation
between Russia and its Western partners to improve family planning and birth
outcomes, mitigate the spread of HIV and other sexually transmitted
diseases, increase public awareness about the risks of substance abuse, and
improve access to prenatal care. Enhanced collaboration between Russian,
European, and American civic groups, healthcare experts, and policy leaders
can make quality care more accessible to expectant mothers, infants and
children. And, partnerships between Russian, European, and American
scientists and doctors hold the promise of new discoveries in preventative
medicine and genetics, which could improve health conditions and birth
outcomes in Russia and beyond. Thus far, these issues have received little
serious consideration.
POLICY RECOMMENDATIONS
For Russia:
1. Focus on prevention initiatives to improve maternal, infant, and child
health. Priority attention should be given to the following key areas:
smoking and substance abuse prevention and treatment for pregnant women and
their infants; programs to improve prematurity risk detection and prevent
preterm births; food and nutrition education programs; preconception
programs including family planning and contraception services; programs to
reduce exposure to environmental and reproductive hazards that are
associated with birth defects; and, initiatives to reduce MTCT of HIV, TB,
and other infectious diseases during pregnancy and after childbirth.
2. Fortify Russia's domestic grain supply with folic acid, iron, and
essential vitamins. In 1996, the U.S. Food & Drug Administration (FDA)
began adding folic acid to flour, breads and other grains in order to
improve nutrition among women of childbearing age. Folic acid is a
naturally occurring B vitamin that helps prevent birth defects of the brain
and spinal cord when taken very early in pregnancy. Between 1996-2001,
debilitating neural tube defects in the U.S. dropped by 19 percent as a
result of fortification of the grain supply and increased education outreach
initiatives. The Russian government should work with the FDA and other
international partners to develop a plan to fortify its own grain supply
with folic acid, iron, and essential vitamins thiamin, riboflavin, and
niacin. Doing so will improve general health in Russia while significantly
reducing the risk of poor birth outcomes.
3. Implement a national birth defects surveillance system. Create an
institution to regularly collect, analyze, and interpret data regarding the
incidence of specific birth defects in communities and regions across the
country. This information will help Russian scientists conduct
epidemiological studies that examine environmental factors contributing to
birth defects in a specific locality, and will help policy planners know
which regional or local healthcare systems are most in need of resources and
training.
For Russia's International Partners:
1. Target resources towards family planning and contraception. Since the
1999 Duma moratorium on federal funding for family planning and
contraception programs, there has been only limited outside funding for
these activities. Family planning programs improve reproductive health by
counseling women on healthy lifestyle decisions before and during pregnancy;
contraception programs reduce the health risks to women who might otherwise
choose abortion as a primary method to control unwanted pregnancy. Women
who are physically and emotionally prepared for childbirth are more likely
to have a healthy pregnancy compared to women whose pregnancies are
unplanned.
2. Expand training programs for Russian health professionals. Expand
specialized training programs for obstetricians-gynecologists,
pediatricians, neonatologists, nurses, midwives, and feldshers in modern
neonatology and counseling skills for reproductive health. Healthcare
providers also require accurate, up-to-date information about the safety and
effectiveness of various kinds of contraceptive methods.
3. Design public health awareness campaigns that will promote healthy
lifestyles and the reveal the risks of substance abuse, especially during
pregnancy. International partners can transfer their own successful public
education strategies to Russia, and work cooperatively with Russian civil
society to design high-impact, low-cost outreach efforts.
Joint Work:
1. Expand scientific partnership initiatives on genetics. The mapping of
the human gene, which began in 1990, holds the promise of new scientific
discoveries that could help identify and prevent heredity disorders. The
pace of such discoveries could come even faster through expanded
partnerships between Russian, American, and European scientists.
Well-trained Russian scientists are often underemployed and cut off from
international advancements in science and technology; Western scientists
should aim to reengage them. International scientific partnerships could
more effectively integrate the expertise of Russian scientists in the
process of identifying disease-causing genes and developing specific
treatments.
2. Work cooperatively to improve maternal & child health in Central
Eurasia. Although little credible data exists on maternal and child health
indicators elsewhere in the NIS, studies suggest that the worrisome trends
seen in Russia are even more severe in Ukraine, Central Asia, and the
Caucasus. Russia should partner with the United States and Europe to design
outreach and assistance strategies to improve the state of maternal and
child health in the countries on Russia's periphery. Given the
transnational nature of infectious disease and the patterns of migration in
Central Eurasia, it is in Russia's interest to address the poor state of
maternal and child health in the states of Central Asia and the Caucasus.
Doing so would allow Russia to work as a co-equal leader with the U.S. and
Europe on an issue that would benefit Russia and its neighborhood.
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