Katya Esipova says she never liked to take chances on her health. So when she continued to bleed after she had an abortion at age 19 she visited two doctors to ask why. They assured her that even after a month, bleeding was perfectly normal.
Only four years later, when she and her husband decided it was time for a baby, did she learn how wrong they were. The abortion had led to an infection that left both fallopian tubes partially blocked. She managed to get pregnant once more, at age 27, but the fetus lodged in one of the fallopian tubes and surgeons aborted it.
Now 30, she has all but given up her hopes of having a baby. "It is so terrible to wait every month and be disappointed," she said over a Greek salad in a downtown restaurant. "I was too young. I did not realize how big a problem an abortion could be."
Russian health specialists call women like Esipova one of the more lasting legacies of a Soviet health system that for decades viewed abortion as the main form of birth control. According to Vladimir Serov, chief gynecologist at the Health Ministry, abortions are one of the primary causes of infertility in a country that is desperate to raise a plummeting birth rate.
About 5 million -- or 13 percent -- of Russian married couples are infertile, and doctors report that diagnoses of infertility are on the rise. In nearly three out of four cases, infertility is attributed to the woman, typically because of complications from one or more abortions, according to Serov and other health experts.
The abortion rate has been declining rapidly for 15 years because of the availability of contraceptives. Still, it remains five times higher than that of the United States. The Health Ministry reports that for every live birth there are 1.7 abortions, compared with more than three births for every abortion in the United States.
A study of mid-1990s data by a group of health researchers showed Russia's abortion rate was the fourth-highest of 57 countries, after only Vietnam, Cuba and Romania.
"It's a habit, a tradition," said Serov. "It is a result of our low level of medical culture."
Russian health and demographics experts say the abortion legacy has created a problem greater than the private trauma of childless couples, because the resulting infertility contributes to a low birth rate. That trend and a soaring death rate are helping reduce Russia's population at a rapid rate.
U.N. population experts predict that in 50 years Russia will be the world's 17th-most populous country; it is now the sixth. Projections show Russia will lose more than a quarter of its population, dropping from 143 million people to 104 million by 2050.
Like other countries in Europe, Russia has been experiencing a falling fertility rate for most of the last half-century. It is now the sixth-lowest in the world, according to U.N. studies. On average, Russian women now bear just more than one child.
Such statistics help buttress Serov's arguments that the government must take better care of women's reproductive health by promoting contraceptives instead of abortions and fighting the spread of sexually transmitted diseases, which he considers the second-leading cause of infertility after abortions. He said the government hopes to set the course with a new program next year.
Whether it will be funded is another question. Abortion-related infertility is one piece of a much bigger health care crisis that has yet to command much of the Kremlin's attention. Russia's health care system is in a state of collapse, and with it, the public's health, by almost any measure, whether heart disease or HIV. Russia spends just 5.3 percent of its gross domestic product on health, less than 37 other European countries, according to the World Health Organization.
"The country just does not have the money," Serov said. "This is very sad. If we are not able to stop the epidemic of abortions and control the transmission of genital infections, the reproductive force will be damaged."
Russia's strides in introducing modern birth control are due mainly to the advent of capitalism. The free market finished off the production of unappealing Soviet-era condoms of thick, dark latex and diaphragms manufactured in only one size. They were replaced by European imports. Although birth control pills made their Russian debut in too high a dosage and scared off some women, they are now becoming more popular. The number of women who use contraceptives has doubled since 1988, according to a two-year-old study by the Rand Corporation.
For four years, the government also funded family planning clinics that distributed free contraceptives and provided medical care. But in 1997, the Communist-controlled Russian parliament cut off financing, leaving some 400 clinics to subsist on local subsidies. Lawmakers said a nation with a falling birth rate did not need to promote birth control. The Russian Orthodox Church, an increasingly influential force, also threw its weight against the program.
The shift was true to form for Russian health care, which emphasizes medical cures over prevention or education, the mantras of Western health care. The government offers no funds for contraceptives and leaves sex education up to individual schools, most of which offer little or none of it. Citing public opposition, federal officials in 1997 scrapped a U.N-funded project to introduce sex education in Russian schools.
But state-funded clinics provide free first-trimester abortions upon request and second-trimester abortions up to the 22nd week of pregnancy for medical or social reasons that include lack of a husband, housing or adequate financial support.
It is typical of Russian attitudes about sex that young people are left to discover the options and risks on their own, said Inga Grebesheva, director of the Family Planning Foundation, a nonprofit organization that works out of the Health Ministry building. Even 12 years after the fall of the Soviet Union, she said, Russians have not shed their reticence to discuss sex openly.
"We had abortions but not sex," she said with a smile. "It's just that we were not supposed to talk about it. Everyone would watch sex on TV with pleasure, but to talk about it would be bad manners."
Despite Moscow's ambivalence over family planning, the rate of abortions in Russia dived by 45 percent from 1992 to 2001.
The number of women who died from them also dropped by one-half in the 1990s, according to the Rand study. Serov predicts abortions will continue to decline as contraceptives become more accepted, even without a federal program. "It will just take more time," he said, to reverse a decades-old predilection.
In most countries, people were introduced to contraceptives before abortions. In Russia, it was the opposite. The Soviet Union first legalized abortion during a widespread famine in 1920, more than a half-century before the landmark Roe v. Wade decision in the United States. They were banned under Josef Stalin in 1936 in hopes of encouraging births, then legalized again in 1955 after his death.
With no access to decent contraceptives, Russian women came to view abortion as a routine procedure, doctors say, comparable almost to a tooth extraction. A study in 1994 found that the average Russian woman had three abortions by the end of her child-bearing years.
Esipova, a tall, friendly specialist in commercial real estate, said she was not overly worried about having an abortion when she found out at age 19 she was pregnant. "All my friends had done it already," she said.
She went to a state clinic because she felt she would get reliable care there. When she discovered the complications four years later, she said, her confidence in Russian medical care was shot. In 1998, she tried artificial insemination at a fertility clinic in the United States, she said, but without success. Four years later, she and her second husband were divorced.
Other problems besides her infertility led to the break-up of her marriages, she said.
But she added: "Of course, if I had gotten pregnant, it would have been a different story."