Patients in Contemporary Russian Reproductive Health Care Institutions: Strategies of Establishing Trust

Abstract: Russian reproductive health care systems have undergone many changes since the 1990s. These changes have given users new opportunities, and users have become more demanding and knowledgeable. At the same time, patients distrust health care institutions and practitioners, which remains one of the Russian reproductive health care's most significant problems. The authors focus on public and private reproductive health care encounters from the patients' perspectives, concentrate on the women's experiences during pregnancy and delivery, explain patients' distrust of medical institutions, and examine the coping strategies patients develop to establish trust. Young, active, educated women do not want to be treated as Soviet patients--disciplined, ignorant, and obedient. They want to find a trustworthy doctor and receive reliable, comfortable, and proximate medical service. Keywords: distrust, health care, reproduction, Russia, strategies, women ********** Russian reproductive health care systems have undergone enormous changes since the 1990s. These changes reflect the economic breakdown of the state health care system, the commercialization of medical services, and attempts to solve Russia's demographic problems. These changes have not only given users new choices and opportunities but have also created unequal access to quality medical services. Russian attitudes toward reproductive health practices have also changed. Women have become more demanding and knowledgeable: they are consciously involved in family planning, including contraceptive use and the exploration of health care options on the Internet. However, patients' widespread distrust of both health care institutions and individual practitioners remains one of Russian reproductive health care's most significant dilemmas. (1) The issue of trust in medical institutions has been analyzed, starting with Talcott Parsons's classical model of clinical encounter, (2) but there have been few previous studies about this problem in the Russian reproductive health system. (3) Here, we focus on encounters in public and private reproductive health clinics from the patients' perspectives, concentrating on women's experiences during pregnancy and delivery. Following a bottom-up strategy of grounded theory (the "systematic inductive guidelines for collecting and analyzing data for middle-range theoretical frameworks that explain the collected data"), we reconstructed the leitmotif (master code) using thematic in-depth interviews. (4) This leitmotif is: "We do not trust/believe our medicine/doctors." The leitmotif is exacerbated by patients' experiences in reproductive health care institutions. We also examine how women cope with needed medical assistance despite the trust deficit. We investigate patients' trust in public (insurance-covered and for-fee) and private (commercial) reproductive health services. We find that although women distrust both, they still confront the medical institutions and develop strategies to establish trust when seeking health care. Field data collected in 2005-6 consists of five participants' diaries and twenty-two in-depth interviews with female reproductive health service clients. (See appendix for the sample's description.) Our subjects were mostly middle-class women of reproductive age who had a postsecondary education. Most were private-sector professionals or ran their own small business. In this article, we discuss the reproductive health system reforms, providing institutional context for the clinical encounters. We then operationalize the concept of "trust" for our research purposes. We look at reproductive institutions, maternity-care institutions, and practitioners (gynecologists and obstetricians) as subjects of "trust." We analyze different medical encounters in reproductive health institutions. We use this material to portray (1) women's distrust of these institutions; (2) trust-establishing strategies; and (3) new reproductive health patients' construction of their identity as patients. …