ASTANA – As a Central Asian country with a Muslim majority and a name ending in ‘stan,’ Kazakhstan might not be expected, by Western observers, to be a place where women are promised access to a spectrum of mostly-publicly funded reproductive options, including a variety of birth control options, abortion, and vaccines against the human papillomavirus (HPV) that are controversial in some parts of the U.S.
On paper, however, Kazakhstan indeed has a variety of public reproductive health options available. In response to questions from this newspaper, Kazakhstan’s Ministry of Healthcare and Social Development explained some of the country’s laws and practices regarding health care.
A Dec. 15, 2009, decree established a list of healthcare services that are guaranteed, free of charge, to citizens of Kazakhstan. For women, the ministry said, these services include gynaecological exams, abortions and intrauterine devices, which are accessed at perinatal centres, maternity hospitals and gynaecological departments of hospitals. Birth control, however – including condoms and contraceptive pills – must be paid for. It is available in the country’s pharmacy network, which has barrier methods, hormonal methods, spermicides and more, the ministry reported. Costs generally range from 1,100 tenge to 2,500 tenge per package of pills (US$5.92 – $13.47), which was confirmed by Kazakh women interviewed for this article.
When it comes to abortion, Kazakhstan exists within two strong but separate traditions. Throughout most of the 20th century, abortion was the principal method of birth control in the former Soviet Union, according to many sources. After independence, contraceptive methods began steadily replacing abortion, and abortion rates are declining.
Views within Islam on abortion diverge, with one common view that abortion is permissible up to four months of gestation, though it is not uncommon for abortion to be viewed as completely impermissible. The Russian Orthodox Church, the second most popular religion in the country, forbids abortions, though in cases where the life of the mother is threatened, the procedure is not ground for excommunication.
Secularly-governed Kazakhstan, however, provides abortions through its code “On people’s health and the health care system.” Article 96 of the code says that individuals have the right for free reproductive choice, reproductive health protection and family planning services, infertility treatment and the use and free choice of contraceptive methods,” the ministry said. Article 104 of the code, dated Sept. 29, 2009, gives women the right to an abortion.
The procedure is legal and free upon request for pregnancies up to 12 weeks, “for social reasons” for pregnancies up to 22 weeks, and at any point during gestation for indications that the life of the woman or fetus is at risk, including abnormal gene disorders, incorrectable congenital malformations and other fetal conditions incompatible with life, the Ministry of Healthcare and Social Development said, and all international methods of terminating a pregnancy are available within the country. Abortions for women under 18 are available with the consent of their parents or legal representatives, they said.
Diseases that affect women are also receiving increasing attention. Since 2008, women have been able to access free screenings for the early detection of pre-cancerous breast disease and cervical cancer, the ministry reported, and since 2013, a programme of free HPV vaccinations has been offered to girls from 11 – 15 in Pavlodar, Atyrau, Astana and Almaty. In May, the Astana.gov.kz website announced that the programme to vaccinate girls age 11 – 12 would be gradually expanded to cover the entire country.
“This year the opportunity to protect girls from cervical cancer and other dangerous diseases caused by HPV will be provided in some more provinces of our country, and in the next few years it will be accessible for all regions of the country,” the May 6, 2014, report said. Kazakhstan joins Australia and New Zealand and a number of European countries including Denmark, Switzerland and the U.K. which provide publicly funded HPV vaccines to citizens.
However, accessing healthcare options provided by the government can sometimes be a challenge in reality. “Women in big cities have access to reproductive healthcare services, but it is difficult to have such access in non-urban areas,” said Galina Grebennikova, executive director of the nongovernmental organisation, Kazakhstan Association on Sexual and Reproductive Health (KMPA). And despite the ministry’s report that 72 percent of doctors in the country are women, there is also a lack of women’s specialists in the country, she said, and a lack of information about existing services.
The ministry reported that more than 350 family-planning offices are operating in primary healthcare centres, offering “family planning methods and services … preparation for pregnancy, contraception, and selection of optimal birth spacing.” There are also youth health centres, the ministry said, plus telephone hotlines and health promotion centres like young mother’s schools and clubs to share information on reproductive health.
In schools and universities, seminars on preventing pregnancy are conducted, the ministry said, and work on preventing abortion and sexually transmitted diseases is conducted through youth health centres “to provide confidential legal, medical and psychological assistance,” the ministry said.
However, this information may not be reaching its targets as effectively as some would hope. Arguably, there are more healthcare options available to women than there is good information about them. “As of today, most women in our country are active users of the Internet and they have access to different sources of information, but unfortunately, we often see that women remember misleading information or they don’t know where to find reliable sources,” said Grebennikova.
“Healthy Life Centres in Kazakhstan distribute informational booklets and posters. … The problem is that often, women have information but don’t use it. For example, they know about hormonal contraception, but it isn’t used in actual fact,” she said.
A 27-year-old Astana resident who did not want to be identified concurred: “No doctor ever offered or told me about contraception,” she said in a February interview. “I had to find information on the Internet,” she said. “I’m not shy and when I needed contraception, I asked my doctor which one is better for me.”
“I would be happier if, by the time my children get older and start having sex, the Ministry of Healthcare will inform teenagers about methods of contraception! It’s hard to control sexually transmitted diseases among teenagers. When I was a teenager, I didn’t want to have sex because my mom frightened me about the consequences, while my peers had sex with different people and didn’t hear about contraception or felt ashamed to go to the pharmacy and buy condoms.”
Women interviewed also preferred paid clinics to free public clinics. Thirty-eight year old Astana resident Shinar Bekisheva said, “Doctors in private centres check patients more thoroughly: we have to do a lot of tests. On one hand I think it’s because they are responsible. On the other hand, it’s business: analyses are expensive.”
“[At public clinics], you have to wait in long queues and wait for hours. And the quality isn’t so good,” Bekisheva said. “Sometimes it just depends on the doctors. But people who really care and have money, they go to private doctors or institutions.”
The anonymous Astana resident said, “In the free clinic [in my district], the gynaecologist is so young, I don’t actually trust her.” She went to another state clinic, she said, but since it was out of her locality, she had to pay 10,000 tenge (US$53.75) for another appointment. She also said she’d never heard of family-planning offices.
“The Ministry of Healthcare has done a lot. A woman can get medical care from a gynaecologist, antenatal care, childbirth and antiretroviral therapy absolutely free of charge in a hospital.” Grebennikova said. She noted that since 2010, the Kazakh government has allocated money for free fertility treatments for some problems. (The country is currently trying to build its population as well as extend life expectancy. On a visit to South Kazakhstan oblast (region) on March 27, President Nursultan Nazarbayev announced that life expectancy in the country reached 70 years.)
“I think that a lot of work has been done, but we have to do much more in the future,” including developing a new state programme of healthcare, improving access to different contraceptive methods and allowing NGOs to provide social projects under Ministry of Healthcare and take part in discussions of existing problems, Grebennikova said.